Shining a light on trans women’s needs in sub-Saharan Africa

Across Sub-Saharan Africa, where HIV epidemics are generalised across the population, transgender women have long been overlooked as a community with particular sexual health needs. 

Instead of investigating their particular needs, transgender women are often analysed within the same category as cis-gender men who have sex with men (sometimes known as MSM). 

A new study published in PLOS Medicine reveals how this is hiding specific drivers of HIV within this community, and ignoring important differences in experiences between these two groups. 

The researchers analysed previously published data from 14 sites across eight countries in Africa, including Côte d’Ivoire, Senegal, Swaziland, Burkina Faso, Malawi, Lesotho, Togo, and The Gambia. The included studies all compared HIV prevalence as well as social and behavioural drivers of infection in transgender women and cis-gender MSM. 

Although HIV prevalence varied significantly across the countries, the study found that on average transgender women were 2.2 times more likely to be living with HIV than cis-MSM. In some countries, this difference was even more pronounced, for example in Lesotho transgender women were 3.6 times more likely to have HIV, with a prevalence rate of 59%. 

Although there were some bio-behavioural differences between the two groups, with transgender women reporting more condomless receptive anal sex, this was not able to fully explain the differences in HIV prevalence between the two genders, especially since transgender women reported greater access to condoms when they needed them and were more likely to have tested for HIV in the last 12 months. 

Instead, the researchers point to social factors as being the main cause of these differences in HIV prevalence between the two groups. Although they found that both groups had experienced high levels of stigma - with many respondents of both genders reporting fear of seeking health services and loss of employment or educational opportunity due to their sexual orientation or gender identity, transgender women were more likely to have experienced family exclusion, rape and symptoms of depression than cis-gender MSM (despite depressive symptoms and suicidal ideation being common in both groups). 

This is the first study to shine a light on the role that gender identity plays in the HIV epidemics of Sub-Saharan Africa. It shows that, like elsewhere in the world, there is an unmet need for HIV prevention and care for transgender people. Despite the World Health Organization (WHO) having stated that the 'specific health needs of transgender people necessitates a distinct and independent status in the global HIV response', only 39% of countries specifically address transgender people in their HIV strategies. 

The authors comment that research like this is crucial for making 'transgender participants visible within the data' and that this is a crucial first step in providing services that are gender affirming and speak to the needs of trans people. 

In a previous interview with Avert, trans activist Marcela Romero commented that across the world, 'trans women are being lost in a system that still believes that they are men'. She stated along with Mitch Yusof, a trans activist from Malaysia that: 'With data, we will be able to argue our position in society, to provide the evidence that we are part of the wider community'.