Enhancing HIV/AIDS Surveillance in the Philippines to Ensure the Transgender Population's Visibility

To combat the Philippines’ HIV/AIDS epidemic, it is critical to implement a countrywide HIV/AIDS surveillance system that is inclusive of the transgender community. The Philippines Department of Health (DOH) monitors the country’s epidemic through the HIV/AIDS and Antiretroviral Therapy Registry of the Philippines, but the transgender community is invisible: traditional data collection, transgender women categorized as men,¹ and lack of HIV testing^2,3 all contribute to closeting the transgender population.

In the Philippines, male individuals make up 93% of the cumulative HIV infections, with 95% of these infections occurring through sexual contact.¹ The HIV/AIDS and Antiretroviral Therapy Registry of the Philippines survey items use dichotomous gender constructs with separate options for men and women and their sexual contact with (1) men, (2) women, or (3) men and women; transgender people do not exist. The few studies of the transgender community, which have focused on transgender women, reported an HIV prevalence of 0.6% to 11.4%, but 48% to 79% had never been tested.^2,3 Thus, HIV prevalence among transgender women may be higher than 11.4%; HIV prevalence among transgender men is unknown. To support current HIV/AIDS policy recommendations, I offer specific suggestions on methods and measures that bring visibility to the transgender community, which can enhance the Philippines’ HIV/AIDS surveillance system.

BRINGING VISIBILITY TO TRANSGENDER PERSONS

Given the rampant rise of HIV/AIDS in the country, policymakers and the World Health Organization (WHO) have outlined DOH’s role in HIV/AIDS surveillance. In 2016, WHO stated that “An effective surveillance system among the transgender population needs to be continued by DOH-[Epidemiology Bureau] to monitor and gather data about the HIV epidemic and risky sexual behaviours, separating transgender women from [men who have sex with men].”^4(p15)

On March 13, 2017, the Philippine HIV and AIDS Policy Act⁵ (Senate Bill 1390) was introduced to improve the existing Philippine AIDS Prevention and Control Act of 1998. Senate Bill 1390 requests that DOH maintain a comprehensive HIV/AIDS monitoring and evaluation program to “receive, collate, process, and evaluate all HIV and AIDS-related medical reports from all hospital, clinics, laboratories and testing centers, including HIV-related deaths and relevant data from public and private hospitals, various databanks or information systems.”^5(p14)

Regardless of the status of Senate Bill 1390, DOH as the country’s surveillance leader can systematically ensure that the transgender community is counted in data collection and visible in national reports. To begin, DOH can work collaboratively with its 13 Philippines National AIDS Council organizations to develop a standard HIV/AIDS questionnaire with existing male–female items, and include transgender items. Next, research experts can offer consultation on methods and measurements (e.g., survey construction, item response theory, cognitive interviewing) for transgender health. Upon confirmation of survey validity and reliability, DOH can mandate that hospitals, clinics, laboratories, and testing centers use the standard survey with patients. Simultaneously, health professionals can receive transgender patient training (e.g., working with transgender patients, correctly marking surveys, data entry in national database).

DEVELOPING A STANDARD SURVEY

To develop a standard HIV/AIDS survey with transgender items, DOH can adopt four examples: (1) the World Professional Association for Transgender Health Professionals,⁶ (2) Being LGBT in Asia,⁷ (3) the Philippine Integrated HIV Behavioral and Serological Surveillance (IHBSS),^2,4 and (4) a sexual contact partnership survey item.

Two-Step Method

First, the World Professional Association for Transgender Health Electronic Medical Records Working Group⁶ suggests applying the two-step method; “Current gender identity” (step 1) contains six response options: “Male,” “Female,” “Transmale/transman/FTM,” “Transfemale/transwoman/MTF,” “Genderqueer/gender-non-conforming,” “Different identity: please state__”; and “Sex assigned at birth” (step 2) includes “Male,” “Female,” and “Other” response choices. Combined, both steps move away from binary male–female constructs, and clarify a respondent’s transgender status.

Transgender Terminology

Next, the Philippines has a wide set of diverse terms (n = 70) used to describe the transgender (transgender man and transgender woman) community as demonstrated in the box on this page. This box was constructed by extracting terms from Being LGBT in Asia: The Philippine Country Report⁷; terms were collected from the lesbian, gay, bisexual, and transgender community, who convened for the Being LGBT in Asia meeting.⁷ Metro Manila (n = 33) had two to three times more transgender terms than Luzon (excluding Metro Manila; n = 13), Visayas (n = 9), and Mindanao (n = 15). While these terms may fit as a subquestion within the World Professional Association for Transgender Health Professionals’ gender identity item, the option of self-identification may reveal the emergence of more culturally relevant terms not listed in the table. Persons who live their daily lives opposite from their assigned birth sex may not consider themselves “transgender.” Thus, DOH can include an open-ended item on “What do you consider yourself to be? (please specify):_____.” An open response item offers respondents options and validates their chosen identity, which may encourage survey participation.

TRANSGENDER TERMINOLOGIES BY ISLAND GROUP IN THE PHILIPPINES

Metro Manilaa (Luzon; n = 33)	Luzon (does not include Metro Manila; n = 13)
AC/DC	Babae
Badaf	Babe
Badette	Baby gandang
Bading	Bakla
Badingger	Bayi
Bakla	Byukonera
Bedidit	Dyosa
Beki/Becky	Ex-men
Binabae	Hari
Cross-dressers	Pagod
Draga	Parlorista
Drag king	Sirena
Drag queen	Syoke
Female-to-male	Visayas (n = 9)
Lady boy	Agi (Ilonggo)
Male-to-female	Bayinhon/babayinon (Waray)
Pa-girl	Binabaye (Cebuano/Hiligaynon)
Pagong	Laki laki (Cebuano)
Postop	Transman
Preop	Transpinay
Okama	Transpinoy
Opeardo	Transwoman
She-male	Mindanao (n = 15)
Silahis	Bayot
Sirena	Dianne
Tranella	Ganda
Trans	Jug-jug
Transgender	Ladyboy
Transman	Madam
Transpinay	Naka-pilar
Transpinoy	Operada
Transsexual	Pa-girl
Transvestites	Pildoras
	Retokada
	Salamat po doc
	Sheman
	Shulang
	Sunshine

^aMetro Manila is on the island of Luzon, but this represents Metro Manila only and not the rest of Luzon.

Specific Sections

Third, DOH can utilize the IHBSS,^2,4 which has a survey for transgender women, and is offered in different languages (e.g., Cebuano, English, Filipino). The survey for transgender women replicates the survey for men who have sex with men (MSM; see 2013 transgender woman and MSM item frequency in Table A, available as a supplement to the online version of this article at http://www.ajph.org), but has seven transgender woman–specific sections. Section C, for example, asks, “What is your current gender identity?” with response options of, “TG [transgender],” “Female,” and “Other.” In addition, entire sections are devoted to sexual contact with male partners (Section D), sexual acts with male partners (Section F), and sex with female partners (Section I). The limitation with the IHBSS, however, is that it was implemented only in three locations (Angeles City, Cebu City, and Manila) and was designed for transgender women, not transgender men. DOH and its Philippines National AIDS Council partners can make improvements by constructing a survey for transgender men, then offer the standard survey in regional languages (e.g., Ilocano, Sambal) and locations throughout the country.

Sexual Partner Contact Survey Item

Lastly, DOH can further enhance their HIV/AIDS surveillance system with a five-option sexual partner contact item. Currently, the HIV/AIDS and Antiretroviral Therapy Registry of the Philippines uses binary male–female sexual contact options. The IHBSS is more expansive, with a transgender women survey and male–female sexual contact sections, but only one item is nonnormative with an option for sex between transgender men and transgender women. A standard HIV/AIDS surveillance survey can be improved by including five respondent groups:

1. male,

2. female,

3. transgender woman (with or without sex-reassignment surgery [SRS]),

4. transgender man (with or without SRS), and

5. other with options to select five possible sexual contact partnerships: (a) male, (b) female, (c) transgender woman (with or without SRS), (d) transgender man (with or without SRS), and (e) other.

These categories and item responses offer options for respondents, including transgender men and transgender women, to more accurately describe their partnerships and sexual contact.

CONCLUSIONS

The paradigm shift of integrating transgender items into HIV/AIDS surveillance systems will make an invisible population become visible just like “men” and “women.” First, the two-step method will confirm transgender status and establish clarity for forthcoming item responses. Couple partnerships (e.g., transgender men with men), and sexual contact (e.g., vaginal intercourse from men to transgender men [without SRS]) items, for example, will be more accurately interpreted, and HIV transmission between sexual partners can be more precisely documented. Thus, HIV prevention and intervention programs can be developed to more effectively serve the given transgender population (transgender women or transgender men) and the risky sexual behavior.

The inclusion of transgender items from the top (DOH) will allow government organizations (e.g., hospitals) and nongovernmental organizations (e.g., Red Cross) to work with civil society to implement programs that enhance the reach–recruit–test–treat–retain HIV-care cascade. Should the current monitoring system continue, in which transgender persons are invisible, HIV may continue to rise among transgender women and perhaps emerge among transgender men. By implementing a countrywide HIV/AIDS surveillance system that is inclusive of the transgender community, the Philippines can move from an HIV care cascade that treats some toward an HIV care cascade that treats all.