“We are not gays… don’t tell me those things”: engaging ‘hidden’ men who have sex with men and transgender women in HIV prevention in Myanmar

Against a background of low and decreasing global HIV prevalence, men who have sex with men (MSM) and transgender women (TW) continue to be disproportionately affected by HIV [1, 2]. In Asia, HIV prevalence greater than 10% has been observed in some MSM and TW communities [1, 3–5], while emergent epidemics in countries as diverse as Thailand [6], India [7] and the Philippines [8] have been recently noted. This ongoing vulnerability of MSM and TW to HIV acquisition may suggest limitations in both the scale and effectiveness of current HIV prevention responses in the region. This includes Myanmar, where the estimated HIV prevalence among MSM and TW is over 11% nationally, and the concentrations reported in major urban cities comprise some of the highest rates seen across Asia [4]. Despite known risks, less than half of all MSM and TW in Myanmar reported receiving an HIV test in the past 12 months and coverage of HIV prevention programs remains suboptimal [4].

Global elimination targets suggest that ending AIDS by 2030 will require 90% of people living with HIV knowing their status [9]. As well as facilitating early initiation of HIV treatment, HIV testing provides an important entry point to bio-medical HIV prevention strategies such as PrEP [10]. Controlling the HIV epidemic requires regular engagement of MSM and TW at risk of or living with HIV in prevention, treatment and care; this includes those that do not or are unwilling to identify as MSM or TW and may be out of reach of specific HIV programs targeting these groups. In Myanmar, as in other Asian countries, a number of indigenous and diverse gender and sexual identities exist among same-sex attracted men. Unlike typical Western characterizations that utilize separate categories to define sexual and gender identities, one set of labels are often used across Asia to characterize both sexual and gender identities, such as Kothis in India and Bóng lộ in Vietnam [11, 12]. These labels typically encompass sexual positioning, power dynamics, and gender expression and are reflective of one’s willingness to disclose their sexual preferences, behaviors and gender identity [4, 13].

There are three main local terms used to classify sexual and gender identity among MSM and TW in Myanmar. Apwint are commonly regarded as transgender women, and locally understood as individuals with male assignation at birth but who openly identify as female and attracted to men. Conversely, Apone are males that typically have a masculine presentation, are sexually oriented towards other men yet conceal their sexual preferences in most social spheres or circumstances and are often locally referred to as ‘hidden, or ‘hider’ for their presentation as ‘men’ in public and certain social environments. Apwint and Apone are thought to share the same ‘feminine’ inner self, but differ in their outward gender expression [14]. Lastly, Thange are males with masculine presentations who also engage in sex with other men, yet do so sporadically or incidentally while also maintaining a heterosexual identity and relationships with women [14–18]. There are an estimated 250, 000 MSM and TW in Myanmar (estimates not disaggregated by gender identity) and as many as 50% are thought to conceal same-sex preferences and behaviors [18].

In Myanmar, sexual and gender identity has been associated with differences in sexual positioning, age of sexual debut, experiences of forced sex, condom use at last sex and access to HIV-related services among MSM and TW and is therefore an important consideration for understanding HIV risk and vulnerability [4, 17, 19, 20]. While in the scientific literature, the term MSM is utilized to reflect behavioral characteristics among male-identified individuals with the intention of respecting individual sexual identity, in Myanmar TW do not consider the term MSM to be restricted only to male-identified individuals and participate in and lead many MSM programs and activities [14]. Additionally, much of the research conducted with MSM and TW is not representative or inclusive of the diversity among sexual minorities in Myanmar. In one of the only published studies on characteristics and risk behaviors among MSM and TW, the majority of participants reported their occupation as beautician or Nat Kadaw (spiritual dancer), roles typically assumed by TW [15, 16]. While some literature is beginning to emerge that disaggregates findings by sexual and gender identity [21], very little specifically addresses subgroups of MSM in Myanmar who are locally regarded as ‘hidden’: those that do not disclose same-sex preference or behaviour or identify as gay. Performance of gender and expression of sexuality among same-sex attracted men in Myanmar is further complicated by the legal environment in which they exist; under Myanmar law, homosexual sex remains criminalised and sexual minorities continue to report ongoing discrimination and harassment [22].

Myanmar’s National Strategic Plan for HIV and AIDS 2016–2020 includes a target of reaching 90% of MSM and TW with combination HIV prevention services and prioritizes the engagement of non-disclosing, or ‘hidden’ MSM [4]. A growing body of evidence from the region highlights the ways in which non-disclosure of sexual identity affects HIV service utilization [11, 23, 24], yet much remains unknown about the barriers faced by hidden MSM in Myanmar in accessing HIV services, hindering the development of culturally-relevant and responsive HIV prevention approaches. This formative research was undertaken to better understand the challenges and experiences of MSM and TW in accessing HIV testing, prevention and care and was conducted as part of a broader implementation science study to improve MSM and TW’s access and retention in the HIV Care Cascade in Myanmar [25, 26]. This paper presents a secondary analysis that explores these issues as they specifically relate to hidden MSM and seeks to further our understanding of the characteristics of this group and the barriers and challenges to engaging with HIV prevention services. We consider the perspectives of hidden MSM, the broader MSM and TW community and the service providers and community leaders who seek to engage hidden MSM in HIV prevention. We have included the perspectives of TW in relation to the experiences of hidden MSM in light of the fluidity of sexual and gender identity in Myanmar (i.e., individuals may move between MSM and transgender identities, often depending of social contexts), the common experiences of TW and MSM (e.g., stigma and marginalisation) and the social and physical spaces TW and MSM share in Myanmar.

Data were originally collected as a formative study to inform a trial to develop and test novel approaches to HIV testing and engagement in HIV care among MSM and TW in Myanmar led by Johns Hopkins University [25, 26]. In-depth interviews (IDI) were conducted with MSM and TW community members to explore personal information and perspectives related to the following domains: characteristics of MSM and TW; social context for MSM and TW including experiences of stigma; availability and accessibility of HIV testing services; knowledge and perceptions on HIV self-testing; preferences for HIV testing, treatment and care models, and; issues related to operational implementation. Eligibility criteria for IDIs was defined as: biologically male, aged 18 years and above, reported anal sex with a male in the past 12 months, resident of greater Yangon and spoke Myanmar. Focus group discussions (FGDs) were also conducted with MSM and TW community leaders and service providers to explore HIV prevention, treatment and care availability and delivery, and participant experiences related to service provision. Those who reportedly engaged in providing services to MSM and TW for 1 year or more, were aged 18 years and over, and spoke Myanmar were eligible for FGDs.

IDIs and FGDs were recorded, transcribed and translated into English. English transcripts were checked for accuracy by local study staff and subsequently entered into Atlas. Ti (Cincom Systems, Berlin). Data from IDIs and FGDs were analyzed collectively using open interpretive coding. Research team members (AW, EC, VV) independently coded transcripts after establishing consistency in the use of codes across team members. Codes were developed based on key domains in the interview guides and openly applied to transcripts to identify and analyze emerging themes. Regular meetings were held to ensure ongoing consistency of coding. A community validation workshop was held in September 2016 in Yangon during which the preliminary findings and analysis were shared with community interviewers and facilitators from the study to verify and validate authors’ interpretations.

A secondary analysis of this data was undertaken to better understand the characteristics of hidden MSM in Myanmar and the barriers and challenges to engaging them in HIV prevention. Specific domains used for this paper include: experiences related to the MSM and TW community; knowledge, preference and perceptions related to HIV prevention, treatment and care services; experiences of stigma and discrimination and access to HIV-related services.

While government literature utilizes the term ‘non-disclosing’ MSM to characterize MSM who do not openly identify their sexual or gender identity, in this paper we utilise the term ‘hidden’ to reflect local parlance and ensure consistency with participant data. The term ‘hidden MSM’ is therefore applied to participants who were purposively recruited to the ‘hidden MSM’ FGD or who identified as hidden or Apone, or those who described concealing behaviors in their interview narratives. Our reference to local identity labels throughout this paper is done with fidelity to the way in which they were utilized by participants throughout the study to convey local understanding and interpretation of  these labels and identities.

Ethics approval was granted by the Johns Hopkins School of Public Health Institutional Review Board and the Myanmar Department of Medical Research, Ethical Review Committee.

In-depth interviews were conducted with 25 participants, 12 of whom identified as MSM (48%) and 13 as TW (52%). The median age of IDI participants was 23 years (range 18–42) and 16 (64%) were aged between 18 and 25. The majority of participants were single (n = 10), while 4 and 7 participants reported a current relationship with a casual and regular partner(s) respectively. Sixteen participants were HIV negative (64%), eight were HIV positive (32%) and one was HIV status unknown or undisclosed (4%). Five FGDs were also held with 35 participants; two with service providers (n = 8 and 6), one with MSM and TW community leaders (n = 9), one with hidden MSM community leaders (n = 6) and one with TW community leaders (n = 6) (Table 1).

Increasing the reach of HIV prevention programs among hidden MSM has been identified as a national priority for HIV control efforts in Myanmar [27], yet much remains unknown about this group. This study furthers our understanding of the characteristics of hidden MSM and how they influence levels of engagement with HIV prevention services. This study identified a number of barriers to HIV service access and uptake which largely stemmed from hidden MSM’s preference to conceal same-sex behaviour and orientation; for example, through avoidance of other MSM and TW, reluctance to attend HIV prevention services, denial of same-sex behaviors and adopting gender-conforming behaviors and presentations, particularly around family. Additionally, fear of stigma and discrimination and a need for privacy and confidentiality were key factors in shaping preferences for HIV prevention services among hidden MSM. Service providers and community leaders corroborated the experiences and characterizations of hidden MSM and noted the unique ways in which these barriers impacted their ability to engage hidden MSM in HIV prevention. Taken together, these findings provide some context for the low rates of HIV testing currently observed among MSM and TW in Myanmar [4] and carry important implications for the enhancing service demand through the development of culturally-relevant HIV prevention programs that are acceptable and can adequately address the specific needs and concerns of hidden MSM in Myanmar.

In this study, we found that non-disclosure of same-sex behaviour and preferences was commonly employed by MSM as a strategy to avoid stigma and discrimination from their families and communities. In Myanmar, although rarely enforced, homosexual sex remains constitutionally illegal and contributes to an environment in which sexual minorities continue to report ongoing harassment and discrimination [15]. The criminalization of homosexual sex has also been associated with reduced levels of access to HIV services among MSM and TW [28]. Service providers in Myanmar have noted how the current legal environment complicates the delivery of HIV prevention services by preventing community-based organizations from official state registration [18]. Anti-homosexual legislation works to legitimize discrimination and negatively impacts the acceptance of sexual minorities, promoting concealment of sexual identity and behaviors among MSM. Across Asia, non-disclosure of sexuality has been associated with higher rates of condomless sex [29] and lower rates of HIV testing among MSM [30, 31]. Similarly, in this study, we found that the requirement to disclose same-sex behaviors in order to receive appropriate HIV services and commodities effectively inhibited hidden MSM’s access to these services; this reluctance hinders the provision of appropriate and tailored care, including specific risk-reduction counseling. Current WHO guidelines for example, recommend the provision of condoms and lubricant and the opportunity for anal cancer screening for all MSM [32], however these services are unlikely to be offered if same-sex behaviors are not revealed.

This study found that many hidden MSM engage in negotiated identity practices in order to carefully manage the concealment and disclosure of their sexual identity. Often this behaviour was tied to environment, with many hidden MSM describing adoption of gender-conforming behaviors and presentation around family and the careful demarcation of social/sexual lives and family/community contexts. This demarcation often involved the public avoidance of other MSM and TW and underscores the importance of privacy and confidentiality as a key determinant of health seeking behaviours and preferences for HIV prevention services among hidden MSM.

Peer-based outreach and health promotion is a fundamental component of Myanmar’s national response to HIV [27] and has been identified as a key strategy to drive up rates of HIV testing among MSM [4]. Yet the demonstrated reluctance among hidden MSM to publically engage with peer outreach workers may undermine the potential effectiveness of national HIV prevention strategies and programs in Myanmar. While some peer workers adopted inconspicuous approaches to engaging hidden MSM in outreach, and in doing so, demonstrated an awareness of this group’s preference for privacy (for example, using more generic terms to address hidden MSM such as “friend” or “brother”), others indicated a sense of frustration at the difficulty of engaging hidden MSM that suggested limited empathy for the psychosocial struggles they experienced. There is an opportunity to strengthen community-based HIV prevention programs by ensuring all peer staff are comprehensively trained to both recognize and deal with these psychosocial struggles, including internal stigma and homonegativity, experienced specifically by men unwilling or unable to disclose same-sex preferences.

In general, responses to HIV are often based on easily identifiable risk categories, including “MSM” and “TW”, which many have argued detract from properly appreciating the complexity of gender and sexual expression and the way this shapes HIV vulnerability and risk [33–35], including in the Asian context [36–38]. Yet, the reappropriation of the term ‘MSM’ as an identity category has been noted, signalling the transformation of ‘MSM’ from epidemiological term to subject position [39]. In this study, numerous participants used the term’ MSM’ as an identity label, parallel to local parlance as has been noted in other settings among same-sex attracted men [40]. Neither continued reliance on the binary MSM/TW categories alone, nor the wholesale integration of local terminology in HIV programing would be sufficient; as argued by Thomann [40], the key to more responsive HIV programing is the recognition of the diverse lived experiences contained within local identities and how this intersects with other local and social realities to shape vulnerability to HIV. Indeed, the differing experiences and perspectives among the various sexual and gender identities, even within the same identity group, documented in this study highlights the importance of service provision that can appropriately cater for different groups and their heterogenous needs. In Laos, for example, behaviorally bisexual men demonstrated reluctance to attend MSM- specific services [23], underscoring the importance of identifying as the intended recipient of HIV services. In this study, attendance at MSM-specific services was believed to present a high risk of association with the MSM community. Yet, while general testing clinics were viewed as providing greater anonymity, these clinics also presented barriers for hidden and disclosing MSM and TW including experiences of stigmatization and discrimination from health care staff. Owing to similar concerns for confidentiality, recent research found that hidden MSM were more likely to seek treatment from public clinics, general practitioners or self-medicate compared to other MSM [18] or may simply eschew HIV services all together [20]. In such contexts, generic Men’s Clinics staffed by MSM-friendly providers who can discretely provide services appropriate for this group’s sexual risk behaviors may be an appealing option for hidden MSM. The latest National Strategic plans identifies ‘One stop shops’ as a potential strategy to increase HIV testing rates among MSM [4]; the findings from this study suggest that such an approach would be well-received by this group, provided staff were appropriately trained and aware of specific barriers encountered by hidden MSM. Delivery of comprehensive training for staff in mainstream HIV services and other government health services, and inclusion into medical and nursing curricula, to enhance both sensitivity and capacity to provide appropriate and tailored services to sexual minorities would also increase the ability of providers in these settings to more comprehensively address the specific needs of MSM.

Myanmar is currently experiencing a period of significant transition and development, which has included an evolving interpretation of homosexuality (including the adoption of more ‘Western’ terminology such as ‘homo’, ‘gay’ and ‘queer’, particularly among younger, urban individuals and/or those connected to the NGO sector as demonstrated by some study participants; [14, 18, 41]). This ongoing development has also led to changing social and political environments, characterized by an emergent LGBTI community and an increasing number of civil society groups and social networks for sexual minorities, many of which are actively engaging in policy discussions and highlighting issues in their communities [18]. In 2012, Myanmar held its first gay pride parade [42], a sign of the shifting attitudes and growing tolerance towards sexual minorities in Myanmar. However the prevailing legal environment sustains a sense of fear of discrimination and possible arrest among some MSM and TW whose desire to avoid both may supersede the importance of HIV testing and engagement with HIV prevention services, particularly those that pose a risk of disclosure, and should be recognized as a key barrier to service access. The expanding availability of information and communication technology (ICT) and infrastructure [43] in Myanmar, including a growing ubiquity of cyber networks among MSM communities [44], offers opportunities to engage MSM and TW in HIV prevention who may otherwise be reluctant to do so. ICT-based approaches have demonstrated some positive results in engaging MSM in HIV testing [45–48], including among non-gay identified MSM [49], and are increasingly used to engage hard-to-reach and hidden MSM populations across Asia [50, 51]. The evolving social and political context offers opportunities to reduce some of the identified barriers to engaging MSM through increasing the social acceptance of sexual minorities in Myanmar, while technological advances can be used to enhance the reach of hidden MSM in HIV prevention through the innovative use of online and new technologies. Together, this new landscape can promote an enabling environment in which some of the barriers to engaging hidden MSM in HIV prevention services described in this study are reduced.

This study has several limitations that should be considered alongside the results. Study participants were recruited from partner NGO organizations and their views and perspectives may not represent MSM and TW who are harder to reach or not currently connected to services. Additionally, this study did not specifically ask participants to identify their sexual identity a priori using the locally accepted terms described in this paper and we cite them insofar as they were used by participants themselves during FGDs and IDIs. Therefore, it is possible that some of the references to hidden MSM may be in relation to Thange participants, who are also considered ‘hidden’ but who are likely to face unique barriers related to their specific sexual identity. More research is warranted to explore how the barriers faced by hidden MSM described in this study may be uniquely and variedly experienced by Thange and Apone MSM respectively. Lastly, our sample was recruited from Yangon, the largest city in Myanmar and may not reflect the lived experiences of MSM and TW in rural or remote areas where access to HIV services and tolerance towards gender non-conformity may be lower. However, we believe the findings are relevant to other urban locations in Myanmar which are typically characterized by larger populations of MSM and TW compared to peri-urban and rural areas [4].

As highlighted by this study, MSM in Myanmar who are unwilling or unable to disclose their sexual behavior and preferences face multiple and overlapping barriers to accessing HIV testing and other prevention services. Strategies such as building the capacity of peer service providers to identify and respond to psychosocial challenges experienced by non-disclosing MSM, sensitivity training to reduce discriminatory attitudes and practices among mainstream health providers and government workers, and innovative approaches such as one stop shop services and ICT-based health promotion that can discretely provide services tailored to the distinct needs of MSM and TW, while ensuring their privacy, may help circumvent some of the barriers identified in this study. Such activities should be considered as part of an overarching HIV prevention strategy that also addresses the broader structural barriers related to stigma and discrimination in the general community to improve the social acceptability of sexual minorities and create an environment in which hidden MSM can comfortably discuss same-sex behaviour and access services appropriate for their risk behaviors.