This year, Guyana will roll out a comprehensive plan for pre-exposure prophylaxis (PrEP). The Guyana Minister of Health, Frank Anthony, announced that the national strategy will be implemented in collaboration with clinics across the country and nongovernmental organizations.

“We want to expand to ensure anyone who is at risk for HIV would have access,” Mr Anthony said. “We believe that with a comprehensive programme for PrEP we can prevent many infections.”

This move marks the culmination of years of advocacy and partial PrEP implementation. The existing PrEP policy is a programme for serodiscordant partners only, so couples in which just one person is living with HIV have been able to access PrEP through the public health-care system to avoid transmission to the HIV-negative partner.  

Since 2015, the World Health Organization has recommended that “people at substantial risk of HIV infection” should be offered PrEP. Several countries have prioritized key populations, including gay men and other men who have sex with men, sex workers and transgender people, for PrEP programming. In Guyana, those groups also have higher HIV prevalence: 8% for transgender women, 6% for sex workers and 5% for gay men and other men who have sex with men.

Last year, Guyana’s Society against Sexual Orientation Discrimination (SASOD Guyana) moved from calling for a more inclusive PrEP programme to offering the service itself. The group teamed with the Midway Specialty Care Centre to fill this gap in the country’s HIV prevention response.

“We want combination prevention to take the front burner,” said Joel Simpson, the SASOD Guyana Managing Director. Through this private sector/civil society partnership, for the first time people in Guyana from any population group were able to elect to initiate PrEP. The medicine was sold to clients at cost price and those accessing the service through the nongovernmental organizations paid no consultation fees.  

A 2018 SASOD Guyana assessment of gay men and other men who have sex with men and transgender people supported by the International HIV and AIDS Alliance (now called Frontline AIDS) found that, when sensitized, there was a high level of interest in taking PrEP. However, just around 60% of focus group participants were willing to pay to do so.

“We need politicians and technical people to base decisions on science and research. At times we have encountered a moralistic approach to setting public policy,” Mr Simpson reflected. “It’s not about whether you belong to a particular population group. It’s about responding to reality and lowering risk.”

Guyana’s HIV programme results are among the Caribbean’s best. The country surpassed the 2020 testing target, with 94% of people living with HIV diagnosed in 2019. Seventy-three per cent of people who knew their status were on treatment. Of those, 87% were virally suppressed. Over the past 20 years, new HIV infections have been reduced by half in the South American nation.

“HIV treatment has come a long way, and not just for people living with HIV. To close the gaps and ensure that no one is left behind it is critical that best practices for prevention and treatment are implemented fully,” said Michel de Groulard, UNAIDS Country Director, a.i., for Guyana and Suriname. “This is why we are pleased about the direction the Health Ministry is taking this year to ensure that PrEP is made available to all who need it. We have the tools to end AIDS. Now we must use them.”

UNAIDS has proposed a new set of bold, ambitious but achievable HIV targets for 2025. Modelling has shown that if the targets promoting favourable societal environments are met, 440 000 AIDS-related deaths would be averted and 2.6 million additional new HIV infections would be prevented. Related modelling has also shown that countries with more enabling societal and legal environments—defined as societies that are gender-equal, free from stigma and discrimination, and with improved access to justice where punitive laws have been lifted and where joint action is taken with the broader development sector—had stronger positive correlations between HIV service coverage and HIV impacts.   

For example, countries with better societal enabling environments are associated with bigger declines in HIV incidence over the past 10 years than countries with worse enabling environments having the same level of condom use by men at the last high-risk sex encounter.

Lower levels of AIDS-related mortality among people living with HIV occur in the countries with the most favourable societal environments, compared to countries with the least favourable societal environments at varying levels of antiretroviral therapy.

Warm smiles greet Lily as she approaches her first stop of the day—one of the 11 brothels scattered across the country that Lily, the President of the Bangladesh Sex Worker Network, visits quarterly to check in with the women and see what assistance they need. Though her visits have been limited in recent months due to movement restrictions to curb the spread of COVID-19, Lily knows well enough that those smiles are a brave front for the troubling times that her peers have experienced.

“I see the sex workers as my sisters—I feel their happiness and pain and I try my best to solve any issue they face,” Lily said. During the COVID-19 pandemic, Lily and the 29 community-based organizations serving sex workers in the country have struggled to respond to the increased calls for support. In March, government countrywide movement restrictions meant that sex workers could no longer have clients, leaving most of them without a source of income and unable to provide for themselves or their families.

“Sex workers’ children faced challenges during the COVID situation because their mothers couldn’t arrange to provide them with food. When we [the Bangladesh Sex Worker Network] learned about this issue, we reached out to many organizations and the private sector for assistance,” explained Lily. Responding to the call to action, the network mobilized funds to support 2100 sex workers across the country. Community-led support in Bangladesh has also garnered global recognition. Most recently, a former sex worker, Rina Akter, was recognized by the BBC for her efforts, and those of her team of helpers, to serve 400 meals a week to sex workers in need.

“While a few sex workers had savings, most could not provide for themselves,” said Rahat Ara Nur, Technical Officer for the United Nations Population Fund in Bangladesh. “Through the United Nations Population Fund, we provided sex workers with COVID-19 prevention commodities, such as masks and handwashing materials, and we also developed public service announcements which were aired on community radio to ensure we raised awareness about COVID-19 precautionary measures among the community."

With the closure of entertainment venues, a classification that includes brothels, some sex workers have resorted to street-based sex work, which increases the risk of violence, condom-less sex and no pay or low pay.

Sex workers are also experiencing increasing vulnerability to gender-based violence. Without a source of income, conflicts about finances arise, and sex worker networks report that their members have experienced abuse at the hands of their spouses, partners and brothel owners.

Some sex workers report that they have become homeless because the brothels have been closed, or in some cases the residents were evicted because rent could not be paid. Many sex workers cite stigma and discrimination as a barrier for other forms of employment. Health outreach services that once provided brothels with sexual and reproductive health services, including HIV testing and prevention, have been suspended due to travel restrictions.

Bangladesh, October 2019. Credit: UNFPA Bangladesh/Naymuzzaman Prince

These developments are not unique to Bangladesh, however. Throughout the Asia–Pacific region, national and regional networks of sex workers are reporting that the COVID-19 outbreak has exacerbated the inequalities faced by sex workers, and many are either not eligible or excluded from social protection services.

“There is no government support specifically targeting sex workers. There is support for the general public, particularly those that are low income, but sex workers are not eligible for these social protections because they work in the informal economy,” said Hnin Hnin Yu, the Chairperson of Sex Workers in Myanmar (SWiM), a nongovernmental advocacy group for sex workers’ rights.

Additionally, many sex workers are migrants (international or internal) and lack the necessary papers or registration with local authorities to access the government’s support. Eligibility criteria for social support, such as documentation of income, proof of residence, national identification, contribution to existing social protection schemes and filing taxes, are all reasons given for excluding sex workers from government support. An online consultation of female sex workers from across the country, organized by UNAIDS and SWiM, revealed that apart from limited funds from humanitarian actors, none of the sex workers had received social support.

“When Global Fund to Fight AIDS, Tuberculosis and Malaria assistance for COVID-19 was allocated, funds for people living with HIV included the most vulnerable sex workers to receive food provisions,” said Mr Myo, Community Support Adviser for UNAIDS in Myanmar. “However, we recognized that this was an ad hoc solution that reached a small portion of the vulnerable population and there is a need for more sustainable support, such as social protection, for sex workers.”

It has become clear that focused support for sex workers must be prioritized. Recognizing that more needs to be known about the gaps in social protection for sex workers, UNAIDS in collaboration with the United Nations Population Fund and the World Food Programme are exploring the possibility of conducting a needs assessment and vulnerability mapping initiative of female sex workers during the COVID-19 pandemic. Data from the community-led mapping initiative will be used to inform programming for livelihood support, food security, improved access to antiretroviral therapy, sexual and reproductive health services and gender-based violence prevention and response services.

Commenting on the prospects of the United Nations agencies joining forces to coordinate a vulnerability mapping exercise with sex worker networks, Ms Nur expressed excitement about how this advocacy tool will not only help to identify the challenges that sex workers face during the COVID-19 outbreak, but it would also catalyse further work to mobilize resources for programmes and address injustices that pre-date the COVID-19 pandemic.

Hnin Hnin Yu cites discrimination and harassment from police as a long-standing challenge facing sex workers’ rights. During the COVID-19 outbreak, communities have reported increased police surveillance, harassment, including physical violence, and demands to pay fees to conduct sex work. In response, SWiM provides community-led, peer-to-peer legal aid for sex workers who have been arrested, educating them about their rights.

For those working closely with community-led organizations it has been inspiring to see that although sex worker networks and the sex workers they represent have seen challenges all around them, they have done their best to support their peers. There is hope that the data gathered in a vulnerability mapping exercise would not only generate the evidence needed to advocate for expanding the reach of social protection and humanitarian response services to be inclusive of sex workers, but could also inform the scale-up of community-led programming. 

Imagine using a health-care system that has no concept of you as a person, or of your unique needs. Nurses might not ask important questions. Doctors might overlook the solutions you really require. You might feel unwelcome.

That has always been the reality for transgender people in Jamaica. A new strategy seeks to change this.

With support from UNAIDS and the United Nations Population Fund (UNFPA), TransWave Jamaica has launched the Trans and Gender Non-Conforming National Health Strategy, the first of its kind in the English-speaking Caribbean. The five-year plan is a rights-based road map for how the health and well-being of transgender people can be advanced. It moves beyond recommendations for the health-care system to the structural and societal changes necessary to achieve equitable access to services and opportunities for the transgender community.

“Too many transgender people stay home and suffer or change who they are to access public health-care spaces,” explained TransWave Associate Director of Policy and Advocacy, Renae Green. “We need improvement to basic services, including psychosocial support. And we need transgender people to be able to access public health services as their authentic selves.”

Through the Unified Budget, Results and Accountability Framework Country Envelope for Jamaica, UNAIDS collaborated with UNFPA to support a robust year-long process of research, community engagement and strategy development, including a monitoring and evaluation framework. The strategy development process was informed by a multisectorial steering committee composed of civil society organizations, international cooperation partners and government authorities.

HIV is a major priority for the Jamaica transgender community. Around 50% of transgender women participants in two recent studies were living with HIV. But there are other pressing concerns. Two surveys found that around half of transgender respondents were unemployed. One third skip meals. One in ten sells sex to survive. Research conducted in 2020 by TransWave found that half of respondents had been physically assaulted in the past year, with 20% reporting sexual assault. More than 80% had been verbally abused.

“The needs go beyond HIV and health care. Other factors affect people’s ability to be safe, to be adherent or to remain HIV-negative. We should take into account the whole person, not just a part,” said Denise Chevannes-Vogel, HIV and AIDS Officer for the UNFPA Sub-Regional Office for the Caribbean.

“We value the fact that we were able to bring together the community to have a discussion about their needs beyond HIV,” said Ms Green.

The TransWave team led the community needs assessment. Some community requests, such as hormone replacement therapy or gender assignment surgery, are unique. But others are common to all people. They want access to health care and housing, education and employment. And they want to see themselves represented in the civil society spaces where many access care and support.

“We will not reach any AIDS-related targets if we do not prioritize transgender health as a whole. People are dying because of violence, living on the streets, lack of jobs and lack of opportunities. Even the HIV prevention knowledge that most people would acquire through formal education settings is not available to transgender people when they are bullied and forced to drop out. So this process was about reflecting on the impact indicators. What would it take for them to live longer, better lives?” said Ruben Pages, UNAIDS Jamaica’s Community Mobilization Adviser.

But what chance does this comprehensive and forward-thinking strategy have of succeeding in a country famed for its social conservatism? The partners are optimistic. On one hand, the approach calls for longer-term goals, including law reform around issues such as gender identity recognition and decriminalizing sex between same-sex partners. But the strategy is also a practical guide for transgender inclusion in systems and frameworks that are already in place. With targeted action there can be quick wins.

Manoela Manova, the UNAIDS Country Director for Jamaica, said the strategy will help the country accelerate progress to end AIDS.

“Going forward, there will be renewed focus on ensuring that excellent prevention, testing and treatment outcomes are achieved across all communities, especially key and vulnerable populations,” Ms Manova said. “This is an opportunity to make good on our commitment to leave no one behind.”

Nadezhda Kilar’s battles with her health service providers began several years ago. “I did not agree with how obstetrics services for women living with HIV are provided in our city,” said Ms Kilar. “From admission to discharge, there was a constant violation of rights.”

Ms Kilar, who lives in Tiraspol, in the Republic of Moldova, has been living with HIV for several years. Her antiretroviral therapy has suppressed her viral load to undetectable levels, but during pregnancy and childbirth she was isolated. She was kept in an isolation ward, gave birth in a separate delivery room and after giving birth was placed in a special room for women living with HIV—a room with bars on the window.

“All the other women leave through the front door, where relatives meet them with flowers and a photographer. But I was let out through the back exit, where there are garbage cans,” she said.

And the discrimination did not stop with her. “Although my son does not have HIV, in the maternity hospital he was alone in a separate special room, under a sign with “HIV contact” written on. Why should a child feel this stigma?” Ms Kilar said.

“I want to give birth to my next child in a normal maternity hospital. And I do not doubt that it will be so. For something to change, a lot still needs to be done, but the main thing is I must defend my rights,” she said.

Ms Kilar’s relationship with her husband started to break down after he became violent towards her. For a long time, she didn’t do anything about it, as she thought that violence was the norm. “My father often beat my mother; I myself was twice in hospital after his beatings.” Not knowing what to do, she sank deeper and deeper into depression. “I didn’t want to live,” she said.

But change slowly came about. When she realized that she could not cope with her financial problems, the violence and her depression, on the advice of a peer consultant at the HIV clinic she attends in Tiraspol she joined the Women’s Mentoring Programme, along with 20 other women living with HIV from different communities in the area. The Women’s Mentoring Programme, a joint project of UN Women and UNAIDS and supported by the Government of Sweden, works through peer consultants and mentors to help women living with HIV to understand and identify their problems, learn about their rights and get support in the fight against violence and discrimination.

“I understood that it would not be the same as before. I realized that I would not tolerate the beatings,” Ms Kilar said.

Since 2019, Ms Kilar has been working in a sales job and has been studying at the university to become a teacher. “It’s not easy for me. I do not sleep much at night, but I have gained confidence that I can solve problems on my own,” she said.

Iren Goryachaya, the Programme Coordinator for the Women’s Mentoring Programme, explained that the programme provides a range of services. “We not only deal with the issues of discrimination in a health-care institution or the fight against violence—we see a woman as a person from different perspectives. First, it is important to help women accept their HIV status and overcome self-stigma. Without this, it is impossible to achieve a different attitude towards herself either from doctors or men.”

“Often, women in the Republic of Moldova have insufficient access to reliable information about HIV. They still cannot defend their right to safe sex. Various forms of violence, including sexual violence, the widespread violation of women’s rights and the controlling behaviour of men further aggravate the situation. All this deprives women of the opportunity to defend their right to health,” said Svetlana Plamadeala, the UNAIDS Representative for the Republic of Moldova.

Ms Kilar looks to the future with confidence. “I see myself as a free woman. I do what I want. My children are growing up in a safe environment. I don't worry about my HIV diagnosis. If I decide to have another child, I will give birth in a normal hospital.”

Communities of people living with HIV have been at the forefront of the community-led response to the COVID-19 pandemic. As part of that response, the Global Network of Young People Living with HIV (Y+ Global), with support from UNAIDS, has launched the Y+ Social Aid Fund for young people living with HIV.

The Y+ Social Aid Fund will be piloted in Nigeria and Malawi, where, with the support of national networks of young people living with HIV ,Y+ Global will offer financial support to young people living with HIV who have been impacted by COVID-19-related restrictions.

“Lockdowns, social instability and treatment interruptions during COVID-19 have further magnified the inequalities that exist in the societies of young people. With grants such as the Y+ Social Aid Fund, young people living with HIV will be able to access basic living essentials that will relieve a portion of the burden on their mental health,” said Igor Kuchin, the Y+ Global Board Chair.

COVID-19 and associated restrictions have had a severe negative impact on the lives of young people living with HIV. Adolescent girls and young women living with HIV are experiencing issues ranging from poor access to menstrual hygiene products to increased need for refuge from gender-based violence while in lockdown. In the 2020 World AIDS Day report, Prevailing against pandemics by putting people at the centre, 27 out of 28 countries surveyed reported that COVID-19 restrictions were impacting antiretroviral therapy initiation for people newly diagnosed with HIV.

“In the context of the COVID-19 pandemic, communities of young people living with HIV are once again leading responses and providing new examples of the solidarity, resilience and innovation that have driven and accelerated the HIV response since the beginning of the HIV pandemic,” said Suki Beavers, Director of the UNAIDS Department for Gender Equality, Human Rights and Community Engagement.

It is hoped that this initial roll-out to provide financial assistance to the most vulnerable young people living with HIV globally will be scaled up. UNAIDS is encouraging other partners and funders to support the scale-up of the Y+ Social Aid Fund in order to ensure that more young people living with HIV are able to access health care and other services during the COVID-19 crisis and beyond. 

“My business suffered because of corona. Before corona, I would sell at least 10 egg trays a week. At the height of the pandemic, I was lucky if I could sell two trays,” lamented George Richard Mbogo, who is living with HIV, a father of two, and owns a chicken, egg and chips business in Temeke, a district in the southern part of Dar es Salaam, United Republic of Tanzania.

The COVID-19 crisis has adversely impacted the livelihoods of people living with HIV in the United Republic of Tanzania, exacerbating the challenges they face. These include HIV service delivery and widening social and economic inequalities.

“Corona has been a very difficult time. I lived with a lot of worry and stress. Driving a bodaboda (motorbike taxi) requires going into crowds and working closely with people. It has been difficult not to fall into anxiety and depression, balancing getting my HIV treatment and work. I had moments thinking of stopping taking my meds, but I didn’t,” said Aziz Lai, a motorcycle driver who also lives in Dar es Salaam. 

Although the colliding pandemics of HIV and COVID-19 are hitting the poorest and the most vulnerable the hardest, through national resource mobilization the COVID-19 crisis has created an opportunity for partners to mobilize in support of the communities they serve.

The collaborative efforts between the government, development partners, including the United States President’s Emergency Plan for AIDS Relief, USAID and UNAIDS, the National Council of People Living with HIV (NACOPHA) and community activists have been key in responding to COVID-19, providing information, services, social protection and hope to people living with HIV during these unprecedented and trying times.

One such initiative is Hebu Tuyajenge, run by NACOPHA and funded by USAID, which focuses on increasing the utilization of HIV testing, treatment and family planning services among adolescents and people living with HIV, strengthening the capacity of community organizations and structures and improving the enabling environment for the HIV response through empowering people living with HIV.

Caroline Damiani is a single mother of three who is living with HIV and keeps chicken and ducks for a living. “Hebu Tuyajenge gave us personal protective equipment, sanitizers, soap and buckets and education about COVID-19 and how to take care of ourselves in order to stay healthy during the pandemic,” she said.

Through community-based services that supplement facility-based care, people living with HIV have been linked to and kept on treatment during the crisis by critical peer-to-peer HIV services.

For Elizabeth Vicent Sangu, who has been living with HIV for 26 years, her “numbers” speak for themselves.

“From my community follow-ups, I have returned 80 people to the clinic for CD4 count testing, inspired 240 people to get tests, reported 15 gender-based violence cases and provided education to 33 groups, including youth and church groups,” she said, beaming with pride.

NACOPHA helped Ms Sangu to come to terms with her status and helped her on her own journey of self-empowerment.

“Since becoming a treatment advocate for Hebu Tuyajenge, I have received help with entrepreneurship and education about HIV. I have become a teacher for others. I have made others brave about living with HIV and getting tested,” she said.

The partnership between community advocates and health facilities has paid off.

“Both we and our patients were fearful initially, but due to information and education, things got better. We focused on providing hourly and daily information to patients about corona and made sure that people practised safe social distancing,” said Rose Mwamtobe, a doctor at the Tambukareli Care and Treatment Centre in Temeke.

“Not only in the United Republic of Tanzania, but globally, COVID-19 is showing once again the cost of inequality. Global health, including the AIDS response, is interlinked with human rights, gender equality, social protection and economic growth,” said Leopold Zekeng, UNAIDS Country Director for the United Republic of Tanzania.

“The key to ending AIDS and COVID-19 is for all partners to come together, on a country and global level, to ensure that we leave no one behind,” he said.

When Lima celebrated this year’s World AIDS Day, the Mayor, Jorge Muñoz, decided to go beyond the traditional lighting of buildings and participation in official events to mark the day. By signing the Paris Declaration to end the AIDS epidemic in cities, he joined the Fast-Track cities initiative, a network of more than 300 municipalities around the world, 70 of which are in Latin America and the Caribbean, and committed to ending the AIDS epidemic as a public health threat by 2030.

Lima has a population of more than 10 million people and accounts for around one third of the national population. Lima and the two other Peruvian municipalities that have already signed the Paris Declaration, Callao and La Victoria, accounted for around 50% of all new HIV infections in the country in 2019.

“Through this public commitment, the city of Lima pledges to carry out the necessary actions to accelerate the response to AIDS, including education, awareness-raising and non-discrimination campaigns,” said Mr Muñoz during the signing ceremony. “We will also implement a work plan to train health personnel and promote access to information and sex education.”

“With the signature of the Paris Declaration, the city has committed to eliminate stigma and discrimination against people living with HIV and key populations, scale up HIV prevention services and contribute to achieving national targets to end AIDS as a public health threat by 2030 as part of the Sustainable Development Goals,” said Andrea Boccardi, the UNAIDS Country Director and Representative for Peru, Ecuador and the Plurinational State of Bolivia.

This is not the first time that Mr Muñoz has taken action against discrimination. In May 2019, when he was the Mayor of the city of Miraflores, he established an ordinance that prohibited discrimination in all its forms in the public and private spheres of the district. Now, as the Mayor of Lima, he has extended that policy to the entire province.

On 1 December 2014, mayors from around the world met in Paris to launch the Fast-Track cities initiative and pledged to adopt a series of commitments to accelerate their response to HIV, with the aim of ending the AIDS epidemic by 2030. Besides committing to ending the AIDS epidemic at the municipal level and uniting as leaders, the signatories also commit to putting people at the centre, addressing the causes of risk, vulnerability and transmission of HIV, using the AIDS response for positive social transformation, building and accelerating appropriate responses reflecting local needs, and mobilizing resources for integrated public health and sustainable development. 

When Lineo Tsikoane gave birth to her daughter, she was inspired to intensify her advocacy for gender equality to give Nairasha a better life as a girl growing up in Lesotho.

“I think a big light went off in my head to say, “What if the world that I’m going to leave will not be as pure as I imagine?” I ask myself, “What kind of world do I want to leave my daughter in?”” she says.

As a result, Ms Tsikoane champions for women’s social, economic and legal empowerment at her firm, Nairasha Legal Support. It offers legal support for women in small and medium enterprises and women who are survivors of sexual and gender-based violence.

“Our main focus is gender-based violence, because this happens to be a country that has one of the highest incidences of rape and intimate partner crime in the world,” she says.

Even before the COVID-19 outbreak, violence against women and girls had reached epidemic proportions globally.

According to UN Women, 243 million women and girls worldwide were abused by an intimate partner in the past year. In Lesotho, it is one in three women and girls.

Less than 40% of women who experience violence report it or seek help.

As countries implemented lockdown measures to stop the spread of the coronavirus, violence against women, especially domestic violence, intensified—in some countries, calls to helplines increased fivefold.

In others, formal reports of domestic violence have decreased as survivors find it harder to seek help and access support through the regular channels. School closures and economic strains left women and girls poorer, out of school and out of jobs, and more vulnerable to exploitation, abuse, forced marriage and harassment.

The United Nations Population Fund (UNFPA) works together with UNAIDS, the United Nations Children’s Fund and the World Health Organization on 2gether4SRHR, a joint programme funded by the Swedish International Development Cooperation Agency, to address HIV and sexual and reproductive health in Lesotho.

During Lesotho’s lockdowns, UNFPA worked with Gender Links, the Lesotho Mobile Police Service and others to support efforts to prevent and respond to incidences of gender-based violence.

“We are ensuring that a helpline, where people experiencing gender-based violence can call, is in place and is working and we are also providing relevant information through various platforms for people to access all the information they need on gender-based violence,” says Manthabeleng Mabetha, the UNFPA Country Director for Lesotho.

Mantau Kolisang, a local policeman from Quthing, Lesotho’s southernmost district, characterized by rolling hills and vast landscapes, says one reason why gender-based violence is prevalent in Lesotho is because the law is not heeded in the rural areas.

“It’s difficult to implement the law since these are remote areas,” he says, adding that while he has made arrests, he has no transport to access far-flung areas in the small mountainous region. 

Lesotho’s law states that a girl can marry at the age of 16 years. However, Mr Kolisang says cultural practices, coupled with contraventions of the law, has made some men believe a 13-year-old girl “can be a wife”, exposing Basotho girls to violence.

“Men don’t regard it as a crime,” he says, adding that girls have been abducted from the mountains for forced marriages.

Between 2013 and 2019, 35% of adolescent girls and young women in sub-Saharan Africa were married before the age of 18 years. Girls married before 18 years of age are more likely to experience intimate partner violence than those married after the age of 18.

Because of poverty, gender inequality, harmful practices (such as child, early or forced marriage), poor infrastructure and gender-based violence, girls are denied access to education, one of the strongest predictors of good health and well-being in women and their children.

In Lesotho’s legal system, women are regarded as perpetual minors. This categorization infantilizes women, Ms Tsikoane says. A man who abuses a woman can often walk away unscathed from the justice system if he says the woman in question is his “wife”, she adds.

“This makes women vulnerable to commodification because a child can be passed around,” she says.

Ms Tsikoane says there is a direct link between the minority status of women and HIV infection in Lesotho. In 2019, there were 190 000 women 15 years and older living with HIV in Lesotho, compared to 130 000 men. 

Adolescent girls and young women between the ages of 15 and 24 years are particularly vulnerable. They accounted for a quarter of the 11 000 new HIV infections in Lesotho in 2019.

“My hypothesis is women cannot negotiate safe sex,” says Ms Tsikoane.

The dangerous reality that Basotho women live in worries Mr Kolisang. But due to a lack of institutional support and resources, he feels his actions have limited effect.

“I feel for these children. I feel for these women. I do feel for them. I can help, but the problem is how?” he laments.

Ms Tsikoane says she finds “trinkets of opportunities” for her and her colleagues to help their clients and navigate a legal system that is not favourable towards women.

“So, if you are not being well assisted at a police station, if you feel like someone is dragging your case and you are struggling to get an audience, we are there. We will support you and we will fight with you,” she says. 

Rena Janamnuaysook steps off the Skytrain in Bangkok’s bustling Sukhumvit shopping district. She looks up, filled with a sense of joy as her eye catches an advert just beyond the platform. The advert is promoting the PrEP in the City campaign to raise awareness and increase the uptake of PrEP among Thai transgender women and shows glimpses of the lives of four transgender women as they juggle their busy work schedules, their role as a mother and their relationship with loved ones, all the while taking control of their health with their daily dose of pre-exposure prophylaxis (PrEP). For Ms Janamnuaysook, a transgender advocate and Program Manager for Transgender Health at the Institute of HIV Research and Innovation (IHRI), this first-ever PrEP campaign for transgender women in Thailand signals promise for the country’s HIV response.

“PrEP campaigns of the past were only targeting other key populations, especially men who have sex with men and gay men. Transgender women were left out from PrEP campaigns or public messages,” says Ms Janamnuaysook. 

HIV prevalence among transgender people in Thailand was estimated to be 11% in 2018, with no sign of a decline in the past few years, and the current uptake of PrEP among transgender women is only 7%, making the group a particularly at-risk population. Less than half (42%) of transgender people reported that they are aware of their HIV status, while services catering to their specific needs are limited.

Limited awareness and knowledge about PrEP contribute to the low uptake. The campaign strategy includes reframing the conversation on PrEP use and challenging negative perceptions of PrEP within the transgender population. “For transgender women who know about PrEP already, they still don't want to get it because it has been associated with risky behaviour or negative behaviour. In Thai society, if you use PrEP then you are perceived to have multiple partners, be a sex worker or must have unprotected sex,” says Ms Janamnuaysook.

Ms Note, a client at the Tangerine Clinic, South East Asia’s first transgender-specific sexual health clinic that offers gender-affirming integrated health care and PrEP, among many other health services, speaks of the perception of PrEP, saying, “I had to be cautious so that nobody sees me taking the pills because sometimes people are worried and think that I am sick.” A goal of the campaign is to normalize the use of PrEP and promote continued use, particularly important when evidence suggests that nearly half of transgender women (46%) in Thailand did not return for their one-month visit after starting PrEP.

“The campaign makes taking PrEP seem similar to taking vitamins or supplements for good health. It removes the image that PrEP is suitable for only certain groups, when in fact it can be taken by anybody,” said Ms Note.  

Adverts for the campaign are on billboards across Bangkok, illustrative of the collaboration with the Bangkok Metropolitan Administration and the commitment to achieve the city’s Fast-Track Targets. Online, IHRI has enlisted various social media influencers, bloggers and opinion leaders in the transgender community to share information about the campaign.

“I personally feel proud to have participated in this campaign, which makes people see the other sides of us, transgender women, and our potentials,” says Jiratchaya (Mo) Sirimongkolnavin, a model and beauty blogger featured in the campaign, who is a former winner of Miss International Queen, one of the world’s largest transgender beauty pageants. She goes on to explain, “It encourages people to have general conversations about sex and how to protect themselves from HIV infection.”

Promoting positive representations of Thai transgender women is an underlying focus of the campaign. “I think the story in the video will help wider audiences to see the diversity among transgender people that actually exists in today’s society,” said Ms Note. “The fact that transgenders have many occupations and abilities.”

At a launch event for the campaign, Satit Pitutecha, Deputy Minister of Public Health, spoke about the government’s commitment to strengthening the HIV response, stating, “The Ministry of Public Health has committed to working in partnership with communities and civil society to promote access to HIV and other health services for transgender people.”

Ms Janamnuaysook is proud of the buzz that the campaign has catalysed, which has been shared widely in Thailand and in surrounding countries. She hopes that this campaign, with its tailored messaging for transgender women, won’t be the last and believes that it can serve as a model for future campaigns focusing on other key populations.

The PrEP in the City campaign was developed by IHRI and is supported by the United States President’s Emergency Plan for AIDS Relief through the United States Agency for International Development’s LINKAGES Thailand Project, managed by FHI 360 and the United States Centers for Disease Control and Prevention, the Bangkok Metropolitan Administration, the Division of AIDS and STIs of the Ministry of Public Health and the UNAIDS Asia–Pacific Office.