Vulnerability to HIV Among Transsexual Women and Transvestites

1. Introduction

Infection by the Human Immunodeficiency Virus (HIV) and the Acquired Immunodeficiency Syndrome (AIDS) comprise chronic, emerging, progressive and universal conditions, which even in the presence of scientific advances, the expansion of strategies for combined prevention and the introduction of Antiretroviral Therapy (ART), show significant notifications in low, medium and high-income countries, as well as a well-documented epidemiological, social, cultural, economic, and health impact in the literature [1,2].

The Joint United Nations Programme on HIV/AIDS (UNAIDS) considers people exhibiting risky sexual practices to be among the population most vulnerable to Sexually Transmitted Infections (STIs) [3]. A study carried out in Brazil showed higher prevalence rates among key populations, which are more vulnerable, with behaviors and situations at risk for infections [4].

Research has shown that the transsexual population (or trans people) have disproportionately higher rates of HIV and other STIs when compared to people in the general population [5]. Globally, for transsexual women, HIV infection has an estimated prevalence of 19.1%, and the chance of infection is 48.8-fold higher than in adults of reproductive age in the general population [6]. Moreover, it has been estimated that the prevalence can reach above 30% in Latin America [4].

It is necessary to address gender identity for a better understanding of this population. Gender concepts and definitions are not limited to the gender ideals associated with genital sex. While sex is related to biology (such as hormones, genes, nervous system, and morphology), gender refers to culture, encompassing psychological and sociological aspects, including all learning experiences since birth [7].

Considering the power established by a heteronormative, patriarchal and sexist society over social relations, transsexual women and transvestites face strong stigmatization and discrimination, which are commonly related to an unfavorable social, economic and psychological context [8].

Regardless of this, discussions about vulnerabilities, aspects that result in limits to effective health care and quality of life of transsexual people with HIV/AIDS, have been scarcely discussed in the public health field. In the study by Abreu et al. (2019) [9], transsexual women and transvestites reported in this context, social prejudice resulting from gender identity and the condition of living with HIV.

The conceptualization of vulnerability to HIV devised by Ayres (2003) [10] highlights the influence of social, economic and cultural factors that reduce the individual's ability to cope, creating conditions that make them more susceptible to HIV infection. This model considers three interrelated dimensions: the Individual Dimension, which includes biological, emotional, and behavioral aspects; the Social Dimension, which encompasses cultural and economic influences; and the Programmatic Dimension, which refers to the availability of resources that are necessary for protection, both social and mental. These dimensions allow a broader analysis of HIV exposure in different groups [10].

In view of the problem, the present study aims to identify vulnerability to HIV/AIDS among transsexual women and transvestites.

2. Materials and Methods

This is a cross-sectional, quantitative-qualitative research carried out with transsexual women and transvestites, aged 18 years or older, with access to a messaging application and/or email, living in a capital city in the northeast of Brazil, from August 2023 to August 2024.

The study capital, located in the northeast region of Brazil, has the Association of Transvestites and Transsexuals of Piauí (ATRAPI) and the Piauí Group of Transsexuals and Transvestites (GPTRANS), which constitute support groups for this population in the state that mobilize transvestites and transsexuals for the defense of their human rights. This population has the support of the Integral Health Outpatient Clinic for the Trans Population, intended for health care.

The transsexual women and transvestites were identified through their social networks, and the snowball technique was used for recruitment. A total of 119 transsexual women and transvestites met the inclusion criteria and 72 agreed to participate voluntarily after signing the Free and Informed Consent Form (TCLE). The inclusion criteria were: being 18 years of age or older, having already undergone a rapid test for HIV; and having been to the health service in the last six months.

This is a population of difficult access and 47 refused to participate, justified by the points, namely: lack of interest in participating in academic research; lack of financial incentive for their participation; lack of representation in the scientific environment and academic spaces, and therefore, they feel little understood; experiences in previous studies that were not very effective and scarce social return; and HIV-related stereotypes.

In this approach, a virtual questionnaire was used to characterize the study population, addressing sociodemographic aspects, sexual behavior, and access to health services.

To expand the assessed topic, and to identify HIV-related vulnerabilities, all participants were invited and 12 transsexual women and transvestites participated in the qualitative stage, using a semi-structured script to carry out the interview. The intentional convenience criterion was adopted, characterized by the selection of participants who can provide valuable and in-depth information about the investigated phenomenon [11].

For the qualitative stage, the participants received an individual invitation by phone call, text message and/or e-mail, and through the social network to participate in the study. After stating their interest in participating in the research, a link to access the virtual questionnaire was made available. The interview took place by appointment, according to the participant's availability. They received a new link to the interview on a virtual platform. The interview was conducted in a single session and mediated by the researcher in charge. The interview was recorded and the average duration was 30 minutes and subsequently, it was transcribed.

Initially, for the quantitative data analysis, the investigated variables were entered into a formatted Excel spreadsheet and transported to the software Statistical Package for the Social Sciences, version 22.0, where frequency measurements were calculated. For the qualitative analysis, the information was transcribed, organized and later analyzed using the thematic content analysis technique based on the sequence of steps proposed by Bardin: Pre-analysis, Exploration of the material and Treatment of the results obtained and their interpretation [12].

During the interviews, aiming to reinforce the confidentiality of the collected information, it was considered, due to the confidentiality criteria, to use pseudonyms to represent the participants. As this is a research with transsexual women and transvestites, the names of representative figures of this population and which recall the historical importance in the transsexual movement were used.

The study followed the rules that regulate research with human beings contained in Resolution Number 466/12 and Number 510/2016 [13,14] of the National Health Council (CNS)[13,14], and Official Letter Number 2/2021/CONEP/SECNS/MS due to the collection procedures in a virtual environment, and the approval of the research ethics committee was obtained through Opinion number 5,543,842.

3. Results

A total of 72 trans women participated in the study, 45 (62.5%) transsexual women and 27 (37.5%) transvestites. Table 1 shows the sociodemographic aspects. Age ranged from 18 to 58 years, with a mean of 30.7 years. Regarding the level of schooling, the majority, 45 (62.5%) completed high school. Regarding skin color, 59 (81.9%) self-declared to be non-white, and 67 (93.1%) stated that they were single. A total of 45 declared they had some kind of profession, (62.5%).

The age at the first sexual intercourse ranged from nine to 24 years, with a mean of 15.4 years, and 42 (58.3%) denied using condoms during their first sexual intercourse. Twenty-two (30.5%) reported having a steady partner, and 27 (37.5%) occasional ones. Condom use during intercourse was declared by four (5.6%) and ten (13.9%) as always using condoms with steady and casual partners, respectively. Of the total number of people who had sexual intercourse in the last six months, 14 (19.4%), said they had sex with four or more people. Regarding the other risk situation, 34 (47.2%) had sexual intercourse against their will.

Alcohol consumption was reported by 53 (73.6%) participants. The frequency of weekly consumption was present in 30 (41.7%). Regarding the use of illicit drugs, 23 (31.9%) reported the use of some substance, with marijuana being reported by 21 (31.9%), cocaine by six (8.3%) and two mentioning the use of crack (2.8%). Others, such as injectable drugs, were not mentioned.

Table 2. Numerical distribution and percentage of sexual behavior characteristics and use of alcohol and other drugs by transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Age at the first sexual intercourse
Under 18 years of age	51	70.8
18 years of age or older	21	29.2
Use of condoms in the first sexual intercourse
Yes	30	41.7
No	42	58.3
Use of condoms with a steady partner (n=22)
Always	04	5.6
Sometimes	07	9.7
Never	11	15.3
Use of condoms with casual partners (n=27)
Always	10	13.9
Sometimes	16	22.2
Never	01	1.4
Number of sexual partners in the last six months
None	09	12.5
One person	27	37.5
From two to three	22	30.5
Four or more	14	19.4
Sexual intercourse against one’s will
Yes	34	47.2
No	35	48.6
He didn't want to answer	03	4.2
Alcohol consumption
Yes	53	73.6
No	19	26.4
Frequency of alcohol consumption
Daily	04	5.6
Weekly	30	41.7
Monthly	06	8.3
Less than once a month	13	18.1
Illicit drug use
Yes	23	31.9
No	49	68.1
Marijuana use
Yes	21	29.2
No	02	2.8
Cocaine use
Yes	06	8.3
No	17	23.6
Crack use
Yes	02	2.8
No	21	29.2

Source: Prepared by the authors (2024).

Table 2. Numerical distribution and percentage of sexual behavior characteristics and use of alcohol and other drugs by transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Age at the first sexual intercourse
Under 18 years of age	51	70.8
18 years of age or older	21	29.2
Use of condoms in the first sexual intercourse
Yes	30	41.7
No	42	58.3
Use of condoms with a steady partner (n=22)
Always	04	5.6
Sometimes	07	9.7
Never	11	15.3
Use of condoms with casual partners (n=27)
Always	10	13.9
Sometimes	16	22.2
Never	01	1.4
Number of sexual partners in the last six months
None	09	12.5
One person	27	37.5
From two to three	22	30.5
Four or more	14	19.4
Sexual intercourse against one’s will
Yes	34	47.2
No	35	48.6
He didn't want to answer	03	4.2
Alcohol consumption
Yes	53	73.6
No	19	26.4
Frequency of alcohol consumption
Daily	04	5.6
Weekly	30	41.7
Monthly	06	8.3
Less than once a month	13	18.1
Illicit drug use
Yes	23	31.9
No	49	68.1
Marijuana use
Yes	21	29.2
No	02	2.8
Cocaine use
Yes	06	8.3
No	17	23.6
Crack use
Yes	02	2.8
No	21	29.2

Source: Prepared by the authors (2024).

Based on the discourse of the participants who work as sex workers, it can be perceived that the use of condoms may be associated with some type of negotiation or relationship of trust with the other person.

"I'm still a call girl, right? But then, I have some regular clients, whom I service at home, I don't stand on the streetcorner, I don't expose myself to danger so much, right? But what I have noticed, is that these clients who come to us, through the Internet, from an ad on some website [...] they do ask, most of them to do it without a condom, [...] so it depends on our awareness of not doing it, right? [...] They even offer extra money to do it without the condom."

"[...] Yes, I did, I had sex without a condom because I felt comfortable with the person." (Xica)

Inconsistent condom use was observed in situations of perceived trust in the sexual partner. Despite reporting the use of condoms, participants affirm that they do not use them in all sexual practices, a behavior also identified with steady partners or people known in the network of contacts.

"I never really had sex without a condom, at least penetration like that, like oral sex, only when I really know the person, right? That you can do it without using it." (Marsha)

"During sexual intercourse we don't use any type of condom, so it's more just checking regularly, doing exams, but for the sake of verification." (Celeste)

"Sometimes when I go out with someone they request "ah, let's do it without a condom", but I don't fall into temptation, I've done it without a condom, a few times... but they were known people and steady partners" (Lea)

Difficulty in accessing health services was reported by 39 participants (54.2%), with the public health service being the main type of access in establishments for 60 respondents (83.3%), whereas 50 participants (69.4%) said they partially solved the problem. The discrimination suffered by these women was stated by 42 participants (58.3%).

Table 3. Situation of access to health services among transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Difficulty in accessing health services
Yes	39	54.2
No	33	45.8
Type of health service you go to
Public	60	83.3
Private	12	16.7
Evaluation of the health service you go to
Excellent	07	9.7
Very good	05	6.9
Good	22	30.6
Regular	30	41.7
Bad	08	11.1
Quality of the health services you go to
Completely solves the problem	13	18.1
Partially solves the problem	50	69.4
Doesn't solve the problem	06	8.3
Can't get health care	03	4.2
Discrimination in health services
Yes	42	58.3
No	30	41.7

Source: Prepared by the authors (2024).

Table 3. Situation of access to health services among transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Difficulty in accessing health services
Yes	39	54.2
No	33	45.8
Type of health service you go to
Public	60	83.3
Private	12	16.7
Evaluation of the health service you go to
Excellent	07	9.7
Very good	05	6.9
Good	22	30.6
Regular	30	41.7
Bad	08	11.1
Quality of the health services you go to
Completely solves the problem	13	18.1
Partially solves the problem	50	69.4
Doesn't solve the problem	06	8.3
Can't get health care	03	4.2
Discrimination in health services
Yes	42	58.3
No	30	41.7

Source: Prepared by the authors (2024).

The perception of embracement is related to the non-use of the social name and/or incorrect form of the pronouns to refer to transsexual women and transvestites. This has shown a direct influence on access to health services. In services specialized in the care of STIs, such as the Testing and Counseling Center, a better embracement of this population was observed, which can justify the greater contact with this public, and thus, the best conduct in the service.

"What is lacking in this embracement is often nominal recognition, right? [...] that I realize there is this difficulty. I already have all the rectified documents [...]. (Katia)

"My SUS card was already up to date, but the system showed the birth certificate name, so I went through this embarrassment when the girl at the reception called me by my registered name and not by my new name, and when you go through that you don't want to go anymore" (Sylvia)

"At the Testing and Counselling Centre I think it's comfortable, they are very polite, very kind, attentive [...] But the other health services aren’t, in the health centers, when we go to one, like, when they identify us, they look at us making a strange face." (Marsha)

In addition to the gaps regarding embracement, other behaviors related to symbolic violence or even transphobia are present in the health service environments. Symbolic violence against trans women is a form of oppression that does not manifest itself physically, but through symbols, language, and social structures that perpetuate discrimination. Trans women face challenges related to their gender identity, and this violence can occur in different ways, as observed in the participants' discourses.

"I think it's strange, because in fact it's that matter of looks, whispers, little things, so like, and there is also a lack of preparedness by several professionals with this relationship, they don't know how to have a sensitive attitude" (Keila)

"Many are not very welcoming, right.. towards us [...] I can guarantee that, because even something that they don't say, even if they're not prejudiced, even if they don't show clear transphobia, right.. but it is veiled according to the looks [...] when you enter a place, you notice how the person is looking at you" (Indianara)

"Because through the health insurance with a private professional, the endocrinologist, she treated me as if I had some kind of disorder, because I was trans and that made me so uncomfortable that I decided it, I was simply not going back to her and looked for the public service of the outpatient clinic." (Celeste)

Another important issue observed was the lack of professional training identified by the population.

This study identified weaknesses in the care provided in specific services for this population.

"Speaking of the trans outpatient clinic [...] It needs to be from trans to trans, for us to recognize each other. So we have qualified and trained trans professionals [...]. So the trans outpatient clinic still doesn't have our trans identity. It is made just to exist. Professionals need to be more qualified, of course [...]. Not only the professionals focused on health, but also the cleaning professionals and the agents who are there complementing the health services, should also be trained to embrace these transgender and transvestite people. And it hasn’t happened yet." (Miss Major)

"Better training of professionals to embrace trans people because, for example, it has happened to me, to go to the trans outpatient clinic to be seen by an endocrinologist, I need to go to the bathroom and the girl directs me to the men's bathroom. Or call me ‘he’." (Celeste)

Regarding the perception of care about HIV/STIs of transsexual women and transvestites in health services, 63 (87.5%) stated that they had already received some recommendations about STIs in general. Regarding the perception of becoming infected with HIV, 27 (37.5%) and 16 (22.2%) considered low or zero chances, respectively. A total of 21 (29.2%) of them said they had already been infected with an STI,.

Regarding the use of PEP and PREP, eight (11.1%) and ten (13.9%) reported using it. As for the rapid HIV test, 67 (93.1%) have already undergone the test, and 16 (50%) do it every six months. Regarding the results of the rapid tests, four (5.6%) were positive.

Table 4. Perception and aspects related to HIV/STI in transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Received recommendations on STIs
Yes	63	87.5
No	09	12.5
Perception of becoming infected with HIV
High	04	5.6
Moderate	13	18.1
Little	27	37.5
Zero	16	22.2
Didn't know how to answer	12	16.7
STI diagnosis
Yes	21	29.2
No	40	55.6
Don't know	11	15.3
Uses PEP
Yes	08	11.1
No	60	83.3
Don't know what it is	04	5.6
Uses PREP
Yes	10	13.9
No	58	80.6
Don't know what it is	04	5.6
Have you already undergone the HIV RT
Yes	67	93.1
No	05	6.9
HIV RT Result
Positive	04	5.6
Negative	63	87.5
Frequency that undergoes the RT
Monthly	03	4.2
Quarterly	15	20.8
Semiannually	30	41.7
Annually	19	26.4

Source: Prepared by the authors (2024).

Table 4. Perception and aspects related to HIV/STI in transsexual women and transvestites. Piauí, Brazil, 2024.

Variables	N	%
Received recommendations on STIs
Yes	63	87.5
No	09	12.5
Perception of becoming infected with HIV
High	04	5.6
Moderate	13	18.1
Little	27	37.5
Zero	16	22.2
Didn't know how to answer	12	16.7
STI diagnosis
Yes	21	29.2
No	40	55.6
Don't know	11	15.3
Uses PEP
Yes	08	11.1
No	60	83.3
Don't know what it is	04	5.6
Uses PREP
Yes	10	13.9
No	58	80.6
Don't know what it is	04	5.6
Have you already undergone the HIV RT
Yes	67	93.1
No	05	6.9
HIV RT Result
Positive	04	5.6
Negative	63	87.5
Frequency that undergoes the RT
Monthly	03	4.2
Quarterly	15	20.8
Semiannually	30	41.7
Annually	19	26.4

Source: Prepared by the authors (2024).

It is important to highlight the professional health behaviors in the presence of HIV, because from the participants' discourses, gaps are observed in these services regarding the recommendations on STI care. Situations such as not requesting the test, monitoring of other STIs, and lack of tests at Basic Health Units were mentioned.

"The doctor, he always requests STI tests and I always ask him to recommend condoms to be performing tests, so yes." (Roberta)

"When I request, when I need or think it is necessary to do tests on STIs and HIV, I request them myself, but I have never been to the health centers that are the gateway, right? They never really give precise guidance, right? That then it would be the Nursing service to do public health, right?" (Miss Major)

"Zero guidance, everything I learned about STIs, about HIV was from my experience in a group, in a social movement, in militancy, the groups I am part of always have lectures, round tables, we are always discussing" (Keila)

Thus, the analysis of the qualitative results on HIV vulnerability among trans women reveals the existence of multiple factors, which go beyond biological issues, encompassing social, economic, and cultural dimensions. The interviews indicate barriers in accessing health services, in addition to the impact of discrimination and stigmatization, which intensify the exposure of this population to HIV.

4. Discussion

The historical and social context of the HIV/AIDS epidemic worldwide and in Brazil is marked by the disproportionality of infection in certain populations, which has historically affected the burden of infection in key populations, when HIV infection rates among Brazilian transsexual women are estimated at 33.1% and the risk of contracting HIV is 19-fold higher when compared to cisgender women in the same age groups, according to [3]. In the present study, four of the total number of the participants reported living with HIV. These data and indicators prompt researchers to investigate the different nuances that exist in the different contexts of health care for trans women and their vulnerabilities.

HIV vulnerability in transsexual women and transvestites exhibit a complexity of social, cultural and structural relationship factors. Thus, situations of stigmatization, discrimination, and marginalization result in significant barriers to health care. Transsexual women and transvestites represent a heterogeneous population group with specific characteristics that impact their experiences and health needs.

Vulnerability is conceptually treated by Ayres (2003) [10] in a comprehensive way and its broader meaning, as it encompasses the aspects that detach from the more traditional approaches, focusing on individual aspects only, that is, centered on the individual. Thus, the conceptualization of vulnerability idealized by Ayres (2003) [10] emphasizes a very close relationship between several factors present in the individual's life: social aspects; economic and cultural aspects that influence the vulnerability of a given person to HIV. Thus, it is understood that this definition of vulnerability can be explained as the situation in which groups or individuals are inserted, which reduce their capacity to face the problem as a result of several difficulties such as reduced understanding, purchasing power, or other characteristics that make them hostage [10].

In this study, important characteristics that may be related to HIV vulnerability were identified in the participants: non-white skin color, inconsistent condom use; negotiation related to condoms use with sexual partners; difficulty in accessing health services; social recognition of gender identity; lack of professional training; and HIV stigma.

The vulnerability of the black population to HIV infection is attributed to structural violence, particularly prevalent in poor communities. The social exclusion they face also affects the development and continuity of HIV prevention programs [15]. Black transsexual women and transvestites face greater vulnerability due to the unfavorable sociocultural context in which the black Brazilian population is inserted. This vulnerability is evidenced by the prevalence of homeless situations and the high rates of sexual violence [16].

A study carried out in a city in the northeast of Brazil showed the importance of the problem affecting black people, a situation that goes beyond the difficulties with HIV care. The study shows that black transsexual women and transvestites have greater social vulnerability due to racial and sexist issues, which may also be related to other structures of oppression, such as regional and class issues [17].

Experiences of discrimination contribute significantly to the internalization of stigma among transgender women, resulting in psychosocial stress, low self-esteem, and negative mental health impacts, including depression, suicidal ideation, and suicide attempts. The use of alcohol and other drugs is common in contexts of high discrimination, increasing the risk of HIV infection, especially during unprotected anal sex [8,18]

In the present study, alcohol consumption was reported by most participants, in addition to the use of illicit drugs. This is an important situation related to HIV control and care, due to the risk behaviors that the consumption of these substances can cause. In addition to strengthening policies related to this problem, there should be psychological and social support services available to deal with mental health issues, which can be the main cause of the use of these substances.

The use of condoms during sexual intercourse is one of the main HIV prevention measures. However, its use by transsexual women and transvestites, especially those who work in the sex market, is inconsistent. According to the study by, Quevedo, Pérez-Arizabaleta and Sevillano (2022) [19], the factors related to this inconsistency are both objective and subjective. Among the objective factors, material conditions stand out, such as the lack of resources to access condoms, and external conditions, such as the refusal of partners to use them during sexual intercourse. Subjective factors include sex education, emotional state, and the use of psychoactive substances.

In Colombia, a study of trans women sex workers revealed that, at some point, they do not use condoms at the request of their clients. Moreover, it has been reported that it is usual for them not to use condoms with regular steady partners [19]. This situation was evidenced in this study, in the participants' statements: "Not in the first meeting, we use condoms, that's fine. But then, in the next encounters, there is already a relaxation [...]".

The responsibility for the use of condoms in sex work falls most of the time on the sex worker, who lacks institutional support, provision of safety nets and/or incentives from the government for means of prevention. In relation to this point, in Pakistan, a considerable degree of knowledge about condoms and awareness of their adequate use was observed [20].

Also in relation to the same study, it was observed that the availability of financial resources was an important motivator for trans women involved in sex work to choose not to use condoms during sexual intercourse with clients. This may be associated with the financial instability this population may present. Thus, there is a disadvantage in the ability to negotiate the use of condoms with their sexual partners [20].

In the situation of vulnerability that transsexual women and transvestites experience, and considering what has been discussed, it is important to highlight that cisgender men should be held more accountable for the dissemination of STIs, and in these situations they are the ones who propose and neglect the means of prevention [21]. Other authors have also addressed the issue of blame and responsibility for STIs, highlighting the association of HIV infections with the male figure [22].

In relation to this topic, in the Brazilian context, in a study carried out in Salvador, (BA), it was pointed out that there is a process of stigmatization that associates transsexual women and transvestites with STIs. According to the study participants, society treats them as the main transmitters of these infections. This conception is reinforced because the approach of health professionals is restricted to sexual health, and trans women have other health needs, such as hormones and mental health issues [21].

This situation was evidenced at the time of data collection for this study, which, at the time of the invitation to participate, many refused, with the justification that scientific research with transsexual women and transvestites was always directed to STIs, and for this reason it would be reinforcing the stigma that the topic may encompass.

The literature points out that the stigma and difficulties in recognizing gender identity are structuring elements to understand vulnerabilities. In addition to the various types of violence and transphobia by society and health services, these women can be absent from HIV prevention and control services, resulting in negative consequences for individual and collective health [8,23].

The non-recognition of gender identity and other types of violence constitute barriers to the access to health services faced by the trans population in various social contexts, both in Brazil and in other countries. Depending on the country, the prejudice and oppression are greater, such as Nigeria, a country where there are punitive laws for the LGBTQIA+ community. A Nigerian study indicated that the disclosure of gender identity is one of the main barriers, especially due to this population's fear of the country's laws. This implies a lack of trust in health services and in the professionals involved, as trans people are afraid of being handed over to the authorities and suffering legal consequences arising from their identities [24].

These facts compromise continuous care and increase vulnerabilities to HIV, since, in most cases, the transsexual population is prevented from having access to infection prevention and control methods, further increasing prevalence indicators [24].

It is important to acknowledge the vulnerability related to the disclosure of one’s gender identity identified in this study. This may imply the expansion of discussions on the guarantees of the trans population’s rights and the reduction of barriers to access to health services. In this sense, based on the identification of the vulnerability described in the study, the data presented herein can guide the construction and implementation of interventions aimed at reducing barriers and expanding access to health services.

As for specialized care services for the treatment and prevention of HIV, it is important that health professionals be attentive and sensitive to the point of perceiving the vulnerabilities that can keep trans women away from HIV prevention and treatment. Here, it is important to highlight the structuring role of health professionals, as respect for gender diversity reduces barriers to access to health services and can guide changes in infection rates in this key population.

Therefore, the national context is surrounded by guarantees for this population, even if they are not fully implemented. For example, it is highlighted that the use of the social name for transvestites and transsexuals is a right guaranteed throughout the Brazilian national territory for people who seek health care in the Brazilian Unified Health System – SUS [25,26].

To broaden the understanding of health care for transsexual women and transvestites and to overcome the reductionist idea of limiting these people to only HIV prevention and control, a permanent articulation between health professionals, managers and public policies is necessary. There is an urgent need to train professionals from different areas to meet the complex demands of the trans population, including everyday situations, gender transition and other aspects, as well as for health professionals to behave in such a way as to provide embracement, humanized care free of discrimination and prejudice [15].

This lack of training of professionals to care for trans women is well reported in the literature, as well as the interventions that should be implemented. In addition to service problems, with due respect to the individualities of the group, gaps in the availability of supplies were also observed.

Regarding access to public health services in Brazil, other complex issues must be considered related to care. A review study on access to health care by the trans population in Brazil emphasized the various barriers that hindered the access of the trans population to the SUS and highlighted, among others, the lack of professional qualification and inadequate embracement. These issues elucidate the vulnerabilities experienced by trans people in Brazil, so that health services need increasingly better trained personnel to meet the demands of this population [27].

Brazil is a reference in the fight against HIV/AIDS for its comprehensive health policies. Primary Health Care is the gateway to health services and has actions aimed at the prevention of HIV and other STIs, in addition to specialized centers such as the Testing and Serological Support Center. Nevertheless, some specific populations, such as transsexual women and transvestites, find it difficult to access health services. Discrimination, fear, and stigma are important barriers that trans women face when seeking various health services. Thus, an integrated approach to health policies is necessary, with efforts to fight stigma and discrimination.

The training of health professionals to assist transsexual women and transvestites is crucial to ensure adequate comprehensive, respectful and sensitive care to the specific needs of this community.

A set of robust actions that involve health professionals, managers, care providers, and governmental and non-governmental actions is necessary, since it is historically a group marked by marginalization and multiple exclusions. In addition to health services and their ramifications, other issues must be considered in the process, such as family, community, and leadership support within trans women's groups. Researchers reinforce that health professionals play a crucial role in guaranteeing access to care services, as they can establish bonds and promote health [15].

5. Conclusions

Vulnerability to HIV/AIDS among transsexual women and transvestites is multifactorial and involves issues related to individual, social and programmatic aspects.

Among the HIV-related vulnerabilities found in the present study, the following stood out: non-white skin color; Inconsistent use and negotiation of condom use with sexual partners; Difficulty in accessing health services, mainly related to situations of symbolic violence, such as not using a social name or pronoun errors, in addition to reports of different treatment and behaviors by other people who attend or work in health services aimed at these women; Lack of professional training and HIV stigma.

The results also showed the intersectionality between social markers of vulnerability, with emphasis on the overlapping of gender, race, and social class issues, which intensify barriers to access to health and HIV prevention. Furthermore, the urgent need for specific public policies that consider the particularities of this population was identified, including continuing education programs for health professionals and social awareness campaigns.

Among the limitations of the study, the sample size, and the number of refusals to participate by transsexual women and transvestites. It is recommended that, based on the data presented herein, new studies be carried out with greater population and context coverage, contemplating aspects that go beyond STIs.