While recent surveillance trends seem to indicate that HIV prevalence has begun to decline among the general population and female sex workers in India's southern states, HIV remains “uncontrolled” among MSM in urban areas.22
Despite this and the national government's designation of MSM as a core HIV risk group, only a quarter of respondents in this study reported participation in any HIV prevention intervention in the past year, with condom distribution being the most common.3
Importantly, this participation was significantly associated with less frequent unprotected anal sex in the 3 months prior to study enrollment.
Additionally, men who were not “out” about having sex with other men, and participants who identified as panthis
were less likely to have participated in a prevention program. Although the present study focused on any serostatus MSM, a recent study of HIV-infected MSM found that those who had unprotected sex with men were less likely to have received HIV prevention services compared to those who had protected sex. These men were also more likely to report unprotected sex with casual partners who were either HIV-uninfected or whose HIV status was unknown.23
The two studies together highlight the importance of expanding on current primary and secondary prevention efforts for HIV transmission among MSM in this region.
The perception of sexual risk for HIV varies among MSM, and throughout the epidemic MSM have engaged in sophisticated decision making about what they consider to be risky.24
Studies have reported that the reasons for continued sexual risk taking among MSM in India include: (1) perceptions that HIV is transmitted through vaginal sex and via sex workers, resulting in individuals engaging in alternate anal and oral sexual practices as a way to avoid infection, (2) stigma and denial of same sex behavior resulting in anonymous, single-encounter sexual relationships, and (3) inequalities in power dynamics that arise from Indian notions of masculinity (e.g., discriminatory attitudes and exploitation of effeminate males).25–27
It could also be that the programs have not reached MSM. A 2006 survey in 15 Asian and Pacific countries estimated that targeted HIV programs reached less than 8% of MSMs.28
It is interesting to note from the study findings that among those who participated nearly half the respondents reported having participated in a condom distribution program and only one third participated in individual-level risk reduction counseling interventions and workshops. Given the complex environments in which MSM negotiate their sexual choices, it is important for interventions to move beyond traditional prevention programs, which tend to focus on condom distribution and fail to address the psychosocial needs of MSM. According to most behavioral models of health care, if the barriers to obtaining care are greater than the benefits, then it is unlikely that individuals will avail themselves of health care services.29,30
Additionally, among MSM in general and MSM in India it appears that sexual risk taking co-occurs within a variety of other contextual factors and psychosocial problems.31–33
Individual and structural interventions are therefore required to assist with the particular problems in their particular contexts.
Furthermore, nearly half the respondents who participated in an intervention indicated exposure to an MSM nongovernmental organization. However, a study by Safren et al.15
point to several important barriers to HIV prevention and care among MSM in South India, including harassment and intimidation toward MSM NGO outreach workers by police and other men. Organizations involved in HIV prevention interventions need the cooperation of police and other local government institutions to ensure the safety of outreach workers and MSM who may otherwise avoid program participation due to this harassment.
It has also been reported in this study that those who are older, educated, open about their MSM sexual behavior, and have had transactional sex were more likely to have participated in an HIV prevention intervention in the past year. Although HIV prevention interventions typically require more than education, education is an essential component.34
This requires HIV prevention programs to understand the profile of their participants if they are to reach those with lower educational attainment, as well as those who may not be open about their status of having sex with other men. For example, kothis
in India are more effeminate acting and therefore easily identified as compared to panthis
and double deckers, who may choose to remain hidden and who may not want to acknowledge their MSM identity. To curb rising HIV rates, prevention programs need to focus efforts to include all subgroups of MSM. It is also interesting that those who have engaged in transactional sex have come forward to partake in HIV prevention programs, indicating the possibility that prevention programs in Chennai are reaching this at-risk subgroup of MSM.
There are limitations to the present study which bear mention. First, data collected were cross-sectional and therefore inferences about causality cannot be established. Second, data were collected via interviewer-administered techniques, and hence social desirability and/or demand characteristics may have influenced the results. Third, because the sample was recruited via outreach efforts by a local MSM NGO, generalizability of the study findings may be limited. Despite the limitations, to our knowledge the present study is the first to examine the degree to which MSM have been exposed to HIV prevention interventions and the correlates to sexual risk taking among MSM in India.
MSM and organizations which work with them are a crucial source of information for improving the effectiveness of HIV programs. The involvement of affected communities in the design and implementation of policies and programs is a core principal of an ethical and effective response to HIV/AIDS.35
Building stronger partnerships between affected communities, service providers and researchers can have a mutually beneficial effect.36
However, to fully maximize effectiveness, HIV prevention interventions must reach infected individuals and those at highest risk for HIV acquisition who are particularly likely to engage in transmission risk behaviors.37
Culturally sensitive HIV prevention interventions continue to be needed for Indian MSM.