HIV-related sexual risk behaviors among male-to-female transgender people in Nepal

(1)

HIV-related

sexual

risk

behaviors

among

male-to-female

transgender

people

in

Nepal

Dharma

Nand

Bhatta

DepartmentofPublicHealth,PokharaUniversity,NobelCollege,Sinamangal,Kathmandu,Nepal

1. Introduction

Researchers,practitioners,andpublichealthagenciescontinue

to be challenged to identify appropriate methodological and

theoretical approaches for the assessment of epidemiological

trendsandthedevelopmentofeffectiveinterventions,particularly

for sexual minorities.1,2 _{National-level} _surveillance _data _are

sparsewithregardtotheincidenceandprevalenceofHIVamong

transgenderpopulationsinNepal. Moststudieshaveintegrated

this population into the‘men whohave sex withmen’ (MSM)

categoryinNepalandinotherplaces.3_Transgender_women_are_at

greaterriskofHIVinfectionthanotherpopulations.Unprotected

sex,druguse,andbeinganethnicminorityhavebeenfoundtobe

associatedwithHIVstatusintransgenderwomen.3–5_The_previous

literature shows that an increased proportion of transgender

womenareoccupiedinsexwork.3,6

InvariouscountriesofSub-SaharanAfrica,transgenderpersons

haveahigherHIVprevalencethanmen.7Aprevioussystematic

reviewfromAsiafoundthattransgenderpeopleare18timesmore

likelytobeinfectedwithHIVthanthoseinthegeneralpopulation.8

Similarly, astudyfromNorth AmericaandEurope showedthat

transgenderwomenhaveanelevatedrateofHIVinfection.9_Due_to

a lack of nationally representative studies, it is difﬁcult to

categorizetheburdenofHIVinfectionwithinthispopulation.A

study from India revealed that transgender persons had an

increasedHIVprevalencecomparedtotheremainingpopulation.10

Nepal has similarities with India regarding its geography and

culture.Asaresult,Nepalmayalsohavethisproblem.Astudyfrom

NepalfoundanHIVprevalenceof3.8%amongurbanMSM.11_This

resultishigherthantheoverallHIVprevalenceinNepalof0.3%,

andtransgenderpeoplearecategorizedasahigh-riskgroup.12,13

Male-to-female(MtF)transgenderpersonsareknownlocally

as‘Meti’and‘chhakka’;theseareNepaliwordsthatappeartobe

used as a way of stigmatizing a man who has female gender

characteristics.11,13_In_this_study,_the_term_‘MtF_{transgender’}_was

usedforapersonwhoisbiologicallyamanbutself-identiﬁesasa

woman; these persons may be either a man or a woman in

appearance. A study to investigate the exact HIV-related risk

behaviorsoftransgenderpersonsinNepalisurgentlyrequired.13,14

ARTICLE INFO Articlehistory:

Received7October2013

Receivedinrevisedform30December2013 Accepted3January2014

CorrespondingEditor:EskildPetersen, Aarhus,Denmark

Keywords: HIVriskbehavior Maletofemale Transgender Unprotectedsex MtF Nepal SUMMARY

Background: TransgenderwomenareavulnerableandkeyriskgroupforHIV,andmostresearchhas shownanincreasedfrequencyofHIVinfectionamongthisminoritypopulation.Thisstudyexaminedthe prevalenceofHIV-relatedsexualriskbehaviorsandthesocio-demographiccorrelateswithHIV-related sexualriskbehaviorsamongmale-to-female(MtF)transgenderpersons.

Methods:Datawerecollectedfromasampleof232individualsthroughvenue-basedandsnowball samplingandface-to-faceinterviews.

Results:TheHIV-relatedsexualriskbehaviorsamongtheMtFtransgenderpersonswere:sexwithout usingacondom(48.3%;95%conﬁdenceinterval(CI)41.8–54.8),unprotectedanalsex(68.1%;95%CI 62.0–74.2), and unprotected sex with multiple partners (88.4%; 95% CI 84.3–92.5). Statistically signiﬁcantdifferenceswerefoundforage,income,education,alcoholhabit,andsexwithmorethantwo partnersperdayforthesethreedifferentHIV-relatedsexualriskbehaviors.MtFtransgenderpersons withasecondaryorhigherlevelofeducationwerethreetimes(OR2.93)morelikelytohaveunprotected sexwithmultiplepartnerscomparedtothosewithaprimarylevelornoeducation.

Conclusions: Age,education,income,frequencyofdailysexualcontact,andanalcoholhabitremain signiﬁcantwithregardtoHIV-relatedsexualriskbehavior.Thereisanurgentneedforprogramsand interventionstoreduceriskysexualbehaviorsinthisminoritypopulation.

ß 2014TheAuthor.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.

E-mailaddress:dnbhatta@yahoo.com.

ContentslistsavailableatScienceDirect

International

Journal

of

Infectious

Diseases

j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / i j i d

http://dx.doi.org/10.1016/j.ijid.2014.01.002

1201-9712ß2014TheAuthor.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.

Open access under CC BY-NC-SA license.

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Theimportanceofriskbehaviorsshouldbeemphasized,

particu-larlyasHIVisinﬂuencingracialandsexualmarginalgroupsmore

thanever.15

Mosttransgenderpersonsengageinriskysexualbehaviorsthat

might help to reinforce their female identity and

attractive-ness.16,17_Previous_studies_revealed_that_condom_use_with_regular

partnerswas14.4%andwithirregularpartnerswas24.1%among

transgenderpersons.18,19_Similarly,_in_a_study_from_Indonesia_on

MtFtransgenderpersons,anaveragecondomuseof1.2wasfound

forthelastﬁvesexualacts.18,20_Another_study_showed_that_12–41%

ofMtFtransgenderpersonsusedacondomduringsex.21_A_study

fromIndiarevealeda lowlevel ofcondom useamong theMtF

transgenderpopulation.22_Further,_a_study_from_Cambodia_found

that 13% of MtF transgender people engaged in risky sexual

behavior.18,23A studyfromThailandfoundthat a mythamong

transgenderpeoplewasthatthelowlevelofcondomusewasnot

thesourceoftheHIVinfection.24_Other_MtF_people_from_Indonesia

believethattheyarenotatriskofHIVeveniftheyhavemultiple

sexpartnerswithoutcondomuse.18,25

A systematic review and meta-analysis based on 39 studies

from15countriesshowedtheprevalenceofHIVtobe19.1%among

transgenderwomen,withaprevalenceof17.7%inlowandmiddle

income countries and 21.6% in higher income countries.26

Moreover,unprotectedsexualintercoursefrequentlytakesplace

undertheinﬂuenceofsubstanceuse.3_Low_condom_use,_casual_sex,

multiplepartners,lowsocioeconomic status,addictiontodrugs

andalcohol,andstreetsexwerefoundtobeassociatedwithHIV

riskamongsexworkers.3,27,28Previousstudieshavefoundthatthe

heavyuseofalcoholanddrugsarerelatedtounprotectedsexual

intercourse.3,29

2. Methods

Across-sectionalsurveywasconductedbetweenOctober2011

and March 2012 among 232 MtF transgender persons. No

document was available showing the exact geographical and

populationdistributionofMtFtransgenderpersonsinNepal.The

information was obtained from the national-level

non-govern-mental organization Blue Diamond Society; this organization

worksforsexualhealth,humanrights,andthewell-beingofsexual

and gender minorities, especially LGBTI (lesbian, gay, bisexual,

transgender and inter-sex persons). Twenty-six districts were

listedfromtheworkingdistrictsofthisorganization.Finally,15

districtswereselectedfromthatlist(Kanchanpur,Kailali,Bardiya,

Banke,Surkhet,Dang,Rupandehi,Chitwan,Kaski,Parsa,Rautahat,

Saptari,Kathmandu,Bhaktapur,Lalitpur).Thesedistrictsrepresent

differentgeographicalareasofNepalandthusprovidedadiverse

sampleoftransgenderpersons andthepossibilityofcomparing

differentepidemiologicaltrends.

Anintervieweradministeredaquestionnairetocollect

inform-ation on demographic characteristics, risk behaviors, and

sub-stanceuse.Recruitmenttookplaceatthelocalnon-governmental

organizationandatothercommunitycontactpointswhere

trans-genderpeople are found. The institutionalethics review board

approvedthestudyandallrespondentscompletedaninformed

consentprocedure.

Eligibility wasscreenedand determinedby trained research

staff with verbal information. The following criteria were

necessaryfor eligibility:(1) biologically maleat birth;(2)

self-identiﬁed as a woman; (3) aged 16 years or older. A total

245peoplewerescreenedforrecruitmentintothisstudy;eightdid

notagreetoparticipateandﬁvedidnotmeettheeligibilitycriteria.

The study used a snowball/chain referral and venue-based

sampling method to recruit participants. Research staff were

postedatdifferentnon-governmentalorganization(BlueDiamond

Society) venues to recruit respondents, and at the same time

snowball/chain referral sampling was used, in which recruited

respondentsreferredaneligiblepeer.30

2.1. Datacollectionandmeasures

TheinterviewinstrumentwasdevelopedinbothEnglishand

Nepali,andface-to-faceinterviewswereconductedusing

struc-tured questionnaires; a pilot was tested among the target

population. Researchers were trained with regards to ethical

andsensitiveissues.Participantsinvolvedinthestudywerefully

informed about the nature of the study, its objectives, and

conﬁdentialityofthedata.Eachparticipant’swrittenconsentwas

obtainedafterassuringconﬁdentiality.Theinterviewwascarried

outinasecretplacewithoutthepresenceofathirdperson.The

researcherdidnotprovideanyﬁnancial recompenseto

respon-dents. Conﬁdentiality of information was assured by removing

individual identiﬁers from the completed questionnaires. Data

collectiontookaround60min.

Socio-demographicmeasuresrecordedincludedage,education,

income,andemploymentstatus.HIV-relatedsexualriskbehavior

amongMtFwasusedasthedependentvariableinthisstudy.In

thisstudy,allthesexualpartnersweremaleanditcouldbeeithera

committed relationship or not. Respondents reported sexual

behaviorwiththreevariables,asfollows:(1)Haveyoupracticed

unprotectedanalsexwithalltypesofpartners(bothcommitted

andnotcommittedsexualrelationship)duringthepast6months?

(2) Have you engaged in unprotected sex with multiple sex

partners(havingmorethanonesexpartnerconsideredasmultiple

partners)duringthepast6months?(3)Haveyouhadsexwithany

partnernotusingacondomduringthepast6months?

Allthevariablesweredichotomizedandcodedas‘no’=0and

‘yes’=1.ThoseMtFpersonswhohadpracticedatleastoneofthe

three acts were considered to have an HIV-related sexualrisk

behavior.

Withregardtosubstanceuse,thismeasurewasfocusedonlyon

whethertheyhadhadsexundertheinﬂuenceofalcoholinthepast

6months.Thevariablewasdichotomizedand codedas‘no sex

undertheinﬂuenceofalcohol’=0and‘sexundertheinﬂuenceof

alcohol’=1.Similarly,thevariableofasmokinghabitinthepast6

months after involvement in sex work was dichotomized and

codedas‘no’=0and‘yes’=1.

2.2. Dataanalysis

Thedatawerecleanedandcross-checkeddailybeforeandafter

data entry for completeness and accuracy. To estimate the

prevalence of thestudyvariables ofinterest (e.g.,condom use,

alcoholuse),SPSSversion16softwarewasused(SPSSInc.,Chicago,

IL,USA).Bothdescriptiveandinferentialstatisticswereapplied.

TheChi-squaretestwasusedtodeterminesigniﬁcantdifferences

between demographic variables and HIV-related sexual risk

behaviors. The variables were examined in the multivariate

analysis(binarylogisticregression)inordertoidentifythefactors

associatedwiththelikelihoodofhavinganHIV-relatedsexualrisk

behavior.Whensamplingisassociatedwithpotentialindependent

variables in a multivariable model, those variables should be

incorporated,butitisnotessentialtoloadobservations.1Thus,the

multivariateresultsshownherewerederivedfromunweighted

estimations, with each variable known to be associated with

participationinthesampleincludedinthemodel.

3. Results

Thedemographic characteristicsof thestudypopulation are

showninTable1.Themedianageoftheparticipantswas25years.

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Morethan half (57.3%)of thetotalsample hada secondaryor

higher level of education. The percentage of unemployed

participantswasalsohigh(46.6%),andincomelevelswerefairly

low,with25.9%oftherespondentsearning5000NPRpermonth

(1 USD = 87 NPR). Nearly half (48.7%)of the MtF transgender

persons were interested in giving birth to a child. Two-thirds

(65.5%)oftherespondentswereinterestedinmarriage.Nearlya

thirdoftherespondentshadsexualcontactwithmorethanone

person per day. All of the respondents in this study were

unmarried.

Table 2 shows the prevalence of HIV-related sexual risk

behaviors and substance use. Heavy alcohol use was highly

prevalentin thetransgenderpopulation (68.5%;95%conﬁdence

interval(CI)62.6–74.4%)aswasa smokinghabit(58.2%;95%CI

51.9–64.5%),although this wasrelativelylower thanalcohol. A

patternofsexualriskbehavioremergedinthissample,showing

thatapproximatelyhalfofrespondents(48.3%;95%CI41.8–54.8%)

engagedinsexwithoutusingcondom.Theprevalenceofmultiple

sexpartnerswasfoundtobeextremelyhigh(88.4%;95%CI84.3–

92.5%) among theMtF transgender persons. The prevalence of

unprotectedanalsexualintercoursewashigherthanoralsexual

intercourse(analsex:68.1%;95%CI62.0–74.2%;oralsex:51.5%;

95%CI45.0–58.0%).

TheprevalencesofHIVriskbehaviorswithregardtoselected

demographiccharacteristicsareshowninTable3.Theprevalence

of HIV risk behavior varied signiﬁcantly by age group; it was

relativelyhigheramongtheparticipantsaged25yearsandabove.

Sexwithoutusingacondomandunprotectedanalsexwerefound

todiffersigniﬁcantlybyage.Whencomparedamongeducational

groups,thehighestprevalencewasfoundamongparticipantswho

hadasecondaryorhigherlevelofeducation.Unprotectedsexwith

multiplepartnersdifferedsigniﬁcantlybyeducationlevel.

The prevalence of HIV risk behavior varied dramatically by

incomegroup, withthelowestincomegrouphavingthelowest

prevalence.Unprotectedsexwithmultiplepartnerswasfoundto

differsigniﬁcantlybyincome.Sexwithoutusingacondomwas

foundtodiffersigniﬁcantlybyemploymentstatus.

Finally, HIV-related sexual risk behavior washigher among

those MtF transgender persons who had an alcohol habit.

Unprotectedsexwithmultiplepartnerswassigniﬁcantly

associ-atedwithanalcoholhabit.Interestingly,asimilarresultwasfound

for smoking habit. Similarly, sex without using a condom,

Table1

Demographiccharacteristicsofthetransgenderpersons(n=232)

Characteristics Result Age Medianyears 25 Minimum–maximumyears 16–55 25years,n(%) 131(56.5) 24years,n(%) 101(43.5) Education,n(%)

Secondaryorhigherlevel 133(57.3)

Primarylevelornoeducation 99(42.7)

Employment,n(%)

Formalemployment 124(53.4)

Informalornoemployment 108(46.6)

Incomepermonth

MedianNPR 10000

5001NPR,n(%) 172(74.1)

5000NPR,n(%) 60(25.9)

Interestedingivingbirthtoachild,n(%) 113(48.7)

Interestedinmarriage,n(%) 152(65.5)

Dailysexualcontactperperson,n(%)

1person 156(67.2)

2–3persons 56(24.1)

4persons 20(8.6)

Table2

Prevalenceestimatesforreportedsexualriskbehavioramongtransgenderpersons (n=232)

Characteristics Prevalence%(95%CI)

Alcoholinlast6months 68.5(62.6–74.4)

Smokinginlast6months 58.2(51.9–64.5)

Sexwithoutusingacondominlast6months 48.3(41.8–54.8) Unprotectedsexwithmultiplepartners

inlast6months

88.4(84.3–92.5) Unprotectedanalsexinlast6months 68.1(62.0–74.2) Unprotectedoralsexinlast6months 51.5(45.0–58.0)

Othersexinlast6months 6.1(3.0–9.2)

Table3

EstimatedHIV-relatedsexualriskbehaviorprevalenceamongmale-to-femaletransgenderpersonsbysocio-demographicvariablesandsubstanceuse(n=232)

Characteristics Sexwithoutcondomuse

(n=232)

Unprotectedanalsex (n=232)

Unprotectedsexwith multi-plepartners (n=232) Yes,% p-Value (Chi-square) Yes,% p-Value (Chi-square) Yes,% p-Value (Chi-square) Age 0.029 0.029 0.180 25years 49.1 58.3 58.0 24years 50.9 41.7 42.0 Education 0.203 0.411 0.022

Secondaryorhigherlevel 61.6 57.7 54.6

Primarylevelornoeducation 38.4 42.3 45.4

Incomepermonth 0.374 0.597 0.019

5001NPR 76.8 73.1 76.6 5000NPR 23.2 26.9 23.4 Employment 0.038 0.063 0.143 Formalemployment 46.4 57.7 51.7 Informalornoemployment 53.6 42.3 48.3 Alcoholhabit 0.526 0.530 0.000 Yes 70.5 69.9 74.1 No 29.5 30.1 25.9 Smokinghabit 0.121 0.728 0.005 Yes 63.4 59.0 61.5 No 36.6 41.0 38.5

Dailysexualcontactperperson 0.022 0.008 0.011

1person 60.7 70.5 63.9

2–3persons 32.1 18.6 26.3

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unprotectedanalsex,andunprotectedsexwithmultiplepartners

were found to differ signiﬁcantly by per-person daily sexual

contact(Table3).

TheresultsofthelogisticregressionforHIV-relatedsexualrisk

behaviorinthistransgenderpopulationareshowninTable4.The

coefﬁcientsdescribechangesintheestimatedoddsofengagingin

unprotected sexualintercourse associated with changes in the

variableinquestion.MtFtransgenderpersonswithasecondaryor

higherlevelof educationwerethreetimes morelikely tohave

unprotectedsexwithmultiplepartnersthanthosewithaprimary

levelornoeducation.Mostofthevariableshadhigheroddswith

differentsexualrisk behaviors,but these werenot statistically

signiﬁcant.

4. Discussion

ThisstudycharacterizedtheHIV-relatedsexualriskbehavior

amongMtFtransgenderpersonscomingfrom15differentdistricts

acrossthe country of Nepal. An appropriate methodology was

appliedtoimprovethereliabilityandvalidityofthestudyﬁndings.

Based on the lack of knowledge in the literature, this study

scrutinizedthesexualhealthneeds andsexualbehavioramong

MtFtransgenderpersonsinNepal,aswellasdiscussingtherisk

andinﬂuencingfactorsthatarelinkedwithHIV-relatedsexualrisk

behaviorsamongMtFtransgenderpersons.

The sampling and recruitment method worked effectively.

Exactpopulationsoftransgenderpeoplein Nepalareunknown.

However, the sample represented different geographical areas.

No major problems were encountered during the recruitment

process.Theresearcheralsofoundno evidenceof coercivepeer

recruitment.

Unemploymentandpovertywerecommonamongthe

trans-genderpersons,asinotherpopulationsinNepal.Nearlyhalfofthe

respondents had no formal employment and a fourth of the

participantsindicatedthattheyhadalowincomestatus,whichis

lessthantwodollarsperday.Thestudyalsofoundthatnearlya

thirdofparticipantshadsexualintercoursewithmorethanone

sex partner per day, which indicates a great risk for HIV and

sexuallytransmitteddiseases. Aprevious studyhashighlighted

thattheMtFpopulationengageswithahighernumberofsexual

associates.13

The ﬁndings regarding substance use suggest that alcohol

consumption is widespreadin the transgender population.This

maybeconsideredaseriouspublichealthproblem,giventhatmore

thantwo-thirdsoftheparticipantshadanalcoholdrinkinghabit.

Similarly,nearlythree-ﬁfthsoftheparticipantshadasmokinghabit.

Unprotected sex with multiple partners was found to differ

signiﬁcantlybyalcoholandsmokinghabits.Previousstudieshave

foundalcoholtobeassociatedwithHIVriskamongsexworkers

andthosehavingunprotectedsexualintercourse.3,27–29_However,

there is no previousevidence for the association between

HIV-related sexual risk behavior and smoking. Nearly half of the

participantsengagedinunsafesexanddidnotuseacondomwith

theirsexpartners.Previousstudieshaverevealedirregularand

low-level condom use among MtF populations.13,18–21_However, _the

greatmajorityoftheparticipantshadmultiplesexpartners.Analsex

appearstobethemostcommonsexualbehavioramongtheMtF

transgenderpersons.

The results showed no distinctive variations in HIV risk

behavior among the age groups. Sex without using a condom

andunprotectedanalsexwerefoundtodiffersigniﬁcantlybyage

group.However,HIVriskbehaviorwasfoundtobemorecommon

among the more educated participants. Educated respondents

were three times more likely to have unprotected sex with

multiplepartnersthanthelesseducatedandthiswasstatistically

signiﬁcant.Previousstudieshavefoundthelevelofeducationtobe

positivelycorrelatedwithunprotectedsex.1Havingverylimited

comparabledata,theresearcherproposesanexplanation.

Trans-genderpersonswithahighereducationlevelmayﬁnditeasierto

buildanetworkwithvariedsexualassociatesthanlesseducated

persons and may thus befurther expected to engage in more

unprotected sexualacts. Theymight be unawarethat they are

themselves at risk either because of the self-conﬁdence that

educationmaybringorbecausetheyareunawareordonotcareto

seetheirsexualpartnersasbeingatriskofHIV.Unprotectedsex

withmultiplepartnerswasfoundtobesigniﬁcantlyassociated

Table4

LogisticregressionforHIV-relatedsexualriskbehavioramongmale-to-femaletransgenderpersons(n=232)

Characteristics Sexwithoutcondomuse

(n=232)

Unprotectedanalsex (n=232)

Unprotectedsexwithmultiple partners (n=232) OR SE B OR SE B OR SE B Age 25years 1.65 (0.30) 0.50 0.99 (0.31) 0.01 0.82 (0.47) 0.19 24years,Ref. Education

Secondaryorhigherlevel 0.66 (0.29) 0.42 0.96 (0.31) 0.04 2.93a _(0.53) _1.08

Primarylevelornoeducation,Ref. Incomepermonth

5001NPR 0.94 (0.34) 0.06 1.15 (0.36) 0.14 0.67 (0.48) 0.40

5000NPR,Ref. Employment

Formalemployment 1.59 (0.29) 0.47 0.59 (0.31) 0.53 1.35 (0.49) 0.30

Informalornoemployment,Ref. Alcoholhabit Yes 1.34 (0.39) 0.30 0.66 (0.41) 0.41 0.13a (0.65) 2.03 No,Ref. Smokinghabit Yes 0.51 (0.36) 0.68 1.04 (0.38) 0.04 1.65 (0.64) 0.50 No,Ref.

Dailysexualcontactperpersons 1person,Ref.

2–3persons 1.30 (0.52) 0.26 0.39 (0.68) 0.95 0.00 (3.93) 18.64

4persons 2.68 (0.56) 0.99 0.18a

(0.69) 1.72 0.00 (3.93) 17.47

OR,oddsratio;Ref.,reference;SE,standarderror. a

(5)

withincome.Riskysexualintercoursemightbeencouragedwith

the inﬂuence of money and somewhat higher in the highest

incomegroupthaninthelowestincomegroup.

It is difﬁcult to make comparisons across studies, not only

becauseoftheproceduraldissimilarities,butalsobecausethere

havebeensofewornostudiesandtheyhavenotbeenconcurrent.

Sexual intercourse under the inﬂuence of alcohol and drugs

appearstobecommon,andsomewhathigherwithanalcoholhabit

thanwithasmokinghabit.31_A_previous_study_has_found_a_higher

levelofsubstanceuseamongtransgenderwomen.32

Astatisticallysigniﬁcantdifferencewasfoundbetween

HIV-relatedsexualriskbehaviorsandsexualcontactwithpersonsper

day.Athirdoftherespondentshadadailysexualriskbehavior

with two or more persons. Unprotected anal intercourse was

reported for 52.9% of participants. Thisis higher than the rate

foundinapreviousstudy.31_This_ﬁnding_suggests_that_the_rate_of

unprotectedsexualintercourseamongMtFtransgender

popula-tionsmayhaveincreased.

This study had limitations that should be noted. First, the

researchercouldnotascertaincausalityoftheassociationbetween

the different variables. Second, the data were obtained by

interviewer-administered questionnaire, including details of

HIV-related sexual risk behaviors; face-to-face interviews may

haveresultedinareportingbias.

Thesamplecamefromdifferentgeographicalareas,and

general-izationstoothertransgenderpopulationsarestrapping.Thisstudy

openedupnewlinesofinquiryregardingthisvulnerableminority

group.In fact,a researchermight beexamining diverse, though

linked,publichealthproblemsnecessitatingdifferentapproaches.

Likewise, the structuralfactors related toHIV, for instance age,

education,income,andemployment,mayfunctionindifferentways

amongthetransgenderpopulation.Studieswithinethnicandsexual

minoritygroupsareessentialtofurtherexploretheroleofthese

structuralfactors.Additionalempiricalevidenceisneededtogaina

ﬁrmunderstandingofthedifferentsamplingapproaches.

Inconclusion,age,education,income,frequencyofdailysexual

contact,andalcoholhabitremainsigniﬁcantwithregardto

HIV-relatedsexualriskbehavior.Thereisanurgentneedforprograms

andinterventionstoreduceriskysexualbehaviorsinthisminority

population.

Acknowledgements

TheauthorthanksAshminHariBhattaraiforhissupportduring

thedatacollectionandforintellectualcontributions.Theauthor

thankstherespondentsandreviewersforgivingtheirvaluedtime

andprovidinginformation.

Funding: This research received no speciﬁc grant from any

fundingagencyinthepublic,commercial,ornot-for-proﬁtsectors.

Ethical approval: The Institutional Ethics Review Board of

PokharaUniversity,NobelCollegeapprovedthestudy.

Conﬂictofinterest:Theauthordeclaresnoconﬂictofinterest.

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