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.

Standard
Blogs posted for BMJ, Public health issues in Asia

How many cases will it take for policymakers to realize there is a HIV problem in Hong Kong?

Announcing the most recent HIV statistics for Hong Kong, the Department of Health’s Centre for Health Protection reported 154 new cases from January to March this year: in effect, almost every day two more people became infected with a preventable disease that requires lifelong adherence to a drug regimen in order to stay alive.

In my last blog post I talked about how Hong Kong’s schools are failing to teach young people even the most basic facts about safe sex, let alone giving them a forum to safely discuss and learn about sexuality. This shows in the sexual practices of young people: research by local NGO AIDS Concern last year, for example, found that among 121 young people aged 14-21, 40% did not use condoms while having sex.

Another consequence of failing to give young people proper sex and sexuality education is low awareness of the risk of HIV infection and the perpetuation of stigmatizing social attitudes towards lesbian, gay, bisexual and transgender people, and towards people living with HIV. For almost all of the new cases for which there was a confirmed transmission route, unprotected sex accounted for all but one case (which was via injecting drug use).

In a recent conversation with AIDS Concern’s chief executive Andrew Chidgey, he explained that stigma and ignorance continue to make their outreach and education work difficult. “Some people don’t want to get engaged in knowing about HIV. It’s not something they want to be associated with,” he told me. When AIDS Concern staff talk to people who get tested and to people living with HIV, they find that most got infected through unprotected sex. Chidgey attributes this to a number of reasons: people aren’t as aware as they have been in the past about the risks and dangers of unprotected sex; complacency about treatment in the era of antiretroviral therapy; and a lack of information. “The sex education that’s going on is still very limited to reproduction and not about relationships and sex,” he says.

Particularly worrying is that 84 out of the 154 newly reported cases were among men who have sex with men, continuing a trend that has emerged in recent years. The CHPs’ Consultant (Special Preventive Programme) Dr Wong Ka-hing admitted to local media that it has so far been unable to develop an effective strategy to address the spread of HIV among the gay community. The CHP is conducting a study among gay men to try and better understand the prevalence of HIV among the gay community.

I do hope they work closely with local NGOs like AIDS Concern, which clearly have their finger more on the pulse of the LGBT community. The organization is already collaborating with the Chinese University of Hong Kong to research into stigma associated with HIV and discrimination experienced by people living with the virus in Hong Kong. Initial findings using the widely respected People Living with HIV Stigma Index found that half of the 291 survey respondents had “internalized stigmatizing beliefs about their identity as a person living with HIV.” Over a quarter had “experienced insults, avoidance or discrimination from general healthcare workers” at accident and emergency units as well as general out-patient clinics.

Clearly the Centre for Health Protection needs to pass on some basic facts about HIV infection to their colleagues on the frontline of health care delivery in Hong Kong. But if they really want to stop the upward trend of HIV infections over the longer-term, they will need to step out of the health sector and engage with their government colleagues in the Education Bureau. It’s time they pointed out the human cost of continuing to shy away from implementing proper, evidence-based sex and sexuality education in Hong Kong schools.

Standard