Activist countries

Trans people excluded from HIV strategic plans in many countries

In a global sample of 60 countries with high HIV prevalence, only 8% fully included trans people in all aspects of their national HIV strategic plans. Some of those countries made no mention of trans people, according to a study presented at the 24th International AIDS Conference (AIDS 2022) last week.

Trans women are 66 times more likely to be living with HIV than the general adult population, while trans men are almost seven times more likely to be living with HIV. Thus, there is a clear need to explicitly include trans people in national HIV strategic plans.

“What we’re seeing is that data doesn’t always mean inclusion,” Jennifer Sherwood of amfAR, the Foundation for AIDS Research, said at the conference. “Internationally, we are almost universally recognized that trans populations are a key population. They are included in all major global donor and policy institution documents – which emphasize both the recognition of higher risk and the call for specialist services – however, the extent to which national governments and documents include trans people is an open question.

Glossary

transgender

An umbrella term for people whose gender identity and/or gender expression differs from the sex they were assigned at birth.

epidemiology

Study of the causes of a disease, its distribution within a population and the measures of control and prevention. Epidemiology focuses on groups rather than individuals.

key populations

Groups of people disproportionately affected by HIV or particularly vulnerable to HIV infection. Depending on the context, may include men who have sex with men, people who inject drugs, sex workers, adolescent girls, prisoners and migrants.

to taste

The studies aim to give information that will be applicable to a large group of people (eg adults with an HIV diagnosis in the UK). Because it is impractical to conduct a study with such a large group, only a subgroup (a sample) participates in a study. This is not a problem as long as the characteristics of the sample are similar to those of the larger group (eg in terms of age, sex, CD4 count and years since diagnosis).

continuity of care

A model that describes the stages of medical care that people living with HIV go through, from initial diagnosis to achieving viral suppression, and shows the proportion of people living with HIV who are engaged at each stage.

Sherwood and her colleagues undertook a review of national HIV strategic plans to seek their inclusion of trans populations. National strategic plans are crucial documents that identify both the populations and the strategies to focus on in a country’s response to HIV. They also set national targets and indicators to track progress, and often report on budgets that have been allocated. These plans are used by governments, advocates and international donors.

A sample of 60 country plans with the highest HIV prevalence in five UANIDS regions was selected for inclusion. Each national strategic plan was analyzed for trans inclusion in five sections: narrative, epidemiological data, monitoring and evaluation indicators and targets, activities across the HIV care continuum, and budgets.

Results

National strategic plans were analyzed for countries with the highest HIV prevalence in Eastern and Southern Africa (16), West and Central Africa (15), Asia and the Pacific (13), Latin America and in the Caribbean (9) and in Eastern and Central Europe. Asia (7).

Of all national strategic plans, 65% mentioned trans people in at least one section. However, only 8% included trans people in everything five key sections. Examples of these countries include the Dominican Republic, Malaysia and Pakistan. Countries like China, Vietnam, Ethiopia and Tanzania have not included trans people at all in their national strategic plans.

Inclusion varied across different parts of the documents, with 62% of countries mentioning trans people in general in the narrative section of plans, 38% in the activities section, 23% in indicators and targets, 20% in epidemiological sections and only 13% in budget allocation sections.

“Countries like China, Vietnam, Ethiopia and Tanzania have not included trans people at all in their national strategic plans.”

However, it is crucial to differentiate trans populations from other key populations. “When we look at indicators and activities, we really want to push to see trans communities separate, especially men who have sex with men (MSM),” said amfAR’s Elise Lankiewicz. “The public health community has traditionally lumped together MSM and transgender people in epidemiological data and activities. It’s really not how it should be.

The authors recommend that governments engage meaningfully with trans communities when formulating strategic plans. International funders, such as the Global Fund and PEPFAR, may provide technical assistance and funding to organizations in the trans community, but may also require the inclusion of trans people in any research they fund. Advocates need to decide what they want to include in their country’s strategic plan (for example, specific trans budget targets for HIV prevention, or the use of peer navigators to conduct HIV testing activities) and the best way to engage with government officials to ensure representation and inclusion. Engaging early is key to this process.

Increasing trans engagement in three African countries

“In Kenya, every five years, a national strategic plan is released,” said Alesandra Ogeta, from the Kenyan trans rights organization Jinsiangu. “We needed to know what to ask for and defend, and when to do it. We were very clear about our priorities when we approached the government and what we were asking for. We noted that other key populations, such as MSM, sex workers and people who inject drugs, were mentioned, but trans people were not. This limits budgets and planning for access to services. If there is no data, there is no inclusion, there is no targeted mention of the population.

Jay Mulucha, from the Fem Alliance, Uganda (FEMA), spoke about the historical lack of inclusion of trans people in its strategic plan in Uganda, and how their organization has trained trans activists to advocate for their inclusion in the next revision of the national strategic plan. “Many trans people in Uganda were unaware of the existence of the national strategic plan. Thus, this initiative has been an enriching experience. The trans community is now more than ever very interested in participating in the upcoming review.

Similarly, many trans people in Zambia were unaware of the national plan or the services already available. “Most community members don’t understand what the national AIDS strategic framework is, they don’t understand that they can easily enter a health facility and get services,” Chengo Chintu said. of the Transbantu Association. services are available, rather than just working on inclusion in the national strategic plan.