Is HIV programming marginalising vulnerable transgender communities?

By Isabelle Tickel.

I think one thing that I would love to see is an organization for the specific reason of empowering transgender people. I think that makes a whole community really care more about informing ourselves about the spread of HIV

Transgender sex worker 
ransgender women
(Source: Avert 2019)

Despite 35 years of the global response to the Human Immunodeficiency Virus (HIV) epidemic, UNAIDS 2019 estimates suggest that 1.4 – 2.3 million people are continuing to be newly infected with the virus every year. The 90-90-90 Fast Track targets for 2020 set by UNAIDS, which included a reduction of new HIV infections to fewer than 500,000 annually, have not been met. HIV/AIDS continues to have serious economic, social and developmental effects across the globe, killing an average of 770,000 people, and costing the international community US $26.2 billion, per year. Key populations remain at-risk of contracting HIV due to higher-risk sexual behaviour and their marginalisation from vital services, and account for more than half of all new infections.

The UN Sustainable Development Goals (SGDs) set out the aim in 2015 to end the AIDS epidemic by 2030 and to ‘leave no-one behind’. If this goal is to be met in the next decade, new approaches to HIV programming must be developed to better include these marginalised key populations.

Key at-risk populations

While the LGBTQI+ community has been a key focus of international responses to HIV since the emergence of the epidemic in the 1980s, programmes have tended to focus on the at-risk category of Men who have sex with men (MSM) and overlook the experiences of male-to-female transgender populations. Transgender communities are some of the most marginalised in the world and are 12 times more likely to contract HIV than the average cisgender population. In many contexts, stigma, discrimination and transphobia compound to exclude transgender communities from economic opportunities, resulting in high levels of engagement in sex work. Avert reports the proportion of transgender women who sell sex to be up to 90% in India, 84% in Malyasia and 81% in Indonesia. 

Transgender sex workers (TSW) face an even greater risk of contracting HIV as a result of specific and complex vulnerabilities, with estimates suggesting that more than 1 in every 4 TSW across the globe could be living with the virus. 

Barriers to service access 

Faced with the double-burden of their non-conforming gender identities and sex worker statuses, TSW report feeling excluded from HIV programmes and services. During both a WHO consultation and a qualitative needs assessment of transgender HIV prevention, TSW reported being turned away by providers delivering HIV prevention services aimed at Female sex workers (FSW) due to discrimination, and feeling that such programmes did not meet their specific biological needs due to a lack of understanding. Yet, TSW also reported feeling marginalised from services targeted at MSM communities, as a result of their self-identification as female, thus leaving them doubly-excluded from potentially life-saving services. 

The traditional at-risk categories used in HIV programming of FSW and MSM therefore do not account for the complex lived realities of vulnerable transgender communities, such as TSW. Moving away from homogenous categories, based on monolithic understandings of gender, and towards the design of more targeted interventions for at-risk transgender populations, could prove more inclusive and better reduce rates of new HIV infections.

Including and empowering marginalised communities

Evidence from a number of peer-led HIV programmes for transgender communities have offered promising ways forward, demonstrating the potential to not only include, but also to empower, highly-marginalised transgender populations. 

Implemented since 2004, Sisters Program takes a targeted and holistic approach to HIV prevention among TSW in Pattaya, Thailand, separate from programmes aimed at the MSM community. The programme’s staff, peer educators and volunteers are all transgender themselves, with many former sex workers among them. Sisters addresses the broad and complex needs of TSW in order to achieve its goal of HIV prevention, providing counselling, social services, on-site HIV and STI testing offered by a transgender nurse, and information on gender reassignment and hormone therapy. Taking a community-based empowerment approach, Sisters employs TSW peer-mentors to lead outreach work in local red light areas and deliver education on safe sexual practices. In doing so, Sisters further addresses the social exclusion of TSW, and has built a safe, strong and supportive transgender community. 

https://unaidsapnew.files.wordpress.com/2016/01/sisters_wt449-e1453281464952.jpg?w=572&h=381&crop=1
Rapid HIV testing conducted by a transgender nurse (Source: UNAIDS 2016)

The programme’s unique and intersectional approach to HIV prevention has proven extremely successful in including previously excluded TSW in HIV prevention in the area. Sisters’ Outreach Supervisor, Nueng, a transgender woman herself, made the following comment about the programme when interviewed by UNAIDS

Before we started the transgender community had nowhere to go and no-one to turn to for advice and support. There were services for male and female sex workers but nothing for transgender, we were on our own and people didn’t understand us.’ 

Following the implementation of Sisters’ TSW-led programme, an increase in both condom use and HIV testing among the transgender community in Pattaya has been reported, demonstrating the potential to reduce new infections. 

Conclusion 

The case study of Sisters demonstrates how specialised HIV interventions targeted at marginalised and intersectional male-to-female transgender communities, independent of programmes aimed at MSM, can prove more inclusive and deliver better results. Disaggregating the lived experiences of those traditionally categorised in HIV programming as FSW or MSM allows for the design of more effective interventions based on lived realities. 

Sisters highlights the value of empowering the most at-risk and marginalised populations to design and lead HIV programmes based on their own unique experiences and needs. A move away from top-down HIV prevention delivered by INGOs, and towards the funding of peer-led grassroots approaches based on local knowledge, can better include and empower the most marginalised communities. Drawing on the successes of transgender-led programmes such as Sisters could help redress the current exclusion of some of the world’s most at-risk populations, reducing the spread of HIV, saving lives, and delivering on the promise to leave no-one behind.


Isabelle is an MA Gender and Development student from the UK. She has worked in the UK, India and France for a number of grassroots NGOs. A passionate feminist, her research interests include: SRHR, HIV/AIDS, SGBV and gender justice. She has experience in both HIV programming and sex worker outreach projects.


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