Sex position, marital status, and HIV risk among Indian men who have sex with men: clues to optimizing prevention approaches

A divide exists between categories of men who have sex with men (MSM) in India based on their sex position, which has consequences for the design of novel HIV prevention interventions. We examine the interaction between sex position and other attributes on existing HIV risk including previous HIV testing, unprotected anal intercourse (UAI), and HIV serostatus among MSM recruited from drop-in centers and public cruising areas in the twin cities of Hyderabad and Secunderabad, India. A survey was administered by trained research assistants and minimally invasive HIV testing was performed by finger-stick or oral testing. HIV seropositive MSM underwent CD4+ lymphocyte count measurement. In our sample (n = 676), 32.6% of men were married to women, 22.2% of receptive only participants were married, and 21.9% of men were HIV seropositive. In bivariate analysis, sex position was associated with previous HIV testing, UAI, HIV serostatus, and CD4+ lymphocyte count at diagnosis. In multivariate analysis with interaction terms, dual unmarried men were more likely to have undergone an HIV test than insertive unmarried men (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.2-6.5), a relationship that did not hold among married men. Conversely, dual married men were less likely than insertive married men to engage in UAI (OR 0.3; 95% CI 0.1-0.6), a relationship that did not hold among unmarried men. Further implementation research is warranted in order to best direct novel biologic and behavioral prevention interventions towards specific risk behaviors in this and other similar contexts.