Another interesting article from Roger Pebody that looks at a range of barriers in Vietnam and also Swaziland to HIV care for men who have sex with men.
Men who have sex with men in Vietnam risk being left behind as the country strives to achieve UNAIDS’ 90-90-90 targets for diagnosis, treatment and viral suppression, according to a qualitative study published online ahead of print in Culture, Health and Sexuality.
Health services need to make greater efforts to provide services that are acceptable and responsive to the needs of men who have sex with men, the authors say. In particular, better pre-test counselling, peer support and respect for confidentiality is needed to help men accept an HIV-positive diagnosis and engage with treatment services.
A separate study, from the very different context of Swaziland’s generalised epidemic, also highlights the need for health services to do more to help people come to terms with an HIV-positive diagnosis, if 90-90-90 targets are to be achieved.
Men who have sex with men in Vietnam
In 2014 Vietnam became the first Asian country to adopt the targets for 90% of people living with HIV to be diagnosed, 90% of people diagnosed with HIV to be on antiretroviral treatment, and 90% of people on treatment to have an undetectable viral load. As in many other countries, there are questions about whether these targets can be achieved if ‘key populations’ continue to be marginalised and discriminated against in healthcare settings.
In Vietnam HIV is concentrated in the key populations of people who inject drugs, female sex workers and men who have sex with men (MSM) – and in the sexual partners of members of these groups. HIV infections continue to rise in MSM, with 16% of MSM in the urban centres of Hanoi and Ho Chi Minh City estimated to be living with HIV.
Quantitative studies have previously shown that the uptake of HIV testing and treatment is lower in MSM than in injecting drug users or female sex workers. But little was known about MSM’s experiences accessing and engaging with HIV services and their journeys to HIV treatment.
Researchers from the Hanoi Medical University and the University of New South Wales therefore conducted in-depth, qualitative interviews with 35 HIV-positive MSM living in Hanoi. Men were recruited via community networks and snowballing techniques.
Nine of the men were not linked to care, six were linked to care but were not taking antiretroviral therapy (ART), and 20 were taking ART. Their average age was 26, half were born in a rural area, two-thirds had completed high school, and two-thirds were employed. While half identified as homosexual, almost half identified as heterosexual or bisexual. Several had married and almost half had experience of sex work.
Men were unprepared for their diagnosis
While a few participants had sought HIV testing because of an awareness of being at risk or because of symptoms, most participants had taken the test after being strongly encouraged to do so by outreach workers. Some reported not wanting to test but agreeing after being pursued by outreach workers, as this man explained:
“A guy asked me to go to an HIV testing event for the LGBT [lesbian, gay, bisexual and transgender] community. I did not want to go at first as I thought that I was not infected and didn’t want to waste time …. However, he kept contacting me and mentioning about testing again. So I did it.”
Many participants had limited knowledge of HIV before their diagnosis and had not perceived themselves to be at risk. Few participants reported receiving counselling, either before or after the test. Providers were described as being reluctant to discuss same-sex relationships or HIV risks associated with specific sexual practices.
As a result, many of the interviewees expressed shock and surprise upon receiving an HIV-positive diagnosis. Several only accepted the result after retesting several times.
“When I was informed of the HIV-positive result, I did not believe [it]. I went to Hanoi to test again but the result stayed the same. So I was very confused about how I could be infected with HIV.”
The researchers note that current policies put an emphasis on numerical targets to increase the uptake of HIV testing. Peer outreach workers receive financial incentives for the number of HIV-positive diagnoses they achieve, but less attention is given to preparing men for the possibility that their test result might be positive. Peer workers encourage MSM to test, but most settings offer no peer support after an HIV-positive diagnosis.
Many interviewees’ response to their HIV diagnosis was intense and painful.
“The result was a tremendous shock… I couldn’t think of anything and just wanted to go somewhere and do something for fun before ending my life… I did all kinds of things such as using marijuana, ecstasy and ice [crystal methamphetamine].”
“I hated him [sex partner] and other gay people also. I couldn’t trust anyone. I didn’t feel like [having sex] any more.”
These kind of reactions inhibited or delayed access to medical care.
Stigma and health system barriers
The interviews highlighted the stigmatisation of both homosexuality and HIV in Vietnam. Gay men were often seen as ‘abnormal’, families were not accepting of same sex relationships and an HIV diagnosis could compound stigma felt in relation to sexuality.
“I was so sad because, first, being a man who has sex with other men means that something is already wrong and now, being HIV infected is too much to overcome.”
The fear of stigma and discrimination made men wary of disclosing their HIV status, but engagement with medical services and daily pill-taking could make inadvertent disclosure more likely. Moreover, some participants had experienced confidentiality breaches at HIV clinics and others were nervous about the identity documents they had to provide to register with a clinic.
“After my ART initiation, the HIV clinic sent my identity information to the health station in my home town and the health station informed my mother of my HIV status… The clinic didn’t inform me that it will send my information back to my home town when asking me my identity information for registration…”
The man said he regretted testing for HIV and accessing ART. He then talked about how he felt when he spoke with his mother:
“I felt much more afraid than the moment I was diagnosed. I did not know how I can live if my family are aware of my HIV status and how my family can live in my commune if my HIV status is revealed…”
Some clinics even wanted a family member to attend with the patient before he could register there.
Participants expressed concerns about the lack of transparency and consistency in the requirements for clinic registration. They expressed concerns about eligibility criteria, having a local residency document, having to pay for services, and so on. All ART was free to patients at the time of the study, but not all participants knew this.
The interviews were conducted in late 2015, several months after Vietnam had adopted World Health Organization guidelines recommending immediate HIV treatment for MSM and other key populations, regardless of CD4 cell count (whereas individuals in the general population were only eligible for treatment if their CD4 cell count was below 500 cells/mm3).
But there was little evidence from the interviews that the policy was being applied in practice – healthcare providers did not ask men about their sexual identity, which meant they were considered ineligible for immediate treatment. In fact, some men talked about visiting several clinics or bribing clinicians in order to try to access ART.
The researchers say that their findings provided valuable insights for Vietnamese policy makers charged with scaling up ART coverage. They also believe their findings challenge the World Health Organization’s recommendation against pre-test risk assessment and counselling – they believe it would have value in this population.
Comparison with Swaziland
While some of the issues in the Vietnamese study are specific to key populations, it is notable how many of the findings echo a study on linkage to care in rural Swaziland, published in the March issue of Social Science & Medicine. In-depth interviews were conducted with HIV-positive men and women who had either engaged, or not engaged, with ART services.
Individuals who had not previously perceived themselves to be at risk of HIV had greater difficulty coming to terms with their diagnosis than others. When individuals did not feel that they had made a personal choice to test (for example, being influenced by the offer of a material incentive), this hampered acceptance of the result. Shock and disbelief at a positive diagnosis delayed linkage to care, but post-test counselling and support that offered reassurance and encouragement was crucial when provided.
“This research shows that how individuals process an HIV-positive result can fundamentally affect their engagement with health services,” the authors conclude. They suggest that testing services need to do more to explore individuals’ perceptions relating to HIV risk and the possibility of a positive result. After diagnosis, counselling over multiple sessions may be required.
“This is particularly relevant considering the 90-90-90 targets and the need to better support PLHIV to engage with HIV treatment and care following diagnosis,” they say.
Bui HTM et al. Barriers to access and uptake of antiretroviral therapy among HIV-positive men who have sex with men in Hanoi, Vietnam: from HIV testing to treatment. Culture, Health & Sexuality, online ahead of print, 2017.
Horter S et al. “Life is so easy on ART, once you accept it”: Acceptance, denial and linkage to HIV care in Shiselweni, Swaziland. Social Science & Medicine 176: 52-59, 2017.