Need for transgender-specific data from Asia

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In The Lancet HIV, Venkatesan Chakrapani1 commented on the study by Adrian D Smith and colleagues and suggested transgender-specific data collection to inform the redress of health inequalities. We believe heeding this call for transgender-specific data could benefit efforts in Asia to identify gaps in HIV response for transgender people.

First, transgender-specific HIV care cascade data are scarce. This scarcity could be because the data are usually merged with data from men who have sex with men (MSM) or not reported due to negligence or not enough attention being paid to this group of people. Among the countries where data were available, HIV prevalence among transgender people reached 24·8% in 2019 in Indonesia, and increased in countries that used integrated biological and behavioural surveillance (eg, Cambodia, Malaysia, and Thailand). The percentage of transgender people reporting HIV testing in the past year ranged from 15% (Philippines) to 89% (Nepal). However, the percentage of transgender people with HIV receiving antiretroviral therapy was not reported, or low if available. Hence, Asian countries need to include transgender people as a separate group in HIV surveillance programmes and expand current programmes to include smaller cities and rural areas.

Second, use of HIV prevention services is low among transgender people in Asia. As of 2019, less than 50% of transgender people reportedly received a combined set of HIV prevention interventions in Bangladesh, Nepal, Pakistan, Philippines, and Sri Lanka. Data on the use of pre-exposure prophylaxis (PrEP) were consistently included with data from MSM. Our cross-sectional study reported in 2020 also showed a low PrEP uptake among transfeminine people in China (24 [8·7%] of 277 people). Additionally, societal stigma and discrimination consistently hindered transgender people’s access to PrEP and other HIV services. Therefore, it is crucial to consider the socioecological systems that dictate access to HIV care and to plan data collection strategies accordingly. We suggest researchers collect interpersonal and structural-level data through both quantitative and qualitative methods when considering health inequalities in transgender people.

Third, few data exist on mental health and gender-affirming interventions among transgender people in Asia. Using the gender minority stress framework, our study in China found that gender-identity-related stress can effect transgender people’s engagement with gender-affirming interventions and HIV prevention services. As access to HIV care services is interconnected with mental health and gender affirmation, we recommend collecting data related to these areas to address health inequalities.