Transcript Center for Public Health and Human Rights HIV prevalence, sexual risks and HIV knowledge among MSM in Malawi: understanding risks among a.

Center for Public Health and Human Rights
HIV prevalence, sexual risks and HIV knowledge among
MSM in Malawi: understanding risks among a stigmatized
population and opportunities for interventions
Andrea L. Wirtz
Gift Trapence
Vincent Jumbe
Eric Umar
Sosthenes Ketende
Dunker Kamba
Mark Berry
Susanne Stromdahl
Chris Beyrer
Stefan D. Baral
International AIDS Conference, Washington D.C.
27 July 2012
Background
Global and Regional Prevalence of HIV among MSM
• Generalized epidemic:
11% among adults
• Preliminary data highlight
HIV-related vulnerabilities
among key populations
• Limited understanding of
vulnerabilities among
MSM
• Study aim: fill gap of
knowledge on HIV among Source: Beyrer, Baral, van Griensven, Goodreau,
Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
MSM in Malawi
• Provide population-based estimates of HIV prevalence
• Associations of infection among MSM in Malawi
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© 2009, Johns Hopkins University. All rights reserved.
Methods
• Data collection: August 2011-March 2012 in Blantyre, Malawi
• Conducted in Chichewa language
• Data collection and analysis via collaboration among community-based
LGBT organization, CEDEP, the Malawi College of Medicine, Blantyre, and
technical support by Johns Hopkins
• In-depth training: confidentiality & protection, qualitative and survey
research, RDS recruitment
• Structured survey instrument: sociodemographics, human rights, social
& sexual relationships, HIV and sexual health awareness and prevention
• Biological tests: Rapid HIV test and syphilis, confirmatory testing
• Eligibility criteria: > 18 years of age, Born male, Report anal sex with
another man in the previous year
• RDS recruitment: three coupons per seed or recruiter
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Results: RDS
RDS Recruitment Diagram (N= 338)
• Majority reported recruitment by friend (60.5%) or sex partner (32.3%)
• Coupon return: 48%; maximum of 19 waves reached
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Results: Demographics
Item:
Employment status:
Marital Status
(with a woman):
Children:
N=338
5
No.
%
Age: median (range)
25.1
(18-49)
Unemployed
158
46.7
Employed
58
17.2
Self-employed
79
23.3
Student
44
13.0
Married
35
10.3
Cohabiting
3
0.9
Divorced/ Separated
17
5
Single Never Married
None
284
286
83.8
84.6
52
15.5
> 1 child (range: 1-7 children)
Results: Demographics
Item:
Employment status:
Marital Status
(with a woman):
Children:
N=338
6
No.
%
Age: median (range)
25.1
(18-49)
Unemployed
158
46.7
Employed
58
17.2
Self-employed
79
23.3
Student
44
13.0
Married
35
10.3
Cohabiting
3
0.9
Divorced/ Separated
17
5
Single Never Married
None
284
286
83.8
84.6
52
15.5
> 1 child (range: 1-7 children)
Results: Sexuality and partnerships
No.
%
Man
264
77.9
Woman
65
19.2
Transgender
10
2.9
Gay or homosexual
210
61.9
Bisexual
126
37.2
Item:
Gender Identity
Orientation
Sexual partners in last 12
mos.: Mean (range)
Male partners (N=334)
3
(1-50)
Female (N=107)
1
(1-20)
Concurrency, last 12 mo.
Two or more men
With regular male partner
(N=312):
With casual male partner
(N=256):
178
52.7
153
49.0
139
54.3
With female partner (N=100):
33
33.0
Consistent condom use
(always or almost always)
N=338
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Results: Sexuality and partnerships
No.
%
Man
264
77.9
Woman
65
19.2
Transgender
10
2.9
Gay or homosexual
210
61.9
Bisexual
126
37.2
Item:
Gender Identity
Orientation
Sexual partners in last 12
mos.: Mean (range)
Male partners (N=334)
3
(1-50)
Female (N=107)
1
(1-20)
Concurrency, last 12 mo.
Two or more men
With regular male partner
(N=312):
With casual male partner
(N=256):
178
52.7
153
49.0
139
54.3
With female partner (N=100):
33
33.0
Consistent condom use
(always or almost always)
N=338
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Results: HIV prevalence, testing/prevention
Item:
Syphilis
Prevalence
HIV Testing
(Ever, n=336)
HIV Prevalence
No.
%
18
5.3
4.90%
(3.06 – 7.61%)
Never
134
39.9
Once
123
36.6
More than once
79
23.5
Last 12 mo. (of ever tested; N=202)
114
56.4
Unadjusted (%, 95% CI)
52
15.8
12.5%
(9.62-16.17%)
Undiagnosed HIV infection (N=52)
47
90.3
Vaginal
176
57.9
44
14.5
83
27.3
75
22.5
Unadjusted
RDS Adjusted (%, 95% CI)
RDS Adjusted (%, 95% CI)
Considered most
Anal
‘risky’ type of sex
All equal
Ever received HIV prevention information
(for anal sex transmission; N=334)
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N=338
Results: HIV prevalence, testing/prevention
Item:
Syphilis
Prevalence
HIV Testing
(Ever, n=336)
HIV Prevalence
No.
%
18
5.3
4.90%
(3.06 – 7.61%)
Never
134
39.9
Once
123
36.6
More than once
79
23.5
Last 12 mo. (of ever tested; N=202)
114
56.4
Unadjusted (%, 95% CI)
52
15.8
12.5%
(9.62-16.17%)
Undiagnosed HIV infection (N=52)
47
90.3
Vaginal
176
57.9
44
14.5
83
27.3
75
22.5
Unadjusted
RDS Adjusted (%, 95% CI)
RDS Adjusted (%, 95% CI)
Considered most
Anal
‘risky’ type of sex
All equal
Ever received HIV prevention information
(for anal sex transmission; N=334)
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N=338
Results: Behavioral risks and exposures
Item:
No
%
149
45.3
106
32.2
No lubricant use
42
12.8
Ever in jail
74
22.0
Access to condoms in jail (N=72)
12
16.7
Sex with other men in jail (N=74)
47
63.5
40
11.8
26
7.7
118
35.0
68
20.1
70
20.8
102
30.2
Petroleum jelly or Vaseline
Lubricant use with condom (n=329) Water-based lubricant made for sex
Jail/prison
Human rights violations as a result Beaten up
of orientation/sexual practice
Raped (N=337)
Ever felt rejected by friends because
of sexual practices/preferences
Ever afraid to seek health services
Disclosure
because of sexual practices
Ever disclosed same sex practices to
health worker
Depressed mood for > 2 weeks
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N=338
(within last 3 yrs)
Results: Behavioral risks and exposures
No
%
149
45.3
106
32.2
No lubricant use
42
12.8
Ever in jail
74
22.0
Access to condoms in jail (N=72)
12
16.7
Sex with other men in jail (N=74)
47
63.5
40
11.8
26
7.7
118
35.0
68
20.1
70
20.8
102
30.2
Item:
Petroleum jelly or Vaseline
Lubricant use with condom (n=329) Water-based lubricant made for sex
Jail/prison
Human rights violations as a result Beaten up
of orientation/sexual practice
Raped (N=337)
Ever felt rejected by friends because
of sexual practices/preferences
Ever afraid to seek health services
Disclosure
because of sexual practices
Ever disclosed same sex practices to
health worker
Depressed mood for > 2 weeks
12
N=338
(within last 3 yrs)
Results: What factors are associated with
HIV infection?
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Mapping quantitative to qualitative results
Quantitative:
Qualitative:
• Low awareness of risk:
•Low awareness of risk:
– Most men believed vaginal sex,
or both was most risky form of
sex
– Most HIV prevention information
targeted to heterosexual, married
couples
– Low proportion ever received
HIV prevention information
– Belief that transmission happens from
wife to husband
• Disclosure fears
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•Disclosure fears
– 20% feared seeking health
services
– MSM concerned about unintentional
disclosure to others/family
– Only 20% had ever disclosed
same sex practices to provider
– “Men walk around with untreated STI”
– 35% felt rejected by friends
– Providers concerned that they would
be seen condoning illegal behavior
– Fear behavior would be reported
Limitations:
• Sociobehavioral risks are self-reported, thus subject to social
desirability and recall biases
• RDS allows us to reach hidden populations but perhaps still
missing older men or those in higher income range
• Stigmatization and fear of unintentional disclosure are a
concern for participants and may impact participation
• Stock-outs that are prevalent in Malawi, affect study as well
and led to some delays
• Security risks have led to temporary closure of the office
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Conclusions:
• Data demonstrate high risk practice, high undiagnosed HIV infection,
and low knowledge of risk and prevention related to anal sex practices
• History of imprisonment, lack of access to condoms in prison, combined with
past studies reporting increased HIV/STI prevalence in prisons is concerning
• Except concurrency, traditionally behavioral risks are not predictors;
prevalence pools and higher order factors play a role in HIV transmission
• Combined with qualitative data, new services and enhancement of existing
services to ensure confidential prevention and care to MSM.
– Confidential testing for HIV/STI, care for anorectal health, psychosocial services
– Provide HIV information to MSM with information about same sex transmission risk
– Assurance of confidentiality and privacy for patients
– Freedom for health providers from requirement to report patients’ practices
– Must have community input
• Demonstrates that MSM are an important population to be considered in
Malawi’s HIV epidemic, deserve access to comprehensive HIV services.
• May 2012: Pres. Banda publicly announced intention to decriminalize
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Suggestions for other studies in challenging
contexts
• Work closely with community: include in design, solicit
feedback during implementation study, interpret data
• Ensure participant privacy and security from beginning and
throughout
– must be staff priority and communicated to participants
• For RDS, encourage participants to take coupons, even if they
are unsure if they will use it
– will have them available if they change their mind later
• Ensure other benefits to participation are communicated to
participants, benefits are more than reimbursement/incentive
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Sincere thanks to:
• Participants, MSM in Malawi, and MSM and prevention
organizations worldwide
• Rodney Chalera, an excellent peer educator coordinator
• Funding support from UNDP, UNAIDS, UNFPA, and
Volunteers Service Organisation
• Support from USAID, who supported the follow-up
Combination HIV Prevention Intervention (CHPI)
• Fenway Community Health who collaborated to host one of
the first health sector training interventions in Blantyre
• The International AIDS Society for their interest in this
important field of research and prevention
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