Associations between HIV stigma, gender, and depression among people living with HIV in Hyderabad, India.

The goal of this study was to explore the association between HIV stigma and depression and whether gender moderated this relationship. The theoretical framework for the study combined an adapted version of Goffman's conceptualization of stigma with gender role theory. We surveyed 150 individuals living with HIV in Hyderabad, India (51 cisgender women, 49 cisgender men, and 50 third gender people) on their experiences with HIV stigma. While third gender people had statistically higher scores for HIV stigma over their cisgender counterparts, the association between each of three different forms of stigma (internalized stigma, perceived stigma, and experienced stigma) on depression was negatively moderated by third gender status. This demonstrates that third gender research participants who experienced certain forms of HIV stigma were less likely to be depressed than cisgender participants. These findings indicate resilience amongst third gender people living with HIV and can be used to better tailor social policies and gender-affirming HIV care programs in south India.

Secret lives and gender fluidity of people living with HIV in Hyderabad, India.

This mixed-methods study sought to explore gender fluidity among people living with human immunodeficiency virus (HIV) in Hyderabad, India, almost all of whom did not identify as hijra. Sixteen gender-nonconforming people living with HIV completed both surveys and in-depth interviews, exploring their experiences with HIV and gender nonconformity stigma. Interviews were conducted in Hindi and Telugu, digitally audio-recorded, then subsequently translated and analyzed in English, using interpretative phenomenological analysis. Our study highlighted three categories of gender expression: (1) "We have to maintain secrecy about our hijra life": Living secret lives; (2) "What happens if my neighbor sees me here?": Contextual disclosure; (3) "Twenty-four hours a day I will wear a sari": Being fully out. Analysis revealed that many gender-nonconforming people reported identifying with two distinct gender identities: one in the daylight, where they identified as men and fulfilled a role of husband and father with their family, and another at night where they identified otherwise-as women, as third gender, as kothis, hijra, transgender. Themes reinforce a phenomenological interpretation of gender identity and expression in the south Indian context, which is grounded in practices regarding identity's embodiment in clothing, vocal intonation, makeup, and context.

Labor Pains: Work-Related Barriers to Access to Health Care for People Living with HIV in Hyderabad, India.

To explore themes regarding work-related barriers to access to health care, we conducted 32 interviews, 16 with third gender people and 16 with cisgender women, all of whom were all living with HIV in Hyderabad, India. Most respondents were members of Dalit castes and had been living with HIV for several years at the time of the interview. Using thematic content analysis, interviews were coded by two researchers using a social determinants of health conceptual framework. Themes highlighted in this study include the burden of taking time off from work, the loss of pay associated with missing work, and the interruption of gendered care work responsibilities that respondents faced when seeking treatment. Findings from this study support the claim that equitable work policies and practices for marginalized laborers can increase access to medical care for people living with HIV.

Using digital communication technology fails to improve longitudinal evaluation of an HIV prevention program aimed at Indian truck drivers and cleaners.

HIV prevention programs for truck drivers and cleaners (TDC) in India are limited. Longitudinal follow-up presents an obstacle to program effectiveness evaluation. We asked 3,028 TDC in a truck-driver HIV prevention program in Hyderabad to leave a cellular telephone number; we contacted participants 6 months after the intervention to assess sexual risk behavior change. Married, older, and better educated participants were more likely to leave phone numbers. Only 6.5% of TDC were reachable after 6 months. Longitudinal follow-up of this mobile sub-population remains a challenge, and more effective methods for evaluating HIV prevention programs are needed.

A protective effect of circumcision among receptive male sex partners of Indian men who have sex with men.

The role of circumcision in the transmission of human immunodeficiency virus (HIV) among men who have sex with men (MSM) in resource restricted regions is poorly understood. This study explored the association of circumcision with HIV seroprevalence, in conjunction with other risk factors such as marriage and sex position, for a population of MSM in India. Participants (n = 387) were recruited from six drop-in centers in a large city in southern India. The overall HIV prevalence in this sample was high, at 18.6%. Bivariate and multivariable analyses revealed a concentration of risk among receptive only, married, and uncircumcised MSM, with HIV prevalence in this group reaching nearly 50%. The adjusted odds of HIV infection amongst circumcised men was less than one fifth that of uncircumcised men [adjusted odds ratio (AOR) 0.17; 95% CI 0.07-0.46; P < 0.001]. Within the group of receptive only MSM, infection was found to be lower among circumcised individuals (AOR, 0.30, 95% CI 0.12-0.76; P < 0.05) in the context of circumcised MSM engaging in more UAI, having a more recent same sex encounter and less lubricant use when compared to uncircumcised receptive men. To further explain these results, future studies should focus on epidemiologic analyses of risk, augmented by social and sexual network analyses of MSM mixing.

"They Kept Away": Social Isolation of Cisgender Women Living with HIV in Hyderabad, India.

Social isolation of cisgender women living with HIV has been recognized as a barrier to early detection of the virus, disclosure of HIV status to partners, and access to healthcare and social work services. The goal of this study is to explore how social isolation and depression affect cisgender women living with HIV in Hyderabad, India. Sixteen cisgender women living with HIV were asked to complete in-depth interviews regarding their experiences with HIV stigma and depression. All interviews were digitally audio-recorded in Hindi or Telugu, then translated, transcribed, and analyzed using thematic content analysis by two to three coders. Three main themes emerged from the qualitative interviews among these cisgender women living with HIV: (1) "They kept away": Experiences with social isolation; (2) "I thought people would think badly about me": Perceived experiences of discrimination; and (3) "I will live till I die": Suicidality, resilience, and gaining hope. Our findings reinforce the need for emphasis on culturally appropriate interventions for depression for cisgender women living with HIV in India, including greater access to mental health resources, greater availability of trained counselors that share the same gender and are native speakers of Hindi or Telugu, and increased family and community support for socially isolated individuals.

Factors associated with non-adherence to antiretroviral therapy among female sex workers living with HIV in Hyderabad, India.

We determined factors associated with non-adherence (consuming <90% of monthly antiretroviral therapy) among female sex workers (FSWs). An interviewer-administered questionnaire was used in a sample of 100 South Indian FSWs living with HIV. We examined demographics, food insecurity, side effects, stigma, alcohol/substance use and self-efficacy. Non-adherence was assessed by self-report, pill-count and combined measures. Prevalence ratios and 95% confidence intervals (CIs) were calculated at p-value <0.1. Thirty-seven percent (33/90) of FSWs were non-adherent by pill-count, 29% (28/95) by self-report and 52% (51/99) by the combined measure. Seventy-six percent (76/100) of FSWs reported experience of at least one form of food insecurity in the past six months. In the regression analysis, arrest in the past year was independently associated with the combined measure of non-adherence (crude prevalence ratios 1.7, 95% CI 1.0-2.8). A successful combination adherence intervention should consider several of the socio-behavioral factors identified in this study including arrest and food insecurity.

Candidate change agent identification among men at risk for HIV infection.

Despite limited HIV prevention potency, peer-based programs have become one of the most often used HIV prevention approaches internationally. These programs demonstrate a need for greater specificity in peer change agent (PCA) recruitment and social network evaluation. In the present three-phase study based in India (2009-2010), we first explored the nature of friendship among truck-drivers, a group of men at high risk for HIV infection, in order to develop a thorough understanding of the social forces that contribute to and maintain their personal networks. This was accomplished in the first two study phases through a combination of focus group discussions (n = 5 groups), in-depth qualitative interviews (n = 20), and personal network analyses (n = 25) of truck-drivers to define friendship and deepen our understanding of friendship across geographic spaces. Measures collected in phases I and II included friend typologies, discussion topics, social network influences, advice-giving, and risk reduction. Outcomes were assessed through an iterative process of qualitative textual analysis and social network analysis. The networks of truck-drivers were found to comprise three typologies: close friends, parking lot friends, and other friends. From these data, we developed an algorithmic approach to the identification of a candidate PCA within a high-risk man's personal network. In phase III we piloted field-use of this approach to identify and recruit PCAs, and further evaluated their potential for intervention through preliminary analysis of the PCA's own personal networks. An instrument was developed to translate what social network theory and analysis has taught us about egocentric network dynamics into a real-world methodology for identifying intervention-appropriate peers within an individual's personal network. Our approach can be tailored to the specifications of any high-risk population, and may serve to enhance current peer-based HIV interventions.

Field-based video pre-test counseling, oral testing, and telephonic post-test counseling: implementation of an HIV field testing package among high-risk Indian men.

In India, men who have sex with men (MSM) and truck drivers are high-risk groups that often do not access HIV testing due to stigma and high mobility. This study evaluated a field testing package (FTP) that identified HIV positive participants through video pre-test counseling, OraQuick oral fluid HIV testing, and telephonic post-test counseling and then connected them to government facilities. A total of 598 MSM and truck drivers participated in the FTP and completed surveys covering sociodemographics, HIV testing history, risk behaviors, and opinions on the FTP. MSM and truck drivers equally preferred video counseling, although MSM who had been previously tested preferred traditional methods. Nearly all participants preferred oral testing. Rates of counseling completion and linkage to government centers were low, with one-third of newly identified positives completing follow-up. With increased public-private coordination, this FTP could identify many hard-to-reach preliminary positive individuals and connect them to government testing and care.

Sex position, marital status, and HIV risk among Indian men who have sex with men: clues to optimizing prevention approaches.

A divide exists between categories of men who have sex with men (MSM) in India based on their sex position, which has consequences for the design of novel HIV prevention interventions. We examine the interaction between sex position and other attributes on existing HIV risk including previous HIV testing, unprotected anal intercourse (UAI), and HIV serostatus among MSM recruited from drop-in centers and public cruising areas in the twin cities of Hyderabad and Secunderabad, India. A survey was administered by trained research assistants and minimally invasive HIV testing was performed by finger-stick or oral testing. HIV seropositive MSM underwent CD4+ lymphocyte count measurement. In our sample (n = 676), 32.6% of men were married to women, 22.2% of receptive only participants were married, and 21.9% of men were HIV seropositive. In bivariate analysis, sex position was associated with previous HIV testing, UAI, HIV serostatus, and CD4+ lymphocyte count at diagnosis. In multivariate analysis with interaction terms, dual unmarried men were more likely to have undergone an HIV test than insertive unmarried men (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.2-6.5), a relationship that did not hold among married men. Conversely, dual married men were less likely than insertive married men to engage in UAI (OR 0.3; 95% CI 0.1-0.6), a relationship that did not hold among unmarried men. Further implementation research is warranted in order to best direct novel biologic and behavioral prevention interventions towards specific risk behaviors in this and other similar contexts.