A Report on Addressing the SRH needs of MSM and their Female Partners

A report on: Addressing the SRH needs of MSM and their female partners using existing SRH facilities and/or working in collaboration with existing organizations Documentation of models that have worked and replicable strategies

Report Submitted to UNDP India by:

FXB INDIA SURAKSHA

Disclaimer: The views in this publication are those of the authors and do not necessarily reflect those of the United Nations Development Programme

Š UNDP India 2012. Published in India

2

ACKNOWLEDGEMENT

This study has been thoroughly reviewed and granted ethical clearance by the Ethics Committee, Family Planning Association of India (FPAI). The study acknowledges the sincere effort and time of FPAI in guiding us modify and finalize the study tools and guidelines. We are also thankful to the IRB of The Humsafar Trust for granting us an ethical clearance for the study at their organization. Our sincere gratitude to all the three organizations: Samgama, Bengaluru; Humsafar Trust, Mumbai and Family Planning Association of India, Mumbai for allowing us to understand and study their initiatives. We thank UNDP India for contracting us for this study and cooperating with us generously during the course of the study.

3

INDEX SL. NO.

CONTENT

PAGE NO.

ACKNOWLEDGEMENT

2

INDEX

3

ACRONYM/ABBREVIATION

4

EXECUTIVE SUMMARY

5

1.

INTRODUCTION

6

2.

PROJECT BACKGROUND

3.

AIM OF THE DOCUMENTATION

4.

METHODS USED

8-9

5.

CASE STUDIES

10

5.1

HUMSAFAR TRUST MUMBAI

10-17

5.2

FAMILY PLANNING ASSOCIATION, MUMBAI

18-25

5.3

SANGAMA, SAMARA, BANGALORE

26-31

6.

CONCLUSION

32-37

7.

ANNEXURES 1, 2, 3, 4 (Attachments)

6-7 8

38

ETHICS COMMITTEE APPROVAL (Attachment)

4

ACRONYM/ABBREVIATION

MSM

: Men having Sex with Men

HIV

: Human Immunodeficiency Virus

AIDS

: Acquired Immunodeficiency Syndrome

SRH

: Sexual and Reproductive Health

HST

: The Humsafar Trust

FPAI

: Family Planning Association of India

ICTC

: Integrated Counseling and Testing Center

STD

: Sexually Transmitted Disease

STI

: Sexually Transmitted Infections

ART

: Anti Retroviral Therapy

CBO

: Community Based Organization

SACS

: State AIDS Control Society

NACO

: National AIDS Control Organization

NACP

: National AIDS Control Programme

5

EXECUTIVE SUMMARY FXB India Suraksha has been contracted by UNDP India to conduct a study on the ‘SRH needs of MSM and their female partners’ in order to document the impact of the ongoing interventions that have so far met needs of the target population through their SRH facilities. This study will help in gauzing the extent of success of such initiatives, reasons for success or shortcomings if any and would bring to the forefront valuable lessons learnt from such experiences for designing future initiatives. The objective of the study is to explore the progress of the initiatives, bring forward recommendations at the service, structural and policy level and suggest practical and feasible models of implementing the same. The study was conducted over a period of two months at three reputed interventions namely: the Family Planning Association of India, Mumbai; the Humsafar Trust, Mumbai and the Sangama-Samara, Bengaluru. The major findings of the study indicate that fear of disclosure of one’s sexual identity becomes a barrier in providing SRH services to the female partners of the MSM. While the need has been felt by the staff and the clientele of the organizations to make SRH services accessible to the female partners of the MSM, an alternative strategic approach needs to be developed in order to reach out to the families as well as their female partners without having to break the confidentiality of the MSM’s sexual identity. Partnering with fellow service providers, strengthening the component of counseling, providing a space to the married MSM/MSM with female partners to disclose their status and problems in order to help the service providers track the female partners etc. was some of the suggested ways for future interventions.

6

1. INTRODUCTION In 2009 it was estimated that 2.4 million people were living with HIV in India, which equates to a prevalence of 0.3%. (UNAIDS report on the global AIDS epidemic, 2010). The third phase (NACP III) began in 2006, with the highest priority placed on reaching 80 percent of high-risk groups including female sex workers(FSW), men who have sex with men (MSM), and injecting drug users (IDU) with targeted interventions (TI). The estimated HIV prevalence among MSM in India is 7.3 % but difficulties in surveying this stigmatized group mean prevalence could be much higher. (National AIDS Control Organization (NACO) Annual Report 2009-2010). Through the TIs under NACP III these populations receive a comprehensive package of preventive services. They include outreach programmes focused on behaviour change through peer education, distribution of condoms and other risk reduction materials, treatment of sexually transmitted diseases, linkages to health services, as well as advocacy and training of local groups.

2. PROJECT BACKGROUND MSM are 19.3 times more vulnerable to HIV than the rest of the population.1 Recent studies confirm that globally men who have sex with men (MSM) are at significantly greater risk for HIV infection than other adults of reproductive age, due to a combination of biological, behavioral, and structural factors.

Various sexual behaviour studies have shown that MSM are also involved in sexual relationships with women. The national BSS study showed that 31% of MSM reported having sexual intercourse with a female partner in the 6 months prior to the survey, and the mean number of female partners was 2.4. Data from Andhra Pradesh show that 65% of MSM had ever had sex with women, among which 76% with their wife, 29% with FSW and 13% with wife as well as FSW. Community studies from Mumbai confirm the above findings that the female partners of MSM were primarily their wife, but about 18% had more than one female partner.

In the year 1998, a participatory mapping by the MSM community was started in Mumbai

by Humsafar Trust being funded by the Maharashtra Directorate of Health Services. A year later, NACO along with the Maharashtra State Control Society in collaboration with Humsafar Trust began India’s first pilot project to promote safer sex among MSM. This was followed by the foundation of ‘The India Network for Sexual Minorities’ (INFOSEM) in 2003, involving community based organizations (CBOs) in three states through Naz 1

Prevention and Treatment of HIV and other sexually transmitted infection among men who have sex with men and other transgender people. World Health Organization, 2011

7

Foundation India and Humsafar Trust. It was since then that the sexual and reproductive health needs of the MSM and their female partners have been recognized to be of importance.

The sexual behavior of the sub-groups of MSM (kothis, panthis, double-deckers, bisexual and hijras) has important implications for the spread of HIV. A study by the Avahan project reports that among the bisexuals, 61% were married and 68% had female sexual partners.

Similarly among the panthis and double-deckers this pattern of marriage or having female partners prevailed. However, it was also reported that condom use with the regular female partners was at an extreme low (29% among panthis, 20% among double deckers and 2% among bisexuals). As men are expected to marry and raise families, those whose primary sexual orientation is towards the same sex might still marry but continue to engage secretively in sex with men. Such men may be reluctant to access HIV prevention services since they are apprehensive of being associated with an identity or behaviour with which they are not comfortable.

Thus stigma and discrimination undermine the effectiveness of HIV and sexual health programs and limit their ability to reach the MSM and TG population. MSM also feel hesitant to bring their female partners to clinics. To overcome the same Humsafar Trust conducted a year long program with family planning clinic counselors to sensitize them about these issues. It was found that female partners of the MSM started coming for counseling at these family planning centers and their numbers have consistently.

Participants noted that MSM that have sex with female partners need to be counseled to practice safer sex outside their marital relationship. (UNDP, 2008)2 Under Fenway Institute and National AIDS Research in Pune, Humsafar has initiated a study on the married MSM in Mumbai using respondent driven sampling to evaluate the characteristics of social and sexual network at risk MSM who are married to women. Also a study on mapping and training MSM and TG Groups in North Eastern India for Participation in NACP-III was conducted by Solidarity and Action against the HIV Infection in India (SAATHII), UNAIDS India and NACO. The data on the SRH needs of MSM and their female partners thus requires systematic recording and documentation from all relevant studies. There have been various interventions that have directly or indirectly addressed the above but knowledge gaps exist. A documentation of all such interventions will help stakeholders reflect and learn from them. It would help put in perspective the various strategies and activities, 2

Missing Pieces. HIV Related Needs of Sexual Minorities in India. UNDP, 2008. New Delhi, India.

8

interactions between stakeholders, issues and other contextual factors related to MSM and their female partners. This might help in overcoming gaps in previous strategies.

3. AIM OF THE DOCUMENTATION The MSM population is put to a lot of pressure by the family to get married to women and start a family as per the hetero-normative societal expectations. Often when a family gets to learn about or comes to suspect their son’s sexual orientation, they discriminate the person at home and even force them into a marriage. Some manage to escape such pressures but many succumb to it. Under such circumstances, it becomes important to address the sexual and reproductive health (SRH) needs of the MSM and their female partners, who are mostly at risk due to their husband’s sexual relationships outside the marriage or their own sexual relationships outside the marriage due to a non-satisfying relationship with the husband.

FXB India Suraksha proposed to document the impact of interventions that have so far met the SRH needs of MSM and their partners through their SRH facilities. This would help in gauzing the extent of success of such initiatives, reasons for success or shortcomings if any and would bring to the forefront valuable lessons learnt from such experiences for future initiatives.

4. METHODS USED The study has tried addressing the above questions by showcasing examples from India viz.

The Humsafar Trust, FPAI clinic, Mumbai and Sangama where SRH and HIV services are being linked at the policy, structural and service delivery levels for MSM and their wives/ female partners.

The study is primarily qualitative in nature and has been conducted on the lines of the following method: a. Desk research has been conducted to understand the background to the study and identification of organizations/interventions that have addressed HIV - SRH needs for MSM in India. This was done by consulting published reports and programme evaluations by local and international NGOs, NACO, UNDP, UNAIDS, WHO, World Bank etc. to understand the current scenario, initiatives, case studies, knowledge gaps and lessons learnt.

9

A query sheet was circulated among the few implementers from various initiatives to map the extent of outreach to the SRH needs of the MSM and their female partners by the target interventions and other initiatives so far. The query sheet addressed questions at service level, structural level and policy level on the lines as indicated in the table.1 of Annexure.1. b. 20 Close ended structured questionnaires have been administered to the MSM clients (15) and the staff (5). This tool provided both the qualitative and the quantitative information about the initiative. An Interview Guide developed helped in facilitating the researcher to appropriately address the issues in the question. c. 2 Focus Group Discussions (FGDs) with 6-8 members has be conducted with each of clients group and the staff group in each of the three initiatives. d. In-depth Interview (IDI) has been conducted in each initiative with end users of the schemes. 8 MSM clients per initiative along with 3 staff of the implementing organization has been interviewed.

The findings of the study have been presented in the form of case studies. Each of the three initiatives has been presented separately under the following heads:     

A brief history to the intervention Service integration achieved Service provider/advocate experiences in overcoming challenges Client experiences Lessons learnt: sustainability and scaling up of intervention

A SWOT analysis has been done for each the three interventions. The final analysis has been done based on the client satisfaction approach and an assessment of the present service delivery model of the three initiatives.

10

5. CASE STUDIES 5.1 The Humsafar Trust (HST), Mumbai A brief history to the intervention Humsafar Trust was set up in April 1994 by a leading gay activist. Humsafar has begun its work right from the grass root level with sex mapping of the Bombay city to sensitization programme at government hospitals. With the support of LTMG hospital, MDACS ad Mumbai Municipal Corporation (BMC), The Humsafar Trust started it first VCTC on 26th June 1999. At present, The Humsafar Trust is managing 2,500 MSM and TGs and providing them with quality services at their clinics. Their clinic has been acknowledged as a model clinic following international norms of quality services by FHI. Apart from providing services directly to the MSM and TG community, HST is also involved in capacity building of other organizations working in similar field as a part of national advocacy strategy.

Service integration achieved The Humsafar Trust is catering to the needs of the MSM community by providing them with counseling and clinical services through their drop in centers (DICs) and clinics. As a part of their target intervention (TI) projects, HST has placed its ORWs at several hot spots and cruising sites in order to provide counseling, HIV and SRH awareness and disburse services like condom distribution etc. to the MSM community. Apart from direct services, the ORWs of HST provides counseling to their clients online and through phones and often convinces them to visit the HST clinic for testing. Once a client visits HST, there seems to be no looking back and their association gets forged up for lifetime. Most of the MSM visit HST for their weekly meetings as well as the drop-in centers as and when need arises. HST has become a platform for them to meet more people of their community, forge friendships, to share and care, get legal and psycho-social guidance and assistance and above everything to be the way they want to be.

However, some members of the MSM community often feel a bit conscious to visit HST office especially with their wives or other family members in the fear of their sexual identity getting disclosed to their wives or been seen by some known person. In order to help such MSM clients’ access services and medical facilities, HST has networked with several government hospitals and after rounds of sensitization of the medical staff, HST 11

refers their clients to these hospitals. A staff is stationed in the hospital premises for direct assistance to the clients during their visits.

In order to widen its outreach, HST runs a CBO named Sanjeevani to reach out to the PLHIV. After counseling, they convince the PLHIVs to get their family and partners tested as well. In this way, The Humsafar Trust reaches its services to female partners of MSM. A counselor or peer of HST usually approaches the female partners as their husband’s friend and convinces them to get themselves tested through individual counseling. Through this approach, HST manages to reach out to female partners while keeping the identity of their MSM clients confidential. Since this support group caters to PLHIVs who are in need of a healthy diet and medications, often clothes, medicines and scholarships for children’s educations are also provided to the PLHIVs and their families.

Through the time to time awareness camps, medical camps and information stalls at various locations, HST is able to identify and provide counseling and other services to increased number of MSM. By providing identity counseling, HST is able to help many MSM self-identify themselves and its team of counselors and advocacy experts has also been providing family counseling to both family members and partners of an MSM as and when crisis arises.

HST has made many of their regular clients well versed with information on HIV awareness and SRH needs and services of the MSM who have now become the torch bearer to disseminate that information to more and more people of the community.

Service provider/advocate experiences in overcoming challenges During the course of our study, almost all the MSM (mostly kothis) reported of not bringing their partners for the HST sessions, events and awareness camps in the fear of losing them although being asked by the HST staff to do so repeatedly. Fig. 1 clearly represents how 60% of the MSM clients interviewed acknowledged that the staff at HST did encourage them to bring in their male and female partners to make their services accessible to them.

This clearly reflects the extent to which the MSM are scared of facing discrimination due to disclosure of their identities to their wives or losing their male partners amidst other kothi MSM; which indeed makes it very difficult to reach out to the partners of the clients.

12

Fig: 1 In order to overcome this challenge, HST places stalls in hot spots and railway stations to increase their outreach and make their services accessible to even people who have not heard about or have not been referred to HST. However, when it comes to the female partners of the MSM, it becomes difficult if not impossible to approach them since the sexual identities of their husbands are mostly undisclosed and care needs to be taken to provide services yet maintain confidentiality. When asked about the reaction of female partners of their MSM friends/ acquaintances whose sexual identities got disclosed to their wives( refer to fig: 2), 54% of the clients did not want to answer owning to the sensitivity of the question, 15% reported of the couple getting separated while 31 % reported of the MSM getting acceptance from their wives.

Fig: 2 The HST clinic being a male clinic does not cater to specialized needs of women. But to widen its reach, HST has also tried providing gynecological support to female partners of 13

MSM and specialized medical care to the MSMs themselves by establishing linkages with maternal clinics and organizations having clinical services primarily for women.

The MSM population especially the kothis are often taken advantage off, harassed, raped and molested by the police and local goons. To escape such situations, kothis often agree to provide free sex or are raped which exposes them to HIV and other sexual diseases.

Awareness and advocacy at such level always has remained a challenge and on the agenda of HST. Keeping these circumstances in mind, 40% of the staff interviewed at HST felt that their clients should disclose their HIV status to their wives to be able to take care of themselves while remaining 40% seemed unsure since revealing of HIV status might also reveal their sexual identities which might at times lead to breaking up of families (Fig: 3).

Fig: 3 Client experiences The MSM mostly meet HST outreach workers at the cruising sites/ hot spots. Some of them are referred to an ORW by their fellow community members while others often come across the well-networked HST ORWs through the internet. The average time of association of these clients with HST more than two years. Most of the MSM clients told us that before coming across HST workers, they weren’t aware of the importance of use of condoms, safe sex or HIV prevention. For most cases, it was only after an awareness briefing by HST (fig: 4) that they got themselves tested for HIV.

14

Fig: 4 6 out of 8 MSM who were married reported of getting their wives tested though most of their wives were not aware of their sexuality. With the help of HST counselors, peers and at times fellow MSM friends, the clients convinced their female partners (wives) to get themselves tested and many of them even disbursed information on HIV and the importance of maintaining a sound sexual and reproductive health to their female partners (wives) .

80% of the MSM respondents (Fig: 5) felt that their female partners are at risk of SRH problems or HIV transmission due to their sexual engagements outside home. However when asked about condom usage, the clients reported of regular usage of condoms with their male sexual partners. Most of the clients who disclosed of having female partners reported of non-usage of condoms with their partners. They felt that since they get involved in ‘safe sex’ outside home, their female partners is at no risk and hence do not require condoms.

Fig: 5 15

The concept of ‘safe sex’ of the MSM respondents however varied which included condom usage along with body sex, thigh sex, oral sex etc. some of them even informed that during cruising they usually do not enquire or disclose about their HIV status to their partners and often due to intoxication especially during group sex fail to realize if the condom is damaged. This makes them vulnerable to HIV and other STDs/STIs. Further although all the MSM clients present during the study acknowledged about being made aware repeatedly about HIV/AIDS and its modes of transmission and prevention, 5 Out of 8 during a one on one interview could not correctly recall all the modes of transmission and ways of prevention. They were aware of the chances of transmission through the sexual route and condom being a way of prevention but couldn’t go beyond that.

While most clients felt that SRH and HIV services should be integrated since one leads to the other, some felt that information and services on both should be imparted separately since it becomes too much to take in so much of information all together. Although providing SRH services to the female partners of MSM is not the prime focus of HST, their staff interview seemed to be sensitive to and aware of the SRH needs of the female partners of MSM (Fig:6).

Fig:6 The MSM clients expressed their reluctance to visit any government hospital for either testing or treatment of STD/STI on their own since 4 out of 8 of them interviewed, especially the kothis have had firsthand experience of being discriminated against or mistreated or denied treatment at such a setup by the medical fraternity. Most of them feel uncomfortable to talk about their STIs to doctors apart from the doctors associated with HST or similar organization being apprehensive about the discrimination that might come their way. Under such circumstances the linkages of HST with government hospitals like

16

Sion Hospital and the presence of their onsite representation helps them to access all kinds of health services which is the right of every citizen of the country.

Lessons learnt: sustainability and scaling up of intervention The staff of Humsafar Trust was of the opinion that their health camps have helped them increase their outreach. By tying up with local youth groups, political groups and ganpati mandals, HST has been able to reach out to a diverse set of population and in the process has been able to make people aware of their presence and services. Through counseling during such health camps, they have been able to identify and attract new clients to the ambit of their services and in the process have widened their reach.

Looking at the increasing number of clients and demand of their services and time, HST has successfully scaled up their Target Intervention (TI) projects by placing one outreach worker per site. The ORW is now present at the site till 10 pm at night and is always available for any counseling or crisis intervention as and when required.

17

SWOT ANALYSIS – HUMSAFFAR TRUST OF INDIA, MUMBAI

I N T E R N A L O R I G I N

E X T E R N A L O R I G I N

STRENGTHS

     

WEAKNESSES

The in-house clinic Presence of community members as staff Outreach on field and established linkages with hospital The reputation and trust within the community that they have attained over the years The CBO, Sanjeevani that reaches out to even the female partners of MSM The weekly gatherings and celebrations organized for the community which attracts the clients to visit HST and stay in touch





 

OPPORTUNITIES 





Reputation of being a gay rights organization keeps many clients away from its office or prevents them to bring in their female partners to avail services There is thin line of demarcation of professional and personal relationship between the clients of HST and their ORW. Limited resources is a barrier to expand its outreach network Organization’s policy decisions and service provisions are limited to female partners than to MSM clients

THREATS

HST can strengthen its component of family counselling by appointing trained female counsellors to speak to the female partners of the MSM. The counselling skills of the outreach workers can be further improved and the existing component of counselling can be systematized.

Weekly gatherings could be used as an advocacy platform for discussing problems pertaining to female partners mainly with the married MSM/MSM with female partners. Example: identity disclosures among the married, HIV status disclosure, problems of STD/STI/RTI, problems of separation.

18



Outreach activities taking place on a regular basis are not technically evaluated on field leaving a gap in the quality of information disseminated during the outreach.

5.2 FAMILY PLANNING ASSOCIATION OF INDIA (FPAI, MUMBAI) A brief history to the intervention Established in 1949, FPA India has been recognized as India's leading and largest reproductive and sexual health organization. They deliver a wide range of services in sexual and reproductive health. FPA India envisions health, particularly sexual and reproductive health for all, especially marginalized and young people, in the broad context of sustainable development leading towards the alleviation of poverty, stabilization of population, gender equality, and human rights.

Program Activities:       

Implementing need based sexual and reproductive health care Developing and implementing behaviour change communication strategies Providing sexual and reproductive health care through clinical and non clinical outlets Maintaining essential standards and adopting quality of care approach Involving men in women's health care Addressing men's reproductive health concerns Addressing women's concerns - gender based violence, increasing self esteem through skills development and income generating activities Service integration achieved

FPAI, Mumbai has a clinic with trained medical and para-medical staff, counsellors and community workers to cater their services mainly to women which ranges from pregnant women, female sex workers, socio-economically vulnerable women etc. In the year 2011, FPAI Mumbai decided to extend their clinical expertise and services to the male sexual minorities and transgender (TG). A need was felt to provide the sexual minorities a cost effective SRH services in an environment free of stigma and discrimination which could be possible replicable model for government service providers in future.

In order to scale up their HIV/AIDS and SRH services to the MSM and their female partners, FPAI trained and sensitised their existing staff to the special technical and psycho-social needs of the MSM and the TG population and then approached the existing local NGOs and CBOs of Mumbai working with the MSM and TG to extend their services to their clients. As fig. 7 indicates, the staff were trained on the components of general awareness about the sexual minorites , safe sex and heath, outreach etc.

19

Fig:7 Through client referrals, FPAI began its project and its clinic soon became very popular among the community. Their trained and sensitized project staff and community workers began to meet the MSM at sites and with time the networking got strengthened.

The clinic of FPAI Mumbai provides the MSM community a space free of discrimination and stigma wherein, they can freely interact with even the non-community population without getting conscious of their identity. This helps them access all medical, pathological and counselling services at par with the rest of the population. The name ‘family planning association’ helps the married MSMs to bring in their wives for maternal and gynaecological treatments without having to worry about their sexual identities getting disclosed. The staff at FPAI, Mumbai abides by the principle of confidentiality and does not reveal one’s HIV or sexual status to any other person , be it their partners ( male or female).

Apart from the doctors and paramedical staff who provides the clients with specialized care and psychological support, the trained counsellors and staff who often are members from the MSM community assists the clients and provides them with necessary counselling and assistance as and when required.

The services that the clinic extends to the MSM and their female partners at present include: 

Contraceptives (for men and women), condom and lubes distribution 20

               

Male clinical services ( sexual dysfunction, sperm mobility, lipid profile, anal examination) Complete Blood Count Pap smear Ultrasonography Abortion (medical and surgical) Emergency contraception Maternal health care Child health care Diagnosis and treatment of reproductive tract infections and sexually transmitted infection and other reproductive health care (for men and women) Infertility Adolescent sexual and reproductive health care Counselling Prevention and management of HIV/AIDS Hepatitis B vaccination Other Specialized referrals Pathological/diagnostic facilities

Fig: 8 As per the response of the clients interviewed, Fig: 8 shows the most popular services disbursed by FPAI, Mumbai clinic.

They spread a word about their services available in the clinic with the help of their IEC materials which they distribute at DICs, CCC and hotspots.

Service provider/advocate experiences in overcoming challenges 21

The service providers of FPAI, Mumbai feel that the integration of SRH services with HIV is helpful since HIV testing becomes the point of entry in order to convince the clients to visit the clinic and get themselves tested after which awareness on HIV prevention and care is imparted to them and they are sensitized about their sexual and reproductive health needs.

FPAI, Mumbai distributes condoms, lubes and medicines to cure STDs/STIs which attract clients to their clinic. During our study, almost all the clients reported of the condoms distributed by FPAI being of better quality as compared to the rest accessible to them and seemed very satisfied with it.

However, often it gets difficult to convince a client to maintain a sound sexual hygiene and hence audio-visual aid for IEC display is made use of which has been reported of becoming an effective means for behavior modification of the clients. Further, it has been felt that marriage counseling could help the MSM and their female partners maintain a psychologically and physically healthy relationship.

However, the key challenge while working with the MSM community on SRH and HIV has been felt to be in convincing them to visit the ICTC regularly and come back with their partners as soon as they get a STI/STD or notice one in their partners. Apart from the task of convincing them to get themselves tested, a major goal of the counselors at FPAI, Mumbai clinic lies in convincing the clients to get their male and female partners tested.

Client experiences The MSM clients of FPAI, Mumbai clinic are all referred to them by local CBOs and NGOs. The clients mostly visit the clinic to get their blood tests and STI check –ups. When they initially come to the clinic, they are given information on maintaining a safe sexual hygiene and are told about the importance of condom use and protected sex. Times to time workshops/sessions are also organized for the clients based for information dissemination based on their needs. (Fig: 9)

22

Fig: 9

While interviewed, the MSM clients mostly expressed their pleasure being able to access the specialized clinical services like Hepatitis B vaccine but at the same time expressed the presence of female staff as a cause of their initial discomfort which however some of them could successfully overcome.

While the presence of mixed set of clients in the clinic made some of the clients conscious, who are mostly used to accessing services from a platform exclusively meant for sexual minorities, others found this mainstreaming of the SRH and HIV services for the MSM to be a pleasant move for as one of the respondents rightly pointed out-‘it makes us feel one’ (lagta hai hum log bhi dusre jaisehi hai). The clients mostly feel happy and confident to be treated well by the majoritarian population. Those who are married can even get their wives to avail maternal services as well as other SRH services without having to worry about their sexuality getting disclosed to their wives and family and the staff can also encourage the clients to bring in their partners being able to assure them confidentiality(Fig:10).

Fig: 10 However some of the clients did mention the problem in accessing information as and when required through the staff present in the clinic since some of them at times get confused and fail to provide them with instant answers. Some felt that this happens since the para-medical staff in the clinic have multiple engagements and are not solely into service delivery for the MSM. Nonetheless, a majority of the clients reported that the staff was well versed and sensitive to the sexual and reproductive health needs of the MSM and their female partners (Fig: 11).

23

Fig: 11 Lessons learnt: sustainability and scaling up of intervention The clinical service delivery model at FPAI could be counted as a success inters of its unique service delivery structure which includes not just the MSM but their female partners as well. Thus even at the end of the first phase of their project, to make their clinical services accessible to the MSM community for life-long, the clinic has convinced the clients recently to avail all the services in return of a nominal fee which has been mutually decided upon.

However in order to make their services reach out to the most, 40% (Fig:12) of the staff interviewed felt that the female partners should be made aware of their husband’s sexual orientations so that she is able to make an informed choice about her sexual and reproductive health. The rest still found the fear of stigma and discrimination to be problematic and instead proposed to continue working with the code of confidentiality under the banner of family planning.

Fig: 12 24

60% of the staff interveiwed even felt that the female partenrs of their MSM clients be officially included in the presence service delivery model ( Fig: 13)with proper planning although its feasiblity still remains a question mark keeping in mind the rights of an MSM to confidentaility.

Fig: 13

25

SWOT ANALYSIS – FAMILY PLANNING ASSOCIATION OF INDIA, MUMBAI

I N T E R N A L O R I G I N

STRENGTHS

   

WEAKNESSES

The clinic-based service delivery model directly addresses and integrates the SRH and HIV services Mainstreaming the services rendered to the MSM by delivering them under the same roof as the rest of the population The visual aid with the help of IEC materials which helps the MSM clients understand their SRH needs The banner -'family planning' allows the MSM bring in their wives without having to worry about their sexual identities getting disclosed

 



OPPORTUNITIES E X T E R N A L

 

Indirect Client outreach which is limited to linkages with local CBOs and NGOs The presence of female staff which at times makes the MSM a little hesitant to open up about their STI/STDs or similar problems The absence of clinical staff specialized in SRH service delivery to the MSM.

THREATS

To combine their clinical expertise with a rights based advocacy model on sexual health This health care service delivery could be a ready reference for institutionalizing female partners participation in main stream programme delivery

O R I G I N

26



Lack of direct community outreach might prevent client pool if provided with a similar service delivery model elsewhere

5.3 SANGAMA- SAMARA, BANGALORE A brief history to the intervention Samara is a community based organization initiated by Sangama that has turned service provision into a Community Lead Structured Intervention (CLSI). The Sangama offices in Bangalore comprise of the head office plus four zones located throughout the city. All of the four zones have a trained counsellor whose responsibilities include providing care, support, and information and referral services. There are three fully functioning Program Linked Clinics (PLC) in each of the three zones with one counsellor, doctor and a nurse. The PLCs provide quality STI health care services, including HIV testing and psychological support. Sangama has been actively intervening in the crisis faced by the community. There are currently six telephone lines that are answered by the crisis team made up largely of community members, but also include staff.

Service integration achieved Samara works in Bangalore with the MSM community by providing them HIV testing, ICTC referrals, SRH and counseling services through 3 DICs based in Bangalore. Under the SRH services, they provide clinical facilities for STD/STI treatments, client referrals to hospitals as and when required and distribute condoms both at DICs aswell as on their field. Clients regularly visit Samara on a weekly or monthly basis to access the services like DIC registrayiona nd support, STD/STI treatment in the DICs, crisis intervention, Hepatitis B vaccination, review of ART drug adherence, referrals to CCC etc( Fig:14 ). Samara’s outreach is rights based and their trainings and knowledge dissemination sessions take place regularly.

Fig: 14 Samara being a human rights organization works within the framework of rights based approach and their component of crisis intervention for their client community makes their 27

work stand apart. Such an intervention seems to be replicable in providing any kind of service to the MSM and their female partners since often disclosure of sexual identity and HIV status creates a social and psychological upheaval in a client’s family life.

The staff at Samara are from the community and are trained in delivering services to the MSM. Clients feel very comfortable in opening up to the staff and have a sense of belongingness to the organization. Once a person comes to Samara they keep coming back since its meetings/gatherings and other events helps the MSM socialise within their community and provides them with a platform to live the way they want to and be the way they feel like. The sesions which are usually organized for the MSM clients in the monthly meetings and quaterly meetings includetopics ranging from high risk behaviour, crisis intervention, need of family sensitizaion, policy awareness etc. (Fig: 15).

Fig: 15 Service provider/advocate experiences in overcoming challenges: Although the workers have been continuously spreading awareness on the possibilities of HIV and modes of prevention, presence of multiple partners of the clients and their inconsistent use of condom with different partners have been felt to be source of constant threat to the service delivery structure. Outreach at the community level also becomes a tough task at times due to lack of staff strength.

In order to overcome these challenges, Samara has trained local community members as peers who disburse awareness on HIV/AIDS and STD/STI to the MSM on site along with the outreach workers (ORWs). Distribution of condoms and ointments for STD/STI as well as client referrals to ICTC attracts many MSM clients to Samara.

Client Experiences:

28

The clients of Samara mostly got associated with the services of the organization through the outreach workers and peers who work within the community (Fig: 16). The reason most of them visited Samara was to be able to meet more people of their community as well as for HIV testing.

Fig: 16 The clients during the course of the study reported of feeling very comfortable in getting them treated especially for STD/STI at Samara clinics and felt grateful to the staff of the organization for making them aware of the threats of HIV, STDs/STIs and its ways of prevention for them. (Fig: 17). However inspire of attending such sessions on HIV and SRH needs, most of the clients were unsure about all the ways of HIV prevention and transmission.

Fig: 17 Most of the clients in Samara reported of not being married while out of those who are married, only one client mentioned of getting his wife tested. The particular person during the study who reported of being married even brought his wife to access other clinical 29

facilities at Samara while keeping his own sexuality confidential and pretending to be worker of Samara.

Samara often organizes sessions and provides one to one information on the legal and sexual rights of the MSM community. However Samara has not yet begun working with the female partners of the MSM and hence any kind of service provision is it direct or indirect for the wives or female partners of the MSM are not a part of their mandate. The staffs at Samara feel that a separate programme for the female partners should be started but should be kept out of the ambit of Samara since people are aware of their work and chances of the sexual identities of their clients getting disclosed to wives and families prevail. However, workers at Samara do encourage the MSM clients to bring in their male partners although they have not attained much success so far in being able to convince in those lines (Fig:18).

Fig: 18

Lessons learnt: sustainability and scaling up of intervention Although Samara doesn’t work with the female partners of MSM, the staff at Samara and even some of the MSM clients felt the female partners of MSM should be included within their present service delivery model. 64% of the clients interviewed felt that the present team of Samara is sensitive and aware about the SRH needs of the MSM and their female partners. They however admitted that the Samara premises or its banner cannot be used to extend services to the female partners in the threat of the confidentiality of their client’s sexuality being threatened.

30

Fig:19 Further in order to reach out the community with specialized clinical services, Samara at present has tied up with an organization with model clinics to strengthen their SRH services.

31

SWOT ANALYSIS –SANGAMA-SAMARA, BENGALURU

I N T E R N A L O R I G I N E X T E R N A L

O R I G I N

STRENGTHS

  



A rights based approach which makes the MSM clients feel secure and confident about themselves Presence of community members as staff helps in outreach and rapport building The drop in centres provides a platform to meet more people and spend time in the way they want to (eg: wear sarees etc.)

The doctor present in the DICs is a reason why clients visit Samara since the services at government hospitals are not easily accessible

WEAKNESSES   

OPPORTUNITIES 

 



Being a human rights based organization and having an outreach to women from other marginalized groups, they can spread awareness on the SRH needs of MSM and their female partners to such groups and can begin a support group for women which might help is reaching out to the female partners of MSM while maintaining confidentiality of their husband’s identity.

Focus on the component of SRH in their service delivery model and train staff accordingly.

Network with government service delivery points for awareness and client referrals especially for the female partners of MSM. Provide frequent and free routine health checkups to encourage the MSM to bring in their female partners.

The outreach and service delivery yet to become as effective as per to the maximum potential of the Organization.

Clients are yet to be well informed enough about their SRH needs In emergency and unexpected situations often MSM clients need to visit unspecialised private medical practitioners

THREATS  

32

Absence of any services for the female partners of MSM from the organizational mandate.

Client dissatisfaction in accessing SRH facilities from any government or private medical bodies apart from the Sangama DICs might discourage clients in opening up about their SRH problems.

6. CONCLUSION The study across these three well recognized and successful initiatives have brought to light many interesting practices and facts. Based on the responses received from the clients during individual interviews and focus group discussions, we have developed a client satisfaction analysis table on the main lines of enquiry of the study.

The Humsafar Trust

LINES OF ENQUIRY

Family Planning Association Of India

Sangama Samara

Assistance received in HIV testing Direct Outreach to Female partners Service Level

Referrals and Assistance received for other SRH problems like STI, RTI, UTI, pregnancy etc.

Routine services received from the organization clinic/doctors Information disseminated on HIV /AIDS

Indirect Outreach to Female partners

Frequency of workshops on HIV/AIDS and SRH Awareness on the SRH needs for the female partners of MSM to the MSM clients

Current Disclosure level of the sexual status to the female partners by the MSM

Structura l Level

Need felt by the staff and the clients to disclose the sexual status to the female partners Awareness level of the MSM about the SRH needs of their female partners Priority given to the services for the female partners Reorganization given to the SRH rights of the female partners of MSM

Policy Level

Easy accessibility and availability of testing and care centres Sensitization and training of doctors and paramedical staff( non-organizational) and law enforcement officials carried out by the organization

33

Satisfactory

Satisfactory

Not in agenda

Average

Satisfactory

Not in agenda

Not in agenda

Satisfactory

Not in agenda

Satisfactory

Satisfactory

Satisfactory

Satisfactory

Average

Satisfactory

Average

Satisfactory

Not in agenda

Low

Low

Low

High

High

High

Medium

High

Low

Medium

High

Not in agenda

Average

Satisfactory

Unsatisfactory

satisfactory

Satisfactory

Average

Satisfactory

Not in agenda

Satisfactory

Representation of CLINET SATISFACTION ANALYSIS  Scales in the ascending order for the service level and policy level 1. Good 2. Satisfactory 3. Average 4. Unsatisfactory 5. Not in agenda  Scales in the ascending order for the structural level 1.

High

2.

Medium

3.

Low

We summarize below few highlights from the study.

OUTREACH TO FEMALE PARTNERS IS A CHALLENGE

As far as the female partners of MSM are concerned, all the three organizations were of the view that reaching their services directly to the female partners is challenging indeed (Fig: 20).

Fig: 20 34

Since there remains always a fear of social discriminationa and stigma at the disclosure of an MSM’s sexual identity due to lack of social undersatnding and tolerance, it was felt that organizations wokring with the sexual minorities needs to network with different service providers be it hospitals, maternal clinics, counsellors etc. to refer their services to the MSM’s female partners indirectly. The methods of approach and mobilization of such clients again needs to be done very carefully and in a sensitive manner. Nonethless, a need was felt to identify the female partners of their clients (Fig:21) and begin a programme exclusively for them as soon as possible inorder to make their existing services for the MSM complete and effective.

Fig: 21

GAIN IN KNOWLEDGE AND AWARENESS

However, one thing that remained common and constant throughout the three initiatives were the trust of the clients towards the organizations they were affiliated to for services and a sense of belongingness to them. Although, their level of disbursal of SRH and HIV services differed, their clients mostly reported of gaining knowledge and information through their association with the respective organizations (Fig:22). While there remains scope to improve their services by disseminating more specialized knowledge on SRH and HIV to the clients while on field, there also remains a need to modify the existing service delivery model in certain areas by referring the client more frequently to other specialized service avenues as per their needs. During the course of the study, it was felt that the outreach workers of HST had further scope to get well versed with the SRH and HIV services, the paramedical and project staff of FPAI had room for adopting a non-formal approach of community mobilization and care along with some of them dedicating their time to specialize in MSM service delivery models, the staff and peers of Sangama similarly 35

had scope to train themselves more in identifying and understanding the SRH needs of their clients apart from the existing clinical treatments for the STD/STIs that they already provide.

Fig: 22 COUNSELLING AN IMPORTANT AND STRONG COMPONENT

The component of individual aswell as group counselling seemed to be the strength of all the three initiatives which can be bettered and formalized through its future course of work. This component can be most useful for solving marital discord and help a client survive any kind of workplace or family discrimination. The component of awareness interventions at different workplace can also be strenghtened in due course.

THE ORGANIZATIONAL SERVICE DELIVERY MODEL AND NACP IV GUIDELINES

The NACP-IV had placed human rights as their guiding principle inorder to ensure that the MSM are able to access services without experiencing discrimination, legal sanctions, social stigma, or violence. The NACP IV had layed down certain functional guidelines to achieve zero infections among the MSM by 2017. It was observed that all the three organizations have been following the guidelines partially.

36

The first guideline of ‘Universal access – inclusion of all high-risk MSM– regardless of sexual identity, marital status, age or presumed/stated sexual practices (receptive or penetrative or both)’; is being diligently practiced at all the three interventions studied. While the existing interventions have taken over a rights based approach to health care for MSM and are working towards eliminating stigma and discrimination against them, they only partially address the vulnerabilities of the MSM in-terms of their marital status. Although the organizations are effectively advocating for safe sex and making condoms and lubes available to the MSM at their most convenient locations, certain unsafe sexual practices like having multiple partners, having unsafe sex while being intoxicated etc. although raising concerns among the service providers, are yet to be addressed through a workable strategy. Further, the existing interventions are still struggling to extend their services and prevent transmission of HIV/STIs to the steady partners of their MSM clients. Although HST is trying to approach the female partners through its CBO for the PLHIVs and FPAI is strongly encouraging their clients to get their partners, the rate of success achieved in it so far has been very poor due to the problem of disclosure of MSM’s identity and requires an alternative way of approach.

SENSITIZATION OF THE GOVERNMENT HEALTH CARE WORKER HAS BEGUN BUT REQUIRES SPECIAL ATTENTION AND NEEDS TO BE PLACED AS A PRIORITY

The existing linkages with the government hospitals especially in Mumbai have helped the MSM access certain public health care facilities but the networking so far has been very limited. All local CBOs and NGOs working with the sexual minorities must place this advocacy with government healthcare providers as an option to be able to transit of certain existing services (such as STI clinical services) to NRHM which would help them improve their competency to provide optimal clinical and counseling services.

As suggested in the NACP IV guidelines again, the existing organizations indeed needs to expand the traditional outreach strategies to reach diverse subgroups of MSM. During the course of our study, it was felt that in spite of the cautions raised during the NACP III reports most ORWs continue to be kothi indentified MSMs and the interventions continue to remain kothi-centric. Under such circumstances, reaching out to the masculine men (panthis) seems to be the next target for which such men need to be employed as ORWs themselves. It is important to reach out to the female partners of such masculine MSM as well.

37

AWARENESS EVENTS AND COMMUNITY PUBLIC GATHERINGS ARE EFFECTIVE MEANS OF SPREADING AWARENESS ON SRH AND REACHING OUT TO INCREASED NUMBER OF MSM

From the responses during the study, it was evident that the community events such as LGBT Pride Marches, LGBT film festivals, medical camps and awareness stalls so far has been venues for reaching some at-risk MSM at least to provide basic information on safer sex, HIV and services available for MSM. Certain local youth groups, political associations, college student unions as well as religious bodies have proven to be effective entry points to reach out to more number of MSMs. Such strategies need to be strengthened and regularized inorder to successfully disseminate SRH and HIV services. Information dissemination about updated health care services and networking through mobile phones and internets are increasingly proving to be successful model of virtual outreach. Such an approach also helps is establishing an inter-personal relationship between the MSM and the ORWs which further helps them discuss freely problems about their partners and especially female partners if present. This might help the ORW understand the need and urgency to deliver services to their male and female partners.

The three organizations studied are very different in terms of their agenda and service delivery model with each having the primary focus on the MSM while the female partners being only the second line of clientele. While Humsafar Trust focuses on outreach and knowledge dissemination, FPAI focuses on clinical service delivery while Samara aims to address the rights of the community and advocate for the same at a larger domain.

However, for all the three types of service provision, the issue of disclosure seems to be the factor creating blockades and preventing the existing models from reaching out to the female partners. This is something which needs to be deliberated upon. Given that each organization has its focus areas, the best way of working out a new model would be to link up all three. An organization like HST can provide the client pool and outreach, an organization like FPAI with clinical facilities and expertise can provide the SRH services directly while an organization like Sangama—Samara with a rights based mandate might be helpful in mainstreaming the issue at a larger group. Further linkages and networking with different stake-holders might make it feasible to reach out the services to the female partners of the MSM directly as well as indirectly.

38

2012

National Consultation on Reaching out to female partners and spouses of MSM UNDP: HIV and Development Unit

39

SUMMARY

UNDP – HIV and Development Unit organized a National Consultation on Reaching out to female partners and spouses of MSM on 5th November 2012 in Mumbai. The consultation was a part of UNDP’s involvement in evidence building, and drafting potential strategies and recommendation to include female partners of MSM in HIV interventions. Female partners of MSM are at risk of the intersection of homosexual and heterosexual contact. The consultation aimed at brainstorming and providing information on knowledge gaps in understanding the needs and developing interventions to reach out to female partners of MSM. The consultation was divided into four sessions. The first session was on understanding the barriers and issues around HIV prevention work for female partners of MSM. A total of three papers were presented under this session which discussed working of three successful interventions with female partners, a situational paper on reaching out female partners of MSM and also Public Health perspective through the findings from a clinical study. The second session was on showcasing cases and success models. In this session three models were presented- FPAI Model, Lakshya Model and Pehchān Model. The third session was titled, Brainstorming, community voices and panel discussions. In this session experience of a self identified married MSM and a CBO’s experience of working with female partners were discussed. The last session, Potential strategies focused on putting forward recommendations and drawing consensus from the previous three sessions and shared experiences. Potential models discussed in the session kept MSM with female partners at the centre of intervention, and a referral mechanism was drawn to connect it to either current HIV interventions or organizations working on Sexual and Reproductive Health to ensure confidentiality.

The consultation brought about discussion on various barriers and facilitators in working with female partners of MSM. Although replicating the models and successes linked to them may not be a workable ground, efforts need to make in devising community led and culturally sensitive initiatives. The recommendations from the consultation can be given to NACO and could also be taken up by UNDP for the next phase.

40

INTRODUCTION India has a significant HIV infection epidemic - current estimates state that there are about 2.4 million HIV infected individuals. The HIV/AIDS epidemic in India can be described as consisting of two co-existing phases: 1) the first phase of spread of HIV among the classically recognized ‘highrisk groups’, and 2) the second phase of spread of HIV to the ‘non high-risk groups’ such as the spouses and children of infected individuals. MSM are a part of the high-risk group or the first phase, the prevalence being of the order of 6 to 19% in the past five years. MSM in India are often married because of existing social pressures; thus they also form a part of the second phase of the HIV epidemic - they represent a ‘bridge population’ between high-risk MSM networks to the non high-risk group of often unsuspecting and monogamous female spouses.

The National AIDS Control Programme (NACP) in India understands the risk and vulnerabilities associated with MSM, TG and Hijra population and hence give high priority to the issue. Research has shown that some subpopulations of MSM, including TG, have high rates of multiple as well as concurrent sexual partners and often engage in unprotected anal sex. In India, many MSM either are married or expect to marry, given this premise, women partners of MSM are especially important but, to date, they are often a neglected, vulnerable population for HIV prevention because the possibilities of HIV infection that they face intersect with both heterosexual and homosexual sexual risks. Given the current reality of the lives that MSM live in India, working with the female partners of MSM is a crucial recommendation for HIV/AIDS prevention and part of NACP IV strategy. NACO defines vulnerability to ‘Women’ for HIV transmission as, “In India, women account for around one million out of 2.5 million estimated number of people living with HIV/AIDS. Their heightened vulnerability has both biological and socio-economic reasons. Early marriage, violence and sexual abuse against women are the major socio-economic reasons of their vulnerability to HIV infection.

Their biological construct makes them more susceptible to HIV infection in any given heterosexual encounter.”

The sexual behaviour among men who have sex with men is varied, and often involves sexual relationships with women. The national BSS study showed that 31% of MSM reported having sexual intercourse with a female partner in the 6 months prior to the survey, and the mean number of female partners was 2.4. Similarly, the data from Andhra Pradesh show that 65% of MSM had ever

41

had sex with women, among which 76% with their wife, 29% with FSW and 13% with wife as well as FSW. (UNDP NACO Study – FXB India Suraksha, 2012) The sexual behavior of the sub-groups of MSM (kothis, panthis, double-deckers, bisexual and hijras) has important implications for the spread of HIV. A study conducted on Social and Sexual Networks o married MSM at the Humsafar Trust, Mumbai identifies the need for strategic interventions with married MSM or MSM with female partners in order to provide services to their female partners.

The study has also documented lower rate of condom usage with female partners and especially with their wives. In a similar study by the Avahan project reports that condom use with the regular female partners among Men who have Sex with Men was at an extreme low (29% among panthis, 20% among double deckers and 2% among bisexuals).

MSM with female partners may also have inhibitions on connecting with organizations and interventions to provide health services to their female partners. There is always a perceived risk of disclosure of their sexuality or HIV status to their wives/ families. The purpose of this consultation is to review the evidence regarding HIV risk to female partners of MSM, showcase success model of interventions and voices of the community members. Based on these evidences, the consultation will propose strategies to promote early diagnosis and treatment of HIV among female partners by community responsive interventions; and emphasis on strategies to be proposed and taken forward in the fourth phase of the National AIDS Control Programme (NACP – IV).

Objective: The overall objective of this consultation was to brainstorm and provide information on knowledge gaps in understanding the needs and developing interventions to reach out to female partners of MSM. Understanding various aspects and issues around female partners of MSM Understanding the strategies that have worked with discussion on success models Recommendations documented for further advocacy and policy change

Scope of the consultation: The consultation aimed at providing an important dialogue on the following

42

Service Provision



What are the services required for female partners of MSM



Service models that are currently running in India



Service delivery strategies



How should SRH and HIV services for wives/ female partners of MSM be integrated?

Structural Level



What are the key operational and structural barriers to achieving and optimizing services of wives/female partners of MSM

Policy Level



What are the potential strategies that can be adapted in the Indian context?

The consultation addressed the above questions by showcasing examples from India viz.

1. UNDP NACO Study (Addressing the SRH needs of MSM and their female partners using existing SRH facilities and/or working in collaboration with existing organizations 2. DFID TAST situation assessment papers on female partners of MSM 3. Showcasing the Pehchan model, FPAI model clinics, Lakshya Trust model where SRH and HIV services are being linked at the policy, structural and service delivery levels for wives/ female partners of MSM 4. Community voices were presented to bring forth issues faced by MSM with female partners, their comfort with interventions, and issues of confidentiality around disclosure The consultation brought together the evidence, risks, strategies and recommendations from the above to facilitate a process of developing strategy towards developing HIV intervention with female partners of MSM. The outcomes of this meeting will provide valuable guidance for communities and the health sector to increase prevention and care and support services for men who have sex with men and their female partners/ spouses thereby achieving the NACP goals and strengthening public health as a whole.

AGENDA FOR THE NATIONAL CONSULATATION 43

S. No. 1

Topic/ Content

Speaker

Timings

Welcome & Objectives of the consultation

Ernest Noronha, UNDP

to

2

Current scenario and work related to female partners of MSM Understanding the barriers and issues around HIV prevention work for female partners of MSM 1. UNDP Study on female parteners 2. TAST situational paper on reaching out female partners of MSM 3. Public Health perspective- Clinical study Open house

Vijay Nair

11.00 am 11.15 am 11.15 am 11.30 am 11.30 am 12.30 pm

12.30 pm 1.00 pm

to

3

5

6 7

8

to

Samik Ghosh FXB India Suraksha Dr. Venkatesn Chakrapani Dr. Maninder Setia 30min

Moderated by: Vijay Nair Lunch 4

to

12.30 to 1.30

Showcasing cases and success models 1. FPAI Model 2. Lakshya Model 3. Pehchan programme Brainstorming, community voices and panel discussions 1. Sylvester Merchant 2. Manjit Singh 3. Manoj Jani Potential strategies- Putting forward recommendations and drawing consensus Concluding remarks NACP IV- Inclusion of prevention strategies for female partners/ spouses of MSM Vote of thanks

FPAI Team Lakshya Team Pehchan Team Faciliated by Vijay Nair

3:00 pm to 3:40 pm

Dr. Chakrapani, FPAI and 3.40 pm to 4.00 Ashok Row Kavi pm NACO 4.00 pm to 4.10 Dr Neeraj Dhingra pm Shankar Silmula

INAUGURAL ADDRESS

44

2.00 pm to 3.00 pm

4.15 pm

UNDP – HIV and Development Unit (India Office) organized a national consultation on reaching out to female partners and spouses of MSM in Mumbai on 5th November 2012.

A welcome note was given by UNDP consultant on that project. It was followed by introduction by the participants. Mr. Vijay Nair moderated the consultation and laid down the objectives of the consultation: 

Understanding various aspects and issues around female partners of MSM



Understanding the strategies that have worked with discussion on success models



Recommendations documented for further advocacy and policy change

Mr. Nair then explained the need of doing this consultation and what UNDP expects to achieve through it. He also mentioned that Pehchān is in the process of implementing aspect of MSM with female partners in their TI-plus program, and hence this consultation will be an important

SESSION 1

45

Understanding the barriers and issues around HIV prevention work for female partners of MSM In India given the strict social norms around marriage, many MSM either are married or expect to marry, and/ or are also sexually oriented towards women. This would also mean that the female partners of MSM are an important sub-group that is vulnerable to HIV transmission. This session will discuss what are the barriers and issues that involved in HIV prevention work for female partners. The session will first build a case on the importance of targeting female partners, their HIV risk and then will discuss various socio-cultural and programmatic hurdles in addressing to their needs.

Presentations 1.1)

Title: UNDP Study on female partners Presented by: Samik Ghosh, FXB India Suraksha

A qualitative study was conducted with support from UNDP and NACO to document the impact of the ongoing interventions that have so far met needs of the target population through SRH facilities and to explore the extent of success of such initiatives, reasons for success or shortcomings if any.

The study was conducted over a period of two months. 3 reputed interventions namely: the Family Planning Association of India, Mumbai; the Humsafar Trust- Mumbai and the Sangama-Samara, Bengaluru Desk research (published report & programme evaluations by local and international NGOs’, NACO, UNDP, UNAIDS, WHO, World Bank etc) Semi structured interviews with implementers of MSM programs on SRH needs, Focus Group Discussions and In-depth Interview with MSM clients and staff of implementing organizations. Ethical clearance and consent of participants The study has discussed the working of projects at these three sites in terms of three aspectsService Integration approach, Service provider experience and client experience.

The Humsafar Trust (HST): Service Integration Approach – counseling, clinical services through DIC and TIs, outreach at hotspots, CBO Sanjeevani, Awareness camps; Service provider experiencerecognize importance of integration; disclosure and discrimination is constraint; Client experienceincrease in awareness; reaching out to female partners, 80% MSM agree female partners are at risk, knowledge on SRH and HIV should be given separately 46

Family Planning Associating of India (FPAI): Service integration approach- specialized clinic HIV linked SRH/FP services; stigma and discrimination free psycho-social, capacity building and client referral; Service provider experience – HIV prevention and awareness, distribution of free medicines, condoms attract clients; convince MSM for repeated follow-up; Client experience- increase referrals, 93% participated in workshops Sangama (Samara): Service Integration approach- DIC based clinical services, ICTC referrals, crisis intervention, rights based approach; Service provider experience: inconsistent condom use. Multiple partners, STD and STI clinic; Client experience- strong networking among MSM and ORW, receive require crisis intervention, 87% attended awareness sessions on advocacy; female partners not encouraged Few barriers from the findings of the study presented were fear of disclosure, female partners as secondary group, strategy to reach out yet to be designed, staff capacity was found limited, tracking female partners and maintain confidentiality. Few recommendations suggested at service level were need for direct service, focused awareness; need to increase workshops, counseling services.

At structural level some recommendations mentioned were, separate specific program focusing female partners to integrate in mainstream HIV & SRH linked health care, increase in the Inter agency for sharing lesson and for replication and sensitization and training of doctors and paramedical staff (non-organizational) and law enforcement officials. While at policy level, it was recommended to expand the outreach program to focus equally on female partners and to develop a system for systematic and regular mechanism for tracking (register) female partners.

1.2)

Title: TAST situational paper on reaching out female partners of MSM Presented by: Dr Venkatesan Chakrapani

Title of the paper presented: Women Partners of Men who have Sex with Men (MSM) in India: Preventing HIV transmission and Promoting Early HIV Diagnosis and Treatment The study was supported by NACO. The study was conducted in the last quarter of 2008 and the dissemination took place in June 2011. The purpose of study stated was: to review the current evidence regarding HIV risk to women partners of MSM in India; to present findings from a multi47

site qualitative study to understand the perspectives of MSM (and other stakeholders) on HIV risk to their women partners and to put forward recommendations to decrease HIV risk to women partners (especially wives). The methods employed in the study were literature review, multisite qualitative field research and synthesis of inference. The findings from the study were: type of female partners (causal, wife, female sex workers), issue of HIV Risk (married MSM are twice likely to have HIV than unmarried; condom use with wives/ steady female partners is comparatively low; and concurrent sex with male and female partners with inconsistent condom use); Marriage and Sexual life of the participants (heterosexual marriage; willingly or forced; sex with wife as duty; satisfaction with partners is sometime seen as a pressure, barriers to condom use with wife); Disclosure: sexuality (it is not clear whether disclosure about sexuality will help decrease HIV risk; and disclosure of HIV status might not always lead to safer sex; lack of simultaneous STI treatment for husband and wives) and Perspectives (MSM take steps to satisfy wives emotionally and sexually; dealing with women towards whom they aren’t sexually interested).

Few key recommendations from the study discussed were like, potential interventions for married MSM- testing and retesting as a safer-sex strategy (negotiated safety); for HIV positive MSM and wife unknown/negative status- support positive MSM to disclose their status to steady partners; counseling/education of safer sex practice; access to sexual post-exposure prophylaxis (sPEP); HIV testing of wife (and if positive working on referral and if negative given appropriate counseling). At Policy level there are no guidelines for disclosure of HIV status or sexuality to family or wives; access to sexual post-exposure prophylaxis (sPEP).

1.3)

Title: Public Health perspective – Clinical study Presented by: Dr Maninder Singh Setia

Title of paper presented: Married men who have sex with men: bridge population to HIV prevention in Mumbai, India.

This study compared the sexual risk behaviors of married and unmarried MSM in Mumbai. Previous studies had shown that several men attending STI clinics in Mumbai were effectively “bisexual” or “trisexual” (trisexual has been understood as those who have sex with men, women and 48

transgender) and engaged in risky sexual practices not only with multiple partners and partners with different genders. In a country like India, given the cultural and social compulsion many MSM are likely to be married to women.

Cross sectional analysis was done on anonymous data collected from STI clinic at the Humsafar Trust in the years 2003 to 2005. Socio demographics, behavioral, and clinical data were compared.

Demographic information, sexual behavior and condom use in a period of 6 months were analyzed.

The mean age of married MSM was statically higher than unmarried MSM; however, there were no significant difference in income and occupation. Unmarried MSM had significantly more number of causal partners and were more likely to have commercial partners compared with married MSM. Married MSM were more likely to have vaginal sex and were less likely to use condoms with their wives. There was no statistical difference in the receptive- anal and oral- sex between married and unmarried MSM. HIV serology was known in 241 unmarried and 39 married MSM; the overall HIV estimate was 8%.

The proportion of HIV was significantly higher in married MSM, and in MSM who were greater than 30 years of age. Lessons/Recommendations from the study:- a ) Married MSM are a bridge population; b) MSM over the age of 25 are more likely to be married; c)there should be different intervention strategies across older and younger MSM; d) in the same sex relationship the married MSM were as likely to be the “penetrated partner” as being the “penetrative partner”; and e) Married MSM had high risk behaviours with both men and women; thus they form an important intervention group. HIV prevention programmes in this specific subgroup will not only reduce the transmission in male-to-male sexual group but may have an effect on the male-to-female transmission of HIV - an important bridge for HIV prevention in India.

Discussion Points 1) There is no figure to quote about HIV status of female partners of MSM. Anal sex continues after marriage in addition to un/protected vaginal sex post marriage. NACO has collected some data and the analysis is in process.

2) There is a trend that condom use with steady partner is low, that is been pointed through research studies as well as TI data 3) The word trisexual, as used by Dr Maninder is his study was used by researchers and is points out how risk behaviour is different with differet sex partners, and also hijra as a different group from MSM 4) There need to be more data collected and evidence gathered from non-urban sites.

49

5) There is a need to conduct more quantitative studies to make it more representative. A ll these discussions are through the eyes of the MSM and there is no data on what female partners have to say about it.

SESSION 2 Showcasing cases and success models Continuing from the last session, this session presented three success models of intervention with female partners of MSM. These models addressed to the issues and barriers of female partners presented in the last session, and described strategies used to design successful interventions. The intention of this session was to present few successful models, the strategies used, the challenges faced and the learning.

2.1)

Lakshya Model

Presented by Siddhi Pandya HIV isn’t restricted among only high risk groups but is moving to general population. Cultural factors like women’s reproductive and sexual health needs remain unattended and the husbands are the deciding factors remain issues faced by women in accessing HIV or STI services. There are also pressure of marriage; issue of masculinity; and bisexual behaviour of MSM that can be observed. There are vulnerability and risk factors of female partners of MSM still they are not considered as KP in the interventions.

In the Lakshya Model, Panthis used to get their female partners to the panel doctors for STI treatment and ORWs were doing regular follow-ups with the positive population. A female peer educator was employed and she started convincing MSM to get their female partners. Another kothi was also employed under this model. This model was applied to only three areas and we were working with 120-150 female partners. This work has been limited now because of the restricted budgets and medicines. All the interventions were made using client at the centre and through the client we got access to female partners.

50

Service provisions and strategies: This model employed outreach through female peer educator; health camps for general and sexual health; counselling and group sessions on health issues focusing on sexual health issues through female counsellors. Women centric services through linkages and referrals, collaborations were made with other govt. schemes. Behaviour Change communication through bi-centric information, education and communication materials to explain sexual health issues Factors unique of female partners: There is a lack of knowledge among female partners, inability to convince their partners for condom use, biologically more prone to STIs, power dynamics and multiple partners of women. They face multiple issues like, sexual health; mental health; sexuality issues; legal and ethical; socio-cultural issues Output 1: awareness about sexual health/ mental health – Outcome: promotion of health seeking behaviour and condom negotiation skills.

Output 2: decreased incidence of STIs after interventions – Outcome: empowering FPs improve in quality of life Output 3: Support groups of FPs- Collectivization – Outcome- economic support to family, savings of FPs, decision-making and condom negotiation Lakshya Model recommended that there should be an inclusion of female partners in NACP, and STI clinic (provision of drugs) should be made available for female partners also, referrals and linkages need to be made and also there is a need of developing bi-centric IEC material.

2.2)

Pehchān Team

Presented by: James Robertson Title of presentation: ‘Reaching MSM with female partner: Experiences from Pehchān’ Through Pehchān, they have been able to reach out 473,750 (MSM, TG and Hijras) in 17 states. In a baseline study conducted with 2762 participants (MSM- 2308, TH/Hijras- 454), 46% reported having sex with a woman ever. Consistent condom use was much lower with regular partners as compared to casual partners.

51

Through the Pehchān project, 221 female partners were reached with counselling services and referrals to ICTCs. James also explained that in the next phase the TI-Plus will be also be focussing on the issue of ‘MSM with female partners’. Pehchān is committed to provide all those supplementary services that are currently not taken up NACO. Working with MSM with female partners will help us to reach out and address issues of HIV risks to their female partners. James also reiterated that for Global Fund/ Pehchān the key population still remains MSM, TG/Hijra and not their female partners and hence the intervention will put the men in the centre while being implemented.

2.3)

FPAI Model

Presented by: Nisha FPAI started working with MSM in 2006 in Mumbai, and it was oriented on providing MSM friendly services. It began with sensitizing the staff on MSM issues by Ashok from HST. The staff members were also made to visit HST. A DIC was open in Bandra- Kurla Complex where some entertainment programs were started and were then linked to the clinic. People started coming once they realise that they can access services as well, and by that time the staff also got sensitized towards MSM issues. For FPAI they took every individual as a client and respect was given to each and everyone.

After completion of first year, they developed partnership with other CBOs and it was discussed that the purpose is not to duplicate the services. In contrast issues of female partners of MSM and other services which referred to FPAI. The identity and confidentiality was ensured so that client could be encouraged to get their wives. This strategy worked out for them, now they are working in 40 centres. Now it has been integrated in most of their centres and the focus remains to give services to the female partners.

Discussion Points: 1) The age group of the female partners in Lakshya study was 22-28, the research was done with 15 Female Partners, and their socio-economic background was mixed. Some of the questions were administered with couple as a unit; from the three sites, two cities where kothi-led model was equally successful; very few were educated and they got to know about it either when husband was positive or found out through other sources. The first subgroup who got their partners were Panthis and with Kothis it was a little difficult in the starting.

52

2) James mentioned that Penchan experience isn’t rich experience but over 3 years and 17 states, they will be more answers. Pehchan isn’t doing something radically different from Lakshya. There is an OR being planned. There is a policy challenge – neither the programmes for Hijras and MSM nor the programmes for women are over funded. There is a funding challenge.

3) Given the models, in the longer run, FPAI model will survive. The emphasis is still on MSM and hence there is an asymmetry. Lakshya is a boutique project. Women are at a huge disadvantage.

Session 3: Brainstorming, community voices and panel discussions The third session aimed at bringing out the voices of the community, their experiences, issues and vulnerabilities. The first community speaker discussed the issues and experiences of a married MSM, the duality of life and challenges. The second speaker discussed HIV intervention for female partners through the lens of a community based organization, the difficulties faced in starting the intervention, new strategies adopted and lesson learned.

3.1)

Manjit Singh

He is from Punjab, and talked about the pressure of marriage and producing a child. Kothis are also harassed by Hijra community. Kothis after marriage face a lot of problem. He has once been divorced and now is again in a marital relationship with another woman. He mentioned that in Punjab there is no organization that works with married kothis. He thinks his last wife was uneducated and had issues with his dressing and appearance but his current wife is NRI and is completely fine with him. He got remarried as again there was similar pressure of getting married from family. He has two kids, a girl from the first one and a boy from the second one. The first wife he thinks divorced him as he was not much interested in him and now he takes more care of his second wife. His family and wife are unaware about his sexuality.

3.2)

Manoj Jani 53

Most of the community members that visit his organization (Arjoo Foundation) come from a Muslim background. During the initial discussions with the community female partners or marriage weren’t talked about but later in a program using a chart called ‘Rangeela’ they started addressing issue of female partners of MSM. It was during one of the first FGD it came out issues of sexual relationship with wife. The organization started focusing on issue of female partners getting tested for HIV. In a couple of the referrals it was realised that the wife was told that STIs and discharge is because of multiple partners because of which there were more frictions that were caused in their married life. There was a consultation organized where FPA helped and discussed the services that they have been providing. Since then they have had very good experience of working with FPA and have referred as many as 23 couples for testing and counselling. Arjoo Foundation has also initiated working on reduction on partners and motivating MSM to get their female partners tested as strategies to reduce incidences of HIV transmission. Now they have started sensitizing few other clinics in the locality especially working with the Skin departments.

Discussion Points: 1) The entry point for the intervention for Arjoo Foundation was using Rangeela as a model.

2) Working with public health system is very important. Sensitizing PHDs is a long process but in working on of the learning has been that sensitizing private clinics is equally important.

3) There are 40 centres of FPAI and since they are general clinics, it remains more confidential.

FPAI is the longest and oldest organization committed to providing Sexual and Reproductive Health service to women.

This session with community speakers gave insights about the issues and challenges faced by a married MSM person in India. One of the important key-player is family who forces or pressurises men to get married to women as per the societal norm. At the same time, in Indian society disclosing about one’s sexuality to family/ wife or taking a divorce is not seen as an option. Keeping this in mind, any community based initiative as discussed in the session must be responsive to these concerns. Hence, confidentiality of one’s sexuality or HIV status should be maintained, while giving services to one’s female partner. Though female partners of MSM are realised to be an important group that needs HIV intervention, the concerns of MSM must also be kept in mind while designing any intervention.

Session 4: Potential Strategies- Putting forward recommendations and drawing consensus 54

The last session of the consultation focused on bringing together the evidences gathered through research studies, models of successful interventions, and community voices. It aimed at putting forth a coherent potential strategies and building consensus on the same. The issues and concerns discussed in different sessions and by stakeholders were collated to give a more responsive recommendation on targeting female partners of MSM in HIV intervention.

Facilitated by: Dr Chakrapani and Ashok Row Kavi

The facilitators pointed out that identity has to be a major factor while devising interventions and working with public health system is very important. They explained that all the three models discussed today had MSM in centre, and all the interventions in terms of reaching out to female partners and connecting them to ICTC, or private practitioner or FPAI WHO has three models: -

Patient directed/initiated partner referral

-

Provider initiated referral

-

Conditional referral

It was discussed that among the above mentioned three models, only the first two are applicable in this case. Patient directed model will be more like FPAI model, where the MSM were encouraged to 55

get their female partners for testing and services. This would mean that the onus for connecting the female partners to the services will lie with the MSM. Second model discussed, Provider initiated referral will be through the outreach work. In this case the capacity of organization to carry out this activity needs to be build, the ones linked to Public health systems or schemes (NRHM) will have sustainability and also it was pointed that pre-TI (Pehchān Model) might not be ready to start with female partner notification. This model will be through the CBOs where the intervention will be through outreach work hence onus will be on CBOs unlike MSM in the previous model.

Discussion Points: 1) Pehchān is not only linking female partners to NACO services but also with SRH services 2) Partnering needs to be done with women’s organizations like organisations in North India where women’s organisation take active participation in the interests of the woman.

(Relating to domestic violence) 3) Vijay Nair pointed out that past experiences have been bad while working with female organisations, since there are run by feminists.

4) It should be community initiated. MSM people don’t want outsiders to enter the domestic affairs.

5) Since the intervention is targeting women, agency of women should be kept in mind.

Working with women groups is important as it would mean putting the onus on women Consensus 

Pehchān model is using TI-plus as strategy to reach out to female partners (MSM, TG/Hijra will remain the centre of Pehchān)



Link to women’s organization / NGOs, so that women’s agency can be revived

CONCLUSION The consultation discussed HIV risks of female partner of MSM and the need to include them in HIV intervention programme. The research studies presented at the consultation provided with 56

evidences to support the argument and also recommendations for carrying out successful interventions. It was recommended that universal access for the prevention, treatment, care and support of HIV and sexually transmitted infections to the female partners of MSM should be provided. Based on the community learning in carrying out interventions, the consultation chalked out two models of HIV intervention with female partner of MSM. The models, ‘patient directed/ initiated partner referral’ and ‘provider initiated referral’ both will have MSM at the centre of intervention, as the confidentiality of their sexuality and HIV status will be an important factor while designing strategies. There is also a need to link these interventions with the national programmes for sustainability, and also to work with public health system and other strengthen referrals to organizations working on Sexual and Reproductive Health (SRH) with women.

Erenst Noronha from UNDP concluded the session by saying that in NACP IV there will be a component on reaching out to female partners of MSM. UNDP commissioned study ‘Female partners of MSM- FXB-India Suraksha’ to look at three CBOs and their work on female partners of MSM was a necessary step in the process. This work has human rights implications, and also issues of confidentiality. Replicating the models displayed by few CBOs and successes linked to them may not be a workable ground; hence there is a need to develop community responsive and relevant interventions which will differ from CBO to CBO. It was discussed that recommendations can be given to NACO and could also be taken up by UNDP for the next phase.

A vote of thanks was given to James Robertson, Dr Maninder Singh Setia and Dr Venkatesan Chakrapani, all the other presenters, married MSM and organizations for sharing their experiences; and also FPAI for helping with ethical clearance and being there throughout the journey.

57

UNITED NATIONS DEVELOPMENT PROGRAMME 55 Lodhi Estate, P. O. Box 3059 New Delhi - 110003, India Tel: +91-11-246532333, Fax: +91-11-24627612 Web: www.in.undp.org Email: info.in@undp.org

58