Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India

Abstract

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men [MSM] whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, health care system-level, and individual-level; however, we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and health care levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one's HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the health care system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the health care system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, health care providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, health care system, and individual levels for aravanis, kothis, other subgroups of MSM and other marginalized groups.

Keywords:

• access to health care
• antiretroviral treatment
• men who have sex with men
• transgender women
• India

Acknowledgements

We thank all study participants for openly sharing their personal life experiences, views, and opinions. We thank the following Chennai-based CBOs for their help in data collection: Social Welfare Association for Men (SWAM),Sahodaran, South India Positive Transgender Foundation (SIPTF), and Transgender Rights Association. We thank Mr. Sandy Michael and Mr. D. Dinesh Kumar for assisting in data analysis. We also appreciate the hard work and commitment of our community-based field research team. And our sincere thanks to Indian Network for People Living with HIV/AIDS board members – especially Mr. K.K. Abraham and Mr. Kh. (Bobby) Jayanta Kumar – for their guidance and support. This study was supported by the International Treatment Preparedness Coalition (ITPC) and the “Sarvojana” project funded by the European Union (EU)/The Humanist Institute for Development Cooperation (HIVOS). The project was also supported by the Yale AIDS International Training and Research Program (5 D43 TW001028), funded by the Fogarty International Center of the U.S. National Institutes of Health. Dr. Newman was supported in part by the Canada Research Chairs Program and a grant from the Canadian Institutes of Health Research.