"Addressing transphobia, stigma and discrimination is central to implementing evidence-informed and rights-based services for HIV prevention, diagnosis, treatment and care."
This publication from a group led by the United Nations Development Programme (UNDP) offers practical advice on implementing HIV and sexually transmitted infection (STI) programmes for transgender people, with a focus on transgender women. Topics covered include community empowerment and human rights, addressing violence, stigma and discrimination, and delivering trans-competent services, especially for HIV and STI prevention, diagnosis, treatment, and care. The tool also covers community-led outreach, safe spaces, and the use of information and communication technology (ICT) in programming, and it offers strategies for managing programmes and building the capacity of trans-led organisations. Featuring examples of good practices from around the world, the tool describes how services can be designed and implemented to be accessible and acceptable to transgender women. This requires respectful and ongoing engagement, and the publication gives particular attention to programmes run by transgender people themselves. It is itself the product of a collaboration among transgender people, advocates, service providers, researchers, government officials, and non-governmental organisations (NGOs) from around the world, as well as United Nations (UN) agencies and development partners from the United States (US).
The tool's creators - UNDP, IRGT: A Global Network of Trans Women and HIV, United Nations Population Fund (UNFPA), UCSF Center of Excellence for Transgender Health, Johns Hopkins Bloomberg School of Public Health, World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United States Agency for International Development (USAID, United States President's Emergency Plan for AIDS Relief (PEPFAR) - point out that, while all transgender people are potentially at risk of HIV infection, transgender women have borne the epidemiologic brunt of HIV disease. Transgender women are significantly and disproportionately affected by HIV globally - in part due to experiences of transphobia, discrimination, violence, and criminalisation.
The tool is aligned with these WHO documents: Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people (2011) and Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. (2014). It is designed for use by public health officials, managers of HIV and STI programmes, NGOs - including community and civil society organisations (CSOs) - and health workers. It may also be of interest to international funding agencies, health policymakers, and advocates.
Each chapter explicitly or implicitly addresses one or more of the 2011 Recommendations or the 2014 Key Populations Consolidated Guidelines. The first 2 chapters describe approaches and principles to building programmes that are led by trans people. Chapters 3 and 4 describe approaches to implementing recommended interventions for HIV prevention, diagnosis, treatment, and care. Chapter 5 describes how to manage programmes and build the capacity of organisations of trans people. More specifically, some of the communication-centred elements of the resource include:
- Chapter 1 - Community Empowerment - describes how empowerment of trans people is both an intervention in itself, and also essential to effective planning, implementation, and monitoring of all aspects of HIV and STI prevention, diagnosis, treatment, and care. Major topics covered include: collaborating with trans communities in programming; fostering and supporting trans-led programmes and organisations; building organisational capacity; building advocacy capacity; addressing stigma as a barrier to empowerment; supporting community mobilisation and sustaining social movements; and resource mobilisation and sustainability. "Community empowerment initiatives should be adaptable to each community's needs....[I]t [is] necessary to pay attention to the local context of trans identities and power dynamics within trans communities." However, some general actions to foster trans community empowerment and collaboration include:
- Acknowledge community members' expertise in their own lives.
- Invite trans people to take the lead and support their leadership.
- Support meaningful involvement of trans people in all aspects of programme design, implementation, management, and evaluation.
- Identify community capacity and engage in transfer of useful skills.
- Strengthen partnerships between trans communities, government, civil society, and local allies.
- Address collective needs in a supportive environment.
- Provide money and resources directly to trans organisations and communities, which become responsible for determining priorities, activities, staffing, and the nature and content of service provision.
- Develop monitoring indicators to measure the progress of empowerment and collaboration.
- Chapter 2 - Stigma, Discrimination, Violence and Human Rights - is based on the observation that the effectiveness of HIV and STI prevention interventions is often compromised when interventions to address violence and promote human rights are not implemented concurrently. Among the topics covered: discrimination and action for legal gender recognition, legal and policy frameworks, and complementary interventions and strategies. The latter include, for instance, online social networking and community-building, which can offer a safe space for trans people to explore and receive support for their gender identity and expression without having to reveal themselves fully. ICT can also be a powerful means for marginalised communities such as trans people to collectivise and organize to counter stigma, discrimination and violence. New technologies allow for real-time citizen reporting, and some platforms also provide levels of protection and anonymity. However, trans-specific health services and information on the internet remain sparse, especially in languages other than English (see also Chapter 4, Section 4.7). In addition, programme implementers report that high levels of illiteracy sometimes prevent trans community members from accessing web-based interventions even if they have access to technology such as smartphones. This calls for creative approaches that can help reach and engage populations in their local languages, including people with varying levels of reading literacy.
- Chapter 3 - Services - presents detailed descriptions of gender-affirming health services and HIV-related and other essential health interventions. Gender-affirming health services include primary care, cross-sex hormone therapy, surgical procedures and service integration. HIV-related services include condom and lubricant programming, harm reduction services for substance use and safe injection, pre- and post-exposure prophylaxis, voluntary HIV testing, antiretroviral therapy, sexual and reproductive health, and mental and psychosocial health. The chapter also addresses HIV and hormonal therapy.
- Chapter 4 - Service Delivery Approaches - describes trans-competent clinical approaches, social and behavioural interventions, approaches to condom and lubricant programming, community-led service delivery, safe spaces (drop-in centres), and the use of ICTs. As noted here, trans HIV and STI programmes, similar to other HIV interventions, are based on the principles and best practices of social and behaviour change communication (SBCC). One tool for developing SBCC is the P Process, a framework originally developed at the Johns Hopkins Bloomberg School of Public Health (see Figure 4.2). Each step in the P Process is based upon the principles of community participation and capacity-strengthening as requirements for effective social and behaviour change; the steps are explored in detail. Here as in all elements explored in the tool, "[i]t is critical that trans community members are involved in every aspect of programme design and implementation to ensure that strategies are relevant and meaningful to them....Trans-led and trans-focused groups, activities and services foster a sense of community, belonging and validation. Whenever possible, hiring from within the trans community sends a powerful message of affirmation. Trans people should be trained and hired to provide professional health services and training. Having trans people deliver services fosters a sense of trust within trans communities."
- Chapter 5 - Programme Management - provides practical guidance on planning, starting, scaling up, managing, and monitoring an effective programme from 2 perspectives: (i) a large multi-site programme with centralised management and multiple implementing organisations, and (ii) more localised organisations, including community groups, seeking to start or expand services. This includes:
- how management systems support effective programmes with trans people, including for HIV and STI prevention (Section 5.1);
- how to design, organise, and implement a programme (Section 5.2), including identifying community needs, tailoring services to meet these needs, ensuring high-quality services, setting up mechanisms to increase acceptance and uptake, and establishing monitoring and evaluation systems;
- how to bring a programme to scale in a staged manner (Section 5.3); and
- how to build capacity within the implementing organisation (Section 5.4).
Throughout the chapter, there is a focus on programme ownership by trans people to support management and delivery of community-led programmes within trans communities. The chapter also provides a list of resources and further reading (Section 5.5).
Each chapter begins with an introduction that defines the topic and explains why it is important. Interventions are then broken down into stages or steps wherever possible, and topics or points of particular interest are presented in text boxes. Case examples from programmes around the world illustrate how an issue or challenge has been addressed and aim to inspire ideas about approaches that could work in the reader's own context. The forms, charts etc. presented from various programmes have the same purpose. Each chapter ends with a list of further resources - tools, guidelines, and other practical publications - available online. Cross-referencing is provided to assist the reader in making connections between chapters.
UNDP website, May 18 2017. Image credit: courtesy of Angel Ventura, UCSF Center of Excellence for Transgender Health