Improving HIV Testing and Counseling among Transgender People in Pattaya, Thailand
In many cases, HIV programming collapses transgender people under the umbrella category of men who have sex with men without taking into consideration the particular needs of transgender people. Yet, surveys of transgender populations in Thailand report extremely high HIV prevalence and very limited access to HIV prevention. Sisters, a transgender-focused, community-based organization in Thailand, helps to fill this gap. Sisters' approach helps transgender people in Pattaya, Thailand access the health system, providing a safe place for health education, prevention services, and overall support.
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"I'm Proud of My Courage to Test"
By Scott Berry, Maria Claudia Escobar, and Heather Pitorak
Improving HIV Testing and Counseling Among Transgender People in Pattaya, Thailand
A boisterous group of young transgender (TG) people are chattering happily at a table outside the building that houses Sisters, a TG-focused, community-based organization in Pattaya, Thailand. Many of them came to this beachfront tourist town to take advantage of its economic opportunities and its relative openness to TG lifestyles. At the center of the group is Wan,(1) a manager at Sisters, who is herself a TG person. Much beloved by her clients, she has a generous smile and great talent at drawing young people out. To build rapport among the group, she asks why they came to Pattaya. "I was born in a small village," says one of the clients. "I knew I was different when I was very young. I used to spend my time at home, dreaming of moving to a big town, being beautiful, and living as a woman…oh yes, and having big breasts!" The group explodes in laughter.
Since 2004, Sisters has provided health, education, and support services to the TG community in Pattaya, a two-hour drive from Bangkok in Chonburi Province. Its goal is to offer a safe and welcoming place for TG people to seek friendship and support, and to encourage the practice of preventive behaviors such as regular HIV testing and counseling (HTC) as well as screening for other sexually transmitted infections (STIs). Also since 2004, Sisters has been funded by the U.S. President's Emergency Plan for AIDS Relief through the U.S. Agency for International Development (USAID)/ Regional Development Mission Asia, and is implemented by PSI.
The TG-focused services and support that Sisters offers are unusual in the region. A recent report on men who have sex with men (MSM) and TG people across Asia's megacities concluded that HIV services for TG populations are "notable by their systematic absence" (United Nations Development Programme [UNDP] 2011, 27). As stated in the report, "In most cases, HIV programming merges transgender people into programming for MSM with apparently little insight into the particular needs of transgender people" (UNDP 2011, 27). Consistent with limited services, there are also limited research data available on HIV prevalence and incidence among TG populations in most countries in Southeast Asia.
Sisters' service approach to HTC and to HIV and STI prevention is effective because of its emphasis on providing a safe space for TG people both at its service center and in public health facilities providing HIV and STI diagnosis and treatment across Chonburi Province. TG persons are active as leaders, staff, and volunteers at the Sisters service center and in the provincial response to HIV. The result of this leadership has been cross-sector partnerships that maximize the quality and sensitivity of provincial services for TG people and promote an environment for ongoing health-seeking among TG people.
Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Transgendered Lives in Thailand
Kathoey is the Thai word that has traditionally described Thai male-to-female TG people, which includes transvestites and, to some extent, gay and other MSM. Despite its deep roots in the Thai language, kathoey can be a contentious term used about TG people by those who are not TG themselves. Thai TG people may refer to themselves as kathoey but also simply as women (reflecting the desire of many TG people to live legitimately as women). The emergence of new MSM subcultures and of new medical technologies that facilitate gender reassignment and cosmetic enhancement have further altered the meaning of kathoey, rendering it ambiguous and unclear. This is significant for HTC services in Thailand because it is not always clear who is TG and who is not, thus impeding targeted programming for TG people. Some individuals who identify as kathoey may, on one occasion, appear at services dressed as a man; while on another occasion they may appear dressed as a woman.
Most male-to-female TG people in Thailand report that their sexual lives began as young MSM who exhibited or were drawn to feminine ways of dressing and behaving. Boys in poor rural villages who are attracted to the same sex believe that by transforming into women and migrating to cities, they will earn higher incomes and improve their economic circumstances (Brummelhuis 1999). Pattaya has become a center for TG activity in Thailand over the past two decades, where TG people are employed as waitresses, hostesses, cooks, and hairdressers, while others work as sex workers, models, performers, or dancers to earn a living or to save money for gender reassignment or cosmetic surgery.
The migration of male-to-female TG people to Thai cities, such as Pattaya, and their engagement in sex work to pay for their physical transformation increases their risk of HIV and other STIs (Guadamuz et al. 2011). Higher rates of suicide, sexual coercion, violence, and lack of social support for TG people compared to the general population have been reported in the international literature on transgenderism (Guadamuz et al. 2011), but no published research has yet been undertaken investigating these social determinants of health among TG people in Thailand.
HIV and Health Risks Among Transgender People in Thailand
According to the Bangkok MSM Cohort Study, conducted between 2003–2007, HIV incidence (the number of new HIV infections in a given period) among MSM has remained at approximately six percent per year with rates highest among young MSM aged 18 to 21 years (van Griensven et al. 2010). The Thailand UNGASS Country Progress Report notes that prevalence rates vary across the region: HIV prevalence among MSM was six percent in Phuket (southern Thailand) in 2005, but increased to 20 percent in 2007. In urban areas, HIV prevalence rates among MSM are higher due to tourism and sex-related entertainment which in 2007 ranged from 17 to 31 percent (National AIDS Prevention and Alleviation Committee 2010).
Epidemiological surveys of TG populations in Thailand report extremely high HIV prevalence, ranging from between 8 to 68 percent in different locations, and incidence of between 3.4 to 7.8 percent per 100 person-years (Guadamuz et al. 2011). Between March and October 2005, the Thai Ministry of Public Health and the U.S. Centers for Disease Control and Prevention undertook a study of 474 TG people in Bangkok, Chiang Mai, and Phuket, finding an overall HIV prevalence of approximately 14 percent (Guadamuz et al. 2011). In October 2005, PSI conducted an assessment that found that of 400 TG people (ages 15 to 35) in Pattaya, only 39 percent of participants reported consistent condom use with regular partners, while 50 percent reported consistent condom use with casual partners (PSI 2005).
Sex work increases TG persons' risk of exposure to HIV and other STIs due to increased levels of sexual activity and pressure from clients to forgo condoms. The commercial sex industry, although technically illegal, operates openly in Thailand and is subsumed within the tourist and entertainment industries. Despite an atmosphere of relative openness, the criminalization of sex work can nevertheless increase the vulnerability and secrecy of TG sex workers, making them difficult for health services to reach (Liamputtong 2007). Anecdotal reports reveal that TG persons in Thailand avoid mainstream services because they fear discrimination and poor treatment (USAID 2009).
In addition to sexual health challenges, TG people face risks associated with gender reassignment surgery, breast and cosmetic augmentation, and drug and hormone treatments. Medical procedures carried out by unlicensed, substandard clinics can lead to health complications, including the risk of HIV (Guadamuz et al. 2011).
Meeting Transgender Persons' Needs
Sisters' service model helps TG people in Pattaya access the health system, providing a safe place for health education, welfare services, and overall support. The program aims to promote positive behaviors and practices to prevent STI and HIV transmission among its TG clients and partners through outreach education at the places where TG people gather and through referrals to health service providers, to which Sisters' staff accompany clients. The program's team includes five core staff members, of which four are TG persons. Additionally, a TG volunteer team supports the staff in the various support activities.
A core component of the program, the drop-in center provides a friendly social haven and support services for TG people. The busiest hours at Sisters are in the evening, when many TG clients gather for dinner prior to work or meet for social activities. At the drop-in center and in surrounding locations, Sisters provides HTC and STI screening services.
Through a partnership with the Banglamung Hospital, a TG licensed nurse comes to Sisters and provides HTC twice weekly for a two-hour period in a private room in the drop-in center. Until recently, after pre-test counseling, the nurse would draw a blood sample that was tested at the hospital. One week later, results were delivered to the counselors to inform clients of their HIV status. At the clients' request Sisters staff also accompanies them to public or private health services for HTC or STI screening; more TG clients underwent HTC at the hospital than at the Sisters drop-in center. However, just recently, in 2011, the Thailand Ministry of Public Health approved a rapid HIV testing pilot on site at Sisters and in other facility- and community-based sites. The number of persons testing for HIV at Sisters is growing rapidly due to this long-awaited policy change (Wolf 2012).
Sisters' outreach staff and volunteers visit the places where TG people gather in Pattaya, such as local bars, clubs, streets, parks, and sometimes even their homes to promote HTC and distribute condoms, lubricant, and information about HIV and STIs, including information about care and support to assist HIV-positive TG people. Sisters' specialized TG services enable clients to benefit from peer-based support that includes offering information and referrals for gender reassignment, hormone therapy, and cosmetic surgery. Assistance is also available for victims of violence and for the homeless. To support these outreach activities and referrals for medical or other needs, Sisters has developed relationships with HIV- and other health-related organizations in Pattaya so that TG people feel comfortable being seen.
Finally, Sisters helps link TG people into established health systems, where traditionally this population may not be inclined to seek health services. Jai, a staff member from Pattaya Rak Clinic, which provides HIV, STI, and HTC services to the general population, explained that Sisters plays an important role in facilitating access to their service. Prior to Sisters' establishment, few TG people visited Pattaya Rak Clinic. According to Jai:
"Sisters exists to support TG people only, but they have actually improved how the whole HIV network works with TG people [in Pattaya]. I personally feel that I understand the issues that affect TG people more clearly and that I can provide better services when they come to our center.
The relationships between staff at Sisters and other organizations have helped nurture skills among service providers to support TG people.
Since its inception, Sisters' client data show a fivefold increase in the number of TG people attending services, with client numbers growing from 261 individual clients in 2006 to 1,311 individual clients in 2010 (see Figure 1). In September 2011, Sisters became one of the sites in the Thailand Ministry of Public Health rapid HIV testing pilot program which has quickly increased the number of people being tested. In just four months, 128 clients have been tested and received results, a greater number than those tested for the entire year in 2010 (Duke 2012).
Results from PSI's cross-sectional surveys of TG people in Pattaya in 2005, 2006, and 2009 show an increase in HTC uptake, awareness of available HIV services, and awareness of Sisters and its work (Pawa, Jittakoat, and Mundy 2009; PSI 2005, 2006, 2009). There was also an increase in those who had ever been tested for HIV from 68 percent in 2006 to 77 percent in 2009, and a significant increase in those who reported having been tested for HIV in the past three months from 31 percent in 2006 to 42 percent in 2009 (PSI 2009). Exposure to an HIV intervention was associated with an increased uptake of HIV testing; results from PSI's 2009 cross-sectional surveys of TG people in Pattaya suggest a statistically significant (p < 0.01) association, showing 53 percent of those who reported taking an HIV test in the past three months had been exposed to an HIV intervention, compared to 35 percent of those who had not been exposed (PSI 2009).
The surveys also included questions on awareness of the Sisters program. The proportion of TG persons who were aware of Sisters increased throughout the three studies. In 2005, 41 percent of TG respondents were aware of Sisters; this increased to 57 percent in 2006 and 74 percent in 2009 (PSI 2009) (see Figure 2).
What Worked Well
The Sisters service delivery model exemplifies how HIV-related services are provided to TG persons, adapted to meet their needs, and integrated with other health and support services to attract clients. The Sisters program also works closely with the local health system to encourage health-seeking behaviors among TG persons, particularly HTC.
Reaching TG persons where they gather: The Sisters program serves TG persons where they live, work, and socialize. Communicating with other TG people where they gather has helped build a community that encourages TG people to learn about health and other TG-specific services. For example, several TG people said they were encouraged to undergo HTC by the example of other TG clients living with HIV who disclosed their HIV status. Sisters' ability to reach TG people in this way is unusual in Thailand, where few programs have depth of understanding about the TG community or the skills to communicate openly with them about sex and relationships.
Attracting and retaining TG clients through a TG-centered approach: Sisters attracts and retains TG clients by providing a TG-centered range of services that meet clients' needs. The staff and volunteers, many of them TG themselves, build solid relationships with clients, who find it easy to identify with those offering to help them. Because the program's partnership with the local hospital includes visits from a TG nurse to conduct HTC, the clients are more likely to accept counseling for HIV testing. Sisters' specialized TG-specific service delivery allows clients to seek HTC and peer-based support that includes information on gender reassignment, hormone therapy and cosmetic surgery, and social and entertainment activities. Sisters' leaders, staff, and volunteers provide powerful role models to help clients build their own self-confidence, self-esteem, and resilience, which helps them take steps to improve their health (Luthar, Cicchetti, and Becker 2000).
Facilitating multiple pathways improves HTC uptake: One of Sisters' most significant achievements has been improving HTC uptake and access to public and private health services for TG persons in Pattaya. PSI's surveys, as well as more recent program monitoring data, of TG people reveal improvements in HTC uptake, particularly after the introduction of rapid testing with same day results; however, the majority of HIV testing still occurs at other local clinics where Sisters helps refer clients. While the Sisters program promotes HTC, the pathways for TG clients to access HTC services vary. As discussed previously, the program offers many services specifically for TG people that initially attract clients; that "foot in the door" exposes them to education and access to HIV testing. Learning about the benefits of HTC and the high risks of acquiring HIV for TG persons helps clients decide whether to test for HIV at the drop-in center or elsewhere. Effective pathways to HTC for TG clients include peer-based services that respond to the issues presented by TG clients, which may relate to HIV risk or preventive behaviors. Along with their partnering organizations, Sisters has helped build awareness of HTC and other health and supportive services among TG people in Pattaya.
Fostering linkages for TG people to access health services: While HTC is offered at Sisters, the program's referral system of TG clients to other organizations for HTC or other services helps collaborating organizations learn about TG needs. As other organizations work with greater numbers of TG clients referred from Sisters, program planners and implementers may tailor services to accommodate TG needs. The Sisters program helps to improve access by creating linkages to other health and support services for TG people. Without this supportive linkage, TG persons may experience obstacles to accessing health care, including personal barriers such as fear and shame. Sisters' staff or volunteers refer or often accompany interested clients to health services.
Loss to follow-up associated with long wait for HIV test results: Staff and clients reported that the one-week period to wait for HIV results was difficult. This lengthy wait, experienced not only at Sisters but also at other testing sites in the Thai public health system, creates anxiety for clients and contributes to loss to follow-up. Because a nurse comes to draw the blood at Sisters and then takes it to the hospital to be tested, the risk of loss to follow-up is great. However, in 2011 Thailand's government, in partnership with USAID Regional Development Mission Asia, began piloting rapid HIV testing services with same-day results for most-at-risk populations. Results from the first four months of the pilot at Sisters have shown a rapid increase in the number of people being tested, suggesting that rapid testing with same day results can effectively resolve the challenge of loss to follow-up.
Economic instability is a barrier for TG people to seek HTC: The low socioeconomic status of TG people is one barrier to seeking HTC or other health or support services. Transgender people in Thailand and around the world are more likely to be living in poverty than others (Hwahng and Nuttbrock 2007; Jackson 1999; Prabawanti et al. 2011; van Veen et al. 2010). Even if clients are tested for HIV, they may not be able to afford transport to return for results or may need to prioritize work to earn income. Low socioeconomic status may also be associated with limited health-seeking behaviors because health may not be a priority. Addressing this problem and its impact on seeking HTC and other health behaviors will be part of building an environment for lifelong health seeking behaviors among TG people.
TG people's migration interrupts HIV service relationships: TG people's frequent movement among Thai cities is a barrier for building relationships between HIV services and clients. Although there is no published research on TG people's migration, interviews revealed that a segment of this subpopulation moves semi-regularly, often to tourist destinations, leaving social and support mechanisms behind. Because this movement interrupts health services, TG clients may be more vulnerable to HIV and other health risks. Sisters staff and volunteers identified migration as a barrier to follow-up for HIV test results or other services.
Recommendations for Program Planners and Implementers
Sisters provides a rich, distinctive experience in serving the TG community while having this same community serve as the staff and volunteers of the organization. The program's service delivery approach—focusing on both social support and HIV and health services—may be useful for other programs seeking to reach TG persons.
Provide rapid HIV testing with same-day results: Because the one-week waiting period creates barriers for clients, national governments should develop a rapid HIV testing algorithm with same-day results for public health clinics and hospitals. Providing HIV test results minutes after the test mitigates loss to follow-up. To gain access to hard-to-reach populations, such as TG people, community-based rapid testing with same-day results, which can be conducted by lay workers, will help to reduce the barriers to HIV testing and increase the number of people who know their status. Sisters implements a successful community HIV outreach program to TG people and, with proper training and quality assurance, could provide HTC with rapid testing and same-day results to reach large numbers of TG people in Pattaya.
Strengthen partnerships at the local level: The local partnerships between Sisters and other organizations in Pattaya, facilitated through memorandums of understanding between USAID-supported international nongovernmental organizations (and their sub-partners including Sisters) and the Chonburi Provincial Health Office, have helped ensure that increasing numbers of TG people are both aware of HIV and aware of HIV services they can access, such as HTC. A system wide, partnership-building approach at the local level helps create a supportive environment for most-at-risk populations, including TG people, to both know their HIV status and get the support and care needed.
Employ TG service providers to generate demand for HTC: Demand-generation strategies are successful when programs hire TG people, who know where TG populations gather, share a common language, and help reduce barriers that TG persons may face in health systems and other settings. The Sisters program was well received by TG persons, largely because the TG-managed service providers used social activities to build a TG community. Also, Sisters' services that use staff or volunteers to accompany their clients to public health services help build relationships between TG individuals, TG groups and health networks, and clinical staff at these services.
Map TG migration and establish links and referral mechanisms to HIV services in other cities: The frequent movement of TG people is a barrier to better HIV health. Mapping that movement would reveal valuable information about migration patterns. Subsequently, this research would facilitate the establishment of linkages and referrals to HIV services where TG people migrate and the provision of ongoing, uninterrupted health service between regional cities.
Promote income-earning or incentive opportunities for TG people: Low socioeconomic status and fluctuating income are barriers to accessing health services for TG people. Promoting behavior change and income-earning opportunities, or training sessions, may help TG persons find work and hold on to their jobs. Incentives for attending HTC and returning for test results (if HIV rapid testing is not used) could be provided, such as free movie tickets or shopping discount vouchers.
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The authors wish to thank the following people for their guidance, input, and review: Vincent Wong, Cameron Wolf, and Kai Spratt, U.S. Agency for International Development (USAID)/Washington; ThuVan Dinh and Panus Rattakitvijun Na Nakorn, USAID/Regional Development Mission Asia; and Clif Cortez, United Nations Development Programme Asia-Pacific Regional Centre. The authors also thank Carmen Chen and the staff at PSI in Thailand as well as the staff, volunteers, and partners of Sisters who participated in the interviews for this case study.
Berry, Scott, Maria Claudia Escobar, and Heather Pitorak. 2012. "I'm Proud of My Courage to Test": Improving HIV Testing and Counseling Among Transgender People in Pattaya, Thailand. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.