Transgender-competent health care in Vietnam has historically been inaccessible or unavailable. Despite a growing network of clinics that provide gender-affirming health services, transgender people continue to face barriers to receiving quality, stigma-free care.
As a result of these health care gaps, the transgender community experiences high rates of HIV and sexually transmitted infections (STIs) and low usage rates of pre-exposure prophylaxis (PrEP)—the use of medications that help prevent new HIV infections.
To improve the availability and use of PrEP, PATH and its partners, alongside the Vietnam Ministry of Health, are working to improve gender-affirming and transgender-competent health care.
Understanding barriers to care
Studies from Vietnam have shown that transgender women experience several factors that increase their risk of HIV infection, such as sex work, poverty, violence, discrimination, stigma, and social exclusion. However, many transgender women are hesitant to seek out health care due to perceived and real shortfalls in gender-affirming care.
In fact, data from the country’s first PrEP pilot in 2017 showed that during the pilot period, there was minimal increase in PrEP uptake among transgender women, who cited concerns that PrEP would interfere with hormone treatment or produce unwelcome side effects.
To improve health care options for transgender women, the United States Agency for International Development (USAID)/PATH Healthy Markets project surveyed over 400 transgender women in 2018 to better understand their needs. The results were telling: while 68.6 percent of transgender women knew about PrEP, only 7.6 percent had previously or currently used it. And while 60.5 percent wanted gender-affirming care, most did not seek health care due to fear of mistreatment and a lack of transgender-friendly providers.
These results prompted Healthy Markets and its partners to convene a health care team—made up of transgender women community leaders and organizations, ten key population-led clinics, and Healthy Markets project staff—to identify and address the barriers to quality of PrEP services experienced by transgender women. The team ultimately found that transgender women in Vietnam experience five main barriers to care:
1) Limited provider knowledge of transgender-competent care.
2) Limited number of transgender women health care providers in clinics.
3) Lack of gender-affirming care integrated into primary health care services.
4) Limited information on the interaction between PrEP drugs and gender-affirming hormones.
5) Lack of national guidelines on gender-affirming care within HIV services.
Addressing barriers through innovative interventions
To address these barriers, PATH has been working alongside local partners to establish key quality improvements in training, staffing, service delivery, outreach, and health care guidelines through the USAID/PATH Healthy Markets project and now, the USAID/PATH Support for Technical Excellence and Private Sector Sustainability in Vietnam (STEPS) project.
“The gap in transgender people’s access to health care is narrowing. Relevant services, such as hormone-level testing, are now more accessible.”— Do Tay Ha, transgender woman and peer service provider
Improving training and staffing
Healthy Markets partnered with a regional leader in transgender health care, the Tangerine Academy, to offer comprehensive training and mentoring to peer health providers. The training helped boost providers’ capacity for managing treatment for transgender PrEP clients and delivering gender-affirming services as part of integrated HIV and primary health care.
PrEP clinics also employed transgender women health care workers to provide counseling and support to clients.
By improving health care provider competencies and staffing key population–led clinics with transgender women themselves, Healthy Markets and its partners aimed to establish high-quality, trustworthy care that met clients’ needs.
Expanding service delivery
In response to clients’ requests for additional service offerings beyond HIV care, several PrEP clinics introduced hormone-level testing, counseling, and referrals for feminizing procedures; STI and viral hepatitis testing and treatment; and mental health assessments and counseling. Healthy Markets and STEPS provided technical and operational support to assist clinics in growing their service offerings, and helped open nine new key population–led clinics from late 2018 to 2022.
Together with the Vietnam Network of Transgender People, transgender women influencers, and key population–led clinics, Healthy Markets helped launch the “Be Me, Be Happy” campaign—an inclusive online and offline community where transgender women could seek information and support.
As part of the campaign, transgender women leaders directly addressed concerns about PrEP through the dedicated transgender Facebook page “Be Me. Be Sexy,” interactive videos, a TikTok ambassador championship, and other engagements. By enabling transgender women to ask their peers about PrEP in a way that felt comfortable and safe, the campaign helped fill key information gaps about PrEP, unpack any stigma or concerns, and facilitate trust in PrEP services.
“Many transgender leaders are now highly skilled in delivering HIV services and have strong voices on HIV and anti-discrimination issues.”— Vu Hoang Mai Chau, transgender community leader and influencer
In 2018, alongside the Vietnam Administration for HIV/AIDS Control, Healthy Markets supported the formation of the first-ever transgender HIV and health care guidelines, which were published in 2020. The creation of these guidelines marked an enormous milestone in improving Vietnam’s ability to provide high-quality health care to the transgender community.
Now, PATH is supporting advocacy for a new gender affirmation law that will guide the delivery of gender-affirming care across the country. Importantly, it will help define who a transgender person is, how to identify a transgender person, and how to legally recognize the gender identity of a transgender person—all of which are critical for meeting the unique health care needs of transgender people.
Delivering more accessible PrEP
As a result of this work, the projects observed a significant increase in PrEP enrollments among transgender women at Healthy Markets/STEPS–supported sites—from 46 in 2018 to 777 in 2022—and high retention in PrEP services. Additionally, more than 500 transgender women have sought out integrated HIV and primary health care services across five clinics in 2022.
Though improvements in the quality of care have been important, a third of transgender women still report wanting PrEP but not yet taking it. The introduction of a long-acting PrEP product, alongside efforts to understand potential challenges and opportunities in the use of this product among transgender women, will be an important approach for addressing this unmet PrEP need.
STEPS is also supporting the establishment of the first-ever transgender women-owned private clinic, Ruby, which will further break down barriers the transgender community faces in accessing PrEP and other health care services.