Kanpur, Uttar Pradesh

Regional Office 9 Gulzar Colony, New Berry Lane, Lucknow 226001, India Phone: +91 (0) 522 2205781-2 Fax: +91 (0) 522 2205783 Email: lucknow@nfi.net Web: www.nfi.net Kanpur, Uttar Pradesh A situational assessment of males who have sex with males and their sexual partners in Kanpur, Uttar Pradesh, India August 2006

Acknowledgements This study would not have been possible without the support for the Department for International Development (UK), India Office and the DfID Project Management Office, along with the study team members in Kanpur, and all the respondents who were courageous enough to respond to the questionnaires. We thank them all. 2

Contents Acknowledgement 2 Acronyms 4 The project 5 Summary of the findings 7 Naz Foundation International 11 Why we should work with MSM 12 Definitions 13 Principles of Good Practices: Towards Universal Access - adopted at the Risks and 17 Responsibilities Male Sexual Health and HIV in Asia and the Pacific International Consultation 23 rd -26 th September 2006, New Delhi, India Model of an MSM community0based HIV prevention, care and support service package 21 Kanpur data 23 3

Acronyms AIDS CBO DFID HIV MSM MSW NFI NGO STI Acquired Immune-Deficiency Syndrome Community-based organisations in this context organisations developed by MSM for MSM Department for International Development, UK Human Immunodeficiency Virus Males/men who have sex with males/men: NFI prefers the term biological term male rather than the socially constructed word man in the South Asia context Male sex workers specifically refers to those males whose sole source of income is from sex work Naz Foundation International Non-government organisation Sexually transmitted infection 4

The Project India is a male dominated society where the social and public spaces are primarily male and masculine. As a homosocial and homoaffectionalist society, sexual boundaries between males can be readily crossed and may often become sexual acts. Whereas some of these acts can perhaps be called homosexual (within the context of local identities based upon female gender identification - also self-labelled as kothis) in that a sexual sense of self is operating within a framework of gender sex roles and desires, the majority of male to male sexual encounters should be seen within a context of semen discharge. With DFID support, NFI is implementing a pilot project to test the replicability of its training programmes and resources for a process of rapidly scaling up of community-led MSM organizations providing HIV prevention, care and support services to their constituents. This involves developing 9 new MSM and HIV projects in each of four states: Andhra Pradesh, Karnataka, Tamil Nadu and Uttar Pradesh. Field visits were conducted in each of these 36 cities by the NFI State Project offices in each state to identify key MSM informants and leaders from the range of social networks who were willing and committed to develop HIV services for their networks (up to 7 such individuals from each city). Each state held its own 3-day consultation meeting with these individuals from each of the 9 target cities to explore issues, needs and concerns in regard to male-to-male sex and HIV risk and vulnerability. This was followed by two 7-day training programmes to develop a community-based organisation, which also included a skills-building component for conducting a peer-led situational assessment of MSM in the specific city. Situational Assessments were conducted in two groups of city projects, the first phase beginning in June 2006 (4 cities in each state), and in August 2006 (second group of 5 cities in each state). Some 200 respondents in each city were identified through snowballing techniques and respondent driven sampling. A questionnaire had been developed and translated into the local language, and field-tested in each city prior to the actual assessment data collection. A drop-in centre was also developed as a part of HIV project development in each city, which was used to conduct the interviews. Confidentiality was assured and informed consent was taken from each respondent. Data analysis was done by Bamon Development Consultancies using an analysis packaged based on SPSS. 5

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A summary of the key findings Kanpur Kanpur is located on the banks of the Ganga and is an important industrial center. It have a population of around 42 lakhs, male population is 22 lakhs and female population is 20 lakhs its literacy rate is 74.4% and sex ratio is 855. Kanpur stands as one of North India s major industrial canters with its own historical, religious and commercial importance. The Situational Assessment consisted of interviewing 200 MSM in Kanpur through questionnaires through snowballing techniques via friendship networks of the study team members. All participants were above 18 years of age. Because of this process for identifying respondents, the study should be considered biased in terms of the age of respondents, marital status, class and self-identity. Thus: Q. No.1 Age of the respondent (N=200) 18 To 21 14 7.00 22 To 30 124 62.00 31 To 40 45 22.50 Above 40 17 8.50 Q. No.2 Marital status of the respondents (N=198) Married 98 49.50 Unmarried 100 50.50 Q. No.3 currently employed? (N=180) Yes 111 61.67 No 69 38.33 7

Q. No.4 Occupation of the respondents (N=163) Student 17 10.43 Private job 12 7.36 Labor 5 3.07 Shop 6 3.68 Cosmetics 10 6.13 Government job 7 4.29 Shoe shop 12 7.36 Job 13 7.98 Business man 4 2.45 Marketing 2 1.23 Rickshaw Puller 7 4.29 Government job 3 1.84 Telephone booth 3 1.84 Swing work 2 1.23 unemployed 2 1.23 Gold smith 3 1.84 Mutton shop 4 2.45 Others 51 31.29 Q. No.5 Monthly Income of respondents (N=196) respondents Below 1000 Rps 39 19.50 1000-2000 39 19.50 2000-5000 87 43.50 5000-10,000 32 16.00 Above 10,000 3 1.50 Q. No.6 Self sexual labeling by respondents (N=200) Kothi 115 57.5.00 Panthi 72 36.00 Double-decker 13 6.50 Heterosexual 0 0 Homosexual/gay 0 0 The Kanpur data does not provide the full picture of the MSM population in Kanpur, but only of those accessed by the research team. Thus we note while 49% of respondents reported being married (table 2), this does not indicate that 49% of all MSM in Kanpur are married. Similarly, while at the same time 69% of respondents reported being between the ages of 18 to 30 years (table 1) this does not necessarily reflect the age range of MSM either. While 62% of respondents reported being employed (table 3), 39% reported having incomes of 2000 rupees or less, while 44% reported that they have a monthly income between 2000 and 5000 rupees (table 5). 58% of respondents self-identified as kothis (table 6), but 36% identified as panthis, and 6% as double-deckers. Kothi identified males in Kanpur appear to be highly sexually active, where these male had an average of 9 different sexual partners in the previous month (table of comparative data). Significant levels of unprotected anal sex exist among MSM, where in the previous month, only 32% of these acts where covered with condoms (table 8ii). The main reasons given for not using 8

condoms were not easy to use followed by never used before and to shameful to buy/use. (table 17). The majority of the sex acts in Kanpur city were in public spaces (57%) such as parks, public toilets, in a train, or in cinemas (table 12). 76% of respondents reported using some form of lubricant, but this was primarily saliva or oilbased products (table 21). The use of oil-based products with condoms increases the risks of condom damage or breakage. While only 39% of respondents had heard of HIV (table 47-i), 95% had heard of AIDS (table 47- ii), but only 13% identified the difference between HIV and AIDS (table 48), indicating poor levels of knowledge. Significantly, only 18% of respondents stated that they had a significant risk of being infected with HIV despite their preferred sexual practice unprotected anal sex (table 50). However, 49% correctly identified that not using a condom for anal sex a person is more likely to get infected with HIV (table 51-ii), clearly demonstrating that knowledge does not always translate into a personal risk perception. Further, where only 28% of respondents suggested condom use as a means of prevention of HIV transmission (table 52), 37% stated that they were carrying a condom at the time of the interview (table 8). 18% of respondents reported that they had been paid for sex by other males in the pervious month (table 23-ii) where the primary sexual activity was anal sex (table 24). Only 2 respondents reported condom use with all the previous five clients (table 25). Married MSM reported regular sex with their wives, but only 33% of these acts were covered with a condom. There was also limited reporting of anal sex with wives (table 35). reported low levels of sex with females other than their wives. Only 5 respondents reported this. Of course this does not necessarily mean that more MSM are not having sex with other females. also reported significant levels of possible rectal damage and STI symptoms, with medium levels (44%) of treatment seeking behaviours (see tables 44 and 45). Only 6 respondents (3%) admitted injecting drug use in the previous year, where 2 stated that at least one of their sex partners also injected drugs in the previous year (table 60). 6 respondents reported being tested for HIV, and none stated that they were HIV positive. Only 2 were counselled before the test. Key points 1. Low level of condom usage with male and female partners 2. Significant level of different sexual partners 3. Low level of knowledge 4. No access to water-based lubricants 5. Anal sex primary sexual activity with male partner 6. High level of possible STI symptoms 7. Significant level of poor health seeking behaviours 8. Low levels of knowlegde 9. Low levels of personal risk assessments Conclusion The above key points indicate that there is an urgent need for an appropriate and comprehensive package of HIV and STI prevention, care and support services for MSM in Kanpur including condom promotion, access to water based lubricant, utilising community sexual networks for promoting risk reduction and safer sex activities, effective and appropriate STI treatment that can address anal and oral sex issues, support and care services for MSM infected with HIV. 9

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Naz Foundation International Naz Foundation International (NFI) was established in 1996, when it became clear that HIV was increasingly becoming a significant issue of concern in South Asia, whilst at the same time, there was not only very little recognition of male to male sex in the region, but even a will or action in providing services to this vulnerable population. NFI has developed a range of capacity-building tools, training manuals, documentation and other resources in order to provide technical assistance and support to MSM networks in a range of cities across South Asia to develop their own responses to HIV/AIDS, as well as work with a range of international NGOs and other organisations towards ensuring the provision of appropriate HIV and AIDS prevention coverage to MSM. As the only agency of its kind in the region, NFI has provided assistance to over forty MSM HIV/AIDS projects across South Asia, building a reservoir of knowledge, skills and expertise that was culturally specific in responding to the HIV/AIDS prevention, care and support needs of males who have sex with males in South Asia. Goal To improve the quality, capacity, and coverage of service delivery of HIV/AIDS prevention, care and support programmes focusing on the needs of males who have sex with males in South Asia. Objectives To enhance the institutional, technical and delivery capacity of organisations working with males who have sex with males on HIV prevention, care and support, whether supported by the Pakistan Enhanced Programme on HIV/AIDS or not. To enhance the institutional and technical capacity of the Provincial AIDS Control Programmes to effectively manage, monitor and evaluate MSM HIV/AIDS prevention, care and support programmes they support. To develop an in-country technical support capacity in the area of appropriate service delivery on HIV and AIDS prevention, care and support for MSM. Explore the possibility of the development of MSM community-based self-help approaches to HIV and AIDS in the country. 11

Why we should work with males who have sex with males Why we should work with male-to-male sex and HIV prevention, care and support? Because: It is the right thing to do on humanitarian grounds. It is the right thing to do epidemiologically. It is the right thing to do from a public health perspective. Males who have sex with males (MSM) whether their self-identity is linked to their same sex behaviour or not, have: The right to be from violence and harassment; The right to be treated with dignity and respect; The right to be treated as full citizens in their country; The right to be free from HIV/AIDS; MSM who are already infected with HIV have the right to access appropriate care and treatment equally with everyone else, regardless of how the virus was transmitted to them. 12

Definitions Double-decker Sometimes known as AC/DC, or even bisexual, this kothi label is used for those who state that they sexually penetrate and are also penetrated. Over the past few years, this label has also been adopted as an identity term. Gay While some males with a specific sexual preference for other labels use the term gay as means of self-identity, these men tend to be from the more educated classes. In its Western meaning, the word gay defines a man who sexually desires other men, and whose sense of self is based on developing egalitarian relationships of mutual desire and similarity in socio-economic status. Gender There are some basic biological differences between female and male bodies, linked to their different roles in reproduction. But beyond these differences, many societies define different roles, rights and responsibilities for women and men. Gender is the term used to refer to these socially defined differences between men and women. Gender differences are based on widely shared beliefs and norms within a society or culture about male and female characteristics and capacities. These beliefs and norms about gender usually create inequality between men and women. In most societies, men have more political, economic, and social power than women. Such gender inequalities have a significant impact on women and men s sexual health. Gendered framework The word gender is a classifying noun and but often when the term gender is used, it is focused on women, where men are absent as a gender in themselves. The author has used the term gendered as an adjective to describe a state. In South Asia where there is often fairly strict social policing of gender(ed) boundaries, and where the primary (and visible) framework of male-tomale sexual behaviours is constructed not around sexual orientation, but around gender(ed) identities, the term gendered framework is used as a short-hand description of this state of affairs, i.e. males/men who identified as kothis do not perceive themselves as males, but as not-males or feminised males. Hierarchical and oppositional framework NFI uses this phrase in the specific context of gender(ed) relationships between male and female, or masculinity and femininity, where these genders and their qualities are seen as a hierarchical and in opposition to each other. In other words, maleness is superior to femaleness and in opposition to it. Hijra A self-identified term used by males who define themselves as not men/not women but as a third gender. Hijras cross-dress publicly and privately and are a part of a social, religious, and cultural community. Ritual castration may be part of the hijra identity, but not all hijras are castrated. Sex with men is common. They also have their own language, known as farsi, which many kothi-identified males share. To often there is a major confusion between hijras and kothi-identified males, with both subpopulations being grouped as one. But this is not so. Hijras represent a specific community with its own rules, regulations and order. To become a hijra is not only about dress code, behaviour and language, but includes the acceptance of the hierarchal structure of the hijra community. There are rituals to perform such as the reet which is a ritual where a young male (and sometimes not so young), primarily kothi identified, who enters a hijra household through ritual 13

offerings made to the guru/nayak, who has absolute authority over the new chela. Thus the hierarchy is chela - guru - nayak. A guru may have several chelas, while the nayak will be the head of the hijra community. Chelas must get permission from their gurus, and gurus must get permission from their nayak - head of a particular hijra household (not a dehra) to be involved in any activity. Hijras have specific beliefs relating to their spiritually given powers over fertility, which are granted following the castration ritual. Not all hijras are castrated, but this is the end goal. Homosocial and homoaffectionalist culture In South Asian countries, gender segregation of social spaces is a strong form of social policing of gender relationships. Primary relations are between the same gender (homosocial). Homoaffectionalism in the sense that the term is used in this text means social acceptance of the public display of male-to-male or female-to-female affection. For example, it is common in Bangladesh to see two males holding hands or arms wrapped around each other as they walk. Often male friends will also share beds when sleeping, wrapping themselves around each other. (See Hardman: 1993; Also Khan: 1996, where he points out that the boundary between homoaffectionalism and homosexual behaviours is very thin particularly in shared spaces and under the blanket. ) Kothi Primarily used in Bangladesh and India, this is a self-identifying label for those males who feminise their behaviours (either to attract manly male sexual partners and/or as part of their own gender construction and usually in specific situations and contexts), and who state that they prefer to be sexually penetrated anally and/or orally. Kothi behaviours have a highly performative quality in social spaces. Self-identified kothis use this term for males who are sexually penetrated, even when their behaviour is not feminised. This is the primary and most visible framework of MSM behaviours. Kothis state that they do not have sex with other kothis; however, they may also be married to women. Masculinity Masculinity is interpreted as the predominant and hegemonic framework, which defines how a man should behave and act personally, sexually, socially, and culturally. However, it is also recognised that there are different constructions of masculinity that vary across cultures, age groups, sexual orientations, sexual preferences, actual behaviours, gender identifications, economic classes, and religions, and thus we should speak of masculinities. Males who have sex with males (MSM) While the term men who have sex with men is generally usede, NFI prefers to use the term males in this context in its biological sense, as many males do not identify as men, nor are they usually perceived by their sexual partners as men. The term man as usually used in India is around how the framework of manhood and masculinity is socially defined, i.e, in terms of social obligations, family duties, and marital status as much as the penetrative role that men are supposed to take. Its use does not imply that it is an identity term referring to an identifiable community that can be segregated and so labelled. Within the framework of male-to-male sex, there are a range of masculinities, along with diverse sexual and gender identities, communities, networks, and collectivities, as well as just behaviours without any sense of affiliation to an identity or community. Panthi This is a kothi label for any manly male primarily used in North India. Male-to-male sexual behaviours are usually highly gendered in terms of sexual roles and reflect insertive or receptive practices. Most male-to-male sex in South Asia appears to follow this pattern, where a kothi is not defined as a man, thus enabling the penetrating partner to still see himself as manly. A panthi is by definition a man who penetrates, whether it is a woman and/or another male. Panthis may also 14

be married to women, and usually are if they are of marital age. Their occupations vary across the social class spectrum from rickshaw drivers to businessmen. An equivalent term is girya which tends to be used more in North India. Sexual health Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, a well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, Protected and fulfilled. World Health Organisation Draft working definition, October 2002 Sexuality Sexuality refers to all aspects of people s sexual lives: their sexual desires, their sexual behaviours and their sexual identities. It is important to focus on sexuality in HIV prevention work because it is important to understand people s risk behaviours in the context of their sexual desires and sexual identities. However, contemporary researchers have been discussing the concept of a range of sexualities, expressing the enormous diversity of cultural interpretations, meanings and significance placed upon sexuality. Transgender Broadly speaking, transgender people are individuals whose gender expression and/or gender identity differs from conventional expectations based on the physical sex they were born into. The word transgender is an umbrella term which is often used to describe a wide range of identities and experiences, including: female-to-male and male-to-female sexual reassigned persons, cross-dressers, drag queens, drag kings, gender queers, and many more. [In the Asia and Pacific region this would include hijras, some kothis, zenanas and metis, kathoey, waria, bakla, fa fa finis, etc.] Because transgender is an umbrella term, it is often thought to be an imprecise term that does not adequately describe the particulars of specific identities and experiences. (For example, the identity/experience of a post-operative FTM transsexual will probably be very different from that of a female-identified drag king who performs on weekends, but both are often lumped together under the term "transgender.") web.mit.edu/hudson/www/terminology.html, accessed 14/9/06 15

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Towards Universal Access to HIV Prevention, Treatment, Care and Support for Men who have Sex with Men and Transgender People Principles of Good Practice We the participants in the Male Sexual Health and HIV in Asia and the Pacific International Consultation: Risks and Responsibilities, New Delhi, September 23-26, 2006, hereby agree on and accept the following Principles of Good Practice towards Universal Access to Prevention, Treatment, Care and Support for men who have sex with men, and transgender people: Bridging the knowledge gap In order to develop strategic and effective responses to the HIV prevention, treatment, care and support needs of men who have sex with men and transgender people, anthropological, sociological, behavioural and epidemiological research are essential, and need to be undertaken in partnership with the affected populations, understanding dynamics of male-to-male and transgender sexuality, including the multiplicity of frameworks, gender identities, behavioural practices within national and local socio-cultural contexts. Governments and donors can and must play a pivotal role in undertaking and supporting such participatory assessments and research concerning the prevention, treatment, care and support needs of men who have sex with men and transgender populations for the development of comprehensive programmes that will be informed by evidence as well as implementing policy support for these interventions. In addition, there is a need to undertake participatory community oriented size estimations of men who have sex with men and transgender populations in order to advocate for and ensure adequate levels of resources for programmes of scale, for the reduction of risk and vulnerability of these marginalised sexualities. Focused participatory interventions For any HIV and AIDS prevention, treatment, care and support intervention to be effective within networks and communities of men who have sex with men and transgender people, these marginalised sexualities must be actively and substantively involved in planning, designing and implementation of such interventions. This includes participation in problem identification, needs assessments, programme design, monitoring and evaluation. Participation is essential in areas related to the development of legal frameworks and laws, policy, advocacy, education and programme design and implementation. Participation must include and reflect the full cultural and sexual diversity of men who have sex with men and transgender people. Further, HIV positive people from these diverse networks, communities, groups and organisations need to be fully involved, with the GIPA (Greater involvement of people living with HIV) principles meaningfully implemented. Promoting ownership and an enabling environment Governments and states can and must enhance efficacy of policy and programme interventions by ensuring that representative ownership is key in all legal, policy and programme efforts aimed at stemming the spread of HIV among men who have sex with men and transgender people s networks, groups and communities. Supportive legal, policy and programme environments are instrumental in helping men who have sex with men and transgender people to acknowledge their own risk and responsibilities in stemming the spread of HIV. For building enabling environments, governments must enact legal and policy guidelines and structures that respect and protect the right of all its citizens to good quality prevention, treatment, care and support services. To ensure moving towards true universal access, actions must include the decriminalisation of sexual acts between consenting men who have sex with men and transgender people, as well as addressing legal issues relating to sex work. Governments, states and donors must play an active role in helping men who have sex with men and transgender people 17

understand their rights and empower them to respond to discrimination and harassment. Organisational development and strengthening To ensure that good quality HIV prevention, treatment, care and support services are provided and accessed, organisations that include and represent men who have sex with men and transgender networks, groups and communities should be fostered and supported. This includes supporting the development of representative service organisations. Where this is not possible because of legal/social constraints, other implementing NGOs/INGOs could act as shelter agencies providing technical, operational, management and other capacity building support. This process recognises the need for empowerment and personal decision-making, along with peer processes for promoting safer sex practices. Safe-spaces (i.e. drop-in centres) where meetings, social gatherings and other community activities can be held should also be supported. Access to appropriate and affordable STI diagnostic and treatment services Many men who have sex with men and transgender people living with HIV are not only stigmatised by their HIV positive status, but also by the route of infection and issues related to their sexual and gender identities. Treatment, care and support programmes need to be competent to address these different frameworks and address them appropriately. All health care providers providing STI prevention, diagnosis, treatment and care services must therefore be professionally competent in addressing specific sexual health needs of men who have sex with men and transgender people. This includes providing STI prevention and management in regard to anal STI and other pathologies that could be a result of anal and/or oral sex. Such services, as all other medical services, must be confidential. This, not only regards STI but also pertains to overall professional conduct and attitudes in providing comprehensive health care related to consenting adults sexual and gender preferences and choices As much as possible these services should be provided to men who have sex with men and transgender people within locally accepted community-based project structures, i.e. as a part of drop-in services. At the same time however, sexual health clinics for the general male population must also address male-male and transgender sexual behaviours and possible related health issues. Access to appropriate HIV voluntary testing and counselling Governments, and CBOs need to provide and donors must support pre- and post-testing counselling services for HIV and other STI that are confidential, non-judgemental and empathic to the needs of men who have sex with men and transgender people. As much as possible these services should be provided to men who have sex with men and transgender people within locally accepted community-based project structures, i.e. as a part of drop-in services. Post-test support services must include counselling on the meaning of an HIV diagnosis and referrals to men who have sex with men or transgender-competent prevention, treatment, care and support programmes and services. Access to affordable condoms (including female condoms ) and water-based lubricants Reducing the primary risk of infection with HIV and other STI must be central to all HIV prevention programmes. Governments, CBOs and donors must support population-specific, free or affordable distribution of condoms along with social marketing campaigns to promote consistent use of condoms, as an essential component of risk reduction strategies for men who have sex with men and transgender people. In addition, governments, CBOs and donors must ensure ready access to appropriately packaged water-based lubricants that enhance the efficacy of condoms used for protection in anal sex, by men who have sex with men and transgender people. 18

Access to specific information through appropriate communication Kanpur, Uttar Pradesh Research consistently shows that HIV prevention information that is communicated to the general population is insufficient to generate sustained protective behaviour among men who have sex with men and transgender people. Governments, NGOs, CBOs and donors must support the development and dissemination of information by and for men who have sex with men and transgender people, addressing their concerns, in languages, terminology and imagery that is realistic, life-affirming, meaningful, understandable, acceptable and engaging. Men who have sex with men and transgender and transgender people must not be passive recipients of such information but as the producers of their own information, education and methodologies of communication. Long-term technical and financial support Governments, national and international donors, multilateral institutions and international NGOs must commit and provide sustained technical and financial support to build the capacity of individuals and service organisations by and for men who have sex with men and transgender people working in the areas of HIV prevention, treatment, care and support. This, in order to enhance core capacities such as HIV competence and other technical HIV-related knowledge and skills, as well as programmatic and managerial governance and monitoring expertise. It is crucial that skills and opportunities in networking, community-building, advocacy and policy development and monitoring are also supported. Successful pilots and programmes must be documented and taken to scale in a manner that ensures sustainability, quality, and community ownership. Advocacy on legal, judicial and social impediments to effective HIV and other STI prevention and sexual health for men who have sex with men and transgender people Governments, international donors, multilateral institutions and international NGOs must assist in developing the capacity of men who have sex with men and transgender people for advocating and effecting change on legal, judicial and social impediments that hinder HIV and other STI prevention, treatment, care and support programmes for individuals or networks, groups and communities of these marginalised sexualities. Laws that criminalise consensual sex between adult males and transgender sex continue to drive the spread of HIV by impeding the development, implementation and access to essential prevention, treatment, care, and support programmes. Donors, multilateral institutions and international non-governmental organisations must therefore support and governments must react progressively to advocacy efforts directed toward law reform and address social stigmatisation that increases HIV vulnerability among men who have sex with men and transgender people. Broadening the education and awareness agenda Unprotected anal sex is not as uncommon as many may assume, and is not restricted to selfidentified men who have sex with men, and transgender people, but includes males in an array of different situations as well as between males and females. Community-based organisations working with men who have sex with men and transgender people in the area of HIV may not be able to reach such non-identified males easily. By ensuring that all HIV and STI prevention materials, programmes, and services include information pertaining to the risks of unprotected anal sex as part of broader sexual and reproductive public health awareness efforts, governments, academic institutions and international donors and international NGOs must ensure that this lifesaving information reaches and is understood by the general population; male and female alike. 19

Transparent governance and accountability to communities and constituencies of males who have sex with males and transgender people Governments, donors and multi-lateral agencies must practice transparent governance and have clear written policies and implementation guidelines on HIV prevention amongst men who have sex with men and transgender communities in a sensitive and supportive manner. Furthermore, non-government and community-based implementing partners must be selected in a transparent and objective manner. Finally, governments, donors, multilateral institutions and international non-governmental organisations must ensure that their own organisational environments are nondiscriminatory and stigmatising towards men who have sex with men and transgender people. 20

Model of an MSM community-based HIV prevention, care and support service package Field services Outreach and friendship building Community development and mobilisation Education and awareness BCC resource/condom distribution Referrals Centre based activities Socialising and support groups Vocational training and skills building Drop-in services Community building activities Advocacy Technical Assistance Clinical services STI and GUD management HIV testing and counselling Referral to HIV clinical services Psychosexual counselling General healthcare HIV care and support Trained volunteer buddies provide support and care Provision of nutritional support Provision of small grants Counselling, advice and referral 21

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Kanpur Section One Your self Page 24 Section Two Sexual activity with other males Page 24 Section Three Paid sex Page 28 Section Four Sexual activity with females Page 32 Section Five Your health and knowledge Page 35 Section Six Comparisons between self-identities Page 43 23

Section One: your self Q. No.1 Age of the respondents (N=200) 18 To 21 14 7.00 22 To 30 124 62.00 31 To 40 45 22.50 Above 40 17 8.50 Q. No.2 Marital status of the respondents (N=198) Married 98 49.50 Unmarried 100 50.50 Q. No.3 Currently employed? (N=180) Yes 111 61.67 No 69 38.33 Q. No.4 Occupation of the respondents (N=163) Student 17 10.43 Privat joob 10 6.13 Labor 5 3.07 shop 6 3.68 cosmetic 10 6.13 Government job 7 4.29 shoe shop 12 7.36 job 13 7.98 Business man 4 2.45 Marketing 2 1.23 Rikshaw Puller 7 4.29 Goverment job 3 1.84 P.C.O. Shop 3 1.84 Swing work 2 1.23 Privat job 2 1.23 Un employee 2 1.23 Gold smith 3 1.84 Muton shop 4 2.45 Others 51 31.29 24

Q. No.5 Monthly income of respondents (N=200) Below 1000 39 19.50 1000 To 2000 39 19.50 2000 To 5000 87 43.50 5000 To 10,000 32 16.00 Above 10,000 3 1.50 Q. No.6 Self sexual labeling by respondents (N=200) Kothi 115 57.50 Panthi 72 36.00 Double - decker 13 6.50 Heterosexual 0 0 Homosexual / Gay 0 0 Others 0 0 25

Section Two: sexual activity with males Q. No.7sexual activities with males (N=195) Sex acts Condom use respondents have had sex with male 195 74 different male sex partners in last week 561 167 different male sex partners in last month 1599 578 Q. No.8 Anal sex acts in last week (N=178) Sex acts Condom use respondents 178 76 Insertive sex acts 163 81 Receptive sex acts 302 99 Q. No.8 Anal sex acts in last month (N=185) Sex acts Condom use respondents 185 80 Insertive sex acts 519 250 Receptive sex acts 1009 318 Q. No.9 Oral sex in last week (N=44) Sex acts Condom use respondents 44 4 Insertive sex acts 63 1 Receptive sex acts 27 4 Q. No.9 Oral sex acts in last month (N=50) Sex acts Condom use respondents 50 11 Insertive sex acts 142 10 Receptive sex acts 69 17 Q. No.10 Relationship with sex partners( N=200) Times Friends 324 Strangers 1064 Neighbors 145 Male Prostitutes 29 Relatives 53 Servants 51 Paying Clients 12 Others 7 26

Q. No.11 Places of meeting with males you had sex with in the last month (N=200) Times Bar / Club 1 Street 56 Personal home 129 Park 778 Friend's home 240 Toilets 86 Railway station 70 Guest house 5 Magazine ad. 9 Neighborhood 106 Health club 0 Bazaar 46 Cinema 103 Hotels 10 Bus Stations 17 Others 17 Q. No.12 Places of sex acts (N=200) Times Your home 394 Friend's home 265 Park/cruising area 508 Hotel/guest house 28 Hostel 8 Cinema/theatre 38 Bar / club 0 Public toilet 335 In a car 5 In a train 58 Train / bus depot 7 Railway Station 18 Others 21 Q. No.13(i) Age of last male sex partner (N=198) 18 To 21 56 28.28 22 To 24 56 28.28 25 To 30 76 38.38 31 To 40 10 5.05 41 To 50 0 0 Above 50 0 0 27

Q. No.13(ii) Age of second last male sex partner (N=193) 18 To 21 33 17.1 22 To 24 37 19.17 25 To 30 94 48.7 31 To 40 26 13.47 41 To 50 3 1.55 Above 50 0 0 Q. No.14 Last 5 male sex partners' marital status (N=95) All were unmarried 1 1.05 1 was married 19 20.00 2 were married 29 30.53 3 were married 19 20.00 4 were married 11 11.58 5 were married 11 11.58 I Don't Know 5 5.26 Q. No.15 Availability of condoms from..(n=89) Pharmacy/medicine shop 81 91.01 Family planning clinic 0 0 Shops/Paanwallas 2 2.25 MSM projects 0 0 Social worker 0 0 Doctors 0 0 Vending machines 0 0 Friends 4 4.49 STD clinics 0 0 Sexual partners 4 4.49 AIDS NGO 0 0 Others 4 4.49 Q. 16 Brand of Condom Used by respondents (N=152) Don't use 100 65.79 Masti 31 20.39 Kohinoor 19 12.50 Zaroor 11 7.24 Kamasutra 9 5.92 Deluxe 8 5.26 Any Brand 1 0.66 K.S 1 0.66 Imported 1 0.66 28

Q. No.17 Reasons for not using condom (N=122) Times Don't carry condoms with me 154 Not satisfying 145 Hard to dispose 64 Never used before 201 To shameful to buy/use 190 Don't know where to get condoms 0 Am not sick 179 Partner not sick 30 Not easy to use 243 Main partner is faithful 8 Others 0 Q. No.18 Do you have a condom now? (N=192) Yes 71 36.98 No 121 63.02 Q. No.19 Can we see your condoms? (N=192) Yes 70 36.46 No 122 63.54 Q. No.20 Use of lubricant for anal sex (N=187) None of the time 3 1.60 Some of the time 42 22.46 Every of the time 142 75.94 Q. No.21 Type of lubricant used for anal sex (N=183) Oil 138 75.41 Ghee/Butter 1 0.55 Saliva 175 95.63 Vaseline 41 22.40 Ky Jelly 0 0 Soap 12 6.56 Others 2 1.09 29

Section Three: paid sex Q. No.22 Have you ever been paid by a man for sex (N=198) Yes 42 21.21 No 156 78.79 Q. No.23 times you have been paid by men for sex in last week (N=33) 1 To 5 times 31 93.94 6 To 10 times 0 0 11 To 15 times 0 0 More than 15 2 6.06 Q. No.23 times you have been paid by men for sex in last month (N=36) 1 to 5 times 31 86.11 6 to 10 times 4 11.11 11 To 15 times 0 0 More than 15 1 2.78 Q. No.24 Pattern of sex when paid for sex (N=24) No. anal insertive sex acts 34 respondents doing anal insertive sex acts 7 anal receptive sex acts 90 respondents doing anal receptive sex acts 26 oral insertive sex acts 5 respondents doing anal insertive sex acts 3 oral receptive sex acts 0 respondents doing oral receptive sex acts 0 masturbation sex acts 0 respondents doing masturbation 0 other type of sex acts 0 No. respondents doing other type of sex acts 0 Q. No.25 During last 5 times, when you were paid for sex, No. of times condom used (N=4) Never 0 Single time 2 Two times 0 Three times 0 Four Times 0 Five Times 2 30

Q. No.26 Who initiated condom use? (N=16) Your Self 13 Your Partner 3 Q. No.27a Last time how much were you paid for sex by a man (N=35) 1 To 10 0 0 11 To 20 3 8.57 21 To 30 7 20.00 31 To 40 0 0 41 To 50 11 31.43 51 To 100 12 34.29 101 To 150 0 0 151 To 200 2 5.71 Above 200 0 0 Q. No.27b Have you ever been given a gift/food for sex (N=0) Yes 0 No 0 Q. No.27c of the gift/food received (N=37) 1 To 10 1 2.70 11 To 20 1 2.70 21 To 30 1 2.70 31 To 40 0 0 41 To 50 3 8.11 51 To 100 27 72.97 101 To 150 3 8.11 151 To 200 0 0 Above 200 1 2.70 Q. No.28 Ever paid for sex with a male? (N=197) Yes 40 20.30 No 157 79.70 31

Q. No.29 times you paid for sex with a male in last week (N=22) 1 to 3 17 77.27 4 to 6 1 4.55 7 to 10 0 0 11 to 15 0 0 16 to 20 0 0 21 to 25 0 0 Above 25 4 18.18 Q. No.29 times you paid for sex with a male in last month (N=33) 1 to 3 20 60.61 4 to 6 7 21.21 7 to 10 1 3.03 11 to 15 0 0 16 to 20 0 0 21 to 25 0 0 26 to 30 0 0 31 to 40 0 0 41 to 50 0 0 Above 50 5 15.15 Q. No.30 Pattern of sex when paid for sex in last month (N=36) No. anal insertive sex acts 161 respondents doing anal insertive sex acts 24 anal receptive sex acts 289 respondents doing anal receptive sex acts 13 oral insertive sex acts 3 respondents doing oral insertive sex acts 2 oral receptive sex acts 14 respondents doing oral receptive sex acts 8 masturbation sex acts 0 respondents doing masturbation 0 other type of sex acts 0 respondents doing other type of sex acts 0 32

Q. No.31 times not used condom when paid for sex (N=7) 1 to 3 6 4 to 6 1 7 to 10 0 11 to 15 0 16 to 20 0 21 to 30 0 31 to 40 0 41 to 50 0 Above 50 0 Q. No.32 Last time how much you paid for sex with a male (N=39) 1 to 10 Rps 2 5.13 11 to 20 9 23.08 21 to 30 3 7.69 31 to 40 0 0 41 to 50 16 41.03 51 to 100 8 20.51 101 to 150 0 0 151 to 200 0 0 Above 200 1 2.56 Q. No.33 Age of last male you paid to have sex with? (N=38) 18 to 21 14 36.84 22 to 24 16 42.11 25 to 30 7 18.42 31 to 40 1 2.63 Above 40 0 0 33

Section Four: your sexual activity with females A: Married Males Q. No.34 times you have sex with your wife in the last month (N=99) 1 to 5 19 19.19 6 to 10 59 59.6 11 to 15 14 14.14 16 to 20 6 6.06 Above 20 1 1.01 Q. No.35 Pattern of sex with your wife in the last month (N=99) No. times of anal sex acts 3 respondents doing anal sex 2 times of anal sex with condom 0 respondents doing anal sex with condom 0 times of oral sex acts 7 respondents doing oral sex 3 times of oral sex with condom 0 respondents doing oral sex with condom 0 times of vaginal sex acts 856 respondents doing vaginal sex 99 times of vaginal sex acts with condom 281 respondents doing vaginal sex with condom 39 times of masturbation 0 respondents doing Masturbation 0 times of other sex acts 0 respondents doing other sex acts 0 times of other sex with condom 0 respondents doing other sex with condom 0 B: All Males Q. No.36 females (not wife) have you had sex with in the last month (N=5) None 0 One 2 Two 1 Three 0 Four 1 Five 1 Above Five 0 Kanpur, Uttar Pradesh 34

Q. No.37 Pattern of sex with females (not wife) in the last month (N=5) No. times of anal sex acts 0 respondents doing anal sex 0 times of anal sex with condom 0 respondents doing anal sex with condom 0 times of oral sex acts 0 respondents doing oral sex 0 times of oral sex with condom 0 respondents doing oral sex with condom 0 times of vaginal sex acts 15 respondents doing vaginal sex 6 times of vaginal sex acts with condom 3 respondents doing vaginal sex with condom 2 times of masturbation 2 respondents doing Masturbation 1 times of other sex acts 0 respondents doing other sex acts 0 times of other sex with condom 0 respondents doing other sex with condom 0 Q. No.38 Relationship with female sex partner to yourself (N=3) Times Friends 2 Relatives 2 Strangers 0 Servants 0 Neighbors 3 Female sex workers 0 Others 0 Q. No.39 Last 5 female Sex partners' marital status (N=3) All unmarried 0 One was married 2 Two were married 1 Three were married 0 Four were married 0 All were married 0 Don't know 0 35

Q. No.40 times condoms used while having sex with last five female sex partners (N=1) No time 0 One time 0 Two times 0 Three times 0 Four times 1 Every time 0 Q. No.41 Have you paid for sex with a female in last month (N=6) Yes 4 No 2 Q. No.42 Pattern of sex, when paid for it with 5 last females (N=3) No. respondents who had anal sex 0 times did anal sex acts 0 respondents who had oral sex 0 times did oral sex acts 0 respondents who had vaginal sex 3 times did vaginal sex acts 10 respondents who had masturbation sex 1 times did masturbation 2 respondents who had other type of sex 0 times did other type of sex acts 0 Q. No.43(i) times condoms used during last 5 times, when you paid for sex with females( N=1) respondents Never 0 Single time 0 Two times 0 Three times 0 Four times 1 Five times 0 Q. No.43(ii) Who initiated condom use? (N=0) respondents Your self 0 Your Partner 0 36

Section Five: your health and knowledge Q. No.44 Currently having these symptoms (N=71) respondents Pain while urinating 23 32.39 Itching or burning around anus 17 23.94 Pus or discharge from penis 13 18.31 Pus or discharge in stools 10 14.08 Pain upon defecation 12 16.9 Bleeding when defeciating 14 19.72 Genital sores 16 22.54 Itchy rash on genitals 23 32.39 Blisters or sores inside mouth 22 30.99 Pain during sex 12 16.9 Others 9 12.68 Q. No.45 What are you doing to treat these symptoms (N=164) respondents Nothing 72 43.90 Medical shop 6 3.66 Private doctor 27 16.46 Hospital 13 7.93 Friends/Relatives 0 0 Street 'Quack' 5 3.05 Other clinic 0 0 Others 58 35.37 Q. No.46 What did you do, when last time you had these symptoms? (N=145) respondents Nothing 104 71.72 Medical shop 4 2.76 Private doctor 25 17.24 Hospital 15 10.34 Friends/Relatives 0 0 Street 'Quack' 2 1.38 Other clinic 0 0 Others 0 0 Q. No.47 Ever heard of HIV? (N=200) Yes 78 39.00 No 122 61.00 37

Q. No.47 Ever heard of AIDS? (N=200) Yes 189 94.50 No 11 5.50 Q. 48 Tell us what you have heard (N= 191) It is a deadly disease 58 30.37 It spreads through sex 29 15.18 HIV is a virus and AIDS is a disease 25 13.09 Use condom for sex 20 10.47 HIV convert into AIDS 12 6.28 It is a dangerous disease 9 4.71 Don't use condom 8 4.19 Don't know 7 3.66 It is incurable disease 6 3.14 Safer sex 6 3.14 Use tested blood 3 1.57 Without condom doing sex attack AIDS 2 1.05 HIV/AIDS is same disease 2 1.05 Avoid AIDS patient 2 1.05 It is manly effected by man 1 0.52 AIDS is attack by infected needle 1 0.52 AIDS is a symbol of disease 1 0.52 Q. No.49 Sources of information on HIV/AIDS (N=198) Doctor 191 96.46 Radio 18 9.09 Social Worker 11 5.56 NGO 64 32.32 Newspaper 56 28.28 Leaflets 1 0.51 Posters 0 0 Hospital 2 1.01 Clinic 7 3.54 Family member 5 2.53 Local MSM projects 1 0.51 Friends 6 3.03 Sex partners 89 44.95 Others 0 0 Q. No.50 What risk do you personally think you have of getting HIV/AIDS? (N=192) Large 34 17.71 Medium 35 18.23 Small 20 10.42 I do not know 103 53.65 38

Q. No.50 What is the reason for your answer? (N=164) I don't know 71 43.29 I don t know about HIV 16 9.76 I use condom 31 18.90 Safer sex 10 6.10 It is incurable disease 1 0.61 Is affected every body who do sex 2 1.22 I have to got this disease 1 0.61 I have single sex partner 1 0.61 I have multi sex partner 3 1.83 I had unsafe sex 6 3.66 I don't use condom 10 6.10 Deadly disease 3 1.83 Avoid anal sex 1 0.61 Other 8 4.88 Q. No.51(i) Tell us whether you think you can get HIV from sharing a needle (N=186) Yes 89 47.85 No 3 1.61 Not Sure 94 50.54 Q. No.51(ii) Tell us whether you think you can get HIV from being penetrated by a man without a condom (N=187) Yes 92 49.20 No 3 1.60 Not Sure 92 49.20 Q. No.51(iii) Tell us whether you think you can get HIV from being penetrated by a man with a condom (N=185) Yes 2 1.08 No 63 34.05 Not Sure 120 64.86 Q. No.51(iv) Tell us whether you think you can get HIV from penetrating a woman without a condom (N=187) Yes 86 45.99 No 4 2.14 Not Sure 97 51.87 39

Q. No.51(v) Tell us whether you think you can get HIV from penetrating a woman with a condom (N=187) Yes 1 0.53 No 77 41.18 Not Sure 109 58.29 Q. No.51(vi) Tell us whether you think you can get HIV from only having a sexual contact with a woman (N=187) Yes 1 0.53 No 69 36.9 Not Sure 117 62.57 Q. No.51(vii) Tell us whether you think you can get HIV from sucking a penis (N=185) Yes 4 2.16 No 31 16.76 Not Sure 150 81.08 Q. No.51(viii) Tell us whether you think you can get HIV from swallowing semen(n=188) Yes 0 0 No 26 13.83 Not Sure 162 86.17 Q. No.51(ix) Tell us whether you think you can get HIV from licking vagina (N=185) Yes 7 3.78 No 18 9.73 Not Sure 160 86.49 Q. No.51(x) Tell us whether you think you can get HIV from masturbating someone (N=188) Yes 2 1.06 No 87 46.28 Not Sure 99 52.66 Q. No.51(xi) Tell us whether you think you can get HIV from rubbing bodies (N=189) Yes 1 0.53 No 88 46.56 Not Sure 100 52.91 40