1. Concepts of risk groups and risk behavior 
   
   
2. HIV risk behaviors among MSM in India - a brief review 
   
   
3. Males who have Sex with Males (MSM): Different scenarios, Different needs, Different solutions
   
   
4. Limitations of research data on MSM in India

1. CONCEPTS OF RISK GROUPS AND RISK BEHAVIOUR IN INDIA

According to official statistics, "The predominant mode of transmission of infection in the AIDS patients is through heterosexual contact…" (National AIDS Control Organization, NACO. http://naco.nic.in/vsnaco/indianscene/trend.htm, accessed on 23rd September 2001). Though this has somewhat prevented the scapegoating of gay men in India, it has also led to not involving MSM in HIV prevention programs of Govt. of India.

In India while majority of people infected with HIV belong to the 'general population', some groups are mentioned as "groups at highest risk" which include commercial sex workers, truck drivers, injecting drug users, migrant laborers and men having sex with men (Note: Until recently the term "homosexuals" was used by Govt. officials and NGOs). Usually MSM is typically listed last even in the list of "groups at highest risk" (see http://naco.nic.in/ vsnaco/nacp/phase2.htm: accessed on 23rd September 2001) or even conveniently ignored.

The following discussion on "risk groups" has been adapted and modified from Michael Rooney and Peter Scott (Rooney and Scott, 1993).

The notion of the risk groups has, in general, fed into preexisting prejudice against the groups mentioned above, and to deny the risk by the general public. The way in which the term "risk group" is understood is different for different people. In India, if the general public knows about the term 'risk-group' at all they usually think of [female] sex workers, clients of the [female] sex workers and truck drivers.

The concerns in using the term "risk group" are as follows.

" HIV transmission or acquisition is by risk behavior such as unprotected penetrative sex. AIDS does not occur as a result of belonging to a particular group [for e.g., sex workers, truck drivers]. This message is very important to make people who do not come under the "risk group" (i.e., heterosexual men and women) to understand that it is the sexual behavior which determines a person's risk. Sexual identity, by itself, neither increases nor decreases the risk of acquisition of HIV infection.

" It might be wrongly believed that HIV is somewhat intrinsic to and contained within the risk groups. People outside the risk groups may believe that there are moral, geographic, demographic, or social barriers between themselves and so-called risk groups.

" Health promotion workers are especially wary of using the term 'risk groups' since they are keen to avoid any suggestion of blaming the victim which may be inherent in using that term.

" The term 'risk group' fails to acknowledge the diversity of behaviors in any particular group. All MSM and all injecting drug users do not have identical behavior or levels of risk.

The above concerns would be easily dismissed as 'being overly sensitive' in the use of language. However, it must be understand that language has a powerful influence over the way people conceptualize and the way people behave.

Since same-sex behavior is not even mentioned as a way of HIV transmission and acquisition in India, the major concern right now is not about whether the term "risk group" should be used or not, but to make the policy makers understand that same-sex behavior does occur throughout India and may be contributing to significant proportion of HIV transmission and acquisition. After a long period of silence and denial, National AIDS Control Organization (NACO) of India has acknowledged "…though highly covert, homosexual behavior has its sure presence in all the [Indian] cities" (NACO, 1997) but "little is known about MSM behavior [in India]" (NACO, 2000).

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2. HIV RISK BEHAVIORS AMONG MSM IN INDIA - A BRIEF REVIEW

Information about HIV infections due to male-male transmission is difficult to attain from STD clinics, sero-surveillance centers or in voluntary counseling and testing centers. It is either under-reported or missed out completely when a sexual history is taken. Inaccurate Sexual History taking has been reported at the ARCON-IADVL (Indian Association of Dermatologists and Venereologists Laboratory) Clinic in South Mumbai (Roy Chan et al, 1998). The questionnaire given to potential blood testees does not mention homosexuality at all. Whether this is because asking questions about stigmatized behavior is disallowed for the fear of it being a criminal sexual activity is not known.

The Humsafar Trust's rapid survey of sexual behaviors among 100 self-identified homosexual men who visited the Humsafar drop-in center in January 1996 revealed that:

• 40% practiced anal sex without condoms.
• 45% had sex with more than five partners in the last 6 months.
• 40% never used condoms
• Of those who used condoms, 40% said they were 'uncomfortable' wearing condoms (Roy Chan et al, 1998)

Another recent study from Chennai conducted among MSM attending a community-based clinic showed the following sexual risk behavior pattern (Venkatesan C and Sekar B, 2001). Among 51 MSM enrolled over a period of three months, majority (64%) have had sex with females. All the married MSM reported never using condoms with their wives and inconsistent use of condoms with other female partners. Unmarried MSM with bisexual behavior also reported inconsistent condom use with their female partners. About 60% of the MS reported penetrative (insertive and/or receptive) anal intercourse with another male in the past 3 months; 40% used condoms at the most recent anal intercourse.

Recent UNAIDS report (2000) states that, "In one study of truck drivers in India - men who spend long hours together on the road - almost a quarter reported oral or anal sex with a man, and all of those said they also had sex with women. A study of men attending a clinic for Sexually Transmitted Infections in the Southern Indian city Pune showed that men reporting receptive anal sex with men were 2-6 times more likely to be infected than men who reported no anal sex, even after taking into account other risk factors" (UNAIDS, 2000).

A baseline study of Knowledge, Attitude, and Behavior among 174 MSM in selected sites in Mumbai was conducted by the Humsafar Trust recently (The Humsafar Trust, 2000a). It gives the following information.

Sexual Behavior

• More than half (53%) of the respondents reported having been receptive partners in anal sex. Of these, 19% (n=17) reported having been engaged frequently in receptive anal sex. 50% of the respondents reported that their sex partner used a condom.
• A majority of respondents (67%) reported having been engaged in insertive anal sex in the last month. Of these 18% reported having been frequently engaged in insertive anal sex. 58% reported having used condoms during insertion. Of these 34% always used condoms during insertion, 55% used it sometimes.
• A total of 64% respondents had been involved in peno-oral sex. Condom use was very low in both oro-insertive and oro-receptive intercourse.
• Almost half of the respondents reported having sex with a female partner in the last month. Half of these frequently had sex with a female sex partner. During these sexual encounters 66% of the respondents did not use condoms. Of those who used condoms, half of them always used them.
• Commercial sex: Almost one fifth reported having engaged in sex in exchange for cash or in kind.

Substance abuse
On substance abuse, 37% respondents reported that they consumed alcohol before sex. Of these, 26% always consumed alcohol before sex. Half of those who consumed alcohol before sex usually consumed a quarter of a bottle (about 100 ml of alcohol) or more.

Knowledge and Attitudes of Indian MSM toward HIV/AIDS

The following information is taken from a recent baseline study of Knowledge, Attitude, and Behavior among 174 MSM in selected sites in Mumbai that was conducted by the Humsafar Trust (The Humsafar Trust, 2000a).

• One fourth of the respondent did not know or were unable to say what HIV is. Only one fifth were aware that it is a microorganism causing AIDS.
• A majority of the respondents (>90%) replied in affirmative to 'transmission through sex with out condoms' and 'transmission using the same toilets used by HIV-positive person.
• All responded in affirmative to 'transmission in hugging a person'.
• A majority (86%) said that using condoms during sex could prevent HIV.
• About 50% said using sterilized needles, syringes and skin-piercing instruments could prevent HIV.
• Two-fifths said avoiding pregnancy if a woman is discovered to be HIV-positive could prevent HIV.
• Almost three-fourths replied in affirmative to whether HIV means death.
• About 60% said that there was no cure for HIV.
• A majority (88%) had correct knowledge of what is AIDS
• About 90% replied in affirmative to whether AIDS means death.
• More than three-fourths said that there was no cure for AIDS.
• Around 32% said they would break off the relationship if their friend were detected to be HIV-positive.
• Around 38% said they would continue friendship but would not have sex.
• Around 32% perceived HIV-positive person to be an immoral person. One fifth of the respondent perceived HIV-positive person to be a curse of god and 90% perceived HIV-positive person to be a bad person.

Thus, the available studies indicate that

• Indian MSM have low levels of HIV/AIDS knowledge and negative attitude toward persons with HIV/AIDS.
• MSM are engaged in high-risk behaviors (e.g., unprotected anal intercourse).
• Many don't use condoms on a regular basis with their male partners.
• A significant proportion of MSM also have sex with female partners without regular use of condoms.
• Indian MSM have high HIV seroprevalance rates (4% - 24%).

Male Sex workers (other than Hijras/Alis):

There remains strong denial of the existence of male sex workers (other than Hijras/Alis [male-to-female transgender/transsexual persons]) in India. However, limited evidence points not only to their presence but also high-risk sexual behaviors among this population (Asthana and Oostvogels, 2001, Venkatesan C et al, 1999b).

The male sex industry in Chennai operates in an underground manner and there are different groups of persons involved in this work like - 'family boys', independent sex workers, callboys, and hotel boys. Many of these persons may not have a self-conscious sexual identity and most get married eventually. Though the clients of these persons are almost always MSM (mostly self-identified gay men), a few also serve women clients who are usually the female partners of their male clients. Condom use among these male sex workers is very poor (Venkatesan C et al, 1999b), although in a recent study from Chennai, MSM recruited from cruising areas were more likely to use condoms regularly with casual partners and commercial sex partners than with steady partners (Venkatesan C et al, 2000b). More research is needed to find out the extent of males in sex work, high-risk sexual behavior among this group, and to develop appropriate intervention programs for this high-risk subpopulation of MSM. Male sex workers are not reached by intervention programs for Hijras in sex work or for female sex workers.

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3. MALES WHO HAVE SEX WITH MALES (MSM): DIFFERENT SCENARIOS, DIFFERENT NEEDS, DIFFERENT SOLUTIONS

Note: In this section, MSM refers to Males who have Sex with Males.

MSM are a heterogeneous group and their needs can be different depending upon many things like their age, presence of self-conscious sexual identity, socioeconomic status, literacy level, sexual role playing, sexual communication skills and negotiation skills. In what follows, some of the different needs are expressed by showing different scenarios. They are not mutually exclusive but serve to illustrate the heterogeneity of the MSM population and thus the need for different solutions.

One can 'discover' different groups of MSM as shown below whose needs may vary widely. Though some solutions have been proposed below to meet the different needs, they are by no means comprehensive and clearly not the only solution(s). Only the specific solution(s) to that group or scenario is given below. The first step is to identify these different groups, the second step is to find out their specific needs, the third step is to find out appropriate ways to meet their needs, the fourth step is to implement them and the final step will be to evaluate the whole process based on the feedback and to continuously enhance and improve the whole process to make it more effective.

• Groups of behaviorally homosexual or bisexual males, single or married, who lack self-conscious sexual identity and who unpredictably and opportunistically have sex with other males. 
  Possible solution: They can be reached through mass or local media which addresses issues of homo/bisexual behavior and the risk of HIV/AIDS in a frank manner.
• MSM who are aware of their attraction towards other males, who tend to have sex more often with males and are often seen in cruising areas.
  Possible solution: They may be reached through peer educators and field staff of NGOs/CBOs.
• MSM who engage in sex work either as a part-time job or as a way to recruit male partners or for both. 
  Possible solution: May be reached through mass media or by peer-educators.
• MSM who may believe that it is safe to have sex with males but not with females and thereby use condoms only with female sex workers or casual female partners. 
  Possible solution: Messages which say clearly that condoms should be used regardless of the gender/sex of the partners and types of sexual partners should be conveyed.
• MSM who use condoms inconsistently with males but don't use any condoms while having sex with their wives or other female partners. 
  Possible solution: Awareness through messages which clarify that condoms should be used regardless of the gender of the partners and types of sexual partners.
• Married MSM who also have sexual relations with males and are unable to negotiate or practice safer sex with their wives because using condoms with wife may arouse suspicion especially if the wife has already undergone tubectomy.
  Possible solution: Teaching sexual communication skills and condom-negotiation skills.
• MSM who are monogamous (may not be mutually monogamous) or who follow serial monogamy and who may or may not know about HIV/AIDS/STD and safer sex information. 
  Possible solution: Concept of 'negotiated safety' can be taught. Sexual communication skills and condom-negotiation skills should be taught.
• MSM who know about safer sex and carry condoms with them but unable to negotiate condom use with their partners and finally end up in having unprotected sex. 
  Possible solution: Self-efficacy/personal management skills, sexual communication skills and condom-negotiation skills should be taught.
• MSM who always carry condoms with them but are unable to use them since they give in to their partners preferences. 
  Possible solution: Self-efficacy skills should be taught.
• MSM who have been practicing safer sex but are experiencing difficulty sustaining it. 
  Possible solution: The need to maintain safer sex practices must be periodically stressed/reinforced.
• MSM who think it is safe to have sex with whom they 'choose carefully' or who 'appear to be unpromiscuous' or 'decent' even though they know about safer sex methods.
  Possible solution: Messages which clearly convey that one can not find out whether a person is HIV-infected or not by appearance alone must be given. Condom use should be stressed regardless of the appearance of the partner.
• Adolescent males who have sex with other males in apparently closed groups such as school, colleges, etc. They mistakenly believe that the closed nature of the group protects them from infection and thus may or may not use condoms even if they have information about safer sex. 
  Possible solution: School/college students should be reached and taught about sexuality issues, safer sex practices and AIDS education programs.
• MSM who have been told that they must give up sex and who, as a result, are unable to practice safer sex when they do have sex. 
  Possible solution: Health care providers should be trained in sexuality issues and in giving competent care to MSM patients. Rather than moralistic messages, pertinent sexual options should be given so that MSM can choose one that is suitable to them.
• MSM who may never use condoms while having sex with their steady partners (male or female) and may use condoms inconsistently with casual partners (male or female). 
  Possible solution: Messages should state clearly that condoms should be used regardless of the gender or types of the sexual partners.
• MSM who consume alcohol or who use illicit drugs and are unlikely to practice safer sex under the influence of alcohol or drugs. 
  Possible solution: Alcohol and substance abuse programs should work in co-operation with HIV prevention programs among MSM.
• MSM who exchange sex for drugs or alcohol and who may not be in a position to negotiate condom use with their partners. 
  Possible solution: Alcohol and substance abuse programs should work in co-operation with HIV prevention programs among MSM.
• MSM who are unwaged, poor or homeless and who cannot afford condoms. 
  Possible solution: Safer sex information and free condoms should be made available through outreach programs for this group.
• In males-only-environment like prisons, some males may have sex with other males either with or without consent. Lack of information about risks involved in unprotected sex between males, non-availability of condoms, and traumatic nature of coercive sex all increase the risk of HIV infection among prison inmates.
  Possible solution: Information about STD/HIV/AIDS and risks involved in unprotected sex between men must be given. Condoms should be freely available to those who might need them.
• MSM who are illiterate or unaccustomed to reading and thus largely untouched by health promotion messages (including HIV/AIDS/STD) to date. 
  Possible solution: MSM should be reached through other forms of media and other ways e.g., through peer outreach.
• MSM who are behaviorally bisexual with very low self-esteem as a result of being 'in the closet'. Their low self-esteem and occasional access to sex makes it harder for them to be concerned about protecting themselves. 
  Possible solution: Programs which boost self-esteem and self-confidence should be conducted.
• MSM who have remain uninfected despite having unprotected sex for a very long time strongly believe they do not need to use condoms since they are 'resistant' to STD/HIV infection. 
  Possible solution: Explaining to them that HIV transmission per sex act is low, but each new partner adds to the risk.
• MSM who are in their forties or fifties and who think there is no point in using condoms since they are going to die in a decade or so and have already 'enjoyed' many things in life. 
  Possible solution: Explain to them their role in stopping the spread of the disease.
• Street male youth because of poverty and alcohol or drug use, may have sex with other males for money and may not have safer sex information or negotiating skills. 
  Possible solution: Provision for information, teaching negotiation skills, survival skills, and condom negotiation skills, enrolling in alcohol and substance abuse programs.
• Some MSM have their identity based on sexual roles. Thus, some MSM who are likely to be mainly, if not only, receptive partners are at a higher risk. For example, MSM who practice mainly (if not only) receptive anal or oral sex (e.g., Kothi, Hijra/Ali) are at a higher risk of getting HIV infection than those MSM who mainly (if not only) insert (e.g., Panthi).
  Possible solution: The identity of Kothis is based on being a receptive partner, so it may be difficult to ask them to practice alternative sexual practices, i.e., other than receptive anal sex, or to ask them to use condoms since they may not feel empowered to do so. Nevertheless they should be advised to use condoms every time and with all partners.
• Some MSM with HIV infection might have been told that they must give up sex (during counseling and medical information) and hence may not be able to practice safer sex when they do have sex. 
  Possible solution: Other than abstinence, alternative options like safer sex practices should be explained to HIV-infected persons.
• Some MSM have the belief that ingestion of semen (during oral sex) gives them energy. Thus to them the idea of using condoms for oral sex may seem too restrictive.
  Possible solution: Emphasis must be given to the fact that risk associated with unprotected oral sex is low but not nil. They must be asked to assess for themselves the risk they are willing to take.
• Some MSM strongly believe that they must release the semen into the mouth or the anus of their partners since they think that only then will the "heat" in their bodies get reduced. Thus they may not be willing to use condoms since condoms 'prevent' the emission of 'heat'.
  Possible solution: Risks associated with unprotected sex should be explained. Their misunderstanding about "heat release" should be clarified.
• Some males, by the nature of their occupation, may have sex with other males for money (e.g., masseurs/maalishwaalas). These persons may not regard themselves as 'homosexual' men and may not follow safer sex practices. 
  Possible solution: Maalishwaalas may not be willing to talk about safer sex practices or HIV/AIDS with outreach workers who are self-identified homosexual males. Peer education using other maalishwaalas should be tried.

It is important not to feel overwhelmed by the range of different needs. Many of them are overlapping needs that may be addressed by actions that fulfil several functions simultaneously. The above long list of possible scenarios and groups has been given for the purpose of illustrating how inadequate a method based upon assuming a single health promotion action, such as leaflet or condom distribution by outreach workers, would be for the majority of those at risk. On the other hand explaining the need for using a condom during any and all sex to protect oneself from STD/HIV infection is at the core of all intervention work.

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4. LIMITATIONS OF RESEARCH DATA ON MSM IN RELATION TO HIV/AIDS IN INDIA

There remains a large gap in actual information on sexual behavior, especially among MSM and gay-identified men. This sector is most difficult to reach stigma and denial attached to these behaviors has pushed it underground. Whatever little material exists indicates strongly the need for intervention among MSM.

Bhushan Kumar and Michael W Ross state that 'Very little systematic research is published on homosexual behavior in the Indian subcontinent in terms of actual practices and associated HIV transmission risks" (Kumar and Ross, 1991). NACO too acknowledges "…little is known about MSM behavior [in India]" (NACO, 2000).

McKenna says, "This absence of enquiry - this failure of research - is in one sense self-perpetuating: if no information exists on sex between men, then sex between men must either not exist or be so rare that it is statistically insignificant in any consideration of HIV and AIDS" (Neil McKenna, 1996).

In a review of HIV prevention interventions in developing countries, Merson et al note, "It is evident from our review that there are three high-risk populations for which there is a dearth of evaluated prevention interventions in developing countries - men who have sex with men, youth and IDUs [injecting drug users]. Notably absent from our review were scientific evaluations of programs that focused on men who have sex with men. These populations are often difficult to reach in many countries because of the stigma associated with homosexuality, but are urgently needed in view of the high-risk of HIV infection among gay men" (M H Merson et al, 2000).

Regarding the reasons for the lack of HIV prevention intervention research in developing countries, Merson et al say, "…One of the most important reasons for the small number of scientific evaluation of HIV prevention interventions in developing countries has been the limited number of researchers in these countries with appropriate training…A fundamental step in improving prevention research in low and middle-income countries must be to expand the training of social scientists and epidemiologists, so that more of them are able to conduct the much needed prevention intervention research" (M H Merson et al, 2000).

Whether the first decade of this new millennium will also be characterized by remarkable lack of attention devoted to the situation of MSM in India remains to be seen.

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