Women Partners of Men who have Sex with Men (MSM) in India: Preventing HIV transmission and Promoting Early HIV Diagnosis and Treatment Presenting author: Venkatesan Chakrapani, M.D.1 Co-authors: Paul Boyce, Ph.D.2, D. Dhanikachalam, Ph.D. 3, N.R. Manilal4 (International AIDS Conference, Washington DC, July 26, 2012) 1 Centre for Sexuality and Health Research and Policy (C-SHaRP), India 2 University of Sussex, UK 3 Futures Group International, India 4 National AIDS Control Organisation (NACO), India

1. INTRODUCTION In India, many MSM either are married or expect to marry, and/or do not necessarily have a sense of identity related to their same-sex sexual practices. Given this, women partners (especially wives) of MSM are especially important but, to-date, often neglected vulnerable population for HIV prevention. Study Purpose : To review the current evidence regarding HIV risk to women partners of MSM in India, and To present findings from a multi-site qualitative study to understand the perspectives of MSM (and other stakeholders) on HIV risk to their women partners To put forward recommendations to decrease HIV risk to women partners (especially wives)

Study sites: 11 urban/semi-urban sites in 7 states 2. METHODOLOGY Study sites: 11 urban/semi-urban sites in 7 states

Sociodemographic Characteristics FGD participants (n=364) Mean age = 30 Self-reported identities included: kothi (68%) double-decker/dupli (17%) bisexual (10%) parikh/panthi (5%) Mixed educational status Nearly half (46%) were married Key informants (n=37) Officials of govt. HIV programme (SACS/NACO Officials) Officials of Technical Support Units of SACS Leaders of NGOs/CBOs working with MSM Health care providers

3. FINDINGS FROM LITERATURE REVIEW & FIELD RESEARCH Types of women partners of MSM HIV risk to women partners – especially wives – of MSM Sexual life of self-identified married MSM Disclosure of HIV status and same-sex sexual behavior to wife Perspectives of self-identified MSM and MSM community leaders in relation to protecting the health of women partners

A. MSM have different types of women partners Studies among MSM in India have consistently shown that a significant proportion of MSM are married (BSS-2006: 12-69%). Married MSM may have extramarital women partners as well – including women in sex work and casual partners. Example: In the IBBA study (Ginnela et al., 2008) conducted among MSM (n=4597) across four high HIV prevalence states, about one-third (32.6% - 42.7%) had ‘regular female partners’ and almost an equal proportion (14% - 35.7%) had ever paid to have sex with a woman.

B. Women partners – especially wives – of MSM are at higher risk of HIV 1. High HIV prevalence among married MSM Married MSM are more than twice likely to have HIV than unmarried MSM Kumta et al., 2010: 23.8% vs. 9.1%; Solomon et al., 2010: 13.4% (married MSM) 2. Condom use with wives/steady partners is lower when compared with paid women partners. Example: Unprotected vaginal sex with wife - 72% (Solomon et al., 2010) and 98% (Phillips et al., 2010). Consistent condom use with women paid partners – 23% to 78% (Ginnela et al., 2006) 3. Concurrent sex with male and female partners (with inconsistent condom use). Thus, it is possible, HIV transmission risk between MSM & their women partners may be bidirectional. Lack of data on HIV prevalence among spouses of MSM

C. Marriage and Sexual life C-1. Self-identified MSM may enter into heterosexual marriage with willingness, under compulsion or indifference Stated reasons for marriage: Marriage as a societal norm An obligation to one’s family Wanting to have children to sustain family lineage Some are attracted to both sexes Some MSM reported being compelled or pressurized by their family members to get married

C-2. Sexual life of married self-identified MSM Participants reported that some self-identified MSM see having sex with their wives as a ‘duty’ and may be mainly concerned about their ability to sexually ‘satisfy’ their wives as they do not want their wife to suspect that they are ‘not men’. Field data and other qualitative studies indicate that married self-identified MSM continue to have sex with other men after marriage; they may or may not decrease the number or frequency of sex with male partners Barriers to condom use with wife Difficult to use condom if wife has undergone tubectomy or using non-condom contraceptives (e.g., pills, Copper-T) Condom use as an indicator of extramarital sex

C-3. Disclosure to wife Of sexuality It is not clear: whether disclosure of sexuality per se leads to any decrease in HIV risk to self or spouses of MSM whether disclosure of sexuality is necessary for prevention of HIV transmission to wife. Of HIV status Disclosure of HIV status by MSM may or may not result in safer sex with male and female partners (Chakrapani et al., 2008) Consequence: If a self-identified MSM (or any men) is diagnosed with STI or HIV, screening and treatment of his wife become a challenge. Lack of simultaneous STI treatment for husband and wives.

D. Perspectives of self-identified MSM and MSM community leaders in relation to protecting the health of women partners a. Participants differed in their opinions on the attitude of self-identified MSM towards their wives. Some participants thought that self-identified MSM would take steps to ensure that their wives have sexually and emotionally satisfying marital life. Some others thought that self-identified MSM could not cope with dealing with women with whom they are not sexually interested in. b. MSM participants and key informants were against the idea of directly approaching the women partners of self-identified MSM because that will not be acceptable to MSM and damage the long-term rapport build by the agencies with those MSM.

4. KEY RECOMMENDATIONS A. Individual or Couple-level Interventions Potential interventions among single MSM Condom use with partners of any gender. Promoting (regular) HIV testing. Providing pre-marital non-judgmental counselling for self-identified MSM (in NGOs/CBOs working with MSM) Messages of safer sex with partners of any gender need to be incorporated into targeted HIV interventions among different groups of men (e.g., youth, migrants, drug users, prisoners) as well as in mass media campaigns on HIV.

Potential interventions for married MSM and their wives a. Testing and Re-testing as a safer sex strategy Married MSM can undertake HIV testing after unprotected sex with partners outside the marriage After testing HIV-negative, MSM need to be supported for consistently using condoms with male sex partners and/or with wife. b. For HIV-positive MSM and wife of unknown/negative HIV status - Support HIV-positive MSM to disclose their HIV status to steady partners (and skills building for health care providers) - Counselling / education to practise safer sex - In case of condom breakage, access to sexual post-exposure prophylaxis (sPEP)

Potential intervention strategies among HIV-positive MSM to prevent HIV transmission or to enable early diagnosis of HIV among wife MSM diagnosed with HIV Suggest safer sex until disclosure Support how to disclose Inform about HIV testing places for wife HIV testing for wife Wife HIV-positive Wife HIV-negative - Referral to HIV treatment, and care/support services - Safer sex counselling Safer sex counselling (‘Positive prevention’)

B. Policy-level Interventions Need for national guidelines on: - assisting people living with HIV (including MSM) to disclose their HIV/STI status; and - sexual post-exposure antiretroviral prophylaxis (especially for HIV sero-discordant couples)