Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Côte d'Ivoire, Togo and Burkina Faso

Abstract

IntroductionTransgender women are at high risk for the acquisition and transmission of HIV. However, there are limited empiric data characterizing HIV-related risks among transgender women in sub-Saharan Africa. The objective of these analyses is to determine what factors, including sexual behaviour stigma, condom use and engagement in sex work, contribute to risk for HIV infection among transgender women across three West African nations.MethodsData were collected via respondent-driven sampling from men who have sex with men (MSM) and transgender women during three- to five-month intervals from December 2012 to October 2015 across a total of six study sites in Togo, Burkina Faso and Côte d'Ivoire. During the study visit, participants completed a questionnaire and were tested for HIV. Chi-square tests were used to compare the prevalence of variables of interest between transgender women and MSM. A multilevel generalized structural equation model (GSEM) was used to account for clustering of observations within study sites in the multivariable analysis, as well as to estimate mediated associations between sexual behaviour stigma and HIV infection among transgender women.ResultsIn total, 2456 participants meeting eligibility criteria were recruited, of which 453 individuals identified as being female/transgender. Transgender women were more likely than MSM to report selling sex to a male partner within the past 12 months (p<0.01), to be living with HIV (p<0.01) and to report greater levels of sexual behaviour stigma as compared with MSM (p<0.05). In the GSEM, sexual behaviour stigma from broader social groups was positively associated with condomless anal sex (adjusted odds ratio (AOR)=1.33, 95% confidence interval (CI)=1.09, 1.62) and with selling sex (AOR=1.23, 95% CI=1.02, 1.50). Stigma from family/friends was also associated with selling sex (AOR=1.42, 95% CI=1.13, 1.79), although no significant associations were identified with prevalent HIV infection.ConclusionsThese data suggest that transgender women have distinct behaviours from those of MSM and that stigma perpetuated against transgender women is impacting HIV-related behaviours. Furthermore, given these differences, interventions developed for MSM will likely be less effective among transgender women. This situation necessitates dedicated responses for this population, which has been underserved in the context of both HIV surveillance and existing responses.

Factors associated with sex work involvement among transgender women in Jamaica: a cross-sectional study

“…Specifically, we found that expressing a higher need for social support was associated with increased odds of paid sex and transactional sex, and participants engaged in transactional sex had the greatest need for social support. We found two-thirds of participants involved in any kind of sex work reported ever experiencing forced sex, consistent with prior literature among transgender women in Peru [2] and San Francisco [3,43]. This is higher than rates in Shannon's [ 10] Canadian study that reported 49% of female sex workers experienced rape or sexual assault by clients in the past 18 months; this could be because we did not have the same timeframe or perpetrator restriction, or because of higher rates of poverty and survival sex, which may place persons engaging in sex work at even higher risk of violence, with less discretion to refuse sex or try to escape.…”

“…Participants that only reported only (b), "money", were coded as involved in paid sex (1). Participants that reported sex work for (a) survival needs, and/or (c) drugs/alcohol, or for (b) money along with (a) survival needs and/or (c) drugs/alcohol, were coded as involved in transactional sex (2). These three categories were pairwise mutually exclusive and were collectively exhaustive.…”

“…Globally, transgender women experience widespread stigma and discrimination that contributes to economic, social and health vulnerabilities [1]. Transgender women are defined as individuals who have been assigned maleat-birth and self-identify as female or as a transgender woman [2]. Transgender women experience social exclusion, stigma, and discrimination, and a lack of human rights protections that result in barriers to accessing adequate housing, education and employment [1,3,4].…”

“…Transgender women have less ability to negotiate condom use due to poverty and need for income from sex work, which increases their exposure to HIV infection [21]. A study with transgender women in three Sub-Saharan African countries reported that social stigma was associated with condomless anal sex and sex work, and stigma from family and friends was also associated with sex workhighlighting how structural (social stigma and marginalization) and interpersonal (family and friend stigma) factors may contribute to engagement in sex work and biological risks (condomless anal sex) [ 2]. Shannon [21] also discusses how punitive policies and police violence may lead to raids that result in confiscation of condoms or clean needles, limiting access to HIV prevention tools.…”

Factors associated with sex work involvement among transgender women in Jamaica: a cross‐sectional study

“…Specifically, we found that expressing a higher need for social support was associated with increased odds of paid sex and transactional sex, and participants engaged in transactional sex had the greatest need for social support. We found two-thirds of participants involved in any kind of sex work reported ever experiencing forced sex, consistent with prior literature among transgender women in Peru [2] and San Francisco [3,43]. This is higher than rates in Shannon’s [10] Canadian study that reported 49% of female sex workers experienced rape or sexual assault by clients in the past 18 months; this could be because we did not have the same timeframe or perpetrator restriction, or because of higher rates of poverty and survival sex, which may place persons engaging in sex work at even higher risk of violence, with less discretion to refuse sex or try to escape.…”