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In India, men who have sex with men (MSM) often face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual identity, especially if they are married to women and have families. Due to pervasive stigma and discrimination, human immunodeficiency virus (HIV) prevention programs are unable to reach many MSM effectively.
The objective of this paper was to describe the design, operations, and monitoring of the Sahaay helpline, a mHealth intervention for the MSM population of India.
We established the “Sahaay” mHealth intervention in 2013; a MSM-dedicated helpline whose main goal was to increase access to comprehensive, community-based HIV prevention services and improve knowledge, attitudes, and behaviors of MSM towards HIV and sexually transmitted infections (STI) in three states of India (Chhattisgarh, Delhi, and Maharashtra). The helpline provided a 24x7 confidential and easy to use interactive voice response system (IVRS) to callers. IVRS function was monitored through an online dashboard of indicators. The system also provided real-time reporting on callers and services provided.
The helpline received more than 100,000 calls from 39,800 callers during the first nine months of operation. The helpline maintained an operational uptime of 99.81% (6450/6462 hours); and answered more than 81.33% (83,050/102,115) of all calls. More than three-fourths of the calls came between 9:00 am-12:00 pm. The most successful promotional activity was “interpersonal communication” (reported by 70.05%, 27,880/39,800, of the callers). Nearly three-fourths of the callers self-identified as MSM, including 17.05% (6786/39,800) as rural MSM and 5.03% (2001/39,800) as a married MSM. Most callers (93.10%, 37,055/39,800) requested information, while some (27.01%, 10,750/39,800) requested counseling on HIV/acquired immune deficiency syndrome (AIDS), STIs, and other health and nonhealth issues. There were 38.97% (15,509/39,800) of the callers that were provided contacts of different HIV/AIDS referral services. Many MSM clients reported increased self-esteem in dealing with their sexual identity and disclosing the same with their family and spouse; and an increase in HIV/AIDS risk-reduction behaviors like consistent condom use and HIV testing.
National HIV/AIDS prevention interventions for MSM in India should consider scaling-up this helpline service across the country. The helpline may serve as an important mechanism for accessing hard-to-reach MSM, and thus improving HIV prevention programing.
Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide and better HIV prevention strategies are urgently needed; epidemics in MSM are reemerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries [
However, HIV prevalence has not declined among MSM compared to other high risk population groups [
A systematic review of literature on “telephone-delivered interventions” [
An important mHealth experience from the HIV/AIDS sector is that of the “Text Me! Flash Me!” Helpline launched in Ghana in September 2008. It used cell phone technology to provide most-at-risk populations with friendly and accessible HIV/AIDS information, referrals, and counseling services from qualified providers. The evaluation of the project suggested that there was an increase in demand for HIV testing and counseling as well as counseling on STI diagnosis and treatment services. The helpline increased client’s knowledge of and intention to use condom and lubricants [
mHealth could significantly transform the health care milieu in India by improving health care access for the huge underserved rural population, and enhancing the care for urban residents. India’s high level of mobile phone penetration, with over 911 million subscribers as of February 2012, comprises the world’s population of mobile phone users. The overall teledensity in India reached 78.1% by the end of February 2012 [
In 2013, we established the “Sahaay” mHealth Intervention, a MSM-dedicated helpline whose main goal was to increase MSM access to comprehensive, community-based HIV prevention services and improve the HIV/STI related knowledge, attitudes, and behaviors of MSM. The purpose of this paper was to describe the design, operations, and monitoring of the intervention.
A consultation with key stakeholders, including representatives from the NACO, MSM community, and various HIV program implementing agencies, was held to outline categories of hard-to-reach MSM, defined as one who is either not registered with a TI project or registered, but has not received any service from a TI in the last six months. The hard-to-reach MSM included: (1) self-identified MSMs, (2) married MSMs, (3) clients of female sex workers, (4) migrant population, (5) clients of male sex workers, (6) rural MSMs, (7) nonself-identified MSMs in cruising sites, (8) male sex workers, (9) MSM people living with HIV/AIDS (PLHIV) network members, and (10) party MSM network members (these MSM are involved in organizing and/or attending sex parties). The categories are not mutually exclusive.
The project included a 9-month intervention in three states of India, namely, Chhattisgarh, Delhi, and Maharashtra, shown in
Family Health International (FHI) 360 worked in coordination with NACO and the State AIDS Control Societies to implement the Sahaay project. The Sahaay helpline operated 24 hours a day, seven days a week, for nine months (September 2013 through May 2014) as the intervention component of the Sahaay mHealth project.
The three study states in India, namely, Chhattisgarh, Delhi, and Maharashtra.
The mHealth Sahaay project was based on the Health Belief Model, and the Transtheoretical Model [
The Sahaay helpline was available to all mobile and fixed phone users. The helpline was managed by four trained counselors in each of the three call centers, serving eight hour shifts (one extra person to account for leaves); at any point of time, there were three counselors available. Counselors with different local dialect backgrounds were purposively hired to provide counseling in local languages as well as Hindi. The duty hours and break-time between the three centers were adjusted to ensure there was no discontinuity in the availability of counselor. Counselors were provided with computer-based software containing a database with a comprehensive list of possible questions and appropriate responses to answer questions promptly and correctly. The database contained an area-wide list of health services that MSM can be referred to for further support and treatment like HIV testing, ant-retroviral therapy (ART), STI diagnosis and treatment, and other general and specialized health issues.
The call centers were housed in three selected MSM-led CBOs that delivered other prevention services for MSM. A caller could receive information and counseling by talking to a counselor, hearing interactive voice response, and receiving text messaging.
The client interaction process comprised a greeting message, then the helpline assured the caller of the confidentiality, and the interactive voice response system (IVRS) asked the caller if they were seeking information for MSM, transgender (TG), or other groups. For MSM or TG selections, it gave the caller different options for seeking information: talk to a counselor (this option provided the caller with an option of interaction with the counselors and to get information and counseling), voice IVR messages (consisted of prerecorded voice messages which offered options for selecting information), or SMS (when the caller selected SMS as means for information seeking on helpline, the caller was sent a SMS message to select the option from the main list of information) (SMS were charged as per the service provider).
If the selection was not MSM/TG, then the helpline gave the caller the other general helpline numbers for HIV/AIDS (in Delhi and Maharashtra, there was a NACO supported general HIV/AIDS helpline) and the call ended. Calls where clients requested to speak to a counselor were received at any of three call centers in Chhattisgarh, Delhi, and Maharashtra where the counselor was available. In case the caller had a specific language preference, the call was transferred to the location where the counselor spoke the desired language. While the call landed with a counselor, a screen called “Call Documentation Sheet (CDS)” popped up to document the call, with the following indicators: new/duplicate caller, categories of MSM, purpose/issues for calling, accessing other sources of help, awareness of HIV and STI, attitude toward HIV/STI, condom use behavior, HIV testing behavior, willingness to pay for helpline, and how they learned about the helpline. Counselors entered this information on the CDS while speaking to the caller. The CDS also had notes from previous calls if the caller had called previously.
In the event a counselor did not have sufficient information on any topic, s/he had access to a knowledge base in the form of “Counselor Manual” and “Standard Operating Procedure”. In case the caller requested the address of any facility, the counselor had an option of searching through a resource directory and sending the address by SMS to the caller. At the end of the call, the counselor saved the information and the CDS was closed. The counselors also documented select case studies of callers and qualitative data in a notebook. Based on counselors’ feedback, the IVR and SMS messages were updated at the third and sixth month.
Helpline interactive voice response system (IVRS).
The following services were provided to the caller: HIV/AIDS counseling, including promotion and referral for HIV testing of callers and their partners to different facilities like TI projects, STI clinics (government run centers for free of cost STI diagnosis and treatment), and Integrated Counseling and Testing Centers (ICTC) (there are 1000s of government HIV testing and counseling centers across the country where the screening and the confirmatory HIV test is done free of cost); and psychosocial counseling, with information and education on HIV/AIDS, MSM risk reduction, and condom and lubricant use.
A team of 12 Community Mobilizers (CMs; who had themselves been hard-to-reach MSM earlier), four in each study state, first mapped hot spots patronized by MSM in each district of the state and planned their recruitment approach. CMs then promoted the Sahaay helpline through interpersonal contact in the community, by distributing contact cards at cruising sites, and posting helpline posters and stickers in key locations like government TI projects, MSM preferred health care providers, and beauty and massage parlors where hard-to-reach MSM either work or go for services. The project also developed radio spots that were broadcast through the All India Radio; these particularly reached the rural population.
Social media, including Facebook, Twitter, and PlanetRomeo, was utilized to disseminate messages widely. Each day a new message was posted on Facebook and Twitter. A promotional video (“BOL NA MERE YAAR”, “Tell me My Friend") posted on YouTube and different other social media channels became very popular. Leading media houses (Times of India, Hindustan Times, Indian Express, and Time Out), prompted by the project’s press releases, published articles on the Internet, and in print.
The software program also functioned as a management information system (MIS). It monitored the content of the call and helpline performance. Data generated by the MIS included,
Helpline system monitoring data generated automatically and collected daily
Counselor call monitoring data, for example, data the counselors documented on the CDS
Case studies recorded in the counselor’s notebook; collected during the weekly counselors mentoring done through conference calls by FHI 360 staff.
The FHI 360 staff (Behavior Change Communication Officer and Program Officer) mentored the counselors and the CMs through weekly teleconferences. The CMs were selected from and worked within their respective states (four from each state) to address local outreach activities for hard-to-reach MSM. The CMs reported the number of new hard-to-reach contacted and motivated to make the first call daily through SMS texts.
The caller’s telephone number was not visible to the counselor, but was stored in the server in computer encryption. Clients making multiple calls using the same phone number were shown as duplicate callers on the computer screen of the counselor. The counselor did not ask any personal identifier (like name and address), but discussed HIV/AIDS risk behaviors and provided the required counseling and information on services. The counselor could not open the CDS after saving it. The CDS was stored as an encrypted file in the cloud-based server; consolidated information was generated periodically by the server administrator and used by the project team to monitor the helpline.
Based on responses given to the counselors,
Categories of men who have sex with men (MSM) (N=39,800; multiple counts).
The project had established a daily target of 260 calls to achieve a target of 50,000 unique callers (callers counted as individuals) during the nine months (September 2013 to May 2014) of the helpline intervention. The helpline maintained an operational uptime of 99.81% (6450/6462 hours). Helpline call volume is displayed in
Sahaay helpline call volume by service request (N=102,115).
Type of calls | Number | Percentage n (%) |
Total calls | 102,115 | 102,115 (100.00) |
Counselor calls | 51,988 | 51,988 (50.91) |
IVR | 45,212 | 45,212 (44.28) |
SMS | 4915 | 4915 (4.81) |
Though promotion through social media; information, education, and communication (IEC) materials, news articles, and other modes of communication helped boost the number of calls, the contacts made by CMs indicate a significant role for interpersonal communication in promoting calls from hard-to-reach MSM. As
Promotional activities used (N=39,800; multiple counts), (Information, education, and communication = IEC).
Many callers in the beginning did not speak, while others spoke very briefly just to confirm confidentiality, and many callers opened up only after multiple repeat calls. Most callers (93.10%, 37,055/39,800) requested information on HIV/AIDS and STI; some also requested information on issues specific to transgenders, for example, breast enhancement and sex reassignment surgery, while some (27.01%, 10,750/39,800) requested counseling on HIV/AIDS, STIs, and other health and nonhealth issues (many callers requested information and also took counseling; hence the total of information and counseling is >100%; 120.11%, 47,805/39,800). Many callers faced psychosocial problems like “self-identity crisis”, crisis in family relationships, violence and abuse, drug abuse, addiction, or discrimination in the work place or an educational institution. Self-identity crisis included MSM trying either by themselves or forced by others to comprehend their sexual identity (the MSM may not feel attracted to a female and start thinking why this is so with me; or his friends may tease him for his attraction toward a male). Crisis in family relationships included family members pressuring unmarried MSM to get married with women and married men pressured to abandon their sexual life choices. The majority of the callers (79.80%, 31,759/39,800) discussed HIV-related issues, while one-third (34.11%, 13,575/39,800) discussed STI-related issues. A small proportion (15.05%, 5989/39,800) of callers discussed other health issues, including psychosocial problems (4.93%, 295/5989) (many callers discussed multiple issues, hence the total is >100%; 128.95%, 51,323/39,800). Though the project did not measure knowledge of the caller, but they indicated they might know less about STI symptoms and treatment compared to HIV (
Type of information asked on HIV and STI (N=39,800).
Type of informationa | HIV (31,759; 79.80%) n (%) | STI (13,575; 34.11%) n (%) |
Prevention | 28,365 (89.31) | 9419 (69.38) |
Symptoms | 16,932 (53.31) | 12,856 (94.70) |
Condom/lubricants | 16,885 (53.17) | 8718 (64.22) |
Treatment | 2958 (9.31) | 10,754 (79.22) |
amultiple counts
Many of the callers, (39.25%, 15,622/39,800), asked for and were provided with contacts for various services. Referrals were made to ICTCs (39.02%, 6096/15,622), TI implementing NGOs (CBO/NGO implemented projects working mostly for HIV prevention and referral for HIV testing and treatment services) (22.95%, 3585/15,622), ART centers (government run HIV treatment centers, the services are provided free of cost) (11.04%, 1724/15,622), STI/STD clinics (9.03%, 1411/15,622), Community Care Centers (CBO run centers for providing supporting role in care and treatment of HIV/AIDS, especially during initiation of ART for early detection and management of side-effects of drugs; and where a long-term stay is required for supportive HIV/AIDS care) (6.96%, 1087/15,622), PLHIV MSM networks (5.96%, 931/15,622), and to tuberculosis directly observed treatment center (centers for diagnosing and treating tuberculosis).
Although none of the 39,800 callers reported consistent use of condoms during all sexual acts with all partners for more than six months, they were at various stages of the behavior change continuum, 17.98% (7156/39,800) reported that they did not intend to use condoms; 58.07% (23,111/39,800) would like to use them; 16.03% (6379/39,800) stated that they used condoms sometimes; and 7.96% (3168/39,800) used condoms always, but for less than six months. The counselors explored the reasons for inconsistent condom use. The most common reason provided was “lack of (sexual) satisfaction” (43.28%, 17,224/39,800), followed by unavailability (24.03%, 9565/39,800), partner refusal (15.03%, 5980/39,800), “does not know how to use” (12.01%, 4780/39,800), and “condom breaks” (10.02%, 3988/39,800). Only 1.00% (399/39,800) said, they do not have money to buy or are embarrassed to buy condom.
Almost 70% of the callers, or 27,963/39,800, did not report HIV testing in the last one year; the counselor probed for the reasons for not getting tested. The most common reason for not getting tested was “fear” (50.82%, 14,211/27,963) followed by “lack of HIV testing awareness” (23.90%, 6682/27,963), “do not know where to go” (14.74%, 4122/27,963), and “lack of confidentiality at the HIV testing center” (11.12%, 3110/27,963). Only 1.03% (289/27,963) said that they did not have money for testing. Counselors reported that some callers were motivated to get tested after the call, of whom a small group called back to inform the counselors that they had taken an HIV test.
The Sahaay helpline had a capacity for 32 simultaneous calls including IVR, SMS, and counselor calls. Information technology system support (server, software, and operational glitches) was provided to ensure uninterrupted service around the clock. The helpline was monitored from the FHI 360 India office in Delhi. A continuous monitoring screen facilitated viewing of how many counselors were online and which calls were diverted to which counselor. The FHI 360 team could observe which counselors took the calls and completed the post call documentation. As part of the helpline quality control strategy, the team at the FHI 360 office used “mystery callers” posing as MSM callers with predetermined questions. The mystery calls demonstrated steady improvement in the performance of counselors in addressing the queries of the callers and counseling them on different issues. The helpline answered more than 80% (81.33%, 83,050/102,115) of all calls. More than three-fourths of the calls came between 9:00 am-12:00 pm.
It is encouraging to note that the helpline received more than 100,000 calls during the nine months of activities reaching out to different profiles of hard-to-reach MSM with information and counseling on HIV/AIDS prevention, care, and treatment. The experience of this helpline is in agreement with the findings of other mHealth service studies, which concluded that these services have wide population reach and can be individually tailored to the caller. This suggests that the service has potential as a delivery channel for HIV prevention and other health behavior interventions. HIV prevention and care programs using digital media have great potential to cost-effectively meet the complex needs of diverse and often underserved populations living with or at high risk of HIV [
Innovative strategies for behavior change communication at individual, group, and community levels may include mobile phone messages, Internet-based strategies, and social marketing campaigns. Current prevention interventions for MSM in India need to consider appropriate modifications to reach out to the hard-to-reach MSM through innovative modalities, like the Sahaay model anonymous helpline service. There are various studies that advocate the use of mobile telephones in scaling up the health care delivery and outcomes. A study by Garai et al [
Our findings show that interpersonal communication was more helpful in promoting the helpline services as compared to other modes of communication including IEC and social media. As reported from case studies and also from the data on issues requested by callers, there were many calls by those who were suffering from psychosocial issues. External factors, like legal and social barriers often aggravate psychosocial issues facing MSM. India needs HIV prevention approaches that simultaneously address behavioral, biomedical, and structural risks like decriminalization of same-sex behaviors, policies that safeguard MSM and transgender rights, engagement with the media, and community and health systems strengthening with participation of the MSM community. Behavioral approaches to promote safer behaviors to prevent HIV, specifically sustained efforts to increase the use of condoms, should be continued.
Though the Sahaay helpline used a meticulously planned, technically sound monitoring system, the helpline experienced several challenges. Owing to the confidential nature of the helpline, a written referral system could not be implemented. Calls came from throughout the country though the study was located in just three states, and the resource directory of services and facilities developed only included services in the three states, hence the counselors were unable to provide the address of the services and facilities in other states. At times, some prank callers used offensive language; this negatively affected the morale of counselors. Sometimes, there were operational glitches, such as the telephone and Internet line leading to the CDS not opening on the counselor computer, or call disturbances and disconnections. Very few callers accessed the SMS service. The Telecom Regulatory Authority of India did not allow delivery of text messages to mobile phones registered for “do not disturb” facility (in India, one can register with the telephone service provider for preventing calls from marketing agencies). It was also not possible for us to make the SMS service free, as a caller had to dial a number different from the toll free helpline number to access Sahaay messages through SMS. Additionally, the SMS service was available only in English (as most of the commonly used mobile phones in India support English and not Hindi). We also had very low utilization of an automated feedback system, potentially preventing detection and resolution of other technical problems. Because of the Indian Supreme Court ruling criminalizing same sex activity, All India Radio was very selective in terms of allowing messages for broadcast; we had to significantly reduce radio messaging.
In conclusion, the Sahaay helpline demonstrated that a large number of MSM could be reached over a short period of time from diverse locations in a wide geographic area with a functioning telephonic communication. The helpline was able to penetrate the hard-to-reach MSM groups and promote HIV/AIDS prevention through a nondiscriminatory approach. The helpline is also able to provide information of different health and other services required by the callers. This intervention could be a useful national strategy for reaching out to hard-to-reach MSM in India and other countries. This approach could also be tried for reaching out to other highly stigmatized and marginalized populations.
ant-retroviral therapy
community-based organizations
Call Documentation Sheet
community mobilizers
Family Health International
human immunodeficiency virus
Integrated Counseling and Testing Center
information, education, and communication
interactive voice response system
management information system
men who have sex with men
national AIDS control organization
nongovernment organizations
people living with HIV/AIDS
short-message service
sexually transmitted infection
transgender
targeted intervention
This document was produced under, Arise: Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through the Department of Foreign Affairs, Trade and Development Canada, and via financial and technical support provided by PATH. The Arise program implements innovative HIV prevention initiatives for vulnerable communities, with a focus on determining cost-effectiveness through rigorous evaluations.
FHI 360 thanks all the stakeholders who made this study happen, the National AIDS Control Organization, Indian Ministry of Health and Family Welfare; the Canadian Government Foreign Affairs, Trade, and Development; PATH; Humsafar Trust; Mitwa; Mitr Trust; Humsaaya; other CBOs; the MSM community; service providers and Development partners; and the media.
None declared.