'No test, no disease': Multilevel barriers to HIV testing among young men who have sex with men and transgender women in three semi-urban areas in Thailand

Young gay and other men who have sex with men and young transgender women in Thailand continue to be at high risk for HIV infection. We explored multilevel influences on HIV testing in order to inform the design of tailored interventions. We conducted four focus group discussions with 16-20-year-old gay men and transgender persons (n = 25) and 17 key informant interviews with healthcare providers, NGO leaders, and youth advocates. Focus groups and interviews were transcribed and reviewed using thematic analysis in Thai and English language by a bilingual team. We identified intersecting, culturally situated barriers at individual (lack of HIV knowledge, low HIV risk perception, denial), social (intersectional sexual- and HIV-related stigma, lack of family communication), institutional (inadequate and non-LGBT-inclusive sexual health education in schools, lack of youth-friendly clinics) and policy levels (parental consent requirements for HIV testing by minors). Multilevel and multisystem factors coalesce to form extensive barriers to HIV testing access and utilisation and promote disengagement from HIV prevention more broadly. Multicomponent, youth-engaged interventions informed by Thai sociocultural history and practices are needed in renewed approaches to HIV prevention and testing to end the epidemic among young gay and transgender people in Thailand.

"Being Born like This, I Have No Right to Make Anybody Listen to Me": Understanding Different Forms of Stigma among Thai Transgender Women Living with HIV in Thailand

This study explores the ways Thai transgender women are affected by internalized, perceived, vicarious and enacted stigma. Participants were eleven Thai transgender women living with HIV, who were asked about experiences of stigma in their daily lives. Various forms of verbal, psychological and physical harassment were reported. Internalized stigma and stigma within the transgender community itself were significant. Participants tended not to blame their family members or others in their social structure for their experiences of stigma. They tended to see the solution to tackle the problem of stigma mainly in changes in the behavior of transgender women themselves. This paper suggests that transgender people themselves should better understand how the structure, culture and institutions of mainstream society instill, reinforce and perpetuate stigma against, within and among them. There is a need for advocacy directed toward manifesting societal emancipation of Thai transgender people-starting with legal reform.

A scoping review of HIV epidemiologic, sociocultural and programmatic studies related to transgender women and men who have sex with men in Cambodia, 1999-2019

Background

Cambodia is widely credited for its successful HIV epidemic control. However, in recent years there have been signs of increasing HIV prevalence among men who have sex with men (MSM) and transgender women (TGW). This paper reviews HIV epidemiological, social science and HIV program implementation studies conducted over the past 20 years to explore possible reasons for the rising HIV prevalence among these groups and to formulate recommendations for improved policies, HIV programmatic interventions and further research.

Methods

For this scoping review, we searched the PubMed and Google Scholar databases for scientific publications related to HIV and MSM and TGW in Cambodia published since 1999. From each of the returned citations we subsequently studied reference lists to find additional data sources. We also searched websites for reports commissioned by national and international governmental and non-governmental organizations.

Results

Twenty-seven relevant studies and papers were found and reviewed; most were epidemiological in nature. Recent epidemiological studies and reports show an increase in HIV prevalence among Cambodian MSM and TGW. The epidemiology of HIV infection in these groups has been relatively well-described and analyzed. While initially MSM and TGW were grouped together, in more recent years they have been studied in their own right, recognizing their specific HIV and other prevention needs. Few studies were found investigating Cambodian same-sex cultures and social and cultural contexts in which HIV transmission among MSM and TGW occurs. A few evaluation studies were found, but it remains unknown how effective current HIV service implementation modalities are, or how successful strategies to increase access to essential HIV prevention, testing and treatment services have been employed for MSM and TGW in Cambodia.

Conclusions

Research about Cambodian MSM and TGW in the context of HIV primarily concerns bio-behavioral knowledge generation. Cambodia is unlikely to achieve control of the HIV epidemic among MSM and TGW without doing better in-depth social science research on its multiple sexual- and gender minority cultures, and without understanding what differentiated implementation modalities, strategies and approaches are most effective to address HIV among its increasingly diverse MSM and TGW populations.

"I am not promiscuous enough!": Exploring the low uptake of HIV testing by gay men and other men who have sex with men in Metro Manila, Philippines

The Philippines faces a severe HIV epidemic among gay and other men who have sex with men (MSM). HIV testing uptake remains low. A case series of 12 men from Metro Manila were interviewed to explore barriers to uptake of HIV testing services. Most did not see the need to get tested for HIV despite significant risk, based on the misconception they were feeling well or showed no symptoms. Being of a higher socioeconomic class, feeling morally superior to other gay men, distance of the testing facility, fear of what will happen once infected, fear of HIV- and sexual stigma, fear of side effects of antiretroviral drugs and fear of high health care expenses after testing positive for HIV were key reasons why MSM kept postponing their test. Misconceptions about HIV risk, disease, and treatment and care need to be addressed in order to increase uptake of HIV services in this population.

Identity management and sense of belonging to gay community among young rural Thai same-sex attracted men: implications for HIV prevention and treatment

Young Thai men who have sex with men continue to have high HIV prevalence and incidence in spite of much investment in community-based prevention approaches. To make HIV services more appropriate for same-sex attracted young men in Thailand, it needs to be considered how target groups view themselves and manage their identities. This paper derives from a qualitative study of 25 same-sex attracted rural young Thai men. It identifies five tactics men employed to manage the discrepancy between their preferences and parental/societal expectations regarding gender and sexuality, and discusses how the young men viewed themselves in the wider context of Thai society, including whether they felt part of a separate gay community. Participants usually did not adopt a gay social identity and were reluctant to join in gay community activities beyond dating. Hence, they would likely experience barriers in accessing gay community-based HIV services. HIV services targeting young same-sex attracted Thai men need to be diversified if they are to be more inclusive, appropriate and effective.

Being both and acting 'man': exploring patterns of masculinisation among young same-sex-attracted men in Thailand

Twenty-five same-sex-attracted rural young Thai men were interviewed three times to investigate how their sexual subjectivity changed over an 18-month period after they completed high school and moved into a new life-phase. Many young men grew up with strong gender-based understandings of homosexuality, in which a masculine (top) partner is seen as complementing a feminine (bottom) partner. The discursive division between the masculine and feminine domains became increasingly blurred in the actual practice of dating, forcing the young men to develop new understandings of homosexuality and same-sex relations. The shift from a rural to urban environment, the use of the Internet and the experience of falling in love played important roles in this experimentation with new, increasingly masculine presentations of the self, also influenced by a modern urban masculine aesthetic. The paper concludes that the encounter between 'traditional' gender-based homosexuality and new ideas, in which masculine object-choice is important in defining sexual identity leads to a variety of fluid ideas and expressions. This process created confusion among some, and opportunities for exploration of new ways of defining sexual subjectivities among others.

Sexual abuse, social stigma and HIV vulnerability among young feminised men in Lahore and Karachi, Pakistan

This study describes the experiences of 10 young feminised men in Pakistan. They face high levels of stigma, violence and sexual abuse. The average age of first sex was 11 years old and all reported having been been raped during childhood and early adolescence, often several times. While some mothers and siblings were quietly supportive, young feminised men often end up running away from home, finding support as a member of a hijra dera, a 'pseudo-household' led by an older feminised man or guru, in which they find employment as dancers or sex workers. After their entry into sex work there is little or no opportunity to use condoms. The hijra dera offer an important entry point for improved social support and sexual health programmes, including efforts to ensure young feminised men postpone their sexual debut and/or improve their sexual health, retain access to education, explore alternative forms of employment and improve access to health care.