Sexual Practice and Perception of HIV/AIDS And Health Seeking Behaviour Among Men Who Have Sex with Men in Hyderabad

Introduction: The Men who have Sex with Men (MSM) are a vulnerable population and need special attention in fight against the HIV/AIDS. The HIV trend has been an increasing trend among MSM. Methodology: It’s a facility based cross sectional study undertaken in the Targeted Intervention sites in Hyderabad, Telangana. A total of 300 Men who have Sex with Men who are above 18 years of age and registered were included. All the MSM visiting the TI centers during the study period were interviewed by using a pre-designed, pre-tested, semi structured and pre-coded proforma. Results: Majority of participants 119(39.66%) had their first sexual encounter at the age of 15-17 years. 130(43.33%) visited the Target Intervention centers 1-2 times during the last month. About half of the participants i.e., 141(47.00%) belongs to Kothi Group and most of the MSM i.e., 198(66.00%) used condom during the sex with male last time. Conclusions: Stigma and cultural intolerance of same-sex relations are often largely to blame for rising epidemics, and until these issues are addressed it will be difficult to make headway in reducing HIV infection levels among MSM - which, in turn, will hinder the wider global efforts to manage HIV and AIDS.


INTRODUCTION
The Acquired Immuno Deficiency Syndrome (AIDS) is a major emerging public health problem in India. According to an estimate made by the regional office of the World Health Organization (WHO) for Southeast Asia, India accounts for over two-thirds of all Human Immunodeficiency Virus (HIV)-infected individuals in the region. 1 The total annual economic loss due to HIV/AIDS in India is estimated to be Rs 3447 billion. 2,3 These figures emphasize the societal burden posed by HIV infection in India.
The National AIDS Control Programme (NACP) of India had estimated that there were 2.7 Lakh Men who have Sex with Men (MSM). 4 National Integrated Behavioural and Biological Surveillance has estimated the HIV prevalence among MSM to be 4.3% at National level, among Female Sexual Workers (FSWs) at 2.2% andamong Injecting Drug Users (IDUs) at 9.9%. 5 The National AIDS Control Organization (NACO) had subscribed to the recommendations made under Asia Epidemic Model that advocated at least 80% coverage of HRG population. 6 The current coverage of services in India among MSM varies widely between 17% and 97%, but mostly being below 80%. 7 The Men who have Sex with Men (MSM) based on their sexual behaviour classified as Kothi (Receive during anal sex ), Panthi ( Insert during Anal sex ) AC/DC or Double decker (Receive / insert during anal sex ) and Bisexual (Sex with male and female). 8 The reliability of HIV infection data among Men who have Sex with Men (MSM) is influenced by: (i) The lack of knowledge and understanding of MSM behavioral patterns as many MSM do not have a conscious sexual identity/orientation; the fact that (ii) Many do not consider reporting on their same sex behaviors even when asked; (iii) Many do not identify their sexual behavior as MSM since their partners are not perceived as men. 9,10 Legal discrimination is a further factor affecting MSM and Transgenders in India. Section 377 of the Indian Penal Code, which makes "Carnal intercourse against the order of nature with any man, woman or animal" a crime punishable by imprisonment, has been interpreted as including anal intercourse and has been used to criminalize sex between men. This law has made them vulnerable to harassment and violence from the police. In July 2009 a landmark judgment of the Delhi High Court ruled that Section 377 was unconstitutional. 11  Out of the five TIs three were selected by convenient sampling method. The Out Reach Workers (ORWs), who are part of the TI centres and from the MSM community, conducted regular outreach at cruising sites of MSM. This outreach often consisted of workers distributing information, condoms, lubricants, and other items to the Men who have Sex with Men. These outreach workers facilitate them to visit the TI centres where they are registered. Neither participants were not asked about their HIV status nor were any biological specimen for HIV testing and other STIs was collected during the study. The sampling strategy was consecutive samplings of those that fulfilled the inclusion criteria and were present at the site on the day of the visit of the investigator.
The subjects for the study were selected based on the following criteria, after a written informed consent was obtained following national guidelines. 12 Inclusion criteria: MSM's above 18 years of age, Men who identified themselves and registered as MSM at the selected Targeted Intervention site, those who have engaged in sex -anal or oral with another male at least once in the previous month and MSMs who were present at the targeted intervention site at the time of visit and given informed consent.
Sample size being 300 and selected Targeted Intervention centres being 3, a total of 100 selected from each TI centre. All The MSM visiting the TI centres during the study period above 18 years of age were interviewed personally in their local language by using a pre-designed, pre-tested, semi structured and pre-coded proforma which was prepared with the help of the faculty. The questions were partially closed ended. Ethical clearance was taken from the Institutional Ethical Committee, Osmania Medical College, Koti, Hyderabad (Regd. No. ECR/300/Inst/ AP/2013). Permission to visit Targeted Intervention centres was taken from the State AIDS control society. Informed consent from study participants and confidentiality was ensured.
Data was entered using Microsoft Excel 2010 version and analyzed manually in the initial stages and later by using Epi-Info version 7. Data was summarized in percentages and proportions. Univariate analysis using Chi-square test with significance level at 5% was used to determine the association of various independent factors.

RESULTS
Out of the total 300 respondents, majority of them 100 (33.33%) were in the age group of 20-24 years with mean age being 27.68±6.34 years. 29% (n=87) were educated up to high school and more than one thirds (40%, n=120) were in Service (Private/Government). With regards to marital status, two thirds (67%, n=201) were never married.        16 These studies underscore the need for a much more vigilant and aggressive prevention and education campaigns targeted towards MSM.
Majority of the participants (50.67%) mentioned no one knew about their MSM identity, (29.33%) participants revealed that they are experiencing discrimi-nation and 20% participants revealed that they never experienced any discrimination by their Family/Friends/neighbors because of their MSM identity. In Health facilities 22% participants revealed that they are experiencing discrimination and 32% participants revealed that they never experienced any discrimination by Health workers because of their MSM identity. In a study by Heather Fay et al in Malawi, Namebia (17%) MSM ever disclosing same sex practices to a health professional and 19% reported ever being afraid to seek health care. Men reported ever been denied health care services (5%) and 21% had ever been black mailed because of their sexual identity. 17 Stigma and cultural intolerance of samesex relations are often largely to blame for rising epidemics, and until these issues are addressed it will be difficult to make headway in reducing HIV infection levels among Men who have Sex with Men. More awareness campaigns are required around combined HIV/AIDS & MSM and coordinated, collective effort should continue to be encouraged between the government, NGOs, and LGBTI organizations working with MSM to develop and implement effective HIV/AIDS prevention programmes.

CONCLUSIONS
MSM's have faced discrimination from Family/Friends/Neighbours and also in Health facilities which can be hurdle in accessing services which needs to be taken into consideration. Though in spite of being in High-risk category, only half of them felt they were at high risk of being infected with HIV/AIDS which needs to be addressed. NGO's and Health workers should play a key role in spreading awareness and conducting campaigns and to promote increased usage of condoms.