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However, very little is known about transgender men and their vulnerability to HIV.Across the world transgender people experience high levels of stigma, discrimination, gender-based violence and abuse, marginalisation and social exclusion.Case Study: Community-led services in Thailand In 2015, the LINKAGES project which works with transgender women as well as men who have sex with men in four high-prevalence provinces of Thailand, introduced a number of innovative approaches to improve HIV testing, care and treatment services.A social network recruitment process means community-based project workers conduct structured outreach focused on individuals at highest risk.It is common for transgender people to obtain injectable hormones, the most common form of gender enhancement, and carry out the injecting themselves.Without counselling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission because of the risk of sharing needles with others.18 Transgender people can have very diverse HIV prevention needs.People who test negative but are at high risk of infection can access free pre-exposure prophylaxis, and are contacted regularly for repeat HIV testing.A mobile data-collection platform, e Cascade, links outreach activities to community-based HIV testing and clinics providing ART.

The programme, which began in October 2010, has helped 200 CBOs to provide tailored HIV services to transgender communities.

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Targeted prevention approaches that respond to the specific needs of individuals are essential to reducing HIV infections.

In addition, prevention initiatives that empower transgender people and enable them to take the lead in meeting the needs of their own community are the most effective.19 Sexual health care for transgender people is often inadequate, with many policy makers and service providers failing to address the needs of transgender women as a population distinct from men who have sex with men.20 Only 39% of countries in 2014 had specific programmes targeting transgender people in their national HIV strategies.21 India is one country where HIV services have been successfully targeted at transgender people – reaching an estimated 83% of the transgender population.

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Stigma and discrimination, leading to low self-esteem and disempowerment, can make it harder for transgender people to insist on condom use.14 In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use.15 Gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.16 There are other social factors that make transgender people more likely to engage in high-risk sex.

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