1. Treatment access for positive MSM in the Asia Pacific lessons learned from the analysis of an APN+ peer-led study in 6 countries M Choo 1, VR Nair 2, A Lim 3, BK Raju 4, N Kustantonio 5, J Jan 6, T Wong 6, MP Thet 7, R Baldwin 8, A Chen 8 1 Centre of Excellence for Research in AIDS (CERiA) Medicine, Kuala Lumpur, Malaysia 2 NIPASHA+, New Delhi, India, 3 Action for AIDS, Singapore 4 Blue Diamond Society, Chitwan, Nepal 5 HIVERS, Jakarta, Indonesia 6 Kuala Lumpur AIDS Support Services Society (KLASS), Kuala Lumpur, Malaysia, 7 The HELP, Mandalay, Myanmar 8 Asia Pacific Network of People Living with HIV (APN+), Bangkok, Thailand

2. Overview Data: Peer-led by PLHIV CBOs in 6 countries in 2009: India, Indonesia, Malaysia, Myanmar, Nepal, and Singapore. 2-stage data collection: –(1) Survey (N=897) –(2) FGD (at least one per country) Study Objectives: –Assess treatment availability and ease of access –Explore structural and socio-cultural barriers –Assess financial constraints –Document stigma and discrimination

3. Methods of Analysis Survey data – macro information, demographics FGD data – interplay between (1) structural barriers and (2) socio-cultural environment 1)Availability of treatment, accessibility, economic costs 2)Social support, social costs, daily life Analytical focus: Exploring dynamic between structural and contextual variations Special focus: Transgender experience

4. Summary of Findings: INDIA Structural Barriers –Lower social status limits treatment options –Medical tests not included in free treatment –Service refusal experienced by 1/3 surveyed Socio-Cultural Environment –Strong heterosexual norms –Dual lives: being married while engaging in MSM activity –Fear of stigma hamper disclosure to families –Healthcare staff involved in stigmatising behaviour

5. Summary of Findings: INDONESIA Structural Barriers –Lack of reliable information on treatment options –Unethical disclosure of status and sexuality high –Institutionalised stigma in service provision Socio-Cultural Environment –Secrecy and taboo of HIV status and sexuality –Disclosure of HIV status to partners low –Disclosure of sexuality to family low –Social isolation and lack of psychosocial support

6. Summary of Findings: MALAYSIA Structural Barriers –Rationing of medication –Expensive medical tests a burden for those not on free treatment –High unethical disclosure of HIV status in healthcare Socio-Cultural Environment –Fear of social reprisal leads to subterfuge –Fear of government reversing decision on free treatment

7. Summary of Findings: MYANMAR Structural Barriers –Limited treatment places in government clinics –Private treatment available, long term costs prohibitive –Reliance on NGOs for treatment and service provision –Institutionalised stigma in public/private healthcare Socio-Cultural Environment –Fear of inability to access treatment when needed –Fear of stigma hamper disclosure of HIV status and sexual activity to families

8. Summary of Findings: NEPAL Structural Barriers –Treatment only available in capital, Kathmandu –Frequency of medical tests and travel costs make treatment prohibitive –High institutionalised stigma, physical abuse and unethical status disclosure by service providers Socio-Cultural Environment –Social aggression towards alternative sexualities systemic and gender ‐ based

9. Summary of Findings: SINGAPORE Structural Barriers –First world prices make treatment costs prohibitive –Resort to medical tourism for treatment but not an option for the infirm Socio-Cultural Environment –Fear of discrimination from employers from status disclosure –Low disclosure of HIV status and sexuality to family erode traditional forms of social support

10. Summary of Findings: TRANSGENDER India and Nepal –Almost half of transgendered surveyed uncomfortable accessing healthcare services –Unethical disclosure of sexuality gender-biased –Nepal: Assaults by healthcare staff and service refusals Malaysia –Transgender surveyed highly likely to face gender discrimination in obtaining ART when needed Myanmar –Positive gender-bias in ART access

11. Lessons Learned from PLHIV MSM/TG: TREATMENT IN ASIA PACIFIC 1.Dynamic interplay between social environment and structure creates practical treatment barriers. 2.Need to account for local cultures in assessing treatment access and individual life chances. 3.Success of Universal Access depends on negotiating localised social forces. 4.High cultural diversity make collective study exceedingly complex.

12. Special thanks to the sponsors who made this study possible