Almost everyone in the HIV world is talking about providing services to key populations – a ground-breaking project in Thailand is providing an example of how to go about it. They kindly answered Spotlight’s questions.
Q: What is the Tangerine project and how does it work?
A: The “Tangerine” Community Health Center is the first transgender-specific sexual health and wellbeing clinic in Thailand and in Asia. Launched in November 2015, Tangerine offers fee-based healthcare services that is situated in an Anonymous Clinic at the largest HIV testing facility in Bangkok at the Thai Red Cross AIDS Research Centre (TRCARC).
The transgender healthcare services include gender affirmative hormone treatment (GAHT) and other sexual health services covering HIV testing and counseling, testing and treatment for other sexually transmitted infections, vaccination for viral hepatitis A, hepatitis B and human papillomavirus (HPV). In addition, the clinic offers antiretroviral treatment (ART), post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP).
Q: What practical steps do you take to create a welcoming environment for trans people?
A: TRCARC conducted a series of transgender community consultations with diverse members of transgender communities, including transgender advocates, healthcare providers, those working within the fashion industry, as well as transgender sex workers. Through the extensive consultations, TRCARC understood the barriers and the unmet health needs. The consultations revealed that transgender people faced obstacles in accessing hormone level monitoring and treatment, the most basic health services that they regularly require to affirm their gender identity. The services available in general are not transgender-friendly, or even worse are provided outside the medical profession. Hormone treatment services were identified as the entry point to make the clinic attractive to its target populations. At the end of the consultation, the name “Tangerine”, the slogan “Where transition fulfils identities” and the logo were mutually adopted.
After the consultation, TRCARC Director Professor Praphan Phanuphak supported all healthcare staff to attend the training on “gender sensitization in healthcare settings” before providing direct services to transgender clients. This created the learning platform between healthcare providers and transgender communities. At the same time, the Tangerine protocol was developed by Dr. Frits van Griensven, which was adapted from international guidelines in order to make it appropriate within the local Thai context. This included hormone supplies, hormone therapy monitoring, and interpretation of laboratory results. Data collection forms were also designed to respond to gender identity, sexual orientation and sex assigned at birth.
Tangerine officially opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. Funding from the United States Agency for International Development (USAID) through the LINKAGES Thailand Project covered the costs of the community consultations, certain healthcare staff, communications, trainings and research studies conducted to specifically address sexual health concerns among transgender people.
Q: What positive outcomes have you seen?
A: From November 2015 to December 2017, there were 1 184 transgender individuals receiving services from Tangerine with 4 501 visits. Of those, 972 were transgender women (TGW) and 212 were transgender men (TGM). Of those TGW, median (IQR) age was 25.4 (22.5-30) years, 55% had education below bachelor’s degree, 25% were unemployed, 56% used alcohol, and 10% used amphetamine-type stimulants. The HIV testing rate among TGW was 91%, with 12% HIV prevalence. 80% were successfully initiated on antiretroviral therapy.
Compared to clients not accessing GAHT services, GAHT service clients were more likely to re-visit the clinic (50% vs. 34%, p<0.001), had higher rates of repeat HIV testing (32% vs. 25%, p=0.019), repeat syphilis testing (14% vs. 9%, p=0.026), PrEP uptake (10% vs. 6%, p=0.015), and use of other sexual health services, including hepatitis B testing/vaccination and sexually transmitted infection treatment (50% vs. 34%, p<0.001).
Recently, Tangerine has intensively utilized transgender influencers as an online-to-offline social media strategy to better reach transgender individuals at high risk for HIV infection, including those who are young and first-time HIV testers. From October 2017-January 2018, there were 247 (60%) transgender clients from online, out of 411 clients.
Jiratchaya Sirimongkolnawin (Mo), Miss Tiffany’s Universe 2016 and Miss International Queen 2017
“Tangerine is the clinic that addressing my several health needs, including hormone treatment. The staff here were very friendly and knowledgeable. Having the HIV testing was no longer fearful for me.” Jiratchaya Sirimongkolnawin (Mo), Miss Tiffany’s Universe 2016 and Miss International Queen 2017
Q: What lessons have you learnt from the project?
A: Some lessons learned from Tangerine are:
- Its strong foundation was built on meaningful participation of the transgender communities at the nascent stage.
- The clinic’s transgender staff who are members of people living with HIV and who represent vulnerable community, have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves.
- Support to enhance knowledge exchange between the trans community and health professionals is necessary to increase access to and provision of transgender health services, aiming at ending AIDS in Thailand and the region.
- The model that integrates gender affirmative hormone services and sexual health services is feasible and effective in increasing access to and retention in HIV testing and PrEP service uptake.
- Available data from Tangerine increases visibility of transgender people in the National AIDS Program and will be further used for the development and refinement of a comprehensive health service package and policy advocacy for transgender people in Thailand.
Tangerine also provides technical assistance to community-based organizations – Sisters Foundation in Pattaya, Mplus Foundation in Chiang Mai, and Rainbow Sky Association of Thailand in Bangkok and Songkhla- in replicating the comprehensive health service model. The community health workers were trained on GAHT and hormone dispensing in different local settings.
Q: What advice could you give to people trying to set up similar projects in other places like e.g. South Africa?
A: In establishing a transgender health project, it is essential to engage transgender communities at the beginning including planning, implementation, and evaluation. This will help you understand their needs and truly respond to the needs of the populations you serve.
Substantial involvement from healthcare providers and leadership from your organization is also fundamental as it will be translated into policy, action and resources. The combination of transgender staff and cisgender staff will help create a learning platform in the healthcare environment and will build mutual trust between transgender communities and healthcare providers.
You may not need to have a full service package at the formation, but you will need to come up with a minimum service package, based on what the communities really need such as hormone counseling, hormone level measurement integrated with other sexual health and HIV services. You can start with a gender-responsive data collection form and gender sensitisation for healthcare team. The services can be integrated in different settings such as public health facilities, MSM-focused community-based organisations or standalone health centres, depending on resources, population size and sustainability.