A total of six FGDs consisting of 67 participants from varied socioeconomic backgrounds were conducted. The participant’s ages ranged from 18–68 years. There were 19/67 participants who resorted to begging at traffic signals and trains. The remaining were either sex workers or dancers at bars or events. There were 4/67 participants who were not married (had never married), and nearly half had been tested less than twice in a year for HIV. All participants were aware of their HIV status. In the category of education, 30/67 had completed graduation, and 26/67 had completed studies until higher school.
Common codes were clustered under a single theme, such as fear of testing HIV positive, and standing in a queue to get tested for HIV was clustered under the theme stigma, where the MSMs feared perceived HIV-related stigma and stigma related to their sexual identity. Overcrowding at hospitals and long waiting timse in queues were clubbed under administrative and procedural barriers. After the final analysis of all the FGDs, the following themes emerged.
Awareness about HIV testing
The participants were asked questions on awareness about the frequency and places of HIV testing. They were also asked about the procedure of getting the HIV test done at the government hospitals.
Frequency of HIV testing
The participants were aware that they should be tested for HIV every six months. Some participants reported testing every three months. As brought out by the participants, there were some who got tested more often because they felt apprehensive after a sexual intercourse with certain high-risk clients.
“If some doubtful client comes in….they get scared, there’s a fear, so they get themselves tested soon after unprotected sex.” (MSM, 24 years)
A few participants opined that there were some MSM, who did not get tested at all.
“I have this friend of mine…… I keep telling him… get tested, get tested… but no, he doesn’t listen to me. He feels… No, no! I will turn positive…..” (MSM, 33 years)
When asked about the type of MSM who should be tested periodically for HIV, most participants felt that those MSM who were at higher risk of HIV/AIDS due to their profession should be tested more frequently.
“ See..we should all get it done, you also … ya!ya! Why not? ..but ok I feel the younger people who cross dress and go into professional sex work should get tested more often” (MSM, 38 years)
Places of HIV testing
Most participants mentioned that HIV testing was available at TI sites, NGOs, government hospitals, ICTCs and private labs. On enquiring about the kind of test done at these places, all participants mentioned that blood samples are taken either by the finger prick method or the venepuncture method for HIV testing.
It happens here (NGO). We come here… He pricks our finger.. collects blood .. and we are done. It also happens at government hospitals…. They draw a lot of blood (laughing)…
(MSM, 29 years)
I know few people.. They are my clients….friends… They don’t come here.. they go to private.
(MSM, 25 years)
Procedure of HIV testing
On enquiring about the procedure of HIV testing, the participants mentioned that once when the screening test was conducted at TI sites, they were sometimes referred from their respective TIs to the ICTCs for confirmatory testing. At the ICTC, they first register at the registration counter following which they are ushered in the counseling room. Counseling is conducted for 15 to 30 minutes, after which they are tested. The test results became available after 2–3 days. The entire process of counseling and testing takes approximately three to four hours.
Barriers to HIV testing
Administrative and procedural issues
The participants brought out that the most common problem faced by them while utilizing HIV testing services was the overcrowding and long waiting time at government hospitals. They have to wait in long queues under the sun as most of the time there are no shaded waiting areas. According to the participants, for every step in the HIV testing, there is a long waiting queue.
“First you go and stand in line for registration slip. Once it is done, then you wait in the line for the test. Once your turn comes, they say date is missing, you go back again and then you stand in line for date…..you keep standing under the sun……you get irritated with all this.” (MSM, 45 years)
Many participants feel that the timings for blood collection are short and inconvenient.
“You have to reach by 9’o’ clock. Samples are collected between 9–12 am only. If you are late by few minutes then come again the next day. Entire day is wasted.” (MSM, 27 years)
As brought out by the participants the test results are communicated after 2–4 days and to collect the test results, one has to come after a few days and again stand in queues.
Rude behavior of medical staff
Some MSM had experienced rude behavior by the health care workers (HCWs) while accessing HIV testing facilities. The participants perceived that the rude behavior of the HCWs was because they belonged to the MSM community. One MSM shared his experience while getting tested for HIV.
“When my turn came to give the blood sample, the nurse first ignored me and kept me waiting. Then, all of a sudden she started shouting and asked me to hurry up. I was lost … like why is she shouting. Then, she applied the tourniquet roughly and took the sample. It was very painful. I screamed a bit. In addition, she sarcastically replied … ‘Don’t get involved in such activities at the first place, had it been so, today, there would have been no need to give the blood sample’…… Now you tell me, who will go to such places for giving samples.” (MSM, 21 years)
Uncomfortable counseling sessions
Other than the perceived rudeness by the HCWs, the personal questions especially those related to sexual behavior asked by the counsellors during counseling and before testing, made most of the MSM quite uncomfortable.
“You know….counseling is less, it is more of personal interrogation. For half an hour, they kept asking me questions such as ‘When was the last time you had sex?, With whom did you have sex?, How many partners do you have?, What do you do for earning? ...and so on.’ One gets scared and uncomfortable with so many personal questions. Why are they so concerned about my sex life?” (MSM, 24 years)
Personal Barriers
The MSM feared the pain and swelling at the site of vene-puncture for collecting blood. The MSM become frightened and nervous on seeing the drops of blood during the collection of blood samples. Many of the MSM, fainted on seeing blood being withdrawn for tests.
“People are scared of injections, you should see there….. on seeing blood these… these… and these faint….like girls ” (MSM, 19 years)
Some MSM feared that the blood collected for HIV testing may be used for other purposes. Few MSM felt that there was no need to collect this large amount of blood samples. According to them this large amount of blood collected is definitely used for blood transfusion to other patients without their knowledge.
How would I know? I’m telling you they use it (blood) for something else. If you can test HIV with a tiny drop of blood, why withdraw so much amount of blood. They must be selling it.
(MSM, 31 years)
According to the participants, another reason for not getting tested is that some MSM were too busy to take out time from their schedule to get tested, as the standard HIV testing is a time consuming process. The participants also described that some MSM fear coming to the NGOs for HIV testing, as they believe that these organizations are mainly visited by the transgenders (TGs) and going to these NGOs would get them labeled as a TG. They also mentioned that the more educated and well off MSM despise coming to the NGOs. These MSM feel that they will be beaten up by their parents and family members on knowing about their visit to the NGOs.
“There are many who do not come to the NGO out of fear……..Only TGs come to NGOs. In addition, some educated MSM… they say…’What will I do at a NGO? If I go there Mummy-Papa will scold me… beat me.’ They have money…. so they don’t come here.” (MSM, 38 years)
Stigma
The participants reported both HIV-related stigma and sexual stigma. According to the participants the MSM who do not get tested, fear of becoming HIV positive. These MSM feel better by not knowing their HIV status. There was fear among MSM that if they turn positive, family and friends will avoid them. MSM mentioned that the general community was disgusted by the disease HIV/AIDS and looked with contempt at people living with HIV/AIDS.
“Out of fear they don’t get tested. They are like, if I’m positive…. he will leave me, people will not sit with me….. I will be left alone, I will die alone.” (MSM, 32 years)
Some MSM stated that for most of the general community, being a MSM was synonymous with having HIV/AIDS. The stigma of the disease being related to sexual orientation prevents the MSM from getting tested.
“People think it is a very bad disease, and people think wrong about it as they believe it spreads only through sex. If they come to know that somebody has HIV……they will assume that he is a gay…. for them gay is HIV and HIV is gay…….and now he will die. ” (MSM, 38 years)
Most participants were concerned about hiding their identity while waiting in the queues for HIV testing. At the hospitals, the set-up is such that the people getting tested for HIV have to queue separately from those getting any other investigations. Waiting in these separate queues for HIV testing, results in giving away of one’s identity as getting tested for HIV in itself was seen with suspicion by the general community. Some MSM felt that if the family members came to know that they went for HIV testing, then they may land into unnecessary trouble in the family. As per the participants, some MSM, to hide their identity, visit hospitals far away from their usual place of residence to get tested for HIV.
“Here in our MSM community most of us know each other. However, when you are standing in the queue, everybody knows why you are there. Nothing is a secret or left hidden. If somebody asks, we tell a lie, like we are accompanying someone, but hearts to hearts they know the truth, and then people will talk behind your back. The word will spread….and friends will come to know that I’m going for HIV testing.” (MSM, 29 years)
Facilitators to HIV testing
Knowledge about HIV testing
MSM who are aware of the importance of regular HIV testing, are tested at definite intervals. As per the participants, these MSM also motivate their partners and friends too for regular testing.
“We people get it done… we know about it.. we go every six months. In addition, few who don’t know but come in our contact, we take them with us to the hospital for testing.” (MSM, 35 years)
Perceived risk of HIV
According to the participants, those MSM with a high perceived risk of HIV are tested often. The MSM who are in professional sex work and have clients on a daily basis, are tested frequently for HIV.
“Some people get tested at three months, some get tested soon after unprotected sexual act… And those who have sex daily… with clients.. they are scared, so they get tested earlier than six months, sometimes as often as fifteen days.” (MSM, 42 years)
Nongovernmental organizations
Many MSM felt comfortable with the availability of HIV testing at NGOs. According to them, all the members at NGO belonged to their community and the staff was supportive. They felt that the entire process of HIV testing at the NGO was quick and convenient. The timings for getting tested were also convenient as per their schedule. Doctors were available for counseling and check-up, and the results were available to them in shorter time. MSM get to socialize with each other and thus, most MSM come out openly at the NGO.
“We feel good here. We do not have any time table. No wake up time, no sleep time….so, here it is as per our timing. We come here, give sample, get our check-up done, talk to friends, get our results and go………Sometimes we even get refreshments.” (MSM, 37 years)