Summary Background Previous systematic reviews have identified a high prevalence of HIV infection in transgender women in the USA and in those who sell sex (compared with both female and male sex workers). However, little is known about the burden of HIV infection in transgender women worldwide. We aimed to better assess the relative HIV burden in all transgender women worldwide. Methods We did a systematic review and meta-analysis of studies that assessed HIV infection burdens in transgender women that were published between Jan 1, 2000, and Nov 30, 2011. Meta-analysis was completed with the Mantel-Haenszel method, and random-effects modelling was used to compare HIV burdens in transgender women with that in adults in the countries for which data were available. Findings Data were only available for countries with male-predominant HIV epidemics, which included the USA, six Asia-Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19·1% (95% CI 17·4–20·7) in 11 066 transgender women worldwide. In 7197 transgender women sampled in ten low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6–19·8). In 3869 transgender women sampled in five high-income countries, HIV prevalence was 21·6% (95% CI 18·8–24·3). The odds ratio for being infected with HIV in transgender women compared with all adults of reproductive age across the 15 countries was 48·8 (95% CI 21·2–76·3) and did not differ for those in low-income and middle-income countries compared with those in high-income countries. Interpretation Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The meta-analysis showed remarkable consistency and severity of the HIV disease burden among transgender women. Funding Center for AIDS Research at Johns Hopkins and the Center for Public Health and Human Rights at the JHU Bloomberg School of Public Health.

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Worldwide burden of HIV in transgender women: a systematic review and meta-analysis

Serving transgender people: clinical care considerations and service delivery models in transgender health

Introduction : Globally, transgender (“trans”) women are one of the key populations most disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is the newest and most promising biomedical HIV prevention intervention to date. This paper reviews relevant literature to describe the current state of the science and describes the potential role of PrEP among trans women, including a discussion of unique considerations for maximizing the impact of PrEP for this vulnerable population. Methods : Available information, including but not limited to existing scientific literature, about trans women and PrEP was reviewed and critiqued based on author expertise, including PrEP clinical trials and rollout. Results : To date, PrEP demonstration projects and clinical trials have largely excluded trans women, or have not included them in a meaningful way. Data collection strategies that fail to identify trans women in clinical trials and research further limit the ability to draw conclusions about trans women’s unique needs and devise strategies to meet them. Gender-affirming providers and clinic environments are essential components of any sexual health programme that aims to serve trans women, as they will largely avoid settings that may result in stigmatizing encounters and threats to their identities. While there is currently no evidence to suggest drug-drug interactions between PrEP and commonly used feminizing hormone regimens, community concerns about potential interactions may limit interest in and uptake of PrEP among trans women. Conclusions : In scaling up PrEP for trans women, it is essential to engage trans communities, utilize trans-inclusive research and marketing strategies and identify and/or train healthcare providers to provide gender-affirming healthcare to trans women, including transition-related care such as hormone provision. PrEP implementation guidelines must consider and address trans women’s unique barriers and facilitators to uptake and adherence. Keywords: transgender women; PrEP; HIV prevention. (Published: 18 October 2016) Citation: Sevelius JM et al. Journal of the International AIDS Society 2016, 19(Suppl 6) :21105 http://www.jiasociety.org/index.php/jias/article/view/21105 | http://dx.doi.org/10.7448/IAS.19.7.21105

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The future of PrEP among transgender women: the critical role of gender affirmation in research and clinical practices.

Transgender (TG) women in many settings continue to contend with barriers to healthcare, including experiences of stigma and discrimination. Argentina has a universal health care system and laws designed to promote healthcare access among TG women. However, little is known about barriers to healthcare access among TG women in this setting. The aim of this study was to explore individual, social-structural and environmental factors associated with healthcare avoidance among TG women in Argentina. Data were derived from a 2013 nation-wide, cross-sectional study involving TG women in Argentina. We assessed the prevalence and factors associated with avoiding healthcare using multivariable logistic regression. Among 452 TG women included in the study, 184 (40.7%) reported that they avoided seeking healthcare because of their transgender identity. In multivariable analysis, factors positively associated with avoiding seeking healthcare were: having been exposed to police violence (adjusted odd ratio [aOR] = 2.20; 95% CI: 1.26 - 3.83), internalized stigma (aOR = 1.60, 95% CI: 1.02-2.51), having experienced discrimination by healthcare workers (aOR = 3.36: 95% CI: 1.25 - 5.70) or patients (aOR = 2.57; 95% CI: 1.58 - 4.17), and currently living in the Buenos Aires metropolitan area (aOR = 2.32; 95% CI: 1.44 - 3.76). In contrast, TG women with extended health insurance were less likely to report avoiding healthcare (aOR = 0.49; 95% CI: 0.26 - 0.93). A high proportion of TG women in our sample reported avoiding healthcare. Avoiding healthcare was associated with stigma and discrimination in healthcare settings, as well as police violence experiences. Although further research is warranted, these finding suggests that socio-structural interventions tailored TG women needs are needed to improve access to healthcare among this population.

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Factors associated with healthcare avoidance among transgender women in Argentina.

We examined the presence and co-occurrence of psychosocial health conditions (depression, frequent alcohol use, and victimisation) among men who have sex with men (MSM) and transgender (TG) women in India, and their cumulative association with sexual risk. A survey questionnaire was administered among a convenience sample of 600 participants (MSM = 300; TG women = 300) recruited through six non-governmental organisations in four states. Prevalences of the number of psychosocial health conditions among MSM were: none = 31.3%, one = 43%, two = 20%, and three = 5.7%; and among TG women: none = 9%; one = 35.33%, two = 38.33%, and three = 17.33%. In bivariate and multivariate models, these conditions were positively and additively related to sexual risk, providing evidence for a syndemic of psychosocial health conditions among MSM and TG women and their synergistic effect on sexual risk. In addition to the number of syndemic conditions, resilient coping and social support were significant predictors of...

Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India.

The transgender people (hijra), who claim to be neither male nor female, are socially excluded in Bangladesh. This paper describes social exclusion of hijra [The term is used in this abstract both in singular and plural sense] focusing on the pathway between exclusion and sexual health. In an ethnographic study, 50 in-depth interviews with hijra, 20 key-informant interviews, and 10 focus-group discussions (FGDs), along with extensive field observations, were conducted. The findings revealed that hijra are located at the extreme margin of exclusion having no sociopolitical space where a hijra can lead life of a human being with dignity. Their deprivations are grounded in non-recognition as a separate gendered human being beyond the male-female dichotomy. Being outside this norm has prevented them from positioning themselves in greater society with human potential and security. They are physically, verbally, and sexually abused. Extreme social exclusion diminishes self-esteem and sense of social responsibility. Before safer sex interventions can be effective in a broader scale, hijra need to be recognized as having a space on society's gender continuum. Hijra , as the citizens of Bangladesh and part of society's diversity, have gender, sexual and citizenship rights, that need to be protected. Key words: Hijra ; HIV; Social exclusion; Bangladesh doi: 10.3329/jhpn.v27i4.3388 J Health Popul Nutr 2009 Aug;27(4):441-451

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Living on the Extreme Margin: Social Exclusion of the Transgender Population (Hijra) in Bangladesh

Despite condom interventions since year 2000 with the transgender (hijra) population, condom use remains low. Consequently, hijra suffer from higher rates of active syphilis, putting them under threat of HIV transmission. In an ethnographic study, 50 in-depth interviews with diverse groups of hijra along with 20 key-informants interviews with various stakeholders, and 13 focus group discussions (FGDs) were conducted with comprehensive field observations. Findings indicate that most hijra understand the importance of condoms, but none use condoms consistently. Complex underlying reasons positioned beyond the individual's cognitive domain include: low self-confidence; economic hardships for mere survival; multiple transient partners; sexual desire, preferences, and eroticisms concerning anal sex; stigma associated with purchasing condoms; poor quality and interrupted supply of condoms and lubricants; limitation of fear-producing messages in favor of condoms; inadequate professional skills and motivational impetus of the outreach staff for condom promotion, and incompetent management with inadequate understanding about the dynamics of condom use. Imposing condoms by disregarding socio-cultural and socio-economic scripts of sexual relationships and eroticism of hijra-sexuality have challenged the effectiveness of current condom interventions. Interventions should not mechanize the process, rather they may humanize and eroticize sexual lives of the hijra. A paradigm shift is required where condoms enhance the dignity and quality of sexual lives of the hijra beyond the framework of disgrace, disease, and death.

Not to Stigmatize But to Humanize Sexual Lives of the Transgender (Hijra) in Bangladesh: Condom Chat in the AIDS Era

Dr. Muhammad Ilyas is an Assistant Professor in Management at the University of Hail. His expertise centres around gender and race equality and cross-cultural management. Dr. Mohammed Ishaq is a Reader in Human Resource Management at the University of the West of Scotland. He specialises in the field of equality and diversity in the workplace with specific focus on the UK public Sector. Dr. Asifa Maaria Hussain is an Assistant Professor at Edinburgh’s Heriot-Watt University. Her expertise is in the area of equality and diversity with specific focus on race, religion and gender. Abstract Purpose - Drawing on access to final year students in Saudi universities, this research explores students’ perceptions of women’s participation in the labour market. Design/methodology/approach - A questionnaire was deployed to garner the views of students across the Kingdom of Saudi Arabia using non-probability purposive sampling. Although the questions were closed-ended, the questionnaire design provided opportunities for respondents to explain their selected responses, thereby allowing some qualitative data to be collected. Findings - The findings reveal support for women’s participation in the labour market among female students but opposition from the majority of male students. There is an awareness among respondents that women’s education and skills are underutilised and they lack opportunities in the labour market due to structural and cultural barriers that limit their agency. Both male and female respondents perceive that women can make a productive contribution to the labour market and are optimistic about future opportunities in the light of recent reforms. Research limitations/implications – The findings are not necessarily transferable to other MENA countries given the unique context of Saudi Arabia, and respondents’ views may not necessarily be representative of general Saudi society or of the employed and unemployed. Originality/value – This research has been carried out against the backdrop of major reforms, so it is relevant and timely. Data collected from Saudi students provides valuable insights into perceptions on the issue of women’s participation in the labour market among the future pool of human resources.

Mohammed Iftekher Hussain

Papers

Living on the Extreme Margin: Social Exclusion of the Transgender Population (Hijra) in Bangladesh

Not to Stigmatize But to Humanize Sexual Lives of the Transgender (Hijra) in Bangladesh: Condom Chat in the AIDS Era

Saudi students' perceptions of women's participation in the labour market