In Asia, as in many parts of the world, men who have sex with men often hide their sexual preferences for fear of being harassed by police, ostracised by their families or discriminated against by their communities.
But transgender people, who do not identify with the sexuality they were born with – known as “warias” in Indonesia and “hijimas” in parts of India – are less likely to hide their sexual orientation, and face even higher levels of stigma and discrimination than men who have sex with men (MSM).
The result, according to presenters at a special session on transgenderism at the 8th International Congress on AIDS in Asia and the Pacific (ICAAP), in Colombo, Sri Lanka, this week, is to push them further underground, making them extremely hard to reach with HIV prevention, care and treatment.
They often suffer from depression as a result of rejection by family and friends, which can lead to substance abuse and other risk-taking behaviours, making them particularly vulnerable to HIV infection.
Aashabharathi Ponnusamy, who heads the Tamil Nadu Aravanigal Association in India (“aravani” is the Tamil word for transgender people), which works to secure the rights of transgender people, said they were often also highly mobile because of the difficulties they faced in finding employment.
Taking on a female identity can also put transgender people at risk of the sexual violence that women are more likely to be subjected to in many societies.
Emasculation surgery is illegal in India, and is done in back-street clinics where the instruments may be unsterilised and the risk of infection is high, while little is known about the side effects of hormone medication on HIV-positive people, or interactions with antiretroviral drugs, yet it is available over the counter in countries such as Thailand.
According to Thomas Guadamuz, of the Centre for Research on Health and Sexual Orientation at the University of Pittsburg, in the US, it is also not uncommon for transgenders in Thailand to buy silicone from illegal traders and to share needles to inject it.
A small but growing number of interventions are now targeting MSM and injecting drug users, but most of the evidence relating to transgenders and their HIV risk is anecdotal, and strategies to provide them with HIV programmes are still in their infancy in most countries.
Several speakers at the conference said getting funding for programmes catering to transgender people was extremely difficult.