Barriers to Free Antiretroviral Treatment Access for Female Sex Workers in Chennai, India

Abstract

India's National AIDS Control Organization (NACO) provides free first-line antiretroviral treatment (ART) at government centers for people living with HIV. To assist in developing policies and programs to ensure equity in ART access, we explored barriers to ART access among female sex workers (FSWs) living with HIV in Chennai. Between August and November 2007, we conducted three focus group discussions and two key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family=social, health care system=programmatic, and individual levels. Major barriers included fear of adverse consequences of disclosure of HIV status due to stigma and discrimination associated with HIV and sex work, lack of family support, negative experiences with health care providers, lack of adequate counseling services at government centers and by outreach workers employed by nongovernmental organizations (NGOs), perceived biased treatment of FSWs who are not referred by NGOs, lack of adequate knowledge about ART, and fatalism. Barriers can be addressed by: creating effective measures to reduce stigma associated with HIV=AIDS and sex work at the familial, societal, and health care system levels; incorporating information about ART into targeted interventions among FSWs; training counselors at government hospitals and NGO outreach workers on treatment issues; improving infrastructure and staffing levels at government centers to allow adequate time and privacy for counseling; and implementing government mass media campaigns on ART availability. Finally, it is crucial that NACO begin monitoring ART coverage of FSWs and other marginalized populations to ensure equitable ART access.

Overlapping HIV and sex-work stigma among female sex workers recruited to 14 respondent-driven sampling surveys across Zimbabwe, 2013

“…While HIV stigma may be declining, sex-work stigma persists. Programmes for sex-workers should confront stigma, strengthen community and support collective action to build self-esteem and work toward mutual goals (Chakrapani, Newman, Shunmugam, Kurian, & Dubrow, 2009;Deering et al, 2011;Robillard, 2010). However, creation of dedicated spaces for sex-workers can dissuade some from participating if they are reluctant to self-identify as sex-workers and risk resulting stigmatisation (Biradavolu, Blankenship, Jena, & Dhungana, 2012).…”

A systematic review of HIV/AIDS-related stigma and discrimination in India: Current understanding and future needs

“…The reality of double stigma is underscored by the following quote, 'My father told me that he could tolerate that I was HIVpositive but asked me not to tell others that I got it by having sex with men' (Chakrapani et al, 2007, p. 355). In another study HIVpositive female sex workers reported experiencing dual stigma on account of their sex work and HIV status (Chakrapani, Newman, Shanmugam, Kurian & Dubrow, 2009). Groups vulnerable to HIV are commonly associated with HIV infection in India which predisposes them to discrimination.…”

“…Perceived stigma discourages HIVpositive women from seeking care in public hospitals in Chennai (Thomas et al, 2008). Among HIV-positive female sex workers, both enacted and perceived stigma are reported as barriers to accessing general care as well as ART services (Chakrapani, et al, 2009).…”

Factors influencing frontline health service providersʼ likelihood to recommend a future, preventive HIV vaccine to key populations in Karnataka, south India

“…Past studies in Karnataka have indicated that many third-line HSPs hold discriminatory views of FSWs and actively engage in stigmatising discourse around sex work, generally [46], though such attitudes have not been found to be as prevalent among first-line HSPs [22]. Alternatively, this barrier may be related to our finding that HSPs perceive that key populations lack trust in HSPs -a point previously recognised in in India [21,39,40] -and would be hesitant to accept advice from them regarding an HIV vaccine. Finally, it is also possible that participants felt somewhat ambivalent towards the idea of promoting a new HIV prevention strategy among MSM and FSWs, given the sub-optimal adoption of existing HIV prevention practices (e.g., consistent condom use) that has been well-documented within MSM [47] and FSW [48] communities in Karnataka.…”

“…Recent literature has focussed on trends in acceptability of a future HIV vaccine [12], willingness to participate in HIV vaccine trials [16][17][18][19][20], and barriers to utilising currently available HIV treatment and prevention technologies [39,40]. This is the first study to specifically explore frontline HSPs' likelihood to recommend a future HIV vaccine to key populations in Karnataka, and the first to describe potential barriers to vaccine recommendation.…”