Barriers To ICTC and ART Linkages Among Men Who Have Sex With Men in Karnataka Single Pages

Barriers to ICTC and ART linkages
among men who have sex with men

in Karnataka
India Health Action Trust

Technical Support Unit, Pisces Building
4/13-1, Crescent Road, High Grounds
Bangalore 560001.
Phone: 080 22201237-9, Fax: 080 - 22201373
Barriers to ICTC and ART

linkages among men
who have sex with men
in Karnataka
Barriers to ICTC and ART linkages among men who have sex with men in Karnataka
Author
: Priya Pillai
Contributors
: Dr. P. Manish Kumar, Team Leader, TSU, KSAPS
Joseph Francis Munjattu, Team Leader, TI, KSAPS
Dr. Shajy Isac, Director of Research and Special Studies, KHPT
Editor
: Shaila Maria Faleiro
Design
: M.B.Suresh Kumar (Artwist Design Lab)
Year of publication : 2014

Acknowledgements :

This publication was commissioned by the Technical Support Unit (TSU)

of the Karnataka State AIDS Prevention Society (KSAPS). KSAPS and the
TSU gratefully acknowledges the participation and contributions of the
CBOs Sweekar in Belgaum and Samara in Bangalore Urban, and the NGO
Samraksha in Koppal. The data collection and analysis for this study were
conducted by Priya Pillai.
Copyright
: KHPT - IHAT
Copies printed
: 200
Publisher
:

II
India Health Action Trust,

Technical Support Unit, Pisces Building,
4/13-1, Crescent Road, High Grounds,
Bangalore 560001.
Phone: 080 22201237-9, Fax: 080 - 22201373
Preface
he National AIDS Control Programme (NACP)

launched two decades ago to arrest the
epidemic of HIV in India has begun to show
impact. The focus of the initiatives under all three
phases of the NACP has been mainly on high risk
groups including female sex workers (FSWs), men
who have sex with men-transgender (MSM-T)
and injecting drug users (IDUs). Prevention efforts
during the last two decades have demonstrated
impact with evidence of declining HIV prevalence
among FSWs both at the national level and in
most states. However, there are increasing trends
of the epidemic among MSM and IDUs.
Karnataka is one of the six HIV/AIDS high
prevalence states in India with recorded rates
of adult prevalence being more than one per
cent in some districts. Since 2004, the Karnataka
State AIDS Prevention Society (KSAPS), the nodal
agency in the state for implementing the NACP,
has been leading the targeted interventions to
prevent HIV transmission and control its spread
among the high risk groups. Behaviour change
communication, provision of free condoms,
treatment of sexually transmitted infections,
creating an enabling environment for better

service access, linkages to HIV and syphilis
testing, and linkages to care, support and
treatment services for those found positive have
been some of the main intervention components.
However, despite the achievements in scaling
up of care and support services, HIV prevalence
among MSM in the state has continued to grow
and was more than five per cent in 2011.
This document provides an analysis of barriers at
multiple levels that of the individual, the health
system and the programme itself that combine
to adversely influence ICTC and ART referrals
and uptake of HIV testing and care services
among MSM in the state. The findings illuminate
important issues at the programme and policy
levels that must be addressed for more effective
HIV prevention intervention among MSM. The
strategies recommended for closing the gaps in
programme design and implementation can help
ensure more effective outreach, improve access
and encourage better utilisation of services
among the target population.
Vjay Hugar
Joint Director, Targeted Interventions,
Karnataka State AIDS Prevention Society
III
Table of Contents
Abbreviations v
1. Introduction
1.1. Methodology
2. Barriers to ICTC linkages among MSM
2.1. Individual level barriers
2.2. Health system barriers
2.3. Programmatic barriers
3. Comparison of barriers to HIV testing among MSM in three districts
11
4. Barriers to ART linkage
12
4.1 Individual level barriers
12
4.2. Health system barriers
13
4.3. Programmatic barriers
14
5. Barriers to ART adherence
16
6. Recommendations
19
7. Conclusion
13
References 24
Appendix 1: Ranking of barriers to HIV testing in Belgaum
25
Appendix 2: Ranking of barriers to HIV testing in Koppal
26
Appendix 3: Ranking of barriers to HIV testing in Bangalore Urban
27
IV
Abbreviations
AIDS
Acquired Immunodeficiency Syndrome
ART
Anti-Retroviral Therapy
ASHA
Accredited Social Health Activist
CBO
Community Based Organisation
DAPCU
District AIDS Prevention and Control Unit
DIC
Drop-in Centre
HIV
Human Immunodeficiency Virus
ICTC
Integrated Counselling and Testing Centre
KSAPS
Karnataka State AIDS Prevention Society
MSM-T
Men who have Sex with Men-Transgender
NGO
Non-Governmental Organisation
ORW
Outreach Worker
PE
Peer Educator
PHC
Public Health Centre
SHG
Self Help Group
STI
Sexually Transmitted Infection
TI
Targeted Intervention
1 Introduction
T
he prevalence of HIV among adults in India

has decreased by 57 per cent over the last
decade. However, an estimated 2.08 million
people, of which adult prevalence constituted
0.27 percent in 2011, continue to live with HIV/
AIDS [1]. Heterosexual transmission through
female sex workers (FSWs), unprotected sex
among men who have sex with men (MSM) and
injecting drug use are the main transmission
routes for the epidemic in the country. At the
national level, HIV prevalence among the high
risk groups is seen as increasing among MSM,
with a very high prevalence of 7.3 per cent
in 2008-09 [3]. Unprotected anal intercourse,
multiple concurrent sexual partnerships, poverty,
and low education, homophobic public policy
and social norms, and attitudes and expectations
within families and communities, have been
identified as some of the drivers of the epidemic
within this group [4].
The southern state of Karnataka is ranked
fifth in the country in terms of HIV epidemic
severity. Here, the adult prevalence of 0.63 per
cent is higher than the national prevalence
rate [3]. As per the HIV Sentinel Surveillance
(2010-2011), the prevalence among MSM in
Karnataka was 5.4 per cent, making it one of
the nine states in the country with over five per
cent prevalence in this group. The Karnataka
State AIDS Prevention Society (KSAPS) has been
implementing targeted interventions (TIs)
since 2004 to reduce HIV prevalence among
MSM in the state. Programme components
include peer led outreach and communication,
drop-in centres (DICs), clinical services
for the treatment of sexually transmitted

infections (STIs), distributing condoms and
lubricants, creating an enabling environment
through police sensitisation, advocating
with stakeholders, crisis management and
community mobilisation. However, despite the
increase in government supported HIV care
and support services, the uptake of HIV testing
and treatment services among this group has
remained low [5]. Stigma and discrimination
related to homosexuality and HIV, poor
healthcare access, demographic variables such
as age and education, and characteristics that
determine risk behaviour such as type of sexual
partnership and internalised homonegativity
have been found to influence utilisation of HIV
testing among MSM [6].
This study was undertaken among MSM
across three districts of Karnataka Belgaum,
Koppal and Bangalore Urban to understand
the barriers to utilisation of HIV testing and
treatment services. In 2011-2012, Belgaum had
an estimated 1797 MSM, with high rates of ICTC
referral (127 per cent), HIV testing (87 per cent)
and ART referral (80 per cent). In comparison,
Bangalore Urban and Koppal recorded low rates
of HIV testing and ART linkage. Bangalore Urban
recorded the lowest ICTC referral and testing
rates, with only 17 per cent of estimated 5476
MSM referred to ICTC and 16 per cent tested for
HIV. ART referral in the district was 42 per cent. In
Koppal, out of an estimated 740 MSM, 40 per cent
were referred to ICTC, and 32 per cent tested for
HIV. None of the positive MSM were referred to
ART for treatment services 1.
Karnataka State AIDS Prevention Society (KSAPS), Monitoring and Evaluation data. 2013.
The study found that individual, health system and

programme level barriers led to low uptake of HIV
testing and treatment services. Fear of stigma, low
risk perception of HIV, and difficulties in accessing
testing and treatment services hinder MSM from
undergoing testing and accessing ART services.
At the health system level, the homophobic
attitude of healthcare providers, fear of breach
of confidentiality, inconvenient timings and lack
of privacy at the centres, extended waiting time
and gaps in ICTC counselling constitute barriers
to uptake of services. In addition, lacunae in

programme implementation such as lack of
coordination among the various institutional
players in service provision, inefficient CBO
management, reduced funding and delayed
disbursement of funds to NGOs/ CBOs, and
discontinuity in outreach caused by high attrition
among peer workers and gaps in communication
between staff and community affect use of
services by the community.
1.1 Methodology
This qualitative operational research study was
conducted in the three districts of Belgaum,
Koppal and Bangalore Urban in the state of
Karnataka. The three districts were chosen on
the basis of the size of their MSM-T population
and their geographical location. The study
was implemented with the active support of
community based and non-governmental
organisations involved in the HIV prevention2
programme for the MSM-T community in
these districts.
The study participants involved MSM and
transgender people selected by the lead
organisations in charge of the TIs in the three
Respondents
Method
districts. Six focus group discussions were

conducted, with two per district. These involved
groups of six to 15 MSM and transgender people.
MSM participants were those who have been
linked to the programme for at least two years.
HIV positive MSM were aware of their status.
Group interviews were held with one group
of peer educators and outreach workers per
district. Key informant interviews were conducted
with ICTC counsellors and HIV positive MSM.
Unstructured discussions were held with one
laboratory technician in Belgaum and two
community advocates in Bangalore Urban.
Belgaum
Number
Koppal
Bangalore Urban
MSM
Focus group discussion
Positive MSM
Interview
Peers
Group interview
Outreach workers
Group interview
ICTC counsellor
Interview
The groups were organised by the CBO Sweekar in Belgaum, by the NGO Samraksha in Koppal and by the CBO Samara in
Bangalore Urban.
Focus group discussion and interview venues

were chosen according to the convenience of
the participants. Verbal consent was obtained
from all participants, including consent to
audio tape the discussions. Focus group
discussions and interviews were conducted
using a semi-structured interview guide. Lead
questions were used to initiate discussions
with the community and new questions
added during the course of the conversation
depending on the responses.
A participatory ranking exercise was conducted
with the peers and outreach workers in all three
districts, wherein they prioritised the reasons
for poor uptake of ICTC services, especially
HIV testing among MSM. At the end of the
discussion, the groups in each district listed
down all the barriers to HIV testing and ranked
them in order of severity. In order to generate
an aggregate index, seven factors common
across all three districts were identified and
ranks were reorganised from 1 to 7. Each rank

was then scored with rank 1 scored the highest
followed by rank 2 and so on. The scores for
each factor, across the three districsts, were
then averaged to get the overall score for each
factor. The barriers to ICTC linkages were then
prioritised based on the overall score.
Discussions and interviews were conducted
in Kannada, Hindi and English depending
on the preferred language of the group or
interviewee. Translators helped facilitate the
communication between the researcher and
the participants. The duration of focus group
discussions ranged from 120 to 180 minutes;
key informant interviews ranged from 60 to
90 minutes. All discussions were taperecorded
and transcribed into English for data analysis.
Analysis was conducted on the basis of theme
and sub-themes.
Barriers to Testing at ICTC
his chapter discusses barriers at the

individual, health system and programme
levels that adversely impact ICTC linkages within

the MSM population.
Barriers to ICTC linkages among men who havesex with men

Individual Level
Health System Level
Programme Level
Fear of a positive HIV test result Negative attitude of healthcare
Lack of coordination among
providers
service providers
Fear of sexual identity being
Limited operating hours of the
Poor communication between
exposed
testing centres
the staff and community
Fear of losing blood
Lack of confidentiality
Reduced funding and delayed
disbursement of funds
Loss of time, wages and money Extended waiting time at the centre High attrition of peer workers
Low risk perception and lack of Lack of privacy at the testing centre Inefficient CBO management
perceived benefits from testing Gaps in ICTC counselling
2.1 Individual Level Barriers

2.1.1 Fear of a positive HIV test result
The majority of participants stated that the fear
of being diagnosed HIV positive was the primary
reason for their not visiting the ICTCs. They dread
the dire consequences of the stigma social
discrimination, loss of respect, abandonment
and isolation by family, partners, friends and
community, loss of business, eviction from their
homes, and the suicidal feelings that this often
entails. They fear that they will be locked in a
dark room, made to eat from separate utensils,
shunned and treated like untouchables. Those
who practice sex work worry about having to
discontinue their profession or earning less due
to the loss of clients. A practising MSM sex worker
in Belgaum district refuses to test for HIV. The
sole breadwinner of his family, he worries about
testing positive and the subsequent probing
by his family despite being counselled by three
3
different counsellors. I agree that I do sex. I

agree that I am a kothi. If the result is positive, I
will consume poison and kill myself. But if I die, my
family dies. So I dont want to test, 3he said. The
A programme manager in the community tested
positive and absconded for a year and a half despite
knowing fully well about everything that needs to
be done. He did not start treatment because he was
scared of being stigmatised by his family, community
and society. He came back because he started
suffering from loose motions, weight loss, vomiting,
high fever, and headaches.
Key informant interview with ICTC counsellor,
26 February 2013, Bangalore Urban
perceived absence of social support coupled

with a low self-confidence to cope with the
eventuality of an HIV positive status emerge as
important obstacles to first time testing.
Focus group discussion with MSM, 8 February 2013, Belgaum

2.1.2 Fear of sexual identity being exposed
2.1.3 Fear of losing blood
Negative social attitudes towards homosexuality

force most MSM to lead double lives, with their
homosexual identity kept hidden from family
and society. As testing centres in government
hospitals are also frequented by the non-MSM
population, they lack privacy. Most MSM prefer
to visit the hospital in a group accompanied by a
peer. This increases the likelihood of their being
identified and stigmatised as an MSM by local
acquaintances, family and friends. The fear of
sexual identity being revealed to the non-MSM
population is a major deterrent to testing.
Misconceptions surrounding the loss of blood

deter MSM from testing. They believe that too
much blood is drawn for various tests and fear
that it would render them weak. Consecutive
testing leads them to believe that blood isdrawn
for no reason. As a result, they are reluctant to
test even when ill.
No one knows that I am a kothi. It scares me that

people will find out about me when I go to the
hospital. Marriages can end (for double deckers),
neighbours will start taunting me and calling me
gandu, people will be disrespectful. If people get to
know, I will get a bad name in my community. That
would make me feel really bad.
Focus group discussion with MSM,
8 February 2013, Belgaum
The need to conceal their sexual preferences

impacts outreach in that many MSM do not want
to be approached by peers at a cruising site. As
the peers are usually overtly effeminate, being
seen in their company poses a threat for those
who have not disclosed their sexual orientation.
The community hesitates to test at ICTC centres
with peers for the same reason. Some participants
recalled being harassed by auto drivers while
travelling with peers to the testing centre. As
cruising sites are meeting points for peers and
MSM, successful outreach and follow up depends
on the regularity of visits to these sites by the
community members. Some MSM are reluctant to
link with the programme as they believe it would
leave them vulnerable to being identified by the
government as homosexual.
One person gives blood for testing, goes out and says
they draw a lot of blood and that it is very painful.
Hearing that, 10 others go away.
Interview with lab technician, Family Planning
Association, 9 February 2013, Belgaum
2.1.4 Loss of time, wages and money

Participants reported that the time, travel costs
and prospect of losing a days wages constrain
poor MSM community members from testing.
Poor road connectivity and irregular public
transport in rural areas increase the difficulties
of rural MSM in getting to ICTC centres at district
government hospitals. Furthermore, travel time
often requires that they take a day off work,
It is expensive for us. Daily wage earners make about
`100-350. What happens now is that we earn `100.
The cost is about `200. If I go for testing tomorrow
and I have `100, I may also have some other family
expense of `500. So what do I do? I dont prioritise
testing even though I know it is important.
resulting in a loss of pay. As they are often the

main or sole breadwinners for their families, they
are reluctant to prioritise the expense of visiting a
centre over financial obligations to their families.
2.1.5 Low risk perception and lack of

perceived benefits from testing
The fact that many MSM do not consider
themselves at risk of contracting HIV influences
their uptake of testing services. Having a

permanent partner, not having had sex for the
past few months and practising safe sex are some
of the drivers of low risk perception. This impacts
testing for HIV every six months, especially
when the result of the first test is negative. A few
participants consider it pointless to ascertain their
HIV status as they believe that they are going to
die eventually anyway.
I dont think its necessary to test every six months

because I have sex only with my permanent partner.
The community has undergone so much pain that
they dont care about testing anymore.
2.2 Health System Barriers

2.2.1 Negative attitude of healthcare
providers
Although some participants said that the
attitudes of doctors and other hospital staff
have improved, many continue to be harassed
and humiliated by healthcare providers. These
behaviours were described to manifest as
coldness, rudeness, refusal to touch them during
examination, telling them to keep a physical
distance and not touch the staff, unwillingness
to counsel and deliberately making them wait
or asking them to come another day. Few
participants described being pricked four or five
times to draw blood for one time testing.
Poor communication between doctors and
the target group also discourages testing.
The absence of rapport with doctors, their
unwillingness to make eye contact or engage
with them is perceived as rude and disrespectful.
We are discriminated against at the hospital. They see
us in and around the hospital and know that we do
sex work and refuse to touch us for this reason. They
just ask us to stretch out an arm and squeeze cotton
soaked spirit on us. Sometimes, they dont use spirit
before giving us injections.
Discussions about their sexual identity are

perceived as deliberately intrusive attempts
to embarrass them. In a socio-cultural space
where doctors are held in high regard, questions

about sexual behaviour such as Do you do sex
work? are seen as an affront. Such experiences
of discrimination significantly deter MSM from
testing for HIV.
2.2.2 Limited operating hours of the

testing centres
Community members must be at the hospital
in the morning as outpatient services in
government hospitals shut at noon. As discussed
earlier, this is problematic for them as it involves
absence from work and loss of pay. Those who do
make the long journey may find the outpatient
service shut by the time they reach the hospital.
The hospital timings dont suit me. They ask me to
collect the report later. Im not bothered about getting
tested. What if I have HIV? I will only suffer and die.
Group interview with peer educators,
12 February 2013, Koppal
This disappoints and demotivates them from

returning. In addition, as outreach activities occur
in the evening, the timings of the ICTC centres
also constrain peer educators who want to
accompany community members to the testing
centres. Participants repeatedly asked for testing
facilities to be made available in the evening after
work hours.
2.2.3 Lack of confidentiality

The ICTCs inform the programme counsellors,
managers or peer educators of a positive result.
Participants fear that their positive status may

be leaked to the community by healthcare
providers, programme staff or their peers. As it
is, spreading a persons HIV positive status was
reportedly common within the community as a
means to increase ones clientele by decreasing
anothers. Consequently, such a breach can
Even community members who are linked with
the programme will not reveal their status to the
counsellor. They fear going for testing with the peer
because the results may be leaked and their wife or
family will get to know. This is a fear they have even
before testing.
cause professional rivalries to seriously impact

the livelihood of an MSM sex worker. In addition,
fear of discrimination and rejection by family,
friends and neighbours in the event of disclosure
prevents many from even considering testing for
HIV.
2.2.4 Extended waiting time at the centre

Extended waiting time for counselling, testing
and results at the centres is demotivating as
it eats into time set aside for personal and
professional matters. This is particularly true
during festival seasons when income from
sex work is high and time spent on testing
We should not be made to wait as long as we are
made to now because others in the hospital look at
us in an inappropriate way and family members may
identify us.
12 February 2013,
is viewed as wasteful. Participants fear that

their sexual identity will become open if they
are seen for extended time at the hospital.
Extended waiting time is perceived to raise
the likelihood of stigmatising behaviour from
people around as well as increase anxiety
7
about the test result. Participants also stated

that repeated visits to the centre in case of a
positive test result put considerable strain on
their limited financial resources.
2.2.5 Lack of privacy

The ICTCs were originally designed to provide
counselling and testing services for populations
at risk for HIV. However, participants reported
that a single ICTC for everyone who comes to
the hospital poses a threat to the confidentiality
of their sexual identity. Meeting with the ICTC
counsellor is the first step in the process of HIV
testing. The participants reported finding it
difficult to answer questions about their sexual
behaviour in a room where conversations are
audible to both MSM and others waiting for
counselling.
Women and men are counselled in the same place.
Information about why we want to test and what
problems we have is collected in front of everyone. It is
crowded there. We cannot reveal that we are MSM or
talk openly about our problems.
Group interview with HIV positive MSM,
The fact that the ICTC and ART centres are located
next to each other in government hospitals and
link ART centres are within the ICTC in rural areas
reinforces the belief that they could be falsely
identified as HIV positive. Participants believe
that low awareness and simplistic assumptions
about HIV in the larger community lead people
to believe that everyone going to an ICTC is HIV
infected.
2.2.6 Gaps in ICTC counselling

Testing centres continue to be staffed by
counsellors who discriminate against MSM.
Participants report that ICTC counsellors are
insensitive to sexual identity issues. They ask
rude, disrespectful questions such as Why do you
behave like women? An incident was reported
wherein the counsellor refused to provide pre-
test counselling to an MSM. He assumed the

person was aware of the implications of HIV and
I dont go to the counsellor. Both the counsellor and
the doctor at the hospital speak pure Kannada, which
we dont understand. They refuse to speak Hindi and
the Kannada dialect they use, we cannot understand.
Most MSM have low levels of education.
testing through his previous association as staff

with the programme.
Language may also pose a barrier to access
counselling services. Communication and
understanding are severely restricted when the
counsellor and the counselled do not speak
the same dialect or language and this further
disheartens the community from visiting the
testing centres.
2.3 Programmatic Barriers

2.3.1 Lack of coordination among the
service providers
Lack of effective coordination between the
CBO/NGO and other stakeholders impacts the
uptake of prevention services by the community.
Programme staff reported instances where
mobile vans with HIV testing facilities from
the District AIDS Prevention and Control Unit
(DAPCU) were unavailable on days that were
The ICTC counsellor is not at the centre when the
community members are taken to the hospital. We
bring them in at 1 pm. The counsellors break for lunch
at that time. At 2 pm they say they have to go meet the
officers. And then the centre shuts at 5 pm.
Group interview with outreach workers,
convenient to the community. Meant to reach

MSM in interior villages, they sometimes arrive so
late that those mobilised for testing have already
left, perhaps after waiting for hours. Issues such
as unavailability of doctors, counsellor or lab
technicians at the ICTC centres, short supply of
ICTC testing kits at government hospitals and
last minute cancellations of testing camps by the
counsellors were also reported.
2.3.2 Poor communication between the

staff and community
Participants reported that a peer worker spends
an average of 10 to 30 minutes with each MSM
during their regular meetings. If the peer happens
to have a client, however, the meeting lasts
about five minutes. The MSM is queried about

his condom usage, informed about programmes
scheduled at the DIC and ICTC and told to visit
the ICTC if he is due for HIV testing. Messages
about the significance of regular HIV testing for
good health are rarely reaffirmed after the initial
orientation to safe sex, clinical and ICTC services.
The peers cite many reasons for this, such as
reluctance to discuss HIV testing at the site for
fear of being identified as homosexual or labelled
as being HIV infected by others, lack of attention
of the MSM community to the issues being
discussed,and the notion that it is unnecessary
to reiterate the same messages. However, brief,
infrequent messages may reduce the target
groups perception of risk.
Some members of the community are scared that
they might test positive. As the programme staff
do not have the patience to repeatedly explain the
importance of testing to them, understanding (of the
issues) within the community is very low.
Community members also reported that they are

not informed about testing schedules in time.
As there is no mechanism to communicate with
those who are not present at the cruising site,
these individuals may miss the testing camps
organised at the DIC or elsewhere. This affects the
mobilisation of the community for HIV testing.
2.3.3 Reduced funding and delayed fund

disbursement
The sudden decrease in funding and downscaling
of HIV prevention programmes was reported
to have significantly affected the effectiveness
of outreach, staff retention, and uptake of HIV
prevention services. Cultural events used to be
organised thrice or four times a week and a big
event once every month. ICTC camps held on
these days have been found to reach HIV testing
services to many more community members.
Decreased funding has curtailed the number of
such programmes, thereby reducing the number
of visitors to the centre, and by extension, the
number of MSM being tested for HIV.
When the programme began, the doctor came to
the DIC everyday. Now he only comes once in a week.
Community members may not be free on the day the
doctor is at the DIC, so the number of people testing
comes down.
Budget cuts have also led to reduction in staff,

thereby increasing the workload for those who
have been retained. The staff reported that
they struggle to meet their monthly targets for
tests at the ICTCs and cannot focus adequately
on tracking the regularity of testing by those
registered with the programme.
Downscaling has reduced the availability
of doctors and counsellors at the DICs. This
has adversely affected access to testing and
counselling services as they may not be available
when members of the community visit the DICs.
2.3.4 High attrition of peer workers

It was reported that the shift from a community
facilitator model to part time peer worker led
model has lowered the monthly salaries of
peers from Rs.4,300 to Rs.1,500. As most of the
peers find it difficult to sustain their families on
such a low income, they engage in daily wage

labour to make ends meet. Peers reported that
accompanying MSM to the hospitals for testing
implies a loss of half a days income, which few of
them can afford. They are reluctant to take time
off their main source of livelihood to focus more
on programme related responsibilities.
Every other day there is some event and peer formats
take one week to complete.
Focus group discussion with peer educators,
The lowering of salaries and delays in payment

have taken a severe toll on the morale and
motivation of this key staff group. By helping
improve outreach and linkages to services, they
constitute the most critical link to a community
that is severely marginalised. In a context where
few openly identify as homosexual or willingly
link with the programme, they establish rapport
with other MSM on the basis of their shared sexual
identity. High attrition and loss of interest in the
job severely weakens, even breaks, the connection
between the programme and a peers group of
MSM. It usually takes as long as a year for a new
peer to re-establish rapport. This lag can result in
low uptake of HIV services in his group.
2.3.5 Inefficient CBO management

Organisational and strategic inefficiencies
among CBOs adversely affect the programme
outcomes of HIV prevention services. For
instance, some TIs recruit volunteers to assist
the peers in outreach and service provision.
The dependence on this group for programme
implementation is problematic as their
commitment to results is limited in the absence
of incentive. Peers reported problems such as
volunteers refusing to do the job because they
are unpaid, not giving time for meetings or
being absent from them altogether.
Another case in point is the constant turnover of

programme managers. The absence of leadership
impacts micro planning, a method introduced
to capacitate the peers to improve outreach and
evaluate progress,4 because there is no one to
guide strategies to improve the effectiveness
of outreach. Similarly, high attrition of outreach
workers results in poor monitoring of peer
performance, disrupts relationships between
the peers and outreach workers, and most
importantly, severs links with those who access
prevention services through outreach workers.
ORW is removed when there is a problem and no one

is appointed to that postnew appointees do not
have any rapport with the peers and peers lose their
sense of responsibilitycommunity members who
have earlier received condoms, gels and links to other
services do not know where to find them anymore and
they stop accessing these services.
Managing HIV Prevention from the Ground Up: Avahans Experience with Peer Led Outreach at Scale in India. New Delhi: Bill
& Melinda Gates Foundation, 2009.
10
Comparison of barriers to
HIV testing among MSM
in three districts
SM peers and outreach workers in the

three districts studied ranked the factors
that prevented members of their community
from accessing ICTC services in an unstructured
discussion5. The table below lists the common

factors and the corresponding scores mentioned
by respondent groups in all three districts.
Table 1: Barriers to ICTC Linkages

Score
Factor
Overall
Score
Belgaum
Koppal
Bangalore
Urban
Fear of a positive HIV test result

Inconvenient timings of the ICTC centres
13
Fear of sexual identity being exposed

Fear of others learning about their HIV status
2
1
1
5
3
1
4
6
Insensitivity of healthcare providers

Fear of family getting to know about their results
Source: Participatory ranking exercise by peer and outreach workers

Personal level barriers caused by the fear of
stigma and discrimination are primary reasons
for the target group not availing HIV testing
services. Among them, the stress of discovering
they are HIV positive ranks high among all
three groups. Fear of inadvertent disclosure
of their sexual identity and HIV positive status
constituted other barriers.
Fear of giving blood for testing was mentioned
as a reason for low testing by all the groups.
Although ranked low in Belgaum district, it was
cited as the primary reason for low testing in
Koppal. Misconceptions about blood lost during
testing causing physical weakness or that the

process is painful may underlie this fear.
Lot of blood is takentears roll down our eyes
when they prick. Before they used to draw blood very
smoothly but now they have to prick four to five times.
Disrespect by doctors and paramedical staff and

the inconvenient timings of the ICTC centres were
reported to constitute health system level barriers
mentioned by all three groups.
District wise ranking of factors is given in Appendices 1, 2 and 3. As the exercise was not structured, the number of factors
listed varied across the three districts. The number of people who participated in the exercise in each district also varied. To
that extent, this should be taken as an indicative rather than representative scoring.
11
Barriers to Linkage to ART
he chapter describes causes for low ART

linkage within the MSM population at the
individual, health system and programmatic

levels in the study areas.
Barriers to ART linkage among men having sex with men

Individual Level
Health System Level
Programme Level
Unwillingness to disclose
Procedural delays at the
High work load of counsellor
positive status
hospital
Fear of being identified as HIV
Mandatory requirement of
Difficulties in follow up of ART
positive
proof of identity
linkage
Sense of fatalism
Family involvement in ART
High staff turnover
enrolment
Lack of faith in the treatment
Discrimination by paramedical
staff
Negative perceptions about
ART medication
4.1 Individual Level Barriers

4.1.1 Unwillingness to disclose
positive status
Fear of familial and social ostracism often lead
members of the target group to deny their
positive status. Non-disclosure of status is also
influenced by the danger of losing their jobs and
being left unable to earn a living. ART linkages
are thus delayed as they may not visit the DIC to
reveal their status or may migrate elsewhere. This
makes it difficult for the TI to refer HIV positive
individuals to ART centres for treatment.
They (MSM) disappeared from service when they
were found to be positive. They told the ORW that
they had tested for CD4 at a private clinic and that
the result was non-reactive. Then they disappeared
from service.
9 February 2013,
Participants reported that sometimes MSM may

be unwilling to start ART, despite a positive test
result, as they do not understand the seriousness

of their condition.
4.1.2 Fear of being identified as HIV positive

Sometimes, MSM do not go for CD4 testing even
after disclosing their status to the counsellor as
they want to avoid being seen at government
hospitals. They fear that going there for CD4
testing will give away their positive status and
prompt family members to probe into why they
require treatment. They are also discouraged by the
fact that taking tablets during ART would expose
their positive status to those who know them.
CD4 facilities are available only in district hospitals
and not in taluka hospitals. Because thats the only
place where it is available, everyone knows that if
they are going to the district hospital for CD4 testing
then that means they are HIV positive.
12
4.1.3 Sense of fatalism

It was reported that many MSM lose the will
to live after testing positive. Overwhelmed by
a sense of hopelessness, they see no point in
undergoing treatment. They choose to suffer the
hardships that result from not revealing their
positive status rather than run the risk of social
ostracism by letting it become known.
Those who dont take the ART say that we are fed
up with life. First, people need peace of mind
if everyone at home and in the society looks at us
despicably, then what is the motivation to stay well?
4.1. 4 Lack of faith in the treatment

Low awareness about the importance and
efficacy of treatment was reported as a reason
for not starting ART. Positive MSM choose not to
avail ART services as they do not view treatment
as a means to a better health outcome.
They dont have faith in the treatment. They dont

think anything good is going to come out of the
treatment. So, they dont want to undergo the
treatment.
Interview with HIV positive MSM,
4.1.5 Negative perceptions

about ART medication
The study found that some MSM were deterred
from initiating treatment in anticipation of the side
effects of ART medication, such as vomiting and
weight loss, and do not want to make the lifestyle
changes necessary for successful ART compliance.
Before starting the treatment, they are scared of
the side effects.
4.2 Health System Barriers

4.2.1 Procedural delays at the hospitals
Pre-ART procedures usually require several days
to complete. Participants reported finding it
difficult to bear the frequent travel and other
costs of visiting the ART centres, which are
located in the district hospitals. As most of them
are daily wage workers, this calls for absence
from work and a loss of income. Married MSMs
find it even more expensive as they must bring
Pre-ART testing and registration takes too long.
Members of the community dont go because they
have to travel on consecutive days and it affects
their work.
13
their wives and children for testing, and if they

test positive, for counselling and treatment.
4.2.2 Mandatory requirement of proof of

identity
Proof of identity or address is mandatory for
enrolment into ART. This was reported as a
major hurdle to linkage to services. Many
MSM are homeless or migrants living in rented
accommodation after opening up about their
sexuality at home. They do not possess ration
cards or voter id, both of which are difficult
to get without proof of permanent address.
Furthermore, positive MSM who volunteer for
treatment are often turned away from ART
registration for their inability to furnish proof of
address.
They ask for proof of address if you want to be on

ART. Most of us do not have this as many have left
home and live away from their villages. Even if they
rent a place, the landlords do not give an agreement
to avoid refunding the advance. So even those of
us who set up homes do not have address proof, a
voters id or ration cards.
4.2.3 Family involvement in enrolment

ART centres require positive persons to bring
their wives and children to initiate treatment.
This threatens to expose their sexual identity and
positive status to the larger community, and give
rise to multiple problems as discussed before, such
as the loss of social support and the breakdown
If the MSM is married, he is asked to bring his family.
This is a problem as they start worrying, how to tell
my wife? How to bring her to the hospital? So he
does not return for counselling or treatment.
of the marriages. MSM drop out from ART linkage

was reported to be very high at this stage for
these reasons.
4.2.4 Discrimination by paramedical staff

Rude, offensive behaviour by paramedical staff
was reported to discourage MSM from accessing
services at the hospital. Their experiences
included avoidance of touch by nurses and
interns, prioritisation of others for testing, and
humiliation through disparaging comments in
front of other patients and being treated roughly
when blood is drawn.
When we go for CD4 testing, the technician abuses
us in front of others. First of all, we are made to wait
even if its our turn in the queue. When we point out
that it is our turn, he rudely says things like where
did you go have sex?, where do you have to go in
a hurry? Instead of attending to patients, he is on
the phone sometimes for an hour. Complaints have
been registered against him six times but no action
has been taken yet.
4.3 Programmatic Barriers

4.3.1 High work load of counsellor
Participants reported that the counsellors are
overburdened with work responsibilities. This
leaves them with little time for the community
and affects the quality of their engagement with
individual community members, particularly
those who are HIV positive. Reductions in funding
and the transfer of the prevention programme
to the government have led to a decrease in the
number of staff. There is presently one counsellor
for all the DICs under a TI as opposed to one
counsellor per DIC previously. This requires the
counsellors to allocate time to multiple DICs, as a
result of which they are not necessarily available

to the community at the latters convenience.
The TI counsellor has to look after STI clinics, camps,
counselling, pass information about services to the
community members. The work load is very high.
How will he look after ART and ICTC?
4.3.2 Difficulties in follow up of ART

linkage
People found to be HIV positive are referred to an
ART centre for testing and treatment,
14
following which they often find themselves with

no counselling support or guidance on where to
access the treatment.
There is no support or service after the TI refers a
MSM to the ART. He falls sick repeatedly, and does not
know where to go for ART, as he does not know about
the merger of community care centres within the
government hospitals. As a result, he ends up leaving
the city, migrating elsewhere, or dropping out of ART.
4.3.3 High staff turnover

The counsellor is usually the only person who is
aware of the HIV status of community members.
15
However, high counsellor attrition means that the

chances of MSM not accessing ART are increased
as there is no one to monitor.
Only the counsellor knows the test results of
people in the programme so he is important for
monitoring CD4 and ART linkages within the
community. What happens in the programme
is that the counsellor keeps changing and
the information goes with him because of
confidentiality issue. The information on positive
persons is not available from the ICTC either for the
same reason.
Barriers to ART Adherence
ear of HIV positive status becoming known

while collecting medicines from the ART
centres or taking them in front of family or
in public places, difficulties with the daily
medication schedule, adverse side effects that
affect their normal lifestyle, and stock out of
medicines at the ART centre were mentioned
as reasons for non-adherence to ART. Some
people are scared to come to the centre. Besides,
the medicines have to be taken in the morning and
evening so you have to take them along wherever
you go. Friends and family will ask why we are
always taking medicines, said one individual
diagnosed as positive6 .
It was stated at a FGD that the dietary

requirements mandated during ART are
difficult to comply with: Positive community
members should be provided nutritious food or
supplements. Most of them do not have jobs and
are not earning so procuring good food while on
ART is very difficult7.
Those who have been on ART drop out because

of the side effects of medication such as not being
able to eat food, sudden ups and downs in health.
Sometimes, you cannot eat at regular intervals
and maintaining the disciplined lifestyle required
for ART is difficult. The community goes to work at
the factories at 5 a.m.The supervisor lets you go for
breakfast sometimes at 10 or 11 a.m. so medicines
cannot be taken on time.
Group interview, outreach worker,
Alcohol, for those dependent on it, was reported

to act as a coping mechanism to deal with the
stress of sex work and to take priority over
medicines. It was stated, Alcohol is a big problem
in the community. They are scared to go out and
do sex work without drinking. Since you cannot
drink when you are on ART, they dont adhere to
ART medicines 8.
Interview with positive MSM, 10 February 2013, Belgaum

Focus group discussion with MSM, 19 February 2013, Bangalore Urban
8
Focus group discussion with MSM, 26 February 2013, Bangalore Urban
6
7
16
17
18
Recommendations
he following recommendations are made

on the basis of the findings of the study to
enable policymakers and service providers to
increase ICTC and ART linkages within the MSM

population.
Barriers and Recommendations
ICTC
Fear of a positive HIV test resul

Loss of time, wages and money
Low risk perception and lack of perceived benefits from testing
ART
Individual Level
Reluctance to disclose positive status

Fear of being identified as HIV positive
Sense of fatalism
Lack of faith in the treatment
Negative perceptions about ART medication
ICTC
Attitude of healthcare providers

Inconvenient operating hours of the testing centres
Extended waiting time for counselling, testing and results
Lack of privacy and confidentiality
Gaps in ICTC counselling
ART
Health System Level
Procedural delays at the hospitals

Mandatory requirement of proof of identity
Family involvement in enrolment
Discrimination by paramedical staff
ICTC
ART
Programmatic Level
High work load of counsellors

Difficulties in follow up of ART linkage
High staff turnover
19
Lack of coordination between service providers

Poor communication between staff and community
Reduced funding and delays in disbursement of funds
High attrition of peer workers
Inefficient CBO management
Recommendations
Ensure continued focus
on raising awareness and
knowledge of HIV/AIDS and
health seeking behaviour
Implement stigma reduction
interventions to create an
enabling environment for service
access
Provide decentralised testing
facilities for efficient and convenient
access to testing and ART
Recommendations
Sensitise doctors, nurses and
paramedical staff
Integrate ICTC services within STI
clinics
Reduce waiting time, and provide
faster services
Ensure patient privacy and
confidentiality of results
Relax the norms for ART
enrolment
Recommendations
Facilitate better coordination
between TIs and DAPCU, ICTC
and ART centres
Revise budgets, and ensure
timely release of funds
Reduce the work load of peers
and counsellors
Strengthen organisational
management capacities of CBOs
6.1 Raising awareness and knowledge of HIV/AIDS

Knowledge and information about HIV and
related treatment and care services helps
the community understand the benefits of
ascertaining ones HIV status, addresses the
problem of low risk perception and helps reduce
the misconceptions and stigma around the issue.
It is necessary, therefore, to continually reinforce
the messages rather than disseminate them
infrequently through media programmes or
meetings with peers at cruising sites and DICs.
functionaries such as ASHA and anganwadi

workers and PHC staff may be trained to generate
discussions around HIV/AIDS and deliver
information to the larger community.
Existing channels of information dissemination

may be supplemented by employing a localised
group of leaders who can mobilise the village
community around issues of HIV. Creating
village level community leaders itself would
result in continuous, consistent reinforcement
of messages about HIV/AIDS. The large number
of womens self-help groups is another potential
resource pool capable of sensitising families
and communities. Village level public health
DIC level events that provide a platform for sharing

experiences within the MSM community would
help mitigate the fear of giving blood for the tests
and discovering the results. They would help
alleviate the sense of fatalism and bring hope to
untested MSM. Regular group meetings would
facilitate interaction between positive MSM and
those who are not on ART, so that the latter can
draw strength from those who are ART adherent.
A decentralised information dissemination

system using a variety of channels at the village
level would ensure easily accessible, sustained
information even to hidden MSM who are not
linked to the programme.
6.2 Creating an enabling environment for service access

As non-disclosure of status and testing avoidance
stem from deep anxiety about social exclusion,
the focus on stigma reduction efforts must be
renewed. It must be noted that stigma and
discrimination are usually rooted in socio-cultural
values and beliefs. It is vital, therefore, to identify
and develop opinion leaders who can influence
community attitudes. Stigma reduction efforts
at the local level, if driven by local government,
religious or educational institutions, would lead
to wider reach and acceptance of MSM and HIV
positive individuals among the community.
Sensitised families and communities would offer
a more supportive environment for positive
people. Creation of crisis support groups at the
community level would help address issues of
discrimination and violence due to stigma.
Doctors and other paramedical staff within the TI

must be regularly oriented by a team dedicated
to keeping track of changes in hospital staff
and sensitising new staff on engagement with
the community and positive MSM, particularly
with regard to attitude, language and topics of
discussion. The counselling and communication
skills of counsellors and healthcare providers
must be developed as an essential part of
job training to enable them to interact more
sensitively with the target group. Appointing
peer counsellors who can provide client friendly
services would be another strategy to improve
service uptake by the target group.
Mechanisms must be put in place to ensure strict
confidentiality of test results by healthcare staff.
Responsibility for counselling and linking
20
community members who test positive may be

entrusted to positive MSM to address the problem
of leakage of test results by programme staff.
of the hospitals. This will reduce the fear of

being spotted by acquaintances and reduce the
possibility of homophobic abuse.
Physical infrastructure at the ICTC and ART

facilities must be improved with a view to
offering greater privacy to those who avail
these services. Separate rooms for one to one
counselling would encourage more open
discussion with the counsellors. Adequate
seating must be provided so that MSM do not
have to walk around or wait in common areas
Rules pertaining to identification proof and the

presence of family for ART registration must be
made more flexible, with the latter requirement
left optional. Effective counselling about the
importance of a support network to monitor
ART adherence may result in those testing
positive choosing to involve their families of
their own accord.
6.3 Efficient and convenient access to testing and ART linkage

Long distances to the centre, loss of work for
temporary workers or daily wage labourers and
the consequent financial loss negatively impact
service access by the community. HIV testing
facilities at village health camps or as a service
component of public health centres and mobile
clinics in remote areas would ease access to
testing. Testing and treatment services at the
local level and as part of routine health checks
would help MSM overcome their reluctance to
visit centres dedicated to HIV services. In addition,
delivering the test results the same day would
ease the anxiety about the results while also
addressing their concerns about loss of income.
ICTC testing could be integrated into STI clinics
to improve service uptake among MSM sex
workers and those MSM who visit cruising sites
regularly. Providing STI services at evening
clinics operational after 5 p.m. was reported
to have increased clinical service uptake.
Participants suggested integrating ICTC services
into these evening clinics strategically located
near the hotspots.
6.4
The mandate of the TIs should be expandedto

include follow up with positive MSM referred to
the ART centres. At present, the ART centre staff
is unable to do regular follow upto ensure that
referred MSM avail the services. The absence of
relationships with ART centre staff combined
with the poor perception of service providers
discourages the community from linking with
them. In such a scenario, it is necessary for
contact with the peers or counsellors to be
maintained even post-testing.
Effective programme management
Given the nature of the community, with its

multiple sub-groups and a social context that
21
Better coordination between the TIs and DAPCU,

ICTC and ART centres would address issues such
as last minute cancellations of health camps,
tardiness of mobile clinics, and the absence
of doctors and other staff when community
members visit the hospitals. Increased and
regular supplies of ICTC kits must be ensured
to guarantee successful testing whenever the
service is sought. Expanding link ARTs and
offering ART at taluka hospitals would improve
access for positive MSM.
compels them to conceal their identity, outreach

and retention would be best addressed by peer
led models of intervention. The prevailing terms

of part time employment and the reduction in
salaries by a third have impacted motivation levels
and retention of peers, as the current pay scales
are inadequate to sustain their families. The high
rate of peer attrition disrupts continuity in contact
with the community and adversely impacts the
effectiveness of monitoring of service uptake.
The peer to community ratio of 1:60 must
be reconsidered as the staff is currently
overwhelmed by the work load. Furthermore,
the extensive reporting formats eat into their
time in the field. Staff policies must be revisited
to employ peers full time so that they can
attend to the full scope of their responsibilities.

High turnover is also caused by delays in the
release of funds, resulting in non-payment of
salaries for up to seven months. More training
and capacity building of the peers is required
to improve performance and commitment to
the programme.
Finally, as conflicts between the management
and staff create a situation of constant flux and
leave a leadership gap that demotivates the
employees and feeds attrition, the management
capacities of the CBOs must be strengthened to
enable them to plan, implement and evaluate the
targeted prevention interventions.
22
Conclusion
This study generates insights into barriers

to ICTC and ART linkages among men
having sex with men (MSM) at the individual,
health system and programmatic levels in three
districts in Karnataka. The fear of stigma and
discrimination emerge as a compelling reason
for the communitys aversion to hospitals
and clinics for HIV services. They fear that
being spotted accessing services at these
facilities would increase their vulnerability to
stigmatisation by family, neighbours and the
wider community. The social consequences of
disclosure of positive status, such as rejection
by family and friends, loss of home and
livelihood also have an adverse impact on the
uptake of services.
Low perception of risk of HIV infection and lack
of confidence in the efficacy of treatment also
deter testing for HIV. Stigma, fatalistic beliefs,
the perceived adverse effects of medication, the
time involved, and the cost of travel and loss
of income are discouraging to the community.
Creating local information dissemination
networks to raise awareness of HIV/AIDS,
mobilising and organising issue based
community interactions, stigma reduction
interventions within and outside the MSM
population, and providing decentralised testing
facilities integrated with routine healthcare
facilities could help the community overcome
23
barriers to ICTC testing and ART linkage at the

individual level.
Unpleasant experiences with healthcare
providers, breaches of confidentiality, undue
delays at the hospitals and inconvenient timings
of the testing centres were reported as barriers
at the health system level. These, coupled
with enrolment norms that demand proof of
identification and the presence of family during
registration are major impediments to successful
ART linkage. Training of doctors and paramedical
staff in counselling and communicating with
sexual minority groups, providing integrated
ICTC and STI services, improving infrastructure
within the hospitals to protect patient privacy,
ensuring strict adherence to confidentiality of
test results and relaxing norms for enrolment
would help address these issues.
Finally, inefficiencies in programme
management and the poor capacity of CBOs
to manage prevention efforts affect outreach
and utilisation of services by the community. In
addition, policies such as part time employment
of peers and low salaries prompt a high rate
of attrition, which in turn affects the smooth
functioning of the programme and consistent
health outcomes. Improving employment terms
and remuneration for peers, increasing human
resource capacity and strengthening CBO
management would help mitigate these issues.
References
1. Union Ministry of Health and Family Welfare, Government of India (2012). HIV Estimations.
http://pib.nic.in/newsite/PrintRelease.aspx?relid=89785. Accessed on 20/03/2013.
2. Department of AIDS Control, Ministry of Health & Family Welfare, Government of India (2012).
Annual Report 2011-12. http://aidsdatahub.org/dmdocuments/NACO_Annual_Report_2011_12.
pdf. Accessed on 27/03/2013.
3. NACO (2012). HIV Sentinel Surveillance 2010-11 - A Technical Brief, September 2012. Department of
AIDS Control, Ministry of Health & Family Welfare, Government of India. http://www.ksaps.gov.in/
KSAPS%20PDF/NACO%20Publications/Surveillance/HSS%202010-11%20technical%20brief.pdf.
Accessed on 27/03/2013.
4. PEPFAR (2010). Priority Issue Areas for Inclusion in OGAC MSM Field Guidance from MSM Policy Working
Group. Submitted to the Office of the Global AIDS Coordinator on May 5, 2010. http://www.msmgf.
org/files/msmgf//Advocacy/PEPFAR_Guidance_Recs.pdf. Accessed on 04/04/2013.
5. Beattie, Dr. Tara and Bhattacharjee, Parinita (2009). Access to HIV testing and treatment services by
high-risk groups in Karnataka: Barriers and Motivators. Karnataka Health Promotion Trust.
6. Andrinopoulos, Katherine, Hembling, John, Hernandez, Flor de Maria, Guardado, Maria Elena.
Internalized homonegativity and HIV testing and counseling among MSM and Transgender Women in
El Salvador. http://paa2013.princeton.edu/papers/132398. Accessed on 04/04/2013.
24
Appendix
Appendix 1: Ranking of barriers to HIV testing in Belgaum
Reasons
Rank
Fear of HIV status being exposed
Fear of family finding out about their identity/HIV status
Inconvenient timing of the ICTC centre
Loss of income on the day of testing
Attitude of the ICTC staff
Low risk perception due to no sex or safe sex in the past few months
Fear of losing customers
Fear of blood being drawn
10
25
Appendix 2: Ranking of barriers to HIV testing in Koppal

Reasons
Rank
Fear of blood being drawn
Fear of HIV status being exposed to other community members and losing partners as
a result
Fear of family knowing about their HIV test result and resultant desertion
Attitude of the ICTC centre staff
3
4
5
26
Appendix 3: Ranking of barriers to HIV testing in Bangalore Urban

Reasons
Rank
Inconvenient timing (10 am -2.30 pm) of the ICTC centre
Disrespectful attitude of the doctors at the government hospitals
Fear of sexual identity being exposed due to lack of confidentiality at the ICTC
Fear of physical weakness because of blood being drawn for multiple tests
Inconvenience in accessing the ICTC centre due to the distance and the travel cost
involved
Poor outreach to the community due to trouble from the police and goondas
Change in the field sites for meeting the community due to the construction of Metro
(Jalahalli cross), and hence poor outreach
Disperal of MSM mobilised for testing due to the late arrival of mobile clinics
High attrition of peer edcuators due to heavy work load, and low or no salary
10
Community does not like to come to the office [DIC]

Lack of proper information about ICTC
Reluctance of community members to come to the ICTC unaccompanied
Gaps in the monthly event [community does not come for the monthly events, and hence
are unaware about the day of testing]
Migration
Perceived confidence about good health leading to irregularity in testing
Inability to keep track of the testing regularity as the community members access private
treatment
Community members miss testing as they are under the influence of alcohol
Negative peer to peer feedback about doctor discourage members from getting tested
Preference to have the testing and treatment at the DIC and not ICTC due to better
rapport with the DIC staff
27
Barriers to ICTC and ART linkages

among men who have sex with men
in Karnataka
India Health Action Trust

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4/13-1, Crescent Road, High Grounds
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Barriers to ICTC and ART linkages

among men who have sex with men

India Health Action Trust

Barriers to ICTC and ART

: Shaila Maria Faleiro

: M.B.Suresh Kumar (Artwist Design Lab)

Year of publication : 2014

This publication was commissioned by the Technical Support Unit (TSU)

India Health Action Trust,

he National AIDS Control Programme (NACP)

creating an enabling environment for better

2. Barriers to ICTC linkages among MSM

2.1. Individual level barriers

2.2. Health system barriers

2.3. Programmatic barriers

3. Comparison of barriers to HIV testing among MSM in three districts

4. Barriers to ART linkage

4.1 Individual level barriers

4.2. Health system barriers

4.3. Programmatic barriers

5. Barriers to ART adherence

Appendix 2: Ranking of barriers to HIV testing in Koppal

Appendix 3: Ranking of barriers to HIV testing in Bangalore Urban

Acquired Immunodeficiency Syndrome

Accredited Social Health Activist

Community Based Organisation

District AIDS Prevention and Control Unit

Human Immunodeficiency Virus

Integrated Counselling and Testing Centre

Karnataka State AIDS Prevention Society

Men who have Sex with Men-Transgender

Public Health Centre

Self Help Group

Sexually Transmitted Infection

he prevalence of HIV among adults in India

for the treatment of sexually transmitted

The study found that individual, health system and

to uptake of services. In addition, lacunae in

districts. Six focus group discussions were

Focus group discussion

Focus group discussion and interview venues

ranks were reorganised from 1 to 7. Each rank

Barriers to Testing at ICTC

his chapter discusses barriers at the

levels that adversely impact ICTC linkages within

Barriers to ICTC linkages among men who havesex with men

2.1 Individual Level Barriers

different counsellors. I agree that I do sex. I

perceived absence of social support coupled

Focus group discussion with MSM, 8 February 2013, Belgaum

2.1.2 Fear of sexual identity being exposed

2.1.3 Fear of losing blood

Negative social attitudes towards homosexuality

Misconceptions surrounding the loss of blood

No one knows that I am a kothi. It scares me that

The need to conceal their sexual preferences

2.1.4 Loss of time, wages and money

resulting in a loss of pay. As they are often the

2.1.5 Low risk perception and lack of

their uptake of testing services. Having a

I dont think its necessary to test every six months

2.2 Health System Barriers

Discussions about their sexual identity are