International Journal of Drug Policy 26 (2015) 404–411

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research paper

Male-to-male sex among men who inject drugs in Delhi, India: Overlapping HIV risk behaviours Gregory Armstrong a,∗ , Anthony F. Jorm b , Luke Samson c , Lynette Joubert d , Shalini Singh c , Michelle Kermode a a

Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia Population Mental Health Group, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia c The Society for Service to Urban Poverty (SHARAN), Delhi, India d Department of Social Work, School of Health Sciences, University of Melbourne, Victoria, Australia b

a r t i c l e

i n f o

Article history: Received 22 May 2014 Received in revised form 12 August 2014 Accepted 17 August 2014 Keywords: India Injecting drug use Men who have sex with men Overlapping HIV risks Psychosocial context Suicide

a b s t r a c t Background: HIV among people who inject drugs (PWID) is a major public health challenge in India. This paper examines PWID in Delhi who also have male-to-male sex with a focus on overlapping HIV risk behaviours and the psychosocial correlates of a history of male-to-male anal sex. Methods: We analysed data collected in April–May of 2012 from a community-based sample of 420 male PWID in Delhi obtained using time location sampling. Results: One third (37%) of the men reported a history of anal sex with men, among whom just 16% used a condom at last anal sex. Almost all (93%) participants who had a history of anal sex with men also had sex with women. Chi-square tests revealed that a history of anal sex with men was associated with a higher number of female sexual partners and sharing of needles and syringes. Additionally, unprotected sex at last sex with a male partner was significantly associated with unprotected sex at last sex with regular and paid female partners. Multivariate binary logistic regression revealed that the psychosocial correlates of a history of anal sex with other men were: being aged 18–24 (OR = 2.4, p = 0.014), illiteracy (OR = 1.9, p = 0.033), having never been married (OR = 2.6, p = 0.007), a main source of income of crime/begging (OR = 3.1, p = 0.019), a duration of injecting drug use greater than 20 years (OR = 3.4, p = 0.035) and suicidal ideation (OR = 1.7, p = 0.048). Conclusion: Male-to-male sex was associated with psychosocial vulnerability, including a longer history of injecting drug use, suicidal ideation and socio-economic disadvantage. Given the extent of overlapping HIV risk behaviours, HIV programs for PWID would benefit from a strong focus on prevention of sexual HIV transmission, especially among male injectors who also have sex with other men. © 2014 Elsevier B.V. All rights reserved.

Background HIV is a major public health challenge in India with concentrated epidemics among high-risk groups (Moses et al., 2006; UNAIDS, 2013). People who inject drugs (PWID) and men who have sex with men (MSM) represent two groups targeted by HIV prevention interventions. The National AIDS Control Organisation (NACO) estimates that HIV prevalence among PWID and MSM is 7.1% and 4.4% respectively (National AIDS Control Organisation, 2012b). The sharing of injecting equipment and risky sexual practices are relatively

∗ Corresponding author at: Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Carlton, VIC 3010, Australia. Tel.: +61 3 8344 2628. E-mail address: [email protected] (G. Armstrong). http://dx.doi.org/10.1016/j.drugpo.2014.08.007 0955-3959/© 2014 Elsevier B.V. All rights reserved.

common among PWID in India (Armstrong, Humtsoe, & Kermode, 2011; Indian Council of Medical Research 360, 2011; Sarna et al., 2012; Solomon, Mehta, Latimore, Srikrishnan, & Celentano, 2010; Solomon, Srikrishnan et al., 2010), and a high prevalence of unprotected anal sex has been documented among MSM groups, in addition to a high level of overlapping homosexual–heterosexual risk behaviours (Brahmam et al., 2008; Dandona et al., 2005; Hernandez et al., 2006; Schneider et al., 2007; Solomon, Mehta et al., 2010; Solomon, Srikrishnan et al., 2010; Verma & Collumbien, 2004). In India, homosexual behaviour is not always linked to a samesex attracted sexual identity (i.e. a Western gay identity) and can occur in diverse contexts (Asthana & Oostvogels, 2001). Khan (2001) talks of the fluidity of male sexual experiences in South Asia and the strong homosocial/homoaffectionalist culture that sees body contact and displays of physical affection between men as

G. Armstrong et al. / International Journal of Drug Policy 26 (2015) 404–411

socially acceptable. Some heterosexual men do not consider maleto-male sex (including anal sex) as “sex” but rather “masti” or play, and may move fluidly between heterosexual and homosexual encounters (Khan, 2001; Patel, Mayer, & Makadon, 2012; Thomas et al., 2009). However, as in many low and middle-income countries, the health issues for MSM in India are under-studied and overlooked in part due to stigma and the criminalisation of homosexual intercourse (legislation enacted under British rule) up until 2009 (Baral, Sifakis, Cleghorn, & Beyrer, 2007; Chakrapani, Newman, Shunmugam, McLuckie, & Melwin, 2007; Setia et al., 2008). Research elsewhere has identified sizeable sub-populations for whom injecting drug use overlaps with male-to-male sex (Chan & Khan, 2007; Ferreira, Caiaffa, Bastos, Mingoti, & Projeto, 2006; Haque et al., 2004; Johnston et al., 2010; Kral et al., 2005; Parviz et al., 2006; Strathdee & Sherman, 2003; Todd et al., 2010; Zamani et al., 2010). Men who both inject drugs and have sex with men are particularly vulnerable to HIV infection and have the potential to transmit the virus across multiple populations. A 10-year prospective study among PWID in Baltimore (U.S.A.) found that male-to-male sex doubled the likelihood of seroconversion among male PWID (Strathdee et al., 2001), and a case-control study in San Francisco found that male injectors were nine times more likely to seroconvert if they had male-to-male sex (Kral et al., 2001). The population of PWID in Delhi is estimated to be between 11,000 and 35,000 depending on the data source and size estimation methodology (Indian Council of Medical Research & National AIDS Control Organisation, 2010) (Aceijas et al., 2006). They are from various walks of life, but most are substantially alienated and impoverished and many are part of the rural-urban migration phenomenon that fuels the city’s rapid population growth (Armstrong, Nuken et al., 2013; Priya, Singh, Dorabjee, Varma, & Samson, 2005). The HIV prevalence among PWID in Delhi is estimated to have risen from 10.0% in 2006 to 18.3% in 2010–2011 and HIV prevalence among PWID in the neighbouring state of Punjab has increased rapidly from 13.8% in 2006 to 21.1% in 2010–2011 (National AIDS Control Organisation, 2006, 2012b), making PWID in this region an important target group for public health interventions. A prior study of male PWID in Delhi undertaken in 2006 found that 18% had a history of male-to-male sex (Sarna et al., 2012) and previous research undertaken in 2005–2006 among male PWID in Chennai found that 5% had male-to-male sex in the preceding one month (Solomon, Desai et al., 2010). However, to the best of our knowledge no previous research has examined PWID in India with a history of male-to-male anal sex to assess the extent of overlapping injecting and hetero-homosexual HIV risk behaviours and the psychosocial context surrounding this behaviour. This represents an important gap in the literature that this paper seeks to address given the potential for this high-risk sub-group to act as a significant transmission vector. This paper reports on sex between men as reported in a crosssectional survey of male PWID in Delhi. We undertook the analyses presented in this paper to better understand the context of male-tomale sexual behaviour and the extent of overlapping injecting and sexual risk behaviours by PWID in Delhi. The objectives were: (1) to examine the overlap between sexual and injecting risk behaviours among PWID who engage in male-to-male anal sex, and (2) to identify the psychosocial correlates of a history of male-to-male anal sex.

Methods Study design and ethics In April and May of 2012 a cross-sectional survey of PWID in Delhi was undertaken using a structured questionnaire that

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was interviewer-administered. Ethics approval was provided in Australia by the Human Research Ethics Committee at the University of Melbourne (HREC 1137025). Local ethics approval was provided in India by the Institutional Review Board (IRB) at Sharan, The Society for Service to Urban Poverty. Sharan is an NGO that provides services to PWID in Delhi. Participants were provided with a small meal (e.g. chai and samosa) while participating in the study. Sampling Eligible participants were men aged 18 years or older, who had injected drugs at least once in the past month, were not currently enrolled in opioid substitution therapy (OST) and had given informed oral consent to participate in the study. Participants were sampled from needle and syringe programmes (NSPs) in Delhi. There are nineteen NSPs of varying size operating in Delhi and it is estimated that approximately 80% of the PWID population usually obtain their needles from NSP targeted interventions (Delhi State Aids Control Organization, 2013; National AIDS Control Organisation, 2012a). We sampled from three NSPs coordinated by our NGO study partner (Sharan), each in a distinctly different geographical location so that a diverse range of PWID from across Delhi were recruited; Yamuna Bazar, Nabi Karim, and Jahangirpuri. Yamuna Bazar is located on the bank of the Yamuna River in central Delhi and is the base for a large proportion of the capital’s homeless and PWID. Jahangirpuri is a slum resettlement colony on the outskirts of metropolitan Delhi. The NSP at Nabi Karim is located in an urban ghetto in the Muslim quarter adjacent to New Delhi Railway Station. We used time location sampling (TLS), a recognized method for obtaining a probability-based sample from hidden populations (Karon & Wejnert, 2012; Magnani, Sabin, Saidel, & Heckathorn, 2005), and our methodological approach has been detailed in previous papers (Armstrong, Nuken et al., 2013; Armstrong, Jorm et al., 2013; Armstrong et al., 2014). In brief, the operating hours of three NSPs were mapped and a list was constructed based on a combination of the locations (i.e. NSPs) and blocks of time during which the NSPs would be operating. Combinations of location and time (i.e. primary sampling units) were then randomly selected from the list to populate a sampling calendar; combinations of location and time were known as sampling events. During sampling events the data collection team approached potential participants immediately after they had obtained new injecting equipment from the NSP. As many interviews as possible were conducted during each sampling event. Sampling continued according to the sampling calendar until the desired sample size was achieved. One member of the data collection team was given the enumerator role and used a “counter” to record the number of people using the NSP during the sampling event and the number of people actually interviewed to enable the construction of selection probability weights. Measures The 30 min-long questionnaire was translated into Hindi, back translated into English, and piloted. Demographics, injecting and sexual practices Questions regarding demographics, drug use and sexual behaviours (predominantly condom use with various partners) were adapted from a previous study (Sarin & Kerrigan, 2012) among PWIDs in Delhi and from the Integrated Biological and Behavioural Assessment (IBBA) survey previously undertaken among PWIDs in three states of India (Indian Council of Medical Research & FHI 360, 2011). Recent sexual risk behaviour with female partners was gathered by first asking participants about the number and type of sex

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partners they had during the preceding six months and then asking whether or not they used a condom at last sex with these partners. With respect to male-to-male sex, information was gathered on whether participants had a lifetime history of anal sex with other men and whether or not they used a condom at last anal sex with a man.

Symptoms of depression, anxiety and suicidal ideation Symptoms of depression were measured using the Patient Health Questionnaire (PHQ-9) (Kroenke, Spitzer, & Williams, 2001; Kroenke, Spitzer, & Williams, 2002) which asks participants whether they have been bothered with nine symptoms in the preceding two weeks, with response options on a four-category Likert scale: not at all (0), several days (1), more than half the days (2), nearly every day (3). The PHQ-9 is relatively short to administer with scores ranging from 0 to 27. Scores of 5, 10, 15 and 20 represent thresholds marking the lower limits of mild, moderate, moderately severe and severe depression. Symptoms of anxiety in the preceding two weeks were measured using the Generalised Anxiety Disorder (GAD-2) scale, a two-item ultra-brief screening tool that follows the same format and response options as the PHQ-9 (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007). Scores on the GAD-2 range from 0 to 6 with a score of ≥3 representing the optimum cut-point with screening for anxiety. Both the PHQ-9 and the GAD-2 have previously been translated into Hindi. Suicidal ideation was captured by a question adapted from the Suicide Behaviours Questionnaire (SBQ) (Osman et al., 2001). Participants were asked whether they had thought about killing themselves in the past 12 months. All participants were provided with details for a local suicide help line and a local psychiatrist was available for consultation should the need arise.

Statistical analysis All analyses were conducted in Stata version 10 using survey commands to account for unequal probability of selection and to adjust the standard errors to account for clustering by sampling event. Sampling events at different times but at the same location were treated as separate clusters. The number of attendees at a sampling location during each sampling event (i.e. enumeration count) was used to construct selection probability weights. More weight was given to participants recruited at highly attended sampling events. Cross-tabulations were conducted using the chisquare test to assess the overlap between male-to-male sexual behaviour and risky injecting practices and sexual behaviours with female partners. We used multivariate binary regression analysis to examine the broader psychosocial correlates of a history of anal sex with other men. Psychosocial correlates examined included socio-demographics (i.e. age, marital status, place of birth, literacy, housing status, main source of income, average daily income, history of imprisonment), experiences of violence (i.e. beaten up in the last six months, ever forced or coerced into sex), substance use (i.e. alcohol use, frequency of injecting, length of injecting career) and mental health (i.e. suicidal ideation, anxiety symptoms, depressive symptoms). The enter method was used and variables with unadjusted odds ratios yielding p-values of 0.1 or less were considered eligible for the multivariate model; additionally, age was included in the final model given that it is an important socio-demographic variable to control for. Unadjusted and adjusted odds ratios with their respective 95% confidence intervals and pvalues are reported in the tables. Goodness of fit was assessed using the survey-adjusted Hosmer–Lemeshow test and collinearity between predictors was assessed using the variance inflation factor (VIF).

Table 1 Socio-demographic characteristics (n = 420). Characteristics

% (95% C.I.)

Age (years): mean = 36.7 years 18–24 25–44 45+

11 (7–16) 63 (56–70) 26 (20–31)

Place of birth New Delhi Uttar Pradesh Other

38 (27–50) 28 (22–34) 34 (25–42)

Marital status Never married Currently married Divorced/separated/widowed

53 (46–60) 25 (18–31) 22 (17–27)

Literate No Yes

62 (57–68) 38 (32–43)

Place slept most of the time in past 3 months Own house or flat Homeless/temporary housing House/flat of relative or friend Rented room

6 (2–10) 72 (60–84) 16 (9–23) 6 (3–5)

Average daily income (rupees): mean = 193.5 rupees 192 rupees or less 193 rupees or more

49 (43–55) 51 (45–57)

Main source of income Skilled manual work Unskilled manual work/trading or vending Scavenging (e.g. rag picking) Crime/begging No source of income Other

11 (6–16) 21 (13–28) 48 (38–58) 7 (4–11) 11 (7–15) 2 (0–4)

Ever been forced or coerced into sex No Yes

84 (80–88) 16 (12–20)

Beaten up in past six months No Yes

51 (45–57) 49 (43–56)

Frequency of alcohol use Less than weekly More than weekly

74 (68–80) 26 (20–32)

Ever been in prison No Yes

30 (27–34) 70 (67–73)

Depression symptom severity–past two weeksa None or mild (PHQ-9: 0–9) Moderate (PHQ-9: 10–14) Moderately severe (PHQ-9: 15–19) Severe (PHQ-9: 20–27)

16 (11–20) 30 (24–36) 37 (31–43) 17 (11–24)

Anxiety symptoms–past two weeksb No (GAD-2:

Male-to-male sex among men who inject drugs in Delhi, India: overlapping HIV risk behaviours.

HIV among people who inject drugs (PWID) is a major public health challenge in India. This paper examines PWID in Delhi who also have male-to-male sex...
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