Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: India is second only to South Africa in having the largest number of persons living with HIV/AIDS in the world (~5.2 million). Although HIV/AIDS in India is predominantly a heterosexual epidemic (National AIDS Control Organization, 2004), men who have sex with men (MSM) may be at particular risk. Human Rights Watch and UNAIDS report widespread human rights violations among MSM and HIV/AIDS peer outreach workers in India. This study explored and assessed experiences and contexts of stigma, harassment, discrimination and violence, and HIV risk among high-risk MSM in Chennai, India.

Methods: A mixed-method design was implemented, including Phase 1, in-depth semi-structured interviews of MSM (n=18) and key informants (n=3); and Phase 2, a cross-sectional survey (n=200). Phase 1: Purposive sampling was used to recruit MSM at high risk for HIV/AIDS, including HIV-positive and heterosexually married MSM. MSM were recruited from community agencies and public sex environments. Key informants were service providers with expertise on MSM. Interviews were audio-recorded with consent and transcribed verbatim. Data were analyzed using line-by-line and thematic coding and a constant comparative method. Prolonged engagement, member checking with key informants, triangulation of methods and peer debriefing increased the trustworthiness of the findings. Phase 2: A 30-minute paper-and-pencil survey questionnaire was administered to MSM (mean age=29 years) recruited using time-space sampling from a random sample of 20 public sex environments. Survey domains, informed by qualitative findings, included HIV risk; harassment; forced sex; HIV testing; and condom access and utilization. Voluntary syphilis testing (VDRL) and free treatment were provided.

Results: Phase 1: Qualitative findings revealed multiple intersecting social and institutional contexts of stigma, discrimination, harassment and violence involving police, “rowdies” (bullies), healthcare providers, family members, heterosexual friends, other MSM, and within “mainstream” HIV-positive support groups. Participants reported being verbally and physically harassed and detained by police for carrying condoms, under allegations of engaging in sex with men or sex work; and stigmatization from healthcare providers. Phase 2: Twelve-percent (among 132 tested) were VDRL reactive (for syphilis); 13% (n=26) self-reported testing HIV-positive. Almost two-thirds (61%) reported harassment or blackmail at least once a month, one-fifth (19%) on a daily basis. Perpetrators included police (37%), “rowdies” (61%), sexual partners (16%), neighbors (4%), work colleagues (3%), and unknown persons (45%). Forty-one percent (n=82) experienced forced sex in the past year. One-third had never been tested for HIV; 40% didn't use a condom during last anal sex. Healthcare institutions were underutilized as sources for condoms (clinic 5%; hospital 11%; family health center 1%) in comparison with voluntary MSM agencies (84%), private shops (36%), friends (29%) and sex workers (47%).

Implications for Practice & Policy: Multi-level HIV prevention strategies are needed among high-risk MSM in India: culturally appropriate behavioral- and knowledge-based interventions to increase condom use, HIV testing, and STD testing and treatment; and structural interventions to combat systemic stigma, harassment and discrimination in legal, healthcare and family systems, and to reduce sexual violence. Criminalization of “homosexual behavior” (i.e., Indian Penal Code-377) is antithetical to public health and HIV prevention.