All three core groups affected and infected in the HIV epidemic -- men having sex with men, sex workers and injecting drug users -- are criminalised in India. How can any intervention work amongst groups whose behaviour is criminalised? Ashok Row Kavi calls for basic structural changes, including the deletion, or at least reading down, of Section 377 of the Indian Penal Code on sodomy, decriminalising sex work and curbing narcotics trafficking instead of punishing end-users

Unlike the other health programmes of the Government of India, the National AIDS Control Programme (NACP) deals with three deeply stigmatised and invisible core populations: intravenous drug users (IDUs), male and female sex workers (SWs) and men having sex with men (MSM). All these three “infected and affected” core populations were not just invisible to the health infrastructure; they were stigmatised and criminalised under Indian law. So the government had to “search and hunt” for these populations. It also had to face the demand for recognition from these communities.

In India, only in the third stage of the NACP did the National AIDS Control Organisation (NACO) acknowledge that MSM populations were not just “highly infected and affected” by HIV but were also a core group that required urgent attention. This was based on evidence from its sentinel surveillance data.

All over the world, men who have sex with men (MSM) have unprotected anal sex, because it is not seen as high-risk. In the Indian cultural context, anal sex is not seen as sex at all; it is called ‘masti’. So the situation among Indian MSM is more serious. However, in India, MSM are not seen as a high-risk group. Such men have poor visibility and they don’t form part of the social landscape.

MSM in India are at significant risk of HIV infection because:

• They have frequent anal sex (45-55% of MSM in India practise anal sex).
• Only between 5% and 20% of MSM use condoms for anal sex.
• They have a large number of partners, reportedly between 11 and 28 casual partners per month.
• They have poor health-seeking behaviour, with only 20-30% of MSM going for STI check-ups.

The invisibility of MSM was driven home to me recently when the project director of NACO, Sujatha Rao, asked me to present operational guidelines for MSM interventions to the project directors of State AIDS Control Societies (SACS). “Start,” she ordered, “with telling them who MSM are.”

That’s when it struck me how far down the road some of us activists have reached and how far behind we have left our health administrators. It was also an indication of how difficult the HIV and AIDS prevention programme is, and the roadblocks the National AIDS Control Organisation faces.

Recently I had the experience of sensitising judges of the various state high courts of India. Here, I was confronted with an incredibly high wall of homophobia and a lack of understanding of issues around sex, sexuality and gender in the highest echelons of the judiciary.

The problem is gargantuan because the issues are problematic. Not only is there no understanding of the populations involved, the approach is also very simplistic.

For example, it seems to be easier to conflate identity with risk behaviours. Thus, instead of talking about “unprotected anal sex between men having sex with men,” all men having sex with men are identified as a high-risk group. All sex workers are not at equal risk; those who are most marginalised, such as street-based women in prostitution, face greater risks. Likewise, in the MSM sector, NACO seems obsessed with ‘kothis’ or effeminate men.

Such a simplistic approach is easier for our health administrators but it is certainly not how HIV prevention programmes should be planned. This is one of the most complex situations the HIV programme confronts today.

Need to focus on risk behaviour

In Humsafar Trust prevention programmes, for example, we discovered that conflating gender and identity to fit into a particular kind of risk behaviour did not work. While effeminate homosexual men, or kothis, were said to be at the highest risk, we found from our grassroots work that, behaviourally, homosexual men who had furtive sex in public toilets, parks and beaches were as much at risk as castrated hijras in sex work. Even among hijras, the Humsafar Trust street outreach programme indicated that nearly 75% of cross-dressing males were not castrated; they were fully functional males who also penetrated other males if offered adequate monetary incentives (‘dhoruu-kothis’).

Such subtleties are lost in a cookie-cutter, ‘one-size-fits-all’ system which does not involve community-based organisations (CBOs). Gay CBOs have sometimes been bypassed in favour of organisations with no experience in work with homosexuals.

Initial prevalence studies provided startling figures. In 2006, the first sentinel surveillance among hijras was done at Mumbai’s Sion Hospital. Samples from 250 hijras (anonymous, unlinked to the source of the sample) were tested and a shocking 26% of them were HIV-positive. In Delhi, the sentinel surveillance among hijras at the NGO Sahara found that 43% were positive. In 1999-2000, Humsafar Trust found that 13.8% of all samples collected as part of a baseline survey of six sex sites were positive. In fact, HIV prevalence in various surveys has rarely been less than 10%. Given that any prevalence above 5% is seen as ‘hyper-endemic’, this was a public health disaster.

After starting with a denial of a large behaviourally homosexual population, the Indian health infrastructure is beginning to face some bitter facts -- not only is there a large population of men having sex with men, but totally new ways would have to be devised to reach out to them.

Bridge population

Unlike the other two core groups (IDUs and SWs) MSM include bisexuals, a huge bridge population or link between a sub-population with very high infection rates and a sub-population with much lower infection rates. In this case, the bridge is between high-risk multi-partner homosexuals having unprotected sex, and married women who are immobile, have no negotiation powers and generally do not have multi-partner sex. The bridge population of bisexual men is not only into high-risk unprotected sex, it is also mobile, extremely diverse and reaches across every social status and age-group.

If ‘large’, how many are they?

The first estimations of the size of the MSM population were attempted by using culturally inappropriate models like the Kinsey Scale which gave very high figures; apparently, over 35% of American adult males were having occasional, frequent or consistent sex with other males for at least five to 10 years of their sexually active lives. But nobody would extrapolate those figures to India. Some activists who conducted qualitative studies found that men in India had more sex with their own gender because of various cultural factors. However, there were few quantitative studies for the government to plan its public health budgets.

New estimates lead to expanded interventions

The first such estimate was attempted recently, during the planning exercise for the third stage of the National AIDS Control Programme. First, a literature search was conducted on all the research available on how many men who had sex with other men were also into anal sex. Not all MSM were into frequent anal sex and it was important to narrow the focus down to only those MSM who were having frequent anal sex. The figures ranged from 6% to over 11% in various sexually active male populations in the country. The group arrived at the conservative, lower estimate of 5% of sexually active adult (aged 18 and above) males in the country.

Data from the census and the National Family Health Survey (NFHS) of 1998-99 was used to calculate that there were approximately 2.35 million vulnerable MSM who had predominantly anal sex. Of these, it was judged that just 20% were to be found in public sex sites in the country. And of these, a minimum of 10% were male sex workers (MSWs).

Epidemiologists from NACO and other researchers determined that it would be very difficult to distinguish between MSM and MSW in public sex sites. Except -- possibly -- for some difference in the level of negotiation skills, both had the same vulnerabilities. They had the same number of partners and low condom use. It was therefore decided that in the first year of NACP III, there would be a scale-up in the number of targeted interventions (each reaching out to 1,000 key populations) for MSM, from 30 in NACP II to 230 in NACP III.

Thus the behaviourally homosexual population has finally been identified as a core segment with which national health programmes have to engage seriously if NACP III is to have a modicum of success.
 
Continuing challenges for the programme

The programme is yet to address some major difficulties in providing support services to MSM. As pointed out earlier, there is no sensitivity to MSM issues. STI clinics directed at oral or anal sex services do not exist, and STI doctors are not culturally sensitised to MSM issues. Further, MSM community-based organisations are not encouraged to take up health issues which directly affect their communities.

Without the active cooperation of non-governmental organisations and community-based organisations, the government HIV/AIDS prevention programme cannot go forward. Government health facilities to access these communities have to be sensitised and trained. Presently, none of the three core groups can even access public health facilities, let alone use them.

Perhaps most important is the question of how the programme can conduct interventions among a group whose behaviour is criminalised.

All three core groups affected and infected in this epidemic are criminalised. Basic structural changes are necessary for health programmes to be effective. These include deletion or reading down of Section 377 of the Indian Penal Code on sodomy, decriminalising sex work and changing the approach to narcotics control by tightening up on trafficking and not punishing end-users. Only then can we openly talk about stigmatised behaviours like anal sex, intravenous drug use and sex work, and engage these groups.

(Ashok Row Kavi is a Founder Member of the Humsafar Trust, India’s oldest gay community-based organisation. He currently works with UNAIDS as Desk Officer of its programme for transgendered people and men having sex with men)

InfoChange News & Features, January 2008