“We are not gays… don’t tell me those things”: engaging ‘hidden’ men who have sex with men and transgender women in HIV prevention in Myanmar

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.

HIV incidence and factors associated with testing positive for HIV among men who have sex with men and transgender women in Myanmar: data from community‐based HIV testing services

“…While MSM and TW in Myanmar self‐report high levels of regular HIV testing , the dissonance with data presented in this paper may suggest an overestimation of testing behaviours among MSM or TW, or ongoing barriers to enacting testing aspirations. Documented barriers to HIV testing among MSM and TW in Myanmar include experiences of stigma and discrimination, perceived unfriendliness of government or mainstream health staff, and avoidance of HIV prevention services manifestly catering for MSM and TW among those for whom concealment of sexual identity is a key priority .…”

“…Client contact information (name, residential township, phone number) and basic demographic details (age, male or female/transgender gender identity, highest level of education attained) were captured. Consistent with indigenous Myanmar labels of sexuality and gender expression among MSM and TW, clients were categorised through self‐identification as either: apone (men who typically do not disclose same‐sex sexual preferences or behaviour in most public spheres); apwint (individuals with male assignation at birth who openly identify as feminine, are sexually oriented towards men and otherwise regarded as TW); and, thange (behaviourally bisexual men who identify as heterosexual and often maintain relationships with women) .…”

“…Homosexual sex remains criminalised under Myanmar's penal code, and while enforcement of this law appears rare, it acts to legitimise the intimidation or harassment of sexual minorities, contributing to stigma and discrimination as key barriers to HIV testing, treatment and care for MSM and TW . These experiences also contribute to many MSM and TW concealing their sexual orientation, particularly in health service contexts . However, recent scale‐up of HIV programs, particularly decentralised HIV testing services run by local and international non‐government organisations (NGOs), has allowed for new models of community‐based and peer‐staffed HIV services.…”

“…However, recent scale‐up of HIV programs, particularly decentralised HIV testing services run by local and international non‐government organisations (NGOs), has allowed for new models of community‐based and peer‐staffed HIV services. These services are now a common feature of Myanmar's HIV response and aim to promote greater engagement of key populations by circumventing known psycho‐social barriers to testing in line with Myanmar's National Strategic Plan on HIV .…”

Network Evolution of a Large Online MSM Dating Community: 2005–2018

“…Influenced by longstanding traditions such as ‘carrying on the family name’, homosexuality is still a sensitive issue in many countries or regions. In the Asia Pacific region, the sexual minority population is often one of the most marginal and vulnerable groups in society [3,4]. The MSM population refers to men who have sex with men [5,6,7], gay men, and some male bisexuals who have exhibit homosexual behavior, who currently account for approximately 5% of the total population in China [8,9].…”