In low- to middle-income countries, trans women are 77.5 times more likely to have HIV than cisgender women 1. Ghana, a lower-middle-income country in West Africa, faces a concentrated HIV epidemic among key populations 2. In 2017, an estimated 28.1% of trans women in Ghana were living with HIV, a prevalence rate exceeding that of all other key populations in the country and far surpassing the national average of 1.7% 3.
While HIV testing has been firmly established as a key and critical step in curbing the epidemic, the existing HIV testing coverage and frequency pose a barrier 4. In low-and middle-income countries, less than half of people living with HIV are aware of their status 5. In Ghana, despite a national increase in HIV status awareness from 43% in 2014 to 72% in 2023, key populations, of which trans women are a part, continue to experience low rates of HIV testing due to pervasive stigma and discrimination that permeate various aspects of their lives 3,6–9.
Within the sub-Saharan region of Africa, trans women continue to face severe societal stigmatization, reinforced by both cultural norms and legal structures 10–13. Cultural norms in many sub-Saharan African societies often dictate rigid gender roles and expectations, leading to the marginalization of individuals whose gender identity do not conform to the dominant traditional norms 14–17. Similar to other African nations, Ghana is deeply religious18, which correlates with widespread anti-LGBT sentiment19. Many Ghanaians perceive non-heteronormative sexual orientations and gender identities as "un-African" or as Western imports, rather than recognizing them as human rights issues20. As a result, physical and violent homophobic attacks against LGBT individuals are frequent and often endorsed by the media, as well as religious and political Figs. 14–17,21.
Additionally, legal structures in several sub-Saharan African countries, including Ghana, criminalize same-sex relationships and behaviors, contributing to the reinforcement of stigma against transgender individuals 22–25. In Ghana, a recently passed anti-LGBT bill by parliament is pending presidential assent to become law, with significant international and domestic pressure urging the president to reject this discriminatory legislation 26. The bill, otherwise known as the "Promotion of proper human sexual rights and Ghanaian Family Values Bill," imposes prison sentences for identifying as LGBTQ + and forming or funding LGBTQ + groups, with penalties of up to three years for individuals and up to five years for groups 26,27. The bill also proposes harsh measures like jail terms of up to 10 years for LGBTQ + advocacy campaigns aimed at children and encourages the public to report LGBTQ + individuals to authorities for action. These legal frameworks not only seemingly perpetuate discrimination but also create barriers to accessing essential healthcare services and support for transgender women. The criminalization of homosexuality in Ghana further entrenches societal prejudices and biases against LGBTQ + individuals, including transgender women 24,28,29
Moreover, within the Ghanaian context, HIV stigma remains profoundly ingrained and fueled by misconceptions, fear, limited knowledge, and the association of HIV with sin and death 30,31. Persons living with HIV often endure rejection, insults, violence, and sometimes denial of health care, resulting in social isolation, restricted healthcare access, and reluctance to seek treatment, ultimately exacerbating the HIV epidemic 30–32.
In healthcare settings, pervasive stigma and discrimination against trans women in Ghana persist, attributed to factors such as a lack of cultural competence among healthcare workers, absence of LGBTQI-specific training in the healthcare sector, and ingrained societal prejudices 8,16,33. Many healthcare providers in sub-Saharan Africa lack the understanding and sensitivity required to address the unique health needs of trans women, often leading to discriminatory practices or reluctance to provide appropriate care 32,34,35. For instance, research across Kenya, Malawi, and South Africa revealed that nearly half (45.3%) of the men who have sex with men (MSM) and transgender women (TGW) reported at least one healthcare-related stigma experience 36. In South Africa, transgender individuals encountered stigma while accessing reproductive healthcare, while other transfeminine and gender-diverse women faced discrimination due to their gender identity and expression37. They described hostile health services, with unrelated health issues often linked to gender or sexual identity, causing discomfort. In Uganda, transgender women experienced various forms of stigma, including police and client violence, workplace and familial discrimination, and a lack of tailored health services38.
These challenges faced by key populations are exacerbated, especially for those residing in urban areas, particularly within slum communities 8,39–44, as residing in these areas, further increases the risk of HIV infection among this population 8,45. Urban slums are informal settlement and pose a multitude of social and structural challenges that amplify vulnerability to HIV, which include crowded living conditions, discrimination, poverty, limited HIV knowledge, high rates of transactional sex, and limited healthcare access 46–49. Notably, certain slum areas within Ghana's capital, Accra, such as Agbogboloshie (5%), Okai Koi North (8%), and Madina (7%), report a higher HIV prevalence, averaging 7% compared to the national prevalence of 1.7% 6,41. Trans women in these areas are likely to have low HIV testing rates due to poor access to services, low HIV risk perception, lower education levels, and poverty 50–53.
Additionally, in low-resource settings, the impact of stigma on healthcare access is even more pronounced, presenting a significant barrier to service utilization compared to other contexts54. Healthcare-related stigma not only leads to avoidance of healthcare services but also adds discomfort and stress, adversely affecting health outcomes55–57. For instance, in Ghana, intersectional stigma and discrimination experienced by key populations not only deters them from seeking healthcare services, resulting in delayed diagnosis and treatment of physical health conditions, but also contributes to increased rates of depression, anxiety, and other mental health issues, as well as social exclusion and isolation 7,8,34,39,58. Furthermore, stigma and discrimination experienced by transgender individuals in other low-income settings have been linked to adverse health effects, including depressive symptoms, anxiety, suicidality, substance abuse, condomless sex and increased HIV transmission 59–61.
Research specifically focused on trans women, especially those living in slum communities, in Ghana is limited, with most studies focusing on gay, bisexual, other men who have sex with men, and female sex workers 8,39,58,62. This paper seeks to address this knowledge gap by offering a qualitative exploration of HIV testing and care experiences within the context of trans women living in Ghanaian urban slums, which can have significant implications for public health interventions and policy development. Identifying the unique challenges and barriers encountered by trans women can contribute to the design of more inclusive and practical strategies to combat the spread of HIV in this vulnerable population.
Theoretical framework
Grounded in the gender-affirmative model, we aim to highlight the nuanced landscape of HIV testing experiences among trans women living in Ghanaian slums, emphasizing both the supportive and challenging aspects of their experiences 63. Recognizing the fundamental principles of the gender-affirmative model, which prioritize the affirmation of gender identity, empowerment, and the mitigation of stigma and discrimination 64, this study seeks to report on the positive and negative HIV testing experiences within this marginalized community 65. By centering the voices and lived experiences of trans women, we seek to identify the facilitators and barriers to accessing HIV testing services. The ultimate goal is to provide actionable insights that can guide policymakers, healthcare providers, and community organizations to enhance the accessibility, acceptability, and effectiveness of HIV testing services, ensuring they meet the specific needs of trans women in Ghanaian slums.