A Qualitative Study of Intersectional Stigma and Discrimination of Transgender Women Living with HIV: Implications for HIV Vulnerability and Access to HIV-Related Care

Background and Purpose: Transgender (trans) women experience a disproportionate HIV prevalence relative to cisgender adults, due to social and structural contexts of inequity which limit their access to the social determinants of health (e.g., income), increasing their exposure to social (e.g., violence) and individual (e.g., substance use) risk factors. Studies also suggest that trans women living with HIV (WLWH) have lower access to HIV care, due in part to transphobia. Scant stigma literature has explored how intersecting stigma, beyond transphobia, may influence HIV vulnerability and limit access to HIV care. Studies have also failed to document the strengths of trans women in navigating intersectional stigma. This exploratory study sought to understand: (1) how does intersectional stigma influence HIV vulnerability and access to HIV care for trans WLWH? and (2) How do women exhibit resiliency and empowerment in relation to intersectional stigma?

Methods: Semi-structured in-depth individual interviews lasting 30-90 minutes were conducted with 11 trans WLWH purposively sampled based on HIV care engagement (e.g., engaged in HIV care, not engaged in HIV care) and intersecting identities (e.g., diverse ethno-racial backgrounds) and experiences (e.g., sex work involvement) from 3 Canadian cities (Toronto, Montreal, Vancouver) between May 2017 and January 2018. Interviews were audiorecorded and transcribed verbatim. Qualitative data analysis was conducted using framework analysis, a qualitative content analysis method, which includes line-by-line coding using an inductive approach to develop themes, development of an analytic framework, application of the analytic framework to subsequent transcripts, charting of the data, and interpreting the data with key stakeholders. Data analysis was supported through the use of NVivo10.
 Trustworthiness and rigor were enhanced through peer debriefing, reflexive journaling, and maintenance of documentation for auditing purposes.

Results: Women's narratives highlighted intersectional stigma and discrimination, including transphobia, gender non-conformity stigma, and HIV stigma, among others (e.g., racism, classism) experienced by trans WLWH. These intersecting stigmas resulted in pervasive violence which increased HIV vulnerability and decreased access to healthcare. However, findings also suggested that trans WLWH exhibit resiliency and empowerment whilst navigating hostile healthcare settings through multiple mechanisms, such as setting boundaries (e.g., refusing care), becoming self-advocates (e.g., informing providers of how/why their actions or words are discriminatory), supporting each other in accessing competent, stigma-free care (e.g., sharing experiences with other trans women), and becoming public advocates for the rights of trans women living with/affected by HIV (e.g., volunteering at AIDS service organizations).
Trans WLWH recommend multilevel interventions to address gaps in access to the social determinants of health, limited social support, and struggles with mental health and substance use. Trans WLWH also recommend structural change whereby healthcare providers and administrative staff receive additional training about their needs.

Conclusions and Implications: Future research should develop/adapt, implement, and evaluate intersectional stigma reduction interventions to address HIV vulnerabilities and healthcare access disparities for trans WLWH. Social workers supporting trans WLWH should take into account the lived realities of trans women's daily lives at the intersection of multiple intersecting oppressions, as well as acknowledge their many strengths as individuals and as a community.