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ORIGINAL ARTICLE
Year : 2023 | Volume
: 50
| Issue : 1 | Page : 83-87
The community of men who have sex with men in Ratlam City, Madhya Pradesh: A case study on risk factors for human immunodeficiency virus infection
Cyril Sajan, Elizabeth Jacob
Department of Pharmacy Practice, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
Correspondence Address:
Cyril Sajan
Department of Pharmacy Practice, Sumandeep Vidyapeeth University, Vadodara, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jss.jss_185_22
Background: Not long ago, the National AIDS Control Organization awakened the matter of men who have sex with men (MSM) and incorporated it as the most important group population. Targeted interventions (TI), as projected in the NACP-III, have made dauntless efforts to launch about, that this group demands an urgent and intensive attention, indicating a significant amount of departure from its previous polices. All above-mentioned reasons prompted us to undertake this study on evaluating the risk of MSM for sexually transmitted infections. Methods: A cross sectional descriptive study was conducted and all the acquired data were entered using epi info version 3.5 software and along with proper statistical procedures. Results: In the current study, 156 participants were involved, of which 90% of respondents were male and the remaining were transgender. Majority of the participants in the present study were involved in MSM activity with both regular and nonregular partners (RP)/casual partners. In the present study, 85.3% of the study participants were involved in MSM activity with a regular partner in the last 6 months, which is similar to nonregular partners reflecting high-risk activity. Conclusion: This study offers compelling evidence that MSM is more vulnerable to HIV due to a variety of variables. According to the current studies, about 37% of MSM were married. This brings up additional issues, such as the fact that women often contract HIV, because they are partners of men who are members of the population groups that are most at risk for HIV infection, such as MSM, rather than due to their own sexual behavior.
Keywords: Anal sex, condom, oral sex, men having sex with men, sexually transmitted infections
The term “homo” in homosexual is derived from a Greek term meaning same and the Latin term “sexus” indicating sex. The term “homosexuality” was first acquainted as medical terminology in the latter part of the 19th century to describe the erotic desire of the same sex.[1],[2] Even in the ancient Indian literature, for instance, Rig Veda, which revolves around 1500 BC, and statuaries and relics represent sexual acts among women. KAMASUTRA's author, Vatsayana, briefly depicts in his concords, the techniques by which men indulge in intercourse with another men.[3] For the purpose of human immunodeficiency virus (HIV)/sexually transmitted infections (STI) prevention, public health experts coined this epidemiological term which focuses solely on sexual practice. It does not represent those categories of males who may possibly have had sex with other males, either as a sexual experimentation or very seldom, depending on special circumstances.[4],[5] In addition, it should be recognized that not everyone who has male-to-male intercourse identifies as a homosexual or even a man.[5] The National AIDS Control Organization (NACO) very recently became aware of men who have sex with men (MSM) difficulties and classified them as a core population segment. The NACP-III's targeted interventions (TI) proposal takes heroic efforts to demonstrate that this population necessitates immediate and focused care, marking a significant change from its past policies.[6] More so, MSM in India is at a significant risk of HIV infections as they have frequent anal sex (45% of MSM practice anal sex).[7] Data from NFHS-III estimate that there are approximately 2.35 million MSM who have predominantly anal sex.[8] About 5.7% of MSM in India are thought to have HIV/AIDS, according to a 2005 estimate by the NACO. However, the researcher felt that this was an understatement, especially given that the global prevalence estimates imply that sexual transmission between males accounts for 5%–10% of HIV prevalence.[9] All the aforementioned reasons encouraged us to conduct this study on evaluating the risk of MSM for STI.
MethodsThe current analysis was carried out among MSM of Ratlam, Madhya Pradesh, to document their risk behavior for STIs with an objective to contribute effectively in the existing literature on the reasons for high STI prevalence among MSM and help in effective implementation of TI under NACP-III.
Study design
This study was a cross-sectional descriptive study.
Study area
Madhya Pradesh's North-Western region is the Ratlam District. Ratlam is one of the first commercial towns in central India and being the center for an extensive trade in opium, tobacco, and salt, and it has a lot of migratory population, mainly single male migrants coming to Ratlam City in search of better job opportunities.[10]
Sampling
A nongovernment organization working as TI for MSM in Ratlam City was selected as unit of study. This selection was purposive and was based on operational feasibility. Drop-in-center (DIC) under the same TI, which is a doorway for MSM and their sexual partners to a welcoming and caring environment, was identified for the study. DIC is envisaged as a hub for all services in their role, which an MSM can access as per his need and convenience. DIC acts as the one point from which all prevention and treatment efforts are coordinated. It provided primary-tier (Level 1) services such as outreach, needle syringe exchange program, abscess management, STI, behavior change communication, networking, and referrals. Beneficiaries under NACP-III are expected to visit the DIC whenever they are free, need STI treatment, need condom, or require assistance.
Investigators visited the DIC every day as a silent observer for a week to have an acquaintance of the daily activities and to build rapport with attendees. Attendees of DIC were explained the objectives of the study and requested to participate. They were assured that absolute confidentiality about their identity and information related to their sexual behavior, practices, and other vital information will be maintained. After receiving written consent, the data were collected in a predesigned, pretested, and semi-open-ended questionnaire. Only researcher collected data to avoid interviewer bias.
The total duration of the study was 5 months, from February 2010 to June 2010, and it was proposed to interview as many DIC attendees as possible.
Inclusion criteria
The study participants who gave consent to be a part of the study registered with the TI.
Exclusion criteria
The study participants who did not give consent were excluded from the study.
Data analysis
All the acquired data were entered into the Epi Info version 3.5 software (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, US) and analyzed using the proper statistical procedures.
Ethical consideration
This study was cleared ethically from the Ethical Committee of the Indian Institute of Public Health, Gandhinagar. Written consent was obtained from each of the participants in Hindi. The right to participate in the study or deny, to decline answering any specific question, and to withdraw from the study at any point in time were allowed to all the participants. Utmost care was taken to minimize the psychological trauma to the participants in the process of data collection or during communication.
ResultsIn the current study, 156 participants were involved, of which 90% of respondents were male and the remaining were transgender. The mean age of the participants was 28 ± 8.9 years. On inquiring about their marital status, 50% were unmarried, 3.2% were engaged, and rests were ever married [Table 1].
Table 1: Distribution of the study population as per the sociodemographic variables (n=156)Majority of the participants (91% [142 participants]) were consuming alcohol more than once a week.
[Table 2] narrates the history of MSM activity in the past 6 months. Majority of the participants in the present study were involved in MSM activity with both regular and nonregular partners (RP)/casual partners. RPs in the present study were defined as a partner with whom the participant was involved in the act/encounter for more than four times in the last month, whereas rest all single act/encounter in a month were considered nonregular or casual partner.
Table 2: Distribution of the study population as per the history of men having sex with men activity with regular partners and nonregular partners in the last 6 months, the frequency of condom uses in the last 6 months, and during the last sexual act with regular partners and nonregular partnersIn the present study, 85.3% of the study participants were involved in MSM activity with a regular partner in the last 6 months, which is similar to nonregular partners reflecting high-risk activity. On inquiring about the use of condom with a regular partner, of 133 respondents who were involved in MSM activity in the last 6 months, only 1/4th reported the use of condom every time; <1/3rd of the study participants used condom occasionally. Almost similar pattern of condom use is seen with nonregular partners in the last 6 months. The use of condom with a regular partner and nonregular partners in the last encounter was similar (55%).
The participants were asked about the mode of act and the number of partners they were involved with in the last 3 months. Oral sex as a method of sexual pleasure was enjoyed by almost all participants (except five) in the study, both as the active and passive partners. However, it was observed that 54% of the participants acted as insertive partners to <5 partners, whereas 46% had more than five partners. Forty-two percent of the participants under study reported to be a receptive partner to <5 partners, and the rest 58% were receptive to more than five partners. Majority of study participants had a very high-risk sexual activity with multiple partners [Table 3].
Table 3: Distribution of the study population as insertive and receptive partner for anal sex and those who had oral sex with reference to number of partners in the last 6 monthsIn the present study, the respondents were inquired about the history of various STI in 12 months. Of 156 participants who responded to this question, 18 (11.5%) had genital discharge and 5 (3.2%) presented with a history of genital ulcers [Table 4].
Table 4: Distribution of the study population with a history of genital discharge and ulcer in the last 12 monthsA history of anal discharge and anal ulcers was narrated by 14 (9%) and 10 (6.4%) participants, respectively. A history of oral ulcers was not seen in majority of the study population (78.2%) though oral sex was being practiced by most of them [Table 5].
Table 5: Distribution of the study population with a history of anal ulcers, anal discharge, and oral ulcer in the last 12 monthsThe present study reflects that almost 75% of the study population is involved in MSM activity for money; this deviates from assertion that MSM activity is as normal as other sexual activity. The monetary angle involved with the increase in MSM activity is a serious concern and needs to be addressed [Table 6].
Table 6: Distribution of the study population involved in the last men having sex with men activity for moneyOn inquiring about paid MSM activity, 91 admitted of being involved in the activity either as insertive, recipient, or acted as both. Of 91 participants, 13.1% acted as insertive partners whereas 51.6% were the recipient. About 35% acted as both insertive and recipient partners for paid MSM activity. Only 6.7% were always utilizing condoms for paid MSM activity, whereas rest 93.3%, were either using condom most of the times or sometimes.
DiscussionIn the context of the HIV epidemic, MSMs represent a significant risk category. Their vulnerability to STIs, including HIV, is exacerbated by intermittent condom usage, risky sexual practices, and different partner types. In the present study, more than half of the respondents belonged to the age group between 20 and 35 years, which is also one of the most productive age groups in the community. About 50% of the participants were unmarried, while 37.8% of respondents were married; this signifies that MSM is just not only restricted to unmarried youth but also it has percolated among married males. Eighty-five percent of respondents were involved in MSM activity with nonregular partners increasing their risk of acquiring HIV infection. The frequency of persistent condoms used during the MSM activity with regular partners and nonregular partners in the last 6 months was only 25.6% and 20.5%, respectively. In the present study, condom use rate during the last MSM act was 55.6% with regular partners and 56.1% with nonregular partners. A very low condom utilization rate makes them prone for the risk of acquiring STIs as well as HIV.
Oral sex was practiced by almost all the respondents, and anal sex was preferred by the majority of respondents either as insertive or receptive partner, with a several of partners increasing their risk of acquiring as well as transmitting HIV infection. The occurrence of STI in the last 1 year in the form of genital discharge (11.5%), genital ulcers (3.2%), anal discharge (9%), and anal ulcers (6.4%) was significant. There is an urgent need to be addressing this issue by the policy planners and program managers. About 92.7% of the study population did not have any history of any STI in the last 12 months. These observations were similar to those made by Kumar and in a meta-analysis conducted in India.[11],[12]
In the present study, more than 75% of the participants were involved in MSM activity for money; this deviates from the assertion that MSM activity is as normal as other sexual activity. The monetary angle involved with the increase MSM activity itself is a serious concern; more so, condom use in paid MSM activity was just 6.7%. More qualitative studies are required to have an insight into low condom use rates in both nonpaid as well as paid MSM activity with regular and nonregular partners.
This study offers compelling evidence that MSM is more vulnerable to HIV due to a variety of variables. According to the current studies, about 37% of MSM were married. This brings up additional issues, such as the fact that women often contract HIV, because they are partners of men who are members of the population groups that are most at risk for HIV infection, such as MSM, rather than due to their own sexual behavior. From a programmatic angle, interventions must be created and put into action through viable entry points. The majority of HIV prevention efforts to date have been directed at those who are urged to use condoms, particularly those for the most vulnerable populations who have regular sexual partners. To safeguard the uninfected partner who is at high risk of infection, specific interventions are designed to address such circumstances, while the other partner is infected. Although the NACP-3 guidelines for TIs stress the need of focusing on the regular sexual partners of the most at-risk populations, specifically injection drug users, migratory workers, and truck drivers, there is a little research on the most effective approaches. The study's suggestions emphasize the necessity for operational research to offer evidence for building appropriate HIV interventions and prevention programs in MSM.
ConclusionHence, this present case study has been conducted with objectives to study risk factors for HIV infection in community of men who have sex with men in ratlam city, Madhya pradesh.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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