Prevalence of HIV in MSM population in India
(Based on the report of Sentinel Survey conducted by NACO, Government of INDIA in 2007)

Defining MSM
The term ‘Men who have Sex with Men’(MSM) is used to denote all men who have sex with other men as a matter of preference or practice, regardless of their sexual identity or sexual orientation and irrespective of whether they also have sex with women or not. This epidemiological term entirely focuses on sexual practice. This term does not refer to those men who might have had sex with other men as a part of sexual experimentation or very occasionally depending on the special circumstances. It should be noted that all who engage in male-to-male sex do not necessarily identify themselves as homosexuals or even males1.
The reliability of HIV infection data among MSM is influenced by:

1. The lack of knowledge and understanding of MSM behavioural patterns as many MSM do not have a sexual conscious, sexual identity/orientation;
2. Many do not consider reporting on their same sex behaviours even when asked;
3. Many do not identify their sexual behaviour as MSM since their partners are not perceived as men;
4. Many gay-identified men as well as others, who have developed a sexual identity, are reluctant to identify themselves and disclose their same-sex behaviours or sexual orientation to health care providers, fearing stigma, discrimination and exclusion2.

What is Sentinel Surveillance?
Sentinel surveillance is a biological surveillance method; the purpose of sentinel HIV sero-surveillance is to track HIV infection levels in populations accessed through “watchpost” institutions. These institutions are generally selected because they provide access to populations that are either of particular interest in the epidemic, or representative of a larger population. In general, sentinel institutions are already drawing blood for another purpose. STI patients, drug users and pregnant women are all likely to give blood for diagnostic reasons3.
Even though the data may not represent the entire population, it provides important aids to policy, planning, and evaluation, weather to obtain a national picture of the burden of certain disease, or more restrictively, in relation to specific health programs. It is generally less expensive than full surveillance of total population, and is particularly appropriate in jurisdiction where such a system is lacking. It conveys a sense of early warning. For the purpose of the survey the population is broadly divided under two headings

A. General population – this group includes

1. Females attending the Antenatal Care (ANC) clinics.
2. Blood Donors

B. High risk population – this group includes

1. Female Sex Workers
2. Men who have Sex with Men
3. STD Clinic Attendees
4. Injecting Drug Users
5. Truck divers

So what do the numbers say?

General Estimates

Estimates of HIV Burden in India
1. Males constitute around 61% of HIV positive population.
2. Children below 15 years constitute 3.5%.
3. Adults aged 15-49 years constitute 88.7%.
4. Elderly people with age greater than 49 years constitute 7.8%.

State- wise distribution

1. Andhra Pradesh– 21%
2. Maharashtra– 20%
3. Karnataka– 11%
4. West Bengal– 10%
5. Tamil Nadu– 08%
6. Gujarat– 06%
7. Uttar Pradesh– 04%
8. Other states– 20%

Estimates of Prevalence in MSM
HIV transmission through sex between men is a major cause for concern in many parts of India. Some studies show that nearly five percent of all sexually active males in India have sex with other men, with Chennai, Andhra Pradesh and Orissa reporting the highest number of cases. Recent research has shown that many MSM also have sex with women. Also, a study in Andhra Pradesh found that 42 percent of MSM in the sample were married; that 50 percent had sexual relations with a woman in the last three months and that just under half had not used a condom. Therefore, attention currently focuses on areas with high rates of recorded prevalence, and concern is about what might be happening in vast areas of the country for which there is little data available4.
The number of Sentinel sites for MSM has increased from 31 in 2006 to 40 in 2007. The sentinel surveillance report says that there rise in the prevalence rate of HIV in MSM (7.4% in 2007, higher than any other group from the high risk category). Expansion of surveillance among MSM has revealed new pockets of epidemic. Among MSM, high HIV prevalence is recorded in the states of

1. Karnataka (17.6%)
2. Andhra Pradesh (17.04%)
3. Manipur (16.4%)
4. Maharashtra (11.80%)
5. Delhi(11.73)
6. Goa (7.93%)
7. Gujarat (8.40%)

In total, 11 states have shown greater than 5% HIV prevalence among MSM. All the new MSM sites established in Andhra Pradesh and Orissa have shown high HIV prevalence, suggesting that there may be many pockets of high prevalence among MSM which need to be detected. Moreover, urban areas of the country such as Delhi, Pune, Bangalore, Surat, Rajkot and Kolkata recorded very high HIV prevalence among MSM. Overall, 21 districts have shown greater than 5% HIV prevalence among MSM.

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Districts with HIV Prevalence > 15% among High Risk Groups, 2007

1. Hyderabad - 41.22
2. Delhi (NE) - 30.00
3. Bangalore - 17.60
4. Warangal - 17.54
5. Cuddapah - 17.20
6. Imphal West - 16.40
7. Rajkot - 15.60
8. Krishna - 15.45
9. Pune - 15.20

References

1. Operational guidelines for HIV Sentinel surveillance, NACO, Ministry of Health and Family Welfare Government of India, 2008.
2. Khan S., MSM and HIV/AIDS in India, Naz Foundation International, January 2004.
3. Guidelines for Second Generation HIV Surveillance, UNAIDS, Working Group on Global HIV/AIDS and STI Surveillance, 2000.
4. Men who have Sex with Men (MSM) and Injecting Drug Users (IDUs), Behavioural Surveillance Survey, 2006, NACO, Ministry of Health and Family Welfare Government of India.