Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience.

Using syndemics theory as a framework, we explored the experience of men who have sex with men in India in relation to four syndemic conditions (depression, alcohol use, internalised homonegativity and violence victimisation) and to understand their resilience resources. Five focus groups were conducted among a purposive sample of diverse men along with seven key informant interviews with HIV service providers. Participants' narratives suggested various pathways by which syndemic conditions interact with one another to sequentially or concurrently increase HIV risk. Experiences of discrimination and violence from a range of perpetrators (family, ruffians and police) contributed to internalised homonegativity and/or depression, which in turn led some men to use alcohol as a coping strategy. Stigma related to same-sex sexuality, gender non-conformity and sex work contributed to the production of one or more syndemic conditions. While rejection by family and male regular partners contributed to depression/alcohol use, support from family, regular partners and peers served as resources of resilience. In India, HIV prevention and health promotion efforts among men who have sex with men could be strengthened by multi-level multi-component interventions to reduce intersectional/intersecting stigma, address syndemic conditions and foster resilience - especially by promoting family acceptance and peer support.