STIGMA AND DISCRIMINATION AFFECT ACCESS TO MEDICAL CARE OF HIV-INFECTED MEN WHO HAVE SEX WITH MEN (MSM) IN CHENNAI, INDIA P Mahalingam, R Watts, J Monica, EC Sundari, S Balasubramaniam, V Chakrapani

ISSUE In Chennai (Madras), India, symptomatic HIV-positive men who have sex with men (MSM) are reluctant to seek medical care in government and private clinical settings due to stigma and discrimination.

DESCRIPTION SWAM – Activities: Social Welfare Association for Men (SWAM) is a community organization that serves MSM in Chennai, India Services offered to MSM: Outreach education (HIV/STD) Condom promotion and distribution Drop-in center Sexual health clinic Voluntary Counseling and Testing (VCT) Day care center for HIV- positive MSM

SWAM – Activities : (Contd.) Until recently SWAM’s focus has been on HIV prevention interventions and offering sexual health services. However, it has been witnessing increasing number of symptomatic HIV-positive MSM in Chennai who are reluctant to seek medical care due to fear of discrimination in the public and private health care system. SWAM has partnered with Indian Network for People living with HIV (INP+) to advocate for the care issues of MSM living with HIV.

Discrimination in the public & private hospitals - 1 Discrimination could be because of HIV status and/or sexuality - difficult to distinguish. Most HIV- positive MSM may not reveal their sexuality or same-sex behavior to their health care providers because of fear of discrimination. This means they will not receive appropriate information about safer sex practices as well as their male partners will not be counseled or referred for HIV testing. Discrimination by commission: –Substandard care –Abusive language –Breach of confidentiality

Discrimination in the public & private hospitals -2 Discrimination by omission: HIV-positive MSM also face hidden discrimination: - health care providers’ assumption about sexuality and sexual activity (after becoming HIV- positive) - Not involving steady male partners in treatment- decision making - Not talking about safer sex practices (assumption that they are not sexually active or should not be sexually active)

Rationale behind starting outpatient care for HIV-positive MSM in SWAM Especially those HIV-positive MSM who are gender-variant and have associated anal STDs could not pass as "normal" [i.e., heterosexual] and are afraid to seek public or private health care services. Hence SWAM has started outpatient care for HIV-positive MSM to offer basic clinical care in a non-judgmental environment. SWAM is taking efforts to change the attitude of health care providers in the public and private hospitals so that MSM could utilize those services without any fear of discrimination.

Services provided to HIV-positive MSM in SWAM A physician takes care of screening and treatment of milder opportunistic infections. A counselor offers various counseling services including risk-reduction counseling and assists in partner notification. Drugs for opportunistic infections are offered free or partially reimbursed. Those patients who need inpatient care are referred to government hospitals or other inpatient care centers - sometimes accompanied by an outreach worker, if necessary. Referral linkages with Govt. TB Hospital and other specialties.

Discrimination faced by HIV-positive MSM from other MSM Many HIV-positive MSM were hesitant in accessing services provided by SWAM since other MSM will come to know about their HIV status. For HIV-positive male sex workers, this also means breach of confidentiality since other MSM may reveal their HIV status to potential clients (though HIV-positive male sex workers may always practice safer sex) thus leading to loss of income as well as creating risk of physical violence.

Support group meetings for HIV- positive MSM HIV-positive MSM are reluctant to attend the support groups organized by 'mainstream' positive groups. However, motivating HIV-positive MSM to attend positive MSM group meeting has also been difficult due to confidentiality issues.

SWAM’s efforts to improve access to medical care of HIV-positive MSM – 1 Conducting sensitization programs for health care providers on the issues of MSM and transgendered persons (including HIV-positive MSM). Documentation of stigma and discrimination faced by HIV-positive MSM in the health care system as part of formal needs assessment and devising appropriate strategies to address the same.

SWAM’s efforts to improve access to medical care of HIV-positive MSM – 2 Sensitizing MSM in Chennai about the issues of HIV-positive MSM and the need to support them so that HIV-positive MSM can access the services offered by SWAM with out fear of discrimination by other MSM. Addressing the self-stigmatization in HIV- positive MSM in informal group discussions and taking steps to increase their self-esteem.

LESSONS LEARNED Stigma and discrimination can significantly impede the treatment-seeking behavior of HIV-positive MSM there by decreasing the opportunity for early intervention. Discrimination within the community can hinder HIV-positive MSM to come together and utilize even the services offered by community organizations.

RECOMMENDATIONS Urgent and intensive efforts need to be taken to create a non-discriminatory and non-judgmental environment for HIV-positive persons of any sexuality in the Indian health care system. Appropriate strategies need to be developed to achieve the same. To decrease the discrimination faced by HIV-positive MSM from other MSM, there is a need to sensitize MSM population itself about the issues of HIV-positive MSM and the need to take care of them. ‘Mainstream’ PLHA groups need to be sensitized about the specific issues faced by HIV-positive MSM. Appropriate ways need to be find out to increase the self-esteem of HIV-positive MSM and to remove the self-stigma.