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PrEP in India’s HIV Prevention 

Policy in the Era of Social Media 

and Sex Positivity 
 

Anindya Kar1*, Dinesh Bhugra2, 

Shuvankar Mukherjee3, Agnibho 

Mondal4, Aaditya Suresh Kumar5  

 
 
1Department of Psychiatry, Advanced 

Neuropsychiatry Institute, Kolkata, India;  
2Health Service and Population Research 

Department, Institute of Psychiatry, 

Psychology & Neuroscience, King’s College 

London, London, UK; 
3Department of Community Medicine, 

Calcutta National Medical College, Kolkata, 

India; 
4Department of Tropical Medicine, School of 

Tropical Medicine, Kolkata, India; 
5Department of Neurology, Institute of 

Neurosciences, Kolkata, India 

 

*Corresponding Author 

 

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DOI 10.5195/cajgh.2020.407   |   http://cajgh.pitt.edu 

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Abstract 

Introduction: The global revolution of online social media and connectivity had a tremendous effect on sexual behavior in both 

developed and developing countries. This global change is influencing the societal structure and existing social principles. 

Moreover, it has a significant impact on the epidemiology of different infectious diseases, especially HIV. 

Discussion: India is one of the most diverse democratic countries that has undergone a social-cultural transition in the last decade. 

However, having the second-highest HIV infection rate in the world, India does not have any other new prevention tools in their 

national HIV prevention strategy. Pre-Exposure Prophylaxis (PrEP), a boon of HIV prevention widely used in different countries, 

is still not implemented in India. The concept of “Digital India” by the Government of India is giving wide access of internet to the 

people of India. Furthermore, people are exposed to social media, and that is impacting their sex seeking behavior. Interestingly, 

recent legal changes in India promotes sex positivity. It also calls for introspection on existing HIV preventive strategies. 

Conclusion: Given the current scenario of PrEP and other existing preventive measurements of HIV, further research is needed to 

determine the acceptance and efficacy of PrEP and improve engagement in care for individuals in India. Various international 

studies recommend effective implication of PrEP to reduce the rate and economic burden of HIV infection. 

Keywords: HIV; PrEP; Social Media; India; Sex Positivity 

PrEP in India’s HIV Prevention Policy 

in the Era of Social Media and Sex 

Positivity 

 

 

Anindya Kar1, Dinesh Bhugra2, 

Shuvankar Mukherjee3, Agnibho 

Mondal4, Aaditya Suresh Kumar5 
 
 
 
1Department of Psychiatry, Advanced 

Neuropsychiatry Institute, Kolkata, India;  
2Health Service and Population Research 

Department, Institute of Psychiatry, Psychology & 

Neuroscience, King’s College London, London, 

UK; 
3Department of Community Medicine, Calcutta 

National Medical College, Kolkata, India; 
4Department of Tropical Medicine, School of 

Tropical Medicine, Kolkata, India; 
5Department of Neurology, Institute of 

Neurosciences, Kolkata, India 

Research 

India’s socio-cultural transition in the last 

decade has been impactful on the demography of HIV1. 

The recent explosion in social media usage and the 

Digital India campaign are remarkably changing human 

interaction on many levels. The giants of social media 

like Facebook and Twitter, along with dating apps like 

Tinder and Grindr, are not restricted to a particular group 

of people in India but cater to wide and diverse 

populations. This heterogeneous distribution of social 

media users has an impact on sexual behavior and its 

risks. Furthermore, it appears that the incidence and 

prevalence of HIV varies among people of different 

cultural backgrounds due to an interplay of psychological 

and social factors. The provision of healthcare in any 

democratic country, such as India, is influenced by the 

demands of its people of many different cultural 

identities and relies on social, political and economic 

factors to achieve an optimal prevention policy. The 

recent changes in HIV prevention policy of India where 

every individual with HIV positive status are being 

treated with free antiretroviral therapy (ART) 

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irrespective of their CD4 count are definitely1 benefitting 

the people living with HIV (PLHIV). However, HIV 

infection is a significant public health burden in India, 

and Pre-Exposure Prophylaxis (PrEP) is still an alien 

concept. The global sexual renaissance2 has changed 

societal attitude towards consensual online sex. In India, 

online dating applications and websites are also widely 

used, and the pattern of sex-seeking behavior has 

drastically changed in the last few years3. Policy makers 

need to take into consideration behavioral responses to 

changes in the cost of disease and implement strategies 

that are holistic and long-sighted. This paper will review 

these changes and how they impinge upon and, by so 

doing, help the policy makers and clinicians to identify 

the need of PrEP and address these issues in a culturally 

sensitive way.  

 

Discussion 

Global perspective of PrEP 

Behavioral interventions and barrier methods, 

such as the use of condoms, slowed down the HIV 

epidemic in past4, but as long as no vaccine is available, 

new intervention strategies are still urgently needed. The 

two drug fixed-dose combination therapy with 

emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) 

became the first to be used as PrEP, known as Truvada, 

and was approved by USA Food and Drug 

Administration (FDA) in July 2012 for high risk groups5. 

Both TDF and FTC are nucleos(t)ide analogue reverse 

transcriptase inhibitors (NRTIs). They have longer half-

lives, which allow for less frequent dosing6. In fact, the 

half-lives of TDF/FTC are the longest for the NRTI class, 

a potentially favorable pharmacological characteristic for 

PrEP from an adherence perspective3. Prior to the FDA 

licensure there was a series of meta-analyses of studies 

on PrEP that had been done on high risk groups, i.e. those 

who are vulnerable to HIV infections. A sub-analysis of 

the men who have sex with men (MSM) study (known as 

the Pre-Exposure Prophylaxis Initiative [iPrEX]) showed 

that with optimal adherence, efficacy was more than 

90%, and incidence of HIV infection was reduced by 

92%7,8. Other trials, including one among serodiscordant 

heterosexual couples in Kenya and Uganda and another 

among sexually active young men and women in 

Botswana, have also demonstrated promising results for 

the use9 of PrEP as a prevention strategy. As clinical trials 

continue to establish efficacy, researchers have been 

increasingly interested in awareness and acceptability 

among potential candidates of PrEP. Studies have found 

that overall knowledge of PrEP is low to modest, with 

concerns relating to potential side effects, costs, drug 

resistance and accessibility10. On a recent study amongst 

HIV-negative individuals, some men suggested that the 

reason for the likely future adoption of PrEP was the 

opportunity to engage in sex without condom use, either 

with their serodiscordant partner or casual partners. Other 

participants equated PrEP adoption with greater sexual 

freedom11.  

In July 2014, the World Health Organization 

(WHO) suggested that all MSM should consider taking 

PrEP in conjunction with other risk reduction strategies12. 

Countries like South Africa, Australia, United Kingdom, 

Germany and other European countries have considered 

PrEP as an emerging strategy and an important addition 

to the toolbox of HIV prevention13. Understanding the 

cultural context of PrEP provision is vital for 

implementation, with factors such as sexual practice, age 

and gender playing important roles in HIV acquisition 

risk and acceptability of interventions. Pressure has 

increased globally for countries to submit to regulatory 

authorities and include PrEP in national policies. 

HIV in India—Current scenario and challenges 

The most prevalent mode of HIV transmission 

in India is sexual route14. According to the recent data of 

2018, the new HIV infections increased to 88,000 from 

80,000 and AIDS-related new deaths increased to 69,000 

from 62,000 in India15. The UNAIDS data suggests 

almost 79% of PLHIV are aware of their status and on 

effective ART. The treatment efforts, primarily through 

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Region Adult HIV Prevalence (%) 

India 0.22 

Mizoram 2.04 

Manipur 1.43 

Nagaland 1.15 

Telangana 0.7 

Andhra Pradesh 0.63 

Karnataka 0.47 

Goa 0.42 

Maharashtra 0.33 

Delhi 0.3 

Tamil Nadu 0.22 

Table 1.  States with Adult (15-49 years) HIV Prevalence about the National Average, 2017 

ART, helped to manage their infection. Most 

importantly, the introduction of Indian government’s 

‘test-and-treat’ policy, irrespective of the CD4 counts and 

clinical stage of the disease, catalyzed the process of 

“Treatment as Prevention” (TasP)11 Moreover, the rate of 

new infections and deaths is not falling rapidly enough in 

meeting the 90–90–90 ambitious treatment target to help 

end the AIDS epidemic given by the Joint United Nations 

Programme on HIV/AIDS (UNAIDS)16. The state wise 

prevalence of HIV infections in India given by National 

AIDS Control Organization (NACO) in 2017 is 

elaborated in Table 1 and Figure 1. A recent study says 

PrEP with a biannual testing program has the potential to 

improve average per-person survival by nearly one year 

and block more than 270,000 HIV transmissions in 

India17. PrEP drug costs18 are lower than HIV treatment 

costs, both per-dose and for the duration of use. 

Moreover, PrEP is prescribed to be taken consistently, 

but only when someone is at heightened risk of HIV, 

whereas, should someone acquire HIV, they will need to 

be on ART for their entire life in order to stay healthy18,19. 

In May 2018, drug maker Cipla received regulatory 

approval in India to sell its version of Truvada as Tenvir 

EM20. However, this highly expensive monthly drug 

remains out of reach for many people who want and need 

it. There are no studies from India that can establish the 

efficacy or acceptance of PrEP in India. The only trial 

that has ever been done on PrEP in India focused on 

female sex workers, led by The Sonagachi Project in 

Kolkata15. The trial was designed to assess PrEP 

feasibility in that particular population but did not 

provide sufficient evidence to recommend that PrEP be 

made routinely available by the National or State AIDS 

Control Programs for high risk individuals. 

Social media and the change in sex-seeking behavior 

With the development of the Internet and 

mobile technology, the ways of socializing and seeking 

sexual partners have changed dramatically21. Mobile 

online dating applications like Grindr and Tinder along 

with other social media sites are widely used to seek 

potential sexual partners among both heterosexual and 

homosexual people22. Seal et al. suggest that because the 

Internet can accommodate a variety of sexual 

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expressions, as well as allow anonymity for the user, it 

provides an ideal environment to explore sexuality23. 

Online partner seeking also allows people to more 

precisely delineate specific partner characteristics, such 

as HIV serostatus or a desire to engage in certain types of 

sexual behaviours20. However, there is no literature on 

sex-seeking behavior in India, especially on the use of 

social media. Most of the current literature on the use of 

the social media has focused on MSM. In contrast, 

relatively little research, especially qualitative research, 

has focused on heterosexual individuals. This is 

potentially due to the large burden that HIV infection has 

on MSM populations or that MSM use the Internet more 

actively to find sex than heterosexual men and women24. 

It was estimated that in the beginning of 2018, there were 

almost 3 million users on one of the most popular 

heterosexual dating apps in India25. On the other hand, 

various gay dating apps also have a significant number of 

users, one example being Grindr, which boasts around 

4.5 million users worldwide as of 202026. Gay dating 

apps often give reminders of HIV testing, ask if the 

person is on PrEP and whether the person has an 

undetectable viral load if the person is seropositive27. 

These dating apps also spread the message that 

‘undetectable equals untransmittable’28. Undetectable 

equals untransmittable is the message of the UNAIDS 

campaign that shows the evidence demonstrating that 

HIV treatment is highly effective in reducing the 

transmission of HIV29,30. 

Apart from this, Facebook is also used for no 

strings attached sexual encounters31. Another popular 

application, Instagram, is also quite popular among the 

youth to find casual partners for physical intimacy32. 

There were around 201 million and 35 million Indian 

users on Facebook and Instagram respectively in 201733. 

Source: National AIDS Control Organization of India, 2017 

Figure 1. People Living with HIV, Percent Distribution Among States, 2017 

 

 

18

15

13
12

10

7

7

6
4 4 4

Remaining States/UT Maharashtra Andhra Pradesh Karnataka

Telangana Tamil Nadu West Bengal Uttar Pradesh

Bihar Gujarat Rajasthan

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Sex positivity and legal changes 

Sex positivity is defined as “a positive attitude 

to sexual activity that is seen as a healthy relationship and 

form of self-expression”34. Sexual pleasure is a valuable 

attribute in itself even without the context of marriage, 

procreation or an intimate relationship. It is, in itself, an 

important and positive part of human existence. 

“Hookups” or uncommitted sexual encounters, are 

becoming progressively more engrained in popular 

culture, reflecting both evolved sexual predilections and 

changing social and sexual scripts35. This particular trend 

has been catalyzed by emerging online dating apps 

coming into the mainstream and challenged the existing 

ideas of monogamous relationships, prioritizing 

consensual sex36. 

Social change influences laws37,38. In 2014, the 

Supreme Court of India recognized the transgender 

persons as members of a third gender alongside male and 

female39. In January of 2018, the Supreme Court in its 

judgment on privacy, said that Right to Privacy and the 

protection of sexual orientation lie at the core of the 

fundamental rights guaranteed by Articles 14, 15 and 21 

of the Indian Constitution40. On September 06, 2018, in a 

historic judgment, the Supreme Court of India removed 

consensual adult sex as a crime under section 377, saying 

sexual orientation is natural and people have no control 

over it41. Before this, the law particularly affected the 

Lesbian, Gay, Bisexual, Transgender (LGBT) 

community and violated the right to form association 

under Article 19 of the Indian Constitution42. On 

September 27, 2018, the apex court also ruled that 

adultery is no longer a crime under law, recognizing that 

the colonial-era law was unconstitutional and had some 

gender based discriminatory elements43. 

Empowering with PrEP 

PrEP empowers the susceptible people 

including women to HIV infection44. PrEP also reduces 

the stigma of HIV infection and hence acts as an 

emancipator of people living with HIV by reducing the 

risk of acquiring HIV infection amongst serodiscordant 

couples39. PrEP is considered as an option for HIV-

negative women who want to have a baby with their 

partner living with HIV45. It is also considered as a 

mature and empowering approach for a person who is in 

a relationship with a partner who is not willing to use 

preventive measures. Furthermore, it is a valuable 

method that allows women to protect themselves from 

HIV infection without dependence on their male sex 

partners to use condoms.  

On the other hand, there is a wide range of 

stigma and stereotyping regarding certain sexual 

positions within the gay community46. The bottom, or 

receptive partner during sexual intercourse, is 13 times 

more likely to get infected with HIV than the top, who is 

the insertive partner47. Furthermore, bottom shaming is 

highly prevalent due to the gender roles related stigma, 

as the receptive partner is associated with femininity48. 

PrEP is the first opportunity bottoms have ever had to be 

in full control of their risk of HIV transmission. 

Moreover, it allows both partners, regardless of sexual 

position, to be responsible for their own protection49. In 

a country like India, where almost 90%50 of transgender 

people are involved in sex work, PrEP, if implemented, 

will be added to the arsenal of measures they can employ 

to protect themselves51.  

 

Recommendations 

Implementation of PrEP is a long time 

constructive work. A few recommendations that can be 

considered are  

a) Policy makers should be sensitive to cultural 

backgrounds and aware of social changes. 

b) There should be further studies on 

acceptance, efficacy and side effects of PrEP in 

India. 

c) The medical curriculum needs to be gender 

sensitive and it is important to discourage moral 

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judgement in clinical practices. The new 

updates of HIV medicine like effectiveness of 

ART to reduce transmissibility, usefulness of 

PrEP, etc. should be taught to the primary health 

care physicians. 

d) The first step in implementing PrEP is 

identifying persons at high risk of HIV 

acquisition. However, identifying such persons 

can be challenging due to perceived fear of 

stigma and social discrimination. The lack of a 

trusting relationship between the patient and the 

clinician may also make it harder. Hence it is 

important that clinicians routinely take a sexual 

and injection drug use history for all their 

patients in an open and nonjudgmental manner. 

PrEP is only fully effective when it is adhered 

to exactly as prescribed. Furthermore, it does not protect 

against other sexually transmitted infections (STIs). 

Hence, it needs to be delivered as part of a comprehensive 

package of HIV/STI prevention services based on an 

individual's circumstances. 

 

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Volume 9, No. 1 (2020) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu 

 

 

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This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by the University Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 9, No. 1 (2020) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2020.407 | http://cajgh.pitt.edu 

 

 

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