Transgender health has drawn widespread attention in the global HIV response, especially the concept of comprehensive healthcare services for transgender people. Established in 2015 as the first transgender-specific sexual health clinic in Asia, the Tangerine Community Health Clinic was able to provide healthcare services to 3,560 transgender clients who made over 10,450 patient visits. Over 3,160 clients received HIV counseling and testing by our trained transgender staff and gender-sensitive medical professionals. 94% of those testing positive for HIV are enrolled and retained in HIV care.
Throughout the years, the Tangerine Clinic has explored different interventions to improve access to HIV and other comprehensive health services among transgender people. Among the most promising intervention is the use of social media influencers to help generate demand for HIV and other health services. Over 70% of all transgender clients are reached through social media influencers and the acceptance of HIV testing is as high as 96%.
In 2017, the Tangerine Clinic extended similar models to local community health centers in Bangkok, Pattaya and Chiangmai to provide transgender health services and improve the health of the transgender community throughout Thailand. The Tangerine Clinic provided on-site technical assistance to setup the clinic and health service packages, training for community health workers on transgender health, data collection systems and dry runs of service flow. The Tangerine Clinic also provides continuous quality improvement and quality assurance to ensure highest quality standards as well as ongoing support based on the needs of the site. So far, the Tangerine Clinic has provided its technical assistance to eight local community health centers, where almost 1,000 transgender women have been served.
In the Region
The Tangerine Clinic has inspired other countries in the region to establish similar transgender health clinics in their own settings. Victoria by LoveYourself, the first transgender health clinic and community center in the Philippines, was among the first in another country to replicate the Tangerine model. The clinic offers integrated trans-related health services such as gender-affirming health services. The clinic also raises awareness and does advocacy activities aimed at educating the community about transgender people.
To respond to the growing interest locally and internationally, IHRI has established the Tangerine Academy as a regional technical assistance platform for the development of tools, training curricula and resources to support the roll-out of HIV and health service models for transgender people. The Tangerine Academy provides technical assistance and capacity strengthening interventions to organizations in establishing transgender health clinics and implementing comprehensive health service packages.
In 2018, the Tangerine Clinic provided technical assistance to USAID Path Healthy Market Project in Vietnam in establishing the transgender health clinics in Ho Chi Minh City and Hanoi. The team provided training for healthcare providers and community health workers on gender-affirming hormone therapy, HIV/STI related services, substance use & mental health assessment and support. Tangerine Clinic is now providing follow-up support to ensure high-quality health services for transgender people.
Transgender Health Research
We found favorable outcomes from transgender women who take PrEP. PrEP use did not result in reduced GAHT levels, and similarly, feminizing hormone levels were not affected by PrEP. Thus, transgender women may gain effective prevention of HIV and still retain the desirable effect from feminizing hormone therapy. Regarding the use of GAHT with ARV, however, we found that when taken concomitantly, levels of ART and feminizing hormone were both reduced somewhat.
Since 2020, we have been developing 2 more study protocols for transgender clients, both of which aim to evaluate potential pharmacokinetic drug-drug interaction, similarly to iFACT.
In order to accelerate an end to the AIDS epidemic, there have been efforts in scaling up pre-exposure prophylaxis (PrEP) among transgender people who are at substantial risk of HIV. To address concerns specific to the transgender population, Tangerine Community Health Clinic conducted clinical research to determine the interaction between the use of Feminizing Hormone Therapy (GAHT) and Antiretroviral agents Concomitantly among Transgender women, the iFACT study, in 2018. The study evaluated interactions between PrEP and GAHT, and between Antiviral treatment and GAHT.c
Tangerine Academy for Transgender Health
In recent years, there has been increased focus on improving HIV service uptake and retention among transgender communities. Many technical and program guidance documents and tools have been developed including the WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key communities, the Transgender Implementation Tool (TRANSIT), and the Asia-Pacific Regional Trans Health Blueprint.
Over the past few years, Tangerine has received significant interest from medical institutions and community health centers in the country and from countries within the Asia-Pacific region to learn from and replicate the Tangerine model in diverse settings. In response to this need for propagating best practices regionally and internationally, IHRI has established the Tangerine Academy for Transgender Health as a regional technical assistance platform for the development and sharing of tools, training curricula, and learning resources to support further roll-out of HIV and health service models for transgender people. The Tangerine Academy will provide technical assistance and capacity strengthening interventions through three main schemes as follows:
A one-to-three-week apprenticeship will provide on-the-job training, coaching, and mentoring to visiting participants based out of the Tangerine Clinic. The apprenticeship curriculum includes compulsory and elective subjects, which will be tailored to the interests of the participants.
Pre- and post-knowledge assessment tests will be utilized with participants at each session in order to measure participants’ understanding and identify areas to strengthen technical capacity. Elective subjects can be tailored to participants’ specific interests such as high-resolution anoscopy and neo-vaginoscopy, development of targeted communication materials, data use for service improvement, client satisfaction, and other possible subjects upon request. Learning methods will involve lectures, case conferences, clinic observation, assignments and practice in certain topics and skills. Participants will be trained and mentored by a healthcare practitioner team including a physician, nurse, clinic supervisor, counselor, and navigator.
The apprenticeship is suitable for community health workers, medical doctors, nurses, counselors and social workers. Upon course completion, a certificate of apprenticeship will be granted to qualified participants.
Compulsory subjects entail the following:
The Tangerine Academy also provides on-site technical assistance (TA) to organizations in establishing transgender health clinics and implementing comprehensive health service packages. The Academy has developed three models of transgender health services in different settings by partnering with three community-based organizations (CBO).
These models are
1) Sisters as a standalone trans health clinic;
2) Mplus as a hybrid model in MSM health clinic; and
3) Tangerine as an integrated trans health service clinic embedded in a public health/hospital facility.
This on-site TA includes site assessment, community consultation, training for healthcare providers, setup of clinic and service package, data collection systems, dry run of service flow, and quality improvement and quality assurance (QI and QA). The TA can be provided as a one-off or as ongoing support based on the needs of the site. This scheme will also provide applicants the opportunity to visit the key population led health service (KPLHS) models.
At least one applicant from the organization will need to attend and pass the apprenticeship as a prerequisite before the organization requests the TA from this scheme.
In addition to in-person technical assistance, the Academy is equipped with an online platform featuring two levels of learning resources.
a. Certified level: This level delivers high-quality core online courses and access to the social and collaborative learning platform. Certificates will be granted upon users’ completion and can be renewed every two years with a refresher course. Other related tools and resources will also be made available to enable the completion of dynamic courses. Registration is needed.
b. Basic level: The basic level shares public resources available to the public who might be interested in the topics. The level does not need any registration but the depth of content will be more generic and no certification will be granted.