Transgender people in Sub-Saharan Africa

Transcription

1 Transgender people in Sub-Saharan Africa Keletso Makofane, MPH The Global Forum on MSM and HIV (MSMGF) Anova Health

2 Transgender adj. an umbrella term that includes persons whose gender expression, or behaviour does not conform to societal gender norms associated with sex at birth A transgender man is someone with male gender iden@ty who was assigned female sex at birth A transgender woman is someone with a female gender iden@ty who was assigned male sex at birth

3 Gender incongruence Incongruence between a person s own experience of their gender (gender iden@ty) and the sex assigned to them at birth (birthassigned sex). Gender incongruence can have two aspects: social incongruence, between a person s gender iden@ty and the gender that others recognise on the basis of that person s birth-assigned sex; and physical incongruence, between a person s gender iden@ty and their primary or secondary sex characteris@cs. Gender dysphoria Discomfort or distress connected with one s own gender incongruence (social, physical, or both). Winter, Sam, et al. "Transgender people: health at the margins of society." The Lancet (2016):

4 Global HIV Epidemic among Transgender Women Baral, Stefan D., et al. "Worldwide burden of HIV in transgender women: a systema@c review and meta-analysis." The Lancet Infec,ous Diseases 13.3 (2013):

5 Global HIV Epidemic among Transgender Women Pooled OR for HIV 48.8 (95% CI ) Baral, Stefan D., et al. "Worldwide burden of HIV in transgender women: a systema@c review and meta-analysis." The Lancet Infec,ous Diseases 13.3 (2013):

6 (Examples of) risk factors for HIV among transgender women high transmission probability of unprotected anal intercourse sexual partners high rates of depression unsafe hormone and silicone drug use before sex selling sex See: Herbst, Jeffrey H., et al. HIV prevalence and risk behaviors of transgender persons in the United States: a systema@c review." AIDS and Behavior 12.1 (2008): 1-17.; and Baral, Stefan D., et al. "Worldwide burden of HIV in transgender women: a systema@c review and meta-analysis." The Lancet Infec,ous Diseases 13.3 (2013):

7 Structural barriers to health Violence and Lack of legal Housing Employment Healthcare Structural barriers operate in different contexts, and across the life course See: Winter, Sam, et al. "Transgender people: health at the margins of society." The Lancet (2016):

8 Risk factors in social context: the social ecologic model Baral, Stefan, et al. "Enhancing benefits or increasing harms: community responses for HIV among men who have sex with men, transgender women, female sex workers, and people who inject drugs." JAIDS Journal of Acquired Immune Deficiency Syndromes 66 (2014): S319-S328.

9 Structural determinants influence mulcple health outcomes Prevalence of agempted suicide among trans people in the U.S.*: 41% Risk factors for suicide agempt**: verbal and physical abuse being recognised as transgender poor unemployment and poverty absence of social support internalized transphobia *Haas, Ann Pollinger, Philip L. Rodgers, and Jody Herman. Suicide a<empts among transgender and gender non-conforming adults: findings of the na,onal transgender discrimina,on survey **Winter, Sam, et al. "Transgender people: health at the margins of society." The Lancet (2016):

10 Structural determinants: Transgender Men Scheim, Ayden I., et al. in access to HIV services for transgender men: results of a global survey of men who have sex with men." Journal of the Interna,onal AIDS Society 19.3Suppl 2 (2016).

11 Lack of data among transgender people in Africa West Africa study Reisner, Sari L., et al. "Global health burden and needs of transgender a review." The Lancet (2016):

12 HIV Prevalence among MSM across Sub-Saharan Africa 4.4% (90) 4.9% (1,778) 21.5% (463) 9.8% (205) Senegal The Gambia 21.8% (501) 13.3% (215) Morocco 50.0% (96) Nigeria Cote d Ivoire Togo Ghana 20.3% (N/A) 25.0% Cameroon (N/A) Legend % (n/a) Burkina Faso 19.0% (n/a) 13.4% (1,125) Tunisia 17.2% (1,291) 21.1% (712) 12.4% (218) Namibia Botswana 10.6% (538) Cape Town 37.0% (511) 25.5% (200) 17.0% (n/a) Zambia 19.7% (117) 5.7% (259) CAR Uganda 40.7% (285) Soweto 6.2% (267) Egypt 9.3% (713) 13.2% (306) 33.0% (641) Sudan Malawi 31.1% (318) Maseru 28.9% (249) Cape Town (Township) 5.9% (262) Tanzania 7.3% (406) 19.0% (563) Kenya 21.4% (201) 9.1% (583) Beira 8.1% (358) Maputo 8.1% (358) Swaziland 35.4% (211) Maputsoe 24.6% (285) 19.8% (253) 12.3% (509) 3.1% (353) Nampula 14.3% (449) Slide credit: Stefan Baral. Adapted from: Van Griensven, Frits, et al. "The global epidemic of HIV infec@on among men who have sex with men." Current Opinion in HIV and AIDS 4.4 (2009):

13 Higher risk behaviour among transgender women Stahlman, Shauna, et al. "Characterizing the HIV risks and pathways to HIV among transgender women in Côte d'ivoire, Togo and Burkina Faso." Journal of the Interna,onal AIDS Society 19.3Suppl 2 (2016).

14 Higher scgma among transgender women Stahlman, Shauna, et al. "Characterizing the HIV risks and pathways to HIV among transgender women in Côte d'ivoire, Togo and Burkina Faso." Journal of the Interna,onal AIDS Society 19.3Suppl 2 (2016).

15 SCgma predicts risk behaviour among transgender women Stahlman, Shauna, et al. "Characterizing the HIV risks and pathways to HIV among transgender women in Côte d'ivoire, Togo and Burkina Faso." Journal of the Interna,onal AIDS Society 19.3Suppl 2 (2016).

16 Evidence hgps://

17 It is possible to deliver HIV services to transgender people

18 It is possible to deliver HIV services to transgender people Some Clean needles for hormones / fillers Transi@on-related services colocated with HIV treatment services Trans-competent sexual health services hgp://

19 Drug-drug interaccons Estrogen vs. ARVs Ethinyl estradiol * has drug interac@ons with ARVs Lack of data on interac@ons between ARVs and 17-β estradiol Testosterone and ARVs have been co-administered for many years with no published reports of problema@c drug interac@ons Many transgender people priori@ze access to and use of hormone therapy over HIV care and treatment HIV infecgon and ART are not contraindicagons for the use of hormone therapy *Ethinyl estradiol is not recommended for hormone therapy. It is some@mes used when 17-β estradiol, which is recommended, is unavailable or inaccessible. For more informa@on see: hgp:// World Health Organiza@on. "Transgender people and HIV." (2015).

20 Delivering gender affirming care hgp://transhealth.ucsf.edu hgp://

21 Conclusions Trans people face structural which influence health across Trans women carry a dispropor@onate HIV burden Primary healthcare sexngs, including HIV services, can and should be trans-competent

22 Acknowledgements Dr. Stefan Baral and collaborators Mr. Ayden Scheim and the MSMGF Research Group

23 Images Cover Slide Zanele Muholi Documents Queer South African Lives In Faces And Phases ( ) hgp:// Slides 2&3 The Pearl Of Africa: A Story About The Struggles Of A Transgender Woman Living Full Time As Trans In Uganda hgp://girlthings.net/the-pearl-of-africa-a-story-about-the-struggles-of-living-full-@me-as-trans-in-uganda/ Slide 6 Changing your gender in South Africa hgps://thisisafrica.me/changing-gender-south-africa/ Slide 7 Love in exile (story of Tiwonge Chimbalanga, a transgender woman who was imprisoned in Malawi for geang engaged to a man) hgps:// Slide 21 'Mama Africa': Corinna Kern Photographs the Lives of Transgender South Africans hgps://