1. RECOMMENDATIONS TO THE GOVERNMENT OF INDIA

HIV/STD preventive intervention programs for MSM:

Since available studies show that a significant proportion of men in India has same-sex/bisexual behavior and also practice high-risk sexual behaviors with both male and female partners, it is strongly recommended that programs of HIV prevention among MSM must begin immediately throughout India.

• Culturally appropriate HIV/STD prevention outreach programs and peer education for MSM population in collaboration with CBOs/NGOs need to be started immediately and evaluated for effectiveness.
• Govt. of India (National AIDS Control Organization, NACO) as well as NGOs/CBOs working in HIV/AIDS should include culturally appropriate and linguistically accessible HIV prevention messages that address the risks of unprotected sex between men and promoting the use of condoms and water-based lubricants in their mass media campaigns. This is especially important since this may be the only way to reach certain subgroups of MSM (like those who don't have self-conscious sexual identity or those who don't cruise) and make them aware of their risk behaviors since they may not be approached even by the community outreach programs. Also, airing the subject of male-to-male sex in public can also help reduce stigmatization.
• HIV/AIDS educational materials of Govt. of India (NACO) as well as NGOs/CBOs should provide accurate and uncensored information about the risks involved in any kind of sexual behavior (hetero, homo, or bisexual behavior) and any kind of sexual practices (vaginal, oral, and ano-rectal).
• There is a need for co-operation and collaboration among various HIV/AIDS prevention intervention projects that concentrate on different subgroups or risk behaviors. MSM are characterized by considerable diversity. MSM could also be sex workers, truck drivers, street youth, injecting drug users (IDUs), migrants, prisoners, or any combination of these and all these groups come under 'high-risk' groups by themselves. Collaborations and interactions among different projects that address different risk behaviors are necessary. Such interactions may result in screening a population for all kinds of risk behaviors rather than concentrating only upon one risk behavior and could more be effective.
• High-quality condoms, which are suitable for use during anal intercourse, should be made available, accessible and affordable. Water-based lubricants, which are at present inaccessible and unaffordable, should be made available widely at an affordable cost.

• Training programs for health care providers on sexuality issues should be developed and evaluated for effectiveness. Also, all health care providers should be provided with adequate training and skills on how to work with sexual minorities. These programs should be an integral part of the STD/HIV/AIDS training programs for health care providers. Sexuality education for the physicians and other allied health-care personnel (e.g. counselors) will enable them to ask sexual history in a comfortable manner and to take care of the patient regardless of his/her sexual orientation or gender identity. It is crucial that staff in STD clinics be educated to overcome ignorance and prejudices about MSM and to be sensitized to the need for examining patients for oral and ano-rectal STDs.
• Models for training health-care providers in MSM-sensitive care need to be developed.
• All health care professionals who encounter MSM in their clinical practice should be able to counsel these persons (or refer them to appropriate specialized settings like STD clinics, voluntary counseling and testing centers, CBOs/NGOs) regarding the risks of HIV/STDs and methods for reducing or preventing high-risk behaviors.
• Health care providers (of any specialty) need to acquire basic knowledge of GLBT/Sexual minority community (through medical academic curricula, inservice programs, or other educational opportunities) and their health needs so that they are comfortable and competent in providing services to them.
• Continuing education for health care providers who come in contact with MSM population in clinical settings should be available through professional organizations, continuing medical education programs, etc. to increase understanding and sensitivity.
• Professional organizations of health care providers (like STD/HIV physicians, DermatoVenereologists, Urologists, Psychiatrists, Clinical psychologists) should address sexual orientation and gender identity concerns in continuing medical education courses, clinical guidelines, risk assessment, and screening policies.

• Research is required to find out the incidence and prevalence of HIV/STD among MSM population, how they identify themselves, and to identify which sexual practices increase the risk of specific STDs.
• Baseline studies on the Knowledge, Attitude, Behavior and Practices (in relation to HIV/AIDS) of MSM in different parts of the country need to be conducted.
• Studies are needed to identify appropriate and effective HIV preventive interventions for MSM in India.
• The quality of epidemiological records, reporting and data analysis should be improved in order to gain a more accurate view of the HIV epidemic in India, while at the same time ensuring respect for human rights.
• Studies are needed to find out how 'minority stress', stigma and marginalization make them more vulnerable to STD/HIV.
• Research is needed to determine the most appropriate health communication strategies for MSM populations including those who don't have a self-conscious sexual identity.
• Support should be given for research to study how different ways of asking questions about sexual orientation, same-sex/bisexual behavior, attraction, and gender identity affect response rates and the validity of responses so as to develop "Sexual history" risk assessment tools that are culturally and linguistically appropriate.
• Research is needed to determine if access to MSM-specific information improves health-seeking behaviors, increases access to health care, enhances knowledge and yields better health outcomes.
• Research is needed to determine the barriers to accessing health care by the MSM population.
• Research is needed to determine the causes of, as well as the resolutions to, homophobia within the health care system.
• Research is needed to test different ways to transfer effective behavior intervention programs to prevention agencies (Govt. and NGOs/CBOs).

Formulating Policies that address issues related to MSM population and repealing discriminatory legislations:

At present there are no national policies that address issues related to MSM population in India. Since having explicit policies usually precede any action, and often are required to substantiate the actions that are being undertaken or have to be undertaken in the future, the following recommendations are made.

• To repeal all discriminatory legislations that criminalizes same-sex sexual behaviors between consenting adults in privacy, which include section 377 of the Indian Penal Code (with suitable provisions/modifications in other statutes/laws to take into account the child sexual abuse and adult same-gender sexual assault), and the relevant sections of the Army, Navy and Air Force Acts, 1950. Decriminalization of homosexual acts and legalization of adult consensual homosexual acts will boost the self-esteem of MSM and also allow them to access/utilize HIV/STD services.
• Serious consideration should be given to introducing anti-discrimination and protective laws to reduce human rights violations against MSM, including those relating to HIV/AIDS.
• There is a need for national HIV/STD prevention strategy for MSM population, the population at great risk for HIV infection. Such strategy should reflect the cultural, linguistic, educational and socioeconomic status and age diversity among MSM population.
• State AIDS Control Societies (SACS), District AIDS Control Societies, and health departments need to form alliances with CBOs/NGOs to address the epidemic at the local level by conducting needs assessment and funding community-based prevention and treatment strategies.
• All central and state government health departments and ministries should adopt a policy of accessibility to care and services for sexual minority community.
• Local health departments, with the assistance of State AIDS Control Societies (SACS)/ District AIDS Control Societies, should consult with GLBT/Sexual minority community organizations in determining how to provide high-quality, comprehensive STD/HIV-related clinical services to MSM population.
• Effective strategies to bridge the gap between the worlds of HIV/AIDS prevention research and prevention service have to be devised.
• There is a growing body of evidence pointing to the importance of community involvement in health interventions (Minkler M et al, 1997). Thus support should be available to strengthen groups representing self-identified gay/bisexual men as well as persons with other identities (like Kothis/Hijras), enabling them to promote HIV prevention and care programs.
• National guidelines for the management of oral and ano-rectal STDs, which are at present lacking, need to be developed and widely disseminated.
• Adequate resources (financial and non-financial) should be allocated for intervention programs for MSM by the Govt. of India and other donor agencies. Government and research agencies should ensure that funding and technical assistance for NGOs/CBOs that work in the area of MSM be available.
• Sexual orientation/identity and gender identity measures should be included within the national HIV/STD surveillance systems.
• Sincere efforts should be made to educate the public about sexuality issues. Several studies indicate that exposure to truthful information about GLBT/Sexual minority communities often leads to reduction in homophobia. Effective methods of breaking down social and cultural barriers against the discussion of male-to-male sex should be identified and implemented. More determined efforts must be made to change public perceptions and to get rid of denial and prejudices on the subject of same-sex/bisexuality.

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B. RECOMMENDATIONS TO NGOs/CBOs: (WHICH ARE WORKING OR INTEND TO WORK WITH SEXUAL MINORITIES)

• Commitment to work with sexual minorities
  Self-assessment of NGOs prior to undertaking prevention intervention programs for MSM is a must in order to work effectively with them.
• Education of all employees and volunteers
  In the Self-assessment, anti-homophobia training and awareness raising courses should always be identified. These measures will be useful in removing barriers in undertaking the work and to facilitate good practices in implementation. 
  Self-education of the planning team and program personnel is needed to ensure that they understand the scientific realities of the HIV epidemic, the sociology of the same-sex/bisexual behaviors and the efficacy of different forms of health educational activity.
• Hiring of sexual minorities as staff
  A formal process of planning which includes a well-resourced planning team consisting of both professional and sexual minority community expertise should be followed.
• Needs assessment need to be conducted locally
  A proper initial assessment should be conducted to identify the local needs and allocate resources most effectively.
• Monitoring and evaluation (Outcomes research)
  Prior to implementation of the programs, clear evaluative criteria and mechanisms need to be established. Programs should be regularly reviewed and evaluated. The interim reviews should be used to modify the future course of the program. The final evaluation of the program should be used to guide the development of the next long-term program.
• Co-operation and collaboration with government organizations
  NGOs should work in collaboration with the State AIDS Control Societies, City AIDS Control Societies, government hospitals, and local health departments.
• Co-operation and collaboration with other NGOs/CBOs
  There is a need for co-operation and collaboration with various NGOs/CBOs that work for MSM. Networking to share lessons learnt, technical expertise and educational materials should be developed. Differences in ideology and competition in getting funds should not interfere in the relationships between different NGOs/CBOs that work for sexual minorities.
• Training programs 
  Training workshops/seminars for organizations working with MSM should be promoted and organized, at the local, state, and national levels, in order to strengthen these organizations in terms of project planning, management methodologies and organizational development.
• To include sexual minority rights in the agendas 
  The issues of sexuality minorities and human rights should be promoted and included in the agendas of NGOs/CBOs that are progressive in social, political and cultural terms, in order to build strategic alliances.
• Participation in conferences and seminars
  Organizations working with MSM should be encouraged to attend and participate in conferences, seminars as well as events on HIV/AIDS and/or human rights so as to improve exchange of experiences with other organizations and create opportunities for debate and problem solving.
• Guiding mass media to portray sexuality issues in a proper manner
  Media awareness of homo/bisexuality, human rights, and HIV/AIDS should be improved to reduce stigmatization, discrimination, and repression of sexual minorities. NGOs/CBOs should, whenever possible, help and direct media to focus on sexual minorities in a nonjudgmental manner and to not think of the issues of sexual minorities as just sensational news.
• Helping in government's efforts in educating others
  NGOs/CBOs should assist in government's efforts to educate and sensitize the public and health care providers about HIV/AIDS, sexuality and human rights issues.
• Advocacy for sexual minority rights
  NGOs/CBOs should advocate for the human rights of sexual minorities including lobbying to repeal all the criminal laws and discriminatory legislations used against sexual minorities.
• Disseminating information on HIV epidemic 
  The information about the gaps in the knowledge on the HIV/AIDS epidemic (in relation to MSM in India) should be disseminated so as to improve the methodology of HIV/AIDS surveillance procedures and to gain the focus of government on MSM issues.
• Reaching the unreached 
  Effective strategies to reach those MSM who don't have a self-conscious sexual identity and those who don't cruise should be identified and implemented.
• Directory of NGOs/CBOs 
  A directory, which describes the various projects undertaken by different NGOs/CBOs among MSM in India, must be prepared, published and disseminated to organizations that work or intend to work on sexual minority issues.
  

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