Consistent condom use by MSW was significantly higher (P < 0.005) with non-commercial, non-regular male/hijra partners (25.3%) compared with non-MSW (17.7%). A significantly higher (P < 0.01) proportion of MSW (48.3%) refused to have unprotected sex, compared with non-MSW (34.6%).
The prevalence of HIV was significantly higher (P < 0.05) among MSW (14.5%) compared with non-MSW (10.8%). Similarly, the prevalence of any STI was also significantly higher (P < 0.01) among MSW (17.5%) compared with non-MSW (11.2%).
Multivariate analysis on factors influencing inconsistent condom use and last time condom use
Multiple logistic regression analysis revealed that self-identified MSM who are illiterate (odds ratio (OR) 0.68, 95% CI 0.51–0.92), bisexuals (OR 2.68, 95% CI 1.90–3.78), have paying male partners (OR 1.33, 95% CI 1.07–1.66), have non-paying regular and non-commercial male/hijra partners (OR 2.15, 95% CI 1.75–2.64) and had sex when they travelled out of town (OR 1.49, 95% CI 1.22–1.82) were less likely to use condoms consistently with regular male/hijra partners. Self-identified MSM who had bought sex from male/hijra partners, in the age group of 25–34 years (OR 1.16, 95% CI 0.75–1.79), had free access to condoms (OR 1.51, 95% CI 1.05–2.17), had paying male partners (OR 1.47, 95% CI 1.00–2.15), non-paying regular and non-commercial male/hijra partners (OR 2.37, 95% CI 1.72–3.27) were less likely to use condoms consistently. Self-identified MSM who were in the age group 25–34 years (OR 2.80, 95% CI 1.71–4.57) or ≥35 years of age (OR 2.64, 95% CI 1.20–5.82), literate (OR 2.64, 95% CI 1.20–5.82), bisexual (OR 4.65, 95% CI 1.72–12.56), having paying male partners (OR 2.13, 95% CI 1.26–3.60) and having non-commercial male/hijra partners (OR 1.74, 95% CI 1.08–2.81) were less likely to use condoms consistently with regular female partners (Table 4).
Multiple logistic regression on last time condom use with regular male/hijra partners revealed that self-identified MSM having paying male partners (OR 0.72, 95% CI 0.56–0.93) and who never refused for unprotected sex (OR 1.47, 95% CI 1.18–1.85) did not use a condom last time (Table 5).
The social construction of sexual identity and orientation of MSM do not have an overriding homosexual identity in India . They are reported to be extensively mingling with female partners [23,24]. They do not just form a separate sexual network but act as a bridge population between the high-risk group and general female populations . The ‘monolithic’ categorization stands in the way of understanding high-risk behavioural outcome differentials within subgroups of the MSM population, which undermines effective interventions and research [19,25]. This is the first time that biological indicators for the risk of HIV infection have been measured at this magnitude among MSM.
The proportion of self-identified MSM who were married was low and a higher proportion of married bisexuals and double deckers were living with their spouses; consistent with other studies on MSM conducted in India and elsewhere [13,19,23,26,27]. MSM in India generally have complex self-identities mixed with strong cultural pressure to marry [14,19,21,23,24].
In the current study almost all self-identified MSM reported having multiple partners and a significant number of them also had sexual contacts with paid/regular female partners. Kothis had more paying partners, whereas panthis and double deckers mostly had sex with regular male/hijra partners and non-commercial, non-regular male/hijra partners. Other studies report a significant proportion of MSM have sexual relationships, wherein they reportedly engage in sex with either or both men and women, and use condoms inconsistently; making them an important bridge group between the high-risk community and the population at large for acquiring/transmitting HIV [19,23,24,28].
Bisexuals had low consistent condom use, and a higher proportion had anal sex during travel as was reported in earlier studies [15,29]. A majority of them had non-commercial, non-regular male/hijra partners and had regular and paid female partners. The spouses of these MSM are at risk of HIV as the majority of them do not use condoms consistently. This is further compounded by the fact that they tend to have higher numbers of female sex partners with low consistent condom use, higher frequency of sexual contacts in a month and a relatively high prevalence of HIV [19,23,30].
A higher mean number of paying sex partners was observed among hijra, bisexuals and kothis; a high percentage of these partners being strangers and with low levels of overall consistent condom use expose self-identified MSM to a higher risk of STI. This is reflected in significantly higher prevalence levels of HIV and reactive syphilis among self-identified MSM. This is further supported by a high prevalence of HIV and syphilis in hijra, bisexuals and kothis reported by other studies [3,19,31].
High HIV prevalence coupled with low consistent condom use, in male–male sexual activity in general and extremely low with regular female partners, is a matter of concern. Even among MSM who reported selling sex or not, consistent condom use with regular female partners stood at an abysmal low of 4% and 12%, respectively. Risk behaviour is high in all self-identified MSM and bisexual behaviour seems to be common.
Reported low levels of consistent condom use, and a high prevalence of HIV/STI and syphilis among MSM in general suggest that targeting just high-risk MSM engaging in commercial sex alone is not adequate. Factors found to be associated with inconsistent condom use by self-identified MSM (excluding hijra) in the multiple logistic regression analysis were having paying male partners, non-commercial non-regular male/hijra partners, bisexuals and MSM in the age of 25 years and above. Having undergone an HIV test was the only strong predictor of using condoms consistently among self-identified MSM; indicating the key role of this factor in HIV prevention interventions.
One of the key findings of the study is that hijras are at high risk of HIV and depend mostly on sex work as their main source of income . Compared with other self-identified MSM, they had the highest prevalence of HIV and syphilis, which can be attributed to a variety of factors such as younger age of initiation into commercial sex, and having more anal sex partners, both known and strangers . This study showed low levels of consistent condom use among hijra.
The majority of the respondents had heard of HIV and AIDS, excluding KTK, and believed that it could be prevented. The study indicated that mere knowledge about the prevention of HIV among MSM is not adequate enough to prevent risky behaviour and HIV transmission among MSM groups. It was also found that self-risk perception across the states was substantial.
Compared with other high-risk populations such as female sex workers and their clients, MSM are more difficult to reach because of the covert nature of their activities, which provides immense challenges for interventions . This survey was implemented in cruising spots in the target districts. With the aid of key informants these cruising spots are relatively easy to identify. Given the high-risk behaviours uncovered in this survey, cruising spots appears to be an important intervention area for conducting HIV prevention programmes among MSM.
In conclusion, these data have important implications for HIV prevention programmes in India. Low consistent condom use, misconceptions about HIV transmission and prevention, a high prevalence of HIV/STI, a higher proportion of MSM belonging to the bisexual category, and diversity of sexual partners, make self-identified MSM a significant group among ‘at-risk’ populations in the areas surveyed [16,32]. High levels of prevention knowledge and easy availability of condoms are clearly not enough, the interventions should focus on motivating community members to engage in safe behaviours taking into account the high HIV prevalence, and understand the ways in which stigma and social exclusion have driven MSM to engage in risky behaviour [3,33]. Correlation between HIV testing and self-protective behaviour suggests that HIV testing services should be expanded to MSM communities. The immediate need is to develop and strengthen strategies as well as interventions for effective condom use. This may also go a long way in preventing HIV not only among MSM but also among their commercial and regular female partners and their partners.
Limitations of the study
(1) Varying definitions of MSM across states was a hindering factor for cross-state comparison. In addition, in-state pooling was problematical because of variations across districts in terms of the stages of the HIV epidemic. (2) Although the sample size per district was adequate to measure one-time prevalence, it may not be adequate to estimate changes in the prevalence of STI that have low or infrequent occurrence. (3) The study included active and visible MSM in the hot spots and their self-identification was mutually exclusive, thus may not be representative of the entire MSM population in the states and probably represents higher-risk MSM. (4) The study did not capture the type of anal exposure (anal-receptive or anal-insertive) for each anal sex experience with different types of partners. (5) Only urethral specimens were collected for testing NG and CT; this might underestimate STI prevalence. (6) The information on characteristics of subjects who refused to participate in the survey was not recorded during the survey. With these limitations, the study still brings out important findings that cannot be ignored.
The IBBA study teams
National AIDS Research Institute (NARI) Pune
Abhijit Deshpande, Amey S., Amol Salagare, Arun Risbud, B. Kishorekumar, Bhagyashri, Deepak More, Dilip Pardeshi, Geetanjali Mehetre, Jagnnath Navale, Jayesh Dale, Mandar Mainkar, Milind Pore, Narayan Panchal, Rahul Gupta, Raman Gangakhedkar, Sachin Kale, Sachin P., Shailaja Aralkar, Shashikant Vetal, Shirin Kazi, Shradha Gaikwad, Shradha Jadhav, Sucheta Deshpande, Sujata Zankar, Tanuja Khatavkar, Trupti Joshi, Uma Mahajan.
National Institute of Nutrition (NIN) Hyderabad
Balamani Donkena, Narayana G. Bhashyam, Sarala Donkena, Sesikeran Bondala, Hanumatha R. Challa, Sarita Chakilam, Madhusudhan R. Dasari, Krishna R. Garlapati, Narendra B. Kondapalli, Rama R.L. Atchuta, Chandra S.R. Matukumalli, Mohamad Shamsuddin, Anil K. Nadukula, Srinivas Pagidoju, Lakshmi D. Ramineni, Prasad Saride, Annapurna Vure.
National Institute of Epidemiology (NIE) Chennai
A. Bhubneswari, A. Manjula, A. Pauline Priscilla, A. Sivaraman, A.K. Mathai, Beena Thomas, C. Femina, C. Kalpana Devi, C. Selvendran, C.P. Girish Kumar, D. Prabhu, J. Rajkumar, Jagan, Jeyasingh, Joseph David, K. Boopathi, K.J. Dhananjeyan, K.J. Kalyanam, L. Palani, M. Amulu, M. Stabri Dhanabakyam, M.D. Gupte, Michael Muniraja, Paul Tambi, R. Muthu, S. Karthikeyan, S. Periasamy, S. Tilakvathi, S. Velan, Stephen Raja, T. Karunakaran, T. Rabinson, T. Venkata Rao, V. Selvaraj, Vasana Joshua.
Karnataka Health Promotion Trust (KHPT) Bangalore
Anitha, B.M. Sangameshwar, Christina, Kaveri Gurav, Raghavendra, Reynold Washington, Shajy Isaac, Shenvi, Sudheer, Sudipto Mondal, Usha Rani.
Family Health International (FHI)
Ajay Prakash, Ashim Chatterjee, Bitra George, Deepak Singh, Gay Thongamba, Kathleen Kay, Manjula Singh, Motiur Rahman, Nandan Roy, Prabuddhagopal Goswami, Prashant Alur, Rajatashuvra Adhikary, Sharad Malhotra, Shubhra Rehman, Sumita Taneja, Tilak Angra, Tobi Saidel, Umesh Chawla.
AC Nielsen ORG-Marg Private Limited Hyderabad
Ranjit Panda, Gopal Krishna Kamat.
The data represent the figures pertaining to populations at increased risk of HIV infection in the survey districts. Estimating state or national HIV prevalence is not possible from the data alone.
Sponsorship: Support for this study was provided by the Bill and Melinda Gates Foundation through a grant to FHI.
The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation.
Conflicts of interest: None.
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Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
AIDS; condom use; HIV; homosexual; men who have sex with men; sexually transmitted infection; unsafe sex