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  • Transgendered people are known as hijras or alis in India. They are biologically men who prefer to be considered as women and may also include people with gender & identity dissociation, transsexuals & transvestites They are marginalized, close knit group, dress up as women, may/may not be castrated and traditionally have been known to have the power to bless, curse, beg for alms It is estimated that there are 5000 hijras in Mumbai, 50,000 all over India Penetrative anal sex is an offence punishable by law in India (Section 377 IPC) but NACO recognizes that MSM are at risk for HIV, and funds prevention efforts In India there has been an acceptance of gender divergent roles and transgendered people have a distinct identity and role in society as compared to the west where gender is dichotomous, oppositional and permanent with no room for contradictions .
  • We report on a study from the Humsafar Trust a community based organisation in Mumbai. It was established in October 1995 as a drop in center, library and cafeteria. In 1999 a Voluntary counseling and testing center for Men who have sex with men and transgendered people was established under aegis of MDACS (Mumbai Districts AIDS Control Society) In the year 2000 Humsafar Trust also became a Sentinel surveillance center for HIV testing and counseling in Mumbai The Humsafar Trust performs Outreach to 7500 new MSM and 50,000 clients every year and has extended VCT services to 8000 clients in the past 6 years
  • 205 consecutive consenting transgendered people attending the VCTC at the Humsafar Trust - January 2003 through December 2004 received pretest counseling, Counselor administered behavioral questionnaire The Questionnaire contained questions pertaining to demographics, reason for testing, sexual risk behavior and condom use Blood was drawn for VDRL & HIV tests. Rapid HIV testing was performed according to National AIDS Control Organization guidelines that is a single screening test for negative results and two more rapids tests to confirm a positive diagnosis Clients also received a clinical examination and medications for sexually transmitted diseases
  • Clients were counseled when they received their results Data entered in Epi Info and secondary data analysis in STATA TM 9.1 Descriptive frequencies were computed for demographics, sexual risk behavior, sexually transmitted infections and HIV prevalence and Pearson’s Chi square test or Fischer’s test of independence were performed We report on 183/205 transgendered people who accessed the VCT 5 did not consent for HIV test 17 missing observations were not considered for data analysis
  • Tg’s accessing VCT services young in age, reported sex work as occupation, tested for HIV on account of high risk behavior. Many transgendered people reported sex work as their occupation. This may be on account of lack of access to mainstream employment. Besides rapid urban development in cities like Mumbai may have lead to a waning in demand for traditional role of transgendered people as in dancing during weddings and blessing newborn children Transgendered people preferred receptive anal sex. This may be on account preference for men who take an insertive role (panthis) as partners. In fact having a male penetrative partner forms an important part of the “hijra” identity Transgenders access VCT services due to high risk behavior, yet did not perceive risk for HIV suggests need HIV prevention interventions
  • Counselors reported that Transgender clients accessed VCT services on account of high risk behavior and yet they did not perceive risk for HIV –suggests the need for HIV prevention education interventions that focus on risk for HIV acquisition We did not find injection drug use as a risk factor for HIV among our population (we did not inquire about sharing needles while injecting hormonal preparations which may be common among transgendered people) Tg’s accessing VCT services had high rates of clinically diagnosed STIs, syphilis seropositivity and HIV prevalence Transgendered people did not return to collect their reports. This may be because they have a low risk perception of HIV acquisition. Also their socially marginalized status coupled with minimal health care access and lack of sensitivity of health care providers to transgendered people may result in reluctance to follow up for preventive health care services. Hence
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    • 1. Sexual risk behavior and HIV among Male to female transgendered people accessing VCT services in Mumbai, India. Sameer Kumta*, Mark Lurie*, Alka Gogate¥, Hemangi Jerajani† Sherry Weitzen*, Ashok Row Kavi¶, Vivek Anand¶, Harvey Makadon‡, Kenneth Mayer** *Brown University, Providence, Rhode Island ¥UNAIDS Project, Mumbai, India †Department of Dermatology, LTM Medical College and Hospital, Mumbai, India @Department of Obstetrics and Gynecology and Community Health, Brown Medical School, Rhode Island ¶The Humsafar Trust, Mumbai, India ‡Harvard Medical School, Boston, MA **The Miriam Hospital, Brown University, Providence, RI.
    • 2. Transgenders - “Hijras or Alis” • Biological men who prefer to be considered as women • Marginalized, close knit group, dress up as women, may/may not be castrated • Estimated number - 5000 in Mumbai, 50,000 all over India • NACO recognizes that MSM are at risk for HIV, and funds prevention efforts • In India there has been traditional recognition of gender divergent roles, but social stigma as well
    • 3. The Humsafar Trust – Mumbai, India • Community based organization • October 1995 - Drop in center, library and cafeteria • 1999 – VCTC was established under aegis of MDACS (Mumbai Districts AIDS Control Society) • 2000 – Sentinel surveillance center for HIV testing and counseling in Mumbai • Outreach to 7500 new MSM and 50,000 clients every year • Extended VCT services to 8000 clients in the past 6 years
    • 4. Study Methods • 205 consenting transgendered people attending the VCTC at the Humsafar Trust - January 2003 through December 2004 • Pre test counseling, Counselor administered behavioral questionnaire • Questionnaire – demographics, reason for testing, sexual risk behavior and condom use • Blood drawn – VDRL & HIV rapid tests (NACO guidelines) • Clinical exam and medications for STIs
    • 5. Study Methods • Post test counseling on receiving results • Data entered in Epi Info and secondary data analysis in STATATM 9.1 • Pearson’s Chi square test or Fischer’s test of independence were performed • We report on 183 transgendered people who accessed the VCT
    • 6. DEMOGRAPHICS (N=183) • 61.7% were between 18 – 24 years of age • 81.4% were not castrated • 67.2% reported sex work as their occupation • 74.8% were reported by counselors as accessing VCT services on account of high risk sexual behavior • Almost all 182 (99.5) preferred males as partners
    • 7. SEXUAL RISK (N=183) • 84.7% reported preferred to engage in anal receptive sex • Perceived risk of HIV – 54.6% said no risk – 30.6% said did not know if they were at risk for HIV • 76.5% reported 5 or more sexual partners in the past 6 months • 51.9% reported 10 or more partners in the past 1 month • 39.4% never used condoms with regular partner during Anal sex in their lifetime
    • 8. HIV AND STI PREVALENCE (N=183) Clinical Diagnosis STIs % 27.9 VDRL test for Syphilis (> 1 : 8) Reactive 13.1 HIV seroprevalence Positive 39.9 Results obtained Yes 45.4
    • 9. Sex work (* p<0.05, ** p < 0.001) Predictors Sex work n=123,(%) Other occupations n=60,(%) Non castrated Tg Castrated Tg 107 (86.9) 16 (13.0) 42 (70.0) 18 (30.0)* Age groups: 18 – 19 yrs 20 – 24 yrs 25 – 29 yrs > 30 years 24 (19.5) 65 (52.9) 22 (17.9) 12 (9.8) 6 (10.0) 18 (30.0) 18 (30.0) 18 (30.0)** Partners in 1 mth: <5 > =5 24 (19.5) 99 (80.5) 53 (88.3) 7 (11.7)**
    • 10. Tgs and other MSM (* p<0.05, ** p < 0.001) Predictors Tg; N=183,(%) Columns MSM; N=831,(%) Columns Employment: Unemployed/unskilled Skilled/ Professional Sex work 56 (30.6) 2 (1.1) 123 (67.2) 293 (35.2) 489 (58.8) 27 (3.3)** Marital Status: Partnered Not partnered 27 (14.8) 156 (85.2) 189 (22.7) 642 (77.3)* Preference of partner: Male Transgender Female Male and Female 180 (98.4) 2 (1.0) 1 (0.6) 0 445 (53.6) 26 (3.1) 161 (19.4) 199 (23.9)**
    • 11. Discussion • Tg’s accessing VCT services young in age, reported sex work as occupation, tested for HIV on account of high risk behavior. • Sex work as occupation – lack access to mainstream employment – waning of demand for traditional role of transgenders • Preference of receptive anal sex – Preference for men who take an insertive role (panthis) – Having a male penetrative partner forms an important part of the “hijra” identity • Access VCT services due to high risk behavior, yet did not perceive risk for HIV – need HIV prevention interventions
    • 12. Discussion • Did not report injection drug use as a risk factor • High rates of clinically diagnosed STIs, syphilis seropositivity and HIV prevalence; rates did not differ among those who reported sex work as occupation and those who did not – high risk is generalized in this population • High rates of clinically diagnosed STIs, reactive syphilis serology as compared to other MSM – need for culturally sensitive interventions among transgendered people • Tg did not return for results – Low risk perception of HIV acquisition – Socially marginalized status (minimal health care access)
    • 13. Limitations • Convenience sample – cannot be generalized • Cross sectional – no causal inference • Some underreport of risk behavior and over report of condom use albeit minimal • Recall bias – number of partners in past 6 months • No confirmatory tests for syphilis – no reports of yaw, pinta from Mumbai
    • 14. Acknowledgements • Miriam Hospital/Brown University Grant 5D43TW000237 –13 • Mumbai Districts AIDS Control Society/NACO • FHI – Impact • Murugesan Subramaniam for meticulous data entry • Outreach, counseling, laboratory and clinical staff at the Humsafar Trust
    • 15. THANK YOU

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