Australian Trans and Gender Diverse ( TGD ) People and HIv / AIDS : A Discussion Paper

We are now in the 21st century where Hiv is a treatable chronic condition through the use of antiretroviral therapies (ARTs). Yet, Hiv remains an issue for minority populations who have been disproportionately and adversely affected by Hiv even in first world countries such as Australia. There is no good reason for this. While TGD people may have access to such therapies as ART, the problem is not access to treatment, but recognition that they actually exist. This paper discusses the erasure of TGD people in the Australian healthcare system in the discourse around Hiv, and concludes that their voices need to be heard.

in a report by the World Health Organisation (WHO) [5], the continued upswing in the use of and improvement in antiretroviral therapy (ART) has meant a substantial reduction in the number of Hiv infections (down 39%) and Hiv related deaths through AiDs (down 33%) in the 21 st century. Consequently, the number of people living with Hiv is increasing [6]. As of 2016, there are 36.7 million people living with Hiv globally in 2016, of which 1.8 million were newly diagnosed. in the same period, one million people died from Hiv-related causes [5]. From a local perspective in Australia, the latest figures are based upon the 2016 calendar year [7]. The Kirby institute [7] reported that the number of people diagnosed with Hiv in Australia since 1984 was estimated at 37,225, with 1013 newly diagnosed in 2016 (including 38% of cases contracted overseas), with total deaths estimated at around 10000 since the early 1980s [8].
The WHO [9] identified several key populations who are "disproportionately affected by Hiv" and underserved globally. These include people who inject drugs, sex workers, Men who have sex with Men (MsM), incarcerated individuals, and trans and gender diverse (TGD) women [9]. According to WHO [9], TGD women "are 49 times more likely to be living with Hiv than other adult females," and yet are largely ignored in the Oceanic region. in a report by UNAiDs [10], it was estimated that 19% of TGD women live with Hiv globally. There is little data available for TGD men. However, the literature that is available [11][12][13]. indicates that TGD men are at similar risk of contracting Hiv to that of TGD women due to risky sexual behaviours. While TGD women are noted as a key population by WHO [9], in the Australian context, they are not included as part of the Australian epidemic [14]. in effect, they are erased from the current discourse on Hiv [15].
According to UNAiDs [15], no official data exists on TGD people from the Australian perspective. in Australia, the discourse around Hiv continues to be concerned with MsM, heterosexual contact, MsM in combination with intravenous drug use, and intravenous drug use alone. Additionally, some discourse exists around Aboriginal and Torres strait islander peoples who are already included in the totals noted above [16]. This accounts for 96% of the total notifications in 2015. TGD people fall in the other 4% of notifications reported by The Kirby institute [16], but they are not specifically categorised. The Australian society Hiv Management (AsHM) [14] also note TGD people as 'other' or 'undetermined'.
Contracting a condition such as Hiv, while having significant ongoing medical implications for individuals including adhering to medication regimes [17], and the possibility of contracting opportunistic infections due to persistently low CD4 counts [1], also brings with it a level of public stigma [18] and possible or outright discrimination at many levels [1], [8], [19]. in particular, is its perceived association with casual sex and sexual promiscuity [1], mostly among the gay male community [20]. Furthermore, the stigma associated with living with Hiv remains a barrier for long term positive health outcomes [21] for many patients. According to vanable, Carey Blair and Littlewood [21], these barriers manifest themselves in "poor adherence, depressed mood, and decisions regarding serostatus disclosure." The stigma experienced through living with Hiv may also be internalised [18], [22]. This aspect could be particularly relevant to TGD people, who suffer from social [23] and internalised transphobia [24].
Returning to the Australian context, a clinical audit in one clinic in sydney [25] reported high rates of Hiv with 6/141 (4.25%) TGD patients diagnosed with the condition; a finding consistent with that of The Kirby institute [16]. Additionally, one Australian study, which reported on the health and wellbeing of TGD people in Australia and New Zealand [26], noted that the literature on Hiv focused on its transmission. Although the numbers of new diagnoses of Hiv in Australia remains relatively constant, according to the Australian institute of Health and Welfare [27], Hiv notifications per 100000 people have trended upwards since 2002 (from 4.4 to 5.7 per 100000). Therefore, Hiv remains a significant chronic condition, and one in which the experiences of TGD people are ignored. The overwhelming majority of TGD related Hiv literature is from an international context [28][29][30].

Conclusion
The prevalence of TGD people is estimated at 1.4% of the global population [31], yet are up to 4% of Hiv notifications in Australia, which indicates a greater prevalence than the cisgender population. As a consequence, little attention is given to the needs of the TGD population in terms of Hiv due to their erasure from the conversation. Furthermore, because there is a paucity of Australian literature in respect to the lived experience of TGD people with Hiv, it is significantly relevant to understand the psychosocial aspects of TGD people living with Hiv, and how they create meaning from their diagnosis. This can only raise greater awareness of the social problems faced by TGD people navigating life with the duel edged sword of being a TGD person living with a notifiable medical condition such as Hiv. it is time to get the conversation started.