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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: Glob Public Health. 2019 Oct 20;15(4):520–531. doi: 10.1080/17441692.2019.1679218

Barriers and Facilitators to Uptake of Condoms among Filipinx Transgender Women and Cisgender Men who have sex with Men: A Situated Socio-Ecological Perspective

Arjee J Restar 1,2,3,*, Alexander Adia 1,2, Jennifer Nazareno 1,2, Laufred Hernandez 4, Theo Sandfort 5, Mark Lurie 6, Susan Cu-Uvin 1,2,7,8, Don Operario 1,2
PMCID: PMC7093239  NIHMSID: NIHMS1541373  PMID: 31630622

Abstract

Transgender women (TW) and cisgender men who have sex with men (cis-MSM) are disproportionately impacted by the national HIV crisis in the Philippines, where the HIV incidence has, in large part, been attributed to condomless sex. This study sought to qualitatively examine the socio-ecological factors that contribute to low condom uptake among Filipinx TW and cis-MSM communities in Manila. Between July and August 2017, we conducted semi-structured qualitative interviews with 30 TW and cis-MSM participants (n=23 and 7, respectively). We identified structural factors described by TW and cis-MSM, and noted that they varied per situation and context of: (a) friends (e.g., as condom promoters and educators), (b) schools (e.g., lack of sex education and HIV curriculum), (c) health care facilities (e.g., availability, educational programs, and HIV testing requirement), (d) stores (e.g., placement of condoms, distance to store, and cost), and (e) church (e.g., prohibition of condom distribution programs, and unsupportiveness). Condom-related stigma as a social factor was pervasively present across all situation or context. Our findings support the need for multilevel condom promotion interventions that are tailored per situation or context. Future research is needed to identify factors that can be leveraged for condom promotion strategies within diverse situations.

Keywords: Transgender Women, Men who have sex with men, Philippines, Condoms, HIV Prevention

Introduction

Globally, HIV infection rates remain extremely high among key affected populations like transgender women (TW; women who are assigned male at birth) and cisgender (cis or non-transgender) men who have sex with men (cis-MSM) (Baral et al., 2013; Beyrer et al., 2012). A worldwide meta-analysis study showed TW are 49 times more likely to be living with HIV compared to all cis-adults of reproductive age, with estimated prevalence rates of 17% among TW in low-income and middle-income countries (Baral, et al., 2013). Pooled estimates of HIV prevalence were consistent across global regions, particularly in South and Southeast Asia with 15% prevalence among cis-MSM (Beyrer, et al., 2012). The Philippines is a middle-income Southeast Asian country that is experiencing one of the fastest growing HIV epidemic crises globally, and stands in stark contrast to other countries in the Asia-Pacific region where HIV rates are declining (Joint United Nations Programme on HIV/AIDS [UNAIDS] 2014). The number of people diagnosed with HIV in the Philippines has increased nearly 15-fold, from 3,800 cases in 2005 to 56,000 in 2016; this emerging epidemic is concentrated among key populations including Filipinx (i.e., a gender-neutral term to describe people living in the Philippines) TW and cis-MSM in Metro Manila (UNAIDS, 2017).

The increasing diagnoses of HIV among Filipinx TW and cis-MSM has been attributed, in large part, to condomless sex (Philippines Department of Health [DOH], 2017; World Health Organization, 2016). According to the Philippines’ 2015 Integrated HIV Behavioural and Serologic Surveillance (IHBSS), which surveyed TW and cis-MSM (n=3,535 and 5,963 participants, respectively), 58% of those who had anal sex in the past 12 months did not use condoms (i.e., had condomless anal sex) (Philippines DOH, 2017). Previous research has identified socio-ecological factors for condomless anal sex are multi-level: personal, social, and structural-level (Hughto, Reisner, & Pachankis, 2015; Sevelius, Reznick, Hart, & Schwarcz, 2009; Sweat and Denison, 1995). No known empirical studies have applied this framework to the context of the Philippines’ emerging HIV epidemic (Restar, et al., 2018). According to the Philippines’ IHBSS report, reasons for condomless anal sex among Filipinx TW and cis-MSM include unavailability of condoms at the structural-level (53%), and having others disapprove use of condoms at the social-level (9%). Personal-level factors such as disliking condoms (21%) and believing that condoms are unnecessary (10%) also contribute to condomless sex; other person-level reasons (7%) included forgetting to use a condom, not knowing how to use condoms, and that condoms are expensive. Additionally, among those who had access to HIV services from clinics and/or peer educators, only 29% received free condoms in the past 12 months. While some of the barriers to condoms use are identified, important questions remain about how and why condoms are or are not utilized, why these barriers exist, how they can be addressed, and what situational factors facilitate condom use (Adia et al., 2018; Restar et al., 2018).

Yet, despite these surveillance indicators, there is limited empirical research on the situational barriers and facilitators of condom use among Filipinx TW and cis-MSM (Asuncion, Segarra, Samonte, N., & Bermejo, 2017). A recent systematic review of the Philippines’ HIV epidemic reveals that there are currently no empirical studies that characterize the multi-level socio-ecological factors that impact uptake of condom use among Filipinx TW and cis-MSM (Restar, et al., 2018). In other studies that examined condoms use among TW and cis-MSM, contextual or situational risk factors have been found to be associated with increased condom use beyond the dominant individual-focused paradigms that emphasize information and motivational factors (Operario and Nemoto, 2010; Sevelius, Patouhas, Keatley, & Johnson, 2013). In order to develop contextually and situationally relevant interventions, research must characterize the multiple co-occurring factors that challenge how condom uptake can be improved for these populations, for example stigma, lack of sex educational programs, discrimination, poverty, and religion (Operario and Nemoto, 2010; Singer and Clair, 2003). These factors are not well-described among Filipinx TW and cis-MSM in Manila. Moreover, the Philippines is a predominantly Catholic country (Pew Research Center, 2016), where stigma and discrimination against trans and cis-MSM people is widespread, and condom distribution and sexual health education programs are stifled by conservative norms (Adia, et al., 2018; Asuncion, et al., 2017; Ross et al., 2013; World Health Organization [WHO], 2015). As such, there is a need to understand how these country-specific socio-ecological factors impact condom uptake of Filipinx TW and cis-MSM’s in Manila.

Given the unique situational context of Filipinx TW and cis-MSM and the need to inform current strategies for condom uptake for this community in an emerging epidemic, the purpose of this study is to qualitatively identify socio-ecological barriers or facilitators to improving uptake of condoms. In this article, we present findings from Filipinx TW and cis-MSM who are at risk for or are living with HIV in Metro Manila.

Methods

Study Design and Participants

Between July and August 2017, we conducted semi-structured, one-on-one qualitative interviews with TW and cis-MSM in Metro Manila, Philippines. The purpose of the interview was to identify and briefly describe socio-ecological factors that impact uptake of HIV-related services including condom distribution programs, HIV and other sexually transmitted infection (STI) testing and counselling, and biomedical modalities like pre- and post- exposure prophylaxes and antiretroviral therapy. This study specifically focused on the uptake of condoms among Filipinx TW and cis-MSM. The study was designed using principles of community-engaged research (Wallerstein and Duran, 2003). Two local HIV non-governmental organizations (NGOs) collaborated as study partners, and an early draft of the interview guide was piloted and iteratively revised through its administration to two Filipinx TW and two cis-MSM community members to ensure that study implementation approaches (e.g., participant recruitment, language of interview, comprehension of interview questions/probes) were appropriate, respectful, and sensitive to participants (Wallerstein and Duran, 2003). Informed by our study partners, we used convenience sampling and active recruitment via posting of study flyers at venues where we know TW and cis-MSM congregate (e.g., community centres, bars/night clubs) and social media (e.g., Facebook). Participants were eligible if they were: (1) 18 to 29 years old, (2) identify as a TW or cis-MSM, (3) self-reported condomless anal sex in the past year with a male sexual partner; (4) living in Manila metropolitan area; (5) willing to be audio-recorded; and (6) willing to provide written informed consent.

Procedures

Interested participants contacted our office phone and were screened for eligibility. Eligible participants were then scheduled for an in-person interview. Each interview lasted between 70 to 90 minutes and was conducted in private rooms at the offices of our local study partners. Interviews were conducted by two trained qualitative researcher assistants (RAs) and by the lead investigator. All interviews were conducted in English as it is a common language throughout the Philippines (Gonzalez, 1998) and was not an impediment to recruiting, creating rapport, and interviewing participants. The interview guide addressed condom use barriers and facilitators across the following multi-level socio-ecological factors: (a) knowledge and personal experiences of using condoms; (b) social communications or discussions about condoms; and (c) structural settings or places where they access condoms (e.g., school, convenience stores, clinics). All participants received $10 USD (~500 Philippine Pesos) for their time and participation.

All procedures for this study were approved by the Brown University Human Research Protection Program Institutional Review Committee in Providence, Rhode Island. Written informed consent was obtained from all participants. Participants were informed about the purpose of the study and their rights to confidentiality, withdrawal, and refusal to answer any questions. Participants were advised to use pseudonyms for their name in the interviews and any mention of personally identifiable information were removed from transcripts.

Analysis

We utilized principles of inductive thematic approach, articulated by Braun and Clarke (2006), to guide our qualitative analysis, which included developing codes and facilitating identification of emergent themes about TW’s and cis-MSM’s knowledge and uptake of condoms. Thematic analysis identifies themes based on patterns that emerge from the data. Its first phases includes immersion in the data for familiarity, generating and defining initial codes, and identifying themes based on codes; the latter phases involve looking for themes that mapped onto an overarching conceptual framework (i.e., socio-ecological framework) (Sweat and Denison, 1995), and noting which themes are more useful than others in understanding the phenomenon. Additionally, we also used a situational analysis approach based on principles articulated by Clarke and Friese (2007) to situate our data within each context or setting explored. This allowed us to identify themes per context, situation, or setting. These approaches are appropriate to our research aims given the dearth of literature and the very little understanding about what is known about condom uptake in this specific context and sample. An inductive approach (rather than deductive) was appropriate as there was no a priori or predetermined theory, structure, or framework utilized during the conception of this paper and when analysis where conducted. The identification of the overarching conceptual framework (i.e., socio-ecological framework) was determined after the research team thematically analyzed the data, which was then used to derive the overall structure of analysis and situate the themes within each context or setting to make meaningful contributions to understanding what is going on within the data. Four members of the research team (AR, AA and two trained RAs) were instructed in the application of the codes and any discrepancies in coding were raised in team meetings via in-person discussions until consensus was reached. Emergent and final themes were agreed upon by all research team members. All coding occurred between September to November 2017 and were performed using Dedoose, a qualitative data management software (Dedoose, 2015).

Results

Participant Description

Table 1 displays the summary of the participant demographics. A total of 23 TW and seven cis-MSM were included. Over half (n=16) reported to be living with HIV, of whom 11 were TW and five were cis-MSM. The average age of all participants in this sample was 25.1 years (range, 18 to 29 years), 24.3 years for TW and 27.7 years for cis-MSM.

Table 1.

Age and self-reported HIV status among Filipinx transgender women and cisgender men who have sex with men (N=30).

N=30 Transgender Women (n=23) Cisgender MSM (n=7)
Age (mean, range) in years 25.1 (18–29) 24.3 (18–29) 27.7 (24–29)
Self-reported HIV Status
  Positive 16 11 5
  Negative 14 12 2
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Overview of the situated socio-ecological condom uptake model

Figure 1 illustrates barriers and facilitators to condom use per situation, derived from findings from this analysis. We looked for thematic differences between TW and cis-MSM with respect to this specific research focus and found no unique themes for either groups; thus, analysis was combined across groups. Based on participants’ interviews, we distinguished five different situations and contexts that were relevant to condom uptake: friends, schools, healthcare facilities, convenience stores, and churches. We further noted that structural factors differ per situation, and that condom-related stigma as a social factor was present across all situations. Structural factors included those situated in the context of friends (e.g., as condom promoters and educators), school (e.g., lack of sex education and HIV curriculum), health care facilities (e.g., cost, availability, educational programs, and HIV testing requirement), stores (e.g., arrangement or placement of condoms, distance, and cost), and church (e.g., prohibition of condom distribution programs, unsupportiveness). These structural and social factors functioned as either barriers and facilitators to TW and cis-MSM’s knowledge and uptake of condoms. These factors are briefly described below by each situation and are further noted as to whether they operate as barriers and facilitators:

Figure 1:

Figure 1:

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Situated socio-ecological condom uptake model among Filipinx transgender women and cisgender men who have sex with men.

Friends

(a). As promoters and educators (structural facilitators).

Through our analysis, we uncovered participants referring to friends as a collective organization (i.e., as clans or situated networks) that comprise structural agents (e.g., promoters, educators) and social norms (e.g., rules about what is or is not taboo to discuss). In the context of friendships, participants described their friends as influential agents who function as promoters who provide them access to condoms, and as educators who shape their knowledge and motivation to use condoms. A 29-year-old TW explained how she often accessed condoms through her friends who “hoard” condoms from the “NGOs [that are] giving away condoms.” A 24-year-old TW described how she always “have a bunch of stock of condoms because [she’s being] depended… [by her friends who] are getting condoms” from her. As such, participants themselves and their friends reciprocally act as promoters of condoms within their communities. Additionally, a 27-year-old cis-MSM described that condom discussions with friends also involve “[talking] with regards to condom use…how can this disease [AIDS] transmit or how it can protect from getting an HIV.” In addition to discussing the purpose of condoms in preventing infection, they also educate each other on how to properly use condoms.

(b). Condom-related stigma among friends (social barrier).

While most participants reported being open to discussing condoms with friends, a few expressed hesitancy in discussing condoms due to the Philippines’ socially stigmatizing views around condoms and sex. For example, a 24-year-old cis-MSM explained that he does not engage his friends in condom discussions as generally, “Filipinos…are uncomfortable to talk about contraceptives, condoms, [and] sex.”

Schools

(a). Lack of comprehensive sex education and HIV curriculum (structural barriers).

In reflecting on the context of schools (including primary and secondary school settings), TW and cis-MSM expressed that a primary reason for their inability to learn about condoms, particularly for the purpose HIV prevention, was because these topics were lacking in the curriculum. Reflecting on her education, a 22-year-old TW described how the Philippines educational system “do[es] not have the comprehensive sexual education” nor does it integrate HIV topics in the curriculum. A 27-year-old TW expressed the need for condoms to be “practiced and discussed to everyone, even to the youth…in school.” While condoms may not explicitly be part of the educational curriculum, some school clinics held condom-related seminars for the purpose of birth control, but not for HIV prevention. For example, a 27-year-old MSM recalled having learned about condoms when participating in a seminar sponsored by his school clinic to “promote condoms for family planning to minimize [family size] … [but] they don’t talk about HIV.” This was echoed by a 29-year-old TW who explained, “[the discussion] was not expounded, it was just enumerated. These [condoms] are available…used for prevention of pregnancy, but not directly for [preventing] HIV and AIDS.”

(b). Condom-related stigma in school (social barrier).

The lack of condom- and HIV-related curricula in schools stemmed in part from the church’s influence on the school system. A 27-year old TW explained the intricacies of the Philippines’ education system and the role of the church in curriculum design. She stated, “The Department of Education is not yet open to [condom promotion]. And the educators don’t know how to do it… [T]he curriculum is not in place. [The] church [fears] that when you introduce condoms…you are giving [the students] the signal that they can do sex everywhere.” As such, in schools, TW and cis-MSM as students are not learning about using condom for HIV prevention as churches and schools in the Philippines continue to stigmatize condoms and sex.

Health care facilities

(a). Condom programs: education, free cost (structural facilitators).

TW and cis-MSM described learning about accessing free condoms via health care facilities and NGO-run condom programs. One 29-year-old cis-MSM learned how to use a condom because an NGO “demoed it” to them. A 22-year-old TW said these demos included “protocol [instructions] about when to use condom…[the] need to see the expiry date, and step by step… [and] it includes correct use of condoms.” One 29-year old TW remembered learning about “correct and consistent use of condoms… when [they were] outreached by an HIV organization.” As such, health care facilities and NGOs not only provided condom education programs to those who come to their facility, but also actively performed outreach in the community. Additionally, some participants described how they prefer accessing condoms at health care facilities and NGOs because condoms are provided at no cost. As explained by a 24-year-old TW, “It’s easy because in the clinic it’s for free. You don’t need to pay for condom… so it’s not hard to access.”

(b). Condom programs: lack of outreach capacity to disseminate information about free cost, out of stock, HIV testing requirements (structural barriers).

Among the key barriers identified by participants included not knowing that condoms are available free of charge. When asked about her thoughts about free condoms, a 21-year-old TW noted how it is beneficial “if [community members] know that they are available” but that “not everyone knows that [they] can get it for free.” When asked about his thoughts about the community’s knowledge of free condoms, a 27-year-old cis-MSM echoed that “knowledge and education [of free condoms]” is important to the “prevention [of] spread of disease risk.” Other barriers included programmatic issues such as temporary stockouts and requiring HIV testing before giving condoms. A 27-year-old TW who promotes condoms among her friends described the “need to communicate to [their health care facility they have] no condoms at all.” She continued by indicating this issue occurs “just minimal[ly].” Additionally, some health care facilities and NGOs required HIV testing prior to giving out condoms to TW and cis-MSM community members, particularly those who are not living with HIV. As articulated by a 28-year-old TW: “Nowadays it’s really hard to get free condoms, especially when you are…a negative person. Cause when you’re negative…you can’t have a free condom until you’re being tested.” As such, while participants are interested in using condoms, having to go through HIV testing as a requirement to receive condoms is in itself a structural barrier.

(c). Condom-related stigma in healthcare facilites (social barrier).

When asked about any difficulties accessing condoms in health care facilities, a few participants noted the lack of discussion they have had with their providers due to stigmatization of condoms. A 27-year-old TW described that she has “never encountered talking about condoms with my doctor [and nurses] … because it’s like a taboo thing to talk about.” Another 22-year-old TW explained how her friends were afraid to get condoms from health care facilities: “For some young transgender [women], they are afraid to get condoms there. Because, they are thinking that the health service provider thinks they will [have] sex with anyone.” As such, while most health care facilities and NGOs promote condoms, some TW and cis-MSM community members may experience or perceive condom-related stigma from some health care providers or staff.

Convenience Stores

(a). Inconspicuous arrangement and placement of condoms, distance to stores, and relative cost (structural barriers).

TW and cis MSM noted that condoms in convenience stores are often placed away from plain sight. This placement is often behind the counters, which makes it difficult to easily find condoms. As noted by a 26-year-old TW, one “cannot see [condoms] around the store.” A 22-year-old TW echoed, “here in the Philippines… the seller of condoms is hiding the condom, or the condom is inside the counter.” Another barrier described is the inaccessibility of condoms due to distance to convenience stores. As a 27-year old cis-MSM explained, “In some other places like provinces or secluded areas…condom use is not being used because… [convenience stores are] far from the center or it’s far from place where you can buy it.” As such, traveling to and from distant convenience stores represents a barrier to buying condoms. Lastly, some participants noted that buying condoms can be a prohibitive expense for them and other people with low-incomes. As a 21-year-old TW explained, “In the Philippines, it’s easy [to buy condoms] if you have money.” Another participant, a 27-year-old cis MSM echoed, “For me, it’s not very easy, but if you have money, you can buy anywhere to use condom.” A 27-year old TW explained how condoms are expensive for their friends, “my friends, they tell me, no, they don’t want to use condoms They reject it, because … it’s very expensive, the condom, so they couldn’t afford to buy.”

(b). Condom-related stigma in convenience stores (social barrier).

Participants also noted that they are often stigmatized when purchasing condoms. As condoms are often placed behind the store counter, it places the individual at risk of being interrogated by the seller. A 22-year-old TW explained why she finds it difficult to buy condoms in stores, “sometimes [the seller asks you,] ‘what do you do, why do you buy a condom’ so sometimes it’s so hard to buy condom in convenience store.” Encountering shame-based stigma while buying condoms was also explained by a 25-year old TW: “[The] culture in the Philippines, they’re not quite friendly with using condoms so the problem is, it’s not easy to buy when in a public place, because people…think ‘oh, she’ll will have sex later’, that’s why.” A 29-year-old cis-MSM also mentioned how it was “awkward buying a condom over the counter” for him. As such, while some TW and cis-MSM participants may make it to the store, their socially stigmatizing experiences in the store discourage them from buying condoms.

Churches

(a). Unsupportive stance and prohibiting condom distribution activities (barriers).

In addition to the disapproving stance of churches in the Philippines with regard to promoting condom education programs in schools, described previously, participants also mentioned how churches prohibit condom distribution activities. As noted by a 29-year-old TW, “there are certain sectors of our government, mainly the church, that prevent these [condom distribution] activities from happening, not merely prevent but they are not pro for these activities.”

(b). Condom-related stigma in church (barrier).

Participants in this sample mentioned that churches in the Philippines are generally unsupportive of condoms and often stigmatize people who use condoms for HIV prevention. As a 27-year-old cis-MSM explained, “With regards to condoms…especially in the church…the church doesn’t want this kind of contraception or using this kind of protection… to prevent the diseases to spread.”

Discussion

This study demonstrates the importance of structural and social factors faced by Filipinx TW and cis-MSM in different situations when considering use of condoms to prevent HIV transmission. Specifically, we found that these socio-ecological factors vary by situation or context, and impact Filipinx TW’s and cis-MSM’s knowledge to navigate access and uptake of condoms. Our findings support the notion that considering multilevel and multi-component HIV prevention interventions to address structural and social factors experienced by TW and cis-MSM could likely enhance behavioural change recommendations such as condom use (Operario and Nemoto, 2010; Sevelius, et al., 2013; Singer and Clair, 2003). This is particularly important in the context of the Philippines where minimal condom distribution programs exist (Asuncion, et al., 2017; WHO 2015). Efforts to optimize facilitators and reduce barriers are therefore needed where such programs are found. Findings from this analysis revealed the role of structural and social factors that can serve as either barriers or facilitators to accessing and using condoms for TW and cis-MSM in the Philippines.

Our participants cited multiple structural and social barriers to condom use, including knowledge and uptake, which have not been described via situational analysis in previous studies among Filipinx TW and cis-MSM (Restar, et al., 2018). Specifically, we found that structural factors vary per situational context. For instance, participants reported not receiving enough sexual health education and HIV curriculum in schools, and when some of them did, condoms are taught as a pregnancy prevention tool rather than for HIV/STI prevention; this type of messaging could likely influence participants’ understanding that condoms may not be applicable to their lives. Due to the influence of the church, the education and distribution of condoms for HIV prevention within school settings are not supported by most school-specific policies in the Philippines. Some participants rely on health care facilities to be their sole source for getting both comprehensive condom education and free condoms, which likely facilitate increase knowledge and uptake of condom use. However, these programs, as described by those who have accessed them, are often undermined by structural barriers (Asuncion, et al., 2017; Restar, et al., 2018; WHO 2015). For example, participants reported that health facilities require HIV testing prior to giving free condoms. This type of protocol, if true, warrants further empirical investigation. Moreover, some participants cited cost as a barrier to purchasing condoms in convenience stores. Given that participants already have access to these stores, future research should examine how free condoms could be placed in stores to remove this barrier, providing a way to leverage this type of setting as access points to free condoms. Overall, these results suggest both a need for structural interventions designed to enable the seeking and usage of condoms as well as a need to tailor other interventions to specific situations or settings rather than a universal intervention across all settings (Blankenship, Friedman, Dworkin, & Mantell, 2006).

We also found that participants experienced stigma relating to condom use pervasively across all situations examined, but also noted that stigma manifested differently within each situation. Our participants expressed that while condoms are generally not discussed openly across most settings in the Philippines, often citing it as a taboo subject, participants also noted that there are differences in which that discussion is being communicated in each situation. For example, in the context of churches and schools, stigma against using condoms is communicated by promoting abstinence and not exposing students to comprehensive sexual education where information about condom can be learned, for fear that condoms might promulgate sexual behaviours and diseases with youths. While abstinence programs have been debunked by HIV and sex researchers as insignificant in delaying both initiation of sex and safer sexual behaviours (Kirby, 2008; Santelli et al., 2006; Underhill, Montgomery, & Operario, 2007), this research remains underexplored among Filipinx TW and cis-MSM individuals. Future research examining how to best adapt and implement comprehensive sexual education programs would need to pay closer attention to context-specific structural and social barriers in schools and faith-based entities in the Philippines, including stakeholders (e.g., professors, church leaders) in these settings.

Another example illustrated by our participants on how stigma is communicated differently at the social-level compared to other situations is in the context of convenience stores. Our participants described being shamed and interrogated by convenience store sellers when asking for help or for location of condoms in stores and being perceived to be sexually sinful or promiscuous—all of which discourage Filipinx TW and cis-MSM individuals from purchasing condoms. Limited access to condoms in stores has been documented previously, but has not been described as a source of stigma (Moore et al., 2008; Rizkalla, Bauman, & Avner, 2010). Researchers have noted that condoms are a “socially sensitive product” that creates embarrasssment in public and can influence buying behaviour of consumers (Moore, Dahl, Gorn, & Weinberg, 2006; Scott-Sheldon, Glasford, Marsh, & Lust, 2006); however, contrary to these studies, our participants cited being shamed by sellers for buying condoms instead of feeling embarrassed. This illustrates the importance of addressing stigma as a social barrier and its unique operationalization in the context of convenience stores in the Philippines. It also highlights how sellers uphold this stigma by communicating about condoms as a taboo commodity. As sellers in convenience stores play an important role in the consumer experience (Rizkalla, et al., 2010; Scott-Sheldon, et al., 2006), future research on HIV prevention that aims to promote condoms in convenience stories should explore how sellers can be leveraged for this work, including their potential role in de-escalating stigma experienced by Filipinx TW and cis-MSM.

Lastly, we found key structural facilitators that positively influence knowledge and uptake of condoms in contexts with friends. Most of our participants and their friends described educating each other about condoms (i.e. as peer educators) as well as promoting the use of condoms by actively stocking and distributing condoms towards their friends (i.e., as peer distributors or promoters). Future research should identify sources of sexual health information among peer educators to ensure that information about HIV and condoms are being accurately and positively promoted and disseminated to or sought by community members. These findings point to the potential role of peer-delivery among Filipinx TW and cis-MSM community members. One program in Cebu City, Philippines called Femina Trans has provided condoms and lubricants via peer-to-peer approach (World Health Organization, 2016), but little is known about the extent in which such program can be scaled up and maintained elsewhere in the Philippines. Studies exploring social linkages such as social cohesion (i.e., working collectively to promote a well-being of community members), have been found to positively impact HIV prevention behaviours including condom behaviours (Abdool Karim et al., 2008; Argento et al., 2016; Grover et al., 2016). Additionally, Filipinx TW and cis-MSM community members have been documented to organize themselves as members of clans (Malonzo and Felix Jr, 2013). As such, future research should understand the role of clan memberships and their impact among Filpinx TW and cis-MSM’s condom uptake. As HIV interventions based on peer-delivery have been shown to have some positive effect on HIV risk behaviour (Shangani et al., 2017), interventions that aim to change these behaviours among these Filipinx groups should also explore this peer approach in promoting HIV-related services including condoms.

Limitations

This study is not without limitations. First, not all barriers and facilitators may have been identified in the present study. Given the limited interview time, attention to participants’ fatigue, and the broad scope of the socio-ecological framework used, not all factors related to access and uptake of condom knowledge and uptake may have been captured in the interviews. Other factors (e.g., demographics) would have also improved the context around the findings of this study. Additionally, various types of each settings such as public vs. private schools, secondary vs. higher education, hospital vs. community-based health care facilities were not fully examined in this study, which may yield various, nuanced differences in the structural- and social-level factors we identified. Other limitations are related to the qualitative study design. Since we utilized a convenience sampling recruitment approach, it is possible that not all of the views of Filipinx TW and cis-MSM community members in Manila are represented in this analysis. It is possible that some TW and cis-MSM who did not go to the health care facilities or other venues where we recruited, and who may have different condom-related experiences, were not captured in this study. Although this research was unable to identify specific factors that differentiate TW and cis-MSM with respect to our primary research aim, it is possible that key differences might arise over time with different samples, especially as these communities continue to evolve in the Philippines. Additionally, the findings of this study may reflect a specific period of time when HIV is on the rise and the political and social responses to the epidemic are at an early phase in the Philippines (UNAIDS, 2017; Restar, et al., 2018). Lastly, as these interviewers were conducted in English and performed by Filipina-American interviewers, it is possible that legacies of colonialism may have influenced the power dynamics between the interviewer and interviewee that could lead to social desirable responses, especially when the behaviours in question are stigmatized and socially taboo (Richman, Kiesler, Weisband, & Drasgow, 1999). Moreover, interviewing in English could also lead to ‘stilted’ responses from participants given English is not usually the language of conversation for most Filipinx.

Conclusion:

To our knowledge, this study represents the first empirical qualitative assessment regarding structural factors affecting condom uptake among TW and cis-MSM in the Philippines. We found that multiple structural and social facilitators and barriers exists across all situations or contexts we examined. Our findings support the other previous studies (Operario and Nemoto, 2010; Sevelius, et al., 2013; Singer and Clair, 2003) that called for a multilevel component intervention to promote condoms use beyond behavioural public health recommendations. We further expanded this call to tailor such multilevel intervention approaches by identifying, evaluating, and addressing barriers and facilitators that uniquely exist in each situation, and leveraging those factors for condom promotion strategies within each context.

Acknowledgments

Funding: This work was supported by the National Institute of Health-Fogarty International Centre under Grant D43TW010565; National Institute On Drug Abuse of the National Institutes of Health under Grant R36DA048682; Providence/Boston Centre for AIDS Research under Grant P30AI042853; and the NIH-National Institute on Minority Health and Health Disparities under Grant 5T37MD008655 at Brown University’s Global Health Initiative. Ms. Restar is a recipient of the Robert Wood Johnson Foundation Health Policy Research Scholars and a Public Policy Fellow at amFAR, the Foundation for AIDS Research. Dr. Sandfort’s contribution is supported by NIMH Centre under Grant P30-MH43520 (P.I.: Robert Remien, PhD). The views and opinions expressed in this article are solely those of the authors and do not necessarily represent the official views of the sponsors.

Footnotes

Conflicts of interest: All of the authors declare that they have no conflict of interest.

Research involving Human Participants and/or Animals: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Brown University Human Research Protection Program Institutional Review Committee in Providence, Rhode Island) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent: Informed consent was obtained from all individual participants included in the study.

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