Identity,stigma,and HIV risk among transgender women:a qualitative study in Jiangsu Province,China

Background:Transgender women have multiple disparities globally,including social rejection and stigma,HIV infection and untreated mental health problems.However,few data on transgender women are available in China.Therefore,this study aimed to explore transgender women's experiences on gender identity,disclosure,discrimination,transgender-specific medical care,and perceptions of HIV and sexually transmitted infections(STI)risk in China.Methods:A qualitative study was conducted in Nanjing and Suzhou city,China in 2018.Key informant interviews(n=14)and focus group discussions(n=2)with diverse transgender women were implemented.Text was transcribed and translated,and Dedoose™software was used for coding,analysis and interpretation by the research team.Results:Chinese transgender women share experiences with transgender women worldwide,including a long and challenging identity search,stigma and discrimination,poor access to trans-specific services and unmet needs for mental health care.Features unique to them include terms used for self-identification,culturally-shaped expectations for reproduction,and ideals of placing the familial and societal welfare over personal fulfillment.Social networks of this population appear sparse,scattered,and underground.Familial rejection was experienced by nearly all respondents.Perceptions of HIV and STI risk and history of HIV testing were notably low.Conclusions:Transgender women in China face high social rejection and discrimination along with unmet need for various types of healthcare.Scaling up transgender-specific services including gender-affirming medical care,mental health care and HIV/STI prevention are warranted to address the social,medical and mental health of transgender women in China.

Correlates of HIV infection among transgender women in two Chinese cities

Background:In an era when HIV transmission has been on the rise among men who have sex with men(MSM),transgender women may play a considerable role in China’s current HIV epidemic as a potential“bridge”of HIV transmission between homosexual and heterosexual populations.We sought to understand the risk behaviours and factors associated with HIV infection among transgender women in two cities in China.Methods:From January to December 2016,we recruited transgender women with the help of community-based organizations(CBOs)through a wide range of methods,including snowball sampling.After recruitment,we asked participants to fill out a structured questionnaire including questions about socio-demographics,sexual behaviours,condom use,substance use and uptake of health care services.HIV infection status was determined by using two different rapid testing reagents.Results:Among 498 subjects enrolled in this study,233 were from Shanghai and 265 were from Tianjin.The median age was 30 years(range:18-68;IQR:24-33).Of them,337(67.7%)preferred feminine dress,13(2.6%)had undergone transsexual operation and 68(13.7%)had used hormones for transition purposes.Nearly half(45.6%)reported having regular partners,and 351(70.5%)had casual partners.Regarding condom use,81.5%reported not always using condoms with stable partners,and 70.9%reported not using condoms with casual partners.Twentyfive(5.0%)had a history of buying sex and fifty-one(10.2%)had a history of selling sex in the past three months.A total of 200(40.2%)participants had used at least one kind of controlled substance in the past six months.The most commonly used substances were amyl nitrates(rush popper)(99.5%)and 5-MeO-DiPT(20.0%).Among rush popper users,170(85.4%)reported always having sex while on the drug,and 177(88.9%)reported increased sexual pleasure after using the drug.The HIV infection risk factors identified in our study were being located in Shanghai(aOR=9.35,95%CI=3.89-22.49),selling sex in the past three months(aOR=3.44,95%CI=1.31-9.01),and substance use in the past six months(aOR=5.71,95%CI=2.63-12.41).Conclusions:Transgender women bear a high HIV burden in the two Chinese cities.Those involved in commercial sex tended to have inconsistent condom use,leading to high risk of HIV infection.Substance use was an independent risk factor of HIV infection by increasing sexual activities and unprotected sex,which indicated an aggravated and complex situation with possible interacting syndemic factors that could cumulatively facilitate sexual risk behaviours and HIV infection in transgender women.There is an urgent need for innovative and appropriate HIV prevention programmes targeting this unique population.Efforts should be made to provide them with tailored services including persuasive communication on consistent condom use,substance use counselling and related referral services,all with the goal of reducing HIV epidemic among transgender women.

HIV incidenee and risk factors among transgender women and cisgender men who have sex with men in two cities of China:a prospective cohort study

Background:HIV epidemic among men who have sex with men(MSM)remains a major public health concern in China.Despite a growing body of research on transgender women worldwide,little is known about Chinese transgender women within MSM.We sought to estimate HIV incidence and distinguish risk factors of HIV acquisition among them from that among cisgener(non-transgender)MSM(cis-MSM).Methods:We conducted an open cohort study among Chinese MSM,including those who were identifed as transgender in Shanghai and Tianjin.Participants were initially recruited by local community-based organizations from January to June,2016,and were followed up approximately every 6 months until June 2018.At each visit,a structured questionnaire was used to gather information on demographics,sexual risk behaviors,and HIV status.HIV incidence was calculated as the number of seroconversions divided by total number of person-years of follow-up among HIV-negatives at baseline.Risk factors of HIV acquisition were assessed by univariate and multivariate Cox regression models with time-dependent variables.Results:A total of 1056 participants contributed 1260.53 person-years(PYs)of follow-up,33 HIV seroconversions occurred during the follow-up period,yielding an estimated HIV incidence of 2.62(95%CI 1.80–3.68)per 100 PYs.HIV incidence among transgender women was 4.42 per 100 PYs,which was signifcantly higher than that of 1.35 per 100 PYs among cis-MSM,demonstrating a threefold higher odds of HIV infection than cis-MSM.For transgender women,those lived locally≤2 years(adjusted hazard ratio[aHR]=1.76,95%CI 1.13–2.76)and unprotected anal sex last time(aHR=4.22,95%CI 1.82–9.79)were more likely to acquire HIV.For cis-MSM,factors associated with HIV acquisition were frequency of anal sex≥3 times in past one month(aHR=4.19,95%CI 1.06–16.47)and unprotected anal sex last time(aHR=5.33,95%CI 1.52–18.73).Conclusions:Compared to cis-MSM,transgender women were at higher risk of HIV acquisition,highlighting an urgent need of tailored prevention.Future HIV program should consider to include them to ensure that this population in China are not left behind.

Health-related attitudes and risk factors for sexually transmitted infections of Chinese women who have sex with women

Background Previous studies have shown evidence of health-related risk behaviors among women who have sex with women （WSW）, such as sex with men, multiple bisexual partners, and drug use. Women who have sex with women have also been known to avoid routine physical examinations and conceal their same-sex history from physicians, which can affect their ability to receive an accurate diagnosis and treatment. No previous research has targeted women who have sex with women in China. We sought to describe women who have sex with women in China and explore risk factors for their reproductive tract infections （RTI）/sexually transmitted infections （STI）. Methods Participants were recruited through outreach in venues and online for a cross-sectional study. Data were collected using interviews and laboratory tests. Results We recruited 224 women who have sex with women. In the year preceding their participation in the study, 92% （206/224） of women reported sexual relations with women. The RTI rates were： gonorrhea （15.8%）, chlamydia （3.5%）, syphilis （0.5%）, bacterial vaginosis （14.4%）, hepatitis B virus （HBV） （0.9%）, hepatitis C virus （HCV） （0.5%）, and candidiasis （6.9%）. No HIV or herpes simplex virus （HSV） positive cases were detected. Factors associated with gonorrhea infection were non-Beijing local residency （odds ratio （OR）=2.1, 95% confidence interval （C/）： 1.2-3.8） and genital-genital contact （OR=3.1, 95% CI： 1.3-7.2）; factors associated with curable STI （excluding bacterial vaginosis, candidiasis, HBV and HCV） were non-Beijing local residency （OR=1.9; 95% CI： 1.2-3.0） and bleeding during or after sex （OR=18.1; 95% CI： 5.2-62.6）; and the factor associated with RTI （including all the infections tested） was bleeding during or after sex （OR=37.8, 95% CI： 11.2-127.4）. Conclusions Behaviors that may cause RTI/STI exist among Chinese women who have sex with women. Researchers should consider these behaviors when planninq correspondin.q prevention and interventions.

Using data from‘visible’populations to estimate the size and importance of‘hidden’populations in an epidemic:A modelling technique

We used reported behavioural data from cisgender men who have sex with men and transgender women(MSM/TGW)in Bangalore,mainly collected from‘hot-spot’locations that attract MSM/TGW,to illustrate a technique to deal with potential issues with the representativeness of this sample.A deterministic dynamic model of HIV transmission was developed,incorporating three subgroups of MSM/TGW,grouped according to their reported predominant sexual role(insertive,receptive or versatile).Using mathematical modelling and data triangulation for‘balancing’numbers of partners and role preferences,we compared three different approaches to determine if our technique could be useful for inferring characteristics of a more‘hidden’insertive MSM subpopulation,and explored their potential importance for the HIV epidemic.Projections for 2009 across all three approaches suggest that HIV prevalence among insertive MSM was likely to be less than half that recorded in the surveys(4.5e6.5%versus 13.1%),but that the relative size of this subgroup was over four times larger(61e69%of all MSM/TGW versus 15%).We infer that the insertive MSM accounted for 10e20%of all prevalent HIV infections among urban males aged 15e49.Mathematical modelling can be used with data on‘visible’MSM/TGW to provide insights into the characteristics of‘hidden’MSM.A greater understanding of the sexual behaviour of all MSM/TGW is important for effective HIV programming.More broadly,a hidden subgroup with a lower infectious disease prevalence than more visible subgroups,has the potential to contain more infections,if the hidden subgroup is considerably larger in size.