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Empowering communities and strengthening systems to improve transgender health: outcomes from the Pehchan programme in India

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      Abstract

      Introduction

      Transgender populations face inequalities in access to HIV, health and social services. In addition, there is limited documentation of models for providing appropriately tailored services and social support for transgender populations in low- and middle-income countries. This paper presents outcomes of the Global Fund-supported Pehchan programme, which aimed to strengthen community systems and provide HIV, health, legal and social services to transgender communities across 18 Indian states through a rights-based empowerment approach.

      Methods

      We used a pre- and post-intervention cross-sectional survey design with retrospective analysis of programmatic data. Using stratified sampling, we identified 268 transgender participants in six Indian states from a total of 48,280 transgender people served by Pehchan through 186 community-based organizations. We quantified the impact of interventions by comparing baseline and end line indicators of accessed health social and legal services. We also assessed end line self-efficacy and collective action with regard to social support networks.

      Results

      There were significant increases in community-based demand and use of tailored health, legal, social and psychological services over the time of the Pehchan programme. We report significant increases in access to condoms (12.5%, p<0.001) and condom use at last anal sex with both regular (18.1%, p<0.001) and casual (8.1%, p<0.001) male partners. Access to HIV outreach education and testing and counselling services significantly increased (20.10%, p<0.001; 33.7%, p<0.001). In addition, significant increases in access to emergency crisis response (19.7%, p<0.001), legal support (26.8%, p<0.001) and mental health services (33.0%, p<0.001) were identified. Finally, we note that the Pehchan programme successfully provided a platform for the formation, collectivization and visibility of peer support groups.

      Conclusions

      The Pehchan programme's community involvement, rights-based collectivization and gender-affirming approaches significantly improved both demand and access to tailored HIV, health and social services for transgender individuals across India. Furthermore, the Pehchan programme successfully fostered both self-efficacy and collective identity and served as a model for addressing the unique health needs of transgender communities. Continued strengthening of health, social and community systems to better respond to the unique needs of transgender communities is needed in order to sustain these gains.

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      Most cited references 48

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      Self-efficacy: toward a unifying theory of behavioral change.

       A Bandura (1977)
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        Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review.

        Transgender populations in the United States have been impacted by the HIV/AIDS epidemic. This systematic review estimates the prevalence of HIV infection and risk behaviors of transgender persons. Comprehensive searches of the US-based HIV behavioral prevention literature identified 29 studies focusing on male-to-female (MTF) transgender women; five of these studies also reported data on female-to-male (FTM) transgender men. Using meta-analytic approaches, prevalence rates were estimated by synthesizing weighted means. Meta-analytic findings indicated that 27.7% (95% confidence interval [CI], 24.8-30.6%) of MTFs tested positive for HIV infection (four studies), while 11.8% (95% CI, 10.5-13.2%) of MTFs self-reported being HIV-seropositive (18 studies). Higher HIV infection rates were found among African-American MTFs regardless of assessment method (56.3% test result; 30.8% self-report). Large percentages of MTFs (range, 27-48%) reported engaging in risky behaviors (e.g., unprotected receptive anal intercourse, multiple casual partners, sex work). Prevalence rates of HIV and risk behaviors were low among FTMs. Contextual factors potentially related to increased HIV risk include mental health concerns, physical abuse, social isolation, economic marginalization, and unmet transgender-specific healthcare needs. Additional research is needed to explain the causes of HIV risk behavior of transgender persons. These findings should be considered when developing and adapting prevention interventions for transgender populations.
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          HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention.

          This study described HIV prevalence, risk behaviors, health care use, and mental health status of male-to-female and female-to-male transgender persons and determined factors associated with HIV. We recruited transgender persons through targeted sampling, respondent-driven sampling, and agency referrals; 392 male-to-female and 123 female-to-male transgender persons were interviewed and tested for HIV. HIV prevalence among male-to-female transgender persons was 35%. African American race (adjusted odds ratio [OR] = 5.81; 95% confidence interval [CI] = 2.82, 11.96), a history of injection drug use (OR = 2.69; 95% CI = 1.56, 4.62), multiple sex partners (adjusted OR = 2.64; 95% CI = 1.50, 4.62), and low education (adjusted OR = 2.08; 95% CI = 1.17, 3.68) were independently associated with HIV. Among female-to-male transgender persons, HIV prevalence (2%) and risk behaviors were much lower. Most male-to-female (78%) and female-to-male (83%) transgender persons had seen a medical provider in the past 6 months. Sixty-two percent of the male-to-female and 55% of the female-to-male transgender persons were depressed; 32% of each population had attempted suicide. High HIV prevalence suggests an urgent need for risk reduction interventions for male-to-female transgender persons. Recent contact with medical providers was observed, suggesting that medical providers could provide an important link to needed prevention, health, and social services.
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            Author and article information

            Affiliations
            [1 ]India HIV/AIDS Alliance, New Delhi, India
            [2 ]International HIV/AIDS Alliance, Brighton, UK
            [3 ]Department of Health Research, Lancaster University, Lancaster, UK
            Author notes
            [§ ] Corresponding author: Simran Shaikh, India HIV/AIDS Alliance, 6 Community Centre, Zamrudpur, Kailash Colony Extension, New Delhi 110048, India. Tel: +91 11 4536 7700. ( sshaikh@ 123456allianceindia.org )
            Journal
            J Int AIDS Soc
            J Int AIDS Soc
            JIAS
            Journal of the International AIDS Society
            International AIDS Society
            1758-2652
            17 July 2016
            2016
            : 19
            : 3Suppl 2
            27431474 4949313 20809 10.7448/IAS.19.3.20809
            © 2016 Shaikh S et al; licensee International AIDS Society

            This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Research Article

            Infectious disease & Microbiology

            transgender, hijra, community, hiv, india

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