The NACO has found that the current AIDS epidemic in India is heterogeneous, disproportionately affecting specific high-risk communities, including MSM.2
The present study found high rates of unprotected sex, bisexuality, and HIV among urban Indian MSM. A study conducted in Andhra Pradesh also found that MSM reported high rates of unprotected anal sex with other men and women.12
Another study among rural men from 5 different states in India also reported that 9.5% of single and 3.1% of married men had anal sex with other men and had greater number of male sexual partners and found high rates of unprotected anal sex with male partners.13
STI and HIV prevalence in the current study are similar to those from a population-based study in Chennai7
but lower than HIV prevalence rates of 19% among MSM attending STD clinics in Pune, India, between 1993 and 2002.14
Men accessing VCT services at the Humsafar Trust were young and most had at least a secondary school education, with a high prevalence of clinically diagnosed STIs and HIV. HIV infection was independently associated with being illiterate, married, and having serological evidence of syphilis or clinically diagnosed STIs. The majority of the men had a predominant same sex preference, but a quarter of the men were married to women. Being married may reflect some denial of same sex behavior by married MSM, who might dissociate and suppress their secret lives and/or think that because they are socially perceived as heterosexual, they would be at low risk of acquiring HIV. They also may be socially isolated from other MSM and not be likely to receive community-based prevention interventions.
The majority of MSM accessing VCT reported that they came to the clinic to be tested for HIV because of their sexual behavior. Many of the men in the cohort misperceived their risk, as evinced by counselors describing the practices of almost 70% of the men as high risk, whereas only quarter of the men described themselves as such.
Those who did not think they were at risk were significantly more likely to be HIV infected, suggesting the need for improved health education interventions for VCT clients designed to increase their knowledge and understanding of how risky sexual behavior can result in STI and HIV acquisition.
About one quarter of the men expressed a bisexual behavioral preference, which was an independent predictor for testing HIV positive. Behaviorally bisexual men preferred insertive anal and then vaginal sex in that order with their partners. These men may form a major bridge population between other high-risk MSM and transgender people and their regular female partners or spouses as also suggested by other studies in the past.12,13,20–22
Ethnographic literature from Chennai suggest that MSM in the West have a collective “gay identity,” whereas in India, same sex relationships are based more on varying sexual identities and behavior based on those identities.5
Men who comprise this bridge population may not identify themselves to be homosexual or “gay.” Further research that looks at linkages between identity and sexual risk behavior among these and other subgroups of men practicing same sex behavior are required in the Indian context.
The present study documented that men in Mumbai who had sex with men but did not identify as gay already had an HIV prevalence more than 10-fold greater than the general population. This presents an increased risk for the wives of men because procreation is a priority in India, and women tend to be monogamous. So they may be at high risk of becoming infected by husbands’ practicing same-sex behavior.20
Interventions that focus on behavioral risks and not cultural identity and which are acceptable in mainstream society are needed to slow HIV transmission in this no-cohesive population.
A limitation of the study is that it is based on a nonrandom convenience sample of MSM who sought VCT services and hence cannot be generalized to all MSM in Mumbai. Social desirability might lead to under reporting of sexual risk behavior and over reporting of condom use. This might be minimized because the Humsafar Trust is perceived as a safe space for MSM. The responses to the questions about the number of partners and condom use with casual partners during anal and vaginal sex involved a time frame of 6 months, which could lead to recall bias. Nevertheless, our estimates of high-risk sexual behavior from self-report of MSM accessing VCT services are corroborated by VDRL results and clinically diagnosed STIs. Lastly, to address concerns that these analyses were conducted on only the 61.6% of men accessing VCT services for whom complete data were available, mean age, employment and marital status, literacy, sexual partner preference, and HIV prevalence were compared between both groups and no statistically significant differences were found.
MSM requesting VCT services in Mumbai have high-risk sexual behavior and are at risk of STI and HIV acquisition. Interventions that target sexual risk behavior and condom uses are necessary in this group. Specific interventions targeting the bridge population of behaviorally bisexual men have implications for HIV risk reduction in them and their low-risk female spouses.