Much of the responsibility for the transmission of HIV/STD lies with men involved in sexually risky behavior. While there are many programs aimed at reducing men's risky behavior, insufficient attention has been paid to men's perspectives on sexual health and the cultural context within which men engage in risky behavior. This paper reports on a multi-year, multi-level research and intervention project to assess men's culturally based sexual health concerns and to utilize those concerns in the development of HIV/STD risk reduction and treatment programs in urban poor communities in Mumbai (Bombay), India. The intervention approach consists of community-level education, training of both public allopathic and private nonallopathic providers and a treatment modality that centers on syndromic diagnosis and management, behavioral change, and a therapeutic approach based on narrative and cognitive therapy termed the "narrative intervention model." The project's pre-post, control, and experimental design allows evaluation of impact at each intervention level.
Keywords: men, sexual problems, HIV, STD, culturally based intervention, risky sexual behavior
Much of the literature with regard to men's involvement in reproductive health emphasizes men's reluctance to address their own health, the health of their sexual partners, and the health of their children. As a result, programs directed toward men and reproductive health have emphasized expansion of their health knowledge, a redefinition of their gender roles, a reduction of their risky behaviors, and an increased utilization of healthcare services. Intervention programs, however, must cope with current realities: Men have poor knowledge of their own health, let alone of the health of women and children: a significant number of men will not easily conform to calls for gender equity: in most locales men underutilize healthcare services: and men are more prone to engagement in such risky behaviors as smoking, alcohol and drug use, and extramarital sex that put themselves and their families at risk.
Although the challenges and obstacles have been apparent, the answers have not been so easily forthcoming. Though there is a commitment to change men's behavior, much of that change is based on concerns and concepts that have been exogenously generated, particularly when directed toward men who must also cope with a wide range of economic, environmental, and structural deficiencies that undermine attention to their own health and the health of their families. This paper suggests that before we move to the change mode, we need to carefully and systematically listen to and observe men within local communities to identify their unique concerns and utilize that knowledge for the development of change opportunities. One such opportunity emerged in the assessment of men's sexual health problems and development of prevention programs for HIV/STD risk reduction in slum communities in Mumbai, India.
The concern about men's sexual health and the health of their sexual partners is set in the context of the rapid spread of HIV/AIDS and increasing rates of STDs in India. It is now estimated that more than five million individuals are living with HIV/AIDS in India, a prevalence of 0.9% (National AIDS Control Organization, 2004; UNAIDS, 2004). Kumar (1999) has estimated the actual burden of HIV-infected people as 1.5% or 11.5 million individuals already infected with HIV, whereas Eberstat (2002) estimated 30-140 million new cases of HIV/AIDS in the period of 2000-2025. Although the actual and projected figures are in some dispute, it is generally agreed that AIDS will emerge as the single most important cause of adult mortality in India in the coming decade (UNAIDS, 2004).
The state of Maharashtra and the city of Mumbai have been severely impacted by the spread of STDs and HIV/AIDS. In Mumbai, surveillance data indicate a steady progression of HIV-positive individuals among patients attending STD clinics rising from a low of 1. …