This study participants were HIV-positive individuals who self-identified themselves as transgender women accessing HIV care in the Buffalo City Metro Municipality, Eastern Cape province, South Africa. Of the 12 study participants, three were on hormonal therapy prescribed from the study setting. The Buffalo City was selected as it was one of the data-collection sites for the first ever bio-behavioural survey to determine HIV prevalence among transgender women in South Africa. The Eastern Cape is one of the poorest provinces in South Africa, although it is endowed with rich mineral resources, high agricultural production and a world-renowned manufacturing base.¹⁸ The estimate is that in 2018, the HIV prevalence for the Buffalo City Metro Municipality was 14.46%,¹⁹ in contrast to the 46% HIV prevalence among transgender women in the Buffalo City Metro Municipality. The demographic data of the participants are displayed in Table 1.

An interview guide facilitated data collection. The development of the interview guide was based on literature review and the study purpose.¹⁶ The interview guide questionnaire consisted of semi-structured, open-ended questions. Initially, a pilot study was conducted, involving two transgender women who were not included in the study. Through this process, the researchers were able to refine the interview guide. Data were collected between March 2020 and June 2020. Each interview lasted for approximately 60 min and was conducted in English. However, participants were allowed to express themselves in their mother tongues, which were mainly Xhosa and Afrikaans where they had some challenges as the interviewer is fluent in both languages. Fortunately, all of them expressed themselves in English that eliminated the issue of translation. The interviews took place at the researcher’s office to ensure privacy and to enable adherence to social distancing in accordance with coronavirus disease 2019 (COVID-19) protocols. The interviews were audio recorded with the consent of study participants.

The interviews were constructed around one request: What were your experiences of using ART services as a transgender woman living with HIV? In order to elicit more detailed descriptions on the phenomenon under study, the interview guide had probing questions such as ‘What is your experience with ARVs?’ and, ‘Can you tell me how that experience made you feel?’ and ‘How do you cope?’ ‘What support system did you have?’. Interviews were conducted until data saturation was reached at the ninth participant, that is the point at which no new analytical information comes forth and maximum information on the phenomenon is provided by the participants.²⁰ Three additional participants were interviewed to establish whether there would be any new information. A total of 12 transgender women participated in the study.

The data were transcribed verbatim into written text. Interpretative phenomenological analysis enabled detailed exploration of how HIV-positive transgender women made sense of their HIV care experiences. The focus of IPA is to examine the lived experiences of the individual by drawing from the concepts of phenomenology, hermeneutics and idiography. This approach has been utilised in related studies and proved to be useful in exploring participants’ experiences.¹⁶ Each transcript was analysed independently by three researchers (L.L.-A.v.d.M., I.M. and A.H.M-M.), using the IPA framework as described by Smith and Osborn.¹⁶ An outsider, but academic expert on IPA, was requested to act as an independent co-coder and given audio recordings and transcripts to compare. Each researcher read the transcript several times and listened to the audio recording a few times. The following steps, outlined by Smith and Osborn,¹⁶ were followed: (1) reading and re-reading the transcript, (2) note-taking and developing emergent themes, (3) clustering the emergent themes, (4) crafting a master table of themes composed of superordinate themes, subthemes and extracts from the interviews (5) examining and comparing divergent and convergent themes, constructs and ideas from the master tables of the themes and (6) compiling a single master list composed of a superordinate theme, themes, and subthemes. Following this process, the independent coder was given a table of themes from all researchers to work on. The research team then met to compare and discuss the preliminary list of superordinate and subordinate themes and developed a detailed description of their meanings. The team had a consensus and agreed on the final master table, composed of superordinate themes, themes and subthemes and related excerpts from the transcripts (Table 2). This was to ensure credibility.²¹

Measures were taken to ensure trustworthiness and rigour as enunciated by Maher et al.²² To ensure trustworthiness, the research should satisfy four criteria, namely credibility, transferability, dependability and confirmability.²² According to Shosha,²³ credibility refers to the accuracy of the study findings. All interviews were audio recorded and transcribed verbatim to enhance credibility. In addition, member checking, peer evaluation and use of an independent co-coder further enhanced credibility as advocated for by Lincoln et al.²⁴

Beck²⁵ indicates that transferability is the ability of the findings to be transferred to other contexts. This was achieved by the provision of detailed descriptions of the research setting and context. To enhance dependability, thick descriptions were provided, and safe keeping of research documents ensured an audit trail that can facilitates replication of the study by any other researcher. Confirmability was enhanced by the use of bracketing to minimise researcher bias.

It is important to recognise that the experiences of participants are understood through the subjective interpretation of the researcher.²³ The first author who collected data is experienced in qualitative research. The researcher involved a lot of introspection and internal examination to explore personal feelings, experiences and biases and all these were bracketed to enhance confirmability. This approach allows one to become less assuming about another’s experience, to be open, compassionate and non-judgemental and present data from the perspectives of the study participant, thus ensuring credibility.²¹ Moreover, as the study was part of a Masters dissertation, the supervisor guided all the process through guiding the formulation of an interview guide, listening to the first two pilot interviews and provided guidance regarding proper questioning and probing to avoid channelling the participants to respond in a particular manner. In addition, peer debriefing was carried out following every interview, and irregularities identified were addressed. An independent co-coder experienced in qualitative research (who was outside the context of the study) listened to the audio-recorded interviews. She went on to review and assess the transcripts to check for the emerging and final categories from those transcripts and the final themes. Consensus was reached on the final master table of themes. This afforded the interviewers the opportunity for continued introspection throughout the process. By coding and recoding many times, comparing the themes and categories with the co-coder, the researchers ensured dependability. To enhance authenticity, verbatim excerpts from the interviews were used to substantiate themes emanating from the transcripts. Throughout, all the steps of analysis, interpretations and ideas were discussed by the research team and the independent co-coder to ensure that the process was as robust as possible. In addition, the research team also met to discuss and compare the initial findings and agreed on the super and subordinate themes.

Protecting the rights of the institution is an important principle of research.^23,24 To ensure that this principle was achieved, the researcher sought and obtained ethical clearance from the University of South Africa Africa’s College of Human Sciences Research Ethics REC-012714-039 (NHERC). Permission to conduct the study was also obtained from the Health and Social, Health and Empowerment Feminist Collective of Transgender Women based in the Buffalo City Metro Municipality. As part of the consent process, participants were informed that participation was voluntary and that the interviews would be audio recorded. Participants were also informed that they were free to decline or discontinue participation at any time, if they wished to do so. Participants were assured that data would be handled confidentially and that the results would be reported in a way that ensured anonymity. Therefore, all identifiers were removed from the transcripts and pseudonyms used. Data were stored in a password-protected computer. The study participants were provided with a detailed information sheet that explained the details of the study. They then gave an informed written consent after reading and understanding all the information.

It is important to acknowledge the study limitations. The study was limited only to transgender women who accessed ART in Buffalo City South Africa; therefore, the findings refer to the experiences in this city. While the existing literature on transgender persons and access to HIV care is limited, that which is available points to the fact that the experience of transgender persons in South Africa and in the region is similar.^6,8,12

The implications are that enabling factors such as differentiated service delivery approaches, medicine related and psychosocial determinants are critical in developing strategies that enhance treatment adherence and continuity. Key to the study findings is that service provision for whom the program is being crafted must be underpinned by an understanding of the communities to enhance the provision of differentiated person-centred HIV care.