HIV among trans women is at crisis levels. Discrimination is fuelling the fire 

By Chris Bateman, Freelance Journalist

With HIV positivity among urban transgender women in South Africa estimated at 46%, it is becoming increasingly urgent for healthcare workers to undergo sensitivity training. A transgender woman is a person who was assigned the male sex at birth but identifies and lives as woman.

This message emerged in a session on, “Social enablers for key populations,” at the sixth HIV Clinicians’ Society Conference in Cape Town last week.

Key populations are defined groups of people who are at increased risk of HIV acquisition. They also often have legal and social issues related to their identities or behaviours that increase their vulnerability to HIV.

Professor Elma de Vries, a family physician, and secretary of the Professional Association for Transgender Health, says gender-affirming healthcare is highly effective in improving health and wellbeing. In the HIV context, it has been shown to improve viral load suppression. Service users on hormone therapy are also three times more likely to achieve viral load suppression.


However, she says staff at healthcare facilities are often unfriendly or even hostile. Transgender, and gender-diverse people – already hesitant to talk to strangers about their health problems – feel unsafe. De Vries cites a Ritshidze key population report which shows that 9% transgender and gender-diverse, respondents are “outrightly refused treatment because they are trans”.

The report found that unfriendly staff (50%), lack of privacy (35%) and not feeling safe (23%) are the top reasons this group of people did not access healthcare services. 

Two years ago, the HIV Clinician’s Association facilitated the first gender-affirming healthcare guidelines for South Africa.  It is currently in conversation with the National Department of Health to make the guidelines an official policy.

Before this can happen, however, the department says “the service delivery platform has to be ready – so staff need training first. While the Knowledge Hub (which does the training for the department) says it first must be policy before they can train. What we need is a champion at the national department,” says De Vries.

Gender-affirming care

Promoting and supporting gender-affirming healthcare guidelines is a sub-objective of the 2023-2028 National Strategic Plan for HIV, TB and STIs. But nothing has happened on the ground.

De Vries says all staff at key-populations-friendly facilities should undergo sensitisation training developed by the national health department. 

Gender-affirming health services such as delivery of hormone therapy need to move away from specialist clinics into primary care services, as has been done with HIV. 

“We’d like to see gender-affirming healthcare at every facility in the country, with hormones available on the primary essential medicines list as part of the comprehensive package of care at primary care level. My dream is that nobody gets turned away. It took years to get ART to every clinic in South Africa – we’ll take inspiration from that,” she says.’

Currently hormone therapy is only available at primary care level at the Wits Reproductive Health Institute and linked transgender clinics in Johannesburg, Cape Town, and East London. The Aurum Institute has pop-in centres in four urban districts, and Beyond Zero has clinics in another four urban districts.

Accepting gender diversity

Throughout history being trans has been viewed in various ways – as a pathology, or abnormal. 

“Some people were more masculine but assigned female at birth, or the opposite. They want to transition – so why does that make them a patient?” asks psychologist Dr Chris McLachlan who is the chairperson of the Professional Association for Transgender Health

He says the perception of trans people as patient with illnesses or mental health challenges is wrong. 

“We often forget that diversity is part of being human. There are many diversities in life. We have different skins, ages, cultures, eye colours. Some of us are neuro typical and other neuro diverse. It’s the same with gender,” he explains. 

“It’s easy to see gender as binary – female or male. We need to unlearn things we thought were the truth. The idea of how gender is currently constructed is very Western.” 

“The question is how to find a space where we can embrace people to be themselves and freely live their identity. That is why South Africa has guidelines, covering the medical, social, psychological aspects. The World Health Organisation is in the process of developing guidelines on gender-affirming hormones plus the legal rights of transgender and gender diverse people.”

McLachlan works in the Department of Clinical Psychology at Edendale Hospital in Pietermaritzburg. He says transgender and gender diverse people come to see him for various reasons.  “[Though] quite often they need the go-ahead to embark on the journey of transitioning. This places us (healthcare professionals) in the role of gatekeeper, which we should never be. 

“I’ve learnt to embrace diversity and help people to live feely and not in fear, or subject to minority stress the whole time. We have the right to be who we are in a world that’s sometimes very unkind. To be trans is just another diversity. All of us have different diversities in ourselves,” he adds. – Health-e News


  • Health-e News

    Health-e News is South Africa's dedicated health news service and home to OurHealth citizen journalism. Follow us on Twitter @HealtheNews

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