Compounding Vulnerabilities: Victimization and Discrimination Is Associated with COVID-19 Disruptions to HIV-Related Care Among Gay, Bisexual, and Other Men and Transgender and Nonbinary People Who Have Sex with Men in Kazakhstan

BACKGROUND AND PURPOSE: Gay, bisexual, and other men and transgender and nonbinary people who have sex with men (MSM and TSM, respectively) are disproportionately impacted by the HIV epidemic in Kazakhstan—where 85% more new HIV infections were recorded in 2019 than 2010. MSM and TSM in Kazakhstan also face high levels of discrimination and victimization, known barriers to engagement in HIV care. COVID-19 has introduced an exogenous stressor that appears to further compound vulnerability and increase barriers to care among marginalized populations. No study had reported on how or which sexual and gender minorities in Kazakhstan have been impacted by COVID-19 in relation to access to HIV care. We examined whether factors known to be associated with lower uptake of testing and care in other populations and settings—exposure to victimization and discrimination—were associated with COVID-19-driven limitations to HIV testing and care access.

METHODS: We examined data from one-time surveys with 455 adult MSM and TSM collected from May through October of 2020 in three Kazakhstan cities. Outcome variable: Participants were asked to answer yes or no to the following question: “Has COVID or the response to COVID limited your ability to get HIV testing or treatment?” Exposure variables: We summed participant responses to 6 questions assessing exposure to sexual and/or gender-based victimization within the past 6 months to create a binary victimization variable, where 0 = never and 1 = once or more. We summed responses to 8 questions assessing sexual/gender-based discrimination across social spheres to create a binary variable wherein 0 = no and 1 = one or more experiences over the past 6 months. Participant scores for both of these variables were summed to create a binary exposure measure denoting whether the participant had (1) or had not (0) recently experienced both victimization and discrimination. We used logistic regression to determine bivariate and adjusted (for age, sexual identity, gender, and employment) associations between experiences of discrimination or victimization and disruptions to HIV testing and treatment. Multilevel models were used to account for clustering within city.

RESULTS: Odds of reporting COVID-19 disruptions to HIV-related care access were significantly higher (OR: 1.93; 95% CI: 1.09-3.42; P = .02) among those who experienced recent sexual or gender-based victimization, and separately, discrimination (OR: 2.90; 95% CI: 1.70-4.92; P <.001), compared to those who did not experience victimization or discrimination, respectively. Odds of reporting disruptions among those who experienced both victimization and discrimination were significantly higher (OR: 3.59; 95% CI: 1.93-6.66; P <.001) compared to those who experienced neither (n=312). Associations remained significant in adjusted models.

CONCLUSIONS AND IMPLICATIONS: Our findings offer evidence of compounding vulnerability and warrant efforts to ameliorate the impacts of COVID-19 that target gay, bisexual, and other men and transgender and nonbinary people who have sex with men and face sexuality or gender-based discrimination and victimization.