Qualitative data from focus groups carried out with trans women in Brazil provides more context to the quantitative data presented above. Six focus groups were conducted with 36 trans women in 2015 in Rio de Janeiro. Three groups were held with 21 HIV-negative trans women and three with 15 HIV-positive trans women. Health professionals, including one trans woman, conducted the focus groups. Topics included HIV prevention and considered both socio-behavioural factors (such as access to social support and adherence support) and biomedical strategies (such as PrEP and self-testing). Forty-two per cent of participants were aged 18-30, with only 6% having college education.
Transphobia in public healthcare settings emerged as a strong theme from the focus groups. There was a link between trans discrimination and HIV-related stigma, with an assumption that any health problems with trans women were HIV-related. In certain instances, this interfered with access to care in order to avoid stigma. Transphobia manifested in ways such as not having one’s social name respected, with health providers instead using male birth names. Participants also expressed a disconnect between transgender-affirming social and civil policies and the reality of day-to-day practice in healthcare settings in Brazil.
“If we arrive in a public hospital now… If I arrive with a pain here… [the response is] to do an HIV test” (Ana, HIV negative).
“Sometimes, they are dying at home and they don’t want to go to urgent care because [they think] ‘they are going to associate me with HIV’” (Gabriela, HIV positive).
Additionally, violence towards trans women (particularly from sexual partners) emerged as a factor that limited HIV prevention. Trans women are in a particularly vulnerable situation as many earn a living through sex work and are in precarious economic positions.
“When I said that I would only have sex with condoms, he had an extremely aggressive attitude… he tried to physically hurt me.” (Juliana, HIV negative).
While biomedical strategies such as PrEP and Treatment as Prevention (TasP) were considered attractive options beyond condoms, there were concerns related to PrEP making individuals feel invulnerable, doubts about the efficacy of PrEP and doubts about having correct and accurate information. There was also concern about PrEP being another source of stigma as those in the community might not fully understand it.
“Let’s talk about PrEP… for as much as I had said it was a treatment for pre-exposure, people called me, sent Facebook messages, others more openly asked if I was sick.” (Juliana, HIV negative).
An important theme that emerged was that participants trusted information more when it came from other trans women. This emphasises the need for peer-based information and support networks. Prevention and treatment services that employed trans women were seen as more desirable and welcoming.
“There is a trans person who knows how to talk like me, like all of us, she speaks the same language and makes us feel considered, we feel welcome thanks to her.” (Ana, HIV negative).
Considering the findings from both these studies, it is evident that trans women are at high risk of contracting HIV and that the combination of low awareness, high willingness and substantial PrEP eligibility means that there is a definite need to upscale PrEP education and access in trans communities.
Brazil is currently in the process of national PrEP implementation through its public health system yet trans-specific interventions are lacking. Additionally, biomedical interventions cannot be removed from their social context and thus social strategies to combat stigma, violence and discrimination – in both healthcare settings and in broader communities – while implementing gender-affirming and empowering services are crucial for trans women in Brazil.