Thailand is one of the primary global centres for gender affirming healthcare practices. Before launching the first four dedicated transgender clinics in this country, the Wits Reproductive Health and HIV Institute (Wits RHI) Key Populations project sent a team to Bangkok, Thailand, in November 2018 in order to learn from experts in the field. Specifically, we wished to gain perspectives that could inform the design and input into an implementation model for our sites in City of Johannesburg, City of Cape Town, Buffalo City, and Nelson Mandela Bay. The team visited four different projects which are serving transgender clients.

RDMA | LINKAGES

The USAID Regional Development Mission for Asia (RDMA), together with the USAID– and PEPFAR-supported LINKAGES project, implements programs to control the spread of the HIV epidemic, and to reach, test, treat and retain transgender women in HIV and AIDS clinical services. LINKAGES also provides technical assistance to the Government of Thailand to strengthen services for high risk populations.

Both RDMA and LINKAGES had a lot to share and trade in terms of how key populations programs can function better in Thailand and South Africa. Lessons gained from South African experience included HIV testing. In Thailand, to provide testing for HIV, one must be a medical technician (a five-year degree). In South Africa on the other hand, given the limited resources, an individual can be trained within six months to conduct testing, which results in better testing rates and faster care. Another key difference is that Thai transgender individuals are not legally allowed to change their gender markers, but in South Africa they can.

RSAT

The Rainbow Sky Association of Thailand (RSAT) is a non-profit organisation dedicated to providing gender-sensitive healthcare to sexually diverse individuals across the LGBTI spectrum. RSAT was founded in 2001 and initiated as a human rights-focused organisation by the National Human Rights Commission in Thailand.

Services include HIV counselling and testing (HCT), antiretroviral therapy (ART), and linkage to care – all with a human rights-based approach to care for key populations. The key organisational focus is to improve the quality of life for people considered to be sexually diverse, improving quality of life and reduction of stigma among men who have sex with men (MSM) and transgender women and reducing stigma and discrimination of sexual orientation, gender identity, and HIV status. All staff at RSAT who engage with transgender clients are transgender themselves or have undergone sensitization training to work with transgender clientele.

TANGERINE

The Tangerine Community Health Centre is the first transgender-specific health center in Thailand. It is a fee-for-service model for quality health services and research on transgender health, with services including:

• HIV/sexually transmitted infection (STI) testing and treatment;
• Psychosocial support and counselling;
• Gender-affirming healthcare;
• Hormone administration, monitoring and use;
• General health services: Hepatitis A, B and C testing, vaginal, neo-vaginal and anal pap smears, anoscope and neovaginoscopy, hepatitis B and HPV vaccinations;
• Medical aesthetics; and
• Other health referrals

Transgender patients can seek services which are not available at public hospitals, which is often a point of entry into HIV prevention and care. Initial consultations and two HIV tests per year are offered free of charge. Tangerine staff members support each client at every step of the cascade of HIV services, helping them navigate the options for prevention or care and providing support for adherence to prevention or treatment regimens. Prioritization of aesthetics is also key for transgender clients. As such, Tangerine also offers botox injections to aid in feminization of features. Clients are referred to Chulalongkorn Hospital for sexual reassignment surgery. The Centre is incorporated into a government health facility, ensuring sustainability for transgender care.

SWING

The Service Workers in Group Foundation (SWING) was established in 2004 to promote and protect the health, human rights, and dignity of sex workers. Programs and activities are run by sex workers and gender diverse staff for sex workers and gender diverse clients.

SWING currently operates drop-in centers in Bangkok, Pattaya and Koh Samui. The centers provide educational and health-related services to sex workers. Core services include English classes; a Non-Formal Education Programme, which enables sex workers to attain a high school certification; and a comprehensive outreach program, whereby health promotion workshops and activities are delivered on HIV and AIDS and sexual health within sex industry workplaces.

SWING offers key populations-led healthcare services (KPLHS) for MSM, male sex workers, transgender people, and transgender sex workers. SWING also participates in community-based research, a Test-and-Treat Cohort Study and an Oral Fluid Operational Research Study. SWING engages in policy advocacy to promote domestic health financing for KPLHS services, pre-exposure prophylaxis (PrEP) scale-up and self-testing. Outreach is conducted as one-to-one contact with key populations in communities, workshops arranged in specific bars and entertainment places, campaigns in public places, and an Enhanced Peer Mobilizer model to create network of peer mobilizers.

The Police Cadet Internship at SWING encourages cadets to work with SWING staff to promote condom use, provide English and Thai lessons, and participate in outreach events. This facilitates the promotion of human rights protection for sex workers and transgender groups, as the police are seen to promote the rights of key populations.

LEARNING IN ACTION

We have incorporated valuable insights gained in Thailand into our programs to ensure that we provide the best gender-affirming healthcare to our own transgender communities.

Through our four transgender sites, the Wits RHI Key Populations Project will implement transgender-specific interventions, including linkage to gender-affirming hormone therapy, reproductive rights counselling, specialist referrals for gender reassignment readiness assessment and surgery. This will include gender sensitization training for staff as well as hormone level monitoring.

Primary health care/HIV interventions will include ART, adherence support, treatment of opportunistic infections, STI screening and treatment, and family planning. Creative Space Workshops will be implemented and used as a platform to discuss transgender-specific issues, including aesthetics and screening. In addition, HIV prevention services will include screening and risk assessment, PrEP, condom distribution, risk reduction interventions, self-screening, and peer outreach. We also intend to use social media and messaging platforms more effectively for outreach.

Psychosocial support will include mental health counselling, peer-led support groups, sensitization training (for gender-affirming care), intimate partner and gender-based violence interventions, and social worker linkage to community support services. We will also train peer educators and counselors to provide gender diverse counselling/sensitized care for transgender clientele.

We look forward to continued learning and sharing from our own experiences to promote empowered transgender communities in South Africa and beyond.