Sudha Sivaram

When HIV-Prevention Messages and Gender Norms Clash: The Impact of Domestic Violence on Women's HIV Risk in Slums of Chennai, India

This paper examines how marital violence affects womens ability to protect themselves from HIV/AIDS. In-depth interviews (n = 48) and focus groups (n = 84, 3–7 per group) were conducted among men and women in two randomly selected slums of Chennai, India. The study showed that community gender norms tacitly sanction domestic violence that interferes with adopting HIV-preventive behaviors. Given the choice between the immediate threat of violence and the relatively hypothetical specter of HIV, women often resign themselves to sexual demands and indiscretions that may increase their risk of HIV acquisition. In conclusion, AIDS-prevention interventions must incorporate gender-related social contexts in settings where husbands strictly enforce their locus of control. HIV-prevention messages targeting men may effectively reduce womens exposure to HIV/AIDS.

High HIV Prevalence and Risk Behaviors in Men Who Have Sex with Men in Chennai, India

ObjectiveTo estimate HIV and sexually transmitted disease (STD) prevalence and behavioral risk characteristics of men who have sex with men (MSM) in Chennai, India. MethodsA cross-sectional population-based random sample survey was conducted in 2001. Randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors through face-to-face interviews. Sera and urine were examined for syphilis, HIV-1, gonorrhea, and chlamydia. Logistic regression analyses were used to assess associations between MSM status and HIV infection and to identify risk characteristics of MSM. ResultsOf 774 men, 46 reported (5.9%) sex with other men. MSM were more likely to be seropositive for HIV (odds ratio [OR] = 8.57; 95% confidence interval [CI]: 1.83, 40.23) and were more likely to have a history of STD (OR = 2.66; 95% CI: 1.18, 6.02) than non-MSM. Men who used illicit drugs in past 3 months (adjusted odds ratio [AOR] = 4.01; 95% CI: 1.92, 8.41), ever exchanged money for sex (AOR = 3.93; 95% CI: 1.97, 7.84), or were ever tested for HIV (AOR = 3.72; 95% CI: 1.34, 10.34) were significantly more likely to report sex with men. ConclusionsMSM in Chennai slums are at high risk for HIV. HIV prevention strategies aimed at changing unsafe drug and sexual practices should target the general population of men, with specific attention to areas with high rates of MSM.

Crossing the threshold: engendered definitions of socially acceptable domestic violence in Chennai, India

The objective of this study was to examine the pathways by which gender norms may influence marital violence in low‐income communities of Chennai, India. As part of a multisite international behavioural HIV intervention trial, 48 in‐depth interviews and 14 focus groups with men and women were conducted in two randomly selected low‐income communities within the city. Interviews were taped, transcribed, translated, coded and analysed to identify recurrent themes. A multi‐layered conceptual framework was used to examine individual, relational, community and societal level determinants of marital violence in this setting. Participants noted that husbands hold decision‐making power in economic, social and sexual spheres. Clear patterns of violence were present; respondents reported that husbands regularly beat wives in most marriages. Marital conflicts were intensified by the presence of community level stressors such as poverty and unemployment. Participants perceived violence to be a necessary tool that served to discipline wives and ultimately enforce gender norms. Although many respondents felt wife‐beating was the norm, the acceptable intensity of violence varied by gender. Interventions that reconsider gender‐based roles and empower men and women to lower the threshold of socially acceptable violence should be developed to alleviate the consequences of violence.

HIV/AIDS Stigma: Reliability and Validity of a New Measurement Instrument in Chennai, India

HIV/AIDS stigma is a frequently cited barrier to HIV prevention, including voluntary counseling and testing. A reliable and valid measurement instrument is critical to empirically assess the extent and effects of HIV/AIDS stigma. The paper reports the development and psychometric testing of an HIV/AIDS stigma scale among 200 men in India. The resulting 24-item scale and the four subscales had good internal consistency (Cronbachs alpha overall was 0.81; subscales were 0.86, 0.73, 0.72 and 0.76, respectively). The scale and distinct subscales suggest a valid and reliable measure for HIV/AIDS stigma in a setting with highly prevalent HIV risk behaviors.

Associations between social capital and HIV stigma in Chennai, India: considerations for prevention intervention design.

Stigma against persons living with HIV/AIDS (PLHA) is a barrier to seeking prevention education, HIV testing, and care. Social capital has been reported as an important factor influencing HIV prevention and social support upon infection. In the study, we explored the associations between social capital and stigma among men and women who are patrons of wine shops or community-based alcohol outlets in Chennai. We found that reports of social capital indicators were associated with reduced fear of transmission of HIV/AIDS, lower levels of feelings of shame, blame and judgment, lower levels of personal support and perceived community support for discriminatory actions against PLHA. Specifically, when participants reported membership in formal groups, perception of high levels of collective action toward community goals, high norms of reciprocity between neighbors and residents in daily life, and presence of trusted sexually transmitted disease care providers, all levels of measures of stigma were lower. Although we defined social capital rather narrowly in this study, our findings suggest that seeking partnerships with existing organizations and involving health care providers in future interventions may be explored as a strategy in community-based prevention interventions.

Measurement of self, experienced, and perceived HIV/AIDS stigma using parallel scales in Chennai, India

Abstract HIV/AIDS stigma can severely compromise the quality of life of people living with HIV/AIDS (PLHA) by reducing access and quality of care, adherence to therapy, and disclosure of HIV status, thereby potentially increasing transmission. The objective of this study was to develop and psychometrically test three parallel scales measuring self, experienced, and perceived stigma among PLHA (n=188) in Chennai, India. Exploratory factor analysis (EFA), which was used to facilitate item reduction and assess construct validity, confirmed the presence of three underlying theoretical domains. The final number of items and Cronbachs Alpha for each scale were: 8 items, Alpha of 0.84, for self stigma; 7 items, Alpha of 0.86, for experienced stigma; and 7 items, Alpha of 0.83, for perceived stigma. External validity was ascertained by confirming a significant positive association between the measure of each type of stigma and depression (measured using CES-D), using structural equation modeling (SEM). Therefore, scales were parsimonious, reliable, and were found to be valid measures of HIV/AIDS stigma. Using these validated scales, researchers can accurately collect data to inform the design of stigma reduction programs and interventions and enable subsequent evaluation of their effectiveness.

Male Alcohol use and unprotected sex with non-regular partners: Evidence from wine shops in Chennai, India

BACKGROUND In India, heterosexual transmission accounts for approximately 80% of the spread of HIV, the virus that causes AIDS. Male alcohol use and its putative association with sexual risk are explored to inform HIV prevention interventions. METHODS A survey of 1196 male patrons of wine shops or bars was conducted from August 2002-January 2003 as part of an ongoing HIV prevention trial in Chennai city in south India. In the analysis, we explored associations between covariates related to sexual behavior and alcohol use and our outcome of unprotected sexual intercourse with non-regular partners among men. RESULTS Nearly half (43%) of the respondents reported any unprotected sex with non-regular partners and 24% had four or more recent sexual partners. Over 85% reported using alcohol at least 10 days a month (17% reported drinking everyday). During a typical drinking day, 49% reported consuming five or more drinks. Alcohol use before sex was reported by 89% of respondents. Unprotected sex with non-regular partners was significantly higher among unmarried men (OR=3.25), those who reported irregular income (OR=1.38), who used alcohol before sex (OR=1.75) and who had higher numbers of sexual partners (OR=14.5). CONCLUSIONS Our findings suggest that future HIV prevention interventions in India might consider discussing responsible alcohol use and its possible role in sexual risk. These interventions should particularly consider involving unmarried men and weigh the role of structural factors such as access to income in developing prevention messages.

HIV rates and risk behaviors are low in the general population of men in southern India but high in alcohol venues: Results from 2 probability surveys

Background:As the HIV epidemic continues to expand in India, empiric data are needed to determine the course of the epidemic for high-risk populations and the general population. Methods:Two probability surveys were conducted in Chennai slums among a household sample of men and alcohol venue patrons (“wine shops”) to compare HIV and other sexually transmitted disease (STD) prevalence and to identify STD behavioral risk factors. Results:The wine shop sample (n = 654) had higher rates of HIV and prevalent STDs (HIV, herpes simplex virus 2 [HSV-2], syphilis, gonorrhea, or chlamydia) compared with the household sample (n = 685) (3.4% vs. 1.2%, P = 0.007 and 21.6% vs. 11.8%, P < 0.0001, respectively). High-risk behaviors in the household sample was rare (<4%), but 69.6% of wine shop patrons had >2 partners, 58.4% had unprotected sex with a casual partner, and 54.1% had exchanged sex for money in the past 3 months. A multivariate model found that older age, ever being married, ever being tested for HIV, and having unprotected sex in the past 3 months were associated with STD prevalence in wine shop patrons. Conclusions:Prevalent HIV and STDs, and sexual risk behaviors are relatively low among the general population of men. We found that men who frequent alcohol venues practice high-risk behaviors and have high rates of STDs, including HIV, and may play an important role in expanding the Indian epidemic.

Gender differences in the prevalence of sexually transmitted infections and genital symptoms in an urban setting in southern India.

Objectives: To examine gender differences in sexual behaviour, the prevalence of laboratory-detected sexually transmitted infections (STIs) and self-reported genital symptoms in urban Chennai, Tamil Nadu, India. Study design: The data were based on a cross-sectional survey (n = 1649) of residents from low-income communities in Chennai. Data were collected during community-wide health camps comprising physical examinations, interviews and laboratory testing between March and June 2001. Results: The population was young, sexually active, with a low prevalence of STI. The most commonly detected STI was Herpes simplex virus type 2 (HSV2; 13.2%). Women had a higher prevalence of HSV2, but were more likely than men to be asymptomatic. Most of the self-reported genital symptoms could not be linked to a laboratory-detected STI. >10% of the cohort had a history of an ulcerative STI and >5% had an inflammatory STI. Conclusions: Given a high prevalence of HSV2 in the study population, interventions targeting HSV2 transmission may be particularly relevant for this population.

Using the Theory of Gender and Power to Examine Experiences of Partner Violence, Sexual Negotiation, and Risk of HIV/AIDS Among Economically Disadvantaged Women in Southern India

SUMMARY This article uses the Theory of Gender and Power to examine womens vulnerability to HIV/AIDS in order to: understand the vulnerability of female sex workers/poor women due to poverty and lack of educational resources; explore womens vulnerability in the context of client/partner violence, alcohol use, male partners high-risk behaviors, and womens lack of control in their intimate relationships; and explore the role of traditional heterosexual gender norms in the outcomes of sexual negotiation. Ethnographic data were collected from 32 women and 38 men in India as part of an ongoing National Institute of Mental Health study. Results highlighted womens vulnerability to HIV/AIDS stemming from partner violence, alcohol use, poverty, dangers of sex work environments, and tacit acceptance of cultural/gender norms.