THE GLOBAL CONTEXT OF TRANSGENDER HEALTH AND HIV: A COMMUNITY DRIVEN RESPONSE

The Need for Targeted investments among Global Trans Communities

Amitava Sarkar

Alarming issues around the globe among transgender people

HIV risk and poor sexual health among transgender people

Substance use

Social marginalization

Violence against transgender people

Lack of proper and scientific care for body modification, hormone therapy and SRS

Employment and financial barriers

Lack of access to basic services (medical, legal and others )

Facts and figures Worldwide, the available evidence suggests that, HIV prevalence rates reach as high as 68 percent in trans communities, with new case incidence from 3.4 to 7.8 per 100 person-years. Epidemiological research for other STIs indicates high rates for syphilis, rectal gonorrhoea, rectal Chlamydia and other STIs among Asia-Pacific trans women. These conditions are believed to put infected individuals at added HIV risk.

HIV prevalence stands at 30% among transgender women in Lima, Peru, according to results of a 450-transwoman study. Trans women completed a survey on socio-demographic characteristics, gender enhancement procedures, and sexual behaviour. All study participants were tested for HIV, syphilis, and herpes simplex virus type 2 (HSV-2). While 70% of trans women reported having gender-enhancement procedures, 64% reported sex work as their main economic activity. Multivariable analysis found a higher risk of HIV infection in trans women older than 35, those with syphilis, and those with HSV-2.

According to figures from the China 2010 UNGASS Report, the country-wide estimated HIV prevalence among MSM and Transgender was 88 times higher than the general prevalence rate of 0.057 per cent in 2009.

The 2010 Surveillance Report records 23 deaths among transgender people; those that died are likely to have been diagnosed earlier. This figure, incidentally, translates to 0.3 percent of AIDS deaths in Australia. 44% of the transgender women had done sex work at some point, and 28% were working when they visited the service

Facts and figures

Transgender women facing violence and discrimination and that could be one of the reasons of high prevalence rate among trans woman in US. According to the federal Centers for Disease Control (CDC) , transgender communities in the U.S. are among the populations at greatest risk for HIV infection. , one meta-analysis of “29 published studies showed that 27.7 percent of transgender women tested positive for HIV infection.” A needs assessment from 2000 found that one in three D.C. transgender women self-reported as HIV positive.

HIV prevalence among transgender sex workers in Argentina was 34.1% (July 8, 2011)

There are possibly 9-9.5 million trans people across the Asia – Pacific region (rough estimate, and is based on UN population data from 2010), but the existing small scale research is largely limited to trans women, an alarming number of who are estimated to be HIV positive, with prevalence rates as high as 49% (May 2012)

A study conducted in a Mumbai STI clinic reported very high HIV seroprevalence of 68% and high syphilis prevalence of 57% among Hijras. In Southern India, a study documented a high HIV seroprevalence (18.1%) and Syphilis prevalence (13.6%) among Hijras. A study conducted in Chennai documented high HIV and STI prevalence among Aravanis: 17.5% diagnosed positive for HIV and 72% had at least one STI (48% tested seropositive for HSV-1; 29% for HSV-2; and 7.8% for HBV).

Situation in India HIV and health: India UNGASS 2010 report estimates that there are 3.1 million MSM for India. Currently there are

no national estimates of the either the enumeration or prevalence of HIV among transgender populations due to lack of data collection on transgender populations at the national level. Anecdotal guestimates peg the transgender populace between .5 – 1 million in India. UNDP study - 166,665 – reported by CBOs in 42 sites. Recent studies among Hijras/transgender (TG) women have indicated a very high HIV prevalence (17.5% to 41%) among them.

Substance abuse: An unknown but significant proportion of Hijras/TG communities consume alcohol possibly to forget stress and depression that they face in their daily life.

Social exclusion of transgender/Hijra women: Exclusion from family and society, exclusion from employment and livelihood, restricted in policy level

Violence , Stigma and discrimination at health care settings and at other service providers

Lack of social security, Lack of specific social welfare schemes (except Tamil Nadu because of Aravani Welfare Board) and lack of access to Health insurance schemes

Lack of access to SRS, HRT and proper feminization process

Achievements from Indian context Tamil Nadu Aravanigal (Transgender women) Welfare Board The government of Tamil Nadu (a state in South India ) established a transgender welfare board in April 2008,

which is the first of its kind by any state government in India.

The board was mainly formed to address a variety of concerns of transgender people that includes education, income generation and other social security measures.

As a first step, the board has conducted the enumeration of Transgender populations in all 32 districts of Tamil Nadu and in some places identity cards - with the gender identity mentioned as “Aravani” - are being issued.

The government has also started issuing ration cards (for buying food and other items from government-run fair-price shops) for transgender people.

In addition, Tamil Nadu government issued a government order in May 2008 to enrol transgender people in government educational institutions and to explicitly include 'other' or 'third gender' category in the admission forms.

Only in the state of Tamil Nadu, in collaboration with the Tamil Nadu Aravanigal Welfare Board, free sex reassignment surgery is performed for Hijras/TG in selected government hospitals.

Transgender/Hijra working group meeting for National AIDS Control Programme (NACP) – phase IV (2011)

Key priorities to initiate transgender/Hijra specific HIV intervention programme -

Scaling up of comprehensive prevention package to achieve significantly increased coverage, particularly where transgender/Hijra people are concentrated and then scale up coverage where they are spread out/ scattered

Improving the quality of prevention services

Building the technical skills and organizational capacity of CBOs and provide transition support

Strengthening the involvement of transgender/Hijra people in HIV/AIDS response through community development and mobilization

Strengthening the partnership between government, non government organizations, CBOs, transgender/Hijra people and technical assistance providers

Reducing stigma and discrimination against transgender/Hijra people

Mobilizing sufficient resource for effective response

Source: http://nacoonline.org/upload/NACP%20-%20IV/Consultations%20II%20July-Aug%202011/Strategic%20Approach%20for%20Targeted%20Intervention%20among%20Transgender%20and%20Hijra.pdf

Proposed models CBO led interventions – working with Gharana and Hijra leaders in Dera

For effective implementation of this model each Gharanas will have to be studied and understood as a separate entity as rules are specific to each and depends on the current Nayak.

Peer Educators may be recruited with the agreement of the Guru.

Capacity building and messages will need to be transparent and may need to be understood and approved by the Guru.

An approach which clearly shows a benefit to the Gharana and its members as well as one that does not threaten in any way the authority and power of the Guru may have to be developed.

Source: http://nacoonline.org/upload/NACP%20-%20IV/Consultations%20II%20July-Aug%202011/Strategic%20Approach%20for%20Targeted%20Intervention%20among%20Transgender%20and%20Hijra.pdf

Transgender/Hijra working group meeting for National AIDS Control Programme (NACP) - phase IV (2011)

Essential components of Gharana based intervention

Psychological support: Helpline as a crisis support and information center to provide information on SRH and SRS

Health referrals: To establish linkages with the local health facilities

Drop in Centres: A platform for psycho-social support to provide information on linkages to services, Information and counseling on nutrition, adherence and legal issues may also be provided

Vocational training and literacy : The training could be provided after assessing their interests.

Self Help & Support Group: Towards increasing awareness, addressing stigma and discrimination

Out reach and Peer Education: Peer led approach

Source: http://nacoonline.org/upload/NACP%20-%20IV/Consultations%20II%20July-Aug%202011/Strategic%20Approach%20for%20Targeted%20Intervention%20among%20Transgender%20and%20Hijra.pdf

Transgender/Hijra working group meeting for National AIDS Control Programme (NACP) - phase IV (2011)

Other initiatives

Transgender identity is recognized in passport, voter id card and UID (Adhar) card

Transgender is a separate category in the 2011 Census of India. An Election Commission directive has also enabled TGs to vote under a separate gender category – ‘others’ . National Institute of Epidemiology with support from UNDP, India organised three regional consultation in 2012 (Kolkata, Chennai and Delhi) to set up a methodology for size estimation of transgender/Hijra populations in India

On October 1, 2010 HIV Alliance India launched a five years project Pehchann (means identity in Hindi) to address SRH related issues of MSM , transgender and Hijra people in 17 states which is being supported by Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM round 9)

Various sensitization events organized by UNDP

Read down of Indian Penal Code (IPC) section 377

Initiatives taken by SAATHII

Activities: Situational analyses Strengthening of leadership, Technical and organizational development skills of communities to collectivize and formalize community-

based organizations for scaling up of community-led targeted HIV interventions Support to CBOs to form coalitions and facilitate their engagement with stakeholders Advocacy with and technical support to government to scale up MTF-TG specific interventions in the

national HIV response

Results: Establishment of 52 transgender support forums (90% registered as CBOs) Public funding for eight MTF-TG specific HIV interventions serving 2000 individuals Development of MTF-TG specific HIV treatment literacy materials Increased engagement of community leaders in media and policy advocacy, and training SAATHII's collaborative efforts with other partners have also led to inclusion of MTF-TG specific HIV

interventions in the fourth phase of the national program GFATM funding for a large national initiative serving MSM, TG and Hijra populations

National transgender/Hijra consultation (2009)

Total six regional consultations were followed by a national level one; supported by UNDP, India to address the key issues –

To find out the gaps in National AIDS Control Programme – Phase 3

Structural determinants of risks and mitigate the impact of risks

Sensitization of health care providers Feminisation and SRS services Stigma and discrimination reduction measures Legal recognition of gender identity of transgender/Hijras Social Welfare Schemes How to eensure greater involvement of vulnerable

communities including Hijras/TG women in policy formulation and program development

National level capacity building initiative under Integrated Network For Sexual Minorities (INFOSEM)

The project titled “Building capacity of transgender/Hijra community based organisations under Integrated Network For Sexual Minorities (INFOSEM)” started from 2010 with funding support from Swedish International Development Co-operation Agency (SIDA) and technical support from RFSU, Sweden

The project is overall supervised by transgender person Average number of transgender/Hijra organisations attended

the workshops from various parts of the country – 21 Training workshops were organised so far on –

- Organisational development

- Training on emotional support and friendly guidance and basic counselling skills

- Training on proposal and report

- Livelihood programmes

- Non-formal education

Regional Community Consultations on TG/Hijra Mapping for methodology determination (2012)

Three regional consultation were organised by National institute of Epidemiology, India and collaboration with C-SHaRP, supported by UNDP, India

All three consultations were co-ordinated by transgender/Hijra leadres Objective - To consult with hijra/TG communities of India to get their perspectives on how the diversities

among the TG/Hijra populations need to be taken into account when conducting mapping and size estimation. Key issues came out – acceptance, livelihood, accommodation and access to services Key methods identified by the TG/Hijra people –

Mapping

Participatory approaches

Community

Community + non-community

Size estimation

Key informants

Consensus

Multiplier methods

Courtesy: National institute of Epidemiology , India; C-SHaRP and UNDP, India

Way to go

Learning from best practices

Finding the gaps in existing HIV/AIDS programmes and also to start programmes to address the core needs

More capacity building initiatives need to be introduced across the globe to strengthen transgender and other indigenous communities

To encourage visibility at all levels

Inclusion of gender and sexuality topic at school level

Networking with existing forums working successfully to address the issues of transgender people across the globe

More sensitization initiatives with GOs, NGOs and UN bodies

More focus on female to male transgender issues

Sources used

1) http://www.snap-undp.org/elibrary/Publications/HIV-TG-people-rights.pdf

2) http://www.unescobej.org/education/resources/news-and-event/2012/lesbian-gay-bisexual-and-transgender-in-china-and-their-vulnerability-to-hiv/

3) http://www.afao.org.au/library/hiv-australia/volume-9/number-4/transgender-women-and-hiv

4) http://www.washingtonblade.com/2012/07/04/the-silent-t-in-d-c-s-hivaids-epidemic/

5) http://www.msmgf.org/index.cfm/id/19/country_id/202

6) http://www.asiantribune.com/news/2012/05/18/report-rights-transgender-people-and-hiv-vulnerability

7) http://www.in.undp.org/content/dam/india/docs/hijras_transgender_in_india_hiv_human_rights_and_social_exclusion.pdf

8) http://nacoonline.org/upload/NACP%20-%20IV/Consultations%20II%20July-Aug%202011/Strategic%20Approach%20for%20Targeted%20Intervention%20among%20Transgender%20and%20Hijra.pdf

9) http://www.massbar.org/publications/lawyers-journal/2012/january/massachusetts-passes-transgender-rights-bill

10) http://baltimore.cbslocal.com/2012/02/21/baltimore-county-council-approves-transgender-rights-bill/

11) http://thtimes.pugmarks.in/fullNews.php?headline=Transgender+category+introduced+in+census&NewsID=272507

12) http://www.undp.org/content/india/en/home/operations/projects/hiv_aids/sashakt_project_strengtheningcommunitysystemsforsexualminorities/