SOCIAL AND STRUCTURAL FACTORS ASSOCIATED WITH HIV RISK AMONG FEMALE SEX WORKERS (FSW) AND MEN WHO HAVE SEX WITH MEN (MSM) IN SWAZILAND, 2011 Stefan Baral, MD MPH, JHSPH

Overview

 Background  HIV Epidemiology among MSM and FSW  Objectives  Methods  Results  Quantitative  Qualitative  Conclusions

HIV Epidemiology

 UNAIDS Classifies Epidemics as:  Low level  Less than 5% Prevalence in any high risk group  Concentrated  Greater than 5% in any high risk group, but less than 1% antenatal clinics  Generalized  Greater than 1% in antenatal clinics

Global HIV Prevalence

HC IDU, SW IDU, MSM, SW, HC Legend • IDU Injection Drug Use • SW Sex Work • HC High Risk Heterosexual Transmission UNAIDS. Global Update on the HIV Pandemic. 2010

HIV Prevalence among MSM in Africa

21.5% (463) 21.8% (501)

Senegal [77]

25.0% (N/A) 13.4% (1,125)

Nigeria [79] Ghana [11]

6.2% (267)

Egypt [90]

9.3% (713) 7.3% (406)

Sudan [86]

24.6% (285) 12.3% (509) 21.4% (201)

Kenya [78] Tanzania [80]

Legend

2002 2003 2004 2005 2006 2007 2008

12.4% (218)

Namibia [82]

19.7% (117)

Malawi [81,82]

28.9% (249)

Botswana [82]

30.9% (68)

Soweto [83]

10.6% (538)

[85] Capetown (Township) [84] Source: van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009

Systematic Review of HIV among FSW

Data Quality

  Disease burden among MARPS in Africa  Data is predominantly Prevalence Data from Convenience Samples  Tells us where epidemic was and not where it is going  May not be generalizable to general population of MARPS   Samples are among young people--likely very conservative estimates of disease burden Compared against age standardized data (15-49) in general population  HIV Incidence has been characterized in cohort studies in Kenya  ~ 10% Incidence among MSM and FSW Prevalence of Same-Sex Practices/Sex work are unknown in most of Africa  Potential Risk Misclassification?

Ecological Model for HIV Risk in MSM

Level of Risks Stage of Epidemic Public Policy Community Network Individual

Source: Baral and Beyrer, 2006

Quantitative Study Goal

 To collaborate with MOH to develop a comprehensive set of data that can be used by municipal and national government in Swaziland to design evidence-based HIV prevention programs for Most at Risk Populations.

Specific Aims

 Calculate a probability estimate of HIV and Syphilis prevalence among sex workers and men who have sex with men in Swaziland  Describe behavioral factors associated with HIV/STI infection, including individual sexual practices, the composition of sexual networks, concurrent partnerships, substance use, and access to clinical health care and prevention services  Examine the role of social and structural factors on HIV-related behaviors and risk for HIV infection among sex workers and MSM including social inclusion, stigma and discrimination

Methods

    Target Populations   328 Men who have had anal sex with another man in the last 12 months 325 women who report sex work as primary form of income Accrual Methodology  Respondent-driven sampling Behavioral Survey  Validated and Piloted in each population Biological Testing   HIV and Syphilis Swaziland National Guidelines with Pre and Post-test counseling

Respondent-Driven Sampling

 Peer-referral system using coupon management system that allows for adjustment for network sizes and homophily (the concept that people recruit people that are similar to themselves)  Allows for estimation of unbiased estimates from a non-probability sample

FSW Demographics

Age <21 21-24 25-29 30+ Total Education Primary or less Some Secondary Completed Secondary or more Total Marital status Married Cohabiting Divorced/Sep Single/Never married Total Number of children None 1 2+ Total Has other income source No Yes Total No.

64 82 91 88 325 106 175 44 325 3 10 23 285 321 80 100 145 325 216 108 324

%

19.7

25.2

28 27.1

100 32.6

53.8

13.5

100 0.9

3.1

7.2

88.8

100 24.6

30.8

44.6

100 66.7

33.3

100

Numbers of Partners

Number of new clients (past 30 days)* 0-1 2-4 5-10 >10 Total Number of regular clients (past 30 days)* 0-1 2-4 5-10 >10 Total Number of non-commercial partners (past 30 days) None 1 2+ Total Disclosed occupation to Family member Health care worker

44 142 108 31 325 27 93 131 74 325 37 172 116 325 13.5

43.7

33.2

9.5

100 8.3

28.6

40.3

22.8

100 11.4

52.9

35.7

100 98 84 30.2

25.9

Condom Use

Always used condoms with new clients in past month No Yes Total Always used condoms with regular clients in past month No Yes Total Always used condoms with non-commercial partners in past month No Yes Total Always used condoms with all reported partners in past month No Yes Total Condom break/slip with any partner in past month No Yes Total

77 222 299 160 149 309 189 95 284 247 76 323 143 177 320 25.8

74.2

100 51.8

48.2

100 66.5

33.5

100 76.5

23.5

100 44.7

55.3

100

Structural Risks for HIV

Characteristic Have ever been raped Instances of rape since age 18

0 1-2 3-4 5-6 6 or more

Responsible for rape

Uniformed Officer (police, military, security) Family Member Regular partner (not client) One-time client Regular Client

As a result of selling sex:

Felt afraid to seek healthcare Experienced legal discrimination Been refused police protection Been blackmailed Verbal and physical harassment Have been tortured Have been beaten up

Have been beaten up by

Uniformed Officers (police, miltary, security) Family Member Regular Partner One time client Regular client, partner Manager/pimp

No.

123 6 77 17 9 23 4 21 14 33 7 45 21 16 11 9 6 143 152 160 113 198 173 125 44.0

46.8

49.4

34.8

60.9

53.2

38.7

20.8

9.7

7.4

5.1

4.2

2.8

Percentage

39.2

4.6

58.3

12.9

6.8

17.4

3.9

20.6

13.7

32.4

6.9

HIV Prevalence among FSW compared to Reproductive Age Women, Swaziland 2011

90 80 70 60 50 40 30 20 10 0 16-20 21-24

Age Groups

25-29 30-40 Source: Central Statistical Office & Macro International, 2008, p. 222 FSW HIV Prevalence Female HIV Prevalence

Significant Univariate Associations with HIV among FSW

 Higher Age  Lower Education  Marriage  Ever Pregnant

MSM Demographics

Characteristic Crude prevalence (N) Age 15-19 20-24 25-29 30-34 35 -39 40-44 Age Below 25 25 or older Marital status Single Married Education Some secondary school Completed secondary school Vocational training College/university Sexual orientation Gay/homosexual Bisexual Heterosexual

22.0 (71) 48.0 (155) 20.4 (66) 5.6 (18) 2.5 (8) 1.5 (5) 70.0 (226) 30.0 (97) 96.9 (310) 3.1 (10) 32.1 (101) 43.5 (137) 4.1 (13) 20.3 (64) 63.3 (205) 35.2 (114) 1.5 (5)

Sexual Practices

Characteristic Always Wear Condoms with Regular Partners Yes No Had both male and female sexual partners in the last 12 months Yes No Had a concurrent regular partnership with two or more regular partners in the last 12 months No Yes male and female Yes, two or more male partners Yes, two or more female partners Exchange sex in the last 12 months Number of male partners in the last 12 months 1 2-5 6 or more Crude prevalence (N)

50.6 (157) 49.4 (266) 37.4 (122) 62.6 (204) 45.5 (148) 20.9 (68) 31.1 (101) 2.1 (7) 26.1 (85) 32.9 (107) 58.5 (190) 8.6 (28)

Condom Use

Characteristic STI testing in the last 12 months HIV testing in the last 12 months No Yes, once Yes, more than once Access to condoms No access Difficult or little access Some access Very easy access Access to lube No access Difficult or little access Some access Very easy access Received HIV prevention for MSM last 12 months Crude prevalence (N)

13.0 (41) 45.7 (149) 30.4 (99) 23.9 (78) 0.9 (3) 17.9 (58) 11.4 (37) 69.8 (226) 26.7 (83) 30.2 (94) 15.4 (48) 27.6 (86) 27.1 (88)

Structural Risks for HIV

Characteristic Afraid to seek health care due to sexuality Felt rejected by friends due to sexuality Faced legal discrimination due to sexuality Ever been raped Ever been to prison Ever beaten up due to sexuality Crude prevalence (N)

55.3 (177) 54.4 (176) 31.2 (100) 6.0 (19) 12.9 (42) 9.0 (29)

HIV Prevalence among MSM compared to Reproductive Age Men, Swaziland 2011

60 50 40 30 20 10 0 16-20 21-24

Age Groups

25-29 30-40 Source: Central Statistical Office & Macro International, 2008, p. 222 MSM HIV Prevalence Male HIV Prevalence

Significant Univariate Associations with HIV among MSM

 Age  Syphilis  Been in Prison  Excessive Alcohol Use

Positive Prevention

    30 years into the HIV epidemic, new infections still outpace people initiating treatment Historically, most HIV prevention interventions targeted uninfected individuals  Globally, little access to HIV testing  Fear of blaming the victim and adding to stigma Recently, dramatic scale-up of HIV testing and treatment services worldwide   More PLHIV now know their status With treatment, PLHIV living longer, healthier lives Positive prevention helps people living with HIV lead a complete and healthy life and reduce the risk of transmission of the virus to others.

WHO guidelines

 In 2007, WHO issued guidelines for positive prevention interventions in resource-limited settings  However, little evidence from studies focused on PLHIV, and little focus on MARPS

Study goal

 To examine the prevention needs of Most at Risk Populations (MARPS) including Sex Workers (SW) and Men who have Sex with Men (MSM) in Swaziland to better tailor PHDP programs for these populations.

Study Methods

 Qualitative study design  One-on-one, in-depth interviews with key stakeholders (n=16) and HIV-positive SW (n=21) and MSM (n=20)  Most MSM and SW interviewed twice each for more depth  Focus groups with SW (n=3) and MSM (n=3)

Data analysis

    Weekly interviewer debriefing meetings All interviews audio recorded, transcribed, and translated into English Full day data analysis workshop held Oct. 13, 2011 at the Mountain Inn  Attended by representatives from MSM and SW groups, MOH and NERCHA staff, interviewers and members of the research team, clinicians, and others  Read transcripts, developed list of key themes, and discussed implications Further coding of transcripts and analysis by 4 study team members

Stigma, discrimination, and violence

    Both groups experienced dual stigma related to both HIV+ and SW/MSM identities  Led to lack of disclosure of both identities SW reported violence from clients and police  Some clients became violence when asked to use condoms   Others would refuse to pay after sex and become violent Police round-ups, demand for sex, violence MSM reported discrimination and violence from a wide range of individuals  Partners, families, general public, police raids Both groups felt they had no recourse to bring such incidents to the authorities

Risk cycle of hunger, sex work, and HIV for SW

   SW described a risk cycle of hunger & poverty driving sex work driving HIV infection.

HIV in turn drives an increased need for ‘healthy foods’ Sex work leads to alienation from social networks which offer material and emotional support against hunger & poverty.

Reduced social support Increased need for healthy foods Hunger & poverty Sex work HIV infection

Challenges keeping MSM/SW PLHIV physically healthy    Perceived stigma from health care settings leading to lack of care-seeking Perceived stigma from families/partners leading to lack of disclosure of HIV status  Challenges with ART adherence, hiding medications, lack of social support for treatment Poverty and hunger   For SW, risk cycle of hunger, sex work, and HIV MSM also reported transactional sex, challenges adhering to ART, and challenges getting to clinic due to poverty and hunger

Challenges keeping MSM/SW PLHIV mentally healthy  Primary challenge of living with dual stigma  Depression and self-stigma or shame  Some MSM said feelings of self-stigma led MSM to drink alcohol to “forget”, which often led to sexual risk behavior

Challenges preventing further HIV transmission

   Questions around HIV prevention during clinical services often assume heterosexuality/one partner  Due to fear of stigma, SW/MSM often just answer the question asked (e.g., ‘I don’t have a steady partner’), rather than discuss their true risk behaviors – missed opportunity for prevention SW offered more money for sex without condoms Clandestine nature of MSM relationships may lead to more and more casual partnerships  MSM described many of their partners as bisexual or having female partners/wives (possibly to hide MSM behavior or to fulfill cultural expectations)  MSM relationships are kept secret and therefore families do not play a role in relationship counseling and peacekeeping

Successes preventing further HIV transmission

    Sex workers appreciated the tailored HIV educational sessions provided for them MSM suggested ‘training of trainers’ model  Train trusted MSM community members who could then share messages with others Both SW and MSM suggested continued/further distribution of condoms and particularly lubricant to prevent condom breakage Consider MSM/SW “expert clients” for those living with HIV

Challenges increasing agency of MSM/SW PLHIV

 Dual stigma and hidden identities  MSM/SW have difficulty trusting outsiders until they get to know particular individuals over time  MSM/SW are often unwilling to disclose their status publically to represent these groups in HIV-related activities

Successes increasing agency of MSM/SW PLHIV

 Ongoing activities by MOH, PSI, SNAP, SWAPOL, and others – including this research – suggests if approached in the right way, MSM and SW are interested in participating in HIV prevention, care and treatment decisions for their communities

Service delivery models

   Some respondents suggested developing special clinics or services for HIV+ MSM or SW Others said targeted services would reinforce stigma Several participants said health care workers should be trained on issues related to MARPS  “I would train health care workers. Even their procedures manuals should have information on how to handle MARPS … Also let’s make educational materials that also speak of MARPS.” – KI

Successful existing models of SW-friendly services

  Respondents emphasized the success of specific SW-friendly services (e.g. FLAS, others) Several said the “support group” code word model used for SW-friendly services in Piggs Peak, Lobamba, and a few other clinics worked well.

  “For instance, Piggs Peak and Lobamba, they come and say, ‘I’ve come to see so and so … and the health care worker will know it’s from the support group so it means she is a sex worker. Same with Lobamba, they meet and she can say, ‘I’m from the support group,’ oh, then she will know she is a sex worker without announcing.” – KI “We could use some of those centres as learning sites, you know. We could share the lessons learnt from those people.” – KI

“They are human beings, they are Swazi.”

 Key informants consistently said that regardless of personal belief, they had an ethical responsibility to provide services to everyone, equally   “As a health sector, my belief is non-discriminatory services to all the members of the population, and issues of legality and everything rest with the Ministry of Justice.” – KI “Even though I don’t approve of what they are doing … as a public health officer, I have to make sure that they have access to health services. I don’t have to judge them. I don’t have to give my views on what they are doing. But my duty is to make sure that they have access to services… whatever their sexual orientation is, they are human beings, they are Swazi.” – KI

Conclusions

  FSW and MSM represent distinct high risk populations in Swaziland   These populations are underserved with only sporadic targeted program Even in the context of countries with hyperendemic HIV prevalence rates, there is still concentration of HIV risk and prevalence Moving Forward  Combination HIV Prevention Programs    Biomedical   Increasing HTC and Active Linkage to ART for eligible Evaluate future strategies as they are developed  Chemoprophylaxis Behavioral  Increasing Condom and Condom Compatible Lubricant Use Structural     Community Systems Strengthening Health Sector Interventions Gender normalization strategies Safe work spaces

Next steps for Studies

 Finalize findings and recommendations with MOH  Write final report  Swaziland dissemination to MOH, MARPS technical working group, stakeholders, media  Global dissemination through peer-reviewed articles and presentations for the International AIDS Conference, July 2012  Compare with same qualitative research in the Dominican Republic (concentrated HIV epidemic)