EPIDEMIOLOGY AND SOCIAL SCIENCE Same-Sex Behavior and High Rates of HIV Among Men Attending Sexually Transmitted Infection Clinics in Pune, India (1993–2002) Amita Gupta, MD,* Shruti Mehta, PhD, MPH,† Sheela V. Godbole, MD,‡ Seema Sahay, PhD,‡ Louise Walshe, RN, MPH,* Steven J. Reynolds, MD, MPH,*§ Manisha Ghate, MBBS, DCH,‡ Raman R. Gangakhedkar, MBBS, DCH, MPH,‡ Anand D. Divekar, MBBS,‡ Arun R. Risbud, MD,‡ Sanjay M. Mehendale, MD, MPH,‡ and Robert C. Bollinger, MD, MPH* k Objectives: To determine HIV/sexually transmitted infection (STI) prevalence, trends, and risk behaviors of men who have sex with men (MSM) and compare these with those of non-MSM attending STI clinics in Pune, India over a 10-year period. Design: Cross-sectional. Methods: From 1993 through 2002, men attending 3 STI clinics in Pune underwent HIV/STI screening. Demographic, risk behavior, clinical, and laboratory data were collected using standardized questionnaires and laboratory procedures. Results: Of 10,785 men screened, 708 (6.6%) were MSM. Among these 708 MSM, 189 (31.7%) had 10 or more lifetime partners, 253 (35.7%) were married, 163 (23.1%) had sex with a hijra (eunuch), and 87 (13.3%) had exchanged money for sex. A total of 134 (18.9%) were HIV-positive, 149 (21.5%) had genital ulcer disease (GUD), 37 (5.8%) had syphilis, and 29 (4.3%) had gonorrhea (GC). Over the decade, neither HIV nor GC prevalence changed among MSM (P = 0.7), but syphilis and GUD decreased significantly (P , 0.0001). Compared with non-MSM, MSM were more likely to initiate sexual activity at age ,16 years, to have .10 lifetime partners, to have sex with a hijra, and to use condoms regularly, but they did not differ significantly in HIV prevalence and had a lower prevalence of GC, GUD, and syphilis. Independent factors associated with HIV among MSM were employment (adjusted odds ratio [AOR] = 3.08; P = 0.02), history of GUD (AOR = 1.86; P = 0.003), and syphilis (AOR = 2.09; P = 0.05). Conclusions: Same-sex and high-risk sexual behaviors are prevalent among men attending STI clinics in India. Although syphilis and GUD rates decreased, HIV prevalence remained high during the decade, highlighting the importance of additional targeted efforts to reduce HIV risk among all men, including MSM, in India. Key Words: India, men, MSM, homosexual, same-sex behaviors, male-to-male sex, HIV, sexually transmitted infections, syphilis, gonorrhea, genital ulcer disease, prevalence, risk factors, trends (J Acquir Immune Defic Syndr 2006;43:483–490) M en who have sex with men (MSM) constitute a high-risk group for sexually transmitted infections (STIs), including HIV, in many parts of the world. 1–4 Data on MSM are not routinely collected in India, however, where MSM is a taboo subject, prohibited by law, and often not recognized as a distinct social construct. Despite these restrictions, MSM are prevalent in India and a better understanding of this risk group is required. HIV was first reported in India in 1986 among female commercial sex workers (CSWs). India is now estimated to have the highest number of HIV infections in the world, with more than 5.5 million persons currently living with HIV. 5,6 Since 1987, when HIV sentinel surveillance and AIDS case identification in India began, the predominant mode of HIV transmission identified has been heterosexual sex. The prevalence of MSM and the role this group plays in the HIV epidemic are largely unknown, because surveillance for MSM has been limited. 7–9 Received for publication October 26, 2005; accepted July 27, 2006. From the *Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, MD; †Department of Epidemiology, Johns Hopkins Bloom- berg School of Public Health, Baltimore, MD; ‡National AIDS Research Institute, Pune, India; §National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; and k Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Supported by the Indian Council of Medical Research (Institutional Support); grants from the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) (grants 1R21-AI3387901 and 1R01-AI41369), and Fogarty International Center, US NIH, Program of International Training Grants in Epidemiology Related to AIDS, (grant D43 TW00010-AITRP); and a contract from the NIAID, NIH, through Family Health International (FHI) (grant AI 35173). Presented at the International AIDS Conference, Bangkok, Thailand, July 11–16, 2004 [abstract WePeC6109]. This manuscript does not include any clinical research or animal studies. The authors have no commercial or other association that might pose a conflict of interest. The views expressed in this manuscript do not necessarily represent the views of the Indian Council of Medical Research, NIH, Fogarty International Center, FHI, or the Johns Hopkins University. Informed consent was obtained from all participants in the study. Human experimentation guidelines of the US Department of Health and Human Services and those participating institutions were followed in the conduct of this research. Informed consent procedures and this research were reviewed and approved by independent ethical committees in Pune, India and the United States. Reprints: Amita Gupta, MD, Division of Infectious Diseases, Johns Hopkins University, 600 North Wolfe Street, Jefferson 2-121B, Baltimore, MD 21287 (e-mail: agupta25@jhmi.edu). Copyright Ó 2006 by Lippincott Williams & Wilkins J Acquir Immune Defic Syndr  Volume 43, Number 4, December 1, 2006 483 Copyright ' Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.