Preventing HIV Infection Among MSM in Southern India

描述（由申请人提供）：本申请汇集了来自约翰·霍普金斯大学和 YRG 艾滋病研究与教育中心（印度）的经验丰富的研究人员，旨在针对男男性行为者 (MSM) 制定“艾滋病毒综合预防”方法。我们建议采取多层次干预措施，以社区、网络和个人层面的行为改变为目标，以整群随机试验的形式实施，以检验男性健康中心对艾滋病毒自愿咨询和检测（VCT）的有效性。印度男男性行为者感染艾滋病毒的负担很高，并且经历药物滥用和心理健康问题。然而，印度的男男性行为者仍然隐藏在公众视野之外，因为婚姻是人们所期待的，而且肛交历来是一种应受《印度刑法》（最近才被推翻）处罚的犯罪行为（第 377 条）。 VCT 服务是艾滋病毒治疗和医疗保健的切入点，可以扩大规模以提供其他预防服务。我们的具体目标是： 目标 1：使用定性研究方法，深入描述安得拉邦、卡纳塔克邦和泰米尔纳德邦（印度南部艾滋病毒负担高的邦）MSM 社区的性认同、性行为、耻辱和歧视、医疗保健获取和寻求健康行为的本质；目标 2：通过使用 RDS 的横断面研究，确定印度南部三个州 12 个地点（每个地点 750 人）的 MSM 的 HIV/STI 患病率、既往 VCT 使用情况、药物滥用模式、抑郁症状、感知和经历的耻辱以及医疗保健需求；目标 3：评估 MSM 友好预防中心对印度南部 MSM 风险行为变化的有效性。目标 1 和 2 旨在确定影响医疗保健利用的因素，并确定干预的离散个人网络。为了实现目标 3，我们提出了在 4 个配对 MSM 社区集群（在基线目标 2 RDS 中确定的个体离散网络）之间进行多级集群随机试验。我们将在 4 个干预集群中建立男性健康中心 (DOST)，并通过基线 RDS 期间确定的 MSM 网络传播有关中心的信息。这些中心将提供适合文化的预防服务，包括 VCT、性传播感染管理、降低风险以及药物滥用和抑郁症状咨询。为了评估社区层面的有效性，我们将在诊所实施 18 个月后对 8 个社区进行 RDS 评估，以衡量干预组与对照组中前 6 个月内接受 HIV 检测的参与者比例的主要结果；次要结果包括 (1) 前六个月内无保护性行为的次数； (2) 过去6个月内非主要合伙人的数量； (3) HIV、HSV-2和梅毒的流行情况； (4) 药物滥用流行情况； (5)抑郁症状的患病率。我们还将进行分析，以评估网络和个人层面干预的成功程度。这项研究将提供证据表明，针对 MSM 提供的改进的、适合文化的服务将有助于更及时地预防、诊断和护理该群体的 HIV 感染。

DESCRIPTION (provided by applicant): This application brings together experienced researchers from Johns Hopkins and the YRG Centre for AIDS Research and Education (India) to plan a 'combined HIV prevention' approach among men who have sex with men (MSM). We propose a multi-level intervention targeting behavioral change at the community, network and individual levels implemented as a cluster-randomized trial of the effectiveness of Men's Wellness Centers on uptake of HIV voluntary counseling and testing (VCT). Indian MSM have a high burden of HIV and experience substance abuse and mental health problems that care. Yet Indian MSM remain hidden from public view as marriage is expected and anal intercourse has historically been a crime punishable by the Indian Penal Code (Section 377), only recently overturned. VCT services serve as an entry point for HIV treatment and medical care and can be scaled up to provide other prevention services. Our specific aims are: Aim 1: To characterize in-depth the nature of sexual identity, sexual practices, stigma and discrimination, health care access and health-seeking behaviors among MSM communities in Andhra Pradesh, Karnataka and Tamil Nadu (southern Indian states with high HIV burden) using qualitative research methods; Aim 2: To ascertain HIV/STI prevalence, prior VCT use, patterns of substance abuse, depressive symptoms, perceived and experienced stigma and health care needs among MSM across 12 sites (n=750 per site) in three southern Indian states through cross-sectional studies using RDS; Aim 3: To evaluate the effectiveness of MSM- friendly prevention centers on changes in risk behavior among MSM in southern India. Aims 1 and 2 are designed to identify factors that influence health care utilization and to identify discrete networks of individuals for the intervention. To achieve Aim 3, we propose a multi-level cluster-randomized trial among 4 pair-matched MSM community clusters (discrete networks of individuals that are identified in the baseline Aim 2 RDS). We will establish Men's Wellness Centers (DOST) in 4 intervention clusters and disseminate information about the centers through networks of MSM identified during the baseline RDS. These centers will provide culturally-appropriate prevention services including VCT, STI management, risk reduction and counseling for substance abuse and depressive symptoms. To assess community-level effectiveness, we will conduct an evaluation RDS among the 8 communities 18 months after implementation of the clinics to measure the primary outcome of proportion of participants tested for HIV in the prior 6 months in intervention vs. control clusters; secondary outcomes include (1) number of unprotected sex acts in prior six months; (2) number of non-primary partners in prior 6 months; (3) prevalence of HIV, HSV-2 and syphilis; (4) prevalence of substance abuse; and (5) prevalence of depressive symptoms. We will also perform analyses to assess success of the intervention at the network and individual levels. This study will provide evidence that improved, culturally-appropriate services for MSM will lead to more timely prevention, diagnosis and care of HIV infection in this group.