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National AIDS Control Programme in India

SCALING UP HIV-related INTERVENTIONS for

MEN WHO HAVE SEX WITH MEN, Transgendered people andHijras

Recommendations from Regional and National Consultations, organized by NACO, supported by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Resource Centre for Sexual Health and HIV/AIDS (RCSHA)

(June 21st – July 5th 2006)

From lessons learned and achievements made, India is now developing its third National AIDS Control Programme Implementation Plan (NACP-III 2006-2011). The overall goal of NACP-III is to halt and reverse the epidemic over the next 5 years. The strategies and activities to achieve this will be informed by a set of guiding principles that include the ‘Three Ones’ principles of HIV programme planning, coordination and monitoring; equity; legal, ethical and human rights, full engagement of civil society - including people living with HIV, etc. The Programme priorities and thrust areas include integration of prevention with treatment, care and support, while those at the highest risk of HIV infection: injecting drug users, sex workers, and men who have sex with men (MSM) will receive priority attention. Gender and age-specific strategies will be followed to address specific needs of women, youth and adolescents, migrants and mobile populations.

National, State and District HIV Plans will be evidence based and subjected to a sound monitoring and evaluation mechanism. Service delivery will be improved and scaled up. Capacities and core competencies will be strengthened at all levels. Mainstreaming and partnerships will be a key approach to facilitate a true multi-sectoral response, engaging the widest range of stakeholders.

These recommendations that were collated from five regional consultations in Chennai, Mumbai, Kolkata, Guwahati and Delhi and one national consolidation meeting, are herewith presented for your comments.

Background

Despite evidence establishing male-to-male sex as one of the driving forces of HIV transmission in Asia and The Pacific, only a few strategic interventions address male-to-male sexuality and related HIV vulnerabilities in the two regions. In recognition of the need for building and strengthening interventions addressing ‘MSM and HIV’ in Asia and The Pacific, a ‘Male Sexual Health and HIV in Asia and The Pacific International Consultation’: “Risks and Responsibilities”will be held in New Delhi from 23rd to 26th September 2006.

This international Consultation will bring together national and local governments, policy-makers, donors, researchers, non-governmental organizations, community-based and grassroots organizations across Asia and The Pacific on a platform for dialogue, learning, networking and skills building for enabling expansion, strengthening and scaling up of strategies and programmes addressing male sexual health and HIV. In addition, the Consultation will provide an opportunity to inform and develop strategic advocacy initiatives and deliberate on key policies and required actions.

This preparatory process has provided India a unique opportunity, especially in light of the special focus on programming for men who have sex with men and HIV as an integral part of the third phase of the National AIDS Control Programme (NACP-III). Five regional stakeholders meetings and one national consolidation meeting were convened in India, in the period 21st June to 5th July 2006, bringing together a ‘tripartite’ of government, communityand donor and technical partners.

Experts, representing government, community and donors and technical partners were invited to generate and share knowledge on technical, social, policy, rights and resources issues relevant to male-to-male sexual behaviours and HIV in India and agree on strategies and direction.

Objectives

These 1-day regional consultations in the South, the West, the East, the Northeast and the North of India and the national consolidation meeting attempted to

1. Answer the questions: “What do we know?” and “What do we need to know about ‘MSM and HIV’ in India?”

2. Identify obstacles and challenges that impede planning and implementation of ‘MSM and HIV-’ specific programmes and services in India

3. Inform the formulation of strategies and programmes for improving and scaling-up ‘MSM and HIV’-specific prevention, treatment, care and support interventions and services

4. Respond to a preformatted Questionnaire to prepare the India Country Report on ‘MSM and HIV’ to be presented and discussed at the ‘Risks and Responsibilities’ International Consultation in September

The larger goal of these consultations was to catalyze and enhance coordinated responses throughout India, as part of the National and State AIDS Control Programmes, by increased commitment and action among stakeholders, in tandem with the real needs of men who have sex with men, transgendered people and Hijras. This would lead to intensified HIV and sexual health interventions for these persons that is evidence-based, with appropriate and supportive policies and adequate funding.

Recommendations

To halt and reverse the epidemic, which is the overarching objective of NACP-III, among MSM, transgendered people and Hijras, there must be comprehensive programme strategies and action instead of fragmented projects with insular outlooks and limited impact. This is a truism with even more truth in India, a vast countrywith a federal decentralized administration. The National AIDS Control Programme (NACO) at the national level and the State AIDS Control Societies (SACS) at the decentralized level must lead a process to move from project to programme operations. In this paradigm, where partnerships are instrumental, aligning of responsibilities and actions of government, community and donors’ efforts is instrumental.

If India wishes to be successful in addressing ‘MSM and HIV,’ it is necessary to institutionalize a ‘tripartite’ of Government, Community (CBO, NGO) and Donors (including International NGOs), with Academics and Technical Institutions.

Such State HIV partnership platforms will prevent fragmented responses and will support the generation and sharing of strategic information; planning; programming; resource mobilization and leveraging of resources; development of core competencies and learning; implementation progress tracking and monitoring of the epidemic. In addition, these partnerships will foster mutual public accountability and responsibility.

It must be noted here, that people with ‘different’ sexual, gender and cultural identities and lifestyles are often, out of misunderstanding (and convenience), lumped together under the identifier “MSM.” It must be clarified that ‘men having sex with men’ signifies sexual behaviour and is not an identifier. It is strongly suggested to discontinue this practiceand address the two issues of sexual behaviour and sexual identity separately. Theseconsultations also highlighted the importance of having special services and programmescatering to identity diversity.

In addition, the culturally distinguishable Hijras have made a strong appeal during the regional consultations and the national consultation to be treated and respected as a unique community. Thus, separate targeted interventions for Hijras are in order instead of being clubbed with interventions for and with MSM. Even under the broad ‘MSM umbrella’ there is diversity that needs to be taken into account. Customization must be introduced in communication and services for different categories such as male-to-female transgendered people and feminized males (Kothis), their sexual partners (Panthis/Giryas), bisexual men, behaviourally bisexual men, male and transgendered sex workers, and men who have sex with men without any specific gender or sexual identity.

The general and overarching recommendations given here above, and especially in detail below, provide more detail for action in the third phase of the National AIDS Control Programme (NACP-III) for better working towards universal access to HIV prevention, care, support and treatment for MSM and Hijras through enhanced community mobilization and engagement; with a central role for CBOs in the Programme.

These recommendations are meant not just for NACO and the SACS, as central and decentralized government with the ultimate responsibility for the health, well-being and development of the people of the nation and the State, but for all other key stakeholders such as NGOs, CBOs, Donors[1], INGOs, Researchers and Technical Institutions.

No. /

Imperatives

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Division of Labour
I / Research for strategic information and evidence building: Institutionalize participatory generation and sharing of strategic information on MSM and Hijras (population size and risk behaviours mapping, networking sites and resources mapping, needs assessments, operations research, STI/HIV prevalence, vaccine and microbicide[2] trials) – on the basis of specific terms of reference (as mentioned under VI, here below) / 1. NACO to engage Technical Institutions for imparting essential training to SACS officials (Project Directors, M&E Officers, NGO Advisors) on population and behaviour mapping, and operational research among MSM and Hijras
2. NACO and SACS to engage Technical Institutions for imparting essential training to representatives recruited from MSM / Hijra CBOs, and to fund them, for conducting participatory community led population and behaviour mapping, and operational research
3. NACO to engage Technical Institutions to train government officials on how to interpret and utilize strategic information for programme planning and undertake mid-course corrections in their programmes, when needed
4. NACO and SACS to engage Technical Institutions to train INGOs, NGOs, CBOs on how to interpret and utilize strategic information for programme planning and undertake mid-course adjustments in their programmes, when needed
5. NACO and the SACS to establish and maintain central strategic information databases, [electronically] accessible to all key stakeholders
6. NACO and SACS to institutionalize confidentiality protocols to prevent misuse of personal data
7. NACO and SACS to allocate separate funds for Hijra interventions (lead by their CBOs
8. NACO and SACS to allocate separate funds and offer technical assistance to MSM and Hijra networks to develop their own CBOs
9. Donors to fund operational research
II / Mainstream ‘unprotected anal sex’ as a public health risk: As a key public health measure, advocate for and put emphasis on unprotected anal sex as a mode of HIV transmission in all relevant health programmes; not just those for MSM or Hijras but also for other populations
Caution: It should be ensured that the practice of anal sex does not get equated with MSM or Hijras, which mightfurther stigmatize these persons. / 1. All agencies (government and non-government) working in the areas of STI and HIV, including media and academia, to include information on unprotected anal transmission of HIV in all HIV messaging, communication and training curricula for medical professionals and other health workers
2. NACO along with SACS to facilitate compulsory inclusion of issues related to diversity in gender and sexual identity and sexual behaviours in their training programmes for SACS officials, counselors, outreach workers, peer educators, medical and legal services professionals and others
3. NACO and SACS (Ministry of Health and Family Welfare) to liaise with the Ministry of Human Resources Development, the Medical Council of India, etc for inclusion of counseling, testing and treatment for anal STI in all relevant medical training curricula
4. NACO to build links with other departments in the Ministry of Health and Family Welfare to facilitate inclusion of education on STI/HIV risks through anal sex, in all reproductive and sexual health programmes (as it is reported that anal sex is perceived by many as ‘non-sex’ and is used by a substantial number of people as a means of contraception)[3]
III / Condoms and lubricants: Reinforce condom use along with use of adequate and appropriate lubricants for anal sex. Lubricant use must also be addressed and talked about in the context of vaginal sex / 1. NGOs,CBOs and INGOs to compulsorily address in all their communication (including sex education programmes) the necessity of condom use in all forms of penetrative sex, and where needed with use of appropriate lubricants
2. SACS to allocate funds for condoms and lubricants in all targeted interventions (not just those for MSM / Hijra interventions) and in all STI/HIV education programmes (including sex education programmes for youth)
3. SACS along with NGOs and CBOs to facilitate increased access to good quality condoms and lubricants by MSM / Hijras and others engaging in unprotected sex
4. NACO to facilitate compulsory inclusion of information regarding condom and lubricant use in all sex education programmes
IV / Societal change, acceptance and legal reforms: In the context of MSM and Hijras, and the larger issue of sexual rights in general / 1. NACO to require urgent revision of laws (Section 377, 292 IPC) that impede HIV prevention work with MSM / Hijras and others engaging in anal sex
2. NACO to mobilize other government ministries – Ministry of Social Justice & Empowerment, Home Ministry, Law Ministry – to generate support for revision of laws that impede HIV prevention work with MSM/ Hijras and others engaging in anal sex
3. NACO,SACS and Donors – in collaboration with Researchers - to facilitate building of core competencies on human sexuality and STI/HIVprevention, care, support and treatment among all stakeholders (based on division of labour and ToRs – as mentioned under VI here below), including counselors, medical professionals, judges, lawyers, uniformed services, educationists, government staff (Project Directors, M&E officers, NGO advisors), media persons, PLHIV, INGOs, NGOs and CBOs
3. NACO, SACS and Donors to allocate resources for addressing “evidence-based needs” of MSM / Hijras identified through needs assessment studies and operational research. Catering to these needs is known to improve the impact of Targeted Interventions
Some of these needs include: Psycho-social health; hygiene; awareness about substance use and unsafe injecting practices; legal needs; protection from abuse – both within and outside the context of sex work; livelihood needs of male / transgendered sex workers and MSM / Hijras; and care, support, treatment needs of MSM / Hijras living with HIV
Some Hijra-specific needs: SRS[4] facilities; addressing issues of interplay between ART and hormone therapy (used for sex change)and involving Hijra Guru Ma’s
In Hijra interventions as key gatekeepers / stakeholders
V / Institutionalization of [central and “Tripartite Partnerships” of Government (all concerned ministries and departments), Donors / INGOs, NGOs / CBOs at state / district levels to set up a comprehensive HIV programme for MSM / Hijras
Note: Thispartnership could be proposed as a State HIV Authority in which a quota of all ‘tripartite’ stakeholders will participate. Its efficacy will depend on both commitment and enforcement / 1. NACO and the SACS to fine-tune policies on institutional arrangements and accountability at a decentralized level and establish partnerships for planning, funding and implementation of all MSM / Hijra related HIV programmes in the states and districts
2. SACS, Donors, NGOs, CBOs to work towards making the partnership legally binding through appropriate MoUs, which should include proper mechanisms for redress[5]
3. NACO, SACS and Donors to immediately develop protocols and mechanisms to synchronies their funding processes to avoid unhealthy rivalries among programme implementers and both wasteful duplication and gaps
4. NACO, SACS, Donors, NGOs and CBOs to jointly engage in realistic albeit ambitious target setting for scaling up HIV prevention, treatment, care and support services and initiatives for MSM, transgendered people and Hijras
VI / Institutionalize good governance principles
Note: Protocols and Terms of Referenceare needed for evidence- and need-based resource allocation, selection of programme implementers, design of research projects, transparent grant processes, reporting and evaluation / 1. NACO, SACS and Donors to develop protocols and terms of reference for good governance to avoid corruption and ensure accountability at all levels – central, state, district, block – among all stakeholders (government, non-government and donors)
VII / Establish a process of inclusiveness by providing community representation and membership in decision making bodies / 1. NACO, SACS and Donors to include community (MSM / transgender / Hijra) members in HIV coordination bodies and other relevant decision making platforms; at national and state levels.
VIII / Facilitate community provision of technical assistance and support to attain greater relevance of HIV programming
Note: ‘Technical’ must not be interpreted as health care provision only. This must be seen in its broader definitionto include mapping, enumeration, programme development, community based monitoring, etc. / 1. NACO, SACS and Donors to invest in community groups and organizations that have competencies to provide and promote technical assistance and support.

NACO, the UNAIDS Secretariat and RCSHA wish to acknowledge the excellent participation of State AIDS Control Societies, (I)NGOs, CBOs, community organizations and community groups for making these ‘tripartite’ consultations a success and developing the recommendations here above. Special thanks are also due to SAATHII (Solidarity and Action Against The HIV Infection in India) for its logistical, technical and documenting assistance throughout the process.