American Foundation for AIDS Research, August 2003
Nicole Rajani

An Urgent Need for Risk Reduction Among MSM

Homosexual relations in India are largely hidden, and men who have sex with men remain at high risk for HIV infection. A remnant of British colonial law, Section 377 of the Indian Penal Code, bans homosexual behavior. Though rarely applied except when minors are involved, Section 377 and other prohibitions against obscenity and “public nuisance” are a source of blackmail and harassment of men who have sex with men (MSM).

India’s National AIDS Control Organisation only recently acknowledged the high prevalence of homosexual activity in India and the urgent need for HIV prevention programs targeting MSM. The national response is lagging behind a few innovative programs initiated by community-based organizations.

Focusing on Mumbai’s Underground Culture

In 1990, Ashok Row Kavi decided to start the first openly gay publication, Bombay Dost. The first issue of the magazine was on the stands the following year. The publication spread rapidly through the gay network and had a snowball effect. After three years, Kavi and others decided to use the subscription base of the magazine to convene a conference on the status of Indian men who have sex with men.

Kavi registered the Humsafar Trust in 1994 as one of the first nongovernmental organizations working with the men who have sex with men. The organization first set up a community center. “There were cruising places all over the city, but this could be a nonthreatening place, where you could talk about and be what you wanted,” said Kavi. The center started Friday workshops to discuss healthcare, beauty and other lifestyle issues. Drop-ins could raise their own issues, too. The workshops grew from an initial attendance of just four people to an average of 100 people every week.

Humsafar quickly became a major MSM resource and research center. It received a government grant in 1998 to survey MSM activity in the city – the first such grant to an openly gay organization.

Kavi recalled, “We insisted that men having sex with men, and self-identified gay men, would really be a huge radiation zone for HIV and STDs. For a very obvious reason, this type of sex is not called sex, and it is free in many cases.” His group created a diagram grouping MSM based on behavior and vulnerability.

“The reason we deconstructed this is for public health reasons,” Kavi explained. “Public health officials have never believed that there are so many men having sex with men. So what we’ve done is deconstructed it, so then it becomes visible. That’s the way we’ve increased credibility with the government.”

In 1999, Humsafar received a National AIDS Control Organisation grant for a pilot project to promote safer sex among men who have sex with men in the Mumbai metropolitan area. It selected six MSM sites and began urging a reduction in sexual partners, greater condom use and healthier behavior overall. Humsafar also conducted an epidemiological survey and found an HIV prevalence of 13%.

Funding for Humsafar’s work continued for the next three years. In 2002, the organization reported that the proportion of MSM using condoms had risen from 43% to 83%. Humsafar’s peer outreach program distributed 600,000 condoms to nearly 58,000 MSM in 2002. The average number of sex partners among MSM had gone from 11 to six per year by 2002. More men were requesting HIV tests and their overall health-seeking behavior had improved, Humsafar also noted.

Kavi estimates that there are about 350,000 MSM in Mumbai. Although sex among men has always occurred in Indian society, he points to the scarcity of women as a prime reason for contemporary increases in homosexual relations. “Even if men wanted to have sex with women, they couldn’t…. There’s a falling gender ratio,” he said. India’s 2001 national census found that the number of girls under six declined from 945 for every 1,000 boys in 1991 to 927 girls for every 1,000 boys. According to UNICEF, there are 50 million “missing” females in India, mainly due to modern ultrasound technology that allows parents to learn the sex of their babies early in pregnancy. They can fulfill the customary desire to have sons by aborting female fetuses.

The shrinking female population has also affected Humsafar’s work with the community. Kavi claims that 20% to 25% of “bar girls” are actually boys in drag. “They’re more vulnerable because the women in bars usually have local pimps; they are well guarded; the gatekeepers are in place. But there’s no such thing for the boys. There’s no protection, and there’s a lot of sexual violence.”

Humsafar targets this vulnerable population by going to local bars, talking with the boys about HIV/AIDS and giving out condoms. Once the boys feel comfortable and gain confidence, they start visiting the center.

Kavi explained, “When a woman takes to sex work, she may be a mother, she may be brilliant, she may have a Ph.D. in literature, but her primary identity is always as a prostitute – that’s what she becomes, that’s the label given to her. But a male sex worker can hide under many labels. He can be a model, masseur.… It’s very interesting how with these groups, you have to pass various barriers and stigmas to get at what they really do.”

Humsafar has been highly successful in attracting MSM to its voluntary counseling and testing center, where it has tested 28,000. Their follow-up rate is 65%, which Kavi claims is one of the highest, even better than at traditional STD clinics. “Basically it comes from the idea of a safe space; when people feel safe, they will come in.”

Besides pre- and post-test counseling, Humsafar offers support services for people living with HIV/AIDS. The group focuses on traditional health and nutrition approaches. Kavi is known as a “Hindu revivalist” for his promotion of time-honored alternative treatments.

Kavi said, “We have a separate nutrition department because we refuse to take part in any HIV treatment till we are promised sustainability, and not before…. If I get in, I must be able to sustain it.” Care and support programs concentrate on more basic needs like potable drinking water. They distribute 70 to 80 bottles of water a day to transgenders and male sex workers, many of whom live in huts near train stations. The dietary program includes utilizing proteins to their maximum benefit – such as mixing soy and wheat flour to make chapatis (Indian flat breads) more nutritious – and eating only fruit in the morning to remove toxins from the body.

“We’re having amazing results. They’re gaining weight without any recourse except to keep away opportunistic infections and managing their diet,” Kavi said. “We have a tradition of 3,000 years. I don’t say all of it is good…but I’m not throwing out the baby with the bathwater. In the next three years…when we sign the [World Trade Organization patent] agreement, even simple antidiarrhea drugs are going to cost 10 times as much. Where are you going to get the money?”

The organization also has founded the Humsafar Parivar Credit Society, which will eventually be used to provide staff members and others with anti-HIV treatment. It has already raised 200,000 Rupees ($4,200) as core capital and will approach funding agencies for matching grants.

Humsafar has negotiated with the Indian generic drug manufacturer Cipla. It managed to bring down the monthly cost of HIV treatment to 1,340 Rupees ($28). Including tests, the total monthly cost will be 1,500 Rupees ($32). Patients will pay half this amount, with the credit society covering the remainder.

Kavi described Humsafar’s approach to public healthcare: “The vision statement of Humsafar Trust is that we will not replicate anything that is already there in the public health system. Our job is to increase the capacity of the public health system and demand as citizens that they understand our problems.”

An important component of the program is sensitizing healthcare providers in the public sector. Humsafar is contacting public healthcare staff and strengthening the personnel’s ability to care and treat MSM with HIV and other STDs. For example, it conducted training at Sion Hospital in north Mumbai to advise doctors on how to ask questions about MSM activity. MSM contact tracing increased from 2% to 23% within a year.

Finally, Humsafar advocates for MSM rights and sensitizing the police to the needs of MSM. Lawyers give educational workshops every three months to MSM about their rights. Humsafar also holds regular workshops at police stations. If it hears that a particular station is very repressive, it arranges a meeting with the top authorities. Kavi said, “Among policemen, we demand that these rights are given to everybody. We agree that sex in public places is wrong, but we make them understand that that’s the only place that allows gay men to be with other gay men.”

Recognizing Sexual Diversity in Tamil Nadu

Diagonally across the subcontinent in Tamil Nadu’s capital, Chennai (Madras), the organization Sahodaran has also made significant efforts to safeguard the health and well being of MSM. Sunil Menon and Lalitha Kumaramangalam started the organization in 1998. Kumaramangalam had been running programs for other marginalized communities, such as truck drivers and slum-dwellers, and realized the dire need to spread HIV awareness to the MSM community.

Self-identified gay men had begun to form more vocal communities in the major urban centers, but homosexual activity remained largely underground, and there was little knowledge of the vast scope of MSM behavior in India. Menon received a World Health Organization grant in 1992 to research homosexual behavior. He recalled that when he presented his findings to India’s National AIDS Control Organisation, “they were really shocked; suddenly I was talking about MSM activity that transcended barriers of identity, behavior patterns. It was very shocking and disturbing for certain people.”

Menon says that the variety of MSM behavior in India is vast and presents a range of challenges for HIV prevention programs. “MSM have not been studied properly in India – they have not been understood. The few groups that exist have been working in small urban areas, around the big metropolises, and that’s not enough – from an HIV standpoint that’s not enough. The scope of their work is limited to upper-middle class, English-speaking, educated, literate, economically independent male adults who know exactly what it means to be ‘gay.’ They identify with the word.”

Sahodaran aims to reach out to those who may not fall into this category, including the many Indian men who engage in homosexual as well as heterosexual activity, and those who feel the strong sociocultural pressure to get married. Some of the men who come to Sahodaran are married, and they have formed their own peer group.

Sahodaran targets MSM behavior rather than solely gay-identified or homosexual men. “We work with the more visible, feminized males, who are called kothis. But that’s a very small group and is the tip of the iceberg,” said Menon. Many men could “go either way” and are neutral in appearance; they are neither markedly feminine nor masculine. There are also the panthis – the heterosexual men who seek out men because they have no access to women.

Menon observed that aside from the artificially skewed sex ratio, the strong emphasis on marriage and premarital virginity greatly increases the likelihood that many nominally heterosexual men will engage in homosexual activity. He said, “You have to get married to have sex with women, or you have to pay for it. Even if the men have girlfriends, their girlfriends are hanging onto their virginity till they get married – because God forbid this boyfriend doesn’t marry her, and she’s not a virgin, she’ll get hell from her [future] husband. MSM activity is easier, more practical; it’s quicker and cheaper – and you can do it in any corner or dark alley. That’s why there’s so much MSM activity happening.”

Sahodaran’s outreach field officers work in 14 major “cruising areas” for MSM, including parks, beaches and railway stations throughout Chennai. Each field officer covers a particular area and has two assistants, who are locals. The assistants know the people in the area and introduce them to the field officer, who offers counseling, HIV/AIDS information and condoms. The field officers document their work and the following day report on how many people they met, which category they were (kothi, panthi, etc.), what they spoke about, how the men responded, and how many condoms and information pamphlets they handed out. “With the new people we meet in the field, we give them our cards, and ask them to come over to the center, we tell them there’s a safe space for you,” said field officer Anto James.

Sahodaran’s drop-in center has 30 to 40 MSM coming in every day for counseling, healthcare referral and information, as well as other activities, like yoga, cooking and dance. They also have literacy classes, in Tamil and English, as well as income-generation activities like candle making and pottery. “Some are shy to come at first. But once they come in here, they are satisfied. They see people like themselves,” said James. “They can’t be very open in the house, with their neighbors, and their straight friends, but here they are very happy. They’re much more open about their identity.”

Finding Validation in Religious Tradition

For two weeks each year in April-May, the festival at the Koothandavar temple in the southern Tamil Nadu village Koovagam draws thousands of transgenders and MSM from all over India. According to Hindu mythology, the warrior Aravanan had to be sacrificed in order for the Pandavas to win the Mahabharata war. Aravanan agreed, but he did not want to die a virgin. He asked to wed prior to the sacrifice, but no father would allow his daughter to lose her virginity for a one-night marriage. Taking pity on Aravanan, the Lord Krishna assumed the female form of Mohini and wed the warrior before his death.

Many of the transgendered and cross-dressing festival participants come in honor of Mohini, with whom they identify. They tie a string on their wrists to symbolize their marriage to Aravanan, and the next day, the string is pulled off to signify their widowhood.

Other male attendees believe they are fulfilling the role of Aravanan. Menon said, “There is a lot of MSM sexual activity [at the festival], and it’s part of the mythology. So we’ve been doing a lot of prevention work around that because there’s a lot of unprotected sex there.”

The transgenders, or hijras, who dominate the Koothandavar festival are considered a “third gender” and have long held a place in Hindu religion as dancers and singers. While some hijras are born hermaphrodites, the vast majority are biological males who have been castrated in religious ceremonies. Traditionally, they were believed empowered by the mother goddess to either bless or curse others. hijras accordingly collect money at weddings and births. In the past, they were commonly greeted with respect, but now they often arouse annoyance and scorn. They live on the fringes of society in their own communities and have increasingly resorted to commercial sex work to make a living.

Sahodaran’s main MSM clientele in the cities, the feminine kothis, strongly identify with hijra lifestyle and culture even though they are not hijras themselves. The hijras embody a tradition that Indian MSM adapt when defining their identity. Menon noted, “We all borrow heavily from the hijra, the transgender community. Our language and most of our rituals are borrowed from, similar to, or part of the transgender community.” As India faces its AIDS epidemic, learning that language and ritual will be critical to reducing MSM’s vulnerability.

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