From the early to mid 1990s, India’s burgeoning HIV/AIDS epidemic was labeled “a heterosexual epidemic”, which led to the assumption that transmission through same sex encounters was negligible. Emerging evidence has shown that men who have sex with men (MSM) in India constitute an extremely diverse population, many of whom are living apparently heterosexual lives, but who are actually engaged in risk-taking behavior with either same sex or both same sex and opposite sex partners. This population of men do not consider themselves to be “gay” and the fact that they quietly engage in sex with other males and transgender males is just another aspect of their lives. In addition, they do not perceive that they at risk of HIV through anal sex with other men, as they prevalently believe that HIV is only transmitted through vaginal sex with women. They are inherently reticent to speak about their MSM behavior for considerable fear of being labeled, stigmatized and ostracized, which makes working with gay-unidentified MSM inherently exigent.
Of all MSM groups, the non-gay identified (truckers and cleaners) are one of the least visible groups and the hardest to reach with information, but the effort is worthwhile especially considering this group constitutes the majority of MSM in India
The male labourers are often orphaned/abandoned adolescents that have left their homes, later to be picked up along the highways by truckers to serve as “helpers” by way of apprenticeship. Some truck drivers may genuinely be attracted to members of the same sex (though this does not necessarily mean they are comfortable with sexual identity labels such as ‘gay’ or ‘homosexual’), and others may have sex with other men purely out of convenience or circumstance. Away from their wives, alone on long journeys for months at a time, truck drivers can take advantage of the obvious power dynamic they hold over their younger, less experienced ‘helper.’ Ashok Row Kavi of Humsafar Trust suggests that this phenomenon is history repeating itself as tragedy, as many truck drivers were actually once ‘helpers’ who had ‘survival’ sex with his driver before becoming one himself.
Aside from this, many Indian ‘port cities’, such as Mumbai, accommodate both major truck terminals as well as Red Light Districts (RLDs). This coincidence lends the option of commercial sex to truck drivers who have ample ‘waiting time’ between assignments and a disposable cash income. However, at this juncture it is important to note that at least in Mumbai, a trucker has one of two main options if he decides to exchange cash for sex. He can either travel to Kamathipura, Mumbai’s RLD (considered the 2nd largest in the world), or save the trip across town and choose from the MSWs that operate at Cotton Green, Mulund, Wadala, and other truck terminals.
Male and transgendered – hijra sex workers are more commonly found soliciting clients at MSM hotspots (sex sites and pick-up points), along the highways, or at truckstops. Since truck stops tend to be exclusively male environments after nightfall, the sex work trade at Mumbai truck stops is dominated by a variety of MSW, who are both male and female identified. In the case of this study, it was primarily the latter. Because long distance truck drivers are highly mobile, it becomes difficult to engage them in conventional peer education methods.
The Humsafar Trust work with bisexual truckers and their helpers have revealed that while truckers are hesitant to admit a clear-cut preference for male or transgender sex workers, they openly comment on the convenience and reasonable rates for their sexual services. Based on field experience and qualitative research, young, low-income men such as helpers, who cannot afford to pay much money for sex, appear more likely to frequent MSWs, especially if their main responsibility is to guard the truck, limiting their mobility to within the confines of the truck stop.
In the last nine years, Humsafar Trust with financial and technical support from the Mumbai District AIDS Control Society has made significant inroads as a community based organization by making concerted efforts to de-stigmatize homosexuality and increase safer sexual behavior among MSM through-
• Engaging, Intensive Outreach - HST engages a strongly motivated team of community led outreach worker and peer educators to speak candidly in public about the entire range of sexual behaviors and sexual partners, including anal sex, and the response from the target group has been surprisingly positive. Entertaining and engaging community-level activities promote the importance of condom and lubricant use, as well as the need for voluntary counselling and testing. By treating the choices of MSM as normal, and by using a matter-of-fact, neutral tone, the team has ascertained that the comfort level of the target population increases substantially, as to raising related questions and concerns.
• Condom Social Marketing - The free distribution and social marketing of condoms have played a significant role in making MSM more comfortable about discussing the dangers of HIV, STIs and condom usage. Through community-based education and the distribution of promotional items, coupled with persuasive communication, and attractively packaged condoms, high awareness and acceptability for condoms has been achieved.
• Lubricants – Outreach workers and peer educators actively promote lubricants through a community-based sales network to facilitate a reduced risk of HIV transmission.
• Voluntary Counseling and Testing - The Shaan project team has been successful in motivating clients to visit the inhouse ICTC clinic at Vakola, primarily because counselors are trained and experienced in eliciting genuine sexual history and exploring risk reduction options with MSM and transgender clients and also to 3 major tertiary hospitals in the vicinity.
Challenges Faced in the Field
• Sex is a socially proscribed topic of discussion, so broaching the subject of various tabooed sexual practices can lead to reticence or minimal participation from the target groups.
• There is a paucity of care and support resources and facilities that are sensitive to the needs of MSM.
• MSM populations are particularly hesitant to get tested for HIV because it involves telling their sexual history to a counselor. Outreach workers have to assure them of non-discrimination and often escort them to the clinic to reduce this fear.
• Levels of “acceptable risk” are particularly high in younger MSM, and condom use is erratic, particularly with known partners.
• The belief that HIV is primarily contracted from vaginal sex is fairly prevalent, especially in MSM who fall outside the purview of HIV interventions.
Lessons Learned about Trucker and Helper Clients of MSM
They are less bothered about condoms than the male sex workers
Peers have greatest influence. Sexual experience is highly respected.
The choice of hijras seems to be related primarily to cost and easy access.
Helpers and second drivers may be having more sex with hijras than with women