Reducing HIV Risk among Transgender Women in Thailand: A Quasi-Experimental Evaluation of the Sisters Program

"Transgender women represent a distinct population often subsumed within men who have sex with men (MSM), but with unique social, cultural and behavioral characteristics that make them particularly vulnerable to HIV infection."

This evaluation explores the Sisters programme, launched in 2004 by Population Services International (PSI) in an effort to prevent HIV among transgender women in the city of Pattaya in eastern Thailand. Specifically, the goal was to find out whether participation in Sisters is related to having received an HIV test and to using condoms and water-based lubricant consistently.

As explained here, PSI uses a social marketing approach to address key motivators and barriers to HIV risk reduction in the context of the stigma that transgender women face in Thai society. Sisters addresses HIV prevention within the context of providing a safe haven and broader social support to transgender women. Staff, peer educators, and volunteers are all transgender women.

In addition to Sisters' drop-in centre (DiC), which provides counseling, social services, and on-site HIV and STI testing and counseling (HTC), Sisters engages in peer-led interpersonal communication (IPC). Outreach workers operate in transgender bars, clubs, and parks to reach transgender women with messages on safe sexual behaviours and HTC. "Outreach workers target areas where commercial sex is available, provided by freelance transgender sex workers or through transgender entertainment/hospitality workers who may also participate in commercial sex. Outreach workers also seek to reach transgender women involved in other occupations. Outreach workers promote awareness of Sisters and its DiC services, and they distribute condoms and water-based lubricants. More in-depth communications are provided through home visits. Peer educators meet clients in a safe, private location for counseling, psychosocial/emotional support, and information on gender reassignment, hormone therapy, and cosmetic surgery. Peer educators facilitate linkages to transgender-friendly government health services and will accompany Sisters clients to appointments for STI treatment, CD4 tests, and anti-retroviral treatment."

Data were collected in December 2011 using time-location sampling (TLS), which is a location-based sampling technique used when the study population congregates in certain venues such as bars, parks, or street corners in red light districts. The research team surveyed sites of transgender activity in Pattaya through ethnographic mapping; the list of sites was then used as a sampling frame to select a probability sample of sites. Four locations were selected where transgender people congregate from 8 PM to midnight for 2 weeks. Peer educators from Sisters assisted in screening potential respondents. Interviews were then conducted in a private and conveniently located setting, with only the interviewer and potential respondent present. During data collection, 336 individuals were screened. Of these, 5 individuals were not eligible for participation, and 23 individuals refused to participate.

Amongst the findings:

• "Three-quarters of transgender women (76%) had received any Sisters services in the past 12 months. Most of this participation was likely through outreach contacts (68%), as only 40% of survey respondents attended the drop-in center, and 18% received a home visit."
• As illustrated in table 3, which presents estimates of programme effects from logistic regression models of the full and matched samples: "In the matched sample, transgender women who participated in any Sisters services in the last 12 months were more likely to use a condom at last sex with any partner (OR 3.75, 95% CI 1.41-9.97) as a bivariate relationship. Transgender women who participated in any part of the program were also more likely to use condoms and water-based lubricant consistently with commercial partners (OR 2.37, 95% CI 1.28-4.41). No statistically significant relationships were found between program participation and condom or condom/water-based lubricant use with casual or regular partners."
• "Breaking out program participation by channel, participation in outreach was associated with condom at last sex (OR 3.10, 95% CI 1.15-8.32) as a bivariate relationship. This relationship was attenuated and borderline statistically significant after adjusting for drop-in center participation (AOR 2.68, 95% CI 0.97–7.40). Outreach was associated with consistent use of condoms and water-based lubricant with commercial partners in a bivariate model and then after adjusting for drop-in center and home visit participation (AOR 3.22, 95% CI 1.64-6.31)."
• "For HIV testing, a statistically significant relationship was found with program participation (OR 2.45, 95% CI 1.36-4.39). Disaggregating by channel, participation in activities at the Sisters DiC was associated with transgender women respondents having received a test in the past 6 months (AOR 2.80, 95% CI 1.62-4.83)."

The researchers share, in the discussion section of the paper, this communication-related finding: "Sisters has organized communications to raise awareness about the benefits of water-based lubricant and to discourage use of oil-based and other lubricants that can damage condoms. A combined package of condom and water-based lubricant was also introduced into outreach activities, replacing condom-only distribution. Evidence suggests that this approach is working. Sisters has achieved generally high levels of outreach coverage. With a transient population, it is important for the program to maintain coverage and frequency of outreach contacts. The outreach interaction itself - short messages plus condom and water-based lubricant distribution - is likely sufficient for this population with high levels of knowledge on condom use and HIV risks and motivated to use HIV prevention methods based on factors such as self-efficacy and positive attitudes..."

Another selected finding: "Because only 40% of the population had attended the DiC, Sisters should consider promotional communication and additional outreach strategies to drive more people to the drop-in center. Alternately, the program could consider how the model developed in the DiC can be adapted to other health and social services that transgender women frequent, such as placing Sisters trained peer educators inside government health services or developing guidelines for specifying services as transgender-friendly."

Potential research suggestions going forward:

• "Despite having evidence on HIV risk reduction through HTC and condom/water-based lubricant use - the aims of this study - we do not know whether Sisters is able to achieve risk reduction or health promotion in other areas of transgender health. Transgender women as a marginalized population have other health risks, particularly around violence, substance use, and mental health. Additional research is needed to determine whether Sisters can achieve a comprehensive approach to transgender health and social services."
• "These findings also highlight the potential value of developing more broad-based HIV prevention programming specific to transgender women and independent of activities for MSM in Thailand. This response could include dedicated sampling of transgender women in integrated bio-behavioral surveys of HIV prevalence plus identification of transgender women as a specified key population in government plans for HIV/AIDS control and in reporting to the United Nations. These efforts would contribute to more effectively meeting the needs of this key population."