Targeted HIV Interventions for MSM Communities –are the current strategies working?

MYRADA	No.2, Service Road Domlur Layout BANGALORE 560 071. INDIA.
Rural Management Systems Series Paper – 56	Telephone Fax E-mail Website	: : : :	25352028, 25353166, 25354457 ++91-80-25350982 myrada@bsnl.com http://www.myrada.org

 Targeted HIV Interventions for MSM Communities –are the current strategies working?

The Myrada Experience

July 2010

 Background

AIDS was first identified among gay men in the US in the early 1980s. Since then, there have been various studies to show that the prevalence of HIV infection amongst men who have sex with other men has been increasing. NACO’s sentinel surveillance data has also reflected this increasing trend, and shows an average of 7.4% positivity amongst MSMs. Among MSM, high prevalence was recorded in Karnataka (17.6%), Andhra Pradesh (17%), Manipur (16.4%), Maharashtra (11.8%), Delhi, Goa and Gujarat.[1]

New sites in Andhra Pradesh and Goa showed high prevalence among MSM, indicating that better detection is required. Urban areas registered much higher rates of HIV among MSM, particularly Delhi, Pune, Bangalore, Surat, Rajkot and Kolkata.

Prevalence among men who have sex with men (MSM) has seen an upward trend in the southern states. In southern India, between 7.6 and 18.1 per cent of all HIV infections are MSM cases[2].

The MSM statistics from the southern states are comparable with some of the most prevalent MSM destinations in Asia like Myanmar (29.3 per cent) Bangkok (30.7 per cent), Chongqing city in China (12.5 per cent) and Indonesia (5.2 per cent).

The MSM population in Asia face the odds of nearly one in five being infected with HIV.  In the last seven years, the proportion of women living with HIV in Asia increased from 19 per cent in 2000 to 35 per cent in 2008.

In Karnataka, prevalence among MSM-T for the year 2006 from Sentinel Surveillance and IBBA conducted by KHPT has shown a prevalence of 19.2 and 19.6 respectively[3].

However, unlike the HIV prevention program for female sex workers, there aren’t many studies describing the factors related to HIV risk in MSMs; or behavioral components of this community. One study clearly describes in detail the various issues that need to be taken into account when understanding the various factors that make the MSM community vulnerable to risk[4]

NACO has detailed operational guidelines for targeted interventions for high risk groups. The components included for a program involving the MSM community is similar to that for the FSW community[5] – outreach and communication using the peer approach, service provision (DIC, STI treatment, condoms and lubricants for MSMs), creating an enabling environment (police sensitization, advocacy with stakeholders, crisis management) and community mobilization (this component is not reflected in the actual TI budget and program). The only difference between the FSW and MSM program in the guidelines is the presence of lubricants for the latter.

There is no doubt that there needs to be a special focus on HIV programs that specifically address the MSM community. Interestingly, there is a separate set of strategies and operational guidelines for targeted interventions for IDU community.

In early 2004, Myrada was selected as a partner by KHPT/Avahan to implement the 5 year Sankalp project in four districts – Gulbarga, Chitradurga, Bellary and Kolar. At that point in time, it was understood that the program would look at reducing the prevalence of HIV in the urban female sex workers and MSMs in the districts. Soon after the initial denominators were established, the project components of a targeted intervention approach for HIV prevention were identified. These components included outreach services of reported STIs, regular health checkups, community mobilisation and establishing an enabling environment (largely limited to police sensitisation in the beginning). They were commonly designed for both female sex workers and MSMs. The delivery system was through peer educators, condom promotion through direct distribution, syndromic management introduced for all these 3 community groups.

 Early findings

Within a year of active implementation (early 2006), Myrada realised and documented a few key issues:

1. FEMALE SEX WORKER PROGRAM

The Avahan program (as well as the NACO program) was designed as a focused prevention program with a major focus on risk reduction measures; these measures were peer based outreach, condom provision and referral to health and STI services. Myrada soon realised that the female sex worker community expressed several needs related to vulnerability reduction. In fact, addressing these vulnerabilities (which would then in turn enable them to focus on reducing risk) was considered more important by the community members. They decided that they wanted to be recognised as human beings who could practice safe sex , free from harassment and oppression; as well as have the freedom to select alternate livelihoods at their pace and time, and most importantly- to be accepted by the general community. They are very concerned about their children’s future and unanimously clear that they do not want their girl children to enter into the sex worker profession.

Therefore, Myrada realised it was important to respond to these needs by addressing several vulnerabilities that these women faced – socio economic issues, family issues, livelihood issues, stigma and discrimination, harassment and oppression by power brokers, health care providers etc.

The Avahan project did include police sensitisation as a major component to provide an enabling environment. Additionally, Myrada initiated several activities to address other issues – which then were adopted later by other Avahan partners. These included linkages to social schemes and entitlements like housing and education support, formation of small groups – Soukhya groups, linkages to banks and financial institutions, etc . They were given as much attention as condom promotion and health services, if not more.

These have now become the “norm” in several “TI” programs across the country for FSW programs.

1. MSM PROGRAM

At the same time, Myrada clearly realised that the prevailing MSM strategy was neither effective nor sustainable.

Outreach and communication using the peer approach was difficult with group which was so diverse. How could one peer look after 60 MSMs who were a mixture of kothis, hijras and double deckers[6]? Each sub group required a different approach and peer training.

Condom distribution was the most successful component of all. The recent introduction of lubricants has also helped. However, peers are not trained on the importance of stressing the use of regular use of condoms and lubricants with all partners- regular, casual or commercial. Also, condom negotiation skills are very different from those required for an FSW program- and these are not clearly communicated to the outreach team.

Service provision is standardised as per the FSW program- a drop in centre, referral to STI services and HIV testing. There is no flexibility to adapt the drop in centre to suit the various sub groups of the MSM community. Also, the doctors for STI services are not sensitised on how to work with the MSM community and often are themselves perpetrators of stigma and discrimination.  There is no separate ICTC for the MSM community with counsellors and laboratory technicians sensitised to the needs of this community.

Community organization strategies, like those adopted by the FSWs, were not very successful since the key ingredients – affinity and economic homogeneity – are not features of this group. There were too many sub groups in conflict with each other, and in competition for recognition. It was found that this community also had a large majority that were educated, with a stable source of income that was mainstreamed and acceptable to the public; their high-risk sexual behaviour was more by choice than due to economic necessity.

Also, in contrast to the FSW program, the vulnerability of MSM was being ignored in the targeted program design and implementation. Creating an enabling environment was limited to dealing with police harassment or issues related to Section 377. The field reality was very different. The MSM community faces a great deal of internal discrimination and harassment, and has vulnerabilities that are not socio-economic in nature. Their vulnerabilities centre on family acceptance, perceived need to be “accepted” by general society, self esteem and self worth, dealing with power relationships, and sexual identity etc. These are not being addressed adequately in the national HIV AIDS prevention program.

Hence, Myrada proposed (in 2008) to pilot a program for MSMs with differing strategies for different sub groups. The idea was to design outreach and service provision differently for the educated and middle income groups within MSMs, where the MSM community would take a larger role in planning and designing their program, while Myrada provided technical support and linkages. For the especially vulnerable sub groups (hijras, male sex workers etc), the program would be closer to a peer designed outreach and direct service provision approach. However, this proposal was not accepted by the donors, and Myrada was asked to revert to the standard “TI” approach.

Current scenario

Now, at the end of completing five years, and in the process of transitioning out of the targeted intervention programs, Myrada has taken stock of the MSM program in its implementing districts.

A profile of the MSM community in the four districts where Myrada has been implementing targeted intervention programs revealed that[7]:

1. The most vulnerable sub groups of MSMs (hijras) constituted only 2% of the MSM population; while the least vulnerable (double deckers) was around 42%.
2. Around 13% of the MSM community were below 20 years of age – mainly college students.
3. Only 24 % of the community were illiterate in contrast to the FSW community where around 88% were illiterate.
4. About 31% of the MSMs were married and only 15% of the community were dependent on sex work for their regular source of income.

We find that the majority do not have livelihood issues; majority are literate enough to read and write; and most are not in the highest risk category (hijras in this case). Perhaps these factors are the reason the MSM community cannot find a common platform or feel the necessity to meet on a regular basis or be part of one common institution.

Since it is known that the MSM community is at high risk of contracting and transmitting HIV, and that they need HIV prevention services such as regular condom and lubricant use and regular health checks including HIV testing, there is no doubt that some sort of service delivery program is necessary.

This has left us with a series of questions:

1. Who (in the MSM community) needs what services? The larger question is to understand who constitutes the MSM community.

Who do we include in the group “men who have sex with men”?

NACO clearly defines this group as “all men who have sex with other men as a matter of preference or practice, regardless of their sexual identity or sexual orientation and irrespective of whether they also have sex with women or not. This term does not refer to those men who might have had sex with other men as part of sexual experimentation or very occasionally depending on special circumstances.”[8]

There are several subgroups among MSM. For the purposes of NACO’s targeted intervention program, these groups are defined as below.

Hijras: Hijras belong to a distinct socio-religious and cultural group, a “third gender” (apart from male and female). They may dress in feminine attire (cross dress). Among the hijras there are emasculated (castrated, nirvan) men, non-emasculated men (not castrated, akva/akka) and inter-sexed persons (hermaphrodites). They are often referred to as transgenders in a HIV program.

Kothis: The term is used to describe males who show varying degrees of “femininity” (which may be situational), they take the “female” role in their sexual relationships with other men, and are involved mainly – though often not exclusively – in receptive anal/oral sex with men. Some proportion of Kothis have bisexual behaviour and many may marry a woman.

Double Deckers: Kothis and hijras label those males who both insert and receive during penetrative sexual encounters (anal or oral sex) with other men as Double Deckers. These days, some proportion of such persons also self identify as Double Deckers.

Panthis: The term panthi is used by kothis and hijras to refer to a “masculine” insertive male partner or anyone who is masculine and seems to be a potential sexual (insertive) partner.

What about many men who have casual sex with other men who do not identify with any of the above groups. What about truck drivers, cleaners, hotel boys, mechanic workers etc? What about the group included under pedophila?  Are these not vulnerable to HIV infection? Who tracks them? Even the existing trucker interventions do not focus on anal sex, assuming that all truckers only indulge in heterosexual vaginal sex.

1. What kinds of strategies are required for each of these sub groups- how do they differ from each other?

We can only say without doubt, that the strategy for MSMs has to be different from the FSW program. It is important to take into account the different sub groups, the different reasons for high risk behaviour, and the different vulnerabilities this community faces. Currently, as quoted by a senior program officer in HIV programs “the only difference between the NACO FSW and MSM targeted intervention program is the provision of lubricants in the latter”.

Do all MSMs need these services to be provided to them directly or can they take the initiative to access these services given the fact that many of them are educated and confident?

In our opinion, most members of the MSM community who are educated or with a stable source of income require a different approach where they make the decisions about what services they need, pay for most services (at least subsidised costs) and plan their outreach strategy to suit them. It is only the very vulnerable, poorer group, largely dependent on sex work that probably requires direct provision of services through an intense outreach approach.

1. Who should provide services? With so many differing sub groups, who will be the peer in a small town scenario? What is the role of the health department? What is the role of existing MSM CBOs?

Expecting one peer (ratio of 1 to 60) to be the answer to all HIV outreach and services is not the approach, given the heterogeneity of this community. Also, with so much internal stigma and discrimination, it is difficult to identify the most suitable person to be peer who will be accepted by all community members (even within a sub group).

The additional stigma and discrimination from the general community including health providers needs to be addressed on a war footing, so that all MSMs are treated with dignity and respect and as human beings first.  So far, Myrada has not come across any models successfully demonstrating programs aimed at reducing stigma and discrimination.

1. From our experience, HIV prevention is not the priority of the MSM community. There are several other issues that are more important to them. Is it reasonable to expect the community to organise themselves around a health/ HIV issue? If not, is it the role of a HIV prevention program to organise this community? Will donors look at the need for MSMs to first organize themselves around other issues (rights, psycho social issues) before addressing HIV specifically?

In our opinion, the MSM community will be best suited to take the lead in addressing the issue of HIV. However, who will help to organise them? Several run of the mill NGOs who are currently implementing HIV targeted interventions for MSMs do not have a clue about how to organise the MSM community. Myrada itself came to the conclusion that it is not possible to use the small group approach here; it is also not feasible to have only one common collective model for all the different sub types of MSMs and expect this CBO to function smoothly and on its own.

Who is best suited to form MSM community organisations or to “train” other NGOs to do this? What are the learnings from existing MSM based CBOs implementing HIV AIDS programs successfully under the NACO guidelines?

We do not have answers to these questions as of now.  But we think it is important to ask them and start looking for the appropriate answers. We do know that if we leave things as they are, the HIV prevalence in the MSM community is only going to increase further, along with continued stigma and discrimination.

Mr. Aloysius. P. Fernandez                                   Dr. Maya Mascarenhas

Annexure – Profile of MSM Community (December 2009)

Myrada Soukhya program

Parameter	Number	Percentage	Remarks
Total registered MSMs	3643	165% of estimated
Regular contact	2971	81.55% of registered	This is in compliance with KHPT / Avahan targets
Typology – Hijras	75	2.06%	Highest risk for HIV
Satla-Kothis	442	12.13%	Transgender who cross dress
Kothis	1037	28.47%	Largely pleasure only MSMs
DD	1521	41.75%	Comparatively lowest risk for HIV – act both as clients and as recipients.
Age group  <20 yrs 21-30 years	437 1833	13% 54%	mainly college students
Education status –Illiterate Completed 4th Completed 10th	836 801 1769	24% 23% 52%
Currently married Unmarried	1071 1493	31.43% 43.81%
Full time commercial sex workers only pleasure MSMs	489   2019	15%   62.47%	Only 15% of the MSMs are full time commercial sex workers and depend on sex work for their income
Volume wise – high	555	16.34%	45.55% are low volume
HIV positive (out of tested)	78/1200	6.5%