1. Epidemiology of HIV/AIDS in India (in relation to MSM)
   
   
2. Estimation of MSM in India
   
   
   

1. EPIDEMIOLOGY OF HIV/AIDS IN INDIA (in relation to MSM)

India is one of the countries worst affected by HIV/AIDS with an estimated 3.86 million persons living with HIV/AIDS (year 2000). In numbers it is second only to South Africa. The estimated HIV infection rate among adult population between 15-49 years of age is 0.7% (National AIDS Control Organization, NACO, India:
http://naco.nic.in/vsnaco/ indianscene/update.htm: accessed on 23rd September 2001). The first case of HIV infection was reported from Chennai (formerly Madras) in 1986.

The epidemiology of HIV/AIDS in India as reported by NACO, India, is given below. (NACO: http://naco.nic.in/vsnaco/indianscene/overv.htm: accessed on 23rd September 2001)

AIDS Cases Reported in India [to NACO] 
(Period of Reporting - 1986 to August 2001)

[Note: The male:female ratio is 3:1]

Risk/Transmission Categories [Among Reported AIDS Cases]

No split up of sexual modes of transmission is given in the recent reports of NACO. This is probably because the Govt. of India has recognized that it has no reliable or valid data on the different sexual (hetero/homo/bi-sexual) transmission modes of HIV/AIDS. Asthana and Oostvogels states "Recognising the difficulties of using the term 'homosexual' in the Indian context, the National AIDS Control Organization now groups both of these categories under 'sexual activity'…" (Asthana and Oostvogels, 2001). However, one can still find statements like "The predominant mode of transmission of infection in the AIDS patients is through heterosexual contact…" in NACO's website (NACO:
http://naco.nic.in/vsnaco/indianscene/ trend.htm: accessed on 23rd September 2001)

HIV serosurveillance (until April 30, 2000)

Break-up of seropositivity in HIV serosurveillance (until April 30, 2000)

From the above data given by NACO one can very well see the lacuna with regard to the modes of transmission of HIV in India.

1. In serosurveillance, sexual transmission is mentioned as only 48.78%. How many of these are due to heterosexual, homosexual or bisexual behavior?
2. In serosurveillance, what does the category "Others" stand for? Does it mean the exact mode of transmission is unknown? Also what does it mean by stating that - "Others (including suspected ARC/AIDS)" - when we are only talking about the mode of transmission and not the clinical stage of the disease?
3. In AIDS case surveillance, sexual transmission is mentioned as 83.23%? How many of these are due to heterosexual, homosexual or bisexual behavior?
4. How can it be claimed that HIV transmission in India is 'predominantly heterosexual'
   • when the HIV serosurveillance report identifies sexual transmission as only 48.78% and split up is not known?
   • the 'others' category in the HIV serosurveillance report is 40.28%?
   • when men are predominantly affected (men:women ratio is nearly 3:1), given the fact that the efficacy of man-to-woman transmission is greater than woman-to-man transmission?
   • when the reliability of sexual history taking in these serosurveillance centers is questionable?

Accepting the lack of reliability in the data from the serosurveillance centers, NACO has recently "withdrawn" all the data from the serosurveillance centers (NACO: http://naco.nic.in/ vsnaco /indianscene/overv.htm: accessed on 23rd September 2001).

In the 1998 data of NACO, it was stated that among the 5204 AIDS cases reported until March 1998, heterosexual transmission constituted 74.15% and homosexual transmission constituted 0.58%, Recipients of blood constituted 7.05%, injecting drug users - 7.3% and "others" - 10.92% (NACO, 1999). Thus according to the NACO, homosexual transmission contributed to only 0.58% among the reported AIDS cases until 1998. Data on AIDS cases provide a picture of HIV infection approximately ten years old. We contend that in order to estimate recent trends in HIV infection, NACO must rely on data on HIV testing, HIV prevalence and incidence reports, and risk behavior among men who have sex with men from centers that deal with MSM. Unfortunately, there is little reliable data on these.

Other factors that may influence the reliability of data on HIV infection are: (i) many MSM don't have a self-conscious sexual identity; (ii) they may not consider telling about same-sex behavior especially if not asked about it; (iii) even amongst persons who are conscious of their same-sex attraction and behavior (and those who have 'western' or 'Indian' identities), many are reluctant to identify themselves as such and to disclose their same-sex behavior or sexual orientation to health care providers, fearing stigma and discrimination.

HIV prevalence among MSM in India 
Ignorance about same-sex behavior and discrimination against MSM affects the extent and reliability of data on HIV infection in this population, contributing to the paucity of studies among MSM and almost no funding, until recently, for HIV prevention programs for MSM.

There is no nation-wide data on the prevalence of HIV infection among MSM in India. National AIDS Control Organization (NACO) of India says "On HIV among MSM groups, little reliable data is available. Informal estimates suggest rapid increases may be taking place in this particularly vulnerable community" (NACO, 2000). Only a few studies from Mumbai have reported HIV seroprevalence among MSM. The prevalence of HIV infection among gay-identified men attending STD clinics in Mumbai metro was studied by the National Institute of Virology over a 6-month period in 1992 in collaboration with Bombay Dost (India's first gay newsletter). HIV prevalence was found to be 20.67%, which was very high given the fact that this studied cohort was of educated middle class and hence had the means and material to be adequately aware of the transmission routes of HIV. It therefore implies that HIV prevalence amongst MSM without a conscious self-identity of their sexual orientation would be higher (Ashok Row Kavi, 1999).

Another study from Mumbai published in 1994 showed that about 16% (among 63 blood samples) of MSM attending STD clinics of Mumbai were seropositive for HIV (Nandi et al, 1994). HIV prevalence of 15% among MSM in Mumbai has been reported recently from the STD clinic of a non-governmental organization (Humsafar Trust) working with MSM (Maninder Setia et al, 2000).

Recent data from NACO (2000) of 232 HIV sentinel serosurveillance sites across India, 2 of which targeted MSM, suggest HIV seroprevalence rates among MSM of 23.94% in Mumbai (in Maharashtra State) and 4% in Tamil Nadu State [in Chennai]. (NACO: http://naco.nic.in/ vsnaco/indianscene/overv.htm: accessed on 23rd September 2001)

STD prevalence among MSM in India

Only limited data are available about STD prevalence among MSM in India. A preliminary analysis of STDs among 85 MSM attending an STD clinic in Mumbai gives the following information: 4 had clinical rectal gonorrhea (among these 2 were culture-positive and remaining 2 were smear-positive), 4 had perianal warts, 3 had gonococcal urethritis, one case each of secondary syphilis, genital molluscum contagiosum and genital scabies. The point prevalence of HIV in this population was 15% and VDRL reactivity was 16% (Maninder Setia et al, 2000).

In a recent study from Chennai, analysis of 51 MSM who attended a community-based clinic over a period of three months showed the following. Thirteen (26%) MSM were clinically diagnosed to have one or more STDs. Clinically the following pattern of STDs was found: Perianal warts - 4 (8%), Genital Herpes - 4 (8%), Perianal herpes - 1 (2%), Secondary syphilis - 1 (2%), Gonococcal urethritis - 1 (2%), Molluscum contagiosum - 1 (2%), Proctitis - 2 (4%), Scabies - 1 (2%) and Prostatitis - 1 (2%). Genital dermatoses like Candidal intertrigo - 4 (8%), Candidal balanoposthitis - 1 (2%), Perianal candidiasis - 1 (2%) and Tinea cruris were also found. Serological testing for syphilis (VDRL) was not routinely conducted due to financial constraints. Seven (14%) self-reported as HIV-positive (Venkatesan C and Sekar B, 2001).

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2. ESTIMATION OF MSM IN INDIA

India being a multi-linguistic country, gay/bisexual men cross all demographic boundaries. Thus they can be of any linguistic group, class, age, occupation, marital status, ability or religion. Also, we cannot neatly compartmentalize human sexuality and many men who have sex with men who do not regard themselves as gay or bisexual men.

Behavior Surveillance Studies (BSS) in India 
In India, there have been no nation-wide BSS studies. State-wise, local BSS studies were both inadequate and badly designed. They ranged from 1.8% of the male population studied in Maharashtra by Dr.Meera Savara and Dr.Sridhar to 11% of the population surveyed in Kerala through a pre-selected procedure. There were many procedural problems in most surveys done in India. They ranged from inappropriate questioning (same-sex relations not defined adequately) to no mention of same-sex relations at all (The Humsafar Trust, 2000c).

Other quantification studies conducted in India 
Quantifying the number of gay men in a given population depends very much on the sensitivity of the methodology used.

Quantitative studies conducted in India include:

• A survey at Patna medical college in India in 1992 revealing that 25% of male medical students and doctors had had same-sex relationships (H V Wyatt, 1993).
• A postal survey of the readership of 'Debonair', an Indian English language magazine from Mumbai revealing that of 1500 men who replied, 29.5% had sex with another man, and in 80% of the cases before the age of 20 years (Roy Chan et al, 1998).
• A survey of 527 truck drivers in northeast India revealing that 15% had sex with men (S I Ahmed, 1993).
• A major study conducted in Pune city, where only 1.2% of men interviewed said they had homosexual relations although the authors did add, "we do feel it is extremely difficult to get an accurate estimation of homosexual experience in a general survey like we did". The researchers agree that a completely different kind of questionnaire has to be designed to get more information on the prevalence of homosexual behavior (Roy Chan et al, 1998).
• A postal survey of rural and semi-rural men in the Indian state of Tamil Nadu to which 1200 men replied found that 8% had had sex with other men (Shreehar Jaya, 1994).
• A survey of gay-identified men performed by Bombay Dost where a noticeable proportion of men [surveyed] indicated that they were coupled to 'both a male and a female' (The Bombay Male Sexual Health Information Project, June 1992) (Roy Chan et al, 1998).
• According to a report on MSM in developing countries, the prevalence of MSM in the Indian male population range from 8 to over 50% (Neil McKenna, 1996).
• In a recent Naz Foundation Report (2000), "guesstimates" of males who have sex with males in different cities of India were given as:

  Hyderabad: 120,000 plus in a population of 4 million plus
  Bangalore: 120,000 plus in a population of 4 million plus
  Pondicherrry:35,000 plus in a population of 700,000 plus

  These figures appear consistent with general research that places levels of "homosexuality" in a majority of populations at between 3-7 %. (www.jsiuk.com/resources/publications/issues papers: accessed on 15th September 2001)

• In a study of sexual behavior among about 1600 college students in Chennai, India, (Hausner D, 2000) it was found that approximately 20% of male students reported having had sex at least once in their lifetime and among these, 35% had their first experience with another male.

The danger of studies that underestimate the prevalence of homosexual behaviour is that they may lead to insufficient resources being made available to prevent the transmission of HIV infection among MSM.

Estimation of Indian MSM based on Kinsey study (Ashok Row Kavi, 1999)

The Kinsey study titled 'Sexual Behavior of the American Male' is one of the most thorough studies on sexual behavior. It is basically a study of white Anglo-Saxon population, but it does procure some baseline data regarding homosexual/bisexual behaviors. Its main result was the famous Kinsey graph where number 6 on the scale was 'permanent practicing homosexual' and number 0 on the scale was ''permanent practicing heterosexual'. It was assumed that a significant proportion of American males fell somewhere between these two extremes though it is not clear whether the scale could 'shift' according to the circumstances. For example, would a person who is number 2 on the scale (mostly heterosexual) ever shift to number 5 (mostly homosexual) in a predominantly single sex environments like those in prisons, remand homes and defense establishments?

The Kinsey surveys have been challenged, criticized, lampooned and dissected. However, the baseline 'five percent' that are number 6 on the scale seem to be a figure that is constant for the human species, independent of race, religion and political system. Sexual behavioral surveys usually hover around this baseline benchmark for 'permanent practicing homosexuals' in any studied population. There is no reason to believe that this benchmark is not applicable to the Indian society. Five percent of the sexually active male population comes to a core homosexual population of 13.5 million homosexual males in India. This figure was obtained from the 1991 census, by calculating the sexually active male population as 60% of the population (males falling between the ages of 15 and 60 years) and then computing five percent of that figure. Another 37.5 million males fell in the ranges between number 3 to number 5 on the Kinsey scale. These males eroticised other males at some time or other in their lives and had occasional sex with them, when they could. Some of these males are behaviorally bisexual and moved up or down the Kinsey scale according to the circumstances. However, the final figure of Indian males practicing homosexual behavior was found to be nearly 50 million by adding up these figures, which is quite considerable.

Sexual behavioral studies in India have classified homosexual men as anything from 1% of the sexually active male population to nearly 28% of the 'occasionally behaviorally homosexual males'. It would be pragmatic to stay close to the Kinsey estimates even if the data suggests otherwise. Factors like, nonrecognition of same sex behaviors being classified as 'sex', the declining female-male ratios in the country further distorted by rural-urban migrations, all point to higher male-male sexual behaviors in India.

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