Rio de Janeiro, Brazil — The greatest barrier to ending AIDS among transgender people in Africa is not a lack of medicine, but laws, stigma and exclusion.
Across sub-Saharan Africa, laws that criminalise homosexuality continue to collide with public health goals, leaving gay and bisexual men, and transgender people more broadly, dangerously underserved in the HIV response. In more than two dozen countries, consensual same-sex relationships are still punishable by fines, long prison terms, or, in a few cases, the threat of the death penalty. It is a legal climate that drives people away from clinics and testing services.
Gay and bisexual men continue to have HIV prevalence rates several times higher than the general population in many countries. Transgender women remain among the populations at greatest risk of acquiring HIV globally. Yet many governments have been slow to fully implement the World Health Organization's recommendations for key populations, and countries across the region are already falling behind on the first of the UNAIDS 95-95-95 targets: ensuring that 95% of people living with HIV know their status.
Yet for many transgender people across the continent, the greatest barrier to HIV prevention and treatment begins long before they reach a clinic.
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They sit at the intersection of two systems that too often fail them: an HIV response still catching up to their needs, and legal frameworks that treat their identities as suspect or criminal. Two advocates working on opposite ends of the continent, Liesl Theron, a South African based in Mexico, and Kelsey Brookes in Nigeria, described a crisis that statistics alone cannot capture.
For transgender rights activist Theron, the connection between law and healthcare has been evident for decades. Theron co-founded Gender DynamiX, South Africa's first civil society organisation dedicated to the needs of transgender people. She has worked on transgender rights and advocacy since 2005, a time, she recalled, when there was almost no information available on the topic in South Africa. She said her involvement was deeply personal, sparked by being in a relationship with a transgender partner when the two struggled to find even the most basic information.
For Kelsey Brookes, the executive director of Nigeria's transgender-led STAG Initiative, the issue is equally personal.
"I did not enter this work from theory. I entered it from survival, from witnessing pain that was too close to ignore, and from understanding very early that silence can be dangerous for people like us," said Brookes.
Brookes said that HIV and transgender health are two issues that sit at the centre of her work and heart.
"They are not abstract policy issues for me," she said. "They are about people I know, people I love, communities I serve, and the everyday fight for safety, dignity, treatment, prevention, and survival." STAG operates at the intersection of transgender rights, HIV advocacy, sexual and reproductive health, gender-based violence response, safe housing and community protection.
As a Black transgender feminist in Nigeria, Brookes said that she has watched transgender people pushed to the margins of almost every system meant to protect them: denied healthcare, afraid to test for HIV because a clinic visit could expose them to shame, ridicule, or violence, choosing silence over care because silence felt safer.
"I have seen people choose silence over care because silence felt safer," she said.
She said that for transgender people, this means people delay testing. They self-medicate. They avoid follow-up appointments. They do not ask questions about PrEP, hormones, STIs, or sexual health. Some only show up when they are already very sick.
"Criminalisation does not stop people from existing," Brookes said. "It only pushes them away from lifesaving care."
While HIV science has advanced dramatically, with pre-exposure prophylaxis (PrEP), effective antiretroviral therapy and community testing models becoming widely available, access remains deeply unequal for transgender people. Both activists argue that the problem is no longer primarily biomedical, but structural.
"The gap exists because science moved faster than society," said Brookes.
She said that although prevention tools have improved, many transgender people still live under laws, cultural norms and healthcare systems that treat them as disposable. For transgender people, especially transgender women in Africa, she said, HIV prevention is about far more than whether medication exists. HIV prevention is not only about whether condoms, testing, PrEP, or ARVs exist. It is about whether someone can walk into a clinic safely. It is about whether their name and identity will be respected. It is about whether a healthcare worker will treat them with care or humiliation. It is about whether they have a home, food, transport money, privacy, and protection from violence.
UNAIDS has shown that transgender women face a much higher risk of acquiring HIV than the general adult population globally, and that many transgender people continue to experience stigma, discrimination, and avoidance of healthcare because of those experiences. So, the gap remains because HIV has been medicalised, but the lives of people most affected by HIV have not been protected enough, said Brookes.
Theron said that while advocacy has led to meaningful progress in parts of Africa and rural South Africa, those gains are increasingly being challenged by a growing wave of social and political conservatism. "We are also living in a world right now that unfortunately moves towards more conservative values and therefore discrimination, and silencing is the order of the day," she said. She believes LGBTQIA+ communities, particularly transgender people, are often used as political scapegoats during election periods to divert attention from governments' shortcomings.
"Politics, religion combined with misinformation is ultimately the underlying issue that keeps the gap in place," said Theron.
Theron said criminalisation creates barriers before a consultation even begins.
"When you are in a community that is outlawed by the government, you are unable to seek healthcare," she said. "Any healthcare facility and clinic, especially subsidised by the state, requires a person to provide their identity card, and this is already the first and most significant barrier."
Criminalising laws, said Brookes, turn healthcare into a place of fear. When LGBTQIA+ people are criminalised, transgender people do not experience clinics as neutral spaces. They worry that disclosure could lead to exposure, arrest, blackmail, family rejection, or violence.
Even where legislation does not name transgender people specifically, she said that transgender people are frequently caught under broader anti-LGBTQIA+ statutes, public morality laws, sex work laws, or simple police harassment. In Nigeria, she pointed to research conducted after the Same-Sex Marriage Prohibition Act, which found increased fear, stigma and reduced engagement with HIV prevention and treatment services among sexual minority communities. Human Rights Watch also documented how Nigeria's anti-LGBTQIA+ legal environment increased vulnerability, fear, and abuse for LGBTQIA+ people and organisations serving them.
Brookes said that punitive laws transform healthcare facilities into places of fear rather than care.
Poverty, exclusion and HIV
Both activists argued that HIV vulnerability cannot be understood without recognising the social and economic realities confronting many transgender people.
Theron described watching transgender community members, transgender women above all, face compounding hardship that shapes their health outcomes directly. Poverty and homelessness are drivers of that risk, she said. She cited sex work as one of the few viable income-generating opportunities available to many transgender women, increasing their exposure to HIV while simultaneously exposing them to violence and further discrimination.
She cites research suggesting that transgender women's average life expectancy sits at around 40 years of age, a figure she said becomes reality wherever these socioeconomic pressures converge. She points to the words of the late Leigh Davids, a sex worker, a transgender woman, and a person living with HIV, who spoke about this same statistic in a widely referenced speech titled "Trans Violent Exclusion." Davids died two weeks before her 40th birthday.
Brookes said the same patterns emerge daily in Nigeria.
"The studies reflect our daily reality," she said. "In the communities I work with, HIV risk is not separate from housing insecurity, hunger, unemployment, family rejection, police harassment, and lack of documentation.
Many young transgender women are pushed out of home or forced to live in unsafe environments. When someone is thinking about where to sleep that night, HIV prevention can feel far away, she said. When someone depends on unstable income or unsafe relationships for survival, negotiation becomes harder. When someone cannot afford transport to a clinic, even free healthcare becomes inaccessible.
It's why, she said, STAG does not treat HIV as an issue that can be addressed in isolation. The organisation combines crisis response, safe housing, psychosocial support, referrals, community education and healthcare navigation, on the reasoning that a transgender woman with a safe place to sleep is more likely to take her medication, keep her appointments, ask for help, and imagine a future for herself. Poverty, Brookes said, doesn't only raise HIV risk biologically or behaviourally. It reduces the range of choices available to a person, and effective prevention has to be about restoring those choices, along with safety and power.
"Poverty does not just increase HIV risk," Brookes said. "It reduces choices."
What the statistics leave out
People often think the story is only about risk. They forget the story is also about love, courage, survival, and systems that have failed people. Statistics can tell you how many people are living with HIV, but they cannot show you the fear of sitting in a waiting room where everyone is staring at you. They cannot show you what it means to hide your medication because your family may ask questions. They cannot show you the exhaustion of being told to "change" before you are treated with dignity.
Brookes said that one of the greatest misconceptions is that LGBTQIA+ communities are difficult to reach. "We are not difficult to reach," she said. "We are deliberately excluded. We are over-policed, under-protected, underfunded, and then blamed for not accessing services."
Behind every HIV statistic, she said, are people navigating fear, rejection, and discrimination while trying to access services many others take for granted. People also forget that LGBTQIA+ people living with HIV are not just patients. They are organisers, artists, sex workers, students, siblings, faith leaders, caregivers, advocates, and community builders. Many are carrying pain, yes, but they are also carrying entire communities.
Theron said that framing the crisis purely through statistics strips away the lived experience underneath the numbers.
For Theron, the HIV response cannot succeed if it ignores the realities of people living at the intersection of multiple forms of exclusion. She said that transgender people are often also affected by homelessness, poverty, migration or sex work, creating layers of vulnerability that healthcare systems frequently fail to address.
"I don't encourage or believe in systems that hierarchise suppressed populations," she said. "Once a person's life has intersectional points... the impact of homophobia and transphobia is even bigger."
Homophobia and transphobia, said Theron, exist to prevent care, prevent access and prevent basic human dignity, and no honest account of progress in HIV prevention can be written while entire communities remain excluded from it.
"It is a form of control," she said. "We cannot fully record progress of HIV prevention while a blind eye is turned on certain communities. Excluding transgender people from HIV care, prevention and programmes ultimately will prevent total HIV care and prevention."
Homophobia and transphobia continue to undermine HIV prevention efforts across Africa, said Brookes, by creating fear and distrust at every stage of the care journey. They stop people from seeking information. They stop schools and communities from having honest conversations. They make healthcare workers judgmental. They make funders cautious. They make governments deny data. They make families reject people who need support. They create shame around testing and silence around prevention.
"When people are afraid to be seen, they are less likely to test. When they are afraid of being judged, they are less likely to disclose. When they are afraid of violence, they are less likely to return for care," she said.
Brookes said that HIV prevention depends on trust, but homophobia and transphobia destroy trust. She said that UNAIDS has repeatedly emphasised that reducing stigma, discrimination, violence, and punitive laws is central to ending AIDS, not separate from it.
"You cannot build an effective HIV response on top of fear," she said.
Transgender advocacy teaches us that HIV prevention must be community-led, not only clinic-led.
Brookes said that transgender advocacy offers valuable lessons for improving HIV prevention among young people, particularly as new HIV infections continue to rise among young gay and bisexual men. She argued that prevention efforts should be driven by communities rather than confined to healthcare facilities, with greater emphasis on peer support, trust and creating safe spaces where young people feel respected.
"Young people do not need lectures," she said. "They need trust, language they understand, services that respect them, and spaces where they are not punished for telling the truth about their lives."
According to Brookes, transgender advocacy has demonstrated the importance of peer support, chosen families, harm reduction and confidentiality, approaches that could strengthen HIV prevention for all young people. She points to UNAIDS data showing that new infections among gay men and other men who have sex with men increased between 2010 and 2022, even as other parts of the global HIV response improved. She said that tells us that traditional prevention approaches are no longer enough on their own.
She said that transgender advocacy offers a template for what comes next, because it was built around community leadership rather than clinics alone. Brookes said that there is a need for youth-friendly, stigma-free, community-owned prevention. We need digital outreach, peer navigators, safe referral systems, PrEP literacy, mental health support, and honest conversations about sex, consent, pleasure, safety, and dignity.
"Transgender advocacy reminds us that people protect themselves better when they feel their lives are worth protecting," she said.
Reforming systems
The biggest fear is not always the test result. Sometimes the biggest fear is what happens after people know.
One of the biggest barriers to HIV prevention among young transgender people is not the fear of a positive diagnosis, but the fear of how they will be treated if others find out, said Brookes. Concerns about confidentiality often discourage young people from seeking testing or treatment, with many worrying that healthcare workers could disclose their HIV status or gender identity to family members or their communities.
She said that many also fear being mocked at clinics, asked invasive questions or having healthcare providers focus on their gender identity rather than the care they need. Others worry about testing positive because they mistakenly believe it is a death sentence, even though HIV is treatable and people on effective treatment can live long, healthy lives. Others fear drug stockouts, transport costs, side effects, or being judged for missing appointments. For those who use hormones, there is also anxiety about whether providers understand both HIV care and gender-affirming needs.
"What young transgender people need is not only information," said Brookes. "They need reassurance, privacy, accompaniment, and providers who treat them as whole human beings."
She said that recent reductions in global funding have made an already precarious situation more dangerous. For transgender communities, funding cuts are not abstract, she said. They mean fewer peer educators. Fewer safe referrals. Less transport support. Less community testing. Fewer emergency grants. Less mental health support. Less ability to reach people who are already hiding.
She described a particular strain on transgender-led organisations, which are often closest to the communities most affected but among the last in line for flexible funding. On the ground, she said she noticed fear. Community organisations are being asked to do more with less. People still come with the same emergencies, but the resources to respond are shrinking. For transgender-led organisations, this is especially painful because we are often closest to the community but last in line for flexible funding, said Brookes.
Brookes recalled working with a young transgender woman who had been rejected by her family, was homeless and had stopped seeking healthcare after experiencing humiliation. When she finally sought help, Brookes said, her first concern was not HIV testing or treatment. It was whether she would be safe.
She did not first ask us for HIV services. She asked, 'Am I safe here?'
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Brookes said that the organisation connected her with shelter, psychosocial support and a transgender-friendly healthcare provider. At first, she was quiet. She barely trusted anyone. But slowly, with consistent care, she began to show up for herself. She went for testing. She asked questions. She started supporting other girls who were afraid. The same person who once whispered became someone who could sit beside another transgender woman and say, "I know it is scary, but you are not alone."
For Brookes, the story reflects the resilience that is often overlooked.
"That is the strength people do not always see," she said. "Transgender communities are not only vulnerable. We are powerful. We build safety out of almost nothing. We turn pain into systems of care. We become each other's emergency response when the world refuses to respond."
Building an HIV response that leaves no one behind
Both advocates frame the path forward as requiring more than the removal of punitive laws, though both agree that has to come first.
Brookes said that governments must repeal laws criminalising LGBTQIA+ people, invest in healthcare worker training and support transgender-led organisations that understand the realities facing their communities.
She said that, firstly, African countries must remove laws and policies that criminalise LGBTQIA+ people, sex workers, and other key populations. Criminalisation is not just a legal issue; it is a public health barrier. The African Commission has recognised that discrimination in access to healthcare is prohibited under human rights standards, and that legal environments matter for HIV outcomes. Secondly, healthcare systems must be trained and held accountable. It is not enough to say services are open to everyone. Providers need practical training on transgender health, confidentiality, gender-affirming care, HIV prevention, trauma-informed practice, and respectful communication. Thirdly, HIV services must be integrated with the realities of people's lives. That means safe housing, mental health support, legal aid, food support, transport, protection from violence, and community-led referrals. Fourthly, data systems must count transgender people properly and ethically. If we are invisible in data, we become invisible in budgets, policies, and programmes.
Lastly, Brookes said that funders and governments must invest directly in transgender-led organisations.
"We know where our communities are. We know what language reaches them. We know what safety requires," she said. "Nothing about us without us must become a funding principle, not just a slogan."
Theron, in turn, said that progress against HIV cannot be measured while entire communities remain excluded. "Excluding transgender people from HIV care, prevention and programmes ultimately will prevent total HIV care and prevention."
As African countries work towards ending AIDS by 2030, activists say the next breakthrough may not come from another biomedical innovation. It may instead depend on dismantling the legal, political and social barriers that continue to keep transgender people away from the healthcare they need.
Brookes said that the hardest part of her work is knowing what people need but not always having the resources to help. She recalled moments when people reached out in crisis, needing shelter, food, healthcare, transport and protection all at once, while support systems struggled to keep pace.
"It is hard when systems move slowly, but crisis moves fast," she said.
Beyond the practical challenges, Brookes said advocacy also means carrying the grief of those who were "protected earlier, loved better, treated faster, and allowed to live with dignity."
Yet she remains motivated by the resilience of the communities she serves. Every young transgender person who returns to school, starts treatment, or becomes a peer supporter reminds her why the work matters.
"Our lives are not a footnote in public health. Transgender people are not an afterthought in the HIV response. We are leaders, knowledge holders, caregivers, and survivors," she said.
For Brookes, the goal extends beyond ending HIV.
"What keeps me going is simple: I have seen what care can do. And I want more of our people to live long enough to experience safety, joy, health, and freedom."
More than two decades later, she said the obstacles facing transgender people have evolved but not disappeared.
