Research That Matters (January 17 - 20, 2008)

Background and Purpose: In India, men who engage in paid sex with other men are at elevated risk for HIV infection relative to female sex workers (Dandona et al, 2006) and other MSM (Gupta et al, 2006). High risk for HIV infection among male sex workers has been similarly documented in Indonesia (Pisani et al, 2004), Thailand (McCamish et al, 2000) and Vietnam (Colby, 2003). Nevertheless, scant research has explored factors associated with paid sex among MSM. The purpose of this study is to identify correlates of paid sex among MSM in Chennai, India, in order to inform tailored HIV preventive interventions.

Methods: A team of three community-based organizations mapped public sex environments (PSEs; n=50) in Chennai. Ten PSEs were randomly selected. MSM (n=200) were recruited using time-space sampling, with probability-proportional-to-estimated-size. Every nth participant was approached based on the target for the site/day/time slot and invited to participate. A 30-minute face-to-face survey questionnaire was administered off-site in Tamil, with items related to demographics, forced sex, harassment, HIV/AIDS knowledge, and sexual behaviors. We used chi-square tests of independence to assess univariate associations between predictors and paid sex. Multiple logistic regression was then used to calculate odds ratios, 95% confidence intervals (CIs) and the net predictive value of each variable (i.e., adjusted for other variables in the model) for paid sex.

Results: Sixty-percent reported engaging in sex for money in the previous three months. MSM who engaged in paid sex had lower levels of formal education and were more likely to report harassment, forced sex and anal sex (past 3 months). Those who engaged in paid sex also scored higher on HIV knowledge. Adjusted odds ratios indicated significant effects on paid sex for harassment, anal sex and HIV knowledge. MSM who reported at least weekly harassment were more than twice as likely to be engaged in paid sex (AOR= 2.63; 95% CI= 1.26, 5.47). Anal sex (past three months) was associated with a more than 2-fold increase in the odds of paid sex (AOR=2.62, 95% CI=1.35, 5.10). Those who scored high on HIV knowledge were four times as likely to be engaged in paid sex (AOR=4.10; 95% CI=1.81, 9.29). Formal education and forced sex were not associated with sex trading after adjustment for the other variables in the model.

Conclusions and Implications: A majority of MSM recruited from PSEs in Chennai engage in paid sex. Paid sex is associated with higher rates of engaging in anal sex, and may place these MSM at increased risk for HIV infection. Interventions may need to target pervasive harassment of MSM who engage in paid sex in order to reduce their risk of HIV infection. Given higher levels of knowledge about HIV transmission risks among these MSM, knowledge-based interventions may be more appropriately targeted to MSM who do not engage in paid sex. Initiatives that target structural factors, such as poverty, lack of economic opportunity, harassment and violence, may be important components of HIV preventive interventions for high-risk MSM in Chennai.