(MSM) and HIV in sub

Transcript (MSM) and HIV in sub

HIV infection among men having sex with men in Kampala, Uganda

Joseph Barker US Centers for Disease Control and Prevention Division of Global HIV/AIDS Co-authors: Wolfgang Hladik, Danstan Bagenda, Tom Tenywa, Michael Muyonga, John Ssenkusu, Jordan Tappero

Men having Sex with Men (MSM) and HIV in sub-Saharan Africa

• In sub-Saharan Africa men having sex with men: – – – Criminalized behavior Highly stigmatized Often not included in national AIDS control programs • MSM often have female sex partners – “Bridging” population 2

HIV Epidemic in Kampala

• HIV in Kampala – Population 1.4 million – – HIV prevalence: 8.5% † HIV prevalence among adult males: 4.5% † – Heterosexual transmission – Little data on hidden populations considered most-at risk for HIV infection, including MSM • Sex among men is illegal 3 † Uganda HIV/AIDS Sero-Behavioural Survey 2004-05

• •

Survey Design

CDC, Makerere University SPH, MOH-Uganda May 2008 – April 2009: concurrent sampling of six most at-risk-populations (MARP) groups – Central survey office • • Respondent-driven sampling (RDS) – “Chain referral sampling” - survey participants refer (recruit) their peers – Probability sample • Projects sample characteristics to target population Eligibility criteria – MSM – – – Age 18+ years Resident in greater Kampala Reported anal sex with a man in last 3 months 4

• •

Data Collection and Biomarkers

Audio Computer-Assisted Self-Interview (ACASI) – – – Increased validity for sensitive questions Focus on behavioral risk English, Luganda Biological Measures

Specimen type

Rectal swab Urine

Agent

Chlamydia trachomatis Neisseria gonnorhea Test

Cobas Amplicor or Amplicor PCR test Venous blood

HIV T. pallidum

EIA in parallel (StatPack – tiebreaker) TPHA  RPR 5

Statistical Analysis

• Descriptive analysis – RDS Analysis Tool (RDSAT) – Weighted population estimates, adjusted for non random sampling frame – Version 5.6

• Bivariate and multivariate analysis – STATA – Associations between respondent characteristics with HIV infection – Logistic regression modeling • Backwards elimination 6

Sampling

• Sample size: 303 participants

Survey start Sampling slumps Sampling recovers Sampling slumps Sampling Sampling remains low effort cease May ‘08 May-Jun

Arrests of LGBT rights activists (Kampala Implementers Meeting)

Jul-Aug Sep

Arrests of gay persons, alleged abuse by police

Oct-Mar

Apr ‘09

Baseline demographics Characteristic n % (95% CI) Age

18-24 years 25+ years Median (IQR)* 143 152 50 (40 – 57) 50 (43 – 60) 25 years old (21 – 29)

Years of School

None 1-7 years (Primary) 8 -13 years (Secondary) 14+ years (Tertiary) Median (IQR)* 21 72 8 (4 – 12) 27 (20 – 36) 108 88 38 (31 – 46) 27 (20 – 34) 11 years (7 – 14)

*Unweighted median and IQR

94% of MSM in Kampala are Ugandan 8

Marriage, female partners, children

• • • • • Ever married: Currently married: 31% 20% Living with female sex partner – – Ever: Currently: 44% 16% Ever sex with women: 78% Fathered children: 29% 9

Sexual orientation and attraction Straight/Heter osexual 7% Mostly/onl y women 19% Bisexual 37% Both men and women 12% Gay/Homosex ual 56% Mostly/onl y men 57% had disclosed their same sex activity to other people

70%

Prevalence ( 95% CI ) of selected STIs Any STI (including HIV) NG (rectal) CT (rectal) NG (urethral) CT (urethral) Syphilis HIV CT: Chlamydia trachomatis NG: Neisseria gonorrhea 0% 1,9% 1,1% 1,4% 1,2% 10% 22,1% One in five MSM has at least one STI 8,3% 13,7% 20%

30%

HIV prevalence by age group Age 25+ Age <25 0% 22,4% 3,9%

Older MSM substantially more likely to be HIV+ than younger MSM HIV prevalence ratio: 5.7

5% 10% 15%

20% 25%

Perceived vs. actual HIV status

Actual Neg Neg

35%

Perceived Pos

D/K

44%

Pos

6% 1% 5%

Most HIV-pos MSM think they are HIV-neg or don’t know their status Most MSM who think they are HIV-pos are not Ever tested for HIV: 44%

D/K: Don’t know

Ever forced to have sex, blackmailed, or physically abused Ever forced to have sex 26% Ever blackmailed Ever physically abused 37% 37%

Median number ( IQR ) of male sex partners by type in last 3 months Men recruits bought sex from

2 Commercial / transactional sex frequent:

2 42% ever sold sex Casual sex partners 2 Steady sex partners 4 0 * Among those engaging in commercial sex 5 10

Median number ( IQR ) of female sex partners by type in last 3 months Women recruits bought sex from *

1 24% ever sold sex to women 0 On average, MSM report one female steady partner in last 3 months Casual sex partners 0 Steady sex partners 1 0 * Among those engaging in commercial sex 5 10

Median proportion of condom use in last 3 months by partner type Commercial partners Female casual partners Female steady partners 33% 40% 39%

Sub-optimal condom use across all partner types, especially for commercial sex

Male casual partners 43%

26% never use condoms

Male steady partners 50%

Most MSM used lubricants, although most lubricants were oil based 17 17

“What kind of anal sex (insertive, receptive) do you think is more dangerous to get HIV?” Both no risk 11% Both equal 65% Insertive 13% Receptive 11%

Multivariate analysis Factors associated with HIV serostatus among MSM Characteristic Unadjusted OR (95% CI)

Adjusted OR (95% CI)

P Age

18-24 years 25+ years Ref 5.7 (2.0 - 16.0) 0.001

Ref 4.3 (1.5 - 12.8) 0.008

History of violence or abuse

Never Ever Ref 6.4 (2.5 – 16.4) < 0.001

Ref 4.8 (1.8 – 13.1) 0.002

Factors non-significant in multivariate analysis but adjusted for: sexual orientation, alcohol consumption, use of lubricants, reported STD symptoms.

•

Discussion

Arrests and allegations impeded sampling • Almost all MSM in Kampala are Ugandan • Most MSM in Kampala had sex with women • Poor knowledge of HIV risk with anal sex • Sub-optimal condom use, high number of partners • Reports of history of violence and abuse 20

Discussion

• HIV prevalence (14%) 3x higher than among Kampala men – AIS 2004/5: 4.5% • Older MSM are 4x more likely to be HIV infected than younger MSM • MSM reporting abuse 5x more likely to be HIV infected than those who are not abused 21

Recommendations

• Include MSM in national strategic AIDS control planning and gender based violence initiatives in Uganda • Work with MOH, NGOs, advocacy groups to initiate tailored interventions – – – – Counseling to address anal sex Promote condom use Make safe lubricants available Increase access to diagnose and treat anal STDs 22

Acknowledgments

(Courageous) Survey respondents CDC Uganda Wolfgang Hladik Frank Kaharuza John Ssenkusu Simon Kyazze Sylvia Nakayiwa David Katuntu Suzanne Theroux Stephen Ssebagala Kelly Bartholow Brad Bartholow Jordan Tappero Makerere University David Serwadda Danstan Bagenda Susan Mawemuko Rachel Kwezi George Lubwama Other Crane Survey staff UCSF Rachel King Ministry of Health Alex Opio Michael Muyonga Tom Tenywa

The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you

Contact: Joseph Barker: [email protected]

Wolfgang Hladik: [email protected]

Types of lubricants used Butter Baby oil 10% cooking oil 11% Vaginal gel 25% Hand lotion 15% Petroleum jelly 35% Saliva 4%

Green font: oil based lubricants

Other

78% ever used lubricants

0% 15% 5% 10% 15% 20% 25% 30% 35% 40%

Type of sex partner at first MSM episode Friend 70% Relative Acquaintance Stranger Prison inmate 'Authority figure' 7% 7% 6% 3% 8% Median age at first sex: 18 years 0% 20% 40% 60% 80%

• • • •

Survey Procedures

Coupon-based peer referral to central survey office 1 st visit to survey office – – – Quantitative data collection Specimen collection Peer referral Interim (2 weeks) – Laboratory testing 2 nd visit to survey office – – Return of test results Interview on peer referral efforts 27

Significant associations (95% CI) with HIV infection* 6.1

Age 25+ Recreational drug use 0.2

Never used lubricants 0.1

Ever been abused STI-positive (any) 3.1

6.7

*Bivariate analysis

0 5 10 Odds ratio 15

28 28

Type of sex partner at first MSM episode Friend 70% Relative 7% Acquaintance Stranger Prison inmate 7% 6% 3% 'Authority figure' Median age at first sex: 18 years 0% 8% 20% Authority figure categories: Religious leader : 50% Teacher: Military : Police : 22% 11% 17% 40% 60% 80%

Reported STD symptoms in last 12 months Anal warts 19% Anal discharge 14%

36% report at least one anal STD problem

Anal ulcer or sore 26% 32% Genital ulcer Genital discharge or burning 29%

30 30

Abuse and HIV infection

• •

Did you ever suffer any violence or abuse because you have sex with other men?

MSM reporting any violence or abuse were 6.4 times as likely to test positive for HIV – 95% CI 2.5 – 16.3,

<0.001

RDS: A chain starts with a seed Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Seed Person fulfilling eligibility criteria - Purposively chosen - Can be one or several

This seed then recruits others Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Seed

…and these recruit others… Wave 1 Wave 2 Wave 3 Wave 4 Wave 5

…and these do likewise… Wave 1 Wave 2 Wave 3 Wave 4 Wave 5

…and so on… Wave 1 Wave 2 Wave 3 Wave 4 Wave 5

…until sample size is reached Wave 1 Wave 2 Wave 3 Wave 4 Wave 5

Factors not associated with HIV infection

• Education • Marital status • Unemployment • Alcohol use • Circumcision status • HIV testing history • No. lifetime partners • History of rape • Reported STD symptoms • Sex with women • Condom use • Mainly receptive anal sex GAP Brown Bag HIV infection among MSM in Kampala, Uganda 38

Sampling characteristics

Sampling duration: Seeds: No. coupons issued: Highest wave achieved: 10 months 14 1,706 11 Equilibrium (HIV), wave No.: 2 Recruits screened: 454 Ineligible recruits:

Eligible recruits:

146

303

What do you think is your HIV status?

Don't know Negative Positive 12% 45% 44%