amfAR, The Foundation for AIDS Research

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Centro de Orientacion e Investigacion Integral (Santo Domingo, Dominican Republic)

Focusing on whole health in order to address HIV

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Strategies

  • Providing transgender-specific primary and sexual healthcare
  • Using anti-homophobia strategies targeting law enforcement officials

For 20 years, Centro de Orientacion e Investigacion Integral (Center for Integrated Training and Research, or COIN) has been caring for vulnerable communities, including people living with HIV. In 2007, however, physicians were surprised to see that many transgender women who were first-time clients of the clinic were being diagnosed with advanced AIDS. The staff soon realized that these transgender clients were rarely accessing medical services, if at all, as a result of years of systematic discrimination and alienation from the public healthcare system.

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COIN offers prevention, care, and testing through its mobile clinic.
(Photo: ProActividad)
 

 As part of its strategy to help transgender individuals, COIN emphasized primary healthcare and health issues unique to transgender needs, and partnered for outreach efforts with COTRAVEDT, an organization that serves transgender sex workers in the city. As more transgender clients arrived at the clinic, the team at COIN soon added support services for them, including peer outreach, a mobile HIV testing service, and a weekly support group called Miercoles con Mama (Wednesdays with Mama), hosted by an older transgender activist and community member. According to Dr. John Waters, medical director of COIN, “There aren’t many other opportunities for trans women in this region to come together. Miercoles con Mama has been a good opportunity for the women to realize they have similar problems.”

But as the program has grown, some serious challenges have arisen. While estimates show HIV prevalence between 11 and 15 percent among MSM in the Dominican Republic, almost no data focus exclusively on the transgender population. A lack of official recognition hinders large-scale approaches to serving this population. Meanwhile, COIN has worked to sensitize staff and the general clinic patient population to the increased presence of transgender clients. Outside the clinic, COIN and its transgender clients have had numerous problems with law enforcement authorities. Police have scared clients away from street outreach and mobile testing encounters, and they are known to harass the women and extort money from them. Many transgender women in Santo Domingo are poor, limiting their access to appropriate health services and driving some to sex work for economic survival.

Even in the face of these difficulties, COIN’s work has produced some clear changes. Many transgender clients now see health as a basic right and they are more actively engaged in taking care of their own health and helping their peers do the same. According to Dr. Waters, “many saw themselves as second-class citizens and had accepted that. So having services that are specific for them has had a big impact on the way they view themselves. It has been hard to quantify this kind of change—but there is clearly a big benefit. And one major sign of that is the pressure we have had from trans people in other cities who are asking, ‘Why don’t we have a program like that here?’”

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A workshop for peer educators (Photo: ProActividad)
 

Moreover, the clinic now finds that more clients are willing to be tested for HIV and STIs, which has led to earlier detection and treatment. HIV prevention behaviors also have increased among COIN’s transgender clients. And the program has established a pathway for even better changes in the future. COIN has conducted trainings with local police in an effort to reduce harassment, and has established a “health committee” of transgender clients that advises the organization on various aspects of its programs for their community.

For a transgender community facing so many complex challenges—high rates of HIV and STIs, economic hardship, police harassment, public discrimination—COIN has had to take a more holistic approach to creating positive change. In order to reach this population, its program had to shift the emphasis away from HIV and AIDS. The stigma attached to having HIV or an STI had made trans women reluctant to visit the clinic. But clients began going in for all kinds of health needs—and once there they showed much more willingness to reveal STI symptoms or take an HIV test. Just as significantly, COIN has become deeply engaged with members of the transgender community, hiring them as outreach workers and organizing an advisory panel that helps establish the daily workings of the program. By truly listening to its transgender clients, COIN has been able to provide services that they want and need.