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Dr Beena E Thomas Social Scientist NIRT

A community-based approach to HIV prevention intervention for men who have sex with men in Chennai, India. Dr Beena E Thomas Social Scientist NIRT. Background. HIV infection among men who have sex with men (MSM) have been increasing in recent years, particularly in Asia.

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Dr Beena E Thomas Social Scientist NIRT

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  1. A community-based approach to HIV prevention intervention for men who have sex with men in Chennai, India Dr Beena E Thomas Social Scientist NIRT

  2. Background • HIV infection among men who have sex with men (MSM) have been increasing in recent years, particularly in Asia. • Men who have sex with men (MSM) in India have an HIV seroprevalence at least 22 times greater than the country's general population, and face unique psychosocial challenges that may hinder HIV prevention program effectiveness

  3. Background • Indian MSM include • kothis(men who tend to be the receptive male partner in anal and oral sex), • panthis(men who tend to be the insertive male partner in anal and oral sex), • “double deckers”(men who are both receptive and insertive partners).

  4. BEHAVIORAL RISK FACTORS & HIV SERO PREVALENCE AMONG MSM (N=210) 22% reported at least one UA (unprotected anal sex) 26% participated in an HIV program 8% HIV infected 28% indicated 6-10 partners 95% did not know the HIV status of partner 19% married(2HIV+) Predictors of UA (participation (OR=3.75; p = 0.05), depression (OR = 2.8; p=0.02), alcohol (OR=3.56; p=0.07)

  5. QUALITATIVE DATAFINDINGS CONTD…. Intense feelings of guilt Majority had not disclosed identity to parents Difficulty in coping with their identity Police harassment, sexual exploitation Negotiating condom use Majority perceived themselves at risk

  6. Aims To identify the HIV prevention service needs for this population, their psychosocial concerns and how these may relate to HIV risk Using a community participatory approach to develop an intervention format feasible and acceptable to MSM

  7. Methodology Qualitative study utilizing focus group discussion and Key informants interview using a semi structured FGD/interview guide Sample: 5 Focus Group Discussions with 47 Participants (8-10 individuals per group) 9 Key informants Interview Site – National Institute for Research in Tuberculosis (NIRT) Referral site – Sahodaran Team – Medical Social workers, Psychologist, staff – Sahodaran Inclusion >18yrs Who identify as a man who currently engages in sex with other men.

  8. Methodology Contd….. The Focus Group Discussion included A free-listing section - participants list and briefly describe the main problems faced Issues relevant to sexual risk taking among MSM in Chennai e.g., “How does the type of MSM one is (panthi, kothi, etc.) influence what risks you may take, if at all?” Perceptions of effectiveness of existing HIV prevention interventions e.g., “What are the least helpful aspects of HIV prevention programs for MSM in Chennai? What are the most helpful aspects of HIV prevention programs for MSM Chennai?” Suggestions for future HIV prevention interventions e.g., “What would you like to see included in HIV prevention programs for MSM in Chennai, if anything?”

  9. Methodology Contd…. Key Informant Interviews includes Four broad domains 1. Relationship of culture and environment to sexual risk taking e.g., “Who or what influences sexual behaviors of MSM?” 2. Issues relevant to sexual risk taking among MSM in Chennai e.g., “What are the main problems of kothis, panthis, and double- deckers (respectively) in Chennai?” 3. Perception of effectiveness of existing HIV prevention interventions e.g., “Tell me about any current or prior HIV prevention programs you are aware of in Chennai.”), 4. Comment on proposed intervention content, format and duration.

  10. Data Analysis • Data were analyzed using thematic content analysis guided by a Grounded Theory methodology • Concepts and themes related to the research questions including • past and current experiences with HIV prevention interventions for MSM in Chennai, • suggestions for future interventions, and • acceptability of the proposed psychosocial intervention. • Initial themes were used construct categories and to develop a codebook (label, a definition, and an illustrative quote from the data) • Categories were considered saturated when no new codes associated with it were formed.

  11. Results Demographics • Among the 56 MSM participants • 68% identified as kothi (receptive partners in anal/oral sex), • 11% panthi (insertive partners in anal/oral sex) • 20% "double decker" (both receptive and insertive sexual partners). • Mean age of participants was 27 years (SD=7) • Education levels varied among participants • Master’ degree (3) • Bachelor‟s degree(12) • Completed either higher secondary or secondary school (22) • Middle school education or less (14)

  12. Previous Experience with HIV Prevention Programs • Seven of the ten respondents reported negative experiences when accessing government-sponsored programs for HIV testing. • The importance of ensuring safe, non-judgmental services which uphold confidentiality, professionalism and culturally sensitive facilitation • “The chances of MSM accepting a STI test at the STD clinic in a government hospital is 70-80% as they fear breach of confidentiality. It is so difficult to get MSMs with symptoms of STI to come forward to disclose their symptoms”.

  13. Previous Experience Contd….. • Patients experienced feelings of “shame” when they exited the clinic because they felt as if everyone was watching them. • Respondents complained that they were ill-treated by health care staff and they had unnecessarily stripped them of their clothing during an examination • Their informed consent had not been properly obtained, or they had not been made aware of tests they were to undergo.

  14. HIV Prevention Message Fatigue • High levels of message fatigue among recipients of current MSM HIV prevention services: • “We know a lot about HIV for the past 10 years. We have had enough programs on HIV and I should take care of my personal risk - how long will NGO’s guide us about this especially. I do not think that anymore messages on condom prevention are needed. We are fed up of HIV/AIDS messages – we need more!” 14

  15. Suggestions Contd… Mental Health • The importance of addressing self-acceptance, self-esteem, and familial and societal pressures should be part of care. • “I feel a prevention program should increase self esteem and self acceptance. This would automatically influence a MSMs health seeking behavior and MSM would claim rights as an individual. I feel that only then can interventions be successful. They would want to abstain from alcohol, look after their STIs, take their medicine they need, protect themselves from HIV…”

  16. Suggestions Contd…. HIV Prevention Education & Condom Distribution • Several respondents the need for exciting and innovative ways to educate MSM in Chennai around condom use, condom access, and sexual risk reduction. As one respondent remarked, “Prevention programs do not give back to the MSM community – they just speak about HIV, but do not help us to enjoy the learning, like through performance or street plays that make learning about HIV fun and enjoyable”.

  17. Focus areas for intervention • Self acceptance • Safe ways of Meeting MSM/Safe sex practices( cruising sites, multiple partners) • Coping with Family pressures/Disclosure issues • Alcohol/Substance abuse • HIV Education & HIV/STI Vulnerability • Risk Reduction Skills & Looking to the Future

  18. Intervention Format • Both group and individual components were recommended for an intervention • Programmatic effectiveness would be augmented by providing separate groups for different MSM identities. • “Kothis and DDs [double deckers] can be included in the same group. If panthis are in the group, kothis will not open up. They will never express their problems”.

  19. Conclusion The findings highlight the need for MSM HIV interventions to adopt - A community participatory approach - To place HIV risk and mitigation within a context that addresses broader psychosocial concerns, including • skills building • strategies to promote family and social acceptance • the need to foster social support, self-esteem and self acceptance

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