Lessons learned: A framework for HIV services for a transgender population in Thailand

While HIV prevalence in Thailand has declined significantly since the 1990s, drastic disparities between sub-populations have arisen, revealing an uneven burden of disease. Notably, estimates of HIV prevalence among male-to-female transgender (TG) individuals are up to 30% higher than in the general population. Widespread discrimination in the employment market drives many TG individuals to urban areas to engage in sex work. A lack of prevention, screening and treatment services for TG sex workers has led to disproportionately high rates of HIV within this group, even as compared with female sex workers. Attempts to provide services to this marginalized community have been sparse and ineffective, as they are typically couched in the broader category of men who have sex with men. This classification is inappropriate for TG individuals, who do not view themselves as men. My research reviewed evidence on health needs and access to care among TG individuals, and found a paucity of data. While some studies describe risk behaviors among TG individuals, none endeavors to illuminate potential structural factors behind their disproportionately high risk, for example: stigma, gender-based violence, and poverty. Efforts to serve TG individuals must acknowledge the social determinants of their health status, as well as their unique and frequently misunderstood gender identity. I present a framework for providing the TG population with HIV services which appropriately address these concerns. This framework is based on international human rights standards, public health behavior models, and lessons learned from work with a Thai-based NGO that serves the TG population.