MSM and HIV/AIDS in Manipur

Nameirakpam Samungou Singh *

HIV/AIDS is one factor for putting Manipur on the global map which is nothing to be proud of. The first HIV positive case in the State was reported in February, 1990 from the blood samples of October, 1989 among a cluster of Injecting Drug Users (IDUs).

According to the Epidemiological analysis of HIV/AIDS (till March, 2008) published by Manipur State AIDS Control Society, there are more than 29,000 HIV positive cases in Manipur.

Officials of the MACS, however, put the figure of HIV-positive cases at more than 40,000, which implies that a large number of cases are unreported. It has also been pointed out that the commonest way of transmission of HIV is using and sharing of infected needles among intravenous drug users.

However, HIV prevalence rate among IDUs did show a declining trend from 1998 onwards with a sero-prevalence rate of 72.78 percent in 1998, 66.02 percent in 2000, 56.27 percent in 2001, 39.6 percent in 2002, 30.7 percent in 2003 and 21 percent in 2004. Though the sero-prevalence among IDUs in Manipur has been brought down to 21 percent in 2004, it is still the highest in the world.

Today, there is a general acceptance of the fact that the HIV epidemic in Manipur is not restricted to IDUs alone. The young widowed HIV positive women, many of whom had never injected drugs, contracted the virus through monogamous heterosexual relationships.

Moreover, society is yet to come in terms with the presence of other vulnerable population groups such as men having sex with men (MSMs) and a diffuse sex trade, the determinants of which are rooted in complex social, political and legal issues.

As per Sentinel Surveillance Report 2006, the rate of HIV prevalence among the IDUs is 19.8 percent while among the MSMs and female sex workers (FSWs) are 11.6 percent and 12.4 percent respectively, which are of great concern.

Who is MSM?

'Men Having Sex with Men' or shortly MSM - is a description of a behavioural phenomenon rather than a specific group of people. It includes not only self identified gay and bisexual men, but also men who engage in male – male sex and self identity as heterosexual, or those sexual identity is but a part of their cultural self identification (UNAIDS).

Thus, MSM refers to behaviour, not an identity and constitute a very large, invisible population of homosexually active men present in all sections of society. In other words, MSM are defined as biological males engaging in sexual activities with other biological males.

MSM and risk behaviours

MSM's higher vulnerability to HIV arises in part from the high rates of partner change which increased risk of infection present during penetrative anal sex, particularly if it occurs without protection. Thus, sex between men carries a high risk of HIV transmission for the receptive partner, and a significant risk for the insertive partner.

Men who have unprotected sex with men may also have unprotected sex with women and thus, serve as an epidemiological bridge for the virus to the broader population. The greater cause of the vulnerability is attached to sex between men that enforces a silence around such sexual behaviour, thereby imposing significant barriers in imparting information on the associated health risks in a safe, objective and scientific manner, and enabling safe sex practices like the use of condoms.

Thus, risk behaviours/factors account for most of the HIV infections in MSM. These factors include unprotected sex and sexually transmitted diseases (STDs). Not using a condom during anal sex with someone other than a main partner of known HIV serostatus continues to be a significant threat to the health of MSM.

STDs, which increase the risk for HIV infection, also remain an important health issue for MSM. In addition to increasing susceptibility to HIV, STDs are markers for high-risk sexual practices, which can transmit HIV.

Further, the use of alcohol and illegal drugs continues to be prevalent among some MSMs and is linked to risk factors for HIV infection and other STDs. Substance use can increase the risk for HIV transmission through the tendency toward risky sexual behaviors while under the influence and through sharing needles or other injection equipment.

MSM and HIV/AIDS in Manipur

Whether officially recognised or not, sex between men occurs in all societies without exception- between men of all ages. In many, it is heavily stigmatized and sometimes officially denied, thus they are largely invisible in many places. This is true in case of Manipur also as in all parts of the world.

At the beginning of the HIV epidemic, in Manipur, IDUs constituted the leading source of HIV transmission from one person to another through heterosexual promiscuity. Even though HIV/AIDS prevalence has seen a decline among the IDUs in the state, new hotspots, particularly among the MSMs have emerged raising concern among the healthcare authorities.

In case of Manipur, the term "gay' or "homo" has become synonymous with the term "Men having sex with men" or MSM. Since homosexuality is natural in every gay and the same is being practiced among them also. Thus, many of these people have accepted themselves with the term MSM.

Unlike other states of India, in Manipur, the existence of feminine are accepted due to the existing role of male artist who play female roles wearing female costumes (nupishabis) of the Shumang Leela group, the centuries-old popular performing art form of Manipur.

These nupishabis are very good-looking. Their co-stars often indulge in homosexual practices while working together. Unprotected sex among these male actors is the main reason for the spread of HIV/AIDS among MSMs in the state.

All the nupishabis in Shumang Lilas are often branded as 'gays'. But these nupishabis are artistes who act out the role of women in plays, perform by all-men theatre groups. Many of them are leading a usual life with wife, children and all.

In recent times, however, these actors who enact plays on HIV/AIDS awareness through their plays are reported to be living with the virus while a few have died of the disease.

A vast majority of MSM remains hidden and has clandestine sexual encounters in public spaces such as parks, shopping centres and toilets.

As such venues used by MSM, however, need to be understood within the local context. A SASO study (March 1999 – February 2001), found that MSM mainly perform their sexual activities at hotels, vendors, rest houses, partner's houses, bazaar gullies, parks, galleries, Lila offices, etc.

The study also reported three types of MSM in Manipur:
(1) Male role, aggressive in sexual behaviour,
(2) Female role, aggressive in sexual behaviour and
(3) passive, not aggressive in sex, not mingling in the group.

The MSMs indulge in anal sex. Many of these MSM are married, compartmentalise their male-male sexual behaviour, and are rarely tested for HIV. Thus, they are highly vulnerable to HIV/AIDS and other STDs. The SASO study also reported that out of 205 MSM clients, 87 are indulged in anal sex, 48 had oral sex and 20 in both.

Like in other societies, many people in Manipur do not come voluntarily for HIV testing, fearing social stigma and discrimination. Due to social pressure, many MSM do not identify themselves as such and so are hidden from MSM-specific intervention programmes. According to Manipur State AIDS Control Society (Annual Report 2006-2007), the estimated number of MSMs in Manipur is 4843.

Despite the vulnerability of MSM to HIV/AIDS, little attention has been focused on this community in Manipur. Stigma and discrimination have marginalized MSM and rendered them invisible, and the result is that the unique prevention and treatment needs of MSM have been largely ignored.

Conclusion

To sum up, ignorance about the extent of men-men sex results in a relative lack of MSM programming which in turn leads to high level of risk behaviors. In the past, HIV/AIDS prevention programmes in Manipur have often concentrated on IDUs based on risk reduction approach by facilitating safe injecting practices through needle syringe exchange programme or drug substitution therapy.

There is also an urgent need of inclusion of MSM in all efforts to address the epidemic, including all partnerships between government and civil society. Information and education and other prevention programmes targeted specifically at men who have sex with men are very important in saving individual lives and curbing the epidemic.

There is also considerable scope for improvement in the health care sector of the state, including better infrastructure, sensitization of medical personnel to HIV/AIDS issues and adoption of universal precautions in all medical settings.