"I'm Proud of My Courage to Test": Improving HIV Testing and Counseling Among Transgender People in Pattaya, Thailand

This case study from the United States Agency for International Development (USAID)'s AIDSTAR-One (AIDS Support and Technical Assistance Resources, Sector 1, Task Order 1, explores the communication strategies developed by the organisation Sisters, which, since 2004, has sought to offer a safe and welcoming place for transgender (TG) people across Thailand's Chonburi province to seek friendship and support, as well as to encourage the practice of preventive behaviours, such as regular HIV testing and counseling (HTC) and screening for other sexually transmitted infections (STIs). "TG persons are active as leaders, staff, and volunteers at the Sisters service center and in the provincial response to HIV. The result of this leadership has been cross-sector partnerships that maximize the quality and sensitivity of provincial services for TG people and promote an environment for ongoing health-seeking among TG people."

Sisters' service model is designed to help TG people in Pattaya access the health system, providing a safe place for health education, welfare services, and overall support. The programme aims to promote positive behaviours and practices to prevent STI and HIV transmission among its TG clients and partners through outreach education at the places where TG people gather and through referrals to health service providers, to which Sisters' staff accompany clients. The programme's team includes five core staff members, of which four are TG persons. Additionally, a TG volunteer team supports the staff in the various support activities. Sisters offers a drop-in centre; twice-weekly, a TG-licensed nurse provides HTC for a 2-hour period in a private room in the drop-in centre. Sisters' outreach staff and volunteers also visit the places where TG people gather in Pattaya to promote HTC and distribute condoms, lubricant, and information about HIV and STIs, including information about care and support to assist HIV-positive TG people. Sisters' specialised TG services are designed to enable clients to benefit from peer-based support. Furthermore, "Sisters has developed relationships with HIV- and other health-related organizations in Pattaya so that TG people feel comfortable being seen."

Since its inception, Sisters' client data show a fivefold increase in the number of TG people attending services, with client numbers growing from 261 individual clients in 2006 to 1,311 individual clients in 2010. In September 2011, Sisters became one of the sites in the Thailand Ministry of Public Health rapid HIV testing pilot programme; in a 4-month period, 128 clients have been tested and received results, a greater number than those tested for the entire year in 2010. (For other results of cross-sectional surveys carried out by Population Services International (PSI), see the "Results" section of the case study.)

Based on Sisters' experience, here are some recommendations for programme planners and implementers:

• Provide rapid HIV testing with same-day results.
• Strengthen partnerships at the local level: "The local partnerships between Sisters and other organizations in Pattaya, facilitated through memorandums of understanding between USAID-supported international nongovernmental organizations (and their sub-partners including Sisters) and the Chonburi Provincial Health Office, have helped ensure that increasing numbers of TG people are both aware of HIV and aware of HIV services they can access, such as HTC. A system wide, partnership-building approach at the local level helps create a supportive environment for most-at-risk populations, including TG people, to both know their HIV status and get the support and care needed."
• Employ TG service providers to generate demand for HTC.
• Map TG migration and establish links and referral mechanisms to HIV services in other cities.
• Promote income-earning or incentive opportunities for TG people: "Low socioeconomic status and fluctuating income are barriers to accessing health services for TG people. Promoting behavior change and income-earning opportunities, or training sessions, may help TG persons find work and hold on to their jobs. Incentives for attending HTC and returning for test results (if HIV rapid testing is not used) could be provided, such as free movie tickets or shopping discount vouchers."