Discrimination, Violence and Access to Care Among High Risk Men Who Have Sex With Men in Chennai, India
An increasing focus on health and HIV prevention among MSM populations in India has documented disproportionately high rates of HIV infection; nevertheless, scant research has explored social and structural determinants of health among MSM that may contribute to risk. We explored stigma, discrimination, violence and access to care among MSM in Chennai, India.
We conducted a community-based mixed methods investigation using a concurrent triangulation design; 3 community-based organizations were engaged across all stages of research design, recruitment, data analysis and dissemination. Qualitative: We developed a semi-structured interview guide in English, which was translated and back-translated to create a Tamil version; questions explored experiences of stigma, discrimination in healthcare, violence, health and risk behaviors. In-depth interviews were recorded, transcribed, translated into English, double-coded and assessed using thematic analysis and a constant comparative method, with all themes organized into a conceptual map. Member checking and key informant interviews informed data analysis. Quantitative: A structured questionnaire included items assessing sociodemographics, harassment, sexual violence, access to HIV information and HIV testing. Survey participants were recruited using time-space sampling from a random sample of public sex environments (cruising areas). Data were analyzed using descriptive statistics, with logistic regression to assess associations of discrimination and violence with health and risk behaviors.
Survey participants (n=200; mean age=28.5 years) were predominantly kothi-identified MSM (71.5%), 13.5% “double-decker”, 9.5% “gay”, 5% transgender women. 60% had less than high school degree education; two-thirds had monthly income <=2000 rupees (~$1.67/day). The majority (59.5%) engaged in survival sex in exchange for money. In-depth interview participants (n=18; mean age=28.2 years) were kothi-identified MSM, with average monthly income <=1500 rupees. In the survey, over one-third (35%) reported verbal or physical harassment on a daily or weekly basis; 41% reported forced sex in the past year. Although 60% reported anal sex (past 3 months), one-third (32.9%) no condom last time, nearly one-third (32.5%) had never been HIV tested. Nearly half reported friend or other person as their primary source for HIV/STI information, 53% a healthcare provider. In adjusted analysis, high HIV knowledge was associated with nearly threefold higher odds of HIV testing; forced sex was associated with 64% lower odds of HIV testing. Qualitative data reveal multiple intersecting social and institutional contexts of stigma, discrimination and violence: from police, healthcare providers (HCP), community and family. Stigma and discrimination from HCP took the form of derogatory comments, inadequate or absent sexual histories and diagnosis, conflicting information about safer sex and outright refusal of service. Participants reported fear of reporting their true symptoms and behaviors. In addition to lack of police protection from neighborhood bullies (“rowdies”), participants reported violence, forced sex and blackmail by police.
Conclusions and Implications:
Epidemic rates of harassment and sexual violence and discrimination in the healthcare system against low socioeconomic MSM indicate the importance of focusing on structural factors that may be fundamental to mitigating risk and promoting health. The effectiveness of individual-level and knowledge-based preventive interventions is likely to be constrained in the context of poverty, low education, harassment and sexual violence.