Male Sexual Concerns and Prevention of HIV/STDs in India

This research project seeks to address the difficult problem of engaging males in reproductive health education, sexual risk reduction, and early treatment of HIV/STD in urban communities in India, a country where HIV/STD rates are increasing at a dramatic rate and national policy makers are seeking new approaches to prevention. This project seeks to identify this new approach by developing, testing, implementing and evaluating a culturally based intervention that is centered on male sexual concerns about masculinity, vitality, sexual performance and fertility. The involvement of males in the reduction of sexually risky behavior and the improvement of reproductive health are vital to reducing HIV/STD transmission both for themselves and for their female and male sexual partners. Finding an approach that begins with and addresses men's most salient reproductive health issues can establish a policy framework and an intervention methodology that has significant implications for India as well as for other developing and developed countries.

India is experiencing a rapid increase in HIV/AIDS and in other sexually transmitted infections. It is now the country with the largest absolute number of HIV infected individuals in the world. At this point in the epidemic in India the disproportionate gender ratio indicates that the primary burden for infection and transmission is on men. However, reproductive health services in India have not as yet found effective approaches for consistent involvement of males in utilization of HIV/STD services and in engagement in reproductive health information, education and communication programs. When males do go to primary care or STD clinics that frequently find an insensitive, judgmental staff with little understanding or appreciation for male reproductive health problems.

Our project approach to male involvement in reproductive health in India is based in culturally defined male sexual health problems. These health problems are widespread and characteristic of South Asia in general and India in particular. Men throughout the world have concerns associated with masturbation, penile size, and sexual performance. South Asian and Indian culture amplifies these concerns through the concept of gupt rog (secret illness in Hindi), which refers to culturally defined illnesses that belong to the secret parts of the body. Most of the gupt rog problems reported by men in India are derived from concerns about excessive semen loss, penile size, and impotence that have a long-standing tradition in India. Since their etiology and diagnosis is outside the allopathic tradition, they have generally been ignored, demeaned and seen as a relic of the cultural past by cosmopolitan health services.

Our pilot/preliminary data show that a majority of men in India define their sexual problems, including symptoms that correspond to STDs, in these traditional (gupt rog) terms. Further, a significant number of men seek treatment for sexual health problems mostly from non-allopathic practitioners, who may have limited understanding of proper treatment for or prevention of sexually transmitted infections. Public health providers' inattention to and lack of respect for gupt rog problems cause men to avoid allopathic services for the treatment of traditional problems or STD-like symptoms. Finally, there is evidence to suggest that riskier lifestyles and symptoms characteristic of STDs also are associated with those male sexual health problems that are seemingly not a result of sexual contact. Any reproductive health service in India that hopes to introduce early identification of STDS/HIV in men and to increase safer sex practices must start by addressing these male sexual health concerns.

For these reasons, the specific aims of this project are to:

• Test the proposition that traditional male concerns predict higher rates of HIV/STD;
• Determine the degree to which an intervention based on culturally based sexual health concerns can attract men into HIV/STD education, sexual risk reduction and early identification of HIV/STDs;
• Further develop, test and evaluate a culturally based therapeutic approach to male sexual health problems we have termed "Narrative Intervention Model (NIM)" that can result in positive social, psychological and health outcomes for male sexual health problems;
• Assess the relative efficacy of developing the NIM with the allopathic providers versus the traditional doctors serving men with sexual health problems;
• Assess the impact of the NIM in decreasing HIV/STDs and traditional sexual health concerns and increasing knowledge of transmission and treatment of HIV/STDs in the general community.

These objectives are currently being operationalized and implemented in three large urban slum communities in the northeastern part of Mumbai in the State of Maharashtra, the epicenter of HIV/AIDS in India. The study will involve the following phases: Formative research on provider/patient interaction around sexual health problems, assessment of study communities to ensure comparability, and refinement of community and patient instruments; Intervention involving training and capacity building for allopathic and traditional sex doctors, and a culturally based therapeutic approach to be implemented in both systems; and Evaluation of the effectiveness, integrity, and acceptability of the intervention among patients and in the community as a whole, utilizing a pre-test, post test control group design and qualitative evaluation methods.

This research, intervention and evaluation project is based on three years of qualitative and quantitative research in one of the three study communities, in which the prevalence of male sexual health problems was determined, the impact of these problems on men's sexual relationships was established, men's treatment seeking patterns delineated and links between lifestyle factors and males sexual health problems identified. This project is the next step in that effort involving the translation of basic research into a community and culturally-based intervention design that seeks to address local, national and international challenges in meeting male reproductive health needs. The reproductive health package of the International Conference on Population and Development in 1994 stressed the need to encourage and enable men to take responsibility for their sexual and reproductive behavior and their social and familial roles. We see this project as a means of addressing that challenge.

This project is a collaboration of researchers at the University of Connecticut School of Medicine and the Institute for Community Research in Hartford, CT in the United States and the International Institute for Population Sciences in Mumbai (Bombay), India. The study's significance lies in: bringing together researchers and interventionists with diverse knowledge, skills, disciplines, and national and cultural backgrounds; addressing the challenge of developing methods for utilizing cultural factors in HIV/STD risk reduction in an underserved population; drawing non-allopathic and allopathic practitioners into an intervention approach and testing the relative efficacy of the intervention with both; developing a culturally based intervention using indigenous concepts and linked to cognitive behavioral/therapeutic theoretical frameworks; and developing the scientific and policy — results, which can provide the basis for scaling up at the national and international level.

This project is funded by the National Institutes of Mental Health (NIMH) for the grant period September 1, 2001 - August 31, 2006. Stephen L. Schensul is the principal investigator. The co-PIs are Ravi K. Verma, Bonnie K. Nastasi, T.K. Roy, and G. Rama Rao. Learn more about the India projects from a recent article in the UConn Advance, the University of Connecticut's official weekly newspaper.

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