Journal of

Journal of Human Health Research

Current Issue Volume No: 1 Issue No: 3

ISSN: 2576-9383
share this page

Review Article Open Access
  • Available online freely Peer Reviewed
  • Provisional

    HIV and Homosexuality: In the Light of Therapeutic Interventions

    Ravinder Yadav 1   Varinder saini 2   Sheshna  3   Ankur  4  

    1Medical Social Welfare Officer Department of Medical Record Government Medical College and Hospital, Sector-32, Chandigarh, India

    2Professor & Head, Department of Medical Records, GMCH, Chandigarh, India

    3BAMS 4th year student Shri Dhanwantari Ayurvedic College and Hospital Chandigarh India

    4PGT Chemistry DAV senior secondary school (Lahore) Chandigarh India


    In this article the author reviews research on high risk factor of Human Immunodeficiency Virus in homosexuals and how lack of awareness & unprotected anal sex contribute substantially to new infections among this population. current HIV prevention efforts by providing insight into the patterns of Indian MSM behavior and sexual partnerships, and the specific cultural, social inequality, the gaps and lack of knowledge and psychological context in which HIV risk is occurring. And the need to develop effective awareness programs for well-functioning prevention of HIV and considerable understanding of the logistical and socio-cultural barriers MSM experience while accessing HIV prevention services. And in last will put light on therapeutic interventions for Human Immunodeficiency Virus, behavioral interventions that are socially and culturally appropriate for the population or community being prioritized and addressing multilevel psychosocial factors, including skills building and strategies to foster self-acceptance and increased social support for MSM. At the same time, prevention messages need to be designed and adapted to the knowledge level and culture of people.

    Author Contributions
    Received 11 Oct 2021; Accepted 09 Mar 2022; Published 02 May 2022;

    Academic Editor: Jong In Kim, Korea

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright ©  2022 Ravinder Yadav, et al.

    Creative Commons License     This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.


    Ravinder Yadav, Varinder saini, Sheshna , Ankur (2022) HIV and Homosexuality: In the Light of Therapeutic Interventions. Journal of Human Health Research - 1(3):35-49.

    Download as RIS, BibTeX, Text (Include abstract )

    DOI 10.14302/issn.2576-9383.jhhr-21-3994


    HIV infection among men who have sex with men (MSM) has been increasing in recent years around the world, particularly in Asia1, estimated HIV prevalence among MSM ranging between 7 and 16.5 per cent2, 3, 4. HIV-preventative services provided in urban areas focus mainly on cultivating behavioral risk reduction skills5, 6. Human sexuality is complex7, it's the way in which we experience and express ourselves as sexual beings8. Evolutionary psychology is the well-developed theory explaining sex differences9and in contrast Medicine & science continue to debate the relative contributions of nature and nurture, biological and psychosocial factors, to sexuality7 Indian MSM concepts of sexual identity can be varied and fluid4, 10, 11, 12, 13. Homosexuality has long been viewed as a sexual aberration14. The argument that homosexuality is a stable phenomenon is based on the consistency of same-sex attractions, the failure of attempts to change and the lack of success with treatments to alter orientation7.

    According to the APA " sexual orientation is an enduring emotional, romantic, sexual, or affectionate attraction towards others. It is easily distinguished from other components of sexuality including biological sex, gender identity (the psychological sense of being male or female), and the social gender role (adherence to culture norms for feminine and masculine behavior). Sexual orientation exists along a continuum that ranges from exclusive heterosexuality to exclusive homosexuality and includes various forms of bisexuality"15.

    Sexually transmitted diseases in particular are notorious for triggering such socially divisive responses and reactions16, 17. The human immunodeficiency virus (HIV) is a lenti-virus (a subgroup of retrovirus) that causes HIV infection and over time acquired immunodeficiency syndrome (AIDS)18, 19. Within just two decades, this immune-stripping disease has infected over five million people20. Recent reports in India indicate high HIV prevalence among homosexual men12, 21. The United Nations General Assembly Special Session on HIV/AIDS Report estimates that there are about 3.1 million MSM in India3. The Government of India's National AIDS Control Organization (NACO) estimates an overall HIV prevalence of 6.41 per cent among MSM, although this may be a lower-limit estimate22.


    Recently, discourse and action related to HIV stigma and discrimination has followed an illness-focused framework23, 24, 25 with stigma related to same sex activities seen as contributing to the symbolic meaning attached to the disease26. In Jamaica, the national HIV prevalence is 1.6% while the prevalence estimated among MSM is between 25-31%, and sexual ‘bridging’ is suspected between MSM and heterosexual networks27. Men who have sex with men (MSM) population account for more than half (53%) of all the new HIV infections, and blacks represent almost half (46%) of people living with HIV in the United States28. UNAIDS 2017 - around 4.3% of men who have sex with men in India are living with HIV, with just over a third aware of their status. Twenty eight districts have 5 per cent or more HIV prevalence among MSM29. Overall HIV trends amongst this population group are stable in India; there is an increasing trend among south Indian States and Delhi. For example, in Mumbai, 12 per cent of MSM seeking voluntary counseling and testing services were HIV-infected, and 18 per cent of the MSM screened in 10 clinics in Andhra Pradesh were found to be infected30, 31, 32. On the basis of multivariate analysis, the data suggested that the association of risk factors was highest amongst MSMs who were engaged in commercial sex. A report from Bangalore found that 15 per cent of MSMs were full time commercial sex workers and 63 per cent reported sex for pleasure33,Overalladult HIV prevalence estimated to be 0.31 per cent (0.25-0.39%) in 20092. During 2008-2009, 513 MSM were recruited from four clinics at two cities of Mumbai and Hyderabad34. The States that have the highest mean HIV prevalence amongst MSM in 2008 are Karnataka, Andhra Pradesh, Manipur, Maharashtra, Delhi, Gujarat, Goa, Orissa, Tamil Nadu and West Bengal35. MSM in India, therefore, experience multiple forms of social and legal discrimination36 and other risk factors included concurrent multiple sexual partners, low condom use during last sexual act and poor health seeking33.

    While it is important to foster a realistic perception of risk among the wider population in a generalized epidemic, in the Caribbean and globally MSM as a group are disproportionately affected by infection and overlap with the heterosexual population37, 38. The incidence of HIV infection among homosexual men in the United Kingdom is increasing despite efforts to reduce high risk sexual behavior39. A survey conducted a decade ago of 1200 self-identified homosexual men in South Asia (largely India) indicates that the vast majority of them were married and living with their wives, reflecting the culture that dictates people to marry the opposite sex, irrespective of their sexual orientation40. A 2015 study of men who have sex with men, conducted across 12 Indian cities, found that 7% tested positive for HIV. Just under a third (30%) of those who reported having anal or oral sex with a man in the past 12 months were married to a women and engaging in heterosexual sex41. It is deep-rooted cultural and familial traditions13, 36 and pervasive social intolerance along with the cultural pressure for men to engage in heterosexual marital relations that have led many MSM to marry women and have children10,12. A study from Chennai reported that 22 per cent of MSM respondents had unprotected anal exposure and 35.9 per cent had ever paid another man for sex4.

    High Risk Factor

    A study among rural men from 5 different States in India also reported that 9.5 per cent of single and 3.1 per cent of married men had anal sex with other men and had greater number of male sexual partners, and found high rates of unprotected anal sex with male partners42. Many MSM engage in unprotected anal and vaginal sex with male and female sexual partners10, 11, 12, 13, 36, 42, 43, 44 unprotected vaginal intercourse is often stated to be approximately 0.1%, or 1 in 1,00045, 46, 47 and oral sex has been associated with a much lower HIV transmission risk than unprotected vaginal or anal intercourse48, 49, 50.

    Rectal fluid undoubtedly contributes to the risk of HIV transmission through anal sex where the insertive partner is HIV negative. Factors that cause inflammation in the rectum of a person with HIV may increase the viral load in the rectal fluid (but not in the blood) and subsequently increase the risk of HIV transmission to an HIV-negative insertive partner51. In fact, one study of 64 HIV-positive men (of which about half were on antiretroviral therapy) found that, overall, the average amount of virus in their rectal fluid was higher than in their semen and blood52. Several studies show that HIV can be found in the rectal fluid of a person living with HIV51, 53, 54, 55, 56. Anal sex is a common practice among men who have sex with men, heterosexual men and women, and transgender individuals and is a known risk factor for HIV infection and transmission 57, 58, 59, 60.

    A study from Chennai reported that significant predictors of unprotected anal intercourse were being less educated, not having previously participated in an HIV prevention programme4. A study conducted in Andhra Pradesh found that MSM reported high rates of unprotected anal sex with other men and women10.

    Unprotected anal intercourse is considered more risky, with an estimated per-act risk of 1 in 100 to 1 in 50, which a risk that is 10 to 20 times higher than for unprotected vaginal intercourse45,61. Anal intercourse Studies show that unprotected anal intercourse is associated with a higher HIV transmission risk than unprotected vaginal intercourse61,62. and that the risk is higher when the HIV-positive person is the insertive rather than receptive partner63, 64, 65. While anal intercourse is part of both heterosexual and homosexual sexual activity, much of the data on HIV transmission risk during anal intercourse comes from studies of MSM. Estimates of per-act risk of HIV transmission for unprotected anal sex derive from individual studies and range widely, from 0.01% to over 3%46, 63, 65, 66, 67.


    Aims to reduce annual new HIV infections by 50% through the provision of comprehensive HIV treatment, education, care and support for the general population and build on targeted interventions for key affected groups and those at high risk of HIV transmission68. Few interventions focus principally on reducing stigma related to transmission behaviors and vulnerable groups at the root of the symbolic element of HIV-related stigma, with the exception of several programmer to reduce stigma related to sex work69. Community and peer-based approaches to sharing prevention tools and increasing awareness about HIV and AIDS have proven to be effective70. Specific behavioral skills developed during these prevention sessions help to decrease the prevalence of high risk behavior as women learn practice how to use male condoms correctly and role-play negotiating safer sex practices with a partner6. Other behavioral sessions examine risk reduction problem solving, assertiveness in sexual situations, self- management, and peer support71.


    In terms of adolescent counseling, the risk reduction approach to HIV counseling can be divided into various phases such as, exploring clients feelings about sexual activity, using their existing HIV knowledge as an engaging tool, addressing the barriers they have for safer sex, focusing on perceptions that might affect risky behaviors, focus on safe sex planning and in the end, referral making72. In India by August 2016, there were more than 20,000 facilities offering HTC73. Between April and September 2015, when NACO last reported data, 6.85 million general users accessed HTC, suggesting India is on course to meet its annual testing target of 12.4 million. A total of 5.32 million pregnant women received HTC over the same period against a yearly target of 9 million74. Despite this progress, around one quarter of people living with HIV in India (23%) are unaware of their status75. An early step in preventive HIV counseling is behavioral risk assessment especially among high risk individuals in resource-limited settings76. It used an intensive one-to-one counseling format over ten sessions to reduce HIV incidence in 4295 men who have sex with men in six US cities77. The counseling was highly individualized. Similar to other behavioral approaches, the counseling attempted to increase knowledge, perceived risk of acquiring HIV, motivation, and skills to change. Counselors and clients assessed circumstances and occasions in which an individual might engage in risky behavior, and then established risk reduction plans to assist the individual in avoiding HIV acquisition. Control participants received counseling on the basis of Project RESPECT model, in which individuals were given brief risk reduction counseling along with HIV testing twice a year78 and is used as a harm reduction technique quite effectively78.Counselors also made the participants aware of alternative to regular use of male condoms79. However, a number of health professionals have argued that, for greatest benefit, counseling should be an interactive process aimed at personal risk reduction80 In this technique, the emphasis is on the clients or patients, as they are the best judge of what is important to them personally and how they would incorporate any change in their behaviors81. Voluntary HIV counseling and testing for couples has shown efficacy in reducing risk behavior and HIV transmission within married or cohabiting couples82, 83, 84. Voluntary counseling and testing for couples can allow them to provide mutual support for accessing treatment and for reproductive decision making88. Adverse consequences do occur, especially if the woman is infected and the man is not and can be predicted from a history of alcohol abuse and violence within the relationship, and these factors should be used to advise couples about the potential negative effects of voluntary counseling and testing for HIV for couples88.Demand for voluntary counseling and testing for HIV in couples might be low because of the myth that monogamy is safe, gender inequality, concerns that individuals infected with HIV will have adverse consequences, and the inherent difficulties of a couple confronting together the possibility of one or both of them being infected with HIV89.

    1. The word ‘client-centered’ meant that counseling should be tailored to needs, circumstances and behaviors of a specific client which entailed active listening, to provide assistance and determining client's specific prevention needs85

    2. Prevention Counseling primarily consists of risk reduction counseling, pretest counseling and post-test counseling. In terms of adolescent counseling, the risk reduction approach to HIV counseling can be divided into various phases such as, exploring clients feelings about sexual activity, using their existing HIV knowledge as an engaging tool, addressing the barriers they have for safer sex, focusing on perceptions that might affect risky behaviors, focus on safe sex planning and in the end, referral making72

    3. Risk Reduction Counseling It is used as a harm reduction technique quite effectively. Results showed that men who received the full information motivation behavior (IMB) model showed greater risk reduction skills and relatively lower rates of unprotected intercourse over 6 months of follow-up and had fewer Sexually-transmitted infections86.

    4. Hierarchical counseling technique as opposed to single-method counseling in a group of women showed that there was a tendency for increased protective behavior among the group which received hierarchical counseling as compared to the other two groups87.

    Cognitive Behavioral Stress Management/Cognitive Behavioral Therapy

    HIV-infected individuals who received training on how to assess and alter their irrational thoughts, and who gained adaptive coping skills to manage and reduce their stress, showed significant improvement in psychological factors including depression, anxiety, anger, and stress when compared to the control group90. A meta-analysis about different CBT approaches found that interventions which incorporate stress management skills training and provide opportunities to increase self-efficacy through practice, were more successful than those that did not90. Cognitive behavioral interventions are highly effective for helping improve psychological factors90 and coping strategies for HIV infected individuals. In a review of the literature91, concluded that stress management interventions are a promising approach to facilitate positive adjustment. A standardized system with high emphasis on counseling and a multidisciplinary approach present within the public HIV healthcare system will have a positive impact on adherence levels and viro-logical suppression among patients92,93.

    Jacobson’s Relaxation Technique/Jacobson’s Progressive Relaxation Technique

    Edmund Jacobson commenced research at Harvard in 1908, and throughout the 1920's and 1930's worked to develop progressive muscle relaxation as an effective behavioral technique for the alleviation of neurotic tensions and many functional medical disorders94. Clinical research studies have generally shown that Jacobson's relaxation technique does indeed lessen muscle tightness, relax the patient, and reduces the patient's experience of pain95, observed an improvement in blood pressure and a decrease in medication after the application of biofeedback assisted relaxation96. Moreover, in a general review on therapeutic use of relaxation response in stress-related diseases, declare that relaxation techniques appear to be highly recommendable97


    The Mindfulness-based stress reduction (MBSR) program98 is a standardized and manualized 8-week mindfulness meditation training intervention that has been shown to reduce stress and improve self-reported health outcomes in a variety of patient populations99. Mindfulness meditation, which is described as a process of bringing awareness to moment-to-moment experience, has been receiving substantial scientific attention as a process that can be stress and health protective99. A recent study found that HIV infected individuals who participated in spiritual activities had a reduced risk of morbidity100. Higher levels of spirituality/religion have also been associated with less psychological distress, less pain, greater energy and will to live, better cognitive and social functioning, and feeling that life has improved since HIV diagnosis101, 102, 103, 104, 105.

    Guided Imagery/Interactive Guided Imagery

    Guided imagery is a mental function that expresses itself as a dynamic, quasi-real, psycho-physiological process that engages all of the senses to bring about individual changes in behavior, perception, or physiologic responses106.  Out of the eight studies reviewed, two demonstrated significant reductions in levels of fatigue after a guided imagery intervention107,108. Stress reduction mind–body modalities such as meditation, guided imagery, and hypnotherapy have been shown to reduce stress and affect other health outcomes favorably109,110,111.


    Yoga therapy which is a mind body intervention was provided to the inhabitants daily for 1-h, twice a day. Yoga practices have shown to reduce fear, anxiety112, stress and depression which also enhances overall well-being113. It includes loosening exercises, asanas (postures), pranayama (breathing techniques) such as nadishuddi114, bhramari114, kapalbhati Saraswathi114, and deep relaxation techniques. Yoga tended to reduce blood pressure in studies of HIV-negative participants with ‘The Metabolic Syndrome’115. Perhaps the practice of yoga improves vascular function/tone, and this mediates the lowering of blood pressure116.

    Information, Education & Communication (IEC)

    Information, education and communication (IEC) campaign is one of the most common cost-effective behavioral intervention strategies implemented so far to fight against HIV/AIDS117. The primary goal of such IEC program is to inspire and educate people about prevention, care and/or treatment of HIV/AIDS and for a better understanding of HIV in a more comprehensive way117. Findings from prior research have indicated the usefulness IEC messages and materials in improving stigmatizing and discriminatory attitudes towards HIV positive people 118,119.


    Although many claims have been made relating to the benefits of aromatherapy, most research has focused on its use to manage depression, anxiety, muscle tension, sleep disturbance, nausea, and pain120. Some studies suggest that olfactory stimulation related to aromatherapy can result in immediate reduction in pain, as well as changing physiological parameters such as pulse, blood pressure, skin temperature, and brain activity121.


    The findings of literature review, that existing models of HIV risk can be strengthened by focusing on and integrating protective factors such as self-acceptance122,123,124. It is not unusual for MSM to be married or have female sex partners as reported in a number of studies125. In the125 report, a substantial proportion of MSM had large numbers of male sex partners of all types—regular, casual, and commercial (paid) and paying. The mean number of male sex partners ranged from 1.7 to 13.9 over one month in India (2006), 3.9 over one month in Bangladesh (2003-2004), and 8.8 over 12 months in Sri Lanka (2006-2007). In Indonesia, the median number of male sex partners of MSM over one month ranged between 2 and 10125 and as MSM behavior is not an accepted norm in Indian culture & pervasive social intolerance along with the cultural pressure for men to engage in heterosexual marital relations. social and family pressure were the reason MSM married a female126. Acute gap separation existed between knowledge and behavior. Some studies reported that 25 to 35% of MSM are currently married to a female127,128 and more than 70% of MSM will potentially get married to a female127,129. Greater visibility in Indian civil society necessitates careful planning and community education130, 131, 132, 133.

    Promoting safer ways to meet and forge supportive relationships with other MSM could foster broader social support networks and enhance community engagement132,134, to effectively reduce HIV and advance the health, multi-level approaches need to consider. Developing an intervention in regard to condom promotion and risk reduction plan by counseling, education, strategic planning, and community engagement. Individual- and group-level behavioral interventions with demonstrated effectiveness have been a focus of CDC's prevention efforts135.

    The surveillance data among MSM indicated that the prevalence of HIV had increased dramatically from 1% in 2006 to 4.4% in 2008 in Harbin136,137. The high AIDS knowledge awareness, high intervention coverage and the low proportion of protective sexual behavior happened simultaneously and presented the separation of knowledge and behavior138. Research in Chennai MSM suggests that psychosocial concerns such as depression may affect HIV risk behaviors and the degree to which MSM may benefit from HIV prevention interventions139 and in U.S. U.S. MSM, these mental health problems have been shown to increase HIV risk 124.

    Additionally, program planners and policy makers need more descriptive interventions and quantitative estimates of intervention effects to make informed choices regarding prevention research and further studies140. Among MSM, unprotected anal sex is the sexual behavior with the highest risk for HIV transmission141, 142, 143, 144, 145. Efforts to improve communication skills related to HIV status and condom use with sexual partners might reduce the sexual transmission of HIV among MSM146,147. However, almost half of the men who tested positive for HIV infection during the survey were unaware of their infection148. Correct and consistent condom use during sexual intercourse remains the most effective method of preventing HIV transmission. Condom promotion and risk reduction education remain necessary components in HIV prevention messages given the low prevalence of reported condom use during anal sex among Indian MSM10.


    In conclusion, the overwhelming majority of HIV prevalence in MSM rapidly increased in the past few years and how almost every society has struggled with the connection between sexuality and society. we should need to consider the individual psychosocial cultural and interpersonal determinants, for educating men about the potential risks associated with participating in anonymous sex. There is a critical need for the development, implementation of appropriate prevention and innovative evidence-based interventions from the individual to the community and focus on screening and treating at-risk sex networks.. It is also important to have Consistent and regular awareness, focus on increasing condom use and strengthen the propaganda of healthy life style to lower the risk factor.


    1.F Van Griensven, HS de Lind van Wijngaarden.A review of the epidemiology of HIV infection and prevention responses among MSM in Asia. AIDS. 2010;24(Suppl3):S30–40 .
    2.Nations United. (2010) General Assembly Special Session on HIV/AIDS. National AIDS Control Organization; , India. New Delhi: .
    3. (2007) . Independent Evaluation of National AIDS Control Programme.Jaipur: Indian Institute of Health Management Research; .
    4.Thomas B, Mimiaga M J, Menon S, Chandrasekaran V, Murugesan P et al. (2009) Unseen and unheard: predictors of sexual risk behavior and HIV infection among men who have sex with men in. Chennai, India. AIDS Educ Prev 21, 372-83.
    5.M P Carey, S A Maisto, S C Kalichman, A D Forsyth, E M Wrigth et al.T.1997).Enhancing motivation to reduce the risk of HIV infection for economically disadvantage urban women.Journalof Consulting & Clinical Psychology. 65(4), 531-541.
    6.Crepaz N, K J Marshall, L W Aupont, E D Jacobs, Mizuno Y et al.H.(2009).The efficacy of HIV/STI behavioral interventions for African American females in the United States: A meta analysis. , American Journal of Public Health 99(11), 2069-2078.
    7.Drescher J, Byne W M. (2009) Homosexuality, Gay and Lesbian Identities and Homosexual Behaviour. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9th ed In: Sadock BJ, Sadock VA, Ruiz P, editors , Philadelphia: Lippincott Williams 2060-89.
    8.A R Rathus, J S Nevid, Fichner-Rathus L. (1993) Human sexuality: In a world of diversity. , Boston:
    9.Wood W, A H Eagly. (2002) A cross-cultural analysis of the behavior of women and men: Implications for the origins of sex differences. , Psychological Bulletin 128, 699-727.
    10.Dandona L, Dandona R, Gutierrez J P, Kumar G A, McPherson S et al. (2005) ASCI EPP Study. Sex behavior of men who have sex with men and risk of HIV in Andhra Pradesh. , India. AIDS 19, 611-9.
    11.Asthana S, Oostvogels R. (2001) The social construction of male ‘homosexuality’ in India: implications for HIV transmission and prevention. Soc Sci Med. 52, 707-21.
    12.Go V F, Srikrishnan A K, Sivaram S, Murugavel G K, Galai N et al. (2004) High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India. J Acquir Immune Defic Syndr. 35, 314-9.
    13. (2002) A baseline study of knowledge, attitude, behavior and practices among men having sex with men at selected sites in Mumbai.Mumbai: Humsafar Trust).
    14.Misra G. (2009) Decriminalising homosexuality in India. Reprod Health Matters. 17, 20-8.
    15.(PDF). University of Illinois, Springfield. Continuum of Human Sexuality.
    16.Carrara S. (1994) AIDS and the history of venereal diseases in. Brazil. In: Parker, R., Bastos, C., Galvão, J. & Pedrosa, J.S., eds. AIDS in Brazil. Rio de Janeiro, RelumeDumará
    17.C S Goldin. (1994) Stigmatization and AIDS, critical issues in public health. , Social Science and Medicine 39, 359-1366.
    18.Weiss R A. (1993) How does HIV cause AIDS?". , Science 260(5112), 1273-9.
    19.Douek D C, Roederer M, Koup R A. (2009) Emerging Concepts in the Immunopathogenesis of AIDS". , Annual Review of Medicine 60, 471-84.
    20.Agoramoorthy G, Hsu M. (2006) Keeping the promise in stopping HIV/AIDS: Can India succeed? Indian J Med Res. 123(6), 830-2.
    21.Lalit M Nath. (2005) . The Independent Commission on Development and Health in India HIV/AIDS in India Some Issues .
    22. (2010) Annual Report 2009-10. New Delhi:. Department of AIDS Control). National AIDS Control Organization) .
    23.Maluwa M, Aggleton P, Stigma Parker R HIV-and-AIDS-related. (2002) Discrimination and Human Rights: A Critical Overview. Health and Human Rights. 6(1), 1-18.
    24.Parker R, Aggleton P. (2003) HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science and Medicine. 57, 13-24.
    25.Norman L, Carr R, Jimenez J. (2005) . Sexual Stigma and Sympathy: Attitudes toward Persons Living with HIV in Jamaica. Culture, Health, and Sexuality 8(5), 423-33.
    26.Herek G. (1999) . , AIDS and Stigma. Behavioral Scientist 42(7), 1102-12.
    27.Figueroa J P, Duncan J, Byfield L, Harvey K, Gebre Y et al. (2008) A Comprehensive Response to the HIV/AIDS Epidemic in Jamaica: A Review of the Past 20 Years. West Indian Medical Journal. 57(6), 562-76.
    28. (2010) HIV and AIDS in the United States [Online] Centers for Disease Control and Prevention.
    29.. Available from: URL:
    30.National Behavioral (2009) Surveillance Survey Executive Summary 2009: National AIDS Control Organisation.
    31.Kumta S, Lurie M, Weitzen S, Jerajani H, Gogate A et al. (2006) ASociodemographics, sexual risk behaviour and HIV among men who have sex with men attending voluntary counseling and testing services in. 16th International AIDS Conference , Toronto, Canada: .
    32.Setia M S, Lindan C, Jerajani H R, Kumta S, Ekstrand M et al. (2006) Men who have sex with men and transgenders in Mumbai, India: an emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol. 72, 425-31.
    33.Sravankumar K, Study Prabhakar P Mythri STIHIV. (2006) Aug 13th-16th, High risk behaviour among HIV positive and negative men having sex with men (MSM) attending Myrthi clinics in Andhra Pradesh. Group.16th International AIDS Conference , Toronto, Canada: .
    34.Phillip A E, Boily M C, Lowndes C M, Garnett G P, Gurav K et al. (2008) Sexual identity and its contribution to MSM risk behavior in Bagaluri (Bangalore), India: the results of a two-stage cluster sampling survey. , J LGBT Health Res 4, 11-126.
    35.Gurung A, Prabhakar P, Narayanan P, Mehendale S, Risbud A et al. (2010) Prevalence of asymptomatic gonorrhea and chlamydia among men having sex with men (MSM) in India and associated risk factors. Paper presented at:. 18th International AIDS conference , Austria: .
    36. (2008) HIV Sentinel Surveillance and HIV Estimation in India. , New Delhi, India:, National AIDS Control Organization)
    37.Chakrapani V, Kavi A R, Ramakrishnan L R, Gupta R, Rappoport C et al. (2002) HIV prevention among men who have sex with men (MSM) in India: review of current scenario and recommendations:. SAATHI (Solidarity and Action Against The HIV Infection in India) Working Group on HIV Prevention and Care among Indian GLBT/Sexuality Minority Communities .
    38.Cácares C. (2002) HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS. 16(Suppl no. 3):S23–S33
    39.Baral S, Sifakis F, Cleghorn F, Beyrer C. (2007) Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and-Middle - Income Countries: (2000-(2006: A Systematic Review. PloS Medicine. 4(12), 1901-11.
    40. (1999) . Communicable Disease Surveillance Centre . AIDS and HIV infection in the UK: monthly report. Commun Dis Rep CDR Wkly 9, 121-122.
    41.Khan S. (1994) Cultural context of sexual behavior and identities and their impact upon HIV prevention models: an overview of South Asian men who have sex with men. Indian J Soc Work. 55(4), 633-64.
    42.Solomon S. (2015) High HIV prevalence and incidence among men who have sex with men across 12 cities in India’. , AIDS 29(6), 723-731.
    43.Verma R K, Collumbien M. (2004) Homosexual activity among rural Indian men: Implications for HIV interventions. AIDS Educ Prev. 18, 1834-7.
    44.Setia M S, Lindan C, Jerajani H R, Kumta S, Ekstrand M et al. (2006) Men who have sex with men and transgenders in Mumbai, India: an emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol. 72, 425-31.
    45.Nandi J, Kamat H, Bhavalkar V, Banerjee K. (1994) Detection of human immunodeficiency virus antibody among homosexual men from Bombay. Sex Transm Dis. 21, 235-6.
    46.Powers K A, Poole C, Pettifor A E, Cohen M S. (2008) Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis. Lancet Infect Dis. 8(9), 553-63.
    47.Boily M C, Baggaley R F, Wang L, Masse B, White R G et al. (2009) Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infect Dis. 9(2), 118-29.
    48.Mastro T D, I de Vincenzi. (1996) . Probabilities of sexual HIV-1 transmission. AIDS 10, 75-82.
    49.Morrow G, Vachot L, Vagenas P, Robbiani M.Current concepts of HIV transmission. Curr HIV/AIDS (2007). Rep 4(1), 29-35.
    50.Centers for (2009) Disease Control and Prevention. Oral sex and HIV Risk. CDC HIV/AIDS Facts.
    51.National AIDS Trust. (2010) . HIV The Basics. National AIDS Trust, UK website, The-basics.aspx .
    52.Kiviat N B, Critchlow C W, Hawes S E. (1998) Determinants of human immunodeficiency virus DNA and RNA shedding in the anal-rectal canal of homosexual men. Journal of Infectious Diseases. 177(3), 571-8.
    53.Zuckerman R A, WLH Whittington, Celum C L. (2004) Higher concentration of HIV RNA in rectal mucosa secretions than in blood and seminal plasma, among men who have sex with men, independent of antiretroviral therapy. , Journal of InfectiousDiseases 190(1), 156-61.
    54.Lampinen T M, Critchlow C W, Kuypers J M. (2000) Association of antiretroviral therapy with detection of. HIV-1 RNA and DNA in the anorectal mucosa of homosexual men. AIDS 14(5), 69-75.
    55.Zuckerman R A, WLH Whittington, Celum C L. (2004) Higher concentration of HIV RNA in rectal mucosa secretions than in blood and seminal plasma, among men who have sex with men, independent of antiretroviral therapy. , Journal of Infectious Diseases 190(1), 156-61.
    56.Kelley C F, Haaland R E, Patel P. (2011) HIV-1 RNA rectal shedding is reduced in men with low plasma HIV-1 RNA viral loads and is not enhanced by sexually transmitted bacterial infections of the rectum. Journal of Infectious Diseases. 761-7.
    57.Kotler D P, Shimada T, Snow G. (1998) Effect of com bination antiretroviral therapy upon rectal mucosal HIV RNA burden and mononuclear cell apoptosis. AIDS. 12(6), 597-604.
    58.Heywood W, AMA Smith. (2012) Anal sex practices in heterosexual and male homosexual populations: a review of population-based data. Sexual Health. 9(6), 517-26.
    59.McBride K R, Fortenberry J D. (2010) Heterosexual Anal Sexuality and Anal Sex Behaviors: A Review. , Journal of Sex Research.47(2-3): 123-36.
    60.Baggaley R F, White R G, Boily M-C. (2010) HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. , International Journal of Epidemiology 39(4), 1048-63.
    61.Bauer G R, Travers R, Todd K Scanlon, Coleman A. (2012) High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health. 292.
    62.Halperin D T, Shiboski S C, Palefsky J M, Padian N S. (2002) High level of HIV-1 infection from anal intercourse: a neglected risk factor in heterosexual AIDS prevention. Poster Exhibition:. The XIV International AIDS Conference: .
    63.Leynaert B, Downs A M, I de Vincenzi. (1998) Heterosexual transmission of human immunodeficiency virus: variability of infectivity throughout the course of infection. , European Study Group on Heterosexual Transmission of HIV. Am 148(1), 88-96.
    64.Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K et al. (1999) Per-contact risk of human immunodeficiency virus transmission between male sexual partners. , Am 150(3), 306-11.
    65.Macdonald N, Elam G, Hickson F, Imrie J, McGarrigle C A et al. (2008) Factors associated with HIV seroconversion in gay men in England at the start of the 21st century. Sex Transm Infect. 84(1), 8-13.
    66.Jin F, Jansson J, Law M, Prestage G P, Zablotska I et al. (2010) . Grulich AE and Wilson DP. Per-contact probability of HIV transmission in homosexual men in Sydney in the era of HAART. AIDS 24(6), 907-13.
    67.DeGruttola V, Seage GR 3rd, Mayer K H, Horsburgh CR Jr. (1989) Infectiousness of HIV between male homosexual partners. J Clin Epidemiol. 42(9), 849-56.
    68.Jacquez J A, Koopman J S, Simon C P, Longini IM Jr. (1994) Role of the primary infection in epidemics of HIV infection in gay cohorts. J Acquir Immune Defic Syndr. 7(11), 1169-84.
    69.NACO. (2013) Statement Containing Brief Activities of the Department of AIDS Control in 2013'.
    70.Herek G. (1999) . , AIDS and Stigma. Behavioral Scientist 42(7), 1102-12.
    71.Salam R A, Haroon S, Ahmed H H, Das J K, Bhutta Z A. (2014) Impact of community-based interventions on HIV knowledge, attitudes, and transmission. Infect Dis Poverty. 3, 26.
    72.Holtgrave D, J A Kelly. (1996) Preventing HIV/AIDS among high-risk urban women: The cost effectiveness of a behavioral group intervention. , American Journal of Public Health 86(10), 1442-1445.
    73.Pinto R M. (2000) HIV prevention for adolescent groups: A six-step approach. Social Work with Groups. 23(3), 81-99.
    74. (2016) NACO ‘Integrated Counselling and Testing Centre webpage’.
    75.(2015). NACO ‘Annual report 2015-16’.
    76.(2017). UNAIDS. Data Book.
    77.Chen Z, Branson B, Ballenger A, Peterman T A. (1998) Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients. Sex Transm Dis. 25(10), 539-43.
    78.Chesney M A, Koblin B A, Barresi P J. (2003) An individually tailored intervention for HIV prevention: baseline data from the EXPLORE Study. Am J Public Health. 93, 933-38.
    79.Kamb M L, Fishbein M, Douglas J M, Rhodes F, Rogers J et al. (1998) Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA 280(13), 1161-7.
    80.Semple S J, Patterson T L, Grant I. (2003) HIV-positive gay and bisexual men: Predictors of unsafe sex. AIDS Care. 15(1), 3-15.
    81.Kamb M L, Dillon B, Fishbein M, Willis K L. (1996) Project RESPECT Study Group. Quality assurance of HIV prevention counseling in a multi-center randomized controlled trial. Public Health Rep. 111(1), 99-107.
    82.Fisher W A, Black A. (2007) Contraception in Canada: a review of method choices, characteristics, adherence and approaches to counselling. CMAJ. 176(7), 953-61.
    83. (2000) The Voluntary HIV-1 Counseling and Testing Efficacy Study Group Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. , Lancet 356, 103-12.
    84.Allen S. (1992) Effect of serotesting with counseling on condom use and seroconversion among HIV-serodiscordant couples in Africa. , BMJ 304, 1605-09.
    85.Allen S A. (1992) Confidential HIV testing and condom promotion in Africa: impact on HIV and gonorrhea rates. , JAMA 268, 3338-43.
    86. (1993) Technical guidance on HIV counseling. Center for Disease Control and Prevention. MMWR Recomm Rep. 42(2), 11-7.
    87.Kalichman S C, Cain D, Weinhardt L, Benotsch E, Presser K et al. (2005) Experimental components analysis of brief theory-based HIV/AIDS risk-reduction counseling for sexually transmitted infection patients. Health Psychol. 24(2), 198-208.
    88.Gollub E L, French P, Latka M, Rogers C, Stein Z. (2001) Achieving safer sex with choice: Studying a women's sexual risk reduction hierarchy in an STD clinic. , Journal of Women's Health 10(8), 771-83.
    89.Grinstead O A, Gregorich S E, Choi K H, Coates T. (2001) Voluntary HIV-1 Counselling and Testing Efficacy Study Group. Positive and negative life events after counselling and testing:. the Voluntary HIV-1 Counselling and Testing Efficacy Study. AIDS 15, 1045-52.
    90.Chomba E, Allen S, Kanweka W. (2008) Evolution of couples' voluntary counseling and testing for HIV in Lusaka, Zambia. J Acquir Immune Defic Syndr. 47, 108-15.
    91.Crepaz N, W F Passin, J H Herbst, Rama S, R M Malow. (2008) Meta-analysis of cognitive behavioral interventions on HIV-positive persons’ mental health and immune functioning. , Health Psychology 27(1), 4-14.
    92.J L Brown, P A Vanable. (2008) Cognitive-behavioral stress management interventions for persons living with HIV: A review and critique of the literature. Annals of Behavioral Medicine. 35(1), 26-40.
    93.Simoni J M, Pearson C R, Pantalone D W, Marks G, Crepaz N. (2006) Efficacy of interventions in improving highly active antiretroviral therapy adherence and HIV-1 RNA viral load. A meta-analytic review of randomized controlled trials. J Acquir Immune Defic Syndr. 43, 23-35.
    94.Rueda S, Park-Wyllie L Y, Bayoumi A M, Tynan A M, Antoniou T A et al. (2006) Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS. Cochrane Database Syst Rev. 3, 001442.
    95.Jacobson E. (1938) Progressive relaxation .
    96.De Paula AA, de Carvalho EC. (2002) dos Santos CB. The use of the "progressive muscle relaxation" technique for pain relief in gynecology and obstetrics. Rev Lat Am Enfermagem. 10(5), 654-9.
    97.Paran E, Amir M, Yaniv N. (1996) Evaluation of the response of mild hypertensives to biofeedback assisted relaxation using mental stress test. J Behav Ther Exp Psychiatry. 27(2), 157-167.
    98.Esch T, Fricchione G L, Stefano G B. (2003) Med Sci Monit. (2003/02/26. The therapeutic use of the relaxation response in stress-related diseases. 9, 23-34.
    99.Kabat-Zinn J. (1982) An outpatient program in behavioral medicine for chronic pain patients based on the practice o f mindfulness meditation: theoretical considerations and preliminary results. General Hospital Psychiatry. 4, 33-47.
    100.Brown K W, Ryan R M, Creswell J D. (2007) Mindfulness: theoretical foundations and evidence for its salutary effects. Psychological Inquiry. 18, 1-27.
    101.A L Fitzpatrick, L J Standish, Berger J, Kim J, Calabrese C.N.(2007).Survivial in HIV-1 positive adults practicing psychological or spiritual activities for one year. Alternative Therapeutic Health Medicine. 13, 18-24.
    102.Szaflarski M, Ritchey P N, Leonard A C. (2006) Modeling the effects of spirituality/religion on patients’ perceptions of living with HIV/AIDS. , J Gen Intern Med 21(5), 28-38.
    103.Trevino K M, Pargament K I, Cotton S. (2010) Religious coping and physiological, psychological, social, and spiritual outcomes in patients with HIV/AIDS: Cross-sectional and longitudinal findings. , AIDS and Behavior 14(2), 379-389.
    104.Tsevat J, Leonard A C, Szaflarski M. (2009) Change in quality of life after being diagnosed with HIV: A multicenter longitudinal study. AIDS Patient Care and STDs. 23(11), 931-937.
    105.Ironson G, Stuetzle R, Fletcher M A. (2006) An increase in religiousness/spirituality occurs after HIV diagnosis and predicts slower disease progression over 4 years in people with HIV. , J Gen Intern Med 21(5), 62-68.
    106.Tsevat J, Sherman S N, McElwee J A. (1999) The will to live among HIV-infected patients. , Ann Intern Med 131(3), 194-198.
    107.Freeman L. (2009) Mosby’s complementary & medicine: A research-based approach. 3rd ed. , Louis, MO:
    108.Eller L S. (1995) Effects of two cognitive-behavioral interventions on immunity and symptoms in person with HIV. , Annals of Behavioral Medicine 17, 339-348.
    109.Freeman L W, Welton D. (2005) Effects of imagery, critical thinking, and asthma education on symptoms and mood state in adult asthma patients: A pilot study. , Journal of Alternative and Complementary Medicine 11, 57-68.
    110.Gruzelier J H. (2002) A review of the impact of hypnosis, relaxation, guided imagery and individual differences on aspects of immunity and health. , Stress 5, 147.
    111.Schneider N, Schedlowski M, Schurmeyer T H, Becker H. (2001) Stress reduction through music in patients undergoing cerebral angiography. , Neuroradiology 43, 472.
    112.Speca M, Carlson L E, Goodey E, Angen M. (2000) A randomized, waitlist controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. , Psychosom Med 62, 613.
    113.Telles S, Naveen K V, Dash M. (2007) Yoga reduces symptoms of distress in tsunami survivors in the Andaman Islands. Evid Based Complement Alternat Med. 4, 503-9.
    114.Woodyard C. (2011) Exploring the therapeutic effects of yoga and its ability to increase quality of life. , Int J Yoga 4, 49-54.
    115.Saraswathi S S. (2008) 4th ed. Bihar, India: Yoga Publication Trust). Asana Bandha Pranayama Mudra Banda.
    116.Cohen B E, Chang A A, Grady D, Kanaya A M. (2008) Restorative yoga in adults with metabolic syndrome: a randomized, controlled pilot trial. Metab Syndr Relat Disord. 6, 223-229.
    117.Sivasankaran S, Pollard-Quintner S, Sachdeva R, Pugeda J, Hoq S M et al. (2006) The effect of a six-week program of yoga and meditation on brachial artery reactivity: do psychosocial interventions affect vascular tone?. , Clin Cardiol 29, 393-398.
    118.Drysdale R. (2004) Franco-Australian Pacific Regional HIV/AIDS and STI Initiative. , Review of HIV/AIDS & STI, Information Materials, Report
    119.Chen J, Choe M K, Chen S, Zhang S. (2007) The effects of -individual-and community-level knowledge, beliefs, and fear on -stigmatization of people living with HIV/AIDS in China. , AIDS Care 19, 666-73.
    120.Peltzer K, Seoka P. (2004) Evaluation of HIV/AIDS prevention intervention messages on a rural sample of South African youth′s knowledge, attitudes, beliefs and behaviours over a period of 15 months. , J Child Adolesc Ment Health 16, 93-102.
    121.Boehm K, Büssing A, Ostermann T. (2012) Aromatherapy as an adjuvant treatment in cancer care—a descriptive systematic review. African Journal ofTraditional,Complementary and Alternative Medicines. 9(4), 503-518.
    122.Shin B-C, M S Lee. (2007) Effects of aromatherapy acupressure on hemiplegic shoulder pain and motor power in stroke patients: a pilot study. , Journal of Alternative and Complementary Medicine 13(2), 247-251.
    123.Herrick A L, Lim S H, Wei C, Smith H, Guadamuz T et al. (2011) Stall R. Resilience as an untapped resource in behavioral intervention design for gay men. , AIDS and Behavior 15, 25-29.
    124.Herrick A L, Stall R, Goldhammer H, Egan J E, Mayer K H. (2014) Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: Theory and evidence. , AIDS and Behavior 18, 1-9.
    125.Safren S A, Reisner S L, Herrick A L, Mimiaga M J, Stall R D. (2010) Mental health and HIV riskin men who have sex with men. , Journal of Acquired Immune Deficiency Syndromes 55, 74-77.
    126.SEARO WHO. (2010) HIV/AIDS among men who have sex with men and transgender populations in South-East Asia,” The current situation and national responses.
    127.Folch C, Casabona J, Sanclemente C, Esteve A, Gonzalez V et al. (2014) Trends in HIV prevalence and associated risk behaviors in female sex workers in Catalonia (Spain)] Gac Sanit. 28, 196-202.
    128.Chow E P, Lau J T, Zhuang X, Zhang X, Wang Y et al. (2014) HIV prevalence trends, risky behaviours, and governmental and community responses to the epidemic among men who have sex with men in China. Biomed Res Int. 607261.
    129.Feng L, Ding X, Lu R, Liu J, Sy A et al. (2009) High HIV prevalence detected in. , China. J Acquir Immune Defic Syndr 52, 79-85.
    130.Chow E P, Gao L, Koo F K, Chen L, Fu X et al. (2013) Qualitative exploration of HIV-related sexual behaviours and multiple partnerships among Chinese men who have sex with men living in a rural area of Yunnan Province. , China. Sex Health 10, 533-540.
    131.Asthana S, Oostvogels R. (1996) Community participation in HIV prevention: Problems and prospects for community-based strategies amongst female sex workers in Madras. , Social Science and Medicine 43(2), 133-148.
    132.Diaz R. (1998) Latino gay men and HIV: Culture, sexuality and risk behavior. , Routledge). New York:
    133.Meyer I H. (2003) Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. , Psychological Bulletin 129, 674-697.
    134.Safren S A, Martin C, Menon S, Greer J, Solomon S et al. (2006) A survey of MSM HIV prevention outreach workers. in Chennai, India. AIDS Education and Prevention 18(4), 323-332.
    135.Spencer S M, Patrick J H. (2009) Social support and personal mastery as protective resources during emerging adult hood. , Journal of Adult Development 16, 191-198.
    136.CDC. US Department of Health (1999) Compendium of HIV prevention interventions with evidence of effectiveness. , Atlanta, GA:
    137.Wang J, Luo C, Wen Y C. (2008) Survey of the HIV infections and risk factors in part of MSM in Harbin. , China STD AIDS 14(1), 75.
    138.Xu J, Han D L, Liu Z. (2010) Survey of the HIV infections and risk factors. in MSM of four Cities in China. China Preventive Medicine 44(11), 975-980.
    139.Safren S A, Thomas B E, Mimiaga M J, Chandrasekaran V, Menon S et al. (2009) Depressive symptoms and human immunodeficiency virus risk behavior among men who have sex with men. in Chennai, India. Psychology, Health & Medicine. China's Ministry of Health/WHO/UNAIDS, Update on the HIV/AIDS Epidemic and Response in China 14, 705-715.
    140.Beyrer C, Sullivan P S, Sanchez J, Dowdy D, Altman D. (2012) A call to action for comprehensive HIV services for men who have sex with men. , Lancet 380, 424-438.
    141.Koblin B A, Husnki M J, Colfax G. (2006) Risk factors for HIV infection among men who have sex with men. , AIDS 20, 731-9.
    142.Ekstrand M L, Stall R D, Paul J P, Osmond D H, Coates T J. (1999) Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status. , AIDS 13, 1525-33.
    143.Morin S F, Steward W T, Charlebois E D. (2005) Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project. , J Acquir Immune Defic Syndr 40, 226-35.
    144.Chen S Y, Gibson S, Katz M. (2002) Continued increases in sexual risk behavior and sexually transmitted diseases among men who have sex with men:. , San Francisco, Calif, Am J Public Health 92, 1387-8.
    145.Crepaz N, Marks G, Liau A. (2009) Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis. , AIDS 23, 1617-29.
    146.Molitor F, Facer M, Ruiz J D. (1999) Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. , Arch Sex Behav 28, 335-43.
    147.Chesney M A, Koblin B A, Barresi P J. (2003) An individually tailored intervention for HIV prevention: baseline data from the EXPLORE Study. , Am J Public Health 93, 933-8.
    148.CDC. (2008) Prevalence and awareness of HIV infection among men who have sex with men-21 cities, United States. , MMWR 59, 1202-7.