"You get HIV because there is no hope" a rapid qualitative assessment of the HIV vulnerabilities of transgender women in three South African metros.

Introduction: Epidemiological data show that transgender women are disproportionately affected by Human Immunodeficiency Virus (HIV). Data in South Africa on the HIV vulnerabilities of transgender women are sparse. This paper qualitatively explores the structural, personal, and economic factors that contribute to making South African transgender women vulnerable to HIV and other sexually transmitted infections (STIs). Methods: We conducted a rapid qualitative assessment in the Cape Town, Johannesburg, and Buffalo City metropolitan municipalities to frame the HIV risk vulnerabilities of transgender women. Purposive sampling was used to recruit study participants. We conducted 25 key informant interviews, five focus group discussions, and 26 in-depth interviews with transgender women. Atlas.ti.8 was used to facilitate qualitative data analysis. Study findings: These data illustrate a pervasive theme of social rejection, discrimination, and everyday victimization among transgender women. The ubiquitous presence of stigma and rejection leads to internalized stigmatization, which affects the social and mental well-being of transgender women, who often turn to alcohol and illicit drug use to alleviate negative emotions. We found that transgender women may engage in high-risk sexual activities like sex work where they can express and affirm their gender identity. In this context, transgender women engaging in high-risk sexual activities found it challenging to access pre-exposure prophylaxis (PrEP). Stigma also leads to reluctance to use public healthcare services. Despite experiencing stigma and discrimination, qualitative data highlights the resilience of transgender women in the study. Conclusions: Qualitative data demonstrate that HIV risk for transgender women is complex. Multi-level community-led interventions grounded in empowerment are also required to address interpersonal, biological, structural, and community risk. Successful interventions should address stigma and draw upon the resilience of transgender women. Peer-driven interventions may motivate personal responsibility to use high-impact HIV prevention and treatment services.