Major Findings from Ishkonnect: A Formative Research Study to Understand the Opportunities and Challenges to Mhealth HIV Interventions for MSM and Hijras in India

Introduction: Internet penetration in India is currently estimated to be at 19% and smartphone use at 10%; the market is rapidly expanding as infrastructure improves and consumers gain access to more affordable products. As technology becomes more prevalent, there are opportunities to develop culturally relevant mHealth interventions for HIV prevention. The ISHKonnect study identified sexual risk behavior among persons meeting male sex partners online and recommendations to develop mHealth interventions for men who have sex with men and hijras (MSM-H) in India.

Methods: Data collection occurred between September 2013 and May 2014 and consisted of an online cross-sectional survey (N=449), four focus groups with MSM (N=24), and individual interviews with hijras/transgender women (N=4) and health care providers (N=10. Eligibility for community participants included being age 18 or over, living in the State of Maharashtra, and, if MSM-H, having sex with a man in the past 90 days. Quantitative data underwent descriptive, bivariate, regression, and latent variable analyses. Qualitative data underwent content analysis.

Results: Among survey participants, the mean age was 30 (SD=8). While 64% self-identified as gay and 25% as bisexual, only 19% were out to most or all people they knew. A quarter were not out to anyone. Further, 18% had sex with a woman (11% were married to a woman) and 3% with a hijra. The median number of male sex partners in the past 90 days was 3 (IQR: 2-6); 58% reported meeting two or more male sex partners online. Compared to gay participants, more bisexuals reported engaging in insertive anal sex (46% vs. 76%) and not using condoms with the insertive partner (10% vs. 19%). Bisexuals were more likely to report positive attitudes towards condomless anal sex when measured by the Benefits of Barebacking Scale (M=2.8 (SD=1.7) vs. M=3.3 (SD=1.9)). 

Qualitative data were collected to identify recommendations for a mHealth HIV intervention. Recommended content included affirming sexuality and STI prevention education for younger MSM-H, information for people living with HIV, routine testing and appointment reminders, role modeling, partner notification, and information on community events and resources. Identified challenges included multiple languages and literacy levels and ensuring that use of the app would not unintentionally out someone as attracted to men or having HIV/STI. Participants stressed the need to tailor content differently for MSM and hijras.

Conclusions: A mHealth HIV intervention that is acceptable to MSM-H in the State of Maharashtra should address sexual concurrency and attitudes towards condom use and be tailored based on sexual orientation and gender identity and expression.