In India and other low-and-middle-income countries, little is known about how intersectional stigma affects MSM engagement in ART. Informed by the Health Stigma and Discrimination Framework, we qualitatively examined how multiple stigmas influence ART engagement among Indian MSM. We conducted 3 focus groups (N = 22) with MSM living with HIV, aged 21-58 years, in Delhi and Hyderabad to identify potential intervention targets and solutions to improve treatment outcomes. Framework analysis and techniques were used to code and analyze translated audio-recordings. Findings revealed enacted stigma, associated with HIV and MSM identity, manifested as familial shame and healthcare discrimination, inhibiting access to support, and decreasing HIV care engagement. Anticipated stigma led to worry about disclosure and societal repercussions. Community-Based-Organizations, ART centers, and family members were primary sources of support, leading to increased ART initiation and retention. Potential solutions included using MSM peer-counselors, increasing social support, and providing HIV education to the general community.

Sexualized substance use (SSU) is the practice of psychotropic substance use before or during sex to increase sexual pleasure. The growing use of SSU has a strong association with sexually transmitted infections (STIs). Community health mobilizers (CHMs) are agents who assist in decreasing the global burden of disease in the communities they serve. They work as unit managers, counselors, or field workers. The managers and counselors have a minimum of a bachelor's degree, and field workers have a minimum of a higher secondary education. This study aimed to qualitatively assess the knowledge gaps regarding SSU among CHMs. In-depth interviews (IDIs) were conducted in New Delhi, India with nineteen CHMs. Majority of the CHMs were men (n = 9, 47%) followed by transgender (TG) persons (TG females n = 5, 26.3%; TG males n = 1, 5.2%), and women (n = 4, 21.1%). Knowledge gaps were identified among the CHMs regarding different types of sexualized substances, drug procurement, human immunodeficiency virus (HIV) infection prevention, and complex health issues associated with SSU. It suggested the need for periodic workshops and training for upgradation of existing knowledge and practices among the CHMs. This formative research may help social scientists to develop protocols for conducting multi-centric, community-based studies across the country for further validation and exploration.

ABSTRACT Among transgender women living with HIV (TGWLH) in India, little is understood about the mechanisms through which multiple intersecting stigmas impact HIV care engagement, or intervention strategies that might mitigate this impact. We conducted focus groups with TGWLH (N = 30) in three Indian cities and analysed data using theoretical frameworks related to HIV stigma, gender affirmation, and syndemics. Findings revealed that enacted and anticipated stigma due to transgender identity, HIV, or sex work status, and lack of gender affirmation (e.g., misgendering) in healthcare settings delayed ART initiation and promoted care disengagement. Having supportive physicians and counsellors within ART centres and peer outreach workers facilitated ART initiation, adherence, and retention. Findings also revealed that HIV stigma within TGW communities led to concealment of HIV status or syndemic conditions such as depression and alcohol use, thereby affecting care engagement. However, the TGW community itself was also described as a resilience resource, offering emotional, psychological and tangible support that decreased the impact of discrimination on care engagement. HIV care engagement efforts among Indian TGWLH could be strengthened by reducing intersecting stigmas in healthcare settings and within TGW communities, providing gender-affirming and culturally competent healthcare, addressing psychosocial syndemic conditions, and strengthening support within transgender communities.

Transgenders (TGs) are highly affected by HIV with high prevalence of 3.14% in India. Since 2017, targeted preventive efforts have been initiated by the government and HIV-infected TGs are being provided the antiretroviral (ART) treatment. Information on the primary HIV drug resistance is crucial for appropriate treatment selection to curb further spread of HIV in this population. In this study, we analyzed HIV-1 pol gene sequences from 36 TGs for presence of drug resistance mutations. To our knowledge, this first study from India reports high-level primary drug resistance (13.8%) among the TG population. Mutations M184V, A98G, K103N, G190A, and Y318F associated with resistance to nucleoside reverse transcriptase inhibitor and non-nucleoside reverse transcriptase inhibitors were observed. All pol gene sequences revealed HIV-1 subtype C in all study TG. High-level HIV-1 drug resistance warrant nationwide larger studies on TGs to understand the level of primary ART drug resistance among this population.

Low community awareness of mental health problems negatively impacts treatment-seeking for such problems. Despite a shortage of mental health providers, there is scope to improve coverage of mental health services in India. In this study, we examined the impact of a multi-statecommunity-based awareness campaign on knowledge, attitude, treatment-seeking behavior and acceptability. Campaign activities included educational materials, public meetings, musical announcements, quizzes, and street plays, followed by a mental health screening camp. A rapid, real-world evaluation was conductedusing post-intervention surveys (n = 693), field notes and telephonic interviews in five states. The campaign, implemented as a public-private partnership between government service providers and community-based organizations, reached ~ 3000 people in 20 new locations across five states. As a result of the campaign, 1,176 persons sought treatment servicesfor mental disorders and 66% received a preliminary diagnosis. Collectively, campaign activities were the first time that ~ 75% of participants reported learning about mental health problems. Participants expressed knowledge that mental disorders are treatable, listed common symptoms and location of available mental health services and attitudes supporting people with mental health problems. The campaign enabled improved coverage for mental health services, potentially by enhancing knowledge, attitude and treatment-seeking behavior. Future research may develop a quasi-experimental evaluation of the current campaign methodology.

Purpose: High levels of human immunodeficiency virus (HIV) prevalence and inconsistent condom use among transgender women in India highlight the need for additional effective HIV prevention methods like preexposure prophylaxis (PrEP). We examined the extent of and factors influencing willingness to use PrEP among trans women in India. Methods: Between June and August 2017, we conducted a cross-sectional survey among 360 trans women recruited through community-based organizations in six cities. We assessed PrEP knowledge, condom use, attitudes toward PrEP (after providing information on PrEP), preferences in PrEP pricing and access venues, discrimination experiences, and the likelihood of using PrEP. Logistic regression analyses were conducted. Results: Participants' median age was 26 years; 50.7% had not completed high school, and 24.8% engaged in sex work. Only 17.1% reported having heard of PrEP before the survey, and 80.6% reported that they would definitely use PrEP. Trans women in sex work had 28 times higher odds of reporting willingness to use PrEP than those not in sex work (adjusted odds ratio [aOR]=28.9, 95% confidence interval [CI]=8.79-95.16, p<0.001). When compared with trans women who did not experience discrimination, the odds of reporting willingness to use PrEP was lower among trans women who had experienced discrimination from health care providers (aOR=0.25, 95% CI=0.06-0.97, p=0.04) and family members (aOR=0.08, 95% CI=0.05-0.14, p<0.001). Conclusion: Willingness to use PrEP was high among trans women, especially those in sex work, despite identified barriers (e.g., discrimination experiences). To promote PrEP uptake among at-risk trans women, the steps needed are as follows: increasing awareness about PrEP; providing easy-to-understand information on PrEP's effectiveness, side effects and interactions between PrEP and hormones; training health care providers on PrEP and cultural competency; and reducing stigmas related to PrEP use and HIV. PrEP implementation research projects to identify effective PrEP delivery strategies are urgently needed to reduce the disproportionate HIV burden among trans women in India.

Background: In India, public social protection schemes for marginalized populations are extended to people living with HIV (PLHIV) and their households. Care and Support Centres (CSCs) linked to antiretroviral therapy (ART) centres play a key role in linking PLHIV to the schemes. In three districts of Rajasthan, India, we assessed the linkage of PLHIV registered at CSCs (2016–18) to social protection schemes and explored PLHIV and provider perspectives into barriers and suggested solutions for improving linkage. Methods: This was an explanatory mixed method study involving a descriptive quantitative phase using secondary data, followed by a descriptive qualitative phase involving face-to-face in-depth (five PLHIV) and key informant (three CSC staff) interviews. Results: Of 1123 registered PLHIV at CSCs, 1026 (91%) expressed willingness to avail social protection schemes. Of 1026, 94% were linked to any one scheme; 52% to Palanhar, 51% to bus fare concession and 42% to widow pension schemes. The perceived barriers were: authenticating Aadhaar number (unique identification number provided to all Indians using their registered mobile phone number), cumbersome application processes for each scheme, limited utility of travel concession, delayed and/or irregular disbursement of benefits and non-availability of comprehensive information, education and communication material with details of all schemes and their application processes. Reaching out to all PLHIV in the designated district was a huge task for outreach workers. Another important barrier was the potential disclosure of positive status to various stakeholders in order to avail the schemes. Suggested solutions were a single window default application process at ART centres with a smart card and a single pamphlet at ART centres with all the required details. Conclusions: Bus fare concession, Palanhar and widow pension schemes were the most widely accepted and linked schemes by PLHIV. Implementation barriers were identified that need to be addressed to improve the linkage.

Media plays an important role in broadcasting stigmas. Research on media and public stigma attitudes toward homosexual stigma show mixed results. Few studies, however, focus on how the stigmatized individuals and groups perceive and react to stereotyped media portrayals. This study focuses on stigma against gender and sexual minorities, targeted as “high-risk” groups in HIV/AIDS campaigns: Men who have sex with men, Transgender and Hijras (MTH). Factor analysis of data from a cross-sectional survey of gender and sexual minorities in three south Indian cities (N=225) indicated five distinct dimensions of minority stigma. Apart from three dimensions of stigma identified by previous studies—experienced or enacted stigma, internalized or self-stigma, felt normative stigma—this study found two new dimensions of stigma—HIV-related vicarious stigma or hearing stories about stigma and discrimination against HIV positive individuals, and perceived media portrayal stigma. Regression models show that media use is positively associated with perceived media stigma, and that perceived media stigma is negatively associated with identity disclosure, but only through experiences of stigma and discrimination. How minorities discursively manage media stigma will have important implications for reducing stigma and discrimination.

Stigma and discrimination are primary drivers of health disparities among marginalized communities. Drawing on stigma management, minority stress model, and social cognitive theories, this article tests the interplay between dimensions of stigma, collective efficacy, and advocacy communication among men who have sex with men (MSM) and transgender females. Using data from a cross-sectional survey conducted in south India (N = 225), five distinct dimensions of stigma were identified using factor analysis: experienced stigma, self-stigma, felt normative stigma, and two new dimensions—HIV-related vicarious stigma and media stigma. Respondents reported highest levels of media stigma. While most of the dimensions of stigma were negatively associated with both collective efficacy and advocacy communication, collective efficacy mediated the relationship between stigma and advocacy. Implications for public health campaigns among MSM groups are discussed.

IntroductionIndia is home to the world’s third largest HIV-positive population. One sub-population- children living with HIV (CLHIV) -requires unique ‘HIV triaging’ to ensure patients at high risk receive treatment without delay. The International Alliance for the Prevention of AIDS (IAPA), an organisation in Chennai, India, supports 43 CLHIV by offering free monthly medical visits. Between monthly visits, all patient calls are triaged by a single staff member. The UTHAVI Project, a training curriculum and web-based telephone triage database, aims to help IAPA’s CLHIV get the treatment they need between monthly visits. The UTHAVI project trains community social workers and IAPA staff in triage categorization, evaluating trainees’ knowledge and preparedness pre- and post-training. MethodsIn-depth Interviews with staff and physicians were conducted to assess program needs. The triage curriculum, ‘The UTHAVI Project,’ was adapted from the WHO’s Integrated Management of Childhood Illness handbook. Using 25 CLHIV triage scenarios, pre- and post-training knowledge and preparedness were assessed in 5 IAPA staff members and 12 Bachelor’s in Social Work students. Participants used a 3-tier triage system (emergent, urgent, non-urgent) to assign a triage level for each scenario. ResultsPaired t-test analysis showed significant differences (p<0.05) in overall pre- and post-test scores. The protocol categories of Fever, Diarrhoea, General Danger Signs, and Opportunistic Infections showed the most significant differences (p<0.05) while the protocol category of Cough showed no significant difference (p>0.05). 94.1% of trainees felt equally or more prepared post-training vs. pre-training. ConclusionFuture research looks to assess the protocol’s impact on control and treatment groups. Future direction of The UTHAVI Project include expanding the healthcare network to physicians of different specialties. Following the completion of the online triage database, trainings on how to use the technology will be conducted and triaging patients will be studied through the website.