1. HIV risk and preventive interventions in transgender women sex workers Tonia Poteat, Andrea L. Wirtz, Anita Radix, Annick Borquez, Alfonso Silva- Santisteban, Madeline Deutsch, Sharful Islam Khan, Sam Winter, Don Operario HIV and Sex Workers, Paper 6

2. Background Transgender - diverse population of people whose gender identity or expression differs from their natal sex Dearth of data on transgender men, sex work, and HIV 24 – 75% of transgender women engage in sex work in U.S. 54% – 80% of transgender women in Asia-Pacific had history of sex work 1 Herbst JH, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008; 12(1): 1-17. 2 Winter, S. 2012. Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region. Bangkok: UNDP Asia Pacific Regional Center,.

3. HIV Epidemiology: Global Meta-analysis Data limitations: sampling methods; population is often subsumed under “men who have sex with men” or “female sex workers” in research; little research specifically about transgender sex workers RR: 4.02 compared to FSW

4. HIV vulnerability: The interaction of multilevel risks

5. Community Voices: Stigma and Resilience Stigma persists. Some of my family members still do not accept me as a hijra. But, at the end of the day, I forget all this pain when I think about the love and respect I have received not only from the hijra community, but from all sex workers and sexual minorities and from many others who work for our community. It will take time to eliminate stigma... However, the movement has started and we are on the right track. Joya Sikder, President of the National Platform of Sex Workers, Bangladesh

6. State of Evidence: A Dearth of Interventions Published Studies CountryIntervention(s) PeruMobile HIV testing India (2)Community empowerment/combination prevention LaosCondom social marketing ThailandCommunity-led peer education USAGroup level behavior change communication (BCC) Abstracts USATransgender friendly medical care Multi-nationalPre-exposure prophylaxis On-going trials IndiaAnti-stigma program for health workers USA (4)Group-level BCC (3); telemedicine to improve care (1)

7. Intervention Opportunities Evidence suggests that best interventions are – Multi-level, addressing structural barriers as well as behavior change – Community-led and grounded in empowerment New biomedical interventions hold promise – PrEP : iPrex included transgender women, however, studies statistically powered to provide results for this population are needed – Early ART: PARTNER study suggest efficacy for insertive and receptive anal sex as well as vaginal sex. Neovaginal transmission risks are unknown – Microbicides: It will be important for rectal microbicide trails to include enough trans women to determine efficacy

8. Modelling Scenarios 2 distinct epidemiologic settings: Lima, Peru and San Francisco, U.S.A Number of new HIV infections Years 10 year Intervention period with clients with stable partners PrEP Early ART Transactions for the same Baseline 50% reduction ?

9. Modelling Results A=condoms with clients; B= condoms with partners; C=number of commercial transactions; D=PrEP; E = test and treat

10. Country Case Studies Research and interventions must be informed by local contexts and adapted to different settings in order to have the most impact Most countries lack basic HIV prevalence data on transgender sex workers

11. Complex Legal and Policy Environments *Laws and policies vary by state within US and other countries

12. Implications of Modeling and Case Studies Combination interventions are essential Prevention programmes must be tailored to the context Structural and psychosocial factors are key to changing proximal determinants More research is needed

13. Conclusion Trans women sex workers bear a heavy burden of HIV Researchers must collect trans-specific data that clearly separates trans women sex workers from male and non-trans female sex workers There is an urgent need for evidence-based interventions that are effective, acceptable and appropriate for trans sex workers

14. Acknowledgements  We’d like to thank Joya, Gulam, and Rose for contributing their voices to the manuscript and putting a human face on the data.  We are grateful to the many transgender sex workers who have participated in research studies that provided data for these analyses.  We’d like to express our gratitude to Mike Pickles and Tim Hallet for their assistance with the modelling.  This paper and The Lancet Series on HIV and Sex Work were supported by grants to the Center for Public Health and Human Rights at Johns Hopkins from The Bill & Melinda Gates Foundation; The United Nations Population Fund; and by the JHU CFAR, an NIH funded program (1P30AI094189)