HIV-positive kothis and aravanis in Chennai face multi-level barriers that prevent or significantly delay their accessing ART, even with free ART programs operational in government hospitals. In order to access a life-saving intervention, many aravanis and kothis must confront formidable risks of losing family and peer support, and economic subsistence, in addition to bureaucratic challenges, outright discrimination and affronts to their human dignity. Failure to access ART seems less contingent on individual-level misunderstanding, fear and lack of information, and on balance may constitute a reasonable choice given the monumental risks. The imperative of ensuring equal access to ART among kothis and aravanis raises the need to radically shift this balance so that accessing ART, despite potential challenges, becomes a well-supported and sensible option.
Barriers to ART access emerged at family/social, healthcare system and individual levels. The primary individual-level barrier was integrally linked to the family/social and healthcare system levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one’s HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgender women, and HIV stigma prevalent in families, the healthcare system, and the larger society(Chakrapani et al., 2007
; Newman, Chakrapani, Cook, Shunmugam, & Kakinami, 2008a
). HIV stigma was present within kothi and aravani communities as well (Chakrapani et al., 2008
). Anticipated consequences of disclosure— rejection by family, eviction from home, social isolation, loss of subsistence income from sex work, and maltreatment within the healthcare system—presented powerful disincentives to accessing ART. As a result of wide-ranging fears of disclosure, many kothis and aravanis postponed initiating ART or even learning their HIV status for as long as possible, until they became symptomatic. Thus, stigma and discrimination were central to multi-level barriers to ART access.
Fatalism also led some kothis and aravanis not to pursue ART. This psychological challenge was linked to fear of adverse consequences of HIV disclosure, which posed an intransigent dilemma: forego one’s family, friends, community, and income from sex work, or forego treatment.
Secondary to stigma and discrimination was limited knowledge about ART. Many kothis and aravanis in Chennai have adequate general knowledge about HIV (NACO, 2007b
; Newman, Chakrapani, Cook, Shunmugam & Kakinami, 2008b
), and receive appropriate peer counseling about HIV and positive prevention; but the present study indicated a lack of knowledge/education about ART.
Given multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, healthcare providers, and the kothi and aravani communities themselves. In addition to public campaigns to promote acceptance and combat discrimination against kothis, other subgroups of MSM, and aravanis, both those living with HIV and HIV-negative, targeted interventions are needed for healthcare providers and staff at government ART centers. Provider and staff education should include training on: 1) non-judgmental, non-discriminatory counseling and treatment services; 2) specific challenges faced by kothis and aravanis regarding ART access and adherence; and, 3) counseling needs regarding mental health, alcohol abuse, and disclosure of HIV status and sexuality to family and peers. Training and utilization of kothi and aravani counselors would also fill an important gap. Healthcare system guidelines should be developed in consultation with aravani and kothi communities to address discrimination based on sexual orientation and gender identity. Improvement of infrastructure and staffing levels at government ART centers is also necessary to allow adequate time and privacy for counseling.
HIV-related stigma and discrimination in kothi and aravani communities should also be addressed, with the help of community leaders, through targeted interventions aimed at creating supportive peer norms.
A limitation of this study was the small purposive sample of kothis and aravanis recruited from CBOs. Kothis and aravanis not associated with CBOs may experience greater barriers to ART access than did kothis and aravanis in our sample. Additionally, other subpopulations of MSM, such as gay- or bisexual-identified MSM (Chakrapani et al., 2007
; Setia et al., 2008
), may experience different barriers to ART access.
In conclusion, we identified an array of barriers to accessing free ART at government centers among kothis and aravanis in Chennai. Interestingly, many of these barriers were similar to barriers faced by female sex workers in Chennai (Chakrapani, Newman, Shunmugam, Kurian, & Dubrow, 2009
). India needs a national policy and action plan to address barriers to ART access at family/social, healthcare system, and individual levels for all marginalized groups.