Public health issues in Asia

Bangkok’s transgender community finally gets the health services it wants

At a HIV conference a while ago I was chatting to one of the other participants, a transgender woman, about why in the HIV world, transgender people are typically lumped in with men who have sex with men. This makes little sense. As my coffee break companion said, with a ‘look at this’ gesture from her high heels, to her fitted dress, all the way up to her long, wavy hair: “In what way does this say I am a man, having sex with men?”

Whilst both gay men and transgender people are known to be at especially high risk of acquiring HIV, for transgender people the risk is far more extreme: 49 times higher than for the general population, in fact. Moreover, they face a degree of marginalization and exclusion from the educational and employment opportunities that men who have sex with men rarely have to grapple with. The lack of a separate ‘key population at increased risk of HIV’ category for transgender people also does nothing to address the lack of data on the HIV epidemic, and what services the transgender community needs, making it difficult to get dedicated funding for HIV programmes for transgender people.

The highly restricted work options for transgender people in many countries see a disproportionate number entering into sex work .What sexual health and HIV prevention services there are tend to focus on transgender sex workers, while stigma and discrimination make the transgender community often extremely difficult to reach with HIV testing, treatment and care services.

Until recently, folding transgender people in with men who sex with men, despite the fact that the two communities have very different needs, was what was happening in Bangkok.

In 2008 the Thai Red Cross AIDS Research Center changed its approach from offering HIV testing to offering anal cancer screening, as a way to get gay men and other men who have sex through the door, and then offer them HIV testing too. It worked: client numbers went up and 80% who came in for anal cancer screening also accepted the offer of HIV testing. Five years on, it was clear that this approach was highly successful in increasing demand for the clinic’s services, but the number of transgender people accessing the clinic remained unchanged. The clinic was missing something if it wanted to appeal to transgender people.

“Through extensive consultations with the transgender community we understood the barriers they face when accessing health services,” Nittaya Phanuphak, Chief, Prevention Department, Thai Red Cross AIDS Research Centre told me. These extensive consultations were with diverse members of the transgender community – including those working as advocates, healthcare providers, within the fashion industry, as well as those working with transgender sex workers – revealed that transgender people face obstacles in accessing hormone level testing and therapy, the most basic health services that they regularly require to affirm their gender identity. What services there are typically are not from transgender-friendly providers, or even worse are provided outside the medical profession entirely.

Hormone therapy services were identified as the entry point to make the clinic attractive to its target population. The Tangerine Community Health Centre opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. The name was carefully chosen. “We knew the clinic’s name should be one that makes everyone feel comfortable, with nothing that can be considered stigmatizing, Tangerine is a play on transgender, and was chosen because it a fruit that is not too sweet not too sour, just the right blend.

Most of the clients have since come seeking hormone level testing and injections, but they are also offered a package of services including anal and neo-vaginal pap smears, cervical smear tests for transgender men, testing for sexually transmitted infections and a free HIV test (all Thai nationals are entitled to two free HIV tests a year). The centre provides both pre and post-exposure HIV prophylaxis and harm reduction interventions for safe injection.

Funding from USAID covered the costs of the community consultation, start-up, and sensitization training for staff, but services are fee-based, with the cost set at a level that makes them affordable to most clients. As the clinic becomes established, should the fees prove to be prohibitive to some, one option is to introduce a co-pay mechanism, but the aim of the clinic is to be self-financing. A clinic that covers its own costs is a sustainable and replicable role model for other cities trying to close the gap between their transgender communities and HIV services.

Tangerine’s catchment area is Bangkok and it surrounding four provinces, although approximately a fifth of its clients so far have travelled from other provinces to access services and a handful were from overseas. The clinic has a target to see over 400 clients in the first year of operation, with at least 600 consultations. From November 27 2015 to February 23 2016, it had seen 84 male-to-female clients, of whom 61 had received HIV testing, with 11% testing positive. Of the 25 female-to-male clients, 16 had been tested for HIV. Most clients also received testing for syphilis, over half of the transgender women requested hormone level measurement, as did four out of five transgender men.

The Tangerine Community Health Center’s key strengths are its foundations built on extensive community engagement, and its model of integrated health services with a self-sustaining funding model. The clinic’s two transgender staff have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves. In time, its usage data will also become an invaluable database of the transgender community’s health profile, overcoming the current invisibility of transgender people in the national AIDS database, and this community’s unique HIV and other health-related needs will be better understood.

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Blogs posted for Asian Development Bank (ADB)

Move away from HIV and AIDS? Not quite yet!

Published on ABD website, Monday, 01 December 2014
By Susann Roth, Patricia Moser and Jane Parry
The AIDS response in our region has undoubtedly made impressive gains in the past 15 years. But as we mark today World AIDS Day, we can reflect that there is so much more that remains to be done.
New infections have fallen since 2001, but in 2013 there were 4.8 million people living with HIV in the region, including 350,000 newly infected that year. Worryingly, the number of new infections has flatlined for 5 years. Treatment access has been massively expanded, and 1.56 million people living with HIV were receiving life-saving antiretroviral therapy by 2013. But at that rate only half of those eligible will be on treatment by 2015.
Resources dedicated to the AIDS response in our region come from both domestic and international sources, and ADB has been supporting HIV prevention projects since the early 1990s. From 2005 onwards, much of ADB’s contribution has been through the ADB Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific, established with a $19.2 million grant from the Government of Sweden.
HIV specialists from ADB and its partner organizations gathered recently to discuss what the fund had achieved as it draws to a close at the end of this year.
The 120 participants from governments, UN agencies, and civil society organizations had a lot of good news to discuss. The fund has supported 17 projects in 12 countries, and had its most notable successes when it focused on ADB’s unique advantages: its key role in the development of the region’s new transport and economic corridors, its convening power and knowledge broker status, and its established relationships with national decision-makers at the most senior level.
The Cooperation Fund’s success stories included projects that capitalized on ADB-supported infrastructure projects to mitigate HIV risk along economic and transport corridors. Projects in Cambodia, the People’s Republic of China, the Lao People’s Democratic Republic, Mongolia, Myanmar, Papua New Guinea, and Viet Nam all used this route to bring HIV prevention interventions to otherwise hard-to-reach vulnerable groups such as migrant workers, mobile populations and people living in border areas; and key populations at higher risk of HIV including sex workers, and people who inject drugs.
The knowledge base on HIV in Asia and the Pacific has been greatly improved thanks to a grant from the Cooperation Fund to set up and manage the HIV and AIDS Data Hub. The Data Hub’s website is now the go-to resource for data on the epidemic and response in the region. Other projects under the fund contributed more than 20 publications and other knowledge products, many of which are routinely used by ADB staff in HIV prevention work as part of infrastructure projects.
Partnerships with specialist HIV agencies, in particular UNAIDS, and grassroots organizations that have strong connections to marginalized groups and target populations, have greatly extended ADB’s reach. They have also enabled resources from the fund to strengthen civil society and nongovernment organizations and build their capacity, notably in the Greater Mekong Subregion.
HIV prevention is not a static target and as the epidemic in this region has evolved, the Cooperation Fund has been able to target resources to areas where there are newly emerging vulnerabilities, e.g., in cities such as Manila, Bangkok, and Chennai; and in border areas throughout the Greater Mekong Subregion.
And thanks to ADB’s established relationships with governments and the private sector in Asia and the Pacific, the fund has been uniquely positioned to convene key players from the private and public sectors, build on their experiences, and foster cross-border collaboration. Some of the most innovative projects are those that have brought on board the private sector, such as the Asian Football Confederation, which was able to use its massive region-wide reach to disseminate HIV prevention messages through the Protect the Goal campaign.
Hearing about the successes of the Cooperation Fund—as well as the lessons learned from those projects that were less successful—was heartening. Based on all this good news, it might be tempting to think that it’s time for HIV to move over and make way for other health and development priorities. What a wrong move this would be.
One only has to look again at the data, and the newly emerging epidemics in hotspots around the region, to see how much more work remains to be done.
HIV/AIDS continues to be a significant threat to economic prosperity and health security in the region. Slowing down efforts now runs the grave risk of unraveling the gains made so far, and missing the opportunity to stop the epidemic in its tracks, reverse its course and get on target for zero AIDS by 2030.
In his opening remarks at the meeting in Bangkok, Myo Thant, an ADB Principal Economist in the Office of Regional Economic Integration, said that we need more resources, but we also need to understand how best to utilize these resources. Specifically, there is a need to increase the knowledge base, not just about the epidemic landscape in the region, but also about what works, and how best to invest previous resources in future interventions.
HIV does not exist in isolation, nor does it respect national boundaries. The strengthening of health systems is crucial to improve access to HIV/AIDS testing, prevention, treatment, care and support, including harmonization of services across the porous national boundaries in border areas. All sectors must be brought onside including, public, private and nongovernment agencies. Moreover, greater domestic responsibility for HIV/AIDS investments notwithstanding, support from regional and international funding sources is still essential.
For its part, ADB must continue to be innovative in its contribution to the HIV/AIDS response, strengthen its partnerships and tirelessly use its influence to ensure that this region does not drop the ball on HIV/AIDS.

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Blogs posted for BMJ, Public health issues in Asia

Why real-name HIV testing won’t fly in China

Two interesting documents that came across my desk this week got me thinking about how different HIV-related human rights look depending on where you’re standing. The first was a press release from UNAIDS, UNDP and the International Commission of Jurists about the first-ever judicial dialogue about HIV, human rights and the law. The second was a news story from the China Daily about legislation recently passed in Guangxi Zhuang autonomous region requiring real names to be used for HIV tests.

The authorities in Guangxi, including doctors charged with the task of treating people who are living with HIV, and keeping the epidemic under control, have sound reasons for wanting to use real-name testing. They say it will reduce loss to follow-up: it will be easier to track people down and convince them to get treated. It will also contribute to better public health policymaking because the region will have a more accurate picture of its HIV epidemic.

No it won’t, AIDS NGOs say, because people won’t come forward for testing in the first place, never mind being lost to follow-up. Instead they will at best do home self-testing, which is not accurate and could leave them with a positive test result and no clue what to do next.

It’s a typical example of how public health policy often serves the needs of the health system instead of the patients. One of the main reasons patients prefer anonymous testing is that they want to know their status but have no inclination to share that information. Once the information leaks out of the medical system, all too common in a society where individuals’ rights are routinely trampled on by the state, people living with HIV are subject to widespread stigma and discrimination.

A 2009 survey conducted by the China Stigma Index found that over 49% of people living with HIV interviewed had experienced discrimination related to their HIV status. Over three quarters said their family had suffered the same discrimination. Pregnant women living with HIV are routinely advised to terminate their pregnancies: 12% of the respondents reported being pressured into having an abortion. The children of 9% of respondents were forced to leave school regardless of their own HIV status. Discrimination by medical staff, teachers and government officials was rampant.

So I think it’s great that eminent judges from the Asia Pacific region gathered to discuss what they can do to provide a supportive legal environment for people living with HIV and to protect those particularly vulnerable to being infected. The conversation has to start somewhere, and there were Mainland Chinese judges participating in this ground-breaking event.

But for people on the receiving end of public policy about HIV, it will be a long while yet before the target of zero discrimination is reached. And until that time, the Guangxi authorities would do well to turn around in their minds the conundrum of how to combat HIV and look at it from the perspective of their patients. Until they can guarantee that those who test positive won’t feel the chill of stigma from the very same health care workers responsible for testing and treating them, and until their communities are educated out of shunning them, real name testing is still just a good idea in theory.

 

Jane Parry is a Hong Kong-based public health and medical journalist and researcher.

 

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