HIV/AIDS, human rights, and transgender people in Latin America

Recently, Annick Bórquez and colleagues1Bórquez A Guanira JV Revill P et al.The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study.Lancet Public Health. 2019; 4: e127-e136Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar did a sophisticated simulation of the effect on HIV transmission of different interventions targeting transgender women sex workers in Lima, Peru. The study is highly relevant and could inform similar efforts in other Latin American and Caribbean (LAC) countries where the HIV epidemic remains concentrated among transgender and gender non-conforming people, female sex workers, and men who have sex with men.2Baral SD Poteat T Stromdahl S Wirtz AL Guadamuz TE Beyrer C Worldwide burden of HIV in transgender women: a systematic review and meta-analysis.Lancet Infect Dis. 2013; 13: 214-222Summary Full Text Full Text PDF PubMed Scopus (930) Google Scholar However, the results might overestimate true effects, given the many challenges faced by transgender and gender non-conforming people, particularly sex workers, that affect their access to health interventions and the quality of those interventions. Transgender and gender non-conforming people from the LAC region face high rates of violence; the region accounts for 78·8% of all murders reported in this population worldwide from 2008–18.3Transgender Europe (TGEU)Trans day of remembrance 2018.https://transrespect.org/en/tmm-update-trans-day-of-remembrance-2018/Date: Nov 12, 2018Date accessed: May 9, 2019Google Scholar Those who are engaged in sex work also face heightened risks of physical and sexual violence, including rape and coerced sex, with these experiences contributing to increased HIV exposure risks.4Poteat T Wirtz AL Radix A et al.HIV risk and preventive interventions in transgender women sex workers.Lancet. 2015; 385: 274-286Summary Full Text Full Text PDF PubMed Scopus (231) Google Scholar Gender-based violence and transphobia are also frequently experienced by transgender and gender non-conforming people at health-care units in the LAC region, jeopardising their access to care, including HIV-related prevention and treatment strategies.5Winter S Diamond M Green J et al.Transgender people: health at the margins of society.Lancet. 2016; 388: 390-400Summary Full Text Full Text PDF PubMed Scopus (464) Google Scholar Gender-based violence, transphobia, and a lack of legal protections and services tailored to the needs of transgender and gender non-conforming people are serious barriers to adequate HIV treatment and prevention. Health-care providers themselves contribute to stigma, discrimination, and violence toward transgender and gender non-conforming people, often denying or delaying basic treatment or providing substandard care.5Winter S Diamond M Green J et al.Transgender people: health at the margins of society.Lancet. 2016; 388: 390-400Summary Full Text Full Text PDF PubMed Scopus (464) Google Scholar Stigma fosters and maintains vulnerabilities and health inequality—yet this inequality in access to care is not fully reflected in the simulation by Bórquez and colleagues.1Bórquez A Guanira JV Revill P et al.The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study.Lancet Public Health. 2019; 4: e127-e136Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar In many Latin American countries, human rights advances that had been made for transgender and gender non-conforming people are being reversed, with stigma on the rise.6Montenegro L Velasque L LeGrand S Whetten K de Mattos Russo Rafael R Malta M Public health, HIV care and prevention, human rights and democracy at a crossroad in Brazil.AIDS Behav. 2019; (published online Mar 22.)DOI:10.1007/s10461-019-02470-3Crossref PubMed Scopus (13) Google Scholar In this context, the possibility to implement evidence-based strategies for vulnerable groups is questionable; the political climate will probably reduce the availability of funds for scientifically sound interventions such as the ones modelled by Bórquez and colleagues.1Bórquez A Guanira JV Revill P et al.The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study.Lancet Public Health. 2019; 4: e127-e136Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar Thus, the optimistic estimates of HIV intervention benefits that have been reported1Bórquez A Guanira JV Revill P et al.The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study.Lancet Public Health. 2019; 4: e127-e136Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar seem unlikely in the current political scenario of many LAC countries. Strategies to reduce inequality in health outcomes among transgender and gender non-conforming people need to address a broad range of cultural, social, political, and interpersonal aspects that contribute to intersecting forms of stigma, prejudice, discrimination, and gender-based violence. We declare no competing interests. The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling studyInvestments in HIV services among TWSW in Lima would be cost-effective, even under stringent cost-effectiveness criteria when accounting for setting-specific resource constraints. Notable improvements in HIV testing rates, innovative interventions to increase condom use, and reduced PrEP costs will be key to achieving the 50% incidence reduction goal. Modelling studies incorporating stakeholders' perspectives and health system assessments can bring added value to HIV policy making.