Men who have sex with men (MSM) in India are disproportionately likely to be HIV-infected, and face distinct psychosocial challenges. Understanding the unique socio-cultural issues of MSM in India and how they relate to HIV risk could maximize the utility of future prevention efforts. This review discusses:(i) the importance of addressing co-occurring mental health issues, such as depression, which may interfere with MSM’s ability to benefit from traditional risk reduction counselling, (ii) reducing HIV-related stigma among health providers, policymakers and the lay public, and (iii) the role for non-governmental organizations that work with the community to play in providing culturally relevant HIV prevention programmes for MSM.
HIV infection among men who have sex with men (MSM) has been increasing in recent years around the world, particularly in Asia1. This global trend is being seen in India, with the current estimated HIV prevalence among MSM ranging between 7 and 16.5 per cent2–4. This is in comparison with the overall adult HIV prevalence estimated to be 0.31 per cent (0.25-0.39%) in 20092. This is concerning in light of recent HIV prevention intervention efforts that have been dramatically expanded across the nation, raising questions about whether additional measures are needed to arrest the spread of HIV in this population. Although findings from the Independent Impact Assessment Study2 show that the National AIDS Control Programme (NACP) is steadily halting the HIV epidemic in India over the period 2007-2012, current prevention interventions for MSM in India involve mainly single dimension modalities including condom distribution, HIV education, voluntary HIV counselling and testing, and the treatment of sexually transmitted infections (STIs). If the NACP’s goals are to be achieved, there is a need for comprehensive, multi-layered approaches to HIV prevention that address the unique needs of Indian MSM. This article seeks to elucidate the specific challenges of providing effective HIV prevention programmes for this diverse and socially marginalized risk group.
The United Nations General Assembly Special Session on HIV/AIDS Report estimates that there are about 3.1 million MSM in India3. Indian MSM concepts of sexual identity can be varied and fluid4–8. Indian MSM include self-identified gay men (Western acculturated), kothis (men who tend to be the receptive male partner in anal and oral sex and typically have more effeminate mannerisms), panthis (men who tend to be the insertive male partner in anal and oral sex), and double deckers (men who are both receptive and insertive partners). While MSM may self-identify as kothi, the terms panthi and double-decker are generally given by kothis to their male partners based on their sexual roles6,9,10. Since individuals may change their self-perception over time and behaviours may be situational, attributing fixed behavioural attributes to these identities is limiting. In most of these constructs, same-sex behaviour does not preclude sex with women or traditional marriage11,12. Thus, here we use the term “MSM” to describe a behaviour rather than a sexual identity. The term ‘gay’ essentially has the same meanings that it does in Western countries for the educated self-identified homosexual males belonging to the middle and upper class.
This review paper aims to highlight the gaps in current HIV prevention efforts by providing insight into the patterns of Indian MSM behaviour and sexual partnerships, and the specific cultural and psychological context in which HIV risk is occurring. Understanding the distinct social forces that shape the HIV risk environment could maximize the effectiveness of prevention interventions and heighten the acceptability of these programmes by MSM. The current review does not include transgender individuals (i.e., Hijras/Aravanis) as they represent a different sexual minority group with varied HIV prevention needs.
This review is based on research publications, reports from NGOs as well as updated surveillance reports of BSS (Behavioral Sentinel Surveillance) and HSS data (HIV Sentinel Surveillance). Since 1998, HIV sentinel surveillance has been conducted annually to track the HIV epidemic in the country. To date, three rounds of Behavioral Surveillance Surveys (BSS) have been conducted; two at the national level in 2001 and 2006 and one at State level (both rural and urban areas) in 2009.The authors are also informed by their own research which includes developing and implementing HIV prevention interventions for MSM in Chennai and Mumbai.
History of the HIV/AIDS epidemic among MSM in India
The estimates for the prevalence of HIV in MSM in India vary. Pockets of high HIV prevalence among MSM are identified in high prevalence States as well as in Delhi, Gujarat and West Bengal. Twenty eight districts have 5 per cent or more HIV prevalence among MSM according to the BSS 200913.
The States that have the highest mean HIV prevalence amongst MSM in 2008 are Karnataka, Andhra Pradesh, Manipur, Maharashtra, Delhi, Gujarat, Goa, Orissa, Tamil Nadu and West Bengal14. While overall HIV trends amongst this population group are stable in India; there is an increasing trend among south Indian States and Delhi.
The Government of India’s National AIDS Control Organization (NACO) estimates an overall HIV prevalence of 6.41 per cent among MSM, although this may be a lower-limit estimate15. For example, in Mumbai, 12 per cent of MSM seeking voluntary counselling and testing services were HIV-infected, and 18 per cent of the MSM screened in 10 clinics in Andhra Pradesh were found to be infected16–18. We found an 8 per cent prevalence in a sample of 210 MSM in Chennai recruited by peer outreach workers4. In the context of this disproportionally high level of HIV risk, it becomes extremely important to understand the socio-cultural factors that may exacerbate sexual risk among this group.
Socio-cultural norms that challenge MSM
MSM and hijras/aravanis (transgendered women or male–to–female transgendered persons) have existed in India for thousands of years. This is evident from the temple carvings in Konark and Khajarao (950-1050 AD) that depict homosexuality and various treatises existing from ancient times. Homophobia was formally codified by legal code Section 377 which, until very recently, made sexual relations between two men a criminal offense (Section 377). MSM in India, therefore, experience multiple forms of social and legal discrimination19. It is this pervasive social intolerance along with the cultural pressure for men to engage in heterosexual marital relations that have led many MSM to marry women and have children5,7. Many MSM engage in unprotected anal and vaginal sex with male and female sexual partners5–9,17,19,20. MSM in India may play a “bridging” role in the spread of HIV into the general public.
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