Abstract
BackgroundIn Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing. As many as 50% of MSM and TW may conceal their same-sex preferences and behaviors, yet little is known about the barriers faced by those who are locally regarded as ‘hidden’ – that is, MSM who do not disclose same-sex preferences and/or identify as gay. This study explored specific barriers to accessing HIV testing and other prevention services among ‘hidden’ MSM to inform appropriate models of service delivery.MethodsIn-depth interviews with MSM (n = 12) and TW (n = 13) and focus group discussions (FGD) with MSM and TW community members, leaders and key informants (n = 35) were undertaken in Yangon during June – September 2015. Participants were recruited by word-of-mouth by trained peer data collectors. Responses to questions from semi-structured guides were transcribed and coded using Atlas Ti. Codes were based on key domains in the guides and applied to transcripts to identify and analyze emerging themes.ResultsFear of stigma and discrimination and the need to meet gender expectations were key reasons for non-disclosure of same-sex preferences and behaviors; this typically manifested as avoidance of other MSM and settings in which sexual identity might be implicated. These concerns influenced preference and interaction with HIV services, with many avoiding MSM-specific services or eschewing HIV testing services entirely. The difficulties of engaging hidden MSM in HIV prevention was strongly corroborated by service providers.ConclusionHidden MSM face multiple barriers to HIV testing and prevention. Strategies cognizant of concerns for anonymity and privacy, such as One-Stop Shop services and online-based health promotion, can discretely provide services appropriate for hidden MSM. Enhanced capacity of peer-service providers and mainstream health staff to identify and respond to the psychosocial challenges reported by hidden MSM in this study may further encourage service engagement. Overarching strategies to strengthen the enabling environment, such as legal reform and LGBTI community mobilisation, can lessen stigma and discrimination and increase hidden MSM’s comfort and willingness to discuss same-sex behavior and access appropriate services.
Highlights
In Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing
Those who reportedly engaged in providing services to MSM and TW for 1 year or more, were aged 18 years and over, and spoke Myanmar were eligible for focus group discussions (FGD)
Service providers and community leaders corroborated the experiences and characterizations of hidden MSM and noted the unique ways in which these barriers impacted their ability to engage hidden MSM in HIV prevention. These findings provide some context for the low rates of HIV testing currently observed among MSM and TW in Myanmar [4] and carry important implications for the enhancing service demand through the development of culturally-relevant HIV prevention programs that are acceptable and can adequately address the specific needs and concerns of hidden MSM in Myanmar
Summary
In Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing. In Asia, HIV prevalence greater than 10% has been observed in some MSM and TW communities [1, 3,4,5], while emergent epidemics in countries as diverse as Thailand [6], India [7] and the Philippines [8] have been recently noted. This ongoing vulnerability of MSM and TW to HIV acquisition may suggest limitations in both the scale and effectiveness of current HIV prevention responses in the region. These labels typically encompass sexual positioning, power dynamics, and gender expression and are reflective of one’s willingness to disclose their sexual preferences, behaviors and gender identity [4, 13]
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