Abstract:

HIV prevalence among transgender women is disproportional when compared to the general population in various countries. Stigma and discrimination based on gender identity have frequently been associated with vulnerability to HIV/AIDS. The objective was to conduct a systematic literature review to analyze the relationship between stigma and discrimination related to gender identity in transgender women and vulnerability to HIV/AIDS. This systematic literature review involved the stages of identification, compilation, analysis, and interpretation of results of studies found in five databases: PubMed, Scopus, Web of Science, Science Direct, and LILACS. No publication time period was determined in advance for this review. The studies were assessed according to the inclusion and exclusion criteria. The review included articles in English, Portuguese, or Spanish that related stigma and discrimination to transgender women’s vulnerability to HIV. We found 41 studies, mostly qualitative, published from 2004 to 2018, and categorized in three dimensions of stigma: individual, interpersonal, and structural. The data highlighted that the effects of stigma related to gender identity, such as violence, discrimination, and transphobia, are structuring elements in transgender women’s vulnerability to HIV/AIDS. The studies showed a relationship between stigma and discrimination and transgender women’s vulnerability to HIV/AIDS and indicated the need for public policies to fight discrimination in society.

Keywords:
Social Stigma; Social Discrimination; Transgender Persons; HIV; Systematic Review

Introduction

HIV prevalence is disproportionally high among transgender women when compared to the general population ¹1. Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV 2017; 4:e169-76.^,22. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22.^,33. Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet 2014; 385:274-86.. A metanalysis estimated a prevalence of 19.1% in 15 countries, which is 48.8 times higher than in the reproductive-age population in the same countries ²2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22..

Various studies have explained this disproportionality by a range of complex individual factors: biological (i.e., unprotected anal sex) and behavioral (i.e., lack of condom use, use of psychoactive substances, etc.), together with structural factors such as stigma and discrimination, which also play an important role and can influence behaviors, practices, and attitudes in relation to HIV, limiting access to socioeconomic resources, especially education, work, and prevention services ²2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22.^,33. Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet 2014; 385:274-86.^,44. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008; 12:1-17.. Thus, researchers, activists, and health professionals have considered stigma and discrimination two key factors associated with high HIV prevalence rates ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,66. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,77. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774.^,88. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24..

Gender performances of transgender women are seen as insubordination to the dynamics established by heteronormative society over bodies and social relations ¹⁰10. Magno L, Dourado I, Silva LAV. Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00135917.^,1111. Butler J. Problemas de gênero: feminismo e subversão da identidade. 11ª Ed. Rio de Janeiro: Editora Civilização Brasileira; 2016.. As a consequence, transgender women face intense stigmatization due to the expression of their gender identities in predominantly patriarchal and male chauvinist societies ³3. Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet 2014; 385:274-86.^,1010. Magno L, Dourado I, Silva LAV. Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00135917.. When comparing men who have sex with men (MSM) and transgender women, the latter experience more stigma and discrimination ⁷7. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774. and more stressful psychosocial events, revealing the existence of discrimination even within the LGBT community ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.. They also present higher HIV prevalence rates than MSM ¹³13. Poteat T, Ackerman B, Diouf D, Ceesay N, Mothopeng T, Odette K, et al. HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: a cross-sectional analysis. PLoS Med 2017; 14:e1002422..

Stigma and discrimination due to gender identity are frequently related to the unfavorable social, economic, and psychological context for transgender women ¹⁴14. White-Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015; 147:222-31., which often relates to their involvement in commercial sex, generally as a result of the limited options for accessing the formal labor market ²2. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22.^,33. Poteat T, Wirtz AL, Radix A, Borquez A, Silva-Santisteban A, Deutsch MB, et al. HIV risk and preventive interventions in transgender women sex workers. Lancet 2014; 385:274-86.^,44. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008; 12:1-17.^,1515. Perez-Brumer AG, Reisner SL, McLean SA, Silva-Santisteban A, Huerta L, Mayer KH, et al. Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru. J Int AIDS Soc 2017; 20:21462.. Even so, the current response to the HIV/AIDS epidemic has emphasized biomedical measures to the detriment and less structural issues, which includes the role of activists that are member of the populations most affected by the epidemic ¹⁶16. Aggleton P, Parker R. Moving beyond biomedicalization in the HIV response: implications for community involvement and community leadership among men who have sex with men and transgender people. Am J Public Health 2015; 105:e1-7.. The current article thus intends to conduct a systematic literature review to analyze the relationship between stigma and discrimination related to gender identity of transgender women and their vulnerability to HIV/AIDS.

Methodology

This is a systematic literature review on stigma, discrimination, and vulnerability of transgender women to HIV/AIDS, involving identification, compilation, analysis, and interpretation of the results of selected studies. The review followed the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), which describe the specific requirements for systematic review studies and metanalyses ¹⁷17. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma G. Preferred reporting items for systematic reviews and meta-analyses: the Prisma Statement (Reprinted from Annals of Internal Medicine). Phys Ther 2009; 89:873-80..

Search strategies and information sources

Independent reviewers (L. M., M. P.-S.) conducted the study search in PubMed, Scopus, Web of Science, Science Direct, and LILACS, using the following combinations of keywords: “discrimination”, HIV, “social stigma” or "stigma” “transgender persons” or “transgender” or “transvestite” (Supplementary Material, Table S1: http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/suppl-e00112718ingles_2106.pdf). The review also examined the reference lists from the relevant studies in order to identify other potentially eligible studies.

In Brazil and Latin America in general, the terms “transvestite” and “transsexual woman” are used more frequently by the communities themselves than “transgender woman”. These differences can mark political and/or subjective identities and are fluid depending on the context ¹⁸18. Lionço T. Atenção integral à saúde e diversidade sexual no processo transexualizador do SUS: avanços, impasses, desafios. Physis (Rio J.) 2009; 19:43-63.. The terms convey different levels of performances as a woman and demand their identity’s legitimacy beyond binary male-female parameters, adequacy of their physical image and bodies via hormone therapy, use of silicone, and other body modifications, and the fact that they wish to be addressed in the feminine and by the name with which they identify. Importantly, there is transit between identities, which are not fixed or isolated categories, but are always in dispute, negotiation, and constant interaction and movement ¹⁹19. Arán M, Murta D. Do diagnóstico de transtorno de identidade de gênero às redescrições da experiência da transexualidade: uma reflexão sobre gênero, tecnologia e saúde. Physis (Rio J.) 2009; 19:15-41.^,2020. Dourado I, Silva LAV, Magno L, Lopes M, Cerqueira C, Prates A, et al. Construindo pontes: a prática da interdisciplinaridade. Estudo PopTrans: um estudo com travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2016; 32:e00180415.^,2121. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.. This study used the term “transgender women”, since most of the literature consulted in the review was in English, and it is an umbrella term for a wide range of transfeminine identities that blur the sex-gender borders, although the term “transvestite” was also included in the search strategy.

The publications were managed in the Mendeley app (https://www.mendeley.com) to remove duplicates. Data collection lasted from October 2016 to February 2017 and was updated in June 2018. No publication period was determined in advance for the review.

Eligibility criteria

Inclusion criterion: studies that addressed the relationship between stigma and discrimination due to gender identity and vulnerability of transgender women to HIV/AIDS. There was no exclusion of any methodological approach; both qualitative and quantitative articles were included. The review included articles written in English, Portuguese, and Spanish. No articles were excluded on the basis of geographic location or time frame or for the term used to define transgender women (transvestite, transsexual woman, aravanis, hijras, metis, etc.).

Data extraction

Study selection began by reading the titles and abstracts, based on the inclusion criteria. The full texts of the selected articles were read. After the assessment, the studies were selected for inclusion in the review’s corpus. An Excel (https://products.office.com) spreadsheet was organized with the following terms: authors, year of publication, study country, study design/methodology, number of persons in study sample, objectives, study population, and main results.

Assessment of risk of bias (quantitative studies) and methodological rigor (qualitative studies)

Next, the methodological quality was assessed according to the study’s nature. Qualitative studies were assessed with the Research Triangle Institute Item Bank (RTI-Item Bank) scale, which evaluates risk of bias ²²22. Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. J Clin Epidemiol 2012; 65:163-78.. RTI-Item Bank contains 29 items to assess studies, 6 of which were applied to the studies included in this review (Supplementary Material, Box S1: http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/suppl-e00112718ingles_2106.pdf): (i) inclusion and exclusion criteria clearly defined; (ii) use of valid and reliable measures to assess inclusion and exclusion criteria; (iii) standardized recruitment strategy for participants in all the groups; (iv) appropriate sample selection; (v) results assessed using valid and reliable measures, implemented consistently for all the study participants; (vi) confounders and effect modifiers considered in the design and/or data analysis ²²22. Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. J Clin Epidemiol 2012; 65:163-78.. Risk of bias was assessed and classified using the studies’ response to the above-mentioned items and classified as follows: high risk of bias - when the study had one or more negative answers to the items; moderate risk of bias - when one or more items were classified as “partially” or “indeterminate”; low risk of bias - when all the items in the scale recorded a positive answer ²²22. Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. J Clin Epidemiol 2012; 65:163-78..

Assessment of qualitative studies used the instrument proposed by the Critical Appraisal Skills Programme (CASP), employed in the critical analysis of reports by qualitative studies. This instrument has ten questions that help the assessor think systematically on the study’s rigor, credibility, and relevance, considering: (i) clear and justified objective; (ii) appropriate methodological design for the objectives; (iii) methodological procedures presented and discussed; (iv) sample selection; (v) data collection described, instruments and saturation process explained; (vi) explanation of the relationship between researcher and study subject; (vii) ethical precautions; (viii) dense and well-founded analysis; (ix) results presented and discussed, featuring the issue of credibility and use of triangulation; (x) description of the contributions and implications for the knowledge generated by the study, as well as its limitations ²³23. Critical Appraisal Skills Programme (CASP): making sense of evidence. London: Public Health Resource Unit, University of Oxford; 2006.. Qualitative studies were classified in two categories: A, for studies with high methodological rigor, since they met at least 9 of the 10 items; B, for studies with moderate methodological rigor, meeting at least 5 of the 10 items ²³23. Critical Appraisal Skills Programme (CASP): making sense of evidence. London: Public Health Resource Unit, University of Oxford; 2006.^,2424. Espíndola CR, Blay SL. Percepção de familiares sobre a anorexia e bulimia: revisão sistemática. Rev Saúde Pública 2009; 43:707-16..

Data analysis

The analysis was oriented according to the theoretical references for the concepts of stigma, discrimination, and vulnerability. The study adopted the concept of vulnerability applied to the field of health, specifically to the discussion on the HIV/AIDS epidemic. This concept can be understood by the analysis of three interrelated components: individual vulnerability, aimed at identifying physical, mental, or behavioral factors through risk assessment and/or other approaches; social vulnerability, analyzing the dimensions of culture, religion, morals, politics, economy, and institutional factors, which can determine the means of exposure to diseases and/or injuries; programmatic vulnerability, examining how policies, programs, and services affect persons’ social and individual situations ²⁵25. Ayres JR, Paiva V, França Jr. I. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: Paiva V, Ayres JR, Buchalla CM, organizadores. Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro I - da doença à cidadania. Curitiba: Juruá; 2012. p. 71-94.^,2626. Mann J, Tarantola D. AIDS in the World II: global dimensions, social roots, and responses: the global AIDS policy coalition. New York: Oxford University Press; 1996.^,2727. Ayres JRDCM, Paiva V, França Jr. I, Gravato N, Lacerda R, Della Negra M, et al. Vulnerability, human rights, and comprehensive health care needs of young people living with HIV/AIDS. Am J Public Health 2006; 96:1001-6.^,2828. Bertolozzi MR. Pode o conceito de vulnerabilidade apoiar a construção do conhecimento em Saúde Coletiva? Ciênc Saúde Colet 2007; 12:319-24.. Vulnerability emphasizes the responsibility of government actions and public policies as an integral part of the determinants of the health/disease process ²⁵25. Ayres JR, Paiva V, França Jr. I. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: Paiva V, Ayres JR, Buchalla CM, organizadores. Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro I - da doença à cidadania. Curitiba: Juruá; 2012. p. 71-94.^,2626. Mann J, Tarantola D. AIDS in the World II: global dimensions, social roots, and responses: the global AIDS policy coalition. New York: Oxford University Press; 1996.. In this article, the theoretical-conceptual understanding of this construct expanded the scope of analysis of the articles beyond the behavioral and individual risk issues, including studies that related stigma and discrimination to barriers in accessing health services.

Stigma refers to a person’s profoundly depreciative attribute, which is perceived as such through social interaction. The presence of this attribute may confirm or reaffirm the “normality” of specific persons or groups. Stigma highlights a specific trait in individuals, subjecting them to the impossibility of social attention to their other attributes, assigning major discredit to them ²⁹29. Goffman E. Estigma: notas sobre a manipulação da identidade manipulada. 4ª Ed. Rio de Janeiro: LTC; 2013.. Hatzenbuehler & Link ³⁰30. Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med 2014; 103:1-6. recently emphasized the need for progress in the conceptualization and measurement of stigma as a social phenomenon with roots in social structures. The authors define structural stigma as conditions at the broader social and cultural levels and institutional policy norms that construct the opportunities, resources, and well-being of stigmatized individuals. The authors call attention to the intense interaction between the microsocial level, the locus of interpersonal relations, and the macrostructural level. Such structures are not unidirectional and static, but shaped by interpersonal relations and individual factors.

Discrimination can be understood as a practical result of stigma, defined by a conceptual review ³¹31. Pescosolido BA, Martin JK. The stigma complex. Annu Rev Sociol 2015; 41:87-116. (p. 34): stigma is a profound attribute of discredit, a “mark” or “socially devalued identity”; stigmatization is related to a social process that produces devaluation through labels and stereotypes; a label is an officially sanctioned term applied to conditions, individuals, groups, places, organizations, institutions, or other social entities, since the stereotype is related to negative attitudes and beliefs targeted to the labeled social entities; prejudice is an endorsement of negative beliefs and attitudes related to the stereotype; and discrimination involves the actions targeted to the endorsement and reinforcement of stereotypes to place the labeled persons at a disadvantage. In this article, we thus consider studies on discrimination and stigma related to the gender identity of transgender women. Since there is no consensus in the literature on this issue ³²32. Phelan JC, Lucas JW, Ridgeway CL, Taylor CJ. Stigma, status, and population health. Soc Sci Med 2014; 103:15-23., we will use “stigma and discrimination” widely speaking throughout the article, but understanding that there are important theoretical and conceptual specificities ³³33. Phelan JC, Link BG, Dovidio JF. Stigma and prejudice: one animal or two? Soc Sci Med 2008; 67:358-67..

In this analysis, we investigated the methodological issues of the studies analyzed here and established key elements that constituted thematic units ³⁴34. Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. New York: Springer; 2007.. This process identified 65 key elements based on a reading of the articles, which were categorized on an Excel spreadsheet based on the three thematic units in the concept of stigma according to Hatzenbuehler & Link ³⁰30. Hatzenbuehler ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med 2014; 103:1-6. and White-Hughto et al. ¹⁴14. White-Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015; 147:222-31.: individual level (psychological issues such as self-stigma), interpersonal level (person-to-person discrimination), and structural level (state policies that can promote social exclusion).

Results

Characteristics of selected studies

We identified 791 articles in the databases, of which 41 were included in the review. Figure 1 shows the search strategies. The reasons for exclusion of articles were the absence of analysis on stigma, discrimination, vulnerability, and HIV (Supplementary Material, Box S2: http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/suppl-e00112718ingles_2106.pdf).

Most of the articles used qualitative methods exclusively (27/41) (Table 1), there were two articles with mixed methods, and 12 exclusively quantitative studies (Table 2). All were published from 2004 to 2018. We observed an increase in publications in recent years, with a peak in 2016 (11/41). The United States published the most articles (or publications) (13/41), followed by India (5/41), Mexico (3/41), and Brazil (3/41).

Measurement of discrimination and stigma in the quantitative studies

To identify how the studies dealt with the construction of the stigma or discrimination variable, we analyzed 12 exclusively quantitative articles and two with mixed methods. Eight studies dealt with the phenomenon as “discrimination” (experience, perception, etc.) ²¹21. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.^,3535. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,3737. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7.^,3838. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787.^,3939. Newman PA, Lee S-J, Roungprakhon S, Tepjan S. Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prev Sci 2012; 13:483-92.^,4040. Operario D, Nemoto T, Iwamoto M, Moore T. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behav 2011; 15:674-82.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303., three articles analyzed “stigma” (experience, perception, etc.) ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,77. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24., one dealt with the phenomenon of “homophobia” ⁴²42. Martins TA, Kerr LRFS, Macena RHM, Mota RS, Carneiro KL, Gondim RC, et al. Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey. AIDS Care 2013; 25:606-12., one with “transphobia” ⁸8. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25., and one of the mixed-methods articles did not use the quantitative method to assess discrimination and stigma ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.. Many of these studies did not provide a theoretical framework on the distinction between the concepts of stigma and discrimination.

Most of the studies (54%) showed high risk of bias ⁸8. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,3535. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6.^,3737. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7.^,3939. Newman PA, Lee S-J, Roungprakhon S, Tepjan S. Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prev Sci 2012; 13:483-92.^,4040. Operario D, Nemoto T, Iwamoto M, Moore T. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behav 2011; 15:674-82.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303., and only 31% were classified as low risk of bias ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,77. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,2121. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.. Inadequate sample selection and assessment of the study outcome with valid criteria were the items that most contributed to bias scores in the studies analyzed here. In one study it was not possible to apply the scale of bias, since it did not present quantitative methodological elements for the assessment ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120. (Figure 2) (Supplementary Material, Table S2: http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/suppl-e00112718ingles_2106.pdf).

The variables related to stigma and discrimination were built on the basis of an unvalidated scale for the population of transgender women, some inspired by previous scales on racial discrimination ⁴⁰40. Operario D, Nemoto T, Iwamoto M, Moore T. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behav 2011; 15:674-82., perception of stigma in MSM ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8., and homophobia ⁸8. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24., while others were created on the basis of previous studies with this population, or drawing on a review of the literature ⁷7. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774.^,2121. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.^,3535. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.. A few studies used just one or two questions on perceived discrimination ³⁷37. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7.^,3939. Newman PA, Lee S-J, Roungprakhon S, Tepjan S. Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prev Sci 2012; 13:483-92. and did not provide details ⁴²42. Martins TA, Kerr LRFS, Macena RHM, Mota RS, Carneiro KL, Gondim RC, et al. Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey. AIDS Care 2013; 25:606-12.. Among the studies that used items to assess discrimination or stigma, the majority used Cronbach’s alpha to estimate the questionnaire’s reliability ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,88. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,4040. Operario D, Nemoto T, Iwamoto M, Moore T. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behav 2011; 15:674-82., one used the Kuder-Richardson coefficient ⁴¹41. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303., one used confirmatory factor analysis ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24., one used exploratory factor analysis ⁷7. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774., and another employed latent class analysis ²¹21. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.. Some did not perform any of these analyses ³⁵35. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,3838. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787..

Data techniques and analysis in the qualitative studies

The techniques for data production and analysis varied in the qualitative studies. Interviews (semi-structured or in-depth) were the most frequently used ⁴⁴44. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,4545. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,4747. Barrington C, Acevedo R, Donastorg Y, Perez M, Kerrigan D. "HIV and work don't go together": employment as a social determinant of HIV outcomes among men who have sex with men and transgender women in the Dominican Republic. Glob Public Health 2017; 12:1506-21.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,4949. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102.^,5050. Wilson E, Pant SB, Comfort M, Ekstrand M. Stigma and HIV risk among Metis in Nepal. Cult Health Sex 2011; 13:253-66.^,5151. Cuadra-Hernández SM, Zarco-Mera A, Infante-Xibillé C, Caballero-García M. La organización de las poblaciones clave ligadas a la transmisión del VIH: una intervención para abatir el estigma; México, 2005-2009. Salud Colect 2012; 8:191-204.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35., followed by a combination of focus groups with interviews ¹⁵15. Perez-Brumer AG, Reisner SL, McLean SA, Silva-Santisteban A, Huerta L, Mayer KH, et al. Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru. J Int AIDS Soc 2017; 20:21462.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6060. Li DH, Rawat S, Rhoton J, Patankar P, Ekstrand ML, Rosser BRS, et al. Harassment and violence among men who have sex with men (MSM) and hijras after reinstatement of India's "Sodomy Law". Sex Res Soc Policy 2017; 14:324-30.^,6161. Nemoto T, Cruz T, Iwamoto M, Trocki K, Perngparn U, Areesantichai C, et al. Examining the sociocultural context of HIV-related risk behaviors among kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care 2016; 27:153-65.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.. There was a predominance of thematic analysis as a qualitative data analysis technique ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,1515. Perez-Brumer AG, Reisner SL, McLean SA, Silva-Santisteban A, Huerta L, Mayer KH, et al. Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru. J Int AIDS Soc 2017; 20:21462.^,4444. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5050. Wilson E, Pant SB, Comfort M, Ekstrand M. Stigma and HIV risk among Metis in Nepal. Cult Health Sex 2011; 13:253-66.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124.^,6565. Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S16-24. (Table 1).

Methodological rigor according to the CASP criteria was classified as B (moderate rigor) in four studies ⁵²52. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,6565. Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S16-24.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8.. Non-rigorous data analysis, research ethics procedures not specified in the methodology, and lack of specification of interaction between researchers and participants in the field were the items that scored negatively and contributed to the moderate methodological rigor (Table 1).

Stigma, discrimination, and vulnerability to HIV

According to the review, stigma produces discrimination and violence at different levels: structural, interpersonal, and individual, which can play a role in the individual, social, and programmatic vulnerability of transgender women to HIV (Figure 3).

Structural stigma

Structural stigma promotes a totally adverse social context for transgender women through transphobia and discrimination ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,4242. Martins TA, Kerr LRFS, Macena RHM, Mota RS, Carneiro KL, Gondim RC, et al. Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey. AIDS Care 2013; 25:606-12.^,4444. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124.. In some countries, especially those with a strong religious tradition, transsexuality, and homosexuality are still legally criminalized, as exemplified in two studies, one in Malaysia ⁴⁶46. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25. and the other in India ⁶⁰60. Li DH, Rawat S, Rhoton J, Patankar P, Ekstrand ML, Rosser BRS, et al. Harassment and violence among men who have sex with men (MSM) and hijras after reinstatement of India's "Sodomy Law". Sex Res Soc Policy 2017; 14:324-30.. In India, section 377 of the Indian Penal Code, known as the “Sodomy Law”, which criminalizes persons who have sex with non-vaginal penetration, was reinstated by the Supreme Court in 2013, but repealed in September 2018 ⁶⁰60. Li DH, Rawat S, Rhoton J, Patankar P, Ekstrand ML, Rosser BRS, et al. Harassment and violence among men who have sex with men (MSM) and hijras after reinstatement of India's "Sodomy Law". Sex Res Soc Policy 2017; 14:324-30.^,6767. Safi M. Campaigners celebrate as India decriminalises homosexuality. The Guardian 2018; 6 sep. https://www.theguardian.com/world/2018/sep/06/indian-supreme-court-decriminalises-homosexuality.
https://www.theguardian.com/world/2018/s... . In India, marriage and procreation, considered key criteria for achieving respect and heterosexual normativity, appear to justify the stigma and violence against groups that do not conform to the hegemonic gender identities ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.. In Lebanon, incarceration on grounds of gender identity or expression has also been reported ³⁸38. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787..

Even in liberal countries (from the legal point of view) such as the United States ⁴¹41. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4444. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8., Mexico ⁵¹51. Cuadra-Hernández SM, Zarco-Mera A, Infante-Xibillé C, Caballero-García M. La organización de las poblaciones clave ligadas a la transmisión del VIH: una intervención para abatir el estigma; México, 2005-2009. Salud Colect 2012; 8:191-204., Japan ⁶⁸68. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94., and Brazil ⁴²42. Martins TA, Kerr LRFS, Macena RHM, Mota RS, Carneiro KL, Gondim RC, et al. Travestis, an unexplored population at risk of HIV in a large metropolis of northeast Brazil: a respondent-driven sampling survey. AIDS Care 2013; 25:606-12., transgender women still suffer discrimination in public spaces and experience difficulty in reassigning their name in keeping with their gender identity ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392..

Family and social stigma was found associated with sex work ⁷7. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774.. It was also reported as an important barrier to access barriers to schooling ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,5151. Cuadra-Hernández SM, Zarco-Mera A, Infante-Xibillé C, Caballero-García M. La organización de las poblaciones clave ligadas a la transmisión del VIH: una intervención para abatir el estigma; México, 2005-2009. Salud Colect 2012; 8:191-204.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35. and formal employment ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,1212. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392., which often leaves them in a situation of socioeconomic marginalization ³⁶36. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,6161. Nemoto T, Cruz T, Iwamoto M, Trocki K, Perngparn U, Areesantichai C, et al. Examining the sociocultural context of HIV-related risk behaviors among kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care 2016; 27:153-65.^,6969. Barrington C, Knudston K, Alicia O, Bailey P, Aguilar JM, Loya-Montiel MI, et al. HIV diagnosis, linkage to care, and retention among men who have sex with men and transgender women in Guatemala City. J Health Care Poor Underserved 2016; 27:1745-60. and entry into the sex work market ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35..

As for access to health services, various studies have documented that stigma and discrimination can pose serious barriers for transgender women ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,3939. Newman PA, Lee S-J, Roungprakhon S, Tepjan S. Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prev Sci 2012; 13:483-92.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8.^,6969. Barrington C, Knudston K, Alicia O, Bailey P, Aguilar JM, Loya-Montiel MI, et al. HIV diagnosis, linkage to care, and retention among men who have sex with men and transgender women in Guatemala City. J Health Care Poor Underserved 2016; 27:1745-60.^,7070. Reisner SL, Perez-Brumer AG, McLean SA, Lama JR, Silva-Santisteban A, Huerta L, et al. Perceived barriers and facilitators to integrating HIV prevention and treatment with cross-sex hormone therapy for transgender women in Lima, Peru. AIDS Behav 2017; 21:3299-311.. Many avoid going to health services because they anticipate discrimination ⁵⁹59. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6565. Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S16-24. and others are denied access even in public services ⁴⁶46. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.. Studies that analyze the use of the public health system in some countries indicate that transgender women prefer to avoid this care and pay for private services or self-medicate, due to the stigma ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,4949. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102.. Lack of access to hormones ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8. and surgical procedures for body modification and gender reassignment ⁴⁹49. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102. has also been identified in the literature as a barrier to a healthy life.

Stigma and discrimination also pose barriers to access to HIV/AIDS prevention and treatment services, such that many transgender women avoid public healthcare services due to previous experiences of discrimination and mistreatment ⁴⁶46. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.. From this perspective, many studies report the difficulties of transgender women in access to HIV testing and counseling services ⁴⁶46. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79., lack of access to information on prevention ⁵⁸58. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392., lack of confidentiality of HIV test results in public healthcare services ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25., and limited access to condoms ⁵⁶56. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.. In Brazil, self-perceived discrimination was associated with resistance to HIV testing ³⁷37. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7.^,6161. Nemoto T, Cruz T, Iwamoto M, Trocki K, Perngparn U, Areesantichai C, et al. Examining the sociocultural context of HIV-related risk behaviors among kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care 2016; 27:153-65.. Even those who have already tested for HIV faced more stigma when accessing HIV testing and care services, when compared to those who had never been tested. Stigmatization can also hinder retention of transgender women in HIV treatment services ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,6969. Barrington C, Knudston K, Alicia O, Bailey P, Aguilar JM, Loya-Montiel MI, et al. HIV diagnosis, linkage to care, and retention among men who have sex with men and transgender women in Guatemala City. J Health Care Poor Underserved 2016; 27:1745-60..

Interpersonal stigma

The experience of transgender women has been marked by a context of violence and social exclusion in various regions of the world. Violence, both physical ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,1212. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,3838. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4444. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,4545. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,4949. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42., verbal ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4444. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,4545. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35., symbolic ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4545. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124., emotional ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37., and sexual ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,3838. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5050. Wilson E, Pant SB, Comfort M, Ekstrand M. Stigma and HIV risk among Metis in Nepal. Cult Health Sex 2011; 13:253-66.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94. has been extensively documented. In addition, assassinations of transgender women on publicly on the streets have been documented in the literature as the effect of stigma ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120..

Exclusion and violence generally begin in the family through family rejection ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,3838. Kaplan RL, McGowan J, Wagner GJ. HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon. J Int AIDS Soc 2016; 19(3 Suppl 2):20787.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4545. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,4949. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102.^,5050. Wilson E, Pant SB, Comfort M, Ekstrand M. Stigma and HIV risk among Metis in Nepal. Cult Health Sex 2011; 13:253-66.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6161. Nemoto T, Cruz T, Iwamoto M, Trocki K, Perngparn U, Areesantichai C, et al. Examining the sociocultural context of HIV-related risk behaviors among kathoey (male-to-female transgender women) sex workers in Bangkok, Thailand. J Assoc Nurses AIDS Care 2016; 27:153-65.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6565. Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S16-24.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8., physical and sexual assault by family members ⁵⁵55. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94., and expulsion from home ⁴⁵45. Koken JA, Bimbi DS, Parsons JT. Experiences of familial acceptance-rejection among transwomen of color. J Fam Psychol 2009; 23:853-60.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42., so that some end up living on the streets ³⁶36. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.. Physical and sexual abuse have been reported as factors associated with HIV risk in transgender women ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24..

Social exclusion due to stigma can cause intense geographic displacement ⁵⁴54. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8. and entry into sex work ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5050. Wilson E, Pant SB, Comfort M, Ekstrand M. Stigma and HIV risk among Metis in Nepal. Cult Health Sex 2011; 13:253-66.^,5151. Cuadra-Hernández SM, Zarco-Mera A, Infante-Xibillé C, Caballero-García M. La organización de las poblaciones clave ligadas a la transmisión del VIH: una intervención para abatir el estigma; México, 2005-2009. Salud Colect 2012; 8:191-204.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5454. Palazzolo SL, Yamanis TJ, De Jesus M, Maguire-Marshall M, Barker SL. Documentation status as a contextual determinant of HIV risk among young transgender Latinas. LGBT Health 2016; 3:132-8.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.. Sex work in precarious conditions and receiving more money for unprotected sex have been reported in the literature as one of the reasons for unprotected anal sex ⁵⁶56. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35..

These experiences also extend to other interpersonal relations over the life course of transgender women, for example, exclusion from the gay community ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94., rejection by friends ⁶³63. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392., partner violence ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16., police brutality ¹²12. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79., and violence by neighbors ⁵⁵55. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93..

The experience of gender-related discrimination has been associated with sexual risk behaviors for HIV infection in this population ³⁵35. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6., such as unprotected receptive anal sex ⁸8. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,2121. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.. Many studies also report discrimination against transgender women by professionals in health services ¹⁵15. Perez-Brumer AG, Reisner SL, McLean SA, Silva-Santisteban A, Huerta L, Mayer KH, et al. Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru. J Int AIDS Soc 2017; 20:21462.^,3939. Newman PA, Lee S-J, Roungprakhon S, Tepjan S. Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prev Sci 2012; 13:483-92.^,4343. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6363. Logie CH, James LL, Tharao W, Loutfy MR. "We don't exist": a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc 2012; 15:17392.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8., who refuse to call them by their female social name ⁴4. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008; 12:1-17.^,3737. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7.^,5151. Cuadra-Hernández SM, Zarco-Mera A, Infante-Xibillé C, Caballero-García M. La organización de las poblaciones clave ligadas a la transmisión del VIH: una intervención para abatir el estigma; México, 2005-2009. Salud Colect 2012; 8:191-204.^,5555. Pollock L, Silva-Santisteban A, Sevelius J, Salazar X. "You should build yourself up as a whole product": transgender female identity in Lima, Peru. Glob Public Health 2016; 11:981-93.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16. or to use female pronouns ¹⁵15. Perez-Brumer AG, Reisner SL, McLean SA, Silva-Santisteban A, Huerta L, Mayer KH, et al. Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru. J Int AIDS Soc 2017; 20:21462., besides leaving them to wait hours to receive care ⁴³43. Boivin RR. "Se podrían evitar muchas muertas": discriminación, estigma y violencia contra minorías sexuales en México. Sex Salud y Soc (Rio J.) 2014; (16):86-120.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27..

Individual stigma

The combination of interpersonal and structural stigma can cause various negative outcomes in the lives of transgender women, for example, social isolation ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,6565. Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R, et al. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S16-24. and fear of discrimination ⁴⁴44. Melendez RM, Pinto R. "It's really a hard life": love, gender and HIV risk among male-to- female transgender persons. Cult Health Sex 2007; 9:233-45.^,5252. Boyce S, Barrington C, Bolanos JH, Arandi CG, Paz-Bailey G. Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city. Sex Transm Infect 2012; 14:313-27.^,5353. Wilson EC, Arayasirikul S, Johnson K. Access to HIV care and support services for african american transwomen living with HIV. Int J Transgend 2013; 14:182-95.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5959. Woodford MR, Chakrapani V, Newman PA, Shunmugam M. Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India. Glob Public Health 2016; 11:363-79.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6464. Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 2011; 8:e1001124.^,6666. Beattie TSH, Bhattacharjee P, Suresh M, Isac S, Ramesh BM, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66 Suppl 2:ii42-8.. The expectation of rejection related to gender was associated with sexual risk behaviors for HIV infection ³⁵35. Rood BA, Kochaver JJ, McConnell EA, Ott MQ, Pantalone DW. Minority stressors associated with sexual risk behaviors and HIV testing in a U.S. sample of transgender individuals. AIDS Behav 2018; 22:3111-6..

Experiences of discrimination are reported as important elements in the internalization of stigma, which can cause a range of psychosocial stress ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17., such as low self-esteem ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94., and compromise mental health with the occurrence of depression ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94., suicidal ideation ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35., and attempted suicide ⁴¹41. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35..

Alcohol use ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,5757. Chakrapani V, Newman PA, Shunmugama M, Dubrow R. Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care 2011; 23:1687-94.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16.^,6868. Di Stefano AS. HIV's syndemic links with mental health, substance use, and violence in an environment of stigma and disparities in Japan. Qual Health Res 2016; 26:877-94. and use of other drugs ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,99. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.^,4141. Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender community. AIDS Care 2005; 17:289-303.^,5858. Rhodes SD, Alonzo J, Mann L, Downs M, Andrade M, Wilks C, et al. The ecology of sexual health of sexual minorities in Guatemala City. Health Promot Int 2015; 30:832-42.^,6262. Sevelius JM, Patouhas E, Keatley JG, Mallory OJ. Barriers and facilitators to engagement and retention in care among transgender women living with human immunodeficiency virus. Ann Behav Med 2014; 47:5-16. are reported in contexts in which transgender women experience high levels of discrimination, besides the use of these substances before sexual relations ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24. as a practice that increases the risk of HIV infection, mainly through unprotected anal sex ⁶6. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,4040. Operario D, Nemoto T, Iwamoto M, Moore T. Unprotected sexual behavior and HIV risk in the context of primary partnerships for transgender women. AIDS Behav 2011; 15:674-82.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25..

Stigma and discrimination are identified as factors that can directly influence vulnerability to HIV. A study showed that stigma related to transgender identity was more prevalent in transgender women living with HIV than in those without the infection ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24.. The relationship between stigma, discrimination, and HIV infection can be explained by transgender women’s low capacity to negotiate condom use, resulting in unprotected anal sex ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,66. Sanchez T, Finlayson T, Murrill C, Guilin V, Dean L. Risk behaviors and psychosocial stressors in the New York City house ball community: a comparison of men and transgender women who have sex with men. AIDS Behav 2010; 14:351-8.^,1212. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of male, travesti, transgender and transsexual sex workers. Cult Health Sex 2009; 11:125-37.^,2121. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.^,4848. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.. In addition, low self-esteem and depression, caused by intense stigmatization of transgender identities, have been reported as important factors for unprotected sex ⁵⁶56. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35..

Some studies suggest that unprotected anal sex is practiced for validation of female status vis-à-vis the male partner ⁵5. Nemoto T, Operario D, Keatley J, Villegas D. Social context of HIV risk behaviours among male-to-female transgenders of colour. AIDS Care 2004; 16:724-35.^,4646. Gibson BA, Brown S-E, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25., especially with steady partners such as boyfriends or husbands ²¹21. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.. A qualitative study in Colombia showed that although transgender women say they use condoms in all their relations, unprotected sex means fulfillment and success in the eyes of their stable partners or husbands. In this context, the risk is even greater in stable relationships due to the “active” sexual role (insertive anal sex) played by the partner, often idealized by some transgender women in that country ⁴⁹49. Estrada-Montoya JH, García-Becerra A. Reconfiguraciones de género y vulnerabilidad al VIH/Sida en mujeres transgénero en Colombia. Rev Gerenc Políticas Salud 2010; 9:90-102..

Discussion

Analysis of the articles highlighted that stigma due to gender identity, and discrimination, violence, and transphobia, have been identified as structuring elements of the vulnerability to HIV/AIDS among transgender women. Stigma and discrimination were observed wherever the studies were performed, in low, middle, and high-income countries. Nevertheless, some studies documented forms of resistance by transgender women through social activism, participation in support groups, and resilience ⁴⁸48. Ganju D, Saggurti N. Stigma, violence and HIV vulnerability among transgender persons in sex work in Maharashtra, India. Cult Health Sex 2017; 19:903-17.^,5656. Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon. Health Care Women Int 2015; 36:917-35.^,7070. Reisner SL, Perez-Brumer AG, McLean SA, Lama JR, Silva-Santisteban A, Huerta L, et al. Perceived barriers and facilitators to integrating HIV prevention and treatment with cross-sex hormone therapy for transgender women in Lima, Peru. AIDS Behav 2017; 21:3299-311..

Research on stigma and discrimination has grown exponentially in the last decade, encompassing various areas and becoming increasingly specific and complex ³¹31. Pescosolido BA, Martin JK. The stigma complex. Annu Rev Sociol 2015; 41:87-116.. In relation to the studies’ methodologies, we found that the majority took qualitative approaches. A plausible hypothesis for this fact is the complexity of operationalizing the concept of stigma in quantitative studies due to the diversity of definitions for stigma. The quantitative studies reviewed here attempted to solve this problem by using scores for variables related to discrimination based on gender identity (at work, in health services, difficulty in obtaining housing) ⁸8. Sugano E, Nemoto T, Operario D. The impact of exposure to transphobia on HIV risk behavior in a sample of transgendered women of color in San Francisco. AIDS Behav 2006; 10:217-25.^,3636. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66., by factor analysis ⁷7. Stahlman S, Liestman B, Ketende S, Kouanda S, Ky-Zerbo O, Lougue M, et al. Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Cote d'Ivoire, Togo and Burkina Faso. J Int AIDS Soc 2016; 19(3 Suppl 2):20774., or by latent class analysis through the inclusion of specific variables of discrimination (in the family, with friends, with neighbors, at health services, verbal aggression), by adaptation of scales for measuring homophobia ⁹9. Logie CH, Lacombe-Duncan A, Wang Y, Jones N, Levermore K, Neil A, et al. Prevalence and correlates of HIV infection and HIV testing among transgender women in Jamaica. AIDS Patient Care STDS 2016; 30:416-24., or directly by the self-perception of discrimination ³⁷37. Pinheiro-Júnior FML, Kendall C, Martins TA, Mota RMS, Macena RHM, Glick J, et al. Risk factors associated with resistance to HIV testing among transwomen in Brazil. AIDS Care 2016; 28:92-7..

Quantitative studies were marked by emphasis on the relationship between experiences of stigmatization and risk of HIV infection. It is important to recall that the initial interpretations of the AIDS epidemic (1981-1984) were marked primarily by a biomedical, epidemiological, and behaviorist focus ²⁶26. Mann J, Tarantola D. AIDS in the World II: global dimensions, social roots, and responses: the global AIDS policy coalition. New York: Oxford University Press; 1996., leading to the identification and stigmatization of population subgroups with the highest likelihood of including persons with the disease when compared to the general population ⁷¹71. Ayres JRCM, França Jr. I, Calazans GJ, Salleti Filho HC. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: Czeresnia D, Freitas CM, editores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Editora Fiocruz; 2003. p. 117-40.. However, the epidemiological studies reviewed here appear to go beyond a merely behavioral relationship. By reflecting on the concept of stigma, they challenge structural and relational issues that affect analytical dimensions of the concept of vulnerability, producing a shift from exclusively individual issues such as behaviors, attitudes, and risk practices to attention to social factors ²⁶26. Mann J, Tarantola D. AIDS in the World II: global dimensions, social roots, and responses: the global AIDS policy coalition. New York: Oxford University Press; 1996..

Qualitative studies of a sociocultural nature featured significant contributions to the analysis of stigma and vulnerability to HIV, since they were not limited to the dimension of individual behaviors, but expanded the analytical window to include issues related to labeling, distinction, and exclusion, which sustain stigma as a profoundly depreciative attribute. Based on an analysis of narratives and daily social relations, these studies were able to relate the process of stigmatization to transgender women’s social and programmatic vulnerability to HIV.

According to Link & Phelan ⁷²72. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 2001; 27:363-85., stigma exists when a set of interrelated components converge. The first refers to the fact that persons distinguish and label human differences through a substantial simplification of differences, as if there were no gradation between the various categories. In this sense, dualism between the categories usually prevails: cis/trans, gay/straight, black/white, etc. An important characteristic of this component is that prominent attributes differ drastically according to time and place. The second component involves the association of human differences - which are labeled - with negative characteristics; the connection between these two properties shapes what the authors call stereotype. The third component of stigma occurs when the social labels promote the separation between two categories of persons: “us” and “them”.

We thus observe that stigmatization of transgender women produces discrimination, which materializes as social exclusion and various forms of violence. The effects of stigma may take the form of psychiatric outcomes (e.g., suicidal ideation and depression) and substance abuse. Social exclusion may also be related to low schooling and barriers to access to the work market, which in turn can influence entry into the sex trade and the adoption of risky behaviors such as the use of injecting drugs without medical orientation and unprotected anal sex with steady or casual sex partners or clients.

We also found that at the individual level, transgender women face major social isolation, exacerbated by fear of rejection and discomfort or insecurity in public places, producing high rates of depression and suicide, as observed in various studies ⁴4. Herbst JH, Jacobs ED, Finlayson TJ, McKleroy VS, Neumann MS, Crepaz N. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav 2008; 12:1-17.^,7373. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons. J Homosex 2006; 51:53-69.^,7474. Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M, et al. Gender abuse, depressive symptoms, and HIV and other sexually transmitted infections among male-to-female transgender persons: a three-year prospective study. Am J Public Health 2013; 103:300-7.. Substance abuse is also closely related to risk behaviors for HIV infection ¹1. Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV 2017; 4:e169-76.^,7575. Clements-Nolle K, Guzman R, Harris SG. Sex trade in a male-to-female transgender population: psychosocial correlates of inconsistent condom use. Sex Health 2008; 5:49-54.. A study in New York produced strong evidence that gender-based discrimination against young transgender women increased the risk of depression and sexual risk behaviors, which in turn increased the likelihood of HIV infection and other sexually transmissible infections ⁷⁴74. Nuttbrock L, Bockting W, Rosenblum A, Hwahng S, Mason M, Macri M, et al. Gender abuse, depressive symptoms, and HIV and other sexually transmitted infections among male-to-female transgender persons: a three-year prospective study. Am J Public Health 2013; 103:300-7..

At the structural level, the studies show that stigma, through discrimination, can affect access by transgender women to health services, including HIV/AIDS testing and treatment services, which is corroborated by other studies that do not focus specifically on the relationship between HIV and stigma ⁷⁶76. Tagliamento G, Paiva V. Trans-specific health care: challenges in the context of new policies for transgender people. J Homosex 2016; 63:1556-72.^,7777. Cerqueira-Santos E, Calvetti PU, Rocha KB, Moura A, Barbosa LH, Hermel J. Percepção de usuários gays, lésbicas, bissexuais e transgêneros, transexuais e travestis do Sistema Único de Saúde. Interam J Psychol 2010; 44:235-45.. A study in Argentina found that 40.7% of transgender women reported avoiding the use of health services because of their gender identity. The study observed that factors related to the stigmatization process were associated with this phenomenon, for example, the report of having experienced discrimination in health services by health professionals or other patients, or having suffered police brutality ⁷⁸78. Socias ME, Marshall BDL, Aristegui I, Romero M, Cahn P, Kerr T, et al. Factors associated with healthcare avoidance among transgender women in Argentina. Int J Equity Health 2014; 13:81..

The diverse ways of measuring stigma and discrimination in the quantitative studies may hinder the production of future metanalyses on the impact of stigma on the risk of HIV infection. Another important issue is the diversity of uses of the concept of stigma and discrimination in this field of studies. We thus suggest constructing, standardizing, and validating scales to measure the different facets of stigma (individual, interpersonal, and structural) and discrimination (as the action or effect of stigma) in quantitative studies. We found that qualitative studies were the best methodology for analyses intended to address the relationship between the categories of stigma, discrimination, and vulnerability to HIV. Quantitative studies should also consider the sampling processes, since the choice of non-probabilistic procedures is one of the elements responsible for the high risk of bias in the studies analyzed here. We thus suggest that in future studies on the theme, the sample size and selection of participants should be adequate for comparison of the groups and to control confounding.

In the qualitative studies analyzed here, the depth and analytical rigor were procedures that displayed limitations. In qualitative studies, we suggest greater analytical depth and the adoption of different methods for understanding stigma and vulnerability, such as triangulation of methods.

This review study has some limitations. The first is the lack of a metanalysis with the data from the quantitative studies, considering the heterogeneity of the variables they used. There was also difficulty in synthesizing the results of studies with different methodological approaches, since most guidelines for systematic reviews do not consider the integration of qualitative and quantitative studies in the same review. In addition, the current review did not include all of the grey literature from a relevant body of scientific output published online by international organizations, outside the scope of peer-reviewed scientific journals. These limitations notwithstanding, we adopted consistent methodological procedures performed by independent reviewers and assessed the studies that met the eligibility criteria in order to reduce the possibility of bias.

In this review study, we found that stigma and discrimination are related in various ways to individual, social, and programmatic vulnerability to HIV/AIDS. It is necessary to understand how stigma and discrimination operate in society to produce and reproduce social and health iniquities. Understanding the history of stigma and its consequences for individuals and communities, such as discrimination, can help us develop better measures to fight it or reduce its effects ⁷⁹79. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003; 57:13-24.. We thus suggest that health measures and HIV prevention should not be limited to behavioral aspects and risk practices, but should embrace the promotion of a culture of non-discrimination and respect for gender differences.

Acknowledgments

The authors wish to thank the researchers that worked in the PopTrans Study: Lucília Nascimento, Fabiane Soares, Vanessa Barros, Ailton Jesus da Silva, Ana Lucia Vilela, and Munyra Araújo; the young scientist scholarship holder Fábio Alves who contributed to the data collection; the Salvador Association of Transvestites and Transsexuals; the Department of Surveillance, Prevention, and Control of STIs, HIV/AIDS, and Viral Hepatitides; and Capes for the doctoral scholarship for the L. Magno (n. #1031340).

References

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