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Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India

Brahmam, Ginnela NVa; Kodavalla, Venkaiaha; Rajkumar, Hemalathaa; Rachakulla, Hari Kumara; Kallam, Srinivasand; Myakala, Shiva Prakasha; Paranjape, Ramesh Sb; Gupte, Mohan Dc; Ramakrishnan, Lakshmid; Kohli, Anjaleed; Ramesh, Banadakoppa Mefor the IBBA Study Team

doi: 10.1097/01.aids.0000343763.54831.15

Objective: To describe the sociodemographic characteristics, prevalence of high-risk sexual behaviours, HIV, sexually transmitted infections (STI), and perception of risk in self-identified men who have sex with men (MSM) in four south Indian states.

Methods: A cross-sectional probability-based survey of 4597 self-identified MSM in selected districts from four states in south India was undertaken. Self-defined sexual identity, sexual behaviour, and STI/HIV knowledge were assessed using a structured questionnaire. Blood and urine samples were tested for HIV and STI. Recruitment criteria differed slightly across states.

Results: When grouped by self-identity, the HIV prevalence was: hijra (transgender) 18.1%; bisexuals 15.9%; kothis (anal-receptive) 13.5%; double-deckers (both anal-insertive/anal-receptive) 10.5%; and panthis (anal-insertive) 7.6%. Reported condom use with last paid male partner was over 80% in all states and categories. Consistent condom use was overall low among self-identified MSM, with less than 29% with non-commercial non-regular male partners and less than 49% with regular male partners. The percentage of self-identified MSM with regular female partners was 4–43% and with commercial female partners was 14–36% across states, and consistent condom use differed by self-identity. Syphilis prevalence was high among kothis and hijras (15.8 and 13.6%, respectively). Urethral gonorrhoea prevalence was less than 1% and chlamydia prevalence ranged from 0.4 to 4.0%.

Conclusion: HIV prevalence and risk behaviour within these self-identified MSM communities in south India is high. Moreover, a significant proportion of them had female partners, both regular and commercial. The national programme's focus on HIV prevention services for these high-risk MSM is justified.

aNational Institute of Nutrition (NIN), Hyderabad, India

bNational AIDS Research Institute (NARI), Pune, India

cNational Institute of Epidemiology (NIE), Chennai, India

dFamily Health International (FHI), New Delhi, India

eKarnataka Health Promotion Trust (KHPT), Bangalore, India.

* Members of the IBBA study team are listed at the end of the paper.

Correspondence and requests for reprints to Ginnela N.V. Brahmam, Division of Community Studies, National Institute of Nutrition, Jamai-Osmania (PO), Hyderabad 500 007, India. E-mail:

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India had approximately 5.1 million people living with HIV/AIDS in 2003. The estimate for 2006 indicated approximately 2.5 million [1], with an adult HIV prevalence of 0.36%. This drastic change could be due to changes in the estimation methods. Andhra Pradesh (AP), Maharashtra (MH), Karnataka (KTK), and Tamil Nadu (TN) contribute 63.0% of reported AIDS cases in India [2]. Among men who have sex with men (MSM), a high HIV prevalence has been recorded in facility-based surveys conducted in selected geographical areas in the states of KTK (19.2%), MH (15.6%), Manipur (12.4%), Delhi (12.3%), Gujarat (11.2%) and AP (10.3%) [1].

There is an increasing recognition of MSM behaviours in Indian and Asian settings, where studies have been done [3–13]. Limited data are available in India on MSM except for some small studies [11,14–18] and one large study from AP [19], which does not provide data on sexually transmitted infections (STI) and HIV.

The Integrated Biological and Behavioural Assessment (IBBA), a cross-sectional survey, was undertaken as part of an overall evaluation of Avahan, the India AIDS Initiative. Avahan supports the implementation of HIV prevention interventions among high-risk MSM in addition to other high-risk groups in six states of India (Refer to the paper on ‘Evaluation Design for Large Scale HIV Prevention Programs’, pp. S1–S10, in this supplement) [20]. This study tries to address the need for detailed information on sociodemographic characteristics, sexual behaviours, the prevalence of HIV and STI and risk perception among the MSM population, a group that remains largely invisible and marginalized [21].

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The survey was conducted in select districts of AP, TN, KTK and MH between March 2006 and April 2007 in a phased manner. Hijra (transgender) were also included in the MSM survey, which was carried out in East Godavari, Guntur, Hyderabad and Vishakapatnam districts of AP (April–July 2006), Bangalore in KTK (July–August 2006) and Pune in MH (October 2006–April 2007). MSM excluding hijra were covered in Chennai, Coimbatore, Madurai and Salem districts of TN and Mumbai/Thane (treated as one district) in MH. In addition, hijra were covered as a separate group drawn from five districts of TN, namely Chennai, Coimbatore, Madurai, Salem and Dharmapuri (March–November 2006).

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A sample size of 400 per district was computed to detect an absolute difference of 15% or more from an assumed value of 50% with 95% confidence intervals (CI), 90% power and a design effect of 1.7 for the estimation of consistent condom use (every sex act), and last time condom use (last sex act) by MSM. Similarly, a sample size of 400 was arrived at for hijra from five districts of TN. A probability sampling method with a varied approach was used to select primary sampling units, the sites. Time location cluster sampling approaches were used taking into account the different subpopulations that congregate in single locations at different times of day or on different days of a week. A ‘take-all’ approach was followed whenever the sampling frame suggested fewer than 400 members of the high-risk population in a district. Refer to the paper on ‘Baseline IBBA among Most at Risk Key Populations in Six High Prevalence States of India: Design and Implementation Challenges’ in this supplement [22].

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Recruitment criteria

Recruitment criteria differed slightly from state to state in response to the need for programmatically relevant data. In AP, KTK and Pune district of MH, self-identified MSM and hijra were considered together for the survey. In Mumbai-Thane only self-identified MSM (excluding hijra) were included. In TN, MSM (excluding hijra) as well as male sex workers (MSW) were also considered as part of the group.

In TN, the criteria used for hijra was, ‘any individual, aged 18–60 years, self-identified as a hijra and exchanged any type of sex for cash/kind in the last one month’, whereas MSM was ‘any man, aged 18 years or above, self-identified as MSM, who had anal sex with other men in exchange for cash/kind at least once in the last one month’.

In AP the criterion was ‘any man or hijra, self-identified MSM, aged 18 years or above, who had any type of sex (oral, manual, or penetrative), paid or unpaid, with another man in the last one month’. Whereas in KTK, ‘any man or hijra, aged 18 years or above, self-identified MSM, who had anal sex with other men in exchange for cash/kind at least once in the last one month’. In MH, the criteria in Pune district for MSM was ‘any man self-identified as MSM, aged 18 years or above, who had any type of sex with a man in the last one month’; while for hijra it was ‘any hijra, aged 18 years or above, who had any kind of sex with a man in the last one month in exchange for cash or kind.’ In Mumbai/Thane the criteria for MSM was ‘any man self-identified as MSM, aged 18 years or above, who had any kind of sex with a man in the last one month.’

The MSM population were asked to self-identify (referred to as self-identified MSM in the paper) into mutually exclusive subcategories of sexual identity such as kothis (mainly anal-receptive), panthis (mainly anal-insertive), double-deckers (both anal-receptive and anal-insertive), hijra (transgender), and bisexuals (engaged in both homosexual and heterosexual relationships). It is to be mentioned here that the categories of MSM referred to in the study are based on self-identification and not on actual sexual behaviours.

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Data collection

IBBA followed a ‘linked anonymous’ strategy to maintain respondents’ confidentiality. A self-coding questionnaire assessing sociodemographic characteristics, migration, sexual practices, awareness and knowledge on STI and HIV, and HIV risk perception was administered by trained members of the MSM community. Blood and urine samples were collected by trained clinical staff. Serological tests for HIV, syphilis and herpes simplex virus type 2 (HSV-2) were run on sera. Nucleic acid amplification tests for Neisseria gonnorhoea (NG) and Chlamydia trachomatis (CT) were carried out on urine.

The study was approved by the respective ethical review boards of all participating institutions and the screening committee, Health Ministry, Government of India.

Community oversight committees were set up in each study district to inform the community about the study, create an ambience of mutual trust, and help ensure the protection of rights as well as the physical and psychological wellbeing of the respondents.

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Statistical analyses

Appropriate weights were applied at district and state levels for unequal selection probability. Similarly, global weights were calculated using district estimates and applied for analysis of all parameters, such as frequency distributions, bivariate and multivariate logistic regression analysis [22]. Sexual partners of self-identified MSM were categorized into: (1) paying male partners (partner who paid to have sex); (2) paid male/hijra partners (paid to have sex with partners); (3) non-commercial, non-regular male/hijra partners; (4) regular male/hijra partners; (5) regular female partners; and (6) paid female partners.

Differences in proportions among different self-identified MSM were tested using Pearson's χ2. Hijra were excluded for testing difference in proportions (χ2) as they form a distinct group based on their behaviours and consider themselves as third sex. As most of the Hijra are engaged in commercial sex, they were not included in the analyses for comparing the characteristics of self-identified MSM who reported ever selling sex.

Multivariate binary logistic regression analysis was performed using SPSS 15.0 to study the factors associated with inconsistent condom use and last time condom use, stratification was done according to condom use by type of partners. Potential risk factors were identified and included in the model on the basis of conceptual and theoretical understanding of risk factors that were collected in the survey [19]. In each multiple logistic regression model, the effect of each of the categorical variable was assessed by keeping the first or the last category as reference, and all variables were introduced simultaneously in the model.

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A total of 4597 self-identified MSM and hijra (2025 from TN, 1621 from AP, 298 from KTK, and 653 from MH) participated in the study. Because of low participation rates in KTK (55%) and fewer than 400 members of the MSM population in the Pune district of MH, the required sample could not be achieved. The study had an overall refusal rate of 31%, which ranged from 9% in Madurai to 47% in Hyderabad (data not shown). The refusal rate among hijra in the five districts of TN was 31%. The survey did not record reasons for refusals.

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Sociodemographic and sexual risk behaviours in different states

The sociodemographic and sexual risk behaviour characteristics of self-identified MSM by state are provided in Table 1. The majority of the respondents were in the age group of 18–24 years in AP (41.6%), MH (62.9%), and KTK (44%) and 25–34 years in TN (41.6%). The median age was 23–26 years across states and 16 years was the median age at first sexual act. More than two-thirds had their first sex act by the age of 18 years (76–84%). The mean age at first commercial sex was 16.5 years in KTK, 18.2 in MH, 18.3 in AP and 19.9 in TN. The literacy rates in self-identified MSM were between 78.2 and 90.9% across states.

Table 1

Table 1

Table 1

Table 1

Approximately 57.8% of respondents in AP identified themselves as bisexuals, 49.9% as kothis in TN, 45.7% as panthis in MH and 35.5% as hijra in KTK. The proportion of ever married self-identified MSM was 18.4% in MH, 20.8% in KTK, 23.3% in TN and 37.1% in AP, a majority of them were currently living with their spouses.

In KTK 67.9%, TN 59.3%, AP 42.2% and MH 40.0% of self-identified MSM reported having ‘paying male partners’. The proportion of self-identified MSM who reportedly paid male/hijra partners for sex was approximately 16.2% in TN, 26.2% in MH and 37.7% in AP. MSM who had ‘regular female partners’ were 42.7% in AP, 32.6% in MH. Approximately 35.7% of MSM in AP, 24.2% in KTK, 14.0% in TN and 20.6% in MH reportedly had ever paid to have sex with a woman.

The prevalence of HIV among self-identified MSM was 20.9% in AP, 17.3% in KTK, 11.3% in MH and 7.5% in TN. The prevalence of syphilis ranged from 8.4% in MH to 14.0% in TN. Awareness levels about HIV/AIDS were low (67.3%) in KTK as compared with other states (over 98%). The proportion who had ever taken an HIV test ranged from 13.0 to 55.5% across states. Only a fifth of them had undergone HIV testing voluntarily; the rest did so on medical advice. Approximately 76.6–87.0% of MSM (excluding KTK) feel at risk of HIV infection. A considerable proportion (30.4–57.3%) had misconceptions that HIV spreads through mosquito bites or sharing utensils/clothes.

Statistical comparison was not done as the purpose was not to compare data across the States.

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Comparison of sociodemographic and sexual risk behaviours among self-identified men who have sex with men

Table 2 details the sociodemographic and sexual risk behaviours of different self-identified MSM. Among the self-identified MSM surveyed, 36.5% were kothis, 21.9% double deckers, 19.8% bisexuals, 12.5% hijra and 9.3% panthis. The mean age at first sex was 15.9–17.5 years and at first commercial sex was 18.8–19.5 years across different categories. A significantly higher (P < 0.01) proportion of kothis (49.2%) had exposure to first sex before the age of 15 years, compared with other categories (24.5–34.0%). In contrast, a higher proportion (61.0%) of hijra had first exposure to sex at less than 15 years of age, with a mean age of 16.5 years at first commercial sex. A significantly higher (P < 0.01) proportion of the bisexuals (61.2%) were ever married, compared with other categories (11.2–25.3%). Similarly, a significantly higher (P < 0.01) proportion of ever married bisexuals were living with their spouses (86.3%), compared with other categories (55.9–67.7%). Approximately 63.5% of the hijra and 16.8% of kothis depend on sex work as the main source of income.

Table 2

Table 2

Table 2

Table 2

Among kothis, approximately 73.9% had paying male partners, 64.5% had regular male/hijra partners, 56.3% had ‘non-commercial non-regular male/hijra partners’. Among panthis, approximately 60.2% had non-commercial non-regular male/hijra partners, 45.4% had paid male/hijra partners for sex, 32.6% had a regular female partner and 30.2% had a paid female partner. Among double deckers, approximately 62.9% each had ‘non-commercial non-regular male/hijra partners’ and regular male/hijra partners. Among bisexuals, approximately 86.2% had ‘non-commercial non-regular male/hijra partners’, 67.6% had regular female partners and 55.4% had paid female partners.

A significantly higher (P < 0.01) proportion of kothis (73.9%) reportedly ever sold sex to men compared with the other categories of self-identified MSM (19.6–43%). The majority (87.3%) of the hijra were selling sex. The mean number of paying anal sex partners in the past week ranged from 6.3 among kothis to 4.2 among bisexuals. Approximately 50% of the paying anal sex partners in the previous week were unknown to the respondents. The proportion of self-identified MSM who ever had a paid male/hijra partner was maximum among panthis (45.4%), followed by bisexuals (41.9%) and double deckers (30.3%). A significantly higher (P < 0.01) proportion of bisexuals had ‘non-regular non-commercial male/hijra partners’ (86.2%), regular female partners (67.6%) and paid female partners (55.4%) compared with the rest of the self-identified MSM groups (barring hijra).

Consistent condom use was significantly low (P < 0.001) across categories of self-identified MSM and types of partners. Consistent condom usage was the lowest among bisexuals (13.1%) and highest among hijra (48.5%) with regular male/hijra partners during anal sex. Consistent condom use was 13.8–28.9% with non-regular, non-commercial male/hijra partners, 2.1–29% with female regular partners, and 23.3–48.6% with paid female partners. Consistent condom use during last one month with a paid male/hijra partner ranged from 17.3 to 50.0%. In contrast, more than 80% of self-identified MSM had reportedly used condom during the last sexual act with paying male partner. Among hijra, consistent condom use during anal sex with regular male/hijra partners was 48.5% as against 7.0% with ‘paid male/hijra partners’.

Approximately 59.4–74.2% of respondents have travelled out of town during the last 12 months. Of them, approximately 77.7% of the bisexuals, 73.6% of the kothis, 61.8% of panthis and 62.7 of double deckers had anal sex (paid/unpaid) at places they travelled to.

HIV prevalence was significantly higher (P < 0.05) among bisexuals (15.9%), compared with kothis (13.5%), panthis (7.6%), and double deckers (10.5%). The prevalence of syphilis ranged from 5.4% among panthis to 15.8% among kothis. The prevalence of urethral chlamydia infection was significantly higher (P < 0.01) among panthis (4.0%) compared with double deckers (2.3%), bisexuals (1.2%) and kothis (0.4%). The prevalence of any STI (NG, CT or syphilis serology) ranged from 8.9 to 16.1% across categories.

Among hijra the prevalence of HIV was 18.1% and syphilis was 13.6%. A majority (65.9–75.5%) of the self-identified MSM (barring hijra, 43.4%) felt that they are at risk of acquiring HIV. A significantly higher (P < 0.01) proportion of kothis (39.7%) had ever taken an HIV test compared with the other MSM (barring hijra, 44.0%) groups (15.9–32.2%).

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Sociodemographic and sexual risk behaviours by men who have sex with men reporting selling sex and not selling sex to men

A comparison of variables between self-identified MSM (excluding hijra) who reported selling sex to other men (MSW) with those who did not (non-MSW) is presented in Table 3. The age group of MSW and non-MSW were similar. Kothis were more (P < 0.01) likely to sell sex (73.9%), compared with double deckers (43.0%), bisexuals (29.5%) and panthis (19.6%). Only 15.0% of MSW reported sex work as the main source of income. The average number of paying anal sex partners among MSW in the previous week was 5.9, with a wide range of 0–60.

Table 3

Table 3

Table 3

Table 3

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%).

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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).

Table 4

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).

Table 5

Table 5

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The social construction of sexual identity and orientation of MSM do not have an overriding homosexual identity in India [11]. 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 [23]. 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 [3]. 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 [3]. 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 [28]. 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.

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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.

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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.

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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.

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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.

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Karnataka Health Promotion Trust (KHPT) Bangalore

Anitha, B.M. Sangameshwar, Christina, Kaveri Gurav, Raghavendra, Reynold Washington, Shajy Isaac, Shenvi, Sudheer, Sudipto Mondal, Usha Rani.

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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.

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AC Nielsen ORG-Marg Private Limited Hyderabad

Ranjit Panda, Gopal Krishna Kamat.

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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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AIDS; condom use; HIV; homosexual; men who have sex with men; sexually transmitted infection; unsafe sex

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