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Valery Blokhin
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A cross-sectional survey of 2910 rural Indian men aged 18-40 years from five rural districts in five different states revealed that nearly 10% of single and 3% of married men had had unprotected anal sex with a man in the past year. Homosexually active men are not a separate sexual category,and report extensive mixing with female partners. They have more female partners than other men and they practised anal intercourse in 11% of their heterosexual contacts.

The results suggest that sex workers and their clients commonly practice anal intercourse, but a relatively high proportion of clients do not consistently use condoms, leading to a greater risk of acquiring HIV and its further transmission to other male and female sexual partners. Given the multidirectional risk, safer sex communication on heterosexual anal intercourse must be incorporated into HIV prevention programmes.

Using data from a large scale multisite bio-behavioural survey, this paper discusses the prevalence and practice of unprotected anal intercourse among clients of sex workers in high HIV prevalent southern states of India.

For the current analysis, a conceptual framework (figure 1, illustrated below) was used as a device to explain and identify the different factors that may be associated with inconsistent condom use during anal intercourse with FSWs.

The independent variables included age in completed years; education (illiterate, can read only, can read and write); occupation (pre-coded as unemployed, student, domestic servant, agricultural labour, non-agricultural/casual labour, skilled/semiskilled labour, petty businessman/shop owner, large businessman/shop owner, bus/truck driver/helper, other transport worker, service and others); marital status (currently married, separated, divorced, widowed, never married, no answer); place of soliciting FSWs (pre-coded as bar/nightclub, public place, street, park, railway station, agent, brothel, hotel/lodge, home, dhaba, by telephone, other); number of FSWs they had sex with in the past month; number of sex acts with FSWs in the past month; ever had anal intercourse with a man/transgender (yes/no); self-risk perception (yes/no); alcohol consumption (every day, at least once a week, less than once a week, never, no answer); and having HIV or any STI (those having HIV, syphilis, gonorrhoea or chlamydia were grouped into positive and the rest as negative).

Descriptive statistics were calculated and used to measure the levels of inconsistent condom use (during anal intercourse) and other selected variables. χ2 Tests were used to assess the significance of bivariate relationships between demographic characteristics of clients and their condom use behaviour during anal intercourse. Multiple logistic regression model was used to identify factors that were independently predictive of inconsistent condom use during anal intercourse, with adjusted OR calculated at a significance level of less than 0.05. Statistical calculations were conducted using aggregated data of clients of FSWs from all three states, since the eligibility critieria for respondents and the methods of sampling and behavioural data collection were standardised and the same in all the three states. Analysis was performed by applying appropriate weights. At the district level, weighting was based on the cluster effect of the sample. At the aggregate level, standardised weights were calculated by combining the 12 districts. STATA/SE V.11 (Stata Corporation, College Station, Texas, USA) was used for all the analyses.

In the absence of comparable estimates on anal intercourse from client surveys in India, we examined the estimates available from studies on FSWs13 14 18 28 and the reported prevalence ranged from 11.9% to 22%. It was apparent from these studies that there is a high demand for anal sex from male clients of FSWs (above 40%). When compared with the prevalence reported by FSWs in these studies, the prevalence reported by clients in the current analysis is comparable and an almost similar prevalence was reported by FSWs in round one of IBBA.28 Anal sex is certainly stigmatised among FSWs and they have a reason to under-report this behaviour, however, we do not know if it is similar for men.

Although studies from the early 1990s have highlighted anal intercourse as a risk factor for HIV,9 36 most AIDS prevention messages targeting heterosexuals continue to focus only on vaginal and oral sex transmission. Cultural taboos have possibly played a major role against acknowledging anal sexual practice. Research on vulnerable populations, including FSWs and youth, indicates that those particularly at risk of being infected by or transmitting HIV are more likely to practice anal intercourse.37 Furthermore, people with experience in anal intercourse have been found to take more sexual risk when engaging in vaginal intercourse than those without anal experience.8 Another important aspect is the condom negotiating ability of sex workers with clients. Factors in the physical, economic and policy environment influence condom use. In addition, the gendered power dynamics and the lack of choice sex workers have with heterosexual anal intercourse exacerbates their vulnerability. Sex workers need to be empowered to negotiate condom use with clients and motivate unwilling clients to use condoms during anal/vaginal sex.38

Our study has its limitations. For one, anal intercourse and condom use are both self-reported measures and may, therefore, be influenced by the social desirability bias. As indicated by previous research, the social desirability bias gives rise to the possibility of under-reporting. Given the difficulty in evaluating the magnitude of under-reporting, we must be cautious in concluding that anal intercourse is practiced at relatively low rates among this population. Further, we did not have information on anal intercourse with regular female partners to establish concurrency or multidirectional risk during anal intercourse. Also, the survey did not gather information on violence/coercion during anal sex. Future studies are needed to address these gaps. In addition, qualitative studies are needed to better understand the context in which anal intercourse occurs. In spite of these limitations, this is one of the first studies to document for the clients of FSWs the practice of anal intercourse and the correlates of condom use during anal intercourse.

The study indicates that HIV prevention programmes targeting FSWs and their clients must highlight the increased risk unprotected anal intercourse poses for self as well as partners. Condoms and water-based lubricants need to be marketed to reduce these risks. Interventions also need to address factors that influence condom negotiation ability of sex workers. Given the multidirectional risk, condom promotion programmes must be extended to include specific information on the benefits of consistent condom use while engaging in anal and other types of sex. Safer sex messages addressing heterosexual anal intercourse need to be incorporated into HIV prevention interventions for FSWs and their clients. Current prevention programmes fail to address this issue. Greater emphasis in AIDS/STI prevention must be given to this typically stigmatised and under-reported sexual practice.

The authors wish to thank the Avahan state implementation partners for their partnership in this study. The authors thank Dr Stephen Schensul, Dr Niranjan Saggurti and Dr Bidhu Bhushan Mahapatra for providing critical inputs during concept development and analysis. The authors also extend their gratitude to Dr Steve Mills from FHI 360, Asia Pacific Regional Office, Bangkok, Thailand, for his inputs in the finalisation of this manuscript. Finally, the authors thank the respondents for their participation in the study. An earlier version (abstract) of this research paper was presented at the STI & AIDS World Congress 2013 in Vienna, Austria.

SR and KN contributed to concept development, data analysis and interpretation, and writing and finalisation of the manuscript. LR, PG, DY, SS, BG, HR, TS and RSP contributed to concept design, review and finalisation of the manuscript.

Importance: HIV transmission rates in the United States have increased among men who have sex with men. However, there are no published randomized trials examining interventions to reduce sexual risk for HIV acquisition in males younger than 18 years. Objective: To determine the efficacy of MyPEEPS Mobile, a mobile-delivered HIV prevention intervention, to reduce sexual risk behavior in same-sex attracted young males. Design, Setting, and Participants: This was a national randomized clinical trial of the efficacy MyPEEPS Mobile vs a delayed intervention among males aged 13 to 18 years to prevent or reduce sexual risk for HIV acquisition. Study activities were completed through 4 study sites in Birmingham, Alabama; New York, New York; Seattle, Washington; and Chicago, Illinois. Study staff at each site met with participants in person or via video conferencing. Data were collected from June 1, 2018, to April 7, 2020, and analyzed from July to October 2021. Interventions: The MyPEEPS Mobile intervention contains 21 online psychoeducational and skill-building modules, which participants completed over a 3-month period. Participants randomized to the intervention group received access to MyPEEPS Mobile for the first 3 months, while those randomized to the delayed intervention group received access at their 9-month visit after data for the primary efficacy analysis had been collected. Main Outcomes and Measures: The self-reported primary outcome was change in the number of condomless anal sex acts between study conditions. Secondary outcomes were change in the number of sex partners, number of condomless anal sex partners, the number of sex acts while under the influence of substances, preexposure prophylactic uptake, nonoccupational postexposure prophylaxis use, and HIV and sexually transmitted infection testing. Results: In the analytic sample of 763 racially and ethnically diverse study participants, the mean (SD) age was 16.2 (1.4) years; 736 participants (97%) were male, 13 (2%) nonbinary; and 6 (1%) genderqueer; 158 (21%) were Black or African American, 311 (41%) were Hispanic or Latino, and 284 (37%) were White. Overall, 382 were randomized to the intervention group and 381 to the delayed intervention group. At 3-month follow-up, there was a significant reduction in the number of condomless anal sex acts in the intervention group compared with the delayed intervention group (incidence rate ratio [IRR], 0.56; 95% CI, 0.32-0.99); however, there was no significant difference between groups at 6 or 9 months. In subgroup analyses, the intervention effect was pronounced among Black non-Hispanic participants at 3-month follow-up (IRR, 0.19; 95% CI, 0.04-0.94) and 6-month follow-up (IRR, 0.15; 95% CI, 0.03-0.78) compared with the delayed intervention group. There were no significant differences in the change in the number of sex partners, number of condomless anal sex partners, the number of sex acts while under the influence of substances, preexposure prophylactic uptake, nonoccupational postexposure prophylaxis use, and HIV and sexually transmitted infection testing between the intervention and delayed intervention groups. Conclusions and Relevance: In this study, the MyPEEPS Mobile intervention demonstrated a 44% overall reduction in condomless anal sex at 3-month follow-up compared with the delayed intervention group, but not at 6 or 9 months. To our knowledge, MyPEEPS Mobile is the first intervention to demonstrate evidence of short-term efficacy for reducing sexual risk among same-sex attracted young males. Trial Registration: Identifier: NCT03167606. 041b061a72


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