The World Health Organization released the new International Classification of Diseases, ICD-11, on 18 June.

The new version no longer defines issues associated with transgender identity as a mental disorder. Instead, there are new categories of gender incongruence of adolescence and adulthood and gender incongruence of childhood, which are classified as conditions related to sexual health.

The ICD provides a holistic look at every aspect of life that can affect health and supports decision-making for programming services and the allocation of spending.

“A shameful history of pathologization, institutionalization, “conversion” and sterilization begins to come to a close,” said Mauro Cabral Grinspan, the Executive Director of GATE, an international organization working on issues of gender identity, gender expression and sex characteristics. 

Michel Sidibé, the UNAIDS Executive Director, welcomed the decision. “This is an important step to increase access to health services by transgender people,” he said.

According to the World Health Organization’s report Transgender people and HIV, transgender people are 49 times more likely to acquire HIV than all adults of reproductive age. They often face, from a young age, stigma, discrimination and social rejection in their homes and communities for expressing their gender identity. Such discrimination, violence and criminalization prevent transgender people from getting the HIV services they need to stay healthy.

Although the new ICD version will be presented for final approval at the World Health Assembly in May 2019, transgender activists are already working on the next steps, including the revision of the categories and definitions, as well as reception at the national level.

Mauro Cabral Grinspan said, “We will work with our allies to ensure effective implementation at the country level to improve regulations while ensuring full access to legal gender recognition and to gender-affirming health care.”

Papua New Guinea has published the results of its first comprehensive survey on key populations in the country. The report is the conclusion of a study that collected estimates of the sizes of key population and biobehavioural data, which will be used to inform prevention and treatment services and policies for HIV and other sexually transmitted infections.

“Only when we ensure that Papua New Guinea’s HIV programming reaches the right people in the right way and place, and at the right time, will the increasing HIV infection rates amongst key populations be slowed,” said David Bridger, the UNAIDS Country Director for Papua New Guinea, at the report’s launch.

The study, Kauntim mi Tu (count us), was carried out in the three largest urban areas of the country—Port Moresby, Lae and Mount Hagen. It revealed that female sex workers, gay men and other men who have sex with men and transgender people often do not seek health care, get tested for HIV or other sexually transmitted infections or use condoms.

Members of key populations in the country face real and perceived stigma, discrimination and violence from police, clients and others in their communities on a daily basis, according to the report. High rates of stigma, discrimination and violence are deterring them from seeking or accessing health-care services.

A member of Friends Frangipani, an organization of sex workers, said, “Many of us live very difficult lives. We don’t all have access to clean water, healthy food or a safe space. We are struggling. Yet we are told to look after ourselves, protect ourselves from HIV and, if HIV-positive, stay healthy. That is very hard for many of us. People need to understand our lives better, and Kauntim mi Tu has done that.”

While adult female HIV prevalence is estimated at 1.1% nationally, the study found that prevalence was nearly 20% among female sex workers in Mount Hagen and almost 15% in the capital, Port Moresby. More than half of gay men and other men who have sex with men and transgender people were found to have never been tested for HIV. Three out of four men in the second largest city, Lae, reported having experienced violence related to their sexuality or sexual identity.

The study included biological testing, with participants offered point-of-care tests and, if needed, same-day treatment for syphilis, chlamydia and gonorrhoea. The research team included members of key populations.

The study’s principle investigator, Angela Kelly-Hanku, noted that much work remains to be done. “This work must be done in the context of safe, respectful and enabling environments that support adequate public health responses and invest in new and dynamic ways to increase HIV testing and ensure that treatment is continuously available, that viral load testing is standard HIV care and that prevention is paramount to everything. We cannot be complacent,” she said.

The report is available at http://www.aidsdatahub.org/sites/default/files/publication/PNG_Kauntim_mi_tu_Multi-Site_Summary_Report_from_the_Key_Population_IBBS_2018.pdf.

Kimi Avalos is a young transgender woman who lives in Buenos Aires, Argentina. Because of stigma and discrimination, she couldn’t continue with her studies and complete high school. She says that she experienced bullying and harassment; her classmates insulted and physically assaulted her, under the indifferent eye of her teachers. “I really wanted to learn, but I had to drop out of school. Now, thanks to the Transgender House, my dream of finishing high school will soon come true,” said Ms Avalos.

Ms Avalos is one of 30 transgender students who recently started a new educational programme through which they can study for primary and secondary school diplomas by attending a combination of face-to-face and virtual classes. This innovative project is implemented in the Transgender House, a community centre for training and empowerment of transgender people founded in Buenos Aires in June 2017 by Marcela Romero, Coordinator of ATTTA (Association of Argentinian Transvestites, Transsexuals and Transgender) in collaboration with the City Council of Buenos Aires.

“To have this house has meant that as transgender people, we can come out from the darkness. The centre is in a visible space, on one of the main streets of Buenos Aires, in the San Cristóbal neighbourhood. This is our achievement; it shows that we exist as a community and that we have the right to a space like any other organization,” explains Ms Romero.

In Argentina, as well as in the rest of Latin America and the Caribbean, stigma and discrimination undermine learning opportunities and educational achievement of transgender people, thus affecting their future employment prospects. Discrimination and stigmatization also prevent transgender people from accessing appropriate health care, including HIV prevention, social protection and justice services.

In the region, transgender people experience frequent physical and sexual violence and hate crimes. According to data from ATTTA, 20 transgender people have been killed in Argentina since the beginning of 2018 and gender-based violence is increasing. Discrimination, gender-based violence and exclusion also contribute to increasing the vulnerability of transgender people to HIV. Transgender women continue to be heavily affected by HIV.

The Transgender House was created with the aim of providing a safe space where transgender people can be empowered and acquire knowledge and skills without the fear of being discriminated against, rejected or attacked. It works in partnership with governmental agencies, civil society and the private sector to provide a wide range of services and programmes based on the specific needs of transgender people.

MORE ON TRANSGENDER DAY OF VISIBILITY

Voices of activists for transgender rights

Among other initiatives, the Transgender House has established integrated counselling services and professional guidance for job searching, as well as legal advice from lawyers, who are available 24 hours a day. In collaboration with the Ministry of Education, Transgender House has recently begun educational projects that range from the implementation of primary and secondary education programmes to professional training, such as on providing care services to the elderly.

Other important activities include the promotion of prevention of HIV and other sexually transmitted infections, HIV testing and vaccination campaigns. The Transgender House also provides continuous psychological assistance and, through a partnership with Fernández Hospital, counselling services on hormone therapy. In addition, the house engages in outreach work with a team of community health promoters that visit sex workers at their places of work at night, distributing condoms and informative material on HIV prevention.

While the Transgender House is currently a successful project, a point of reference for transgender people in Buenos Aires and has multiple partnerships in the city, it hasn’t been an easy process to get to this point. Ms Romero says that she first approached the Buenos Aires City Council eight years ago, advocating for a space where transgender people could meet. Finally, two years ago, the council approved the remodelling and refitting of one of their buildings, and with the help of an architect and the vision of the ATTTA Coordinator, the Transgender House became a reality.

“The Transgender House is a best practice of community service delivery that is contributing to the achievement of the Fast-Track Targets, leaving no one behind,” said Carlos Passarelli, the UNAIDS Country Director for Argentina, Chile, Uruguay and Paraguay.

Around 400 people visit the Transgender House each month to receive counselling and information and approximately 600 people regularly participate in workshops, group meetings and courses there. “I couldn’t be happier and more grateful for the opportunity that I am given at the Transgender House. I hope that this model of respect and promotion of human rights serves as an example to transform and change society so that all of us can live with dignity,” said Ms Avalos.

Close to 10 years after its first edition, a fully updated International Technical Guidance on Sexuality Education published today by UNESCO advocates quality comprehensive sexuality education to promote health and well-being, respect for human rights and gender equality, and empowers children and young people to lead healthy, safe and productive lives.

“Based on the latest scientific evidence, the International Technical Guidance on Sexuality Education reaffirms the position of sexuality education within a framework of human rights and gender equality,” says UNESCO Director-General Audrey Azoulay. “It promotes structured learning about sexuality and relationships in a manner that is positive and centred on the best interest of the young person. By outlining the essential components of effective sexuality education programmes, the Guidance enables national authorities to design comprehensive curricula that will have a positive impact on young people’s health and well-being.”

The Technical Guidance is designed to assist education policy makers in all countries design accurate and age-appropriate curricula for children and young people aged 5 – 18+.

Based on a review of the current status of sexuality education around the world and drawing on best practices in the various regions, the Guidance notably demonstrates that sexuality education:

•  helps young people become more responsible in their attitude and behaviour regarding sexual and reproductive health
• is essential to combat the school dropout of girls due to early or forced marriage, teenage pregnancy and sexual and reproductive health issues
• is necessary because in some parts of the world, two out of three girls reported having no idea of what was happening to them when they began menstruating and pregnancy and childbirth complications are the second cause of death among 15 to 19-year olds
• does not increase sexual activity, sexual risk-taking behaviour, or STI/HIV infection rates. It also presents evidence showing that abstinence-only programmes fail to prevent early sexual initiation, or reduce the frequency of sex and number of partners among the young.

 The publication identifies an urgent need for quality comprehensive sexuality education to:

• provide information and guidance to young people about the transition from childhood to adulthood and the physical, social and emotional challenges they face.
• tackle the challenges posed by sexual and reproductive health issues, which are particularly difficult during puberty, including access to contraception, early pregnancy, gender-based violence, sexually transmitted infections (STIs) and HIV and AIDS
• raise awareness of HIV prevention and transmission, of which only 34 per cent of young people around the world can demonstrate accurate knowledge
• complement or counter the large body of material of variable quality that young people find on the internet, and help them face increasingly common instances of cyberbullying.

The Guidance was produced in collaboration with UNAIDS, United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), UN Women, and the World Health Organization (WHO).

While running a legal clinic for refugees 10 years ago, Kene Esom, former Director of African Men for Sexual Health and Rights (AMSHeR), saw how difficult it was for marginalized or vulnerable people to access health-care services. “That is where I realized that as a lawyer and a human rights defender, I could play a role in increasing access to health-care services and defending human rights.” In his more recent role as Strategic Initiatives Adviser to the AMSHeR Board, he is still at the forefront against discrimination, especially discrimination against gay men and other men who have sex with men in Africa.

Mr Esom makes it clear that when he is talking about human rights in the context of HIV, it is not just the right to health that matters. “There is a pattern of human rights violations towards gay men in many countries, owing particularly to the criminalization of consensual same-sex conduct,” said Mr Esom. “For example, when a newspaper decided to publish a sensational story about gay men having a party, the men were arrested. detained and forcibly tested for HIV. All their due process rights were violated and their right to privacy breached to the extent that their names, addresses and pictures were published in the newspaper.”

Mr Esom said that incidents such as this can roll back years of progress in providing HIV services for key populations. “You cannot provide health services without taking into consideration the human rights context of the populations you are providing the services for. You can build the best health-care facility, but gay men will not come to that facility if they are worried that police will arrest them or that doctors will report their sexual behavior.”

Globally, gay men and other men who have sex with men are 24 times more likely to acquire HIV than adults in the general population. Stigma, discrimination, violence and the criminalization of same-sex sexual practices make it more difficult for these men to access HIV prevention, testing and treatment services.

AMSHeR supports human rights organizations to undertake evidence-informed advocacy. “Human rights defenders play a key role in bringing these issues to light and showing the impact that human rights violations can have on HIV responses, especially on services targeting key populations,” said Mr Esom.

Although there is still a lot of silence around issues surrounding sexuality, sexual orientation and gender identity, there is hope. “When I started this work six years ago it was a completely different context. There were very few people who wanted to advocate on these issues. Now, we have a greater pool of people in countries all over Africa and the world, and the communities are standing up for their rights and demanding access to services and a rights-based approach to service delivery.”

In its work, AMSHeR emphasizes the role of communities in advocating for change and speaking directly to policy-makers. “They are the voices and faces of the issues that affect them.”

The right to come together is key. “Many gay men think they are alone. Isolation increases their vulnerability. Bringing people together to discuss their issues creates a community that is empowered to speak up. If that space is not there, engaging policy-makers and service providers becomes more challenging.”

Mr Esom will be speaking about the promotion and protection of human rights in the context of HIV and other communicable disease at the Human Rights Council Social Forum, which is being held from 2 to 4 October. To hear more from Mr Esom and other human rights activists, register to participate at the Human Rights Council Social Forum at https://reg.unog.ch/event/6958/.

Although new HIV infections and AIDS deaths among young people have decreased, in many places knowledge about how to prevent HIV remains worryingly low. Ahead of International Youth Day UNAIDS spoke to four young people about the challenges they face around HIV.

Pavel Gunaev is 16 years old and lives in St. Petersburg, where he is part of the youth-led network of adolescents and young people living with HIV Teenergizer! Pavel said that in his city young people are not aware about HIV.

“AIDS isn't talked about so young people don’t know about the risks or how to protect themselves from HIV,” he said. “As a result, so many uninformed young people are acting and making decisions based on rumors.” Pavel believes that if everyone does more to inform adolescents and young people and dispel the myths around HIV, ending AIDS will be possible.

Chinmay Modi was born with HIV twenty-three years ago. He is a member of the National Coalition of People Living with HIV in India and country focal point for the Youth LEAD Asia Pacific Network.

“The biggest problem is raising awareness and giving young people age-appropriate information,” he said. In his view, parents are not comfortable talking with their children about sex and society shies away from it too. As a result, he explained, young people are engaging in sex and experimenting new things but with little knowledge of the risks involved.

“Condoms need to be promoted and partners should support youth empowerment so that everyone is held accountable,” Chinmay said. He is also frustrated because in India people cannot access stigma-free HIV services at an early age.

In his view, self-stigma is hampering efforts to tackle discrimination, violence and inequalities related to HIV. That’s why, he explained, he wants more people to share their stories and be positive about being positive.

Moises Maciel couldn’t agree more with Chinmay. He is a 20-year-old LGBT and HIV activist. He became a  member of the National Network of Adolescents and Youth Living with HIV/AIDS in Brazil after discovering his positive HIV status two years ago. Since then, he has been on a journey against HIV-related stigma. He has also been motivating his peers to get tested.

“Young people are still at great risk of HIV infection due to a variety of factors such as social marginalization related to gender and racial inequalities,” he said. “In Brazil, young transgender and gay people are particularly targeted,” he explained.

He said that it baffles him to see how stigma and prejudice still dominate despite people living with HIV living healthy lives with the help of antiretroviral therapy. “We should start talking to young people in an open and responsible way about sexuality, sexually transmitted infections, teenage pregnancy and life responsibilities,” Moises said.

Lorraine Anyango, a Boston-based youth health and rights advocate, works to ensure that young people's voices, specifically around HIV, get heard.

“Young people continue to be left out of spaces and discussions on issues that impact their lives,” Lorraine said. “Their autonomy as individual human beings continues to go unacknowledged, leaving them susceptible to the risk of HIV infection.”

In her opinion, young people’s participation in decisions that affect their health can contribute to strengthen national-level accountability, by ensuring that programmes are effectively responding to their needs. Lorraine concluded by saying, “Recognizing youth sexual and reproductive health and rights, and continuing the conversation on HIV will get us closer to ending AIDS by 2030.”

The 2030 Agenda for Sustainable Development takes ​to scale ​what the AIDS response has been working towards for 30 years—a multisectoral, rights-based, people-centred approach that addresses the determinants of health and well-being. The individual stories in this series highlight the linkages between HIV and related Sustainable Development Goals (SDGs), each told from the personal perspective of people affected by HIV. The series paints a picture of how interconnected HIV is with the SDGs and how interdependent the SDGs are with each other. Most importantly, the stories show us the progress we have achieved with the AIDS response and how far we have left to go with the SDGs.  

Klinika Bernardo, popularly known as the Sundown Clinic, is located along a bustling highway. It operates from 15:00 until 23:00, allowing a maximum number of clients to visit. “We cater to men who have sex with men from all over the Philippines,” said Leonel John Ruiz, head physician at Klinika Bernardo. “Only 40% of our clients are from Quezon City.”

In 2012, Quezon City became the first city in the Philippines to open a clinic providing services for men who have sex with men and transgender people. From the start, demand for services at the Sundown Clinic was high. Almost 250 HIV tests and pre- and post-test counselling services were carried out in its first two months of operation, and 18 people tested positive for HIV.

Although same-sex relationships are legal in the Philippines, there is a high degree of stigma and discrimination towards men who have sex with men. Fear of being outed and ostracized prevents many men from accessing traditional health services. Studies by city health officials show that two-thirds of men who have sex with men in Quezon City have never had an HIV test.

“This is my first HIV test. I do not know what to expect,” said one young man while filling out registration forms. “I tried to read up on HIV so I would have some background information, but it took me a while to gather the courage to come here.” The young man found the staff supportive and skilled at calming his nerves. People who test positive for HIV receive counselling on antiretroviral medicines and are accompanied by staff through their initial months of HIV treatment, which is free in the Philippines.

Quezon City now operates three Sundown Clinics and in the past few years has significantly increased investments in its HIV programmes. With nearly 3 million residents, Quezon City is the Philippines’ most populous urban centre and has made stopping a burgeoning AIDS epidemic a top priority. Mayor Herbert Bautista has encouraged city residents to know their HIV status, and he has taken an HIV test in public. The city’s effort to scale up HIV testing among men who have sex with men has proven successful, with such tests increasing 30 times. Forty per cent of the city’s HIV tests take place in Sundown Clinics, effectively proving that removing barriers increases access to services.

“Since we have been operating, the perspective has definitely changed,” says Leonel. “Before, we would have a hard time inviting people for testing. Now, most of our clients are walk-ins. People are personally and actively seeking information.” Several other local city governments are starting to adapt the Quezon City model and establish their own clinics.

The Sundown Clinic staff speak proudly of their achievements, but they look forward to closing shop one day. “I pray before sleeping,” says Adel, the only female peer educator at Klinika Bernardo. “I hope that one day there will be no one in need of our services. That’s what I am working for.”

SDG 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development

Early in the AIDS response, in the absence of treatment options and the overwhelming scale of people affected by HIV, it was clear that a purely clinical response to the epidemic was not sufficient. Relatives, faith-based organizations and alliances of people affected by HIV stepped in to do what they could to help people die with dignity, to support the orphans, spouses and dependants left behind and to fight for a new way of doing things. Groups of vastly different people linked by the shared experience of the fear and stigma and horror of HIV and AIDS came together to demand that the response go beyond clinics, hospitals and the formal health service.

Embracing and expanding the concept of partnership was revolutionary, not for AIDS but also in the broader development sphere. Partnerships continue to be central to the AIDS response. Coordination and collaboration across a wide range of partners, including sex workers, scientists and social workers, helps to identify and use expertise more effectively, overcome barriers more quickly and allocate resources more efficiently. Partnerships increase awareness and knowledge and create a critical mass of power and support that help to influence policy-makers and spur stakeholders to take action.

The story of the Sundown Clinic in Quezon City in the Philippines embodies SDG 17—strengthen the means of implementation and revitalize the global partnership for sustainable development. The success of the original clinic and the subsequent addition of two more clinics demonstrate how inclusivity continues to define the AIDS response and provide the inspiration for successful partnerships between a wide diversity of stakeholders.

The Martin Ennals Foundation has announced the names of the three finalists for the prestigious global Martin Ennals Award for human rights defenders, which will be awarded in October 2017. One of the three finalists is Karla Avelar, a transgender woman living with HIV from El Salvador who, for more than 20 years, has been defending the human rights of lesbian, gay, bisexual, transgender and intersex (LGBTI) people and advocating for access to health care for people living with HIV.

In 1996, Ms Avelar was one of the founders of the first association of transgender people in El Salvador, and in 2008 she founded the first organization of transgender women living with HIV, COMCAVIS TRANS. The organization works to advance, defend and promote the human rights of LGBTI people, scale up HIV prevention and care and improve access to HIV services for people living with HIV and prisoners.

"On a daily basis, lesbian, gay, bisexual, transgender and intersex people are exposed to death threats, extortion, harassment, physical and verbal violence and discrimination because of our gender identity or sexual orientation,” said Ms Avelar. “This situation makes us vulnerable to HIV."

Ms Avelar, together with COMCAVIS TRANS peer educators, promotes HIV testing and HIV prevention and care among the LGBTI people through outreach activities, such as education and information dissemination in different parts of San Salvador.

Ms Avelar and her team also work on strengthening access to HIV prevention and treatment services for LGBTI prisoners in two penitentiary centres. “We are working on two fronts: with lesbian, gay, bisexual, transgender and intersex people, training them on sexual and reproductive health and HIV prevention, and raising awareness among administrative officials and custodial staff on human rights and zero discrimination,” explained Ms Avelar.

In 2013, the partnership between COMCAVIS TRANS and the penitentiary center of SENSUNTEPEQUE led to the adoption of an agreement, which allows prisoners to have access to condoms each month. COMCAVIS TRANS also supports LGBTI prisoners living with HIV to adhere to their treatment and monitors their access in order to ensure their psychosocial and emotional well-being. 

In El Salvador, LGBTI people continue facing a climate of discrimination and violence, exacerbated by high levels of impunity and limited access to justice. “El Salvador is a country with one of the highest rates of violence in Latin America and, as it is the case throughout the region, the life expectancy of a transgender woman does not exceed 35 years,” said Ms Avelar.

She supports LGBTI people who have suffered human rights violations and acts of violence. Together with her team and the group of volunteers, she advises them and accompanies them to file a complaint. Thanks to the collaboration of other organizations, she makes sure that people in need have open channels to legal and economic assistance. “There are still a lot of barriers,” she says. “However, we are promoting a dialogue with representatives of the national civil police and Office of the National Counsel for the Defense of Human Rights and other authorities to improve the mechanisms to denounce and investigate human rights violations and provide proper and sustained monitoring and evaluation.”

Ms Avelar has also played a significant role advocating for legislation reforms to protect and promote the rights of LGBTI people and address their needs. For example, together with UNAIDS and other national organizations, she participated in a review of an HIV law approved last January. Among other things, the law allows transgender people to receive a better health care free of stigma and discrimination, improve their quality of life and access to health services, education and work, ensuring the respect to their gender identity.

“For all those who know her, Karla Avelar is already the winner of the Martin Ennals Award,” said Celina Miranda, UNAIDS Country Director for El Salvador. “In the midst of all adversity, she is a tireless advocate for human rights, making a difference in the lives of lesbian, gay, bisexual, transgender and intersex people in El Salvador.”

About the Martin Ennals Award

The Martin Ennals Award is an annual prize for human rights defenders. Finalists and the laureate are selected by a jury of 10 of the world’s leading human rights nongovernmental organizations.

UNAIDS is working with partners to reaffirm that the full enjoyment of all human rights and fundamental freedoms for all supports the global response to the AIDS epidemic, including in the areas of prevention, treatment, care and support, and address stigma and discrimination against all people living with, presumed to be living with, at risk of and affected by HIV as a critical element in ending the AIDS epidemic and as outlined in the 2016 United Nations Political Declaration on ending AIDS.