Shahzad Rasheed
For most people, going to a healthcare facility begins with a simple thought: I don’t feel well, so I need to see a doctor. For a transgender person living with HIV, that ordinary decision can involve a much more complicated calculation. Before leaving home, there may already be questions about which name to use at reception, which queue to join, whether people will stare, and whether the healthcare provider will listen to the medical complaint or focus instead on gender identity.
Living with HIV adds another layer of anxiety: Will my status become known? Will my information remain confidential? Will I be judged? And if they know I am living with HIV, will I still be treated with dignity?
For Dilruba (name changed), a transgender person living with HIV in Pakistan, what should have been an ordinary visit to a healthcare facility became an experience difficult to forget. She had gone to collect her HIV medication and continue her treatment. Instead, she was told by a doctor not to return.
For someone who depends on regular medication and continued engagement with healthcare services, rejection like this does more than cause humiliation. It can undermine trust in the very system on which their health depends.
Dilruba’s experience cannot be understood through HIV alone. Like many transgender people in Pakistan, her life has also been shaped by family rejection, interrupted education, social exclusion and limited access to reliable information about HIV prevention and treatment. Her experience points to a wider problem: access to healthcare is not determined only by whether a hospital exists, a doctor is available or medicine is stocked. It is also determined by whether people feel safe enough to walk through the hospital door.
Pakistan’s HIV Stigma Index Study 2.0 provides troubling evidence of these barriers. The national study, involving 1,500 people living with HIV, found that more than 16 percent of transgender respondents reported being denied healthcare services because of their HIV status.
Qualitative research conducted by Blue Veins and the National Commission for Human Rights on the impact of HIV stigma on transgender people living with HIV in Khyber Pakhtunkhwa further illustrates these challenges. Transgender women from different districts described discrimination, uncomfortable waiting environments and difficulties navigating healthcare facilities organised strictly around male and female categories.
Some participants did not know which queue to join and felt exposed simply while waiting for treatment. To someone who has never faced such circumstances, a queue, registration form or waiting area may appear to be a minor administrative matter. For a transgender patient, these can become the first indication of whether a healthcare facility recognises their identity and dignity.
Together, seemingly small barriers can communicate a powerful message: this place was not designed for people like me.
Sometimes discrimination is obvious. A patient may be mocked, misidentified, subjected to unnecessary questions or refused care. At other times, exclusion is quieter: a receptionist who does not know how to respond when identity documents and gender expression appear different, a registration system that offers no appropriate option, a waiting area divided rigidly between men and women, or a healthcare provider with little understanding of transgender-inclusive care.
The most serious consequence may never appear in hospital records. There may be no complaint and no investigation. The patient simply decides not to return.
For transgender people living with HIV, that decision can have particularly serious consequences. Antiretroviral treatment can control HIV and enable people living with the virus to live long and healthy lives, but treatment requires continuity. Medication must be taken consistently, while patients need dependable access to healthcare, monitoring and follow-up.
This makes trust part of treatment.
When patients believe their information will remain confidential and that they will be treated respectfully, seeking care becomes easier. When they expect judgement, disclosure or humiliation, even a necessary appointment can become something to postpone. In HIV care, returning to healthcare is not incidental to treatment; returning is part of the treatment itself.
This can create a damaging cycle. A person who expects humiliation may delay seeking healthcare. A delayed visit can allow a manageable health problem to become more serious. Another negative experience reinforces the belief that healthcare facilities are unsafe, making the next visit even less likely. Eventually, staying away can feel safer than going back.
HIV stigma therefore cannot be understood simply as offensive language or negative attitudes. When stigma prevents someone from testing, collecting medication, discussing symptoms honestly or returning for follow-up, it becomes a barrier to healthcare and an obstacle to an effective HIV response.
Confidentiality is especially important. For someone living with HIV, the fear may not simply be that a healthcare worker will know their status, but that the information will travel beyond the consultation room—to other staff, patients, family members or the wider community.
For transgender people already experiencing social exclusion, involuntary disclosure can create another layer of vulnerability. Digital services, confidential information and HIV self-testing can provide valuable alternatives and greater privacy. But technology cannot substitute for an inclusive healthcare system. People will still need doctors, medicines, examinations and follow-up care.
The solution cannot be to help people avoid discriminatory healthcare indefinitely. Healthcare itself must become safe enough to use.
This is where the conversation must move beyond sympathy towards rights and accountability. Respectful treatment should not depend on finding a sympathetic doctor or understanding receptionist. Confidentiality is not a favour, and equal treatment should not be an optional feature of an “inclusive” clinic.
When discrimination interferes with access to HIV prevention, testing, treatment and continuing care, it becomes a healthcare-quality issue, a public-health issue and a human-rights issue.
Creating a more inclusive system does not necessarily require separate hospitals or expensive technology. Registration procedures can respect patients’ identities. Healthcare workers can use appropriate names and forms of address. Medical information can be protected from unnecessary disclosure, and waiting arrangements can avoid placing transgender patients in humiliating situations.
Healthcare providers need practical training. Facilities need enforceable confidentiality and non-discrimination standards. Patients need safe mechanisms for reporting mistreatment. Most importantly, transgender people living with HIV should be meaningfully involved in designing and monitoring the services intended for them.
Inclusivity cannot be measured by a poster on a clinic wall or by adding the word “transgender” to a policy document. It is measured at reception, in the waiting room and during examination. It is measured by whether confidentiality survives beyond the consultation room and whether a healthcare provider listens before making assumptions.
Ultimately, it is measured by whether a patient leaving a healthcare facility feels safe enough to return.
For Dilruba, the journey began with something ordinary: the need to collect medication. For someone else, it may begin with a fever, an injury or a routine check-up. No patient should have to calculate how much humiliation they can tolerate before deciding whether healthcare is worth seeking.
A healthcare facility should be a place where a person can walk through the door, explain what hurts and expect to be heard.
For transgender people living with HIV, dignity should not have to be negotiated at the hospital door. It should already be part of the treatment.
