Introduction

Men who have sex with men (MSM) or gay men are disproportionately impacted by the HIV epidemic. The MSM population is 26 times more likely to be infected by HIV than the general population [1, 2]. In the year 2019, 23% of new HIV infections globally were among gay men / MSM [2]. The geographical importance of India is critical because the HIV prevalence among MSM might translate into large numbers. As reported by Elangovan et al, as of 2018–2019, there were nearly 5.7 lakhs estimated MSM in India [3]. The HIV epidemic in India is ‘concentrated’ among ‘key populations’ (KPs) who are engaged in unprotected sex with multiple partners or injecting drug users [4]. People with Injecting Drug use are concentrated in a small geographic area of India as compared to MSM who are spread all across the country. Hence MSM population becomes one of the key drivers of the HIV epidemic in India and has been prioritized as a core high-risk group for HIV prevention [5, 6]. Trends show stabilization of the HIV epidemic among MSM in India despite the targeted intervention (TI) programs being implemented specifically for this population. The HIV prevalence, among MSM, was 4.3% between 2011 and 2016 indicating stabilization of the HIV epidemic [6].

Under the National AIDS Control Program (NACP), HIV prevention services are provided through Targeted Interventions (TIs) and the Link Workers Scheme (LWS) in rural India where health services are active in 219 districts. Three implementation models viz. Focused, Transit, and Convergence models at the state and districts level have been implemented to address diversity in the epidemic in rural settings. TI program in India provides a basket of services focusing on HIV prevention, and support, and provides linkage to a high-risk vulnerable key and bridge population in defined geographies [7]. Non-Governmental Organizations (NGOs) and Community-Based Organizations (CBOs) use a peer-led, outreach-based service delivery approach for this. LWS covers high-risk and vulnerable key populations in the rural areas. It primarily focuses on demand generation for various HIV/AIDS-related services, linking target populations to existing services, and providing a stigma-free environment for sustained access to information and services to key populations (KPs) under the NACP of India. The LWS covered around 18.88 lakh people including 9,850 MSM population in 2020–21 [8]. However, despite this, gaps continue to exist for coverage of key and bridge populations under TIs and LWS [9]. As a part of TI, MSM is primarily reached through hotspot-based approaches and LWS primarily does not create any service delivery points but rather focuses on linkages to existing health facilities under various programs. Fear of stigma and discrimination makes it difficult for rural MSM to reach these facilities. Achieving the first 95 of 95-95-95 targets of UNAIDS necessitates reaching this Hard to Reach MSM [HR-MSM] population for HIV testing and linking them with HIV care as per their HIV status [10].

In India, the spatial invisibility of high-risk MSM might be sustaining the HIV epidemic as they prefer to remain hidden due to prevailing stigmatizing socio-cultural and religious norms targeting same-sex relationships [11–13] and the socio-economic status of some geographical settings. High population densities in urban areas lead to individual anonymity giving safe spaces for the MSM to network. On the other hand, rural areas are smaller settings, less densely populated, close-knit communities, which live in self-inflicted social isolation as they have to hide their identity and very limited scope of covert networking [14–17].

The link between urban and rural MSM networks was evident in a study from Gujrat where 10% of the 200 MSM reported having their first homosexual encounter with a co-villager [18]. Another study in the four talukas of a Bangalore rural district also reported 1,060 estimated MSM of the total 8 lakh population [19]. These rural MSM have been traced despite their lack of self-identity, hidden nature, and a “language” for expressing the idea of male-to-male sex [20]. There is evidence for the existence of a still considerable proportion of MSM who might be either hidden or invisible and need to be reached to facilitate health care access to this vulnerable population. The TIs and LWS are specially provided for key vulnerable populations such as MSM, Female Sex Workers (FSWs), and People Who Inject Drugs (PWID). However, the reported decade-long stabilization of the HIV epidemic among MSM in India indicates the existence of hidden populations that might not be accessing TI services [21, 22].

Under the LWS of the national program, MSM are focused mainly on spot-based ‘TI’ settings and health facilities [23]. Data on MSM networks and their structures in settings outside TIs are limited in urban and rural areas. Although remaining hidden is one’s right but access to health care falls under the purview of a health program. One of the first global target goals is that 95% of People Living with HIV (PLHIV) should know their status by the year 2030 [10]. Although LWS is quite active in rural settings in India, to achieve this target, MSM, who remain hidden anywhere more so in rural settings in especially the socio-economically disadvantaged states of India, need to be given access to public health facilities, especially for HIV testing which is a major gap. We present a multi-stakeholders analysis of the facilitators and barriers to health care access among Hard to reach-MSM and try to understand the programmatic gaps in reaching them in the rural settings in some of the socio-economically disadvantaged states of India.

Materials and methods

A qualitative exploratory study was conducted in four urban and seven rural districts of the four states of India. Maharashtra (MH) in Western India, Uttar Pradesh (UP) in Northern India, Madhya Pradesh (MP) in Central India, and Odisha (OR) in Eastern India were included. We are presenting the findings from seven rural districts of these states. Only one relevant quote from urban data is included to support the findings of rural sites.

In each region, the states were selected based on the prevalence of HIV/AIDS among the MSM population reported in HIV Sentinel Surveillance (HSS) [24] and consultation with the national program. HSS is India’s first intervention that plays a key role in monitoring the level and trend of the HIV epidemic in different categories of the high-risk population at different locations in the country using bio-behavioral data collection. The activity is conducted on a biennial basis. We used data from this survey to select the study sites. Maharashtra and Madhya Pradesh were selected considering the high HIV prevalence among the MSM population, with 4.69% and 4.40% respectively. Uttar Pradesh and Odisha were selected as there were scarce data on HIV and associated behaviors among MSM. According to recent data, the HIV prevalence was 1.14% in UP, whereas it was 0.80% in Odisha. Karad and Ichalkaranji (MH), Angul, Sundergarh & Banki (OR), Barabanki (UP), and Hoshangabad (MP) were the seven rural sites. The operational definition of the MSM was men who had male-to-male sexual encounters (oral or anal) in the last three months and belonged to rural study sites. All study participants were adults and of legal age. Overall 20 Key-informant Interviews (KIIs), 20 In-depth Interviews (IDIs), and eight Focus Group Discussions (FGDs) were conducted across four study areas in rural settings. All participants were recruited purposively and conveniently for the interviews and FGDs. Five in-depth interviews were conducted in each study area with adult HR-MSM (not reached by TIs ever). MSM participants were recruited with the support of trained community liaison officers who belonged to the MSM community and who were employed to recruit study respondents and key population leaders using the snowballing technique. A Community Advisory Board (CAB) comprising both direct and indirect stakeholders was also established at all sites that provided inputs on the topic guides, study tools, and participant recruitment plan. The following strategies were used for the recruitment of participants: 1) Stakeholder engagement: Indigenous informants are the final and most valuable source of information to the researcher attempting to identify hard-to-reach populations. We identified primary and secondary stakeholders for the study to facilitate recruitment. 2) CBO Leadership engagement: CBO leaders were a valuable source of information and support. This engagement enhanced the community sensitization, mobilization, and recruitment processes. 3) Community Liaison Officers (CLOs): Employing personnel from the study community helped gain the community’s confidence, build trust, and establish rapport. 4) Cultural engagement: Participating in the programs conducted by the LGBTQ community facilitated the visibility and acceptability of the research team. Five key informant interviews (KIIs) per study area were conducted with private doctors, NGO/CBO representatives, TI representatives (counselors, clinicians), ART counselors, and key community representatives respectively. Two focus group discussions (FGDs) per study area were conducted with kothis (sexually receptive MSM) along with double-decker (sexually receptive and penetrative MSM)) and bisexual individuals.

Results

Twenty IDIs, 20 KIIs, and 08 FGDs which included a total of 42 participants were conducted in rural districts of the four selected states of India. The mean age of the MSM who participated in IDIs and FGDs was 24.5 and 32.7 years respectively. Seventy percent of the FGD participants reported staying in a joint family, and 90% of IDI and 76% of FGD participants were unmarried. The emerging themes were 1) Wanting to remain hidden/ invisible, 2) No risk of acquiring HIV, 3) Not perceiving the need for HIV testing, 4) Lack of awareness about programs in rural areas, and 5) Program gaps: dissatisfaction with the existing services. For effective utilization of the services, most of the MSM felt the need for an MSM-exclusive (confidential) health facility led by ‘community literate’ healthcare providers in the program setting.

The emerging theme of ‘Wanting to remain Hidden/ invisible’ is explained as follows:

Counseling needs-understanding the approach of peers

A lack of skills among HCPs to understand the issues and needs of MSM were reported. Participants from rural areas voiced the need for a community-based health facility.

"…there the main role is of counseling. The community member whether he is kothi or panthi or DD [/Double Decker/] whatever he is, so he [/MSM/] can share everything with the counselor freely. The counseling is the only session where he [/MSM/] can share all his views. For that we have to give them [/MSM/] a special time, we have to give the time according to their needs, we have to meet them according to their comfort."

[MP-R-KI-09, Madhya Pradesh]

Community engagement by facilitating peer counseling was another expectation. MSM were aware of community representatives working in other public health programs for providing care like Accredited Social Health Activists (ASHA) or Multipurpose Workers (MPWs). Community-led health provision was found to be acceptable to MSM as reported by KI.

“Definitely I will go to the doctor. I want that ASHA should be there for us, like others with whom we can share our problems regarding our disease. If somebody would be there from the MSM group, then we would be comfortable. If somebody else would be there, then, we would not be able to express our issues.”

[OR-R-IDI-02, Odisha]

“Change what, we just want everything fine. Good counseling to be done, and good conversation to be done. All we just want is a little better attitude”

[UP-R-IDI-01, Uttar Pradesh]

One of the study sites mentioned marriage as a facilitator for confidentiality which did not emerge in any other sites.

“Marriage was one of the other reasons that made them not disclose that they were MSM. They felt ‘getting married’ was the facilitator of their confidentiality but experiences were varied”.

[OR-R-ID-06, Odisha]

To achieve a sustainable response to HIV, addressing the needs of the key population is critical [26]. Hence considering the WHO’s framework of six building blocks of a health system [27] the following model (Fig 1) emerged to improve access to the health care system in rural India for MSM.

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Fig 1. Model adapted from WHO to improve MSM’s access to health care in rural India.

https://doi.org/10.1371/journal.pone.0284901.g001

Discussion

To the best of our knowledge, this qualitative study is one of the first studies among hidden and rural MSM in four states of India that explored the facilitators and barriers to their healthcare access, and the programmatic gaps. Strategic planning in the location of HIV testing services such as TIs, the deeply ingrained culture of confidentiality protection, and targeted information, education, and communications emerge as key pillars of addressing barriers to access and health care service utilization among MSM in rural settings. A very young age of introduction to sexual activity which must have been coercive in comparatively conservative societies of rural India is a matter of great concern. This calls for community-based structural interventions for the protection of young boys. Prevention programs need to be implemented at young age possibly at the school level. Protection and education of ‘boys’ emerge as a need in a country where the male gender is considered strong, not requiring protection. In 2007, the Ministry of Women and Child Welfare, supported by the United Nations Children’s Fund, Save the Children, and Prayas, found that 53.22% of children faced one or more forms of sexual abuse; among them, the number of boys abused was 52.94% [28]. It is critical to focus on young boys, especially in India where male rape and sexual abuse of a male child although legally a crime; but socially, is kept hidden due to the hegemony of patriarchy and ensuing attitudes towards masculinity [29]. Young adolescent boys, panthis, and MSM afraid of the stigma and the possibility of breach of confidentiality remain as hidden/ hard-to-reach MSM. Enabling an environment for greater acceptance of sexual orientations is needed to be inculcated at a younger stage of life. This might help in mainstreaming the otherwise stigmatized population. Homophobia against the ‘visible MSM population’ differentially influences the HIV/ STI care needs of MSM. Homophobia needs to be addressed through structural interventions to bring acceptance not only in the community but also in the HCPs by mainstreaming the population.

Geographical differences in the utilization of HIV testing and prevention services are evident. Issues of the invisible/ hidden key population in a rural setting especially among MSM are different than those in urban settings. Although, India sets a strong example of a TI program for key vulnerable populations; the visibility of interventions especially targeting MSM emerges as a gap in rural India. LWS focuses on identifying and reaching networks of high-risk vulnerable populations in rural settings. However, large geographical rural areas and limited resources limit the optimal reach of this scheme in rural settings. Respondents from rural settings in two of the states did share about MSM’s unawareness of the program. In addition to low-risk perception, other barriers included sub-optimal quality of care at government facilities, stigma, discrimination, and fear of breach of confidentiality. The need for a safe private place for discussing community issues and genital examination by experienced health care providers belonging to the community, and counseling were voiced strongly by the community.

After the proven efficacy of Pre-exposure prophylaxis (PrEP) [30], FDA has recommended the use of PrEP in high-risk populations for the prevention of HIV [31, 32]. HIV testing provides an important entry point to such bio-medical HIV prevention strategies including PrEP and also targets the first goal of the End AIDS epidemic [10]. However, cited reports of past sexual abuse at a very young age (four and eight years) when they do not know anything about HIV is a matter of concern for the linkage to HIV care services among MSM. It is already known that an early sexual debut poses potential health risks. In a study conducted among young MSM, the younger age group reported more exchange sex; drug use; emotional/ psychological problems, history of suicide attempts, and contracting HIV with an increased risk of unprotected intercourse [33]. In our study, many MSM were either unaware or in denial about the risks of same-sex behaviors among men. Lack of awareness of services and protective interventions were other critical barriers faced by the hidden, young MSM in rural settings in India. Similar findings were reported from studies conducted in Myanmar [34], Thailand [35], and Peru [36].

Stigma is universal for MSM which limits them from accessing health care and similar findings were reported in South Africa [37, 38]. In our study too, stigma forms the key social determinant of poor or no access to HIV care services among rural MSM. In rural India, the fear of breach of confidentiality is likely to be more pronounced for which safer spaces away from denser areas, are expected from the program. The abolition of section 377 [39] has not changed the attitude of the community or the law enforcers and it continues to force an MSM to hide. Most participants who took part in our study expressed conditional willingness to get registered with TI, only after the assurance that their identity will not get revealed. The assurance on the degree of anonymity drives the health-seeking behavior among hidden MSM and hence needs to be addressed sensitively. Development of structural interventions under stigma reduction activities, and clinic setups ensuring privacy and confidentiality are needed for acceptance of MSM to improve HIV testing and health care access. Strategic planning for improving the visibility of the services is needed for optimal utilization of health care services. Electronic and /or media sources mentioned by rural MSM can be a potential strategy to advertise government programs and services in villages.

Community mobilization is important to understand issues of MSM in the community. Village-level healthcare workers such as Accredited Social Health Activists (ASHA) designated specifically for MSM-related issues emerged as a need. NACP needs to focus on programs tailored for MSM in rural areas/ settings specifically focusing on hidden MSM who are left behind. Expansion of prevention and IEC services for HRGs which are more hidden in both urban and rural areas form one of the key strategies of NACP IV. However, while designing new strategies, a community-based person needs to be involved for empathetic understanding and redressal of their needs. Our study findings give new insights into the unidentified MSM network that might not have been covered under TI settings. One of the crucial emerging groups is very young adolescent boys. Further, this study generates information on the MSM network, mostly hidden, in rural settings for the first time in India which is indicative of a need for culturally and locally acceptable strategies for HR-MSM in the rural area.

The key informants raised their concerns about the paucity of targeted HIV prevention and treatment services for MSM in rural areas. In many places, there was no TI site although the key population did exist indicating the need for new mapping. The lack of less-equipped TI services was another concern shared by the participants. Non-recognition of panthis (MSM who practice penetrative sex or both penetrative and receptive sex) in the TI program got highlighted as these are the most at-risk hidden MSM in the community as indicated in previous studies too [40, 41]. In our present study, participants did bring their sexual partners but it was a challenge. Godbole et al. recommended focusing on a targeted intervention program for MSM who show penetrative behavior with other men, which could help in reaching this population [40]. The partners of kothi are the hidden MSM, not linked to care indicating the need for a unique targeted strategy to reach masculine sexual partners of the MSM. These men might be a new group of bridge population adding to the stabilization of the HIV epidemic being observed in the country.

The next emerging issue was the positioning of healthcare services. Although there were varied responses on whether health services for MSM should be mainstreamed within the public sector, or whether separate services were needed; overall, there is agreement on the need for some specialized services for MSM. The engagement of the community was voiced clearly. MSM conveyed their preference for community people providing services in such health centers for them. There is a need for strengthening government capacities and available systems for support, and this is a critical output of the analysis. The program needs to focus on building the capacities of the healthcare providers for MSM ambient facilities.

Participants in our study reported initiation of same-sex activities in their adolescent years when they are afraid and felt constrained. Therefore, an ambient environment for youth is required where they would come forth with their issues such as confusion about feeling attracted to the same gender; being forced, and having succumbed to pressure. A socio-culturally acceptable intervention is needed to target adolescent age groups. An adolescent might not acknowledge their orientation, avoid thinking about it or come up with an alternate explanation for their feelings [42] but improving risk perception is critical in improving acceptance of biomedical HIV prevention strategies such as PrEP [43]. Community mobilization and structural interventions for the protection and empowerment of young adolescent boys are recommended. Adolescent-friendly health clinics for all adolescents can address some of these issues [44].

Integration of programs emerged as a strategy for optimal utilization of program services. For effective reach to rural MSM, in addition to improving program visibility, the service delivery needs to be shifted to “MSM-friendly health clinics” under Sexual and Reproductive Health Care. The primary focus of information would be “addressing health issues of same-sex behavior ensuring privacy and confidentiality”. As recommended by most participants a knowledgeable staff belonging to the community is needed under the ‘Health Workforce’. Considering this, an already existing ASHA model can be replicated for the MSM population which could be conducively instrumental in reaching the community. Uninterrupted access to medicines for the treatment of STIs at these clinics and PrEP delivery also can be considered through these clinics if the model shows efficacy. The involvement of outreach workers and peer educators from NGO/ CBO working with the community has already been used in the program as a useful strategy for reaching out to hidden MSM and linking them to HIV care. However, expectations were voiced for key population-based community outreach workers. The primary objective of restructuring existing interventions/ schemes should be on improving: 1) Access, 2) Coverage, 3) Quality of Care, 4) Safety, 5) Privacy, and 6) Confidentiality. The overall goals and outcomes would then include improved reach out to HR-MSM that should include Panthis and adolescents. We suggest feasibility testing of this model through implementation research for improved efficiency of the existing program in reaching HR-MSM.

Strengths and limitations

This was a qualitative exploration of facilitators and barriers to healthcare access among four rural districts covering four regions in a second-populous country like India. In-depth interviews helped in understanding the grass root challenges of the community and feasible solutions to overcome them. Although the data presented in this paper represent four rural districts of India, the generalizability is limited. However, an in-depth identification of programmatic gaps in healthcare access among rural MSM paves the way forward for hidden and invisible populations and can be tested further.

Conclusion

The MSM face pressures of remaining invisible in less dense settings of rural India. A close and watchful community makes them conform to social norms by getting married. The initiation of MSM behaviors at a very young stage spells sustained risk with no program to address the problems of adolescent MSM. Attaining adulthood brings not much relief as the study participants professed ignorance of the program. The program’s invisibility, misconceptions and denial of HIV risk, suboptimal quality of services, and anticipated stigma at government health facilities emerged as barriers to healthcare access among MSM in rural settings. There is a need to include panthis both as a new bridge and MSM key population in the program along with designing strategies to reach them to be formulated and tested. Adolescent-friendly health clinics are recommended for providing sexual and reproductive health education and to help acknowledge and respect the existence of various sexual orientations.

Acknowledgments

The study was led by ICMR-National AIDS Research Institute, Pune. We acknowledge the support received from Director, ICMR-NARI for the entire study. We are thankful for the continued support received by the Indian Council of Medical Research, India. We sincerely acknowledge the support received from the National AIDS Control Organization, India right from the inception to the conclusion of Phase 1 of the study. It was critical to receive support from State AIDS Control Societies of the respective states which were facilitated by NACO. The entire study team expresses heartfelt thanks to our study participants without whom this study would not have been completed. We sincerely acknowledge the support received from Professor Prashant Kumar (Retd), Head of Department, Department of English, SK University, Dumka, Jharkhand, India for copy editing and grammar corrections.