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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 349-355

Human immunodeficiency virus infection and acquired immune deficiency syndrome vulnerability of men who have sex with men in a border area of West Bengal, India


1 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Pulmonary Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
3 Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal, India
4 Department of Community Medicine, Calcutta National Medical College, Kolkata, West Bengal, India

Date of Web Publication18-Sep-2015

Correspondence Address:
Kanti Bhushan Choudhury
Meghalaya Apartment, 2nd floor, Room-5, 10 Kamalapur East, PO-Kamalapur, Kol-28, West Bengal
India
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Source of Support: Nil., Conflict of Interest: None


DOI: 10.4103/2348-3334.165736

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  Abstract 

Background: Studying level of living, awareness about sexually transmitted infections (STIs) including human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) and sex behavior of men who have sex with men (MSMs) is prerequisite for control of increasing AIDS among them in India. Objective: To assess sociodemographics, awareness about STIs including AIDS, and find out the pattern of high risk sex behavior of MSM. Methodology: Cross-sectional survey was undertaken in May, 2012 among MSMs catered by T I program via Nongovernmental Organization "Madhya Banglar Sangram" in Murshidabad District. 62 MSMs were included from five cruising spots sampled randomly out of fourteen such. Information was collected via interview and focused group discussions (FGD) using questionnaire and FGD guide. Blood samples were examined for VDRL reactivity. Results: Median age was 25 years and sexual debut at 13.67 ± 4.29 years. 87% respondents were residing in parental house, 20% was married, 40% had low education, 80.33% had additional jobs but 54% reported poor income. About 56% respondents knew "what is AIDS" and its spread via anal sex, mother to child transmission, needle sharing, sex worker, and blood transfusion reported by 52.46, 50.82, 47.54, 45.90, and 34.43%, respectively. More than 2/3rd, about 40 and 34.43% MSMs played "anal and oral receptive," "anal insertive" and "oral insertive" role. About 33% used condom regularly. Majority knew main symptoms of STIs. About 2/3rd reported discrimination by neighbors. Blood examination showed 6.45% VDRL reactivity. Conclusion: Reducing vulnerability of MSMs to HIV/AIDS requires holistic programs.

Keywords: High-risk sex behavior, human immunodeficiency virus infection and acquired immune deficiency syndrome, men who have sex with men, targeted intervention


How to cite this article:
Haldar D, Dwari AK, Sinha A, Goswami DN, Bisoi S, Bhattacharya N, Choudhury KB. Human immunodeficiency virus infection and acquired immune deficiency syndrome vulnerability of men who have sex with men in a border area of West Bengal, India. CHRISMED J Health Res 2015;2:349-55

How to cite this URL:
Haldar D, Dwari AK, Sinha A, Goswami DN, Bisoi S, Bhattacharya N, Choudhury KB. Human immunodeficiency virus infection and acquired immune deficiency syndrome vulnerability of men who have sex with men in a border area of West Bengal, India. CHRISMED J Health Res [serial online] 2015 [cited 2019 Sep 23];2:349-55. Available from: http://www.cjhr.org/text.asp?2015/2/4/349/165736


  Introduction Top


In depth study of perception and practice of people engaged in various modalities of sex behavior is sine qua non for control program of deadly human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS). Men who have sex with men (MSM) is a special group of people indulging somehow deviant, culturally unacceptable form of homosexual behavior. The United Nations General Assembly Special Session on HIV/AIDS report estimates that there are about 3.1 million MSM in India.[1] HIV infection among MSMs has been increasing globally in recent years particularly in Asia.[2] India is no exemption of this trend with current estimated HIV prevalence among MSMs ranging between 7% and 16.5% compared to the overall adult HIV prevalence estimated to be 0.31% (95% CI = 0.25–0.39%) in 2009.[1],[3],[4] The National AIDS Control Organization (NACO) of India estimated an overall HIV prevalence of 6.41% among MSMs, although this might be a lower limit estimate.[5] As per BSS 2009, 28 districts have 5% or more HIV prevalence among MSMs.[6] Karnataka, Andhra Pradesh, Manipur, Maharashtra, Delhi, Gujarat, Goa, Orissa, Tamil Nadu, and West Bengal are the states having the highest mean HIV prevalence among MSMs in 2008.[7]

Unfortunately around the world, transgenders and MSMs often face stigma, discrimination, poverty which lead to risky behavior among them. Violence against them often is a manifestation of stigma and discrimination due to the fact that they don't exhibit traditional sexual behavior. Lack of other employment opportunity limits option to profession like sex work.[8] Indian MSMs also experience multiple forms of social and legal discriminations.[9] It is this pervasive social intolerance along with the cultural pressure for men to engage in heterosexual marital relations that have led many MSMs to marry women and have children.[10],[11] Many MSMs engage in unprotected anal and vaginal sex with male and female sexual partners.[9],[10],[11],[12],[13],[14] Thus, MSMs community in India plays "bridging" role in spread of HIV into general population.

Murshidabad; a district of State West Bengal, India at Indo-Bangladesh border has a vulnerability to women trafficking and cross-border sex trade which is further complexed by a huge rush of tourists for its historical importance. The sex trade is a problem of this area. NACO is operating here via nongovernmental Organizations (NGOs) to cater MSMs through targeted intervention (TI) which involves single dimension modality including condom distribution, HIV education, voluntary HIV counseling and testing, and treatment of sexually transmitted infections (STIs). The purpose of the present study was to elucidate the challenges of providing effective HIV prevention program for this diverse and socially marginalized group at risk.

Objectives

(1) To describe the sociodemographics of MSMs, (2) to assess their awareness about STIs including HIV/AIDS, and (3) to find out the pattern of high-risk behavior existing among them.


  Materials and Methods Top


A cross-sectional survey was conducted in May 2012, among the MSMs catered by NGO "Madhya Banglar Sangram" in Murshidabad. It was selected randomly out of the 36 such NGOs providing TI under National AIDS Control Programme (NACP) in West Bengal. It reported catering of 200 MSMs in Berhampore, Lalbagh, and Beldanga areas of Murshidabad to implement TI program. Five Hot Spots were sampled randomly out of total 14 such cruising areas within the territory of the organization. From the selected spots, 62 (31% of total) MSMs were gathered by grass root workers of the NGO (peer educators [PE] and out-reach worker) and included in the study. Data were collected via both quantitative and qualitative approaches by interviewing individual MSMs and conducting focused group discussions (FGDs) among them using prescribed questionnaire and FGD guide in local language designed by West Bengal State AIDS Control Society (WBSACS). After interview blood samples collected from all participants were sent to laboratory for VDRL reactivity. Finally, three FGDs were scheduled at different locations involving 25 (10 + 7 + 8) MSMs.

Ethical clearance

"Ethical approval" from the appropriate Ethical Review Committee as well as "informed consent" of the participants were obtained.

Statistical framework

Data were summarized by calculating percentage, mean, standard deviation (SD), median, range and were displayed using charts and tables.


  Results Top


One response sheet was incomplete and data from 61 MSMs were analysed.

Base line characteristics

Majority (40%) of MSMs were in age range of 21–30 years. Average age was 28.43 ± 10.56 (mean ± SD) with range of 16–60 years and median of 25 years [Figure 1]. Almost 90% (87%) of respondents were reportedly residing in their own/parental house. Four out of every 10 reported to have low or no education. It was happy note that about 80% MSMs had additional jobs like petty business, salesmanship, agriculture works, animal husbandry etc., and sex trade was not their principal earning source, however, 54% reported poor income range of Rs. <1000/-3000/month. Few young MSMs went to Kolkata and earned handsome amount per month. About 20% of MSMs was reported to be married.
Figure 1: Distribution of men who have sex with mens as per the age groups

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Perception about human immunodeficiency virus infection and acquired immune deficiency syndrome

About 56% knew specifically "what is AIDS." Spread of HIV through anal sex, mother to child, sharing needles, sex worker, and blood transfusion was reported by 52.46, 50.82, 47.54, 45.90 and 34.43% of respondents, respectively [Table 1]. More than 90% of them were found to be aware about genital ulcer and discharge and swelling of groin [Table 2].
Table 1: Distribution of the participants as per their knowledge about transmission of HIV/AIDS (n= 61, multiple response)

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Table 2: Distribution of MSMs according to their sexual behavior (n=61, multiple responses)

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Sex-behavior and apprehension

As per the observation from FGDs, the sexual debut of MSMs was estimated to be at the age of 13.67 ± 4.29 (mean ± SD) years. Many MSMs were reportedly the victims of sexual coercion in their adolescence by any of their close relatives or else. At later age they developed the so called deviant sexuality and starting of sex adventure might be slightly earlier than their so called normal counterpart.

Majority (70.49%) of the MSMs declared them as "Kothi" [Figure 2]. More than 2/3rd, about 40% and 34.43% reported to play "anal and oral receptive," "anal insertive" and "oral insertive" role, respectively [Table 3]. About 1/5th (21.31%) of respondents had sexual act with woman in last 1-year out of that 61.54% had it with their wife and rest with female sex worker or stranger/girlfriend. This was both vaginal and anal sexes. However, in this respect only 38.46% used condom regularly. About 20% had insertive sexual act with woman in last 1-month and all of them used condom in every sex act including the last one.
Figure 2: Distribution of respondents as per their predominant role in sex behavior

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Table 3: Distribution of study population as per their knowledge about symptoms of STIs (n=61, multiple responses)

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About 64 (63.93)% participants reported to have oral sex with male in last 1-year and 70.49% reported to have anal sex with male in last 1-month.

On the whole, 32.78% of MSMs had used condom persistently and unavailability of condom at the time of sex was mentioned as the main cause (95.12%) of nonuse on regular basis by others.

They reported collection of free condom mainly (77.05%) from the TI workers. Due to irregular supply of free condom, MSMs had to purchase condom from different other sources among which other NGO's workers was on the top 63.93%). About 3/4th of the respondents (46 out of 61 i.e. 75.41%) stated use of lubricant on condom and majority (68.85%) of them used spit as lubricant. However, 57.38, 37.70, and 32.78% of the participants reported using of cream/vaseline, oil/grease, and KY jelly, respectively.

About 30% of participants informed that their partners consumed alcohol before or during sex. It was found that about 59% of participants solicited clients in more than one places, the average number of cruising area being 2.33.

Analysis further revealed that 85.25%, that is, 52 participants apprehended that they might acquire AIDS and out of that 59.61%, that is, 31 underwent blood examination, 25.0%, that is, 13 attended for counseling and blood examination and 5.76%, that is, 3 sought only the advice of doctor or counselor.

Overall, 33% reported regular use of condom. About 1/5th (13 i.e. 21.31%) participants confessed that they had an attack of STI in last 1-year of which self-medication was tried by 11 that is 84.62% and ultimately 12 that is, 92.31% were treated in the STI clinic run under the TI project. Blood examination under the survey showed 6.56% reactive to VDRL.

Sex trade

About 2/3rd of the respondents confessed acceptance of money in turn of sex with male and 34.43% reported paying money for having sex as well. Six out of every 10 MSMs also reported acceptance of gifts, especially from their Parikh in turn of sex and 41% offered the same as well. About 1/5th (21.31%) confessed receiving money for sex act with female and 22.95% MSMs reportedly pay money having sex with any female as well.

About 20% of participants believed that spread HIV/AIDS might occur by mere touching of PLHIV, 16.39% were found to have misbelief that AIDS could be cured through having sex with virgin and 36.07% believed that HIV would be acquired even if anybody had only one sex partner. However, 24.59% were found to have no knowledge on this issue and 63.93% had knowledge that HIV could also be acquired through male with male sex. Majority (91.80%) of participants had heard about integrated counseling and testing center, 88.52% knew places for testing for HIV, 72.13% reported that they underwent blood examination for STIs including HIV.

Discrimination and violence

About 2/3rd participants reported discrimination by neighbors, 41% by family members and about 46% by friends as well as at work place [Table 4]. The sex behavior of study subjects was accepted by their parents only in case of 34.43% and by siblings in 32.79% [Table 5]. Three out of every 10 (31%) MSMs experienced sexual violence in last 3 months period reportedly done mostly by local muscle-man (anti-social) and Police out of which 73.68% of victims reported to the T I workers and only 5.26% went to police, however 21.06% didn't report to anybody. Two third (67.21%) of respondents stated that they faced physical, emotional or social violence in last 6 months period. Seventy percent (70.49%) reported that they didn't get any service from the routine health workers.
Table 4: Distribution of MSMs as per the type of people by which they were discriminated

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Table 5: Distribution of MSMs as per the attitude of people around them (n=61, multiple response)

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Men who have sex with mens reported to come across harassment frequently. Majority (75.41%) of them inclined to report the "Crisis management team" running under the current TI project in case of any harassment. After sensitizing the police through its continuous advocacy the NGO could motivate a substantial portion (31.15%) of study subjects for reporting police directly in case of any harassment.

Program coverage

The NGO got financial aid from NACO via WBSACS. They submitted a growing beneficiary list of 300 MSMs. Though it is always very difficult to conduct any survey to estimate the number of MSMs who don't want to come on the surface because of stigma, still it was fact that only 62 MSMs could be assembled for interview. Total beneficiary was estimated to be hardly 150. Program component like STI clinic, regular condom distribution, establishing lianson with local community etc., were not found very compact.


  Discussions Top


Median age of MSMs was estimated to be 25 years as per the present study compared to 27 years observed in Pehcha-n baseline survey [15] in India as well as in a study conducted by Keer-Pontes in Brazil.[16] The median age offirst sex act, as revealed by present study was found to be somewhat lower compared to Pehcha-n base line survey (about 14 vs. 17 years). Like the Brazil study, this study also reported that majority of the MSMs lived with their family (59 vs. 75.41%). Concurrent with observation by Setia et al., this study also revealed that most of the MSMs were engaged in occupations like petty business, salesman, agriculture works, animal husbandry etc., as their principal earning source.[13] However, they were having low range of income. Low education, poor income level forced them to earn via sex trade and made them more stigmatized, marginalized, vulnerable to HIV/AIDS due to high risk sex behavior. Analysis also revealed that about 20% MSMs were married and played the role of bridge population compared to 22% observed by Setia et al.[13]

More than 2/3rd, about 40 and 34.43% of participants were found to play "anal and oral receptive," "anal insertive" and "oral insertive" role, respectively. Almost 2/3rd (67.22%) didn't use condom regularly mainly due to lack of its availability during sex act. The married group practiced bisexuality and acted as a "bridge" population for transmission of HIV among their wives. This was supported by other investigators.[10], 14, [17],[18],[19] During 2008–2009, 513 MSMs were recruited from four clinics at two cities of Mumbai and Hyderabad. On the basis of multivariate analysis, the data suggested that the association of risk factors was highest amongst MSMs who were engaged in commercial sex. Other risk factors included concurrent multiple sexual partners, low condom use during last sexual act and poor health seeking.[20]

A study conducted in Andhra Pradesh, India found that MSMs reported high rates of unprotected anal sex with other men and women.[10] A study among rural men from five different States in India also reported that 9.5% of single and 3.1% of married men had anal sex with other men and had greater number of male sexual partners, and found high rates of unprotected anal sex with male partners.[14]

The high level of awareness about STIs including HIV/AIDS as reflected from present study was a welcome phenomenon and might be result of the TI project.

In the present study apprehension of "being affected by HIV" was found in 85.25% of MSMs and a higher proportion of them sought care like counseling and testing. Similar finding was made from a recent estimate which also reported that MSMs have higher perceptions of risk from 62% to 75.5% and the authors too hoped that this perception of risk should increase HIV testing across the sites.[4] It might be due to this that the VDRL reactivity was low (6.56%) in this study compared to 16% in the study conducted by Setia et al.[21] HIV seropositivity was also found to be lower (3.33%) in this study than the recent NACO estimates of about 6.41%.[5]

Getting treated for STIs, a substantial proportion of MSMs tried self-medication (84.62%) based on others' advice and consulted quacks (46.15%) before going finally to STI clinic run by the NGO under TI program, chose care from private clinic (53.84%) as well and only 34.46% attended government health facility or workers. Only 16.39% stated that routine health workers met them. As per the study conducted by Chakrapani et al. in 2007 the kothis of India suffer oppression by health providers in the form of insults, breaches of confidentiality, and refusal of services.[22] It is because of the stigma, reluctant attitude of government STD clinic MSMs tried all avenues and finally it was the credit of the TI workers who motivated these victims of STIs for attending the counseling and treatment center run by the TI project. It was revealed that majority (61.54%) of these STIs affected MSMs sought treatment after 3 days but within 1-week from the onset of symptoms.

In India, MSMs encounter derogatory comments, criticism and ridicule, abandonment, isolation, and expulsion from family or marital home.[22] Facing discrimination, sigma and violence by MSMs as revealed in present study was in concurrence with the findings made in a survey of 500 MSMs in Kenya where 1/3rd of respondents reported experiencing some form of stigma or discrimination in the past 12 months, such as public humiliation.[23]

Take home message

Low education and poor income base, sex-trade, bisexuality, discriminating and stigmatized behavior of near and dear ones, sex-violence imposed by muscle-man and police, differential behavior from police and health workers, etc., continued the vulnerability of MSMs to HIV/AIDS that could not be curbed only by the existing fragmented intervention approach like TI which no doubt empowered them in the form of increase in awareness regarding HIV/AIDS in spite of its poor coverage and service delivery.


  Conclusions Top


Human immunodeficiency virus infection prevention among Indian MSMs requires a holistic approach rather than a segmental piecemeal measure like TI. The MSMs are to be considered in their sociocultural melieu, not just targeting them as vectors of HIV transmission. The stakeholders should be reoriented to consider the whole gamut in totality that is, how the low SES status, societal intolerance, stigma, violence, rejection, inadequate legal protection, etc., enhance risk requiring combined preventive measures that use new biomedical interventions aligned with culturally tailored behavioral approaches and that consider mental health and psychosocial concerns and lead to positive sexual health and overall well-being of MSMs. Reducing HIV related stigma among health providers, policymakers and the lay public can't be over-emphasized and the role for NGOs that work with the community to play in providing culturally relevant HIV prevention programs for MSMs is to be strengthened.

 
  References Top

1.
Independent Evaluation of National AIDS Control Programme. Jaipur: Indian Institute of Health Management Research; 2007.  Back to cited text no. 1
    
2.
van Griensven F, de Lind van Wijngaarden JW. A review of the epidemiology of HIV infection and prevention responses among MSM in Asia. AIDS 2010;24 Suppl 3:S30-40.  Back to cited text no. 2
    
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Thomas B, Mimiaga MJ, Menon S, Chandrasekaran V, Murugesan P, Swaminathan S, et al. Unseen and unheard: Predictors of sexual risk behavior and HIV infection among men who have sex with men in Chennai, India. AIDS Educ Prev 2009;21:372-83.  Back to cited text no. 4
    
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9.
Chakrapani V, Kavi AR, Ramakrishnan LR, Gupta R, Rappoport C, Raghavan SS. HIV prevention among men who have sex with men (MSM) in India: Review of current scenario and recommendations: SAATHI (Solidarity and Action Against The HIV Infection in India) Working Group on HIV Prevention and Care among Indian GLBT/Sexuality Minority Communities; 2002.  Back to cited text no. 9
    
10.
Dandona L, Dandona R, Gutierrez JP, Kumar GA, McPherson S, Bertozzi SM, et al. Sex behaviour of men who have sex with men and risk of HIV in Andhra Pradesh, India. AIDS 2005;19:611-9.  Back to cited text no. 10
    
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Go VF, Srikrishnan AK, Sivaram S, Murugavel GK, Galai N, Johnson SC, et al. High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India. J Acquir Immune Defic Syndr 2004;35:314-9.  Back to cited text no. 11
    
12.
A Baseline Study of Knowledge, Attitude, Behavior and Practices Among Men Having Sex with Men at Selected Sites in Mumbai. Mumbai: Humsafar Trust; 2002.  Back to cited text no. 12
    
13.
Setia MS, Lindan C, Jerajani HR, Kumta S, Ekstrand M, Mathur M, et al. Men who have sex with men and transgenders in Mumbai, India: An emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol 2006;72:425-31.  Back to cited text no. 13
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15.
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16.
Kerr-Pontes LR, Gondim R, Mota RS, Martins TA, Wypij D. Self-reported sexual behaviour and HIV risk taking among men who have sex with men in Fortaleza, Brazil. AIDS 1999;13:709-17.  Back to cited text no. 16
    
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Gangakhedkar RR, Bentley ME, Divekar AD, Gadkari D, Mehendale SM, Shepherd ME, et al. Spread of HIV infection in married monogamous women in India. JAMA 1997;278:2090-2.  Back to cited text no. 17
    
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Hernandez AL, Lindan CP, Mathur M, Ekstrand M, Madhivanan P, Stein ES, et al. Sexual behavior among men who have sex with women, men, and hijras in Mumbai, India-multiple sexual risks. AIDS Behav 2006;10 Suppl 4:S5-16.  Back to cited text no. 18
    
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20.
Phillips AE, Boily MC, Lowndes CM, Garnett GP, Gurav K, Ramesh BM, et al. Sexual identity and its contribution to MSM risk behavior in Bangaluru (Bangalore), India: The results of a two-stage cluster sampling survey. J LGBT Health Res 2008;4:111-26.  Back to cited text no. 20
    
21.
Setia M, Jerajani HR, Kumta S, Mathur M, Kavi AR. A Preliminary Analysis of the Population at a Clinic for MSMs. 13th International AIDS Conference. Durban, South Africa; 2000.  Back to cited text no. 21
    
22.
Chakrapani V, Newman PA, Shunmugam M, McLuckie A, Melwin F. Structural violence against Kothi-identified men who have sex with men in Chennai, India: A qualitative investigation. AIDS Educ Prev 2007;19:346-64.  Back to cited text no. 22
    
23.
Onyango-Ouma, W, Harriet B, Scott G. Understanding the HIV/STI Prevention needs of men who have sex with men in Kenya. Washington, DC: Population Council, Horizons; 2006.  Back to cited text no. 23
    


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