A Study on HIV Related Risk Behaviors of Men Having Sex with Men In Mumbai and Thane -Wave IV The Humsafar Trust

1. Research studies as an integral part of an intervention were in-built into the programs of Humsafar Trust. This study is the third in that series which looks into the crucial indicators of enhancement in knowledge and change in sexual behavior of men-having-sex-with-men (MSM) in Mumbai city and some suburbs located in Thane district. Research studies as an integral part of an intervention were in-built into the programs of Humsafar Trust. This study is the third in that series which looks into the crucial indicators of enhancement in knowledge and change in sexual behavior of men-having-sex-with-men (MSM) in Mumbai city and some suburbs located in Thane district.

2. Objectives 1. To assess the knowledge and attitude of MSM towards HIV/AIDS 2. To assess sexual behavior and practices 3. To assess the health seeking behavior of MSM

3. Indicators Awareness Related Indicators Knowledge of HIV prevention No incorrect beliefs about HIV transmission Sexual Behavior Related Indicators Number of male sex partners in last one month Condom use at last peno-oral sex (with a male partner)

4. Indicators (contd.) Consistent condom use during peno-oral sex (with a male partner) in last one month Condom use at last insertive anal sex (with a male partner) Consistent condom use during insertive anal sex in last one month (with a male partner) Condom use at last receptive anal sex (with a male partner)

5. Indicators (contd.) Consistent condom use during receptive anal sex in last one month (with a male partner) Number of female sex partners in last one month Condom use at last vaginal sex (with a female partner) Consistent condom use during vaginal sex during last one month(with a female partner)

6. Study Methodology The Respondents Self-identified homosexual men (or men having sex with men) in mapped out sites Coverage: 310 Final sample size: 295 Instrument: Semi structured questionnaire As a first step, a technical advisory group comprising the chairman of Humsafar Trust, Outreach Manager, Fieldwork Manager, Social Research Consultant, FHI Technical Research Expert, MDACS’ monitoring officer was formed to take up decisions on technical, operational and ethical issues of the study. This group met and discussed number of times to finalize the methodology, sampling and instrument. An e-mail group was formed to keep every member abreast of the developments. As a first step, a technical advisory group comprising the chairman of Humsafar Trust, Outreach Manager, Fieldwork Manager, Social Research Consultant, FHI Technical Research Expert, MDACS’ monitoring officer was formed to take up decisions on technical, operational and ethical issues of the study. This group met and discussed number of times to finalize the methodology, sampling and instrument. An e-mail group was formed to keep every member abreast of the developments.

7. Procedure of Sampling Two-stage Time- Location- Cluster Sampling Step-1: Required no. of time, location and clusters were selected through systematic random sampling Step-2: Required no. of respondents were randomly drawn from each time location cluster

8. Training, Fieldwork & Analysis Team: Investigators : 8 Supervisors : 2 Manager : 1 Training program Fieldwork: June, 2005 Data analysis: SPSS/PC Questionnaire which was used for first two rounds was used this time also, albeit with some additional questions as well as some modificationsQuestionnaire which was used for first two rounds was used this time also, albeit with some additional questions as well as some modifications

9. Respondents Eligibility Criteria Men who have had manual/oral/anal sex with another man in last one month Men who have completed 18 years of age

10. Socio-Economic Profile 74% of respondents born and brought up in Mumbai 26% MSM mainly from districts in Maharashtra, followed by Uttar Pradesh. 79% came to find work Mean age of the respondents: 27 years, Median 25 years 68% unmarried, 30% married

11. Socio-Economic Profile(contd.) Occupation: 65% in private or govt. Service 12% Self employed 8% small business/shop 6% students 2% commercial sex Average monthly family income: Rs. 11,701 Individual monthly income: Rs. 5351

12. Socio-Economic Profile (contd.) Mobility Pattern - 81% respondent travel outside - 31% travel at least once a month Reasons of Travel - Work, entertainment, family commitment - 8% reported to travel in search of sex partner Cities of Travel Pune, Nasik, Ratnagiri, Delhi, Bangalore, Baroda and others

13. Knowledge, Attitude of MSM Towards HIV/AIDS This section presents knowledge related indicators for those respondents who had sex with another man in last one month. Interventions related to HIV/AIDS historically began with awareness building about the transmission as well as methods of prevention. Therefore, issues pertaining to awareness about HIV/AIDS go beyond `ever heard of HIV/AIDS’ in this section. An in-depth knowledge about respondent’s epidemiological understanding HIV/AIDS, prevention, transmission and treatment has been presented in this chapter. This section presents knowledge related indicators for those respondents who had sex with another man in last one month. Interventions related to HIV/AIDS historically began with awareness building about the transmission as well as methods of prevention. Therefore, issues pertaining to awareness about HIV/AIDS go beyond `ever heard of HIV/AIDS’ in this section. An in-depth knowledge about respondent’s epidemiological understanding HIV/AIDS, prevention, transmission and treatment has been presented in this chapter.

14. Knowledge of Modes of Transmission Correct Beliefs on Modes of Transmission Through sex without condoms (99%) From infected mother to unborn child (86%) Through transfusion of HIV infected blood (94%) Through usage of infected needle (92%)

15. Incorrect Beliefs on Modes of Transmission `No’ to Modes of Modes of Transmission Mosquito bite (80%) Kissing on cheeks (89%) Using same toilet as HIV+ve person (84%) Eating in the utensils of the infected person (74%) Residing with an HIV+ve person (87%) Hugging infected person (91%)

16. Knowledge of Prevention of HIV By avoiding penetrative sex (75%) By using condoms during penetrative sex (96%) By using sterilized needles, syringes and skin piercing instruments (69%) By avoiding pregnancy if a woman is discovered to be HIV+ve (81%)

17. Awareness Indicators Summed 81% of respondents knew all four correct modes of transmission 43% of respondents knew all four correct methods of prevention

18. Whether HIV Means Death?

19. Whether There Is Cure For HIV?

20. Knowledge About AIDS 54% respondent said that AIDS was a killer disease 87% replied in affirmative that AIDS means death 72% replied in negative to whether there is any cure for AIDS

21. Attitude and Perception About HIV+ve Person 32% respondents said they would continue the relationship but not have sex if they learnt their partner was HIV+ve 13% perceived a HIV+ve person to be immoral, however 22% had sympathy 61% identified HIV treatment as a support service 29% knew someone who was PLWHA

22. Sexual Behaviors And Condom Usage- Types of Partners In Last One Month Spouse: MSM Husband/Wife Regular: A partner with whom the respondent has sex at least once a month but not a spouse Irregular: Casual partner meaning any pick up from these sites Commercial sex partner: Sex in exchange of cash or kindSpouse: MSM Husband/Wife Regular: A partner with whom the respondent has sex at least once a month but not a spouse Irregular: Casual partner meaning any pick up from these sites Commercial sex partner: Sex in exchange of cash or kind

23. Sexual BehaviorPartners Average no. of male partners in last one month: 5 (Median=4) Respondents reporting having sex with female partner in last one month: 37% Average no. of female partner in last one month: 2 It must be noted here, that mainly cruising (92%) and friends (56%) served sources through which respondents met their sex partners. Local railway station (81%), public toilets (69%) served as places of meeting. Most of the sex activities took place in the safety of friend’s (70%) and own home (63%).It must be noted here, that mainly cruising (92%) and friends (56%) served sources through which respondents met their sex partners. Local railway station (81%), public toilets (69%) served as places of meeting. Most of the sex activities took place in the safety of friend’s (70%) and own home (63%).

24. Sexual Behavior & Condom UsageSexual Identity MSM Identities (Khoti, Panthi, Gay, MSM) 52% Bi-sexual 20% Human Being 15% Ambiguous 3% DK 10%

25. Sexual Behaviors And Condom Usage (contd.)Condom Availability 88% respondents said condoms were easily available 94% respondents knew where to obtain condoms from Places and People to obtain condoms Medical shops (94%), Humsafar Trust (83%) Friend (51%) Family Planning Centers (51%)

26. Sexual Behaviors And Condom Usage (contd.)Condom Lubricants 39% had heard of lubricants 49% said lubricants were used to reduce pain during anal sex 87% aware of K.Y.Jelly 71% said lubricants could be obtained from the Humsafar Trust

27. Sexual Behaviors And Condom Usage (contd.)Condom Lubricants (contd.) 79% had used lubricants 23% reported having always used it Lubricants used were K.Y.Jelly (88%), Coconut Oil (28%), Vaseline (12%)

28. Peno-oral Sex and Condom Usage Sexual Behaviors And Condom Usage (contd.) Peno-Oral sex activities - Respondent giving oral sex to another person: sucking licking penis of another person Respondent receiving oral sex from a partner/s: getting penis sucked/licked by another person 89% respondents reported engaging in peno-oral sex in last one month

29. Peno-oral Sex and Condom Usage Sexual Behaviors And Condom Usage (contd.) 70% respondents gave oral sex to another person in last one month Only 21% respondents reported last time partner condom usage Only 13% respondents reported `always’ partner condom usage in last one month

30. Peno-oral Sex and Condom Usage Sexual Behaviors And Condom Usage (contd.) 70% respondents received oral sex from another person Only 24% respondents reported last time self condom usage Only 15% respondents reported always self condom usage when they received oral sex in last one month

31. Anal Sex and Condom Usage Sexual Behaviors And Condom Usage (contd.) Insertive Anal Sex: Respondent inserting penis in another person’s anus Receptive Anal Sex: Another person inserting penis in respondent’s anus 81% engaged in anal sex in last one month

32. Insertive Anal Sex With Male Partner And Condom Usage Sexual Behaviors And Condom Usage (contd.) 68% of respondents were engaged in insertive anal sex in last one month 72% of respondents reported last time condom usage when they engaged in insertive anal sex Only 40% respondents reported always condom usage in last one month

33. Receptive Anal Sex With Male Partner And Condom Usage Sexual Behaviors And Condom Usage (contd.) 62% of respondents reported receptive anal sex in last one month 76% of respondents reported last time condom usage by partner when respondent had receptive anal sex 47% of respondents reported always condom usage by their partner/s in last one month

34. Exclusivity And Role Overlap In MSM Sexual Behavior Sexual Behaviors And Condom Usage (contd.) 37% of respondents engaged exclusively in Insertive anal sex only, 16% exclusively in receptive anal sex 30% of respondents engaged in receptive as well as insertive anal sex

35. Sex With Female Partner Sexual Behaviors And Condom Usage (contd.) Peno-vaginal sex 97% of respondents had peno-vaginal sex with female partners 38% of respondents reported condom usage when they had peno-vaginal sex last time 24% of respondents reported always condom usage during last one month Respondents had sex with wives as well as other female partnersRespondents had sex with wives as well as other female partners

36. Commercial Sex And Condom Usage Sexual Behaviors And Condom Usage (contd.) Sex in Exchange of Cash 18% of respondents had been picked for sex in exchange of cash exclusively All types of sex activities, occurred during such encounters, primarily anal and oral sex Respondents reported self condom usage (76%) and usage by their partner (71%) Sex in Exchange of Cash: Getting picked up for sex and paid in cash Sex in Exchange of Cash: Getting picked up for sex and paid in cash

37. Commercial Sex And Condom Usage Sexual Behaviors And Condom Usage (contd.) Sex In Exchange Of Gift, Articles, Things Or Taxi Fare 16% of respondents reported this kind of encounter Mainly oral sex and anal sex occurred during such encounters Respondents reported self condom usage (84%) and their commercial partner (75%) Sex In Exchange Of Gift, Articles, Things Or Taxi Fare: no predetermined transaction, but after sex receiving gift, articles or taxi fare Sex In Exchange Of Gift, Articles, Things Or Taxi Fare: no predetermined transaction, but after sex receiving gift, articles or taxi fare

38. STI In Last Six Months

39. STI In Last Six Months (contd.) Symptoms 28% reported itching in genital 16% reported greenish-yellowish discharge from penis 15% blisters and ulcers on and around penis 46% anal sores

40. Treatment Seeking Behavior 83% of respondents took medical treatment 63% respondents reported taking treatment from an allopathic doctor

41. Approach Towards HIV Testing

42. HIV Testing HIV Testing Facilities: Private Testing Facility (50%) Humsafar Trust (27%) Government Testing Facility (21%) PSI (2%) 94% respondents reported having collected the report

43. Comparing Situations 2000-2005 This study has the advantage of making comparison across previous studies. With every round, the Humsafar Trust’s capability to conduct research on HIV related MSM risk behaviors have positively grown. There has been approximately twenty months gap between three studies. The indicators as mentioned in Chapter 2 have been the same. The first study was conducted in February, 2000. An instrument consisting socio-economic profiles and main areas of sexual behavior was prepared and rigorously pretested. The sample size (174 MSM) was determined in consultation with the Family Health International (FHI). Convenient sampling was utilized for sampling 174 MSM. Any MSM who was sexually active in last one month and consented to participate in the study was sampled for the study. This study was disseminated in March, 2000. The second study took place in October, 2001 in which 327 MSM were sampled. This time a list of time location clusters was prepared and every second time location was chosen from which required number of respondents was randomly selected. This study was disseminated in March, 2002. One of the major changes in the study is the respondent selection criteria. In first two rounds, only those people who had sex with another man were selected. In the third round in order to ensure that no subjective considerations came in way of selecting respondents, this question was not asked as a selection criteria. Therefore, after administering 23 questions, `whether had sex with another man in last one month’ was asked and an affirmative respondent became the mainstay of the study. By and large the instrument remains the same with some changes and few additional questions. In this section, a comparison will be made on select common parameters across the three studies. As some changes had been made in the current questionnaire, it must be noted that previous studies’ data has been reanalyzed for comparability purposes.This study has the advantage of making comparison across previous studies. With every round, the Humsafar Trust’s capability to conduct research on HIV related MSM risk behaviors have positively grown. There has been approximately twenty months gap between three studies. The indicators as mentioned in Chapter 2 have been the same. The first study was conducted in February, 2000. An instrument consisting socio-economic profiles and main areas of sexual behavior was prepared and rigorously pretested. The sample size (174 MSM) was determined in consultation with the Family Health International (FHI). Convenient sampling was utilized for sampling 174 MSM. Any MSM who was sexually active in last one month and consented to participate in the study was sampled for the study. This study was disseminated in March, 2000. The second study took place in October, 2001 in which 327 MSM were sampled. This time a list of time location clusters was prepared and every second time location was chosen from which required number of respondents was randomly selected. This study was disseminated in March, 2002. One of the major changes in the study is the respondent selection criteria. In first two rounds, only those people who had sex with another man were selected. In the third round in order to ensure that no subjective considerations came in way of selecting respondents, this question was not asked as a selection criteria. Therefore, after administering 23 questions, `whether had sex with another man in last one month’ was asked and an affirmative respondent became the mainstay of the study. By and large the instrument remains the same with some changes and few additional questions. In this section, a comparison will be made on select common parameters across the three studies. As some changes had been made in the current questionnaire, it must be noted that previous studies’ data has been reanalyzed for comparability purposes.

44. Comparing Situations 2000-2005

45. Comparing Situations 2000-2005

46. Comparing Situations 2000-2005

47. Comparing Situations 2000-2005

48. Comparing Situations 2000-2005

49. Comparing Situations 2000-2005

50. Comparing Situations 2000-2005Commercial Sex

51. Comparing Situations 2000-2005

52. Comparing Situations 2000-2005

53. Comparing Situations 2000-2003

54. Points To PonderAreas of Improvement Low condom usage by partners when respondents engage in receptive anal sex Low condom usage with female partners Consistent condom usage must increase Increase in number of male partners

55. Points To PonderAreas of Improvement Awareness about lubricants needs to be increased Reporting of sores on anus is a serious concern Public, NGO and Humsafar VCTC needs to be advertised

56. Points To PonderWhat may be done.. Level 1: Project Revamp of IEC Outreach Staff to be made to understand research and its’ link with their work Targeting MSM cruising sites and public toilets for safe sex communication Repackage condom usage Lubricants should be promoted Cruising has again assumed importance to meet sex partners. Cruising takes place in public places Cruising has again assumed importance to meet sex partners. Cruising takes place in public places

57. Points To Ponder What may be done.. Level 1: Project (contd.) Intensify efforts to motivate MSM to seek voluntary HIV tests Find out missing population of 40+people Intensify messages on safer sex with female partners Partner Notification

58. Points To Ponder What may be done.. Level 2: Research Link between substance use and safe sex must be explored Qualitative research to seek answers pertaining to sexual behavior Research to explore mobility, migration and link with HIV/AIDS

59. Points To Ponder What may be done.. Level 3: District (MDACS) Exploring the possibility of MSM as a bridge group and strategizing accordingly Active promotion of government VCTCs Awareness regarding HIV treatment

60. Some Difficulties…. What parameter to be taken for consistent condom usage? Currently the scale is Always Sometimes Rarely Never Should we take always or all other reply (combined) by excluding never? First two studies posed questions differently.

61. Some Difficulties…. How do we make use of demographic information? What additional analysis is required?

62. Qualitative Research Issues MSM understanding of HIV/AIDS pandemic, Mobility, migration and sexual risk taking, Substance addiction and its’ impact on sexual behavior, Sexual Identity Sexual behavior with a male partner and condom usage, barriers, Sexual behavior with a female partner and condom usage, barriers, Treatment of STIs and partner notification, barriers in STI treatment, Stigma and discrimination

63. Qualitative Research (contd..) Participants for Group Discussion Should be above 18 years of age, Has oral/manual/anal sex with a male partner in last one month, Falls in the required age group for the study Has heard informed consent and has agreed to participate Site: Sites having high MSM turnover

64. Qualitative Research (contd..)

66. Qualitative Research (contd..) Duration: 3 months

67. Our Support Although it may be difficult to implement, but discussions on mass media may be started on HIV/AIDS and different sex practicesAlthough it may be difficult to implement, but discussions on mass media may be started on HIV/AIDS and different sex practices

68.  THANKS !