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Paper text:
men who have sex with men ( msm ) are a highly vulnerable population and substantially affected by the hiv epidemic worldwide . in india , msm have a very high hiv prevalence ( 7.4% ) compared with the general population ( 0.31% ) . the national aids control organisation ( naco ) has recognized msm as a  key population  at risk for hiv and it funds targeted hiv interventions among msm [ 2 , 3 ] .
unprotected anal sex among msm increases probability of transmission of hiv , but using water - based lubricants along with latex condoms can reduce hiv risk by reducing friction and condom damage . several studies [ 610 ] have documented that a significant proportion of msm and hijras ( male - to - female transgender people ) in india use condoms inconsistently in anal sex acts and do not use latex condom compatible lubricants .   in india , there is limited data on the use of lubricants along with condoms during anal sex by msm .
understanding the extent and type of lubricants used by msm will help policy - makers and program managers make evidence - informed decisions on promoting and distributing latex condom - compatible ( water - based or silicone - based ) lubricants along with condoms .
we describe the prevalence and type of rectal lubricants use and factors associated with exclusive use of water - based lubricants among msm in three southern states of india using data from a large cross - sectional bio - behavioural survey .
data for the current analysis were drawn from the second in a series of cross - sectional surveys known as integrated behavioral and biological assessment ( ibba ) conducted in 2009/10 .
that survey was part of evaluation of a large - scale hiv prevention program in three states in india : andhra pradesh , tamil nadu , and maharashtra .
msm participants were recruited using time - location cluster sampling from cruising sites such as parks and local train stations . in andhra pradesh and maharashtra ,
the inclusion criteria were self - identified msm who were 18 years of age or older and who had any type of sex ( oral , anal , or manual ) with another man in the past month . in tamil nadu ,
the inclusion criteria were similar , except that the type of sex was limited to anal sex with another man in the past month .
behavioral data were collected using a structured interviewer - administered questionnaire , and blood and urine samples were tested for hiv and sexually transmitted infections ( stis ) .
the study protocol was approved by the local ethics committees of the implementing institutes of indian council of medical research ( national aids research institute , pune ; national institute of nutrition , hyderabad , and national institute of epidemiology , chennai ) and protection of human subjects committee of fhi 360 .  
lubricant use was assessed by the following question : have you ever used a lubricant while having anal sex ?
type of lubricants used in the past year was assessed by a multiple response question where up to six responses could be recorded .
the response choices included baby oil , butter , cooking oil , coconut oil , hand moisturising lotion , ky jelly , vaseline , and saliva .
as the analytic focus was to examine the factors associated with exclusive use of water - based lubricants , based on the combination of responses received , we created three sets of variables in relation to the type of lubricants used .
one set was created for the descriptive analysis and it had three categories : ( a ) exclusive oil - based lubricant users ( those using baby oil , butter , cooking oil , coconut oil , and hand moisturising lotion ) , ( b ) exclusive water - based lubricant users ( those using ky jelly , a famous brand of water based lubricants ) also referred to as latex condom compatible lubricant users in the paper , and ( c ) mixed users ( who reported using oil - based or water - based lubricants , or saliva ) .
two other sets were created for multivariate analysis each having two categories : exclusive water - based lubricant users and mixed users ; and exclusive water - based lubricant users and non - users .  
exposure to hiv interventions was measured using a composite indicator created from three questions that assessed whether the participants ever visited clinics operated by nongovernmental organizations , ever received condoms from peer educators or outreach workers , and were ever contacted by peer educator or outreach workers .
those who reported receiving any one of these three services were considered to be  exposed to any hiv prevention intervention .  similarly , those msm who tested positive in blood or urine samples for either one of the three stis  gonorrhoea , chlamydiasis , and syphilis  were categorized as  having any sti . 
syphilis was screened by rapid plasma reagin ( rpr ) test and confirmed by treponema pallidum hemagglutination assay ( tpha ) . nucleic - acid amplification ( gen - probe aptima combo 2gen - probe inc . ,
san diego , ca , usa ) tests on urine samples were conducted for chlamydial infection and gonorrhoea .
bivariate associations between type of lubricant used and independent variables ( related to sociodemographics and exposure to hiv interventions ) were assessed by chi - square tests , and logistic regression was used to identify correlates of exclusive use of water - based lubricants versus non - users or mixed users .
all analyses were conducted in stata-11 ( stata corporation , college station , tx , usa ) .   when conducting bivariate and logistic regression analyses , to aid in analysis and interpretation , variables which initially had three or more categories
were collapsed into two meaningful categories , especially if there were very low frequencies in certain categories of those variables .
25 years  and  above 25 years ,  educational status was categorized as 
less than higher secondary  and  higher secondary and above ,  and marital status was categorized as 
never married  and  ever married .  for occupation , we categorized respondents into two groups :  manual laborers  ( agricultural / nonagricultural laborers ) and another group that included  students , unemployed , and white - collar workers . 
while the proportion of msm with different self - identities are provided in table 1 , for logistic regression , we categorized self - identity of msm as kothis and  nonkothis , 
the latter including identities such as panthi , double decker , and bisexual - identified msm .
this was because , in general , kothis are relatively visible , well organized , and more accessible to interventions when compared with other subgroups of msm .
similarly , for alcohol consumption , we created two groups : drinkers ( everyday , at least once a week , and less than once a week ) and nondrinkers ( never in life and never in the past month ) , as alcohol use in general has been shown to influence condom use among indian msm .
of the 3,880 msm who were interviewed , a majority reported using lubricants ( 64% , n = 2487/3872 ; 60.4% in andhra pradesh , 42.4% in maharashtra , and 76.6% in tamil nadu ) and more than half of these ( 53% , n = 1325/2485 ) exclusively used water - based lubricants .
less than one - tenth of users ( 7.6% , n = 191/2485 ) reported exclusive use of oil - based lubricants and nearly 40% ( n = 969/2485 ) of these msm were mixed users ( using both water - based and oil - based lubricants ) ( see table 1 ) . characteristics of lubricant non - users ( nu ) and exclusive water - based lubricant users ( ewu ) are presented in table 2 . when compared with non - users , ewu were more likely to be residents of tamil nadu ( ewu-58.4% , nu-27.2% , p = 0.000 ) , exposed to hiv prevention programs ( ewu-93% , nu-60% ; p = 0.000 ) , self - identify as kothis ( ewu-71% , nu-38% ; p = 0.000 ) , consume alcohol ( ewu-63% , nu-59% ; p = 0.023 ) , aged above 25 years ( ewu-55% , nu-48% ; p = 0.000 ) , and have hiv ( ewu-12.9% , nu-9.8% ; p = 0.013 ) and stis ( ewu-7.8% , nu-5.7% ; p = 0.032 ) ( see table 2 ) .  
characteristics associated with increased odds for exclusive use of water - based lubricants taking non - users as the reference group were exposure to hiv prevention interventions ( aor : 6.18 , 95% ci 4.827.92 ) , self - identity as kothis ( aor : 2.56 , 95% ci 2.123.10 ) , and consumption of alcohol ( aor : 1.28 , 95% ci 1.071.53 ) . when adjusted for sociodemographic and other contextual factors such as exposure and consumption of alcohol
we obtained similar results ( details are not shown ) when we had mixed users as the reference group instead of non - users except that those who were hiv - positive were at decreased odds ( aor : 0.75 , 95% ci 0.580.95 ) for exclusive use of water - based lubricants when compared with those who were hiv negative .
our analysis has provided program - relevant information on the extent and type of rectal lubricants use among indian msm and the factors that might facilitate the use of water - based lubricants .
more than half of the lubricant users reported exclusively using water - based lubricants in the past year , and exposure to hiv prevention intervention was found to be a significant associated factor . during the period between round 1 and 2 of ibba ( i.e. , before and during this survey ) , hiv interventions among msm in the study sites promoted use of water - based lubricants along with condoms , and in some study sites ( such as mumbai and hyderabad ) , water - based lubricants were distributed freely or provided at a subsidized cost through social marketing [ 15 , 16 ] .
thus , our finding indicates that indian msm are willing to use water - based lubricants , if information is provided on condom - compatible ( water - based or silicone - based ) lubricants and access to lubricants is facilitated through interventions .  
another key finding that about one - third of the lubricant users who reported using both water - based and oil - based lubricants could mean that many msm may not be aware that oil - based lubricants should not be used with condoms [ 1719 ] .
this is despite the fact that the operational guidelines ( 20072012 ) of the national aids control organisation ( naco ) for targeted hiv interventions for msm recommend use of only water - based lubricants along with condoms during anal sex .
it is also possible that many msm might have very limited access to water - based lubricants , given that they are expensive , and the free or subsidised lubricants distributed in targeted hiv interventions for msm would have barely met the needs of all msm [ 9 , 21 ] . if oil - based lubricants are used along with condoms during anal sex , then the chances of condom breakage are higher thereby increasing the risk of hiv transmission .
this might explain why we found a statistically significant association between being hiv - positive and using both water- and oil - based lubricants .  
the finding that kothi - identified msm are more likely to report using water - based lubricants when compared with other subgroups ( like double - decker  both anal - insertive and anal - receptive or panthi  anal - insertive ) could be because hiv interventions among msm in india are reported to reach a higher proportion of kothis   and thus more likely to have access to water - based lubricants or information about the proper use of lubricants .
this also indicates the need to intensify efforts to promote water - based lubricants among other subgroups of msm such as double - deckers and panthis .  
this finding is counter - intuitive as alcohol consumption is usually associated with hiv - related sexual risk behaviors such as multiple sex partners and inconsistent condom use [ 22 , 23 ] . as we did not collect any sexual event - level data on alcohol use , condom use , and lubricant use , we could not provide plausible reasons for the association between alcohol use and water - based lubricant use in this sample .  
a major gap in this analysis is the lack of information on the use of water - based lubricants in last anal sex and consistency of lubricant use in a recent timeframe ( past month ) and whether type and consistency of lubricants use differ according to type of partner ( regular , casual , or paid ) .
factors associated with lubricant use among hijras or transgender people may be quite different from msm , but our study did not have adequate sample size of hijras for a separate comparative analysis .
as we did not have specific questions on the use of lubricants along with condoms , for example , use of lubricant along with a condom in the last anal sex episode , it is possible that lubricants could have been used without condoms .
however , almost all the persons ( > 95% ) who reported using lubricants also reported using condoms ( although inconsistently ) in anal sex , making it less likely that lubricants could have been used without condoms in this sample .
the current analysis provides important program - relevant information on rectal lubricants use among msm in india , which has not been available until now .
the familiarity and widespread use of water - based lubricants among msm means that the national hiv program , through its targeted hiv interventions among msm , has an opportunity to provide information on the effects of oil - based lubricants on condom slippage and breakage and to promote and distribute latex condom - compatible lubricants along with condoms during anal sex . intensifying
the efforts to reach all subgroups of msm ( kothis , panthis , double - deckers , and bisexuals ) through targeted interventions and promoting latex condom - compatible lubricant use among them , irrespective of their presumed or stated sexual role ( receptive or insertive or both ) in anal sex , will help in increasing the use of latex condom - compatible lubricants during anal sex .
we examined the prevalence and type of rectal lubricants use and factors associated with exclusive use of latex - condom compatible lubricants ( water - based lubricants ) among men who have sex with men ( msm ) using data from a large - scale cross - sectional survey conducted in 2009/10 in three indian states . using time - location cluster sampling , 
 3880  msm were recruited from cruising sites . 
 we used multiple logistic regression to assess the association between type of lubricants used and sociodemographic and programmatic indicators . among those who reported using lubricants ( 64% ) more than half ( 53% ) exclusively used water - based lubricants , less than one - tenth used exclusively oil - based lubricants , and nearly 40% used both water - based and oil - based lubricants . 
 factors associated with exclusive use of water - based lubricants were exposure to hiv prevention interventions ( aor : 6.18 , 95% ci 4.82 to 7.92 ) and kothi - identified msm  feminine / anal - receptive ( aor : 2.56 , 95% ci 2.12 to 3.10 ) . 
 targeted hiv interventions among msm need to promote and distribute latex condom - compatible lubricants for use during anal sex  irrespective of their presumed or stated sexual role in anal sex , and educate them not to use oil - based lubricants with condoms .