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Dr . Venkatesan Chakrapani, M.D. Monica Joseph, SWAM

REVIEW OF DATA ON SEXUAL BEHAVIOR AND HIV/STD PREVALENCE AMONG MEN WHO HAVE SEX WITH MEN (MSM) & ARAVANIS/ALIS IN TAMIL NADU: PROGRAMMATIC AND POLICY IMPLICATIONS. Dr . Venkatesan Chakrapani, M.D. Monica Joseph, SWAM. Purpose of the presentation.

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Dr . Venkatesan Chakrapani, M.D. Monica Joseph, SWAM

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  1. REVIEW OF DATA ON SEXUAL BEHAVIOR AND HIV/STD PREVALENCE AMONG MEN WHO HAVE SEX WITH MEN (MSM) & ARAVANIS/ALIS IN TAMIL NADU: PROGRAMMATIC AND POLICY IMPLICATIONS Dr . Venkatesan Chakrapani, M.D. Monica Joseph, SWAM Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  2. Purpose of the presentation • To review the existing data on sexual behavior, HIV and STD prevalence among MSM and Aravanis/Alis in Tamil Nadu and to understand the policy and programmatic implications of these data. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  3. Terminology Used: Men who have Sex with Men (MSM) • Denotes all those men who have sex with other men regardless of their sexual identity. This is because a man may have sex with other men but still consider himself to be a heterosexual or may not have any specific sexual identity at all. • This means one has to concentrate on behavior, in addition to the sexual categories, in the area of HIV/STD prevention. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  4. Terminology Used: (contd.) Aravanis/Alis/Hijras(male-to-female transgender/transsexual persons) • Born as biological/anatomical males who reject their 'masculine' identity in due course of time to identify either as women, or not-men, or in-between man and woman, or neither man nor woman. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  5. Terminology Used: (contd.) Aravanis/Alis/Hijras(male-to-female transgender/transsexual persons) • Aravanis/Alis often resist including them under the umbrella term “men who have sex with men” (or even under the term “males who have sex with males”) since they don’t consider themselves as “men” even though they were born as biological males. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  6. MEN WHO HAVE SEX WITH MEN (MSM) Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  7. MSM – being a behavioral /epidemiological term include (but not limited to): • MSM who don’t have any specific identity • Kothi-identified homosexual males (Kothi = “feminine and mostly receptive”) • The masculine partners of kothis who are called ‘Panthis’ (Panthi = “real men who only penetrate”). • Double-decker (“who penetrate and insert”) • Gay-identified homosexual men • Bisexual identified men with same-sex/bisexual behavior Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  8. 1. MSM – being a behavioral /epidemiological term include (but not limited to):(Contd.) Note: • “Panthi” and “DD” are labels and usually not ‘identities’ • Identities may not correlate with the presumed sexual behavior. Example: A kothi-identified male can get heterosexually married and thus have bisexual behavior (and assumes insertive role with female partner) Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  9. 2. Estimation of MSM population in Tamil Nadu: • No population-based behavioral survey among sexually active male population to find out the extent of same-sex or bisexual behavior. • A study from Chennai that examined sexual behavior in male students from two colleges showed that among the 1600 male students participated in the survey 20% reported having had sexual activity at least once in their lifetime. Among these, 35% had their first experience with another male. (D. Hausner. Sexual risk among male college students in Chennai, India: implications for HIV prevention strategies. XIII International AIDS Conference, Durban, 2000. [TuOrD437]) Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  10. 2. Estimation of MSM population in Tamil Nadu: (Contd.) Estimation using Kinsey scale: • According to Kinsey scale, a significant proportion of humans falls in between the exclusive heterosexual and exclusive homosexual polarities. And estimates that about 5% of the sexually active male population anywhere in the world might be coming under predominantly homosexual spectrum (Kinsey scale 6 = ‘exclusive homosexual’). Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  11. 2. Estimation of MSM population in Tamil Nadu: (Contd.) Estimation using Kinsey scale:(Contd.) • Total number of males in Tamil Nadu = 31268654 (2001 census) Total number of male children in Tamil Nadu (0 to 6 years) = 3515562 (2001 census) Thus, males above 7 years = 27753092 Since no data on males between 7- 15 years (or >45 years), let us take the number of sexually active male population in TN as roughly 2 crore (20000000). Five percent of this 2 crore = 10 lakhs Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  12. 3. Risk-groups and risk behavior: The way in which the term "risk group" is understood is different for different people. Concerns in using the term "risk group": • HIV transmission or acquisition is by risk behavior such as unprotected penetrative sex and limited to particular ‘groups’. • It might be wrongly believed that HIV is somewhat intrinsic to and contained within the ‘risk groups’. • Some activists as well as some policy makers are especially wary of using the term 'risk groups' since they are keen to avoid any suggestion of blaming the victim which may be inherent in using that term Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  13. 3. Risk-groups and risk behavior:(Contd.) “MSM” as ‘risk group’: • Since same-sex behavior is not even mentioned as a way of HIV transmission and acquisition in India, the major concern right now is not about using the "risk group" but to acknowledge that same-sex behavior does occur throughout India and may be contributing to significant proportion of HIV transmission and acquisition. • NACO has acknowledged “…though highly covert, homosexual behavior has its sure presence in all the [Indian] cities” (NACO, 1997) but "little is known about MSM behavior [in India]" (NACO, 2000). Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  14. 4. Sexual risk behavior among MSM in Chennai a. Venkatesan Chakrapani, S.D. Fernandes, J. Mallika and M. Ganapathy. (2000). Self-reported sexual behavior of men who have sex with men in Chennai, India. [WePeD4747] XIIIth International AIDS Conference, Durban, South Africa, 9-14 July 2000. Number:96 MSM Recruitment: from the cruising areas Method: Survey questionnaire administered by 4 trained MSM. Socio-demographics: Mainly middle-class and educated. 26% were married and more than 60% had had sex with a woman at least once in their lifetime. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  15. 4. Sexual risk behavior among MSM in Chennai(Contd.) Sexual behavior/practices: • Mean number of male and female partners in the last year was 51.5 and 1.4 respectively. • Common penetrative sexual practices with males were insertive and receptive anal/oral sex. Condom use: • Most used condoms only occasionally or never. • Condom use was greater with sex workers and casual partners compared to steady partners. • Condom use with female partner (spouse) was lower than with male partners. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  16. 4. Sexual risk behavior among MSM in Chennai(Contd.) b) Venkatesan C, Sekar B. (2001). Demographic and Clinical Characteristics of males who have sex with males (MSM) attending a community-based STD clinic in Chennai. Poster Presentation at the III International Conference on AIDS. AIDS India 2000, Chennai, India. Dec 1 - 5, 2001 Number: 51 MSM Recruitment: community-based clinic, SWAM (over 3 months) Method: clinical record review Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  17. 4. Sexual risk behavior among MSM in Chennai(Contd.) Sexual behavior/practices and Condom use: Majority (64%) have had sex with females. • All the married MSM reported never using condoms with their wives and inconsistent use of condoms with other female partners. • Unmarried MSM with bisexual behavior also reported inconsistent condom use with their female partners. • About 60% of the MSM reported penetrative (insertive and/or receptive) anal intercourse with another male in the past 3 months; 40% used condoms at the most recent anal intercourse. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  18. 4. Sexual risk behavior among MSM in Chennai(Contd.) c) Venkatesan C, Ganapathy M, Fernandes SD, Mallika Johnson and BalaSubramaniam MP. (2000b). Consistency Of Condom Use Among Men Who Have Sex With Men (MSM) With Different Types Of Sex Partners. 24th National Conference of Indian Association of Sexually Transmitted Diseases (IASSTD) & AIDS and 11th SEAWP IUSTI Regional Meeting. Oct 2000, Chandigarh, India. Number: 96 MSM Recruitment: from the cruising areas Method: Survey questionnaire administered by 4 trained MSM. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  19. 4. Sexual risk behavior among MSM in Chennai(Contd.) Findings and implications: (also see study – ‘a’) • Condom use with Steady partners (male or female) is very low, putting them at increased risk of STI/HIV infection • Condom use with female partners (spouse) is low compared to that with male partners. • Condom promotion programs should stress consistent use of condoms with any type of partner • Bisexual behavior needs to be addressed in HIV prevention programs • Qualitative research could find out the reasons for differential use of condoms Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  20. 4. Sexual risk behavior among MSM in Chennai(Contd.) d) Male Sex workers (other than Hijras/Alis): • Available studies point out not only the presence of male sex workers but also high-risk sexual behaviors among this population (Asthana and Oostvogels, 2001*, Venkatesan C et al, 1999b**). • No quantitative studies have been done exclusively among male sex workers and no specific studies to study STD and HIV prevalence among them. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  21. 4. Sexual risk behavior among MSM in Chennai(Contd.) • *Sheena Asthana and Robert Oostvogels. The social construction of male ‘homosexuality’ in India: implications for HIV transmission and prevention. Social Science and Medicine, 52 (2001): 707-721. • **Venkatesan C, Fernandes SD, Ganapathy M and Mallika Johnson. (1999b). The hidden population of male sex workers in Chennai, Tamil Nadu - The need to develop specific intervention programmes. II International Conference on AIDS - ‘AIDS India 2000’, Chennai, December 1999. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  22. 5. STD Prevalence among MSM in Chennai: a) Venkatesan C, Sekar B. (2001). Demographic and Clinical Characteristics of males who have sex with males (MSM) attending a community-based STD clinic in Chennai. Poster Presentation at the III International Conference on AIDS. AIDS India 2000, Chennai, India. Dec 1 - 5, 2001 Number: 51 MSM Recruitment: community-based clinic, SWAM (over 3 months) Method: clinical record review Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  23. 5. STD Prevalence among MSM in Chennai: (Contd.) Thirteen (26%) MSM had one or more STDs. Clinically the following pattern of STDs was found: • Perianal warts - 4 (8%) • Genital Herpes - 4 (8%) • Perianal herpes - 1 (2%) • Secondary syphilis - 1 (2%) • Gonococcal urethritis - 1 (2%), Molluscum contagiosum - 1 (2%), Proctitis - 2 (4%), Scabies - 1 (2%) and Prostatitis - 1 (2%). • Serological testing for syphilis (VDRL) was not routinely conducted due to financial constraints. • Seven (14%) self-reported as HIV-positive Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  24. 5. STD Prevalence among MSM in Chennai: (Contd.) b) Dr. Srinivasan. K. STD/HIV prevalence and high-risk sexual behavior among men who have sex with men (MSM) attending a STD referral center. Dissertation submitted to the TNMGR Medical University through the Institute of STD, MMC, Chennai, 2002. Number: 150 MSM Recruitment: STD outpatient clinic, Institute of STD, Madras Medical College (over 3 months) Socio-Demographics: Almost half [50.7%] < 25 years and 43.3% in-between 26-35 years. 78% unmarried and 18.7% married Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  25. 5. STD Prevalence among MSM in Chennai: (Contd.) Sexual behavior/practices: Last year, 42.7% of MSM had sex with male and female partners, and 41.3% had sex with only male partners. 11.3% received money for sex Last year, 78% practiced anogenital sex (insertive or receptive) with male partners Condom use: Last year, in anogenital sex 46.7% of the patients never used a condom. 32.7% reported occasional use of condom in anogenital sex. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  26. 5. STD Prevalence among MSM in Chennai: (Contd.) Clinical pattern of STDs: Syphilis: Early Latent Syphilis (ELS) alone 11.3% Secondary syphilis alone 3.3% Primary chancre 5.3%. Ulcerative STDs (other than chancre): Genital herpes alone 6% Chancroid alone 1.3%. Mixed cases: ELS and genital herpes 1.3%. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  27. 5. STD Prevalence among MSM in Chennai: (Contd.) Urethral Discharge: Non-Gonococcal Urethritis (NGU) alone - 6% Acute Gonococcal Urethritis (AGU) alone - 3.3%. Mixed infections: ELS and AGU 1.7%. Anogenital warts: Perianal warts alone 1.3% Mixed: ELS with perianal warts 0.6%. Other diseases: Balanoposthitis - 6%, candidal intertrigo alone 3.3 %, Molluscum Contagiosum alone 2.6%, genital scabies alone 2.6% and Prostatitis alone 5.3% Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  28. 5. STD Prevalence among MSM in Chennai: (Contd.) VDRL/TPHA reactivity, and HBV: VDRL reactive – 24% (36/150) TPHA reactive – 14.7% (22/150) HBsAg positivity: 10.7% [16/150]. (None having used illicit drugs by injection). This is significantly higher compared to HBV prevalence in the general population of TN. HIV positivity: 13.3% [20/150] Co-infection rates: 3 were HIV-positive & VDRL reactive, 6 were VDRL reactive & HBsAg positive, and 7 were HIV and HBsAg-positive Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  29. 6. HIV prevalence among MSM in Tamil Nadu:  HIV serosurveillance by TNSACS/NACO: 2000: HIV – 4% 2001: HIV – 2.4% 2002: HIV - 2.4% (VDRL - 4%, HBV- 6.4%, HCV- 0.8%) • Self-reported HIV among MSM attending a community-based clinic (Venkatesan C et al, 2002): 14% • HIV prevalence among MSM attending the Institute of STD, Govt. hospital, Chennai (Srinivasan K): 13.3% Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  30. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM): The available studies indicate that • MSM engage in high-risk behaviors (e.g., unprotected anal intercourse). • Many don’t use condoms on a regular basis with their male partners. • A significant proportion of MSM also have sex with female partners without regular use of condoms. • High prevalence of STDs • Significant HIV seroprevalance rates (2.4% to 14%). Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  31. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) a) Sexual behavior and condom use: • Many MSM have bisexual behavior and significant proportion was married. This means the risk of HIV infection is not only to their male partners but also to their female partners and children to be born to them. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  32. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) Recommendations: • Public should be educated about the risk of HIV transmission through unprotected same-sex and bisexual behavior. • Condom use should be promoted irrespective of the sex of the partner or type (regular or casual) of sexual partner. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  33. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) • Sexual behavior and condom use: (Contd.)  2. Significant number of MSM have unprotected anal sex with their male partners and some also have anal sex with their female partners. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  34. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) • Sexual behavior and condom use: (Contd.)  Recommendation: • Since unprotected anal sex is a high-risk behavior, prevention messages should address the risk of unprotected anal sex – both homosexual and heterosexual anal intercourse. • Condom use should be promoted in all type of sexual encounters. Appropriate condoms and lubricants should be available for those who want to practice anal intercourse. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  35. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) • Sexual behavior and condom use: (Contd.)  3. Non-penetrative sexual practices like mutual masturbation, dry and wet kissing, intercrural sex are commonly practiced with male partners. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  36. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) • Sexual behavior and condom use: (Contd.)  Recommendation: • Since non-penetrative sexual practices pose low risk of HIV infection, there should be prevention messages which show them as alternatives to unprotected penetrative sexual intercourse, thereby decreasing the risk of HIV infection. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  37. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: 1. There is high prevalence of STDs among men who have sex with men (MSM) when compared to the general population. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  38. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: Recommendation: • More studies to document the prevalence of symptomatic and asymptomatic sexually transmitted infections among MSM need to be conducted. This will give an accurate picture of the magnitude of the problem of STDs among this specific population. These studies can also serve as baseline studies based on which appropriate HIV preventive intervention programs can be designed and later compared to assess the impact of intervention programs Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  39. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) 2. Syphilis (especially latent syphilis) is the most common STI found among MSM. Ulcerative diseases like primary chancre, chancroid, genital herpes were documented but not very common. Mixed infections were not uncommon. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  40. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) Recommendation: • Lab screening for syphilis (VDRL test) should be offered to all MSM because of the very high prevalence of asymptomatic syphilis in this group. • Since mixed infections are common in ulcerative STDs, in absence of quality lab support, syndromic management should be followed as per NACO guidelines or appropriate lab tests to exclude other ulcerative STDs should be done. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  41. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) 3. Perianal STDs like perianal warts and proctitis were seen. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  42. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) Recommendation: • All MSM should be offered complete clinical examination which should include per-rectal examination and if necessary, proctoscopic/ anoscopic examination. • All MSM should be asked specific symptoms of peri-anal STDs since they might not be willing to disclose those symptoms for fear of rejection and discrimination. • This also points out the need of sensitizing the health care providers about alternative sexualities and the need to be nonjudgemental when providing clinical care to sexual minorities Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  43. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) • Prevalence of HIV among MSM is comparatively higher than that in general population. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  44. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) Recommendation: • There should be public awareness about the transmission of HIV infection through sex between men. • Appropriate and culturally-sensitive HIV prevention messages addressing the risk of unprotected sex between men should be made. • Appropriate HIV preventive intervention programs should be developed to decrease the risk of HIV infection among MSM. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  45. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) b). STD/HIV Prevalence: (Contd.) 5. Prevalence of HBsAg, marker of Hepatitis-B infection, was significantly high (twice the prevalence in general population). Recommendation: • Prevention messages which convey the risk of HBV transmission through sexual route must be developed to educate the public as well as MSM. • Screening for HBV infection should be offered for MSM who practice unprotected penetrative sex. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  46. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) c) Other Issues: 1. Surveillance of HIV among MSM There are only two surveillance sites in TN for MSM (Chennai and Villupuram) Recommendation: In consultation with the community organizations in different parts of TN, the number of sites for serosurveillance could be increased. (Note: when increasing the number of sites, aggregation of data from different sites can show a lower prevalence rate. Hence prevalence rate need to be linked to the site of the serosurveillance) Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  47. 7. PROGRAMMATIC AND POLICY IMPLICATIONS (MSM):(Contd.) c) Other Issues: (Contd.) 2. There are many registered and unregistered community groups in TN. Recommendation: The capacity of these community groups need to be built and needs assessment to be conducted to find out the feasibility of intervention programs in different areas in TN. Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  48. ARAVANIS/ ALIS/HIJRAS Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  49. 1. Aravanis/Alis include(please see previous operational definition)  -         Aquwa/Ackwa Kothis (those who are not castrated and may or may not crossdress fulltime and might undergo operation in the future) -         Nirvan Kothis (those who have undergone castration/emasculation) Venkatesan C: MSM - TN - Policy Implications, Sep 2003

  50. 1. Aravanis/Alis include(please see previous operational definition) Note: • All Aravanis usually identify themselves only as ‘kothis’. • There is some overlap between ‘Ackwa kothis’ of Aravanis and Kothi-identified feminine homosexual males who might also cross-dress part-time Venkatesan C: MSM - TN - Policy Implications, Sep 2003

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