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missing pieces
HIV Related Needs of Sexual Minorities in India

National Stakeholder Consultation Report
October 24-25, 2008
New Delhi, India
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United Nations Development Programme, 2008
All rights are reserved. The document may, however, be freely reviewed, quoted,
reproduced or translated, in part of full, provided the source is acknowledged. The
document may not be sold or used in conjunction with commercial purposes
without prior written approval from UNDP. The views expressed in documents by
named authors are solely the responsibility of those authors.
The views expressed in this report do no necessarily represent the views of the
United Nations Development Programme, its Executive Board or its Member States.































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A National Consultation on the HIV related needs and concerns of Sexual
Minorities in India was held on October 24 and 25, 2008 at the India International
Centre, New Delhi. The participants at the consultation discussed issues related to
Men having Sex with Men (MSM) and Transgender (TG), as well as the status of
programmes and advocacy activities within the third phase of the National AIDS
Control Programme (NACP-III). They subsequently suggested action in strategic
areas where UNDP can provide support to the National AIDS Control Organisation
(NACO).






From left to right:
1
st
row: Sabrina Sidhu (UNDP India) , Tarini Arogyaswamy (consultant) , Arif Jaffer (Bharosa Trust), Mona Mishra (UNDP India),
Lakshmi Tripathy (Astitva), Aditya Bandopadhyay (APCOM), Ranjit Sinha(Anandam)
2
nd
row: Rajendra Shirke(UNDP India), Shashi Sudhir (UNDP India), Alka Narang (UNDP India), P. Shailaja (HLFPPT), Sonal Mehta
(HIV AIDS Alliance), K. K. Abraham (IN P+), R. Jeeva (Transgender Rights Association) , Vijay Nair (Udaan), Agniva Lahiri (PLUS)
Standing 3
rd
row: Mona Sinha (HLFPPT), Anupam Hazra (SAATHI), Vandana Bhatia (UNFPA), Sylvester Merchant (Lakshya Trust),
Vivek Anand (Humsafar Trust), Sunil Menon (Sahodaran), Yatin J Patel (SAATHI), Subharthi Mukherjee (Prothoma)






Table of Contents



Acronyms...5
Executive Summary...6
UNDP and its Work...................7
Background of the Consultation...7
Purpose ..............................8
National Response......9
Historical Perspective on MSM and TG........10
Surveillance Data...............11
Roll out of National Programme ....13
The Legal Environment ...14
Targeted Interventions and Beyond........15
Missing Pieces in Interventions........17
Trends and Patterns in Community Action ....18
Care and Support for MSM and TG.....20
Areas for further research, exploration and study.21
Recommendations to UNDP........23
Annex I: Participants.................................27
Annex II: Targeted Interventions for MSM..28










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Acronyms


AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ART Antiretroviral Therapy
BCC Behavior Change Communication
BSS Behavioral Surveillance Survey
CBO Community Based Organizations
CCM Country Coordinating Mechanism
FHI Family Health Initiative
FSW Female Sex Workers
GFTAM Global Fund to Fight AIDS, Tuberculosis and Malaria
GIPA Greater Involvement of People Living with HIV/AIDS
HIV Human Immunodeficiency Virus
IDU Intravenous Drug Users
IEC Information, Education, Communication
ILO International Labor Organization
INFOSEM India Network for Sexual Minorities
KABP Knowledge, Attitudes, Beliefs and Practices
MSM Men who have Sex with Men
NACO National AIDS Control Organisation
NACO National AIDS Control Programme
NACP III National AIDS Control Project- Phase III
NFI Naz Foundation International
NACP National AIDS Control Programme
NGO Non-Governmental Organization
PLHIV People Living with HIV
PLUS People Like Us
PIP Programme Implementation Plan
PIL Public Interest Litigation
STD Sexually Transmitted Diseases
STI Sexually Transmitted Infections
SAATHI Solidarity and Action against the HIV Infection in India
SACS State Aids Control Society
TI Targeted Interventions
TG Transgender
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDAF United Nations Development Assistance Framework
UNDP United Nations Development Programme
VCTC Voluntary Counseling and Testing
WHO World Health Organization






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Executive Summary

India has an estimated 2.3 million HIV infections, which translates into an overall HIV prevalence rate
of 0.34 percent. The epidemic has many specific variations within India, as several states in southern
and the north-eastern part of the country show higher HIV prevalence. They also demonstrate
diversity in predominant patterns of HIV transmission as the epidemic in southern India is largely due
to unprotected sexual intercourse, and that in the north-eastern part of the country due to unsafe
needle usage. Even low HIV prevalence states are characterized by the presence of high risk pockets
with potential for greater spread of epidemic in these states. Thirty nine percent (39%) of HIV
infections are in women, and many infections are in rural areas. There could be a significant burden on
communities and the health services sector with numbers of infections on the rise in many districts.

The epidemic in India is still concentrated in groups with particularly high risk behaviour including
men who have sex with men (MSM), female sex workers (FSW) and injecting drug users (IDUs). At the
national level, the overall HIV prevalence among different population groups in 2007 continues to
portray a very high prevalence among these groups IDU (7.2%), MSM (7.4%), FSW (5.1%) & STD clinic
attendees (3.6%) and low prevalence among ANC clinic attendees (0.48%). Clearly, increased focus on
MSM/TG interventions is the necessary way forward within the national HIV programme. UNDP has
recently been identified as the UN agency to lead work on issues of sexual minorities, and therefore, is
working to develop a strategy for its work.

UNDP India supports the National AIDS Control Organisation (NACO) of India to implement the
current national programme, and helps to expand its reach. It also helps NACO to ensure that the
programme is inclusive of those vulnerable to HIV. UNDP approaches its support to the NACP-III from
the gender and rights perspective, with a significant emphasis on stigma reduction and greater
involvement of PLHIV and members of key populations such as sexual minorities.

The practice of male to male sexuality in India is very complex and in many ways, unique; MSM and
Transgenders have emerged as a core high risk group in NACP-III. Decriminalization, although
necessary, is not enough to combat homophobia and even in settings where some rights have been
secured for MSM, they can easily be eroded. MSM interventions have thus to go hand in hand with
fighting against stigma and discrimination and promoting human rights.

At this two-day national consultation of MSM and TG, their representatives, donors, government
functionaries, NACO, State AIDS Control Societies (SACS), programme planners and those involved in
implementation came together to provide UNDP with strategic advice on the way forward.

Recommendations of the Consultation

The participants urged UNDP to support processes that enable effective implementation of Targeted
Interventions for Sexual Minorities, support rights based community action and develop leadership
among their representatives, build capacities of State and District level functionaries (health and non-
health) on issues of Sexual Minorities, generate new knowledge and evidence on issues of HIV and
Sexual Minorities, and develop strategies to sharpen focus on the needs of the TG (Transgender)
community. The report discusses these and other recommendations in detail. On the basis of this
report, UNDP will work with NACO, UNAIDS and community representatives on an action framework
for providing focused technical and financial support to NACP-III on issues around HIV and Sexual
Minorities.





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UNDP and its work in India


UNDP works with other UN agencies as a co-sponsor of the Joint UN Programme on AIDS (UNAIDS).
Within this partnership, UNDP has the special responsibility of addressing the connections among HIV,
poverty and development, as well as advancing human rights and gender equality. UNDP tries to
achieve this in a variety of ways around the world. For example, because the spread of HIV is fueled by
human rights violations and by discrimination against women, men who have sex with men, people
who inject drugs, and sex workers, UNDP helps countries to enact and enforce laws to protect the
rights of these groups.

In addition, recognizing the role parliamentarians play in setting and enforcing new laws and
jettisoning old prejudices, UNDP has collaborated with the Inter-Parliamentary Union and the UNAIDS
Secretariat to produce a handbook for parliamentarians that provides guidance on the vital role they
can play in responding to the epidemic.

Tackling this epidemic remains a top priority for UNDP. With strong leadership, by empowering people
living with HIV, and by delivering on the promises that have already been made, there is real hope that
the tide can be turned against AIDS. UNDP recognizes that no poverty reduction strategy is complete
without addressing HIV; the loss of parents and productive citizens not only affects their immediate
families, but schools, governments, agriculture and other productive sectors of societies. In the most
affected countries, the impact of AIDS can undermine national economies and considerably reduce
average life expectancy. Costly treatment, absenteeism and mortality, which is heavily concentrated
among working age adults, have a direct socio-economic impact. Seeking to address this, UNDP has
assisted 25 countries to integrate responses to AIDS into poverty reduction strategies and national
development plans.

In India, the UNDP works with the National AIDS Control Organisation and supports the
implementation of the national programme across nine states of India, with the aim of expanding its
reach to include those more vulnerable to HIV. According to the UN Global Division of Labour on HIV,
UNDP has recently been identified as the lead UN Agency to work on issues of sexual minorities.

Background


The practice of male to male sexuality in India is very complex and in many ways, unique; MSM and
Transgenders as a group have emerged as a core high risk group in the national HIV/AIDS programme.
According to recent sentinel surveillance data in India, sero-prevalence among MSM and TG
populations is greater than among female sex workers. Interventions among MSM and TG population
groups are still very new and do not perhaps reach the most vulnerable. Decriminalization, although
necessary, is not enough to combat homophobia and even in settings where some rights have been
secured for MSM, they can easily be eroded. MSM interventions have to go hand in hand with fighting
against stigma and discrimination and promoting human rights. In this regard, UNDP India is initiating
a dialogue with a range of stakeholders to contribute to UNDPs process of articulating its strategic
focus on the HIV needs of sexual minorities.

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Purpose of the Consultation


UNDP is the UN Agency mandated to work on issues of sexual minorities. To develop a strategic
framework for this work, based on participatory stakeholder analysis, UNDP convened a consultation to
identify the urgent needs of MSM and TG communities. Community representatives, donors,
government functionaries, the NACO, SACS, programme planners and those involved in
implementation came together at a two-day consultation to formulate a strategy.
UNDP set out the two broad objectives of the two-day Consultation:

To discuss the trajectory of programmatic and advocacy activities on MSM and TG issues within
the framework of National AIDS Control Programme -III (NACP-III), its roll out in 2007 and the
key successes; and

To ascertain key strategic areas within MSM and TG issues where UNDP can provide
support to NACO and NACP-III.























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National Response


Presenter: Mr. Pravir Krishn, Joint Secretary
Organisation: National AIDS Control Organisation (NACO)

The Joint Secretary of the NACO made a special request that the targeted interventions for MSM be
made stronger in terms of quality of trainings and service delivery. He urged the community leaders,
donors and state representatives gathered at the consultation to bring to NACOs notice any areas of
improvement in this regard. Given that the NACP-III strategy has clear directions on creating
community ownership of targeted interventions, he urged UNDP and all present to invest resources
and technical support to enhance community action, and to provide the groups with high quality
support to implement HIV prevention and care
services at the community level.

In a moment of pride, he informed the group that the
third phase of the National Programme of India is
indeed one of the best and biggest in the world;
however, much more can be done to improve the
reach of the programme and make a real and
sustainable difference.

He provided strategic direction to the Consultation
members and requested them to remain focused on
the gaps in the work with sexual minorities, spend time on critical analysis, and provide concrete
suggestions to NACO and UNDP on the way forward. He also suggested that UNDP invest technical and
financial resources to strengthen the capacity of state officials and Community Based Organisations
(CBO) on diverse programme implementation issues related to sexual minorities, and to undertake
specific activities to help NACO to monitor and evaluate
ongoing interventions.

Members of the Consultation were appreciative of the Joint
Secretarys openness to their suggestions. During a brief Q&A,
they shared their concerns regarding quality of trainers who
may have Masters degrees in Social Work (MSW) but lack any
knowledge about the MSM community. This suggestion was
taken on board and the group was informed that NACO is
considering ways to include members of the community as
trainers, provided they fulfill some basic criteria. The Joint
Secretary urged the participants to evolve systems to develop
leadership among community members, so that the
programme can be showcased as a model of good practice. He
was aware that while significant capacity building work is being
undertaken under the Mainstreaming Project of UNDP and
NACO, more focused capacity building and quality assurance
work needs to be done at a larger scale on issues of Sexual
Minorities.






10

Historical Perspective on MSM and TG Communities
Presenter: Ashok Row Kavi
Organisation: UNAIDS

For the past year UNAIDS has provided NACOs policy makers and implementers technical assistance
on MSM and TG issues, one of the key steps forward has been the finalization of a definition of MSM for
programme implementation. This definition, now accepted at all levels of the national programme, is as
follows: MSM is any man who has sex with another man, regardless of sexual orientation or gender
identity, not considering the fact that he is also having sex with women.

As per available estimates, there are 3.5
lakhs estimated MSM population in the
country. Those MSM who are most at
risk will receive priority attention in the
Targeted Interventions (TIs) as designed
and implemented in the NACP. These
MSM have been defined as those who
have more than 15 partners. Many
participants felt that limiting TIs to those
most at risk makes the response a very
public health centric one rather than a
development response. Some TI
implementers, for example, may view
the definition narrowly and refuse
services to men that have less than 15 concurrent partners; this can increase stigmatization, and ignore
women who are at risk by virtue of being partners of MSM. UNAIDS, however, did stress that the
current data methodology views HIV as a disease and that NACP-III is about disease prevention. A clear
consensus emerged among participants that while the TIs will continue to function within set
parameters for ease of making them measurable, there needs to be a parallel programmatic process
that looks at MSM needs that fall outside the purview of a standard TI.

There was also concern expressed that MSM is a very technical term. It could perhaps be more
beneficial to use male instead of men because there are many males, such as eunuchs, who dont
consider themselves men. Advocacy activities and interventions, therefore, should be centered on
males who have sex with males rather than men who have sex with men. Transgenders (TG) are a
vital part of the picture but NACO has not as yet determined the total number of TGs that it will work
with or the number of TGs that are most at risk. New guidelines for TGs will take this forward.

With a specific view towards TIs, UNAIDS recommended that UNDP undertake:

Mapping of MSM and TG networks and sites;
Sensitizing health systems towards needs of MSM and TG;
Setting up more systematic mechanisms for education about oral/anal sex and sexually
transmitted infections (STIs);
Developing holistic packages for vulnerable MSM and TG even if they do not fall in the category
of the most at risk as defined within the parameters of a standard TI ;
Empowering MSM leadership at community level, with sustained capacity building;
Developing links to the family planning clinics to reach wives and female partners of MSM ;
Supporting NACO to develop new guidelines for working with TG;
Advocating to remove the anti-sodomy laws and sensitizing the police; and
Educating youth in schools and colleges as part of the overall adolescent education
programme.
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Surveillance Data
Presenter: Dr. Ajay Khera
Organisation: NACO

HIV Sentinel Surveillance is an annual
exercise conducted to monitor the trends and
levels of HIV epidemic among different
population groups in the country. It is
implemented with the support of two
national institutes and seven regional public
health institutes of India. The methodology
adopted is Consecutive Sampling at the
service facilities and Unlinked Anonymous
Testing after removing all the identifiers.
HIV Sentinel Surveillance study 2007 was
conducted from October 2007 to December
2007 at 1134 sentinel sites 646 sites among
general population and 488 sites among high
risk group population (FSW, MSM, IDU,
Migrants and Truckers). A total of 3, 58,797
samples were tested during HIV Sentinel
Surveillance 2007.


According to HIV Sentinel Surveillance 2007, the
prevalence amongst MSM is 7.41%. A high HIV
Prevalence is recorded in the states of Karnataka
(17.6%), Andhra Pradesh (17%), Manipur (16.4%),
Maharashtra and Delhi (12%), and Goa and
Gujarat (8%). Overall, 11 states have shown
greater than 5% HIV Prevalence among MSM. 21
districts have shown greater than 5 percent 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, Vadodara, Rajkot
and Kolkata recorded high HIV Prevalence among MSM.















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Roll out of the National Programme


Presenter: Dr. S. Jana
Organisation: NACO

Dr. Jana applauded UNDP and the participants for a very timely and substantive discussion on issues
of sexual minorities within the national AIDS programme. While he agreed that all the HIV related
needs of Sexual Minorities that were being discussed were of key significance for the success of NACP-
III, he also cautioned the group that the government programme will need additional support for
undertaking these suggested activities; in which context, UNDPs support will be welcome. At
present, there are 121 MSM interventions in the country. During the Financial Year 2008-09, the target
is to establish 126 MSM sites. More information about MSM TI sites is given in Annexure-II. The MSM
coverage at present is about 60 percent of the total estimates.
NACP-III has been developed to provide
coverage of most at risk population
groups through targeted
interventions (TIs). This is as per the
national data trends and the recent AIDS
Commission report. However, several
aspects of the HIV related needs of sexual
minorities remain un-addressed namely,
the issues around social stigma, a
disempowering legal environment and
the needs of those among them who are
HIV positive.

He was clear that even though many may disagree with the specific benchmarking and definitions of
MSM that have been adopted by NACP-III, these boundaries are required for NACO so that it can arrest
the spread of the virus and remain accountable on this front. This by no means disregards the needs of
those MSM and TG who do not fall within this definition; he urged UNDP to consider options for such
population groups, saying this will only strengthen the national response.

The NACP-III is a clear departure from earlier programmes as it vests great emphasis on the formation
and development of CBOs as a key strategy. The roll-out of this strategy requires substantial support
and assistance from all development partners, especially UNDP. He laid special emphasis on the new
strategy of encouraging community led and owned targeted interventions , which has worked in
almost all settings, and been highlighted in the AIDS Commission report as well. However, Dr. Jana
sought the support of the participants and UNDP for the smooth roll out of the strategy that
encourages community action.

Participants reiterated that since NACP-III talks about a rights based approach, it should be a
development mechanism not just a disease control programme. There were many concerns
expressed by the participants on the manner in which NACP-III is implementing its TI work on MSM.
First, the participants felt that the criteria used for selection of organizations for implementation of TIs
was not always fair. Second, the mapping of MSM sites seems to have been skewed. Third, there has
been insufficient monitoring and evaluation at the field level to understand successes and failures.
Fourth, the absence of a complaint and redressal mechanism greatly limits debate and feedback.
These critical observations were taken on board and appropriate action was promised at different
levels.
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The Legal Environment
Presenter: Tripti Tandon
Organization: Lawyers Collective

A Public Interest Litigation (PIL) had been filed by a representative from Naz Foundation contesting
Section 377 of the Indian Penal Code, which criminalizes sodomy. Lawyers Collective is representing
the petitioner and their representative Tripti Tandon presented an update from court sessions on the
PIL. The Assistant Solicitor General continues to cite arguments in support of the Section 377, saying
that the key question that needs to be answered is whether there is evidence that decriminalization of
same sex behavior will prevent HIV transmission.

The Government (Ministry of Home Affairs) has several
arguments in defending the constitutionality of Section
377. The representatives state that the right to privacy
can be intruded upon to preserve health, decency and
morality (Article 21). They also argue that the Law is not
discriminatory as it applies to all persons (Article 14), and
that sexual orientation is not a prohibited ground for
discrimination (Article 15). The Government also stress that
this causes no interference in freedom of speech and
expression (Article 19). The Government feels that the
legislative intent is clear and must prevail (Article 14).
According to them, it is the legislatures prerogative to decriminalize homosexuality, and the court
cannot read down the law. The judges responses have been positive as they discount references to
religious quotes or mythical ideas about HIV by urging the Government to focus on the scientific
arguments.

Tripti Tandon also presented the gaps in their own arguments. First, the representatives from Lawyers
Collective feel handicapped as there is very minimal data available on MSM and same sex activity, with
almost no data on TG. Due to the difficulty in supplying condoms in certain spaces, such as jails, there
is insufficient data to show that condom use by MSM decreases HIV incidence in MSMs. Since MSMs
are driven underground due to stigma, the attendance rates at STD clinics show that MSMs dont
receive services. It is also difficult for Lawyers Collective to determine the influence of HIV incidence in
MSMs to HIV in India, and to capture the impact of MSM interventions.

MSM/TG living with HIV often get harassed by
complaints filed under Section 268 IPC (causing public
nuisance) or under Section 294 (Obscene Acts and
songs). Complaints are also registered under Section 269
and 270 Act (likely to spread infection), or under the
Bombay Police Act, 1951. All these result in random
pickups by the police. Participants brought to light two
TIs under NACO and some other interventions which
show the impact of empowerment of MSM on
prevention of HIV transmission. However, these are not
documented and peer reviewed in a scientific way, and UNDP was urged to undertake this
documentation. Others expressed caution in using this data as the Government may use i t to show
that despite interventions, there is no decrease in HIV in the MSM population. It was suggested,
however, that the data be used to demonstrate that consistent condom usage reduces HIV and the
absence of condom use leads to an increase in HIV prevalence.
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Targeted Interventions and Beyond
Presenter: Vivek Anand
Organization: Humsafar Trust

A Targeted Intervention (TI) is a programme targeting
a high risk group to bring down the HIV prevalence in
that group. According to the NACP-III, there are four
most-at-risk population groups, which are MSM, TG,
FSW and IDU. The TI for MSM specifically aims to
promote the use of lubricants and condoms among
MSM, as well as conduct behaviour change
communication with the help of peer educators. The
TI helps to link prevention to HIV related care and
support services. The TI normally also focuses on
greater community mobilization, provision of STI
services, promoting an enabling environment for
MSM, conducting advocacy, and building stronger referral systems to health systems. Mr. Anand
however, stressed, that there arent enough TIs that focus on MSM and TG populations, despite a
commitment in the NACP-III to increase them to 230 in the next 5 years.

He provided a brief summary of the various initiatives that have been conducted across the country
under the TI programme. They include the preparation of a strategic advocacy plan for MSM and TG
by the India Network for Sexual Minorities (INFOSEM). Several capacity building workshops have taken
place for 25 existing CBOs on issues of advocacy, grant writing, program planning, monitoring and
evaluation
and reporting. Research was done in four states and eight sites to explore social and sexual networks,
and to help scale up NACP-III programmes. The evidence from TI programmes for MSM and TG
populations clearly establishes that they have multiple partners. There is, however, no significant
research available that explains the reasons behind the multiple partners.

Mr. Anand also shared his experiences in running a TI
programme by highlighting some challenges. The lack of
services for sexual minorities who do not fit the criteria of
the TI is a definite challenge. MSMs also feel hesitant to
bring their female partners to clinics. To overcome that,
Humsafar Trust conducted a year-long program with
family planning clinic counselors to sensitize them about
these issues. It was found that the female partners of
MSM then started coming for counseling at these family
planning centers, and their numbers have consistently
increased to 27 women per month. Participants noted
that those MSM that have sex with female partners should be urged to practice safer sex outside that
relationship.





16


UNDP should explore the integration of MSM and TG populations with national health programs so
that the focus on MSM and TG populations does not get lost. More regional and local trainings are
needed in view of the linguistic diversity in India. Even though the issues of MSM and TG populations
are similar, they require specific attention.

The participants felt that UNDP should:

Foster emerging CBOs from the MSM and TG communities;

Identify gaps in NACP-III , and help focus on sexuality, crisis and trauma centers, families of
MSM and TG populations, and better access to ART;

Strengthen health care support through trainings in public health systems;

Support rights based initiatives by NGOs and CBOs;

Promote initiatives that build capacity, and develop organizational and leadership skills
among MSM and TG populations;

Sensitize the police and significant stakeholders like SACS, DACS and District AIDS Prevention
and Control Unit (DAPCU) immediately;

Involve female partners of MSM;

Promote condom usage between MSM;

Encourage regional and national networks that bring together isolated or marginalized
communities to empower and effectively mobilize them; and

Conduct regional and local trainings in view of the linguistic diversity in India.
17

Missing Pieces in Interventions with MSM and TG


Presenter: Arif Jaffer
Organization: Bharosa Trust

Mr. Jaffer highlighted the missing pieces in the interventions with MSM and TG populations. He
started by pointing out that targeted interventions in India currently reach out largely to Kothis
(feminized males who have sex with other males), and only a limited number of the gay and the
eunuch (hijra) population. In many states, SACS have preferred to combine MSM and TG populations
by relying on an earlier mapping. This is also used as justification to ignore the need to separate MSM
and TG populations.

There is enough diversity within the MSM group to indicate that the varying needs of eunuchs, kothis
and gays need to be addressed differently. The tools and techniques used for urban MSM, for
example, will be ineffective in rural areas. Rural MSM populations, for example, have mostly been
ignored because most MSM programmes are located in urban areas. A mobile programme that can
reach a larger population in many villages will perhaps be more successful in reaching out to rural
MSM.

A number of groups with MSM and TG are also not being reached in the national programme. The
male partners of kothis, hijras and other TG populations and self-identified adolescent MSMs are also
not being reached in the national programme. Most programs, moreover, dont effectively target
female partners of MSM including wives.

There is also insufficient data on MSMs who are
also IDUs and vice versa. The possibility of cross
infections and re-infections due to the lack of
condom usage has not been studied. To top it all,
an insufficient number of service organizations
provide HIV services for MSM, which has resulted
in low coverage. There are only 11 CBOs, for
example, that work with TG. Peer leadership by
MSMs also needs to emerge.

It is important to mainstream the issue with
other development activities in order to reach the MSM and TG populations. More research is needed
on these populations. Stronger community action and capacity are also required. More female
counselors are needed at the community centers to encourage female partners to get counseling.



18


Trends and Patterns of Growth of MSM Community Action


Presenter: Anupam Hazra
Organization: SAATHI

Presenter: Agniva Lahiri
Organization: PLUS

There are many innovations that have taken place over the years, which have helped to bring greater
attention to the issues of the MSM and TG populations.

Bombay Dost was one of the first innovations in the arena
of same sex behavior. This little magazine became an icon
of the growing liberation of this marginalized population,
and the NGO, Humsafar Trust, eventually grew out of the
community mobilized through this magazine. Magazines
for the MSM community are also a vital source of
knowledge and experience. They have helped people
from remote areas to come together.

Many organizations such as Manas Bangla in West Bengal,
Kranti and Astitva have been pioneers in community work
by going to rural areas. Sangama, a human rights
organization for sexuality minorities, has helped to
organize TGs and to advocate with the police in
Bangalore. Prothama Plus is the first such short stay home in eastern India for TGs.
Many events also helped to bring the community together, and to highlight their issues. SAATHI
organizes community parties to raise funds to support CBOs in initiatives such as
non-formal education programmes. Some innovations have become regular events. They are the
Rainbow Proud Week, SAATHIs Siddhartha Gautam festival, Nigaah Queer Fest and the Queer Media
Awards instituted by Queer Media Journalists with innovative awards such as Most Visible Gay Person
in the Media.
The use of internet technology for improving
social networks is another innovation. Some
support groups, including Gay Bombay and
Gay Delhi, use mobile and internet technology
to access social networking sites like Orkut and
G forum.

Naz and Humsafar Trust set up Drop in Centers
(DIC), which ran very well, and became a model
for future DICs. At the centers, activities range
from dance competitions, performance-based
programmes and street theatre. SAATHI has been an innovator and created books, journals and CDs,
while Naz and Humsafar have developed training manuals for MSM and HIV interventions back in
1999. Similarly, Bharosa Trust has done trainings with medical students and Sangama has built
linkages with civil society organizations. In terms of products, lube sachets are amongst the most
innovative product.
19




These innovations have been fostered by community action. It is therefore very important that
genuine community action be encouraged by those working in HIV. Ideally the identity of the CBO
should stem from the community and not from its location or legal status. The participants strongly
felt that being community owned implies accountability to the community, despite funding coming
from government sources. The experience in the
past has shown that the opening up of the Indian
economy, along with ample funding, as well as high
prevalence in some states has resulted in the
registration of a large numbers of NGOs working on
HIV. This could have resulted in the CBOs lacking
democratic participation from the community.
Many CBOs are also not structurally sound.

There have, however, been some critical successes
in the community movement. This year, Tamil Nadu
became the first Indian state to recognize TGs as a separate gender, at least when seeking
government assistance. In addition, the government is attempting to broaden the employment
opportunities available to TGs by providing computer, stenography and beauty parlor trainings. This
victory can be attributed to direct community action alone, which in turn developed strong
partnerships for advocacy and change. There are many initiatives undertaken by the Tamil Nadu State
government for hijras (known as aravanis there). These include an ongoing census of 30 districts to
count the number of TGs in each district. The Aravani Welfare Board will be formed in 8 districts of
these 30 districts, after strong advocacy from the Tamil Nadu Womens Commission.

These rights, activities and programs are justified and needed as they are innovations that help to
provide HIV services smoothly. The participants affirmed the lack of systematic documentation of
these innovations is an impediment, and that is something that needs to be done.



20

Care and Support of PLHIV from MSM and TG
Presenter: Vijay Nair
Organization: Udaan

Social, legal and health barriers in India often prevent the provision and access of care and support
services for people living with HIV (PLHIV) among the MSM and TG populations. Stigma and
discrimination against the MSM/TG is doubled if they are also HIV positive. Exclusion and lack of
support from friends, colleagues, family or partners, as well as pressure from the family to get married
are other social barriers. Many MSM fear the loss of their jobs anyway, and being HIV positive doubles
that risk of losing their livelihood and their dignity.

In the health care setting, many MSM shy away from
testing due to the fear of being identified without
informed consent. Stigma and discrimination from
health care providers at various levels, and lack of
support services, like homes and hospices, makes the
situation worse. MSM also lack access to treatment
and education especially in the first and second tiers
of treatment. The lack of information on
psychological and other social support systems, and
non-adherence to Anti-Retroviral Therapy (ART) are
other factors that exclude MSM from health care. These issues force people to hide either their MSM or
HIV status. A majority of married MSMs do not reveal their MSM or PLHIV status even to their female
partners because of the stigma and discrimination. When they do so, it is often too late and their
partners are infected.

The following strategies were suggested to provide and strengthen the provision of care and support
to

PLHIV in the MSM and TG populations:

Provide technical assistance to sensitize health care professionals and law enforcement
officials working with sexual minorities living with HIV and AIDS;

Build an enabling environment to reduce stigma and discrimination and build capacities to
deal with issues like the stigma and discrimination that goes with being both HIV positive ,
and MSM/TG;

Encourage NGOS working on the issues and give technical and financial help to involve
members living with HIV from the community , and to ensure the meaningful involvement of
MSM/TG people living with HIV at all levels;

Strengthen syndromic management of STI;

Support pre/post test counseling for HIV testing and psycho-sexual counseling; and

Strengthen access to treatment for MSM/TG living with HIV

21


Areas for Further Research, Exploration and Study

Even though issues of sexual minorities are becoming
more and more relevant in the context of HIV prevention
and care the world over, evidence on the varied aspects of
these groups, their community networks, their social
kinship patterns and the impact of HIV prevention and care
activities on their well being is still not very well
understood. There is definite scope to ask and answer
some critical questions that will enhance understanding
about these groups, which in turn will assist and help to
develop strategies on HIV prevention and care activities.
The members of the consultation discussed and offered suggestions on the types of research that is
needed on the MSM and TG populations who are vulnerable to HIV or living with the virus.

Some areas for further exploration are as below:
Knowledge, Attitude, Beliefs and Practices surveys on HIV, especially among TG;
Specific research studies to determine patterns of migration among TG groups, which make them
more vulnerable to HIV;
A separate consultation to understand the HIV specific needs of TG groups was recommended. This
would then be a start for any research activities among this group across the country. The
participants felt that no research could be facilitated if the leaders of the group were not on board;
A focused research on the HIV prevention to determine Information Education and Communication
(IEC) messages that are most applicable and effective among TG and MSM groups;
Operations research on effective interventions among Eunuchs and TG groups;
A study to determine the effectiveness of lubricants on the rate of transmission of HIV;
Research to determine the rate of transmission of HIV from MSM and TG to partner, particularly female
partners;
A study of the gender based violence in MSM and TG populations;
A study of the impact of creating proper spaces for TGs and Eunuchs in reducing prevalence of HIV;
Study to assess the effect of promoting safer sex as a means of enhancing pleasure;




22
A study of the caste system of hijras;
Research on patterns in substance abuse among MSMs and TGs;
The impact of condom promotion on penetrative and non-penetrative sex;
Research to develop an operational strategy to integrate sexual minorities into Greater Involvement of
People Living with HIV/AIDS (GIPA);
Study of the products that address oral sex habits and subsequent engagement of social marketing
organizations to develop specific products;
Research on effective models of sensitization of health care workers , and the safety of Hormonal Therapy
during ART;
Establish the patterns and trends in health and treatment seeking behavior of MSM and TG;
Research to determine how MSM access and receive treatment under NACO and SACS;
Study the needs of people with disabilities who are sexual minorities and PLHIV;
Needs assessment on geriatric issues of MSMs and TGs;
Data on mental health of MSM and TG populations;
Research on the issues and vulnerabilities of Male Sex
Workers ;

Assessing the needs of people from the MSM/TG
community who are children of sex workers; and

Research on ways to reach those MSM and TG who do not
visit standard cruising sites.

Study to assess the effectiveness of lubes














23

Recommendations to UNDPs Strategy


(1) Mainstream sexual health for better delivery of health care services
Participants called for the mainstreaming of sexual health by conducting sex education campaigns
and educating people about anal sex. Messages and images for such awareness activities must be
developed in collaboration with the MSM/TG communities, and be sensitive to the audience. These
messages could be relayed via mainstream media including the internet and the mobile phone.
(2) Analyze and work to fill gaps in universal access
This would mean sensitizing people from positive
networks, and building linkages with those working
with positive networks for MSMs living with HIV and
community centers.
(3) Reduce stigma and discrimination
It is essential to promote the creation of an enabling
environment that helps reduce stigma and
discrimination. UNDP can also build capacities to deal
with issues like double stigma and discrimination of
being HIV positive and MSM/TG. UNDP needs to
undertake stigma reduction as a separate programme
area across key populations.
(4) Strengthen argument against section 377
UNDP should ideally work with the National Commission to strengthen the Naz petition and
arguments. UNDP could support Nazs argument that aversion therapy, which aims to change a
persons sexual orientation, is a violation of human rights even if Section 377 criminalizes
homosexuality. The submission of written reports for inclusion in the case will help to strengthen the
Naz petition in Court.
(5) Legal education
UNDP could also help improve legal literacy by working with law enforcement officials, lawyers.
UNDP can also provide legal support, and advice on techniques to intervene with judiciary, police,
government, ministries, and other policy makers including NACO, SACS, and district level agencies
such as DACS and District AIDS Prevention and Control Unit (DAPCU). This could largely be done
through trainings, advocacy and human rights education.
(6) Strengthen health care for MSM and TG
It is essential to strengthen health care support through sensitization of health care professionals and
advocacy in the public health systems. UNDP could work on the well-being of MSM and TG
especially with psychological and psychiatric associations that insist that sexual orientation is a
mental health problem. It would be equally important to support the provision of HIV pre/post test
counseling and psychosexual counseling.
(7) Promote accountability
UNDP should support NACO in setting up and implementing governance structures for the MSM
and TG interventions at state level. In the absence of such a system, complaints are not being heard
and addressed; this will impact the quality of the interventions and, eventually on, the HIV prevention
efforts of the national programme.

24



(8) Advocacy for Hijras (Eunuchs) and TGs
UNDP could advocate for a separate category for hijras and TGs in government documents. It would
help ensure greater visibility and reduce harassment of these communities. UNDP could also work
to educate diplomats of countries with whom India has diplomatic relations about the meaning
of the category. The creation of a National Task Force and a Hijra Welfare Board was also highly
recommended by the participants.

(9) Provision of lube
(10) Housing for hijras
(11) Educating, sensitizing and advocating to the media
(12) Research on gender and sexuality from the point of view of MSM and TG concerns
(13) Choose representative by the community
There are interventions needed to advocate for an
elected representative to the Country Coordinating
Mechanism (CCM) of the Global Fund, a
representative that has been chosen by the MSM/TG
community. This could be done by strengthening the
civil society response to CCM.
(14) Strengthen INFOSEM
Strengthen INFOSEM to become the national
network. It could also help increase dialogue with
NACO and other regional or national networks that
bring together isolated or marginalized communities to empower and mobilize them.

(15) Foster community based organisations
UNDP needs to support emerging MSM and TG CBOs, and actively assist them to follow a model
of democratic participation and governance.
Equally important is the need to support NGOs
with technical and financial assistance to involve
members from the community that are living
with HIV and to further the meaningful
involvement of MSM/TG PLHIV at all levels.
(16) Support peer leadership
Support initiatives focused on peer leadership by
MSMs and TGs and female counselors at
community centers.

(17) Focus on crisis intervention
UNDP should focus on crisis intervention as a strategy for HIV prevention and creation of enabling
environment.



25
(18) Reach out to MSM living in rural areas
UNDP should reach out to rural MSM population and active partners of MSM. Mobile Programme
targeting MSM and TG populations to reach many villages and a large population.
(19) Workplace issues for MSM
Intervening with organizations like International Labor Organization (ILO) to formulate policies to
deal with workplace issues for MSM and TG populations.
(20) Identify gaps in NACP- III
Identify gaps in NACP-III especially a focus on sexuality, crisis and trauma centers, families of MSM
and TG populations, and Access to ART.
(21) Rights based initiatives
UNDP should support rights-based initiatives for MSM that go beyond the TIs.

(22) Capacity building and leadership
Promote initiatives for capacity building, organizational development and leadership skills among
MSM and TG populations.
(23) Reaching out to partners
UNDP needs to support programmes that reach self identified adolescent MSMs/TGs and female
partners of MSMs.
(24) Inclusion
UNDP should work for the inclusion of all of these activities and initiatives in Round Nine of the
Global Fund.





















26






ANNEXURES

27

Annex I



Participants
Name Organization
Aditya Bandopadhyay Asia Pacific Coalition on Male Sexual Health (APCOM)
Agniva Lahiri People like US (PLUS)
Anupam Hazra Solidarity and Action against the HIV Infection in India (SAATHI)
Arif Jaffer Bharosa Trust
Ashok Row Kavi Joint UN Programme on HIV/AIDS (UNAIDS)
Billy Stewart Department for International Development (DFID)
Dr. Khera National AIDS Control Organisation (NACO)
Dr. S. Jana NACO
K.K. Abraham Indian Network for People Living with AIDS (INP+)
Laxmi Tripathy Astitva
Mona Sinha Hindustan Latex Family Planning PromotionTrust (HLFPPT)
Nandini Bandopadhyay PATH
Nandita Naik Orissa State AIDS Control Society
Pravir Krishn NACO
P. Shailaja HLFPPT
Rahul Singh Naz Foundation
Raman Chawla Lawyers Collective
Ranjit Sinha Anandam
R. Jeeva Transgender Rights Association
Sabeena Sarne DFID
Shaleen Rakesh Family Health International (FHI)
Sonal Mehta International HIV/AIDS Alliance in India
Subharthi Mukherjee Prothoma Plus (Transgender Shelter Home and Crisis
Intervention Center)
Sunil Anand FHI
Sunil Menon Sahodaran (a male sexual health project)
Sumit Baudh Talking about Reproductive and Sexual Health Issues
(TARSHI)
Sylvester Merchant Lakshya Trust
Tripti Tandon Lawyers Collective
Vandana Bhatia United Nations Population Fund (UNFPA)
Vijay Nair Udaan
Vivek Anand Humsafar Trust
Yatin J. Patel SAATHI/Jyothi Welfare Society

28


Annex II

Targeted Interventions for MSM

Distribution of TIs by typology, Oct 2008 (Total no. of TIs: 1257 till Oct 2008)







Only 11 percent of Targeted Interventions are for MSM (Source: NACO 2008 An update)
Current coverage of high risk groups, Oct 2008







The current coverage for MSM is 212106, and the estimated size is 351013 (Source: NACO 2008 An update)

Percentage
FSW
Core composite
Truckers
Migrants
IDUs
MSM

0
200000
400000
600000
800000
1000000
1200000
1400000
IDUs MSM FSWs
Current coverage ( in
numbers)
Size estimate

29





United Nations Development Programme, 2008