Gender-affirming care: Thailand's transgender people lead by example

According to the article published in The Lancet last year, “transgender-specific data could benefit efforts in Asia to identify gaps in HIV response for transgender people.” Despite alarming evidence of high HIV incidence among key affected populations, such as transgender people, transgender-specific data related to HIV care cascade are scarce (and often merged with data for gay and other men who have sex with men). Countries like Thailand, Cambodia, and Malaysia, that have used integrated biological and behavioural surveillance, show an increase in HIV prevalence among transgender people.

While countries improve data on full range of HIV care cascade for key populations, people themselves are rising up to improve responses from the grounds-up. Transgender people in Thailand have led by example in demonstrating leadership in setting up gender-affirming healthcare services for their communities – the first of its kind in the entire Asia Pacific region.

Ahead of the 24th International AIDS Conference (AIDS 2022), CNS (Citizen News Service) spoke to one of the featured plenary speakers of the conference, Rena Janamnuaysook, who is one of the co-founders of Thai Transgender Alliance, the first transgender-owned human rights organisation in Thailand. Rena is also credited to have established the Tangerine Community Health Clinic, the first transgender-led health clinic in the Asia Pacific region.

“Currently, in Thailand, like in many other Asian countries, gender-affirming care for transgender populations has not yet been supported or subsidised under universal health coverage. But since the past five years we have been actively working closely with the Thai Ministry of Public Health and the National Health Security Office to include gender-affirming care for transgender populations in the universal health coverage,” said Rena, who also serves as Programme Manager for Transgender Health at the Institute of HIV Research and Innovation (IHRI) in Bangkok, Thailand.

Rena and other people from transgender communities had organized a community consultation twelve years ago where consensus emerged to set up the first-ever human rights organization for the transgender people. That is how Thai Transgender Alliance came into being. “At that time we were not visible as a community-based organization, so we established this Alliance because human rights are for all individuals, regardless of their gender, race, religion, ethnicity or age. Human rights should be integrated well into our lives as a human being and as a citizen of Thailand, I think that everyone should respect transgender populations. Right to healthcare services is one of the human rights,” said Rena.

Tangerine Community Health Clinic

Till seven years ago, not enough transgender people were opting for HIV testing. “It could have been because of stigma and discrimination within healthcare settings, or because no transgender specific services were available, or because the healthcare providers were not gender-sensitive enough towards transgender population. For us at IHRI, this was an alarming situation that we needed to address. So, in 2015 we organized a national transgender community consultation and invited transgender representatives from across the country, from diverse backgrounds of transgender populations, to take part in it. They included young transgender people, transgender sex workers, transgender men and transgender women, transgender celebrities as well as transgenders living with HIV. Based on that national dialogue we agreed for the establishment of transgender specific healthcare clinics in Thailand,” shared Rena.

This clinic was named Tangerine Community Health Clinic. “The name Tangerine was chosen as it is neither too feminine nor too masculine, and it represents a fruit that is healthy and has an attractive colour. One of the main strengths of this clinic is that it is led by a team of trained transgender staff. We have transgender counsellors, transgender clinic supervisors and they are working along well with other gender-sensitive healthcare practitioners, including physicians and nurses,” added Rena.

When the going gets tough, the tough get going

Looking back over the past seven years, Rena shared that the journey has been not without challenges. One of the HIV prevention options is Pre-Exposure Prophylaxis (PrEP) which got US FDA approval in July 2012. Low uptake of PrEP among transgender people, especially transgender women, was one of the challenges. HIV-related stigma, risky behaviour, multiple sexual partners, and stigma related to HIV prevention strategies in Thailand were some of the reasons why PrEP uptake remained low, back then.

“Many transgender people perceive that if they are using PrEP, they will be stigmatized by their society, family members and partners or even healthcare providers. To address these challenges we launched the first transgender-specific PrEP campaign in Bangkok to increase the visibility of the transgender women in public healthcare system. The messages that we used around PrEP were very positive. We did not use any stigmatising messages. Instead we used empowering messages for transgender people to consider whether or not PrEP is right for them. After the launch of this campaign in the city we have seen an improvement in PrEP uptake among transgenders,” shared Rena.

The Tangerine Community Health Clinic has emerged as a model for other countries. “We are providing technical assistance to many organisations to establish similar transgender-focussed or transgender-specific clinics in many countries including Myanmar, Laos, Vietnam, Philippines, and Sri Lanka,” confirmed Rena.

When transgender people seek gender-affirming HIV care services managed by transgender people along with gender-sensitive staff, the uptake is much better. From HIV testing to linking to antiretroviral therapy, results speak volumes of this approach. “This is leading to viral load suppression,”she added.

“More service providers from key populations must be trained to be able to provide HIV services for their own communities by task-sharing and/or working together with the professional healthcare service providers. I think one of the strengths of the key populations is that they understand the community better due to their own lived experiences. They know how to access or reach out to the community members and how best to communicate with them. So we need more community-led responses for HIV care and control,” rightly said Rena.

Rena is among the featured plenary speakers of AIDS 2022. Reflecting on the theme of the conference, ‘Re-engage and follow the science’, she said, “Undoubtedly we need to fully re-engage with the communities of key populations because in the past 2-3 years during the pandemic, these were the people who were mostly left behind in the HIV response. All innovative approaches and methods, including those of service provision, must be evidence based and evidence informed in order to push for policy and advocacy in their respective countries. Working actively with the communities promotes their meaningful engagement with key populations, which is key to the HIV care and control response.”

Shobha Shukla – CNS (Citizen News Service)

(Shobha Shukla is the award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate. She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media). Follow her on Twitter @shobha1shukla or read her writings here www.bit.ly/ShobhaShukla)