Several factors may increase the risk of transgender populations for HIV infection. Trans women were identified as having more significant risks for acquiring HIV infection than other transgender populations. They were also least likely to receive any HIV treatments or interventions and other preventative services [2, 22–24]. The transgender community is also known to experience an increased risk for sexual behaviors, family rejection, stigma, discrimination, and safety concerns [25–27]. In addition, numerous individual, social, and interpersonal factors provide an interplay in terms of the experiences the transgender community experiences [28, 29].
Report on the education and training for health professionals in the Philippines provided information on the adequacy of the current health curricula in terms of the HIV response . Moreover, the Integrated HIV Behavioral and Serologic Surveillance embedded in the Health Sector Plan for HIV and STI 2015 to 2020 of the Philippine Department of Health (DOH), an active sentinel serologic and behavioral surveillance, suggested actions to increase HIV and HIV-related services both for the transgender (TG) and men-having-sex-with-men (MSM) populations [31, 32]. However, the guidelines for the increase in uptake for HTC services among the TW and TM should be further strengthened because of the existing barriers to testing. Our study aimed to identify the factors that enable the TG populations to refuse or decline HIV testing services. Through medical records review, our study showed that most TM did not consent or accept HIV testing services from the VLY, and they are more likely to refuse HIV testing services compared to TG.
Our results conformed with the prevalence report of the Center for Disease Control (CDC) recommended guidelines for HIV and Sexually Transmitted Infection (STI), wherein suboptimal trends on HTC services were observed among TG . This finding is congruent with the results that TM did not know their HIV status . However, one study on TG youth showed that TW was significantly less likely to get tested for HIV compared with TM . Contrary to this finding, a recent publication on an extensive survey from the United States consisting of 26,927 TG respondents in 2015 revealed that TW had significantly higher odds of reporting their HIV status than TM , which was also seen in our study. In addition, the most common reason for never testing for HIV among TM was a low-risk perception of their sexual activities. Low-risk perception as a significant barrier to HIV testing was also seen in previous studies [38–41], not only among TG populations. Others reasons for TM or TW not getting their HIV testing also included fear of HIV-related stigma and discrimination [42, 43], insufficient knowledge on HIV/AIDS or poor health literacy [44, 45], and limited availability due to lack of time . Further investigation on why TM and TW in VLY not knowing their HIV status because of refusal should be conducted to engage more TM and TW clients in HTC services. Moreover, increasing willingness for HIV self-testing among TM or TW to ensure one’s safety and confidentiality is an approach that can also be explored [47, 48].
The third-year since the launch of VLY in 2017 recorded the highest number of TM and TW clients consenting to HIV testing. Furthermore, our results showed that these clients in 2019 were more likely to get themselves tested for HIV compared with clients during the formative years of VLY. As an exclusive health center for the transgender community under the supervision of LoveYourself Inc., Victoria was initially established to provide HTC . Over the years, through community consultations, partnerships with LGBTQIA + organizations, and transgender health capacity building of the community center, VLY officially rolled out their gender-affirming services, the first in the Philippines. The one-stop-shop model of integrating sexual health services and transgender health could translate to the gradual increase of HIV testing uptake among VLY clients. This strategy further establishes that gender-affirming care services can be an entry point in accessing HIV services.
Similarly, research has suggested that a gender-affirmative integrated care framework complemented by peer navigation effectively addresses the HIV burden experienced by the transgender population . Our results also showed that the later years of VLY operations had established trust and confidence with its TM and TW clients to encourage them to avail themselves of the HTC services. Building trust and rapport between physicians, HTC service providers, and clients are crucial in all central HIV testing practices . The integral approach in establishing trust is, to begin with, simple steps, to take part in clients with small successes, and to show dedication and commitment through continuous communication . VLY used this strategy to build trust and rapport with TW and TM clients, which was also seen in previous studies conducted by other HTC providers [53, 54]. The establishment of VLY as a community-based transgender health center for TM and TW provides an essential avenue for these populations to avail HTC services in confidence and without the stigma.
HIV testing lacking good motivational counseling and linkage to care may not be effective . Our study provided information on reactive TG clients in which almost all of them were linked to care, particularly in HIV treatment through ART. Engagement in HIV care among all vulnerable populations, not only TG clients, is essential in the HIV care continuum. The role of HTC service providers such as VLY in the delivery of services and building relationships is characterized by their provision of time and emotional and social support to their clients [56, 57]. However, previous studies documented low ART coverage among TG respondents [58–60]. Nevertheless, our findings demonstrated improved access and link to care among HIV-reactive TW and TM clients of VLY, similar to another published study .
To our knowledge, this is the first quantitative retrospective study conducted in the Philippines that looked at the HIV testing preferences of TM and TW clients. Using a modest sample size of client records, we presented the disparity between characteristics of TM and TW accessing HTC services in Metro Manila and their linkage to further HIV treatment after testing reactive. Through continuous monitoring and engagement of TM and TW in the community-based transgender health center, the identified disparities and gaps provided an opportunity for the VLY to enhance its services for TM and TM accessing HTC services. Furthermore, by gradually eliminating these gaps through the retention of commitment and trust built around with clients and proper dissemination of the availability of HTC services for TM and TW, HIV cases may be reduced.
However, this current study is limited by its retrospective study design in which participants are recruited by convenience sampling and may be prone to selection bias. Moreover, our study did not account for sexual orientation. TM, who have sex with men, and TM, who have sex with TW, are increasingly at risk of HIV. Given the current growing number of national and global programs focused on TW, and not TG in general, the exploration of HIV testing preference in terms of sexual preference has important implications on TM not perceiving they are actually at risk for the infection. In addition, the potential effect of unmeasured confounding factors (HIV-related social stigma and discrimination) or residual confounding factor bias should not be dismissed. Furthermore, we only involved TM and TW clients who accessed VLY from 2017 to 2019, which may not be representative of other TM and TW clients in other parts of the Philippines, other races, and other vulnerable populations at risk for HIV. Further studies are needed to validate our findings across all other populations.