“You are not a man”: a multi‐method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda

Abstract

Introduction Transgender (trans) men in sub‐Saharan Africa are a hidden and vulnerable population who may engage in sex work due to socio‐economic exclusion and lack of alternative employment opportunities. Little is known about HIV and sexually transmitted infection (STI) risk among trans men in this setting. We conducted a multi‐method study to characterize HIV/STI risk among trans men in Uganda. Methods Between January and October 2020, we enrolled 50 trans men into a cross‐sectional study through snowball sampling. Data were collected on socio‐demographic characteristics, sexual practices and depression. We conducted 20 qualitative interviews to explore: (1) descriptions of sexual practices that could increase HIV/STI exposure; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) HIV and STI service delivery; and (5) drug and alcohol use. We used an inductive content analytic approach centring on descriptive category development to analyse the data. Results The median age was 25 years (interquartile range 23–28). The prevalence of HIV, syphilis and hepatitis B was 4%, 6% and 8%, respectively. We observed multiple levels of intersecting individual, interpersonal and structural stigmas. (1) Trans men reported transphobic rape motivated by interpersonal stigma that was psychologically traumatizing to the survivor. The resultant stigma and shame hindered healthcare access. (2) Structural stigma and economic vulnerability led to sex work, which increased the risk of HIV and other STIs. Sex work stigma further compounded vulnerability. (3) Individualized stigma led to fear of disclosure of gender identity and HIV status. Concealment was used as a form of stigma management. (4) Multiple levels of stigma hampered access to healthcare services. Preference for trans‐friendly care was motivated by stigma avoidance in public facilities. Overall, the lived experiences of trans men highlight the intertwined relationship between stigma and sexual health. Conclusions In this sample from Uganda, trans men experienced stigma at multiple levels, highlighting the need for gender‐sensitive healthcare delivery. Stigma reduction interventions, including provider training, non‐discrimination policies, support groups and stigma counselling, could strengthen uptake and utilization of prevention services by this marginalized population.

Distinguishing trans women in men who have sex with men populations and their health access in East Africa: A Tanzanian study

“…It is clear that there is significant stigmatisation for trans women and nonbinary people assigned male at birth. These data echo the study of Mujugira et al 18 in Uganda, which found that multiple levels and sources of stigma in trans men impeded access to healthcare services. The need for trans-friendly care noted in that study was mostly motivated by stigma avoidance in public facilities.…”

Population size, HIV prevalence, and antiretroviral therapy coverage among key populations in sub-Saharan Africa: collation and synthesis of survey data 2010-2023

“…Systematic reviews and meta-analyses of population size, HIV prevalence, or ART coverage encompassing SSA have been conducted for FSW, 9,10 MSM, 11 and PWID. 12,13 Studies on transgender populations in SSA have been published, [14][15][16][17] but data were insufficient to conduct region-level meta-analysis of HIV prevalence. Several organisations have undertaken efforts to consolidate key population surveillance data, including the Joint United Nations Program on HIV/AIDS (UNAIDS) Key Population Atlas, the US Centers for Disease Control and Prevention (CDC), the Global Fund to Fight AIDS, TB, and Malaria (GF), and the Johns Hopkins University Global.HIV initiative.…”

“…Systematic reviews and meta-analyses of population size, HIV prevalence, or ART coverage encompassing SSA have been conducted for FSW, 9,10 MSM, 11 and PWID. 12,13 Studies on transgender populations in SSA have been published, [14][15][16][17] Atlas, the US Centers for Disease Control and Prevention (CDC), the Global Fund to Fight AIDS, TB, and Malaria (GF), and the Johns Hopkins University Global.HIV initiative. [18][19][20][21] These efforts aim to monitor the state of the epidemic, evaluate programmes, and make recommendations on key population data reporting and quality thresholds.…”

A qualitative study to explore the healthcare-seeking experiences of men who have sex with men and transgender women in Rwanda

“…Although same-sex relationships are not criminalized in Rwanda, the healthcare-seeking experiences of MSM and TGW in Rwanda were similar to that in neighboring countries where same-sex acts are illegal; causing many of them to resort to self-medication rather than seeking proper care (21,23,24,25). Same-sex relationships not being criminalized does not translate to acceptance; homophobia and transphobia remain rampant in Rwanda, resulting in many negative consequences on the health and well-being of MSM and TGW.…”