S. Joseph Visva Bharati University, Department of Social Work, Visva Bharati University, Sriniketan P.O., W. Bengal, India Different forms of same-sex sexualities among males coexists in India. Some of them are the continuation of the traditional forms of transgenderal, transgenerational or class-structured homosexuality and the others are expressions of modern egalitarian form of same-sex sexualities. The objective of this study is to acess the sexual orientation, sexual partnership and sexual identities of MSM involved in formal networks.

Method: 52 MSM, selected from 2 formal networks in Kolkata responded to an anonymous questionnaire. Sexual orientation was measured using the variables of sexal attraction, sexual behavior, sexual fantasies and self-identification. The sexual identity, that compose of a personal sexual identity and a public sexual identity, was measured using a 3-point scale.

Results: The subjects belong to an average age of 27, educated, less religious and belong to middle class families. The variables sexual attraction, sexual behaviour, sexual orientation and self-identification are valid indicators for measuring sexual orientation of MSM. 63.5% have a predominantly homosexual, 32.7% have a predominant bisexual orientation and 3.8% have a predominant heterosexual orientation. The partnership of different forms of commercial (vocation & non-vocation) and non-commercial (anonymous, non-anonymous & intimate) was found to exist among the MSM. 69.2, 26.9, 3.9 percent of the subjects have a personal sexual identity of homosexual, bisexual and heterosexual respectively, while the percentages are 13.5, 26.9 and 59.6 respectively for public sexual identity.

Conclusion: MSM is a diverse population on sexual orientation, sexual partnerships and sexual identities. Majority of the subjects have a homosexual orientation and they self-identify as homosexual at the personal level, while maintaining a heterosexual public identity. Any HIV/AIDS intervention programme should recognise these aspects and different strategies adopted to control male-to-male transmission.Presenting Author: SHERRY JOSEPH,

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S. Singh DART, B-226, First floor, Greater Kailash - I, New Delhi, 110 048, India

Issue-DART is a small CBO working with MSM since the last three years in India. We have faced the problems of trying to provide MSM with culturally sensitive HIV/AIDS prevention education. Since, there is hardly any material available in India on addressing the specific needs related to HIV/AIDS/STRD prevention issues amongst MSM, we have tried to develop a small booklet which addresses questions that MSM have around HIV/AIDS. We have tried to make it culture specific and user friendly.

Description-Through interactive sessions with peer educators and MSM community a booklet idea was concretized. Through our regular training sessions a list of frequently asked questions was drawn up, answers to these were framed and field tested by peer educators. With feedback and comments informing and guiding the development of the booklet it was finalized. Due to funds constraint we limited use of illustrations. These too were tested till the MSM group was satisfied and sure that the proposed booklet would work and achieve the desired result-behavior change, self acceptance, enhanced esteem and confidence.

Lessons learned-The issue of illiteracy amongst a majority of MSM is not seen as a major constraint because the process of booklet development was participatory and need based. It has in fact had a snowball effect, non-literate MSM take the booklet and share it with friends who can read and in the process the information is passed on to more and more people. The booklet is small in size; it can fit into a wallet and can be safely hidden on person or elsewhere and therefore is in great demand. Due to lack of funds only a small number of copies have been printed, further support would enable us to print more copies of the booklet and would benefit more MSM.

Recommendations-More such material needs to be produced for MSM and their special needs that is culture sensitive and addresses HIV/STD transmission and prevention concerns in a user friendly way.

Presenting Author: Sandish Singh,

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V. Chakrapani1, T. Ebinezer 2, A. Fernandes 3, M. Dhanam 4 1 Social Welfare Association for Men (SWAM), 12/5, Natarajan Street, Balakrishna Nagar, Jafferkhanpet, West Saidapet, Chennai-600 083, India; 2 31, VGP Rajesh Nagar, Narayanapuram, Pallikaranai, Chennai, India; 3 Social Welfare Association for Men (SWAM), Chennai, India; 4 ThamilNadu Aravanigal Association (THAA), Chennai, India

Background: Ali community has been in India for centuries. Still there is lack of understanding about and acceptance of Alis among the public and health care providers. This study's objective was to identify the health care service needs and access issues of Ali community.

Methods: In mid-2001, two Focus Group Discussions (FGDs) with 19 Alis & two in-depth interviews were conducted by a trained facilitator in Chennai. Nirvan Kothis (emasculated/"post-operative" Alis) & Aquwa Kothis (non-emasculated Alis in female/male attire) participated in the FGDs. Sessions were audiotaped, transcribed & analyzed qualitatively.

Results: Alis face diverse issues in health care settings: discomfort in disclosing gender identity, need to 'control' gender expression, enrollment as 'males', admission in male wards, and ill-treatment & risk of sexual abuse by co-patients. Most health care providers were ignorant of & insensitive to the issues of Alis. HIV-positive Alis received substandard care. Psychiatrists attempted 'converting' Alis into "man". Because of the ambiguous legal status of Sex Reassignment Surgery (SRS), it is not done in government or private hospitals. Plastic surgeons who do SRS charge heavily. Consequently, many Alis go to unqualified medical practitioners ('quacks') or "Thai-Amma" (senior Ali) for emasculation. Urinary stenosis/stricture following emasculation by Thai-Amma or quacks was mentioned as their main health problem. Many wanted free services for SRS, facial hair removal, scalp hair growth & voice change. Many were self-administering hormones. Some earned money for SRS through sex work. Alcohol use & suicidal ideation are common.

Conclusions: Health care providers should be trained on sexuality issues to ensure quality health care to Alis. Legal status of SRS needs to be clarified. Free service for SRS can lead to a decrease in the morbidity & mortality following emasculation by Thai-Amma or quacks.

Presenting Author: Venkatesan Chakrapani,

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P. Babu, A. Kirupa Vadivelu, A. Barathi Ponnusamy ThamilNadu Aravanigal Association (THAA), 20/29, Kattabomman street, Kamaraj Nagar, Peerkankarani, New Perungalathur, Chennai - 600 063, India

Issue: Ali/Aravani (male-to-female transgender/transsexual) community is one of the most vulnerable & marginalized groups in India. Adequate attention has not been given to Ali community in the HIV prevention and care programs of government of India.

Description: In Tamil Nadu, over the past 10 years some HIV prevention projects for Ali (Aravani) community were run by some non-governmental organisations. Though in some of these projects Alis themselves have worked as outreach workers and peer educators, these programs did not make any impact. Reasons were - lack of trust with the NGO personnel and lack of the feeling of ownership of the program. Hence it was decided that the Ali community itself should come forward & run its own programs which led to the formation of Thamil Nadu Aravani Association (THAA). It has been started with the aim of advancing and protecting the rights of Aravanis. It also tries to provide alternative job opportunities by providing skills-training and guidance for self-employment. THAA has a temporary shelter home for HIV-positive Alis who come from different parts of India to Chennai. THAA has plans to make this shelter home into a comprehensive care center. THAA has motivation & energy to work for its community but lack t echnical & fund-raising skills. THAA is at present running with generous grants from a few committed Alis.

Lessons learned: Involvement of the community members in planning, implementation and evaluation of the programs is a must so as to get the community's perspective and to know whether the programs are acceptable to them. Community members might be in a better position to plan & develop suitable programs.

Recommendations: HIV prevention and care programs for Ali community should be initiated by the government of India & non-governmental organizations. Community-based organizations should be given technical & financial support to plan and implement its own programs.

Presenting Author: Priya Babu,

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A.H.M. Haque Azizul, M.S. Laila Hijra, M. Ahmed Shale Bandhu Social Welfare Society, 106 kakrail, dhaka 1000, bangladesh, Bangladesh

Background: Bangladesh-traditional Muslim society includes a strong Hijra community defined as 'transgender' their life style as males includes full genital castration and cross-dressing. Main profession is 'Badhai Khata' (asking for money for the sake of god) in addition selling of sexual services. Bandhu Social Welfare Society is working with Hijra community, highly stigmatized and vulnerable in Dhaka since October'00 and providing assistance for a community-based sexual health program 'Sushtha Jibon' (Healthy Life) the first program of its kind in Bangladesh.

Methods: Preliminary estimates, around 5000 Hijras in Dhaka alone. Hijras tend to lack education, empowerment and low self-esteem, basic civil rights are denied. Based on 'Guru' (leader) system, a Guru will have a group of 'Chelas' (followers) many offer sexual services after dark, along with female sex workers. Survey indicates Hijras have the highest risk for STI/HIV infection because of multiple partners and anal sex activities. 'Sushtha Jibon' is managed by Hijra community as its outreach program, providing medical services by a trained female-doctor,along with empowering activities as vocational classes, loan club, etc.

Results: From Jan-Sept'01, 418 complications reported with Anal STD18%; STD cases10%.Through outreach program contacted1661,empowering social-support-group meetings attendees1332.It was revealed 98.9% of participants had engaged in selling sexual services, with only 3.4% using condoms only 1% reporting consistent use of condoms in commercial sex shows the high vulnerability of Hijras to the risks of HIV /AIDS. Through active lobbying of Dr. Carol Jenkins who was working for FHI Bangladesh, Bandhu includes Hijras into the National Surveillance.

Conclusion: A great deal more needs to be done to ensure that the Program can reach Hijras across Dhaka and the country, not only to reduce their risks for HIV/STIs, but also towards,enabling them to feel a part of the greater society.

Presenting Author: ahm azizul haque,

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N. Nahar, S. Jana, S.M. Sohel Uddin Chowdhury, A.S.M. Enamul Hoque, P. Pinky, J. Joy, K. Khoki CARE-Bangladesh, 49/1, Babor Road, Mohammadpur, Dhaka 1207, Bangladesh

Issue: Providing clear & correct information about health facilities to Transgender (TG) Community is extremely important besides education on STD/HIV/AIDS.

Description: In Bangladesh most of TG's are directly involved in selling sex to clients as women. TG's put makeup, wear women's clothes, plucked facial hair, took hormone therapy (mostly contraceptive pills) to achieve feminization or to counteract their naturally produced testosterone without consulting any physician. Being a TG they took active role in anal intercourse, & to avoid masculine genitalia during sex they keep their penis hidden from clients through clothes, special musk's. Some of them have removed their penis because they feel penis is the main barrier in their profession. The way TG's are castrated is a terrible experience. Some TG's tied up the patient hands & legs with one pillar, one old TG (locally called "hazam") cut her penis with a very sharp razor. Since this is a very painful process, TG's are put under the influence of alcohol or narcotic drugs the process. Many of them got seriously infection after operation some died due to heavy bleeding or gangrene. Most of time they used herbal medicine after operation. Bandhan (a self-help group-TG's) is trying to organize themselves to address their human rights through outreach activities, peer training. They organize workshop,open dialogue with policy makers, do local & national advocacy to help them to access health care facilities in the country with support of CARE.

Lesson learned: TG's life style & culture differs from common people. They are marginalized group. So they are more vulnerable to getting STD/HIV/AIDS need to empower them through their self-help group.

Recommendation: Effective way to address TG's problem is to help them develop self- help group, create social acceptance & support, network with other NGO's. Government should collect updated information about TG's health facilities & support & design program accordingly.

Presenting Author: Nazmun Nahar,

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S. Kumta1, M. Setia 1, H.R. Jerajani 1, M.S. Mathur 1, A. RaoKAvi 2, C.P. Lindan 3 1 Sion LTMG Hospital and Medical School, 74 New Montgomery Street, Suite 600, San Francisco, CA, 94105, India; 2 The Humsafar Trust, Mumbai, India; 3 University of California, Center for AIDS Prevention Studies, San Francisco, United States

Objectives: MSM are an important emerging risk group in India and have received scant attention. MSM include gay and heterosexual-identified men and transgender (TG) who often sell sex and may be castrated. Systematically collected data on these groups are limited. We evaluated MSM accessing the Humsafar Trust, a male-health NGO and one of only 2 MSM sentinel surveillance sites in India. We present data on HIV and STI.

Methodology: We report on the first 150 (122 MSM and 28 TG) enrolled since 3/2001. We evaluated gonorrhea (GC) with urethral and rectal swabs for smear/culture; we used urine PCR (Roche) to detect GC and chlamydia (CT). We collected blood for syphilis (VDRL/TPHA), HSV2 IgG, hepatitis B surface antigen (HBsAg) and hepatitis C (HCV); we confirmed HIV+ EIA results with a 2nd test.

Results: 17% of men and 68% of TG were HIV+. 19/95 (20%) uncircumcised men vs. 2/27 (7%) circumcised men were HIV+. HIV was associated with age (25-29), being married and receptive anal sex. STI prevalence rates are shown in the table.

THPA HBsAg HCV HSV-2 CT 
Men 17% 10% 8% 40% 11% 
TG 57% 21% 22% 71% 0%

Only 4% presented with active genital ulcers, urethritis, or proctitis HIV was significantly associated with TPHA, HCV, HSV2 in TG and men; HIV prevalence was 48% in TPHA+ men and 88% in TPHA+ TG; 62% in HCV+ men and 100% in HCV+ TG; and 38% in HSV+ men and 80% in HSV2+ TG.

Conclusions: Extremely high rates of HIV are present in these men, particularly TG, and are associated with syphilis and HSV. High HCV+ rates may indicate transmission through traumatic anal sex and self-treatment of STD's with injections. Circumcision may decrease the risk of HIV but is confounded by religion. Many MSM are married and may pass HIV and STIs to their wives. These groups can no longer be ignored but must be the focus of intensive education and prevention programs.

Presenting Author: Christina P Lindan,

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A.R. Bamne1, S.J. Kunte 2, A.S. Gogate 1, M.N. Khetarpal 1 1 Mumbai districts AIDS control society, 6,Sadhana Sahaniwas,plot no-82-83, TPS-VI,Relief Road,Daulat Nagar,Santacruz-West, Mumbai-400054, India; 2 Mumbai districts AIDS control society, Mumbi, India

Issue: Socially deprived & vulnerable group i.e. Eunuchs with their changing lifestyle for earning are indulging into the anal & oral sex, are at highest risk for STD/HIV infection. But there are no health & other program for them by community group or government. Hence, there was urgent need to recognize & act for provision of sexual health services to prevent spread of STD/HIV infection.

Description: Eunuchs are socially not accepted & non-organized. This community has complex dynamics of power & hierarchical system. There are no government support policies for medical treatment, education, employment. Innovative Strategy- Joint initiative through self-motivated eunuchs & local health authorities i.e.Mumbai Districts AIDS Control Society. Process evolved - 1.Need assessment & eunuch mapping; 2.Accessing eunuch community with motivation; 3.Convergence meetings with eunuchs & stakeholders; 4.Active support to form NGO with legal status; 5. Successful establishment of eunuch NGO i.e.DAI Welfare Trust (18 Aug.99); 6.Technical & financial support for Intervention program with STD & VCTC services,capacity building,creating enabling environment,etc.

Results: In a year, > than 899 eunuchs contacted, 358 examined & 62 treated for STDs, 143500 pieces of condoms were utilised. Created health-seeking behavior for adopting safer sex practices.

Lessons learnt: 1.Innovative strategic approach & extra efforts can break social, cultural & bureaucratic barriers; 2. Encouragement & strong persuasion is a must for involvement of stakeholders; 3.Intensive efforts can only reduce self-hatred within eunuchs & attitudinal change in population.

Recommendations: Additional efforts & innovative approach through initiative of local health authorities & community group can formulate NGO. An intervention program through this joint effort is successful & replicable strategy to mitigate spread of HIV infection & is adoptable in similar settings.

Presenting Author: Arun Bamne,

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U. Irudayasamy, J. Williams, S. Shyamprasad, V.A. Prabhu AIDS desk - UELCI, 94 pursawalkam high road, kellys, chennai 600 010, India

Background: The AIDS desk runs clinic where 300+ve cases were referred. Among them 65 were TG. To understand TGs involvement in High risk behavior(HRB) and vulnerability to STD/HIV/AIDS and low treatment seeking behavior.

Methodology: A Questionnaire & Group therapy was developed to analyze their HRB and co-relate with socio-economic systems.

Results: 
i) social issues: TGs faces social discrimination, Own parents rejection, neighbors treat different. Find difficult to rent house. 55% Health Professionals reluctant to treat TGs. Cultural beliefs and pressuring gender diversity, force them to migrate for livelihood.
ii) Economic issues: 35% infected TGs live in poverty and struggle with complex economic issues as a result of homelessness, migration, mental health disorders and violent relationships. Most of their energy is spent in meeting their basic needs. 92% of them are illiterate and don't have any livelihood skills. 28% of them are street begging and remaining of them are involved in CSW, 78% of them as early as age of 16-20 years. 83% of them never use condoms. 12% of them use rarely. These combined factors leads to large percentage of TGs with STD/HIV.
After our interventions one to one interaction, group therapy, STD identification and treatment, referral of serious cases. IEC materials and insisted condom use & supplied it. Our sustained intervention reduced CSWs from 78% to 43%. Condom use increased 12% to 67%. Promoted 90% TGs accessible to health care system. iii) Political Issues: There is no specific plans or programs from the Government for development of TGs. Since they are illiterate do not possess any livelihood skills, employment opportunities were limited.

Conclusion: We understood that Low socio-economic condition co-relates to the HRB and acquire STD/HIV. To reduce risk, it is important to take a holistic approach to provide quality care, not only addressing medical needs, but also education, reduce stigmatize and provide livelihood.

Presenting Author: irudayasamy ulaganathan,

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D. Noorie AIDS desk - UELCI, 94 pursawalkam high road, kellys, chennai 600 010, India

Background: Noorie Durai is a transgender. She was born in Ramnad district of South India, a male by birth she later developed female characteristics by the age of 13. Before that her life as a male child was idyllic. When the external characteristics of feminisation began to be visible, her parents and family rejected her and threw her out of their home. Noorie had no idea what to do, was her future to be a void and yet full of darkness?
Methodology An In depth case history was elicited over a period of 4 months

Results: A majority of transgenders involve themselves in commercial sex work as a means of livelihood, Noorie at first declined to get involved and tried her level best to get a decent job, this was unsuccessful, finally for reasons for survival she was inducted into the commercial sex trade. Her earnings were substantial, however she had no peace of mind. In 1982 she was married and settled down. Her past life caught up with her when she was tested positive at a Government Hospital for HIV/AIDS (without counseling). By this she was prompted to start to work for her own affected community. Her first job and subsequently have been with civil socity groups serving for the cause of HIV positives. Later she joined the AIDS desk and involved with sex workers, Transgender intervention activities. Sept 2001 there was a demand from Transgender who are HIV positive in South India for common activities. The South Indian Positive Network was initiated. There are 300 members in the Network and supporting Orphan Widows, remarrying, Home care and hospital care with available resources.

Conclusion: The untold miseries of transgender people have yet to be addressed, opportunities for education, employment and health care have been long pressing. The stigma attached to this group needs to be addressed through awareness and interaction. (The above is the life story of the author)

Presenting Author: noorie durai,

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P. Palaniswamy Institution, 127, First Floor, Sterling Road, Numgambakkam, Chennai-600 034, India

Issues: Low-Self Esteem due to low literacy rates, lower income and negligible survival skills were debilitating Kothis (MSM) vis-a-vis their self respect and confidence. Hence, Self-help was seen as a method of improving their situation.

Description: Various skills and training programs were organized within the MSM Sexual Health Program, to improve the chances of Kothis (MSM) survival and hence negotiate safer sex practices while accessing male sexual partners. Pottery, Candle Making and Art Work were taught and the products put up for sale. Besides, Spoken English classes and vernacular literacy classes were conducted to improve their reading and writing skills.

Lessons learned: Income generated from these handicrafts helped improve their self confidence and sense of self-worth. On the anvil, is a Kothi-run self-employed group so that those kothis who have the talent to create and market various products would be encouraged to become independent.

Recommendation: The necessary training and basic infrastructure and guidelines must be in place before the venture is taken up. This self help system has proved that given the opportunity and encouragement these marginalized, vulnerable and even ostracized group of males, could rise above various daunting obstacles in their lives, to emerge as competent and capable survivors.

Presenting Author: Senthilvel Palaniswamy,

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S. Balasubramaniam, M. Joseph, J. Govindan, V. Chakrapani Social Welfare Association for Men (SWAM), 12/5, Natarajan Street, Balakrishna Nagar, Jafferkhanpet, West Saidapet, Chennai-600 083, India

Issue: In India, few resources are available to counselors working with sexuality minorities. Lack of formal training in sexuality issues & limited resources hinder effectively counseling Indian gay/bisexual men.

Description: Social Welfare Association for Men (SWAM) is a community-managed organization that focuses on promoting the sexual health of gay/bisexual men and Kothis. A trained counselor & an HIV-positive gay man (peer counselor) provide counseling in sexuality issues. Also, a physician provides STD treatment & risk-reduction counseling. The clients come with different problems like - non-acceptance of their own sexuality, coping with family pressure to get married, worry about sexually satisfying wife, the need to act as a straight person, suicidal ideation, etc. Some gay men request us to change their sexual orientation. Inspite of counseling, condom use with primary partners (male/female) is often low. Married gay/bisexual men find it difficult to use condoms with their wives since that will lead to suspicion. Also, gay men find it difficult to bring their partners (male/female) for STD treatment. Sometimes we face ethical dilemmas in counseling gay/bisexual men because of our own attitude/beliefs a bout certain issues of sexuality. The peer counselor sometimes finds it difficult to counsel his clients because of 'burn out'.

Lessons learnt: Gay/bisexual men have unique problems for which counselors need information & formal training. Counselors' prejudices/misconceptions in sexuality issues may hinder effectively counseling gay men.

Recommendations: Formal training programs & guidelines to effectively counsel sexuality minorities need to be developed in India. Counselors have to overcome their own prejudices/misconceptions by educating themselves & through discussions with gay/bisexual men who are comfortable with their sexuality. The role of peer counseling needs to be explored in the Indian context.

Presenting Author: Sekar Balasubramaniam,

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M.L. Martin Louis, M. Marutharaj Institution(siaap), 4, 1 st street, Kamaraj Avenue, Adyar, Chennai, Tamilnadu

Background: Providing services for HIV prevention and care has to be reinforced by building community identity and empowerment for vulnerable people, especially women in sex work, gay and bisexual men and people affected by HIV and AIDS.
The role of NGOs had been in identifying vulnerable communities and initiating prevention interventions. However, empowerment of communities is a difficult process and cannot easily be implemented. Collectivisation of communities is critical strategy to identify and structure support for greater empowerment of vulnerable communities.

Method: Two levels of initiatives have been supported within the community (a) collectives (Sangam) that address only the needs of the members, and Community Managed Organisations (CMOs), that take on interventions both within and outside the community. Appropriate funding, training and capacity building support for the Sangams and CMOs has been a critical in registration, networking, organisation management, programme planning, advocacy against violence, access to health, education and civil supply services and liaison work with local administrations. 90% of training is done by skilled people from the community.

Results: 15 sangams registered, 5 CMOs functioning, 4640 people outreached, 75 panchayat resolutions against discrimination, 6 court cases won, 29 violence redressed, 19 representations made at district, state, national levels, 16 members receive voter identity cards and civil supply cards, 22 children admitted to residential schools for children

Conclusions: Structured plan to increase policy support for community managed interventions in place. Community managed organisations networking meeting planned for 2003. Plan for federation of community managed organisations in South India.

Presenting Author: Prabakar Martin Louis,

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V.N. Deshmukh The Humsafar Trust, Mumbai, India

Issue: The greatest risk of HIV infection for women married to Self identified Gay men (SIGM) and Men having sex with Men (MSMs) is being in a monogamous relationship with their husbands. The trauma of being HIV infected, married to a man who has same sex relations and who is also positive is immense. These women are discriminated and lack support from their husbands, families and the society.

Description: As marriage and begetting progeny are considered as sacred duties in the Indian society, men who are exclusively homosexual in their sexual orientation are often forced into undesirable marriages. These men have no remorse and secretly continue their same sex relationships with multiple male partners, making themselves prone to contracting HIV and having greater opportunity to pass the virus to their wives. Due to the stigmatized nature of same sex behaviour and HIV, they do not disclose either of it to their wives. Many women get to know they are HIV positive during their pregnancy or childbirth. In some cases their husbands blame them being unfaithful, as they believe sex between men is fun and not real sex and hence is free from HIV transmission. Sometimes women, due to economic dependence on men, have no option but to remain in the marriage despite suspecting that their husbands have multiple sex partners.

Lessons learned: In the Indian society, a man who is HIV positive is not looked down upon so much as much as a woman who is positive. Families are more inclined to seek and pay for the medical treatment for men as compared to women even if both need it equally. Women with HIV have great difficulty accessing health care services.

Recommendations: Sensitizing married SIGM and MSMs to concerns of their wives is important. Programmes for women will be more effective if they are accompanied by parallel efforts directed at MSMs. Partner notification and treatment have to be emphasized.

Presenting Author: Vrushali Deshmukh,

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