Around 2.7% of men who have sex with men (MSM) in India are living with HIV, of whom around 65% are aware of their status.

HIV prevalence varies greatly between areas. For example, around 10% of MSM in Andhra Pradesh and 5% in Maharashtra are estimated to be living with HIV.

A 2015 study of men who have sex with men, conducted across 12 Indian cities, found 7% tested HIV positive. Just under a third (30%) of those who reported having anal or oral sex with a man in the past 12 months were married to a woman and engaging in heterosexual sex.The study also found evidence of emerging epidemics among men who have sex with men in urban areas not previously recognised as having high HIV burdens.

In September 2018, India’s Supreme Court decriminalised homosexuality between consenting adults. The decision overturned a ruling made by the Supreme Court in 2013 that reinstated Section 377, a British pre-colonial era law that carried a maximum jail sentence of 10 years, resulting in HIV services being out of reach for many MSM.

Despite changes to the legal environment, men who have sex with men in India remain extremely marginalised and face widespread stigma, homophobia and discrimination, all of which prevent them from accessing HIV services and can make them more vulnerable to acquiring HIV.

HIV prevalence among people who inject drugs (sometimes referred to as PWID) in India is high, with injecting drug use the major route of HIV transmission in India’s north-eastern states. In 2017, 6.3% of people who inject drugs were thought to be living with HIV, of whom 50% were aware of their status.Prevalence varies between areas, standing at 12.1% in Manipur, 10% in Mizoram, and 3.2% in Nagaland.

A 2018 study analysed unsafe injecting and sexual risk behaviours among 20,000 Indian men who inject drugs. Results suggest that beginning drug use at age 25 or above, longer engagement in drug use, injecting three or more times a day, sharing needles and syringes, and having a sexually transmitted infection (STI) were all linked to an increased likelihood of HIV infection.

Age is also a factor in HIV-risk for people who inject drugs. A 2019 study conducted in India’s north-eastern states of around 14,300 people who inject drugs found young people (under 30 years) who use drugs were more likely to share needles, have multiple sexual partners and engage in unprotected sex but were far less likely to get tested for HIV.

HIV prevention efforts in the northeast of the country have been effective in reducing the number of new infections. However, there is evidence that the number of people who inject drugs is growing. In addition, evidence of higher HIV prevalence among sub-populations of people who inject drugs is also emerging. For instance, a 2015 study found prevalence to be more than three times higher among women who inject drugs than men.The reasons for this are numerous, including high levels of sexual violence experienced by women who use drugs.

HIV prevalence among transgender people in India was estimated to be 3.1% in 2017, the second highest prevalence among all key populations in the country. Around 68% of transgender people living with HIV are aware of their status.

In India, being a hijra (known as ‘aravani’, ‘aruvani’ or ‘jagappa’ in some areas) is an identity associated with being a transgender woman, intersex or a eunuch. However, not all transgender women in India belong to a hijra community. The traditional background of hijras is linked to high-risk behaviours, such as alcohol and substance abuse, and low literacy rates.

In April 2014, the Indian Supreme Court recognised transgender people as a distinct gender.Since then, health and welfare programmes to meet this group’s specific needs have been set up. In 2017, NACO reported that around 45% of transgender people and hijras were receiving targeted HIV interventions. In the same year, around 80% of transgender people surveyed reported using a condom.

Despite the change in law, transgender people face pervasive stigma and violence, linked not only to being transgender, but intersected with a range of social inequities. A 2017 study featuring in-depth interviews with around 70 transgender sex workers in Maharashtra found many had experienced stigmatisation, discrimination and violence.

Hotspot/ Pick-up point/Cursing

1. Areas within a site where there is a significant concentration of HRGs are referred to as “hotspots”.

2. Within hotspots, Target Group may solicit, cruise, and interact with other Target Group members, or solicit clients for sex or purchase injecting drugs.

Encounter point

The place/point/spot where actually entertain the clients by doing sexual intercourse/ injecting drugs

1. After building rapport with the Target Group, the HRG is registered by filling out the registration form (Form A).

2. A 19-digit Unique Identification number (UID) is assigned to each HRG and this enables the project to plan and track outreach and clinic services provided to him/her.

3. Registration can happen after 1- 8 contacts in the field.

Coverage

The no. of HRGs were contacted at least once during the project period.

Regular Contact

• A Target Group is receiving education regularly (once every 15 days), over a period of one year or until the Target Group is no longer in that location (total of 24 interactions a year).

• The no. of HRGs contacted on a regular basis at least twice in a month with commodity distribution services i.e. condoms, lubes, syringes and needles etc.

The objectives of the site assessment are to determine the site-specific design of TIs through:

• Validation of broad mapping size and location estimates

• Contact with at least 50% of the broad mapping denominator at least once

• Gaining details on risks/vulnerabilities by typology and location for HRG members

• Initiating interventions

Apart from the quantitative information gained in the assessment, there are qualitative outcomes:

• Establish contact with community – the site validation helps the project to meet at least 50% of the estimated population in a given location on a one-to-one or group basis

• Generate interest and curiosity about the project

• Operationalising Targeted Interventions for FSWs/MSM/TGs: Guidelines for NGOs

• Dispel myths about the intervention before it even begins, and communicate correctly the project’s scope and plans, avoiding false promises

• Identify potential peer educators for future hiring

In order for the community to have faith in the project and see early signs of benefit from it, basic prevention services (as per TI guidelines for FSWs/MSM/TGs) should be in place as early as possible. The basic services that can be established quickly are:

1. Referral systems for treatment of STIs

2. Availability of free condoms (and lubricants) through the project/staff/guides

3. Setting up of a drop-in centre (DIC, also known as a safe space)

“Safe spaces” are critical in the early phase of service delivery, especially for street-based populations.

• Public sites such as streets, parks, etc. do not allow much contact time for outreach workers or peers, so the creation of DICs as safe spaces is important

• At DICs, FSW/MSM/TGs can interact with each other, rest, seek advice, share information, approach someone in case of a crisis, or pick up condoms

• Other popular DIC activities are teaching self-defence, literacy classes and rotational savings schemes trainings

• Counselling and/or STI services can be provided at the DIC through counsellor and/or doctor visits on certain days/times. Referral to satellite services such as de-addiction, crisis response, social welfare schemes and services can also be provided through the DIC.

• The DIC should ideally be located close to the sex work sites or hotspots. The choice of the centre location will be dictated by availability and the preference of the community as to whether the centre should stand out or be relatively anonymous.