Public Participation of Men Who Have Sex with Men in the Context of Community Empowerment in India

HIV epidemic in India is a major public health concern, featuring high prevalence and infection rates in many states and among high risk groups (HRGs) [1]. Men who have sex with men (MSM) are a high-risk group (HRG) noted for high HIV prevalence and risk status globally and in India [2-4]. MSM in India remain largely hidden due to social and cultural stigma [5-8] and the stigmatizing socio-cultural environment, hinders them from accessing essential preventive services from existing social spaces [9,10]. MSM population has been prioritized under the National AIDS Control Programme but this population remains hard to reach due to high stigmatization, social stigma, and discrimination prevailing in the Indian society. In addition, criminalization of MSM activity by the Indian penal code under section 377 adds to their societal vulnerability.


Introduction
HIV epidemic in India is a major public health concern, featuring high prevalence and infection rates in many states and among high risk groups (HRGs) [1]. Men who have sex with men (MSM) are a high-risk group (HRG) noted for high HIV prevalence and risk status globally and in India [2][3][4]. MSM in India remain largely hidden due to social and cultural stigma [5][6][7][8] and the stigmatizing socio-cultural environment, hinders them from accessing essential preventive services from existing social spaces [9,10]. MSM population has been prioritized under the National AIDS Control Programme but this population remains hard to reach due to high stigmatization, social stigma, and discrimination prevailing in the Indian society. In addition, criminalization of MSM activity by the Indian penal code under section 377 adds to their societal vulnerability.
In this context of vulnerability, the "organized participation" of MSM in open public spaces, where they identify themselves as MSM without stigma or fear, could be a proxy factor of empowerment against structural barriers that criminalize and stigmatize them.
Studies have highlighted in general, the positive relation of HRG "participation", with their practice of preventive sexual behaviors [11][12][13]. We assessed the MSM "public participation" in an empowerment context, through which they address structural barriers. Our study pertains to the MSM participation in "public" spaces which is a first of its kind in distinguishing and assessing the so far theoretically defined participations in the contexts of community mobilization [14].
The study used a well represented high risk population which was undergoing wider "community mobilization" process in India. Thus it provided the opportunity to quantitatively verify and assess the transforming nature of participation from a "utilitarian tool" to an "empowerment tool" in a community mobilization process, the factors of community mobilization which influences such participations and other contextual factors.

Methodology
Study design, population and period location clusters as primary sampling units, except in East Godavari district of Andhra Pradesh, where fixed location clusters were additionally used. The primary sampling units were selected by systematic random sampling, by probability proportional to size. From the selected clusters, respondents were chosen through simple random sampling using their dress code as labels. Sample sizes were calculated on the basis of the following factors typically used in surveys with probability samples: 1) The expected baseline value of key behavioral indicators (e.g. consistent condom use with various partner types): 50%; 2) Magnitude of change it is desired to be able to detect : 10-15%; 3) Confidence level set at 0.05, corresponding to 95% confidence in the observed estimates; 4) The beta level was set at 0.10, corresponding to 90% and 5) Design effect: 1.7 and 4) This adjusts for the use of sampling designs that are not simple random methods, e.g. cluster sampling [15].

Eligibility criteria
Men aged ≥18 years who had anal sex with another man in exchange for cash/kind in the last one month were included in the study.

Data collection procedure
Face-to-face interviews were conducted by trained field workers in Tamil, the local language of the state, using a structured questionnaire that included questions on socio-demographic characteristics, selfidentity, public participation, community mobilization, vulnerability and risk perception.

Ethics statement
Approval for the study was taken from ethics committees of the participating institutes of Indian Council of Medical Research. All study participants were requested to provide informed written consent prior to participation in the study at the time and site of enrollment. Trained study staff read the consent form aloud to the participant in the language of preference. The informed consent process informed the participants about the study intent, procedures, risks, benefits, compensation, and their rights to not participate or to withdraw at any time, and contact information for the study PIs and the Ethics Committee (EC) Chairperson.

Operational definitions
Public participation: It was defined as an active role played by MSM openly expanding his consciousness and presence without hiding his identity in public spaces and actively influencing decisionmaking which impacts their life. Each respondent was asked a direct question: In the past six months have you participated in a public event (like gatherings, rallies) where you could be identified as a MSM? It was measured as a categorical variable with responses as 'Yes' or 'No' .

Pull factors
Two sets of contextual measures were used to assess MSMs' public participation. Measures related to community mobilization status were considered "pull factors" which attract MSM toward "public participatory" spaces. The "pull factors" act by creating supportive environments that provide advocacy and incentives for MSM, which encourage public participation along with community members. Pull factors encourage the MSM towards participation in public.
The following measures of Pull factors were used in this study: Collective Identity: Defined as the shared sense of oneness developed among people with shared identity. Variable used: You feel a strong sense of unity with other MSM/male sex workers (MSW) with whom you do not have an acquaintance. It was measured as a categorical variable with responses as 'Yes' or 'No' Collective agency: Defined as the choice, control, and power that marginalized groups have to act for themselves to claim their rights and to hold others accountable for these rights. Variable used: In the past one year have you negotiated or stood up against the following (police, madam, and broker, and landlord, local politician) in order to help a fellow sex worker? It was measured as a categorical variable with responses as 'Yes' or 'No' Membership in a collective: Measured by asking respondents whether they were members of a community based organization in the past one year. It was measured as a categorical variable with responses as 'Yes' or 'No' Exposure to peer education: Measured by asking respondents whether they had received sexually transmitted infection (STI)/HIV information from a peer educator in the past one year. It was measured as a categorical variable with responses as 'Yes' or 'No'

Push factors
Measures related to the vulnerability and risk status of MSM were considered "push factors," which serve as negative experiences of MSM, prompting them to participate in public spaces as a response to confronting vulnerabilities against structural barriers. Push factors are negative experiences of MSM which force them towards participation in public.
The following measures of Push factors were used in this study HIV risk perception: This was measured based on respondents' reports of MSM whether they felt themselves to be at high risk of acquiring HIV infection or not. It was measured as a categorical variable with responses as 'Yes' or 'No' If 'yes', then the respondent was considered to have HIV risk perception if 'No', the respondent was considered to have no HIV risk perception.

Experience of AIDS caused peer death/ HIV infection:
Measured by asking respondents whether they know someone (who also knows them) who is infected with HIV, or AIDS, or has died of AIDS? It was measured as a categorical variable with responses as 'Yes' or 'No' Experience of police arrest: Measured by asking whether respondents had ever been arrested by the police. It was measured as a categorical variable with responses as 'Yes' or 'No' .
Socio-economic vulnerability: This was measured by asking respondents whether they have currently borrowed money as debt from others? It was measured as a categorical variable with responses as 'Yes' or 'No'. If 'yes', it was considered as an indicator for socio economic vulnerability of MSM.

Data analysis
Descriptive statistics were used to assess level of public participation among participating MSMs . Chi-square tests were used to assess the significance of bivariate relationships between demographic characteristics and public participation. Univariate and multiple logistic regression models were used to identify factors influencing MSMs' public participation. The dependent variable was taken as public participation (coded as 1 if participated and coded as 0 if not). The "push" and "pull" factors were used as the independent variables. The regression model was adjusted for age, duration of sex work, marital status, occupation status, and self-identity of MSM. All the variables which were included in the univariate regression were also used in multivariate regression to check for consistency of results with and without adjustment for background variables. The independent variables included in the analysis were based on contextual relation they had with the dependent variables and also from references from relevant studies published in the same study context among FSWs (Karikalan N, et al., 2014). Adjusted odds ratios were calculated at a significance level of < 0.05. All statistical analyses were done after adjusting for sampling differences by applying state sampling weights. STATA/SE version 12.0 was used for all analyses.

Results
Descriptive statistics show that nearly half (48% (n=884) of the participants reported public participation in the past six months (data not shown in table). Bivariate analysis in Table 1 shows that duration of sexual exposure was a characteristic that significantly distinguished MSMs' public participation.
Univariate and multivariate regression results in Table 2 show that MSM who had an exposure to peer education ( OR 8.2 -CI 4.0-16.6, AOR 6.1-CI 1.9-19.4; P<0.05) ; had collective membership ( OR 10.2 -CI 6.4-16.3, AOR 9.7-CI 5.9-15.9; P<0.05) and collective agency ( OR 3.2 -CI 2.0-5.2, AOR 4.3-CI 2.3-8.1; P<0.05) were 3 to 10 times more likely to report public participation respectively. MSM who had been arrested by the police were over three times more likely to have participated publicly (AOR-3.7 CI 1.6-8.4; P<0.05) than who MSM who were not arrested. MSM who experienced an AIDS caused peer death/ HIV infection were less likely to report public participation (OR 0.4 CI 0.3-0.7; AOR 0.4 CI 0.3-0.7; p<0.05) than MSM who had no such experience.

Discussion
This is first report from India that reveals that community mobilization factors act as potential "pull factors" in enabling public participation in the empowerment context of MSM in addition to influencing safe sexual behaviors.
Our assessment of MSMs' public participation is significant in Indian settings, where social stigma remains a key structural barrier for MSM, increasing their vulnerability. Public participation can be theoretically explained as participation with an "intrinsic value", through which marginalized communities seek a wider vision of societal empowerment. Other studies have noted two different rationales for participation in the context of HIV intervention: "considering participation as a means to a more effective intervention, and participation as a desirable end in itself" [16,17]. Here , public participation serves as desirable end in itself a tool for self-and social empowerment for vulnerable populations like MSM to increase their social capital, self-efficacy, ability to renegotiate social norms and health enhancing social support [18].
Results show that only half of the MSM in the study population of Tamil Nadu reported public participation, which indicates the marginalization experienced by the remaining 50 percent who remain hidden; hence vulnerable. MSM with a higher duration of sexual exposure were more likely to participate in public places, underlying the role of their years of experience as MSM in realizing their empowerment needs. Community mobilization indicators have been widely noted for influencing safe sex behaviors among HRGs in their sex settings. Multiple studies have noted that public visibility, collectivization and collective efficacy were associated with safe condom use among female sex workers and MSMs [11,13,19,20].
While peer education has been generally stressed in the context of promoting individual safe behavior changes and awareness creation among HRGs in general [1,3,21]; this study shows that peer education has a positive impact on the empowerment efforts of MSM by influencing public participation , signifying that it is a principal    [22]. The community mobilization intervention brings in confidence because it conforms to the theoretical postulates especially that of Health Belief Model (HBM) which shows that interpersonal and external social factors act together in an individual, for her/him to adopt a beneficial action [23]. Thus "peer education exposure," which influences MSMs' public participation , can be explained as a "cue of action", a theoretical construct of the HBM, which is defined as external events/persons that " triggers a person on the way to changing behavior" [24].
MSMs "experience of police arrest" was a push factor, another cue to action, that influenced their public participation in this study, which corroborates findings from studies of FSWs where police related violence was effectively addressed by collective action [25,26]. Overall mobilization related "pull factors" have played a greater role in bringing MSM towards organized public participation, as compared to vulnerability-related "push factors," thus underlining the importance of community mobilization interventions which was proven as an effective intervention strategy in Indian settings [1].
This study highlights the specific nature of MSMs' "public participation", which indicates their level of empowerment efforts against structural barriers. A study by Tedrow et al. [27] highlighted that while few aspects of community mobilization are more quantifiable others measure intangible, such as the extent to which communities accepted the intervention and the level of diffusion. The study also recommends for a comprehensive measurement tool for community mobilization which should consider "discrete process outcomes as well as the more complex nuances of the mobilization" [27] . In this back ground, the measure of MSMs' "public participation" identified in this study could serve as a new and valid measure reflecting a crucial stage of their community mobilization process. MSM public participation measure would lead to better tracking of the mobilized status of hidden population which needs to be further assessed based on the preliminary findings of this study, in the context of addressing "structural changes" without which HIV prevention remains unfulfilled.
The limitation of this study is that it is cross sectional in design which could not capture the dynamic and lengthy process like community mobilization. The study itself had limited variables to completely represent all crucial stages of community mobilization (like collective efficacy were not covered in this study) and the further assessment of its relation with public participation was not possible. Also due to the small sample size we were limited from doing sub analysis based on self identity of MSM.

Conclusion
MSM "participation in public spaces" which is also noted as "public visibility of sex workers" quantifies a critical step in the community mobilization process, which has the potential to evolve strongly over time. It symbolizes the passage of MSM community from their individual issues of disease and safety towards broader societal issues and engages with structural barriers.