Understanding Social and Structural Drivers of HIV Vulnerability Among Transgender Women in Jamaica: Implications for Intersectional and Multi-Level Interventions

Objectives: Globally stigma and discrimination are social drivers of HIV among transgender women. Transgender women are overrepresented in the Caribbean's HIV epidemic. Yet little is known regarding transgender women's HIV prevention and care needs in Jamaica—where there are reports of pervasive stigma and human rights violations targeting transgender women. Transgender women may experience intersectional forms of stigma, including HIV-related, transgender, and sexual stigma. The study objective was to examine intrapersonal, social, and structural correlates of HIV testing, HIV incidence, and sex work involvement among transgender women in Jamaica.

Methods: Cross-sectional survey data collected between March and November 2015 were analyzed for transgender women enrolled in a community-based research study using respondent-driven sampling in Kingston, Ocho Rios, and Montego Bay, Jamaica. Multivariable logistic regression was conducted to identify factors associated with: ever having received an HIV test; HIV-positive serostatus; and sex work involvement in the past year.

Results: Among 150 transgender women (mean age: 24.35 [SD: 13.67]; median monthly income: $124 USD [range: 0-$2489]; residence: 64% Kingston, 22% Ocho Rios, 7% Spanish Town, 2% Montego Bay, 5% elsewhere), half (49%) reported sex work in the past year. Three-quarters (74%) had received a HIV test; of these, 17% were HIV positive. In multivariable analyses, HIV testing was associated with: intrapersonal (perceived HIV risk [AOR: 2.42, CI: 1.36-4.28], perceived STI risk [AOR: 2.09, CI: 1.20-2.42], not getting drunk/high during sex [AOR: 0.49, CI: 0.25-0.95]), social (lower HIV-related stigma [AOR: 0.96, CI: 0.92-0.99], childhood sexual abuse [AOR: 4.30, CI: 1.17-15.78]), and structural (having a regular healthcare provider [AOR: 5.89, CI: 1.46-23.77]) factors.  HIV-positive participants reported intrapersonal (lower self-rated health [AOR: 0.55, CI: 0.30-0.98]), social (forced sex [AOR: 4.14, CI: 1.49-11.51], interpersonal violence [AOR: 6.04, CI: 2.13-17.14], childhood sexual abuse [AOR: 2.71, CI: 1.07-6.83], transgender stigma [AOR: 1.26, CI: 1.06-1.51], sexual stigma [AOR: 1.11, CI: 1.01-1.23]), and structural (homelessness [AOR: 5.06, CI: 1.14-22.49], unemployment [AOR: 4.40, CI: 1.11-17.52]) disparities. Sex work involvement was associated with: intrapersonal (depression [AOR: 1.55, CI: 1.24-1.93], perceived HIV risk [AOR: 1.50, CI: 1.07-2.11]), social (forced sex [AOR: 2.76, CI: 1.36-5.58], transgender stigma [AOR: 1.25, CI: 1.11-1.40], sexual stigma [AOR: 1.15, CI: 1.04-1.27]), and structural (homelessness [AOR: 18.84, CI: 4.92, 72.13], unemployment [AOR: 6.24, CI: 2.42-16.13]) factors.

Conclusions: This research highlights the salience of an intersectional and multi-level approach to explore transgender women’s HIV vulnerability across intrapersonal, social and structural domains. HIV-related stigma was associated with lower uptake of HIV testing. Sex workers and HIV-positive participants were more likely to experience homelessness, unemployment, forced sex, and intersecting forms of stigma based on transgender identity and sexual orientation. International social work with transgender persons can address, and extend beyond, HIV prevention to focus on human rights. HIV prevention and care continuum interventions with transgender women in Jamaica must attend to stigma, violence, mental health, and survival needs. Multi-level interventions can address structural (e.g. homelessness, unemployment, healthcare access), social (violence, intersectional stigma) and intrapersonal (e.g. mental health, substance use) issues to advance social justice, health and wellbeing among transgender women in Jamaica.