Risk factors for HIV infection in males who have sex with males (MSM) in Bangladesh

Changing hearts and minds: Results from a multi-country gender and sexual diversity training

Engaging key populations, including gender and sexual minorities, is essential to meeting global targets for reducing new HIV infections and improving the HIV continuum of care. Negative attitudes toward gender and sexual minorities serve as a barrier to political will and effective programming for HIV health services. The President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003, provided Gender and Sexual Diversity Trainings for 2,825 participants including PEPFAR staff and program implementers, U.S. government staff, and local stakeholders in 38 countries. The outcomes of these one-day trainings were evaluated among a subset of participants using a mixed methods pre- and post-training study design. Findings suggest that sustainable decreases in negative attitudes toward gender and sexual minorities are achievable with a one-day training.

Stigma Reduction Training Improves Healthcare Provider Attitudes Toward, and Experiences of, Young Marginalized People in Bangladesh

PURPOSE

Working with health providers to reduce HIV stigma in the healthcare setting is an important strategy to improve service utilization and quality of care, especially for young people who are sexually active before marriage, are sexual minorities, or who sell sex. A stigma reduction training program for health providers in Bangladesh was evaluated.

METHODS

A cohort of 300 healthcare providers were given a self-administered questionnaire, then attended a 2-day HIV and sexual and reproductive health and rights training (including a 90-minute session on stigma issues). Six months later, the cohort repeated the survey and participated in a 1-day supplemental training on stigma, which included reflection on personal values and negative impacts of stigma. A third survey was administered 6 months later. A cross-sectional survey of clients age 15-24 years was implemented before and after the second stigma training to assess client satisfaction with services.

RESULTS

Provider agreement that people living with HIV should be ashamed of themselves decreased substantially (35.3%-19.7%-16.3%; p < .001), as did agreement that sexually active young people (50.3%-36.0%-21.7%; p < .001) and men who have sex with men (49.3%-38.0%-24.0%; p < .001) engage in "immoral behavior." Young clients reported improvement in overall satisfaction with services after the stigma trainings (63.5%-97.6%; p < .001).

CONCLUSIONS

This study indicates that a targeted stigma reduction intervention can rapidly improve provider attitudes and increase service satisfaction among young people. More funding to scale up these interventions is needed.

Extent of Knowledge about HIV and Its Determinants among Men in Bangladesh

Background

Bangladesh is currently a low human immunodeficiency virus (HIV) prevalent country. However, the risk factors are widespread and the number of at-risk population is also rising, which warrants special policy attention. The risks of transmission were shown to be correlated with the level of HIV knowledge of individuals. In this study, we aimed to explore the level and influencing factors of HIV knowledge among adult men in Bangladesh.

Methodology

Data for the present study were collected from the sixth round of Bangladesh Demographic and Health Survey. Participants were 3305 men between 15 and 54 years of age regardless of HIV status. The primary outcome variable was the HIV knowledge score, which was calculated by responses to questions regarding general concepts and the mode of transmission of HIV. Association between the HIV knowledge score and the explanatory variables were analyzed by binary logistic regression methods.

Result

The mean HIV knowledge score was 7.2 (SD 1.3). Results indicate that being an urban resident [p < 0.001; odds ratios (OR) = 0.56, 95% confidence intervals (CI) = 0.48–0.64], having secondary/higher educational level (p < 0.001 OR = 0.56, 95%CI = 0.48–0.64), reading newspaper [p = 0.006; OR = 0.76, 95%CI = 0.62–0.92], and communication with community health workers (CHWs) (p = 0.05; OR = 0.77, 95%CI = 0.60–10.00) were significantly associated with a high (equal or above mean value) HIV knowledge level.

Conclusion

The level of HIV knowledge among Bangladeshi men is low. Leveraging HIV awareness programs targeting adult men to prevent future expansion of the epidemic should be a high priority. Revitalization and restructuring of the education sector and strengthening CHW’s engagement to improve knowledge about HIV transmission among men could generate beneficial returns for HIV prevention programs.

Transactional Sex and the HIV Epidemic Among Men Who have Sex with Men (MSM): Results From a Systematic Review and Meta-analysis

Engagement in transactional sex has been hypothesized to increase risk of HIV among MSM, however conflicting evidence exists. We conducted a systematic review and meta-analysis comparing HIV prevalence among MSM who engaged in transactional sex to those who did not (33 studies in 17 countries; n = 78,112 MSM). Overall, transactional sex was associated with a significant elevation in HIV prevalence (OR 1.34, 95 % CI 1.11-1.62). Latin America (OR 2.28, 95 % CI 1.87-2.78) and Sub-Saharan Africa (OR 1.72, 95 % CI 1.02-2.91) were the only regions where this elevation was noted. Further research is needed to understand factors associated with sex work and subsequent HIV risk in Latin America and Sub-Saharan Africa.

Prevalence and associated factors of HIV infection among men who have sex with men in Hefei, China, 2013-2014: a cross-sectional study

The objective of this study was to investigate the prevalence and influencing factors of HIV infection among men who have sex with men (MSM) in Hefei, China. A total of 578 MSM were recruited, with a mean age of 28.13 ± 6.91; 70.7% were under 30. The awareness rate was 95.4% (560/587) in the cross-sectional study. Of all the respondents, 73 (12.44%) were seropositive for HIV and 56 (9.54%) for syphilis. Multivariate analysis showed that self-reported sexually transmitted infections (STIs) (AOR = 8.02, 95% CI: 2.58-24.98, P < 0.001), received HIV testing in the past year (AOR = 0.33, 95% CI: 0.19-0.60, P < 0.001) and syphilis (AOR = 3.40, 95% CI: 1.69- 6.85, P = 0.001) were independently associated with HIV infection. It is necessary for post-test counselling to address risk among those who engage in sexual risk behaviours. More efforts are needed to enhance HIV/STI testing and treatment services in China.

Male-to-male sex among men who inject drugs in Delhi, India: overlapping HIV risk behaviours

BACKGROUND

HIV among people who inject drugs (PWID) is a major public health challenge in India. This paper examines PWID in Delhi who also have male-to-male sex with a focus on overlapping HIV risk behaviours and the psychosocial correlates of a history of male-to-male anal sex.

METHODS

We analysed data collected in April-May of 2012 from a community-based sample of 420 male PWID in Delhi obtained using time location sampling.

RESULTS

One third (37%) of the men reported a history of anal sex with men, among whom just 16% used a condom at last anal sex. Almost all (93%) participants who had a history of anal sex with men also had sex with women. Chi-square tests revealed that a history of anal sex with men was associated with a higher number of female sexual partners and sharing of needles and syringes. Additionally, unprotected sex at last sex with a male partner was significantly associated with unprotected sex at last sex with regular and paid female partners. Multivariate binary logistic regression revealed that the psychosocial correlates of a history of anal sex with other men were: being aged 18-24 (OR = 2.4, p = 0.014), illiteracy (OR = 1.9, p = 0.033), having never been married (OR = 2.6, p = 0.007), a main source of income of crime/begging (OR = 3.1, p = 0.019), a duration of injecting drug use greater than 20 years (OR = 3.4, p = 0.035) and suicidal ideation (OR = 1.7, p = 0.048).

CONCLUSION

Male-to-male sex was associated with psychosocial vulnerability, including a longer history of injecting drug use, suicidal ideation and socio-economic disadvantage. Given the extent of overlapping HIV risk behaviours, HIV programs for PWID would benefit from a strong focus on prevention of sexual HIV transmission, especially among male injectors who also have sex with other men.

Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis

BACKGROUND

Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts.

METHODS

We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004-2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men.

FINDINGS

Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5).

CONCLUSIONS

The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.

Factors associated with HIV infection among men who have sex with men in Henan Province, China: a cross-sectional study

Background

HIV prevalence among men who have sex with men (MSM) has increased rapidly in China. Behavioral and biological interventions are key to controlling the spread of HIV in the MSM population and the primary strategy for reducing the spread of AIDS in China. The purpose of this study is to investigate the prevalence of HIV among MSM in Henan province and to assess their knowledge levels and risk behaviors related to HIV/AIDS.

Method

A cross-sectional survey was conducted among 388 MSM in 2010 in Zhengzhou City, Henan province, China.

Results

Of the 388 respondents, 13.1% were infected with HIV and 10.3% were infected with syphilis. The results of multivariate analysis showed that participants who had a history of being infected by syphilis were more than 4 times more likely to be HIV positive (AOR=4.91; 95% CI: 1.70 to 12.02). For those who were residents from other provinces, the risk of HIV infection was 5.53 times higher (OR=5.53, 95% CI: 1.14, 6.25). Receipt of condoms (AOR = 0.15; 95% CI: 0.02 to 0.87), consistent condom use during last intercourse with a male (AOR=0.35; 95% CI: 0.14 to 0.87), and consistent condom use during last intercourse with a female (AOR=0.16; 95% CI: 0.08 to 0.90) were associated with a lower risk of HIV infection.

Conclusion

The study suggests that some intervention strategies, including education intervention, condom promotion and distribution, and HIV counseling and testing are necessary to control HIV infection among MSM.

Factors associated with unprotected anal intercourse among men who have sex with men in Liaoning Province, China

Background

HIV prevalence among men who have sex with men (MSM) has increased rapidly. MSM may play a bridging role in the spread of HIV and other STDs from the high-risk population to the general population. Interventions to reduce high-risk behavior are the key to controlling the spreading of HIV in the MSM population and the primary strategy for reducing the spread of AIDS in China. The purpose of the study was to examine the demographic characteristics of MSM, evaluate the HIV-related knowledge of MSM, and identify factors associated with unprotected anal intercourse (UAI) among MSM to make recommendations for future research.

Methodology/Principal Finding

A cross-sectional survey was conducted among 293 MSM in Fushun and Huludao City, China. A total of 91 participants (34.0%) reported engagement in UAI with a male partner during the previous six months. The results of univariate analysis showed that UAI was associated with older age, lower levels of education, less knowledge about HIV, and not receiving condoms, lubricant, peer education, AIDS counseling, STD checks, and informational materials (p<0.05). In a multivariate logistic regression model, awareness of the major HIV transmission routes (OR = 2.191; 95% CI: 0.869 to 5.524), receiving condoms (OR = 2.164; 95% CI: 1.149 to 4.076), receiving peer education (OR = 2.632; 95% CI: 1.566 to 4.426), and AIDS counseling (OR = 2.347; 95% CI: 1.260 to 4.372) were independently associated with a lower risk of UAI.

Conclusions/Significance

The study suggested that UAI could be decreased by improving education about AIDS, increasing the promotion of voluntary counseling and testing (VCT), and improving the accessibility and convenience of service.

Sexually transmitted infections and risk behaviors among transgender persons (Hijras) of Pune, India

BACKGROUND

The objectives of this cross-sectional study were to determine the prevalence of HIV and sexually transmitted infections (STI) in Hijras (self-identified transgenders of South Asia), study associated risk factors, and compare the prevalence with that in heterosexual men and men having sex with men (MSM) in Pune, India, between 1993 and 2002.

METHODS

After informed consent, individuals attending 3 STI clinics were administered a questionnaire regarding their demographic, socioeconomic, and sexual behaviors. Blood samples were collected for STI and HIV diagnosis. Bivariate and multivariate analyses were performed to determine the correlates of HIV infection.

RESULTS

The prevalence of HIV (45.2% in Hijras vs 20% in heterosexual men vs 18.9% in MSM, P < 0.0001) and warts (10.3% vs 4.6% vs 7.0%; P = 0.004) was higher in Hijras as compared with heterosexual men and MSM; whereas that of genital ulcer disease (15.3% vs 32.6% vs 21.5%; P < 0.0001) and discharge (5.4% vs 13.6% vs 9.0%; P < 0.0001) was lower. Hijras were more likely to have received money for sex and have an earlier sexual debut than the comparison groups. In multivariate analysis, receiving money for sex (adjusted odds ratio: 4.49; P < 0.04) and having genital ulcer disease (odds ratio: 3.87; P < 0.08) were independently associated with high HIV prevalence in Hijras.

CONCLUSIONS

Considering the high HIV and STI burden, it is important to review current prevention strategies and stress the need to engage Hijra community members through appropriate targeted intervention programs.

Factors that influence risky sexual behaviors among men who have sex with men in Liaoning province, China: a structural equation model

HIV prevalence among men who have sex with men (MSM) has increased rapidly in China. Behavioral and biologic interventions are the key to control the spreading of HIV in the MSM population and the primary strategy for reducing the spread of AIDS in China. The objective of this study is to explore the relationship among HIV-related knowledge, the basic information of respondents, service utilization and risky sexual behavior. Respondent-driven sampling was used to recruit 225 MSM in Fushun and Huludao in China. The results of univariate analysis showed that condom use in the past 6 months was associated with age, being more knowledgeable about HIV, accepting lubricant distribution, and peer education (p<0.05). The structural equation modeling (SEM) results was as following, χ(2)=863.45 (p<0.01); root mean square error of approximation (RMSEA)=0.04; goodness of fit (GFI)=0.94, which indicated the model fitted the data well. The factor loads of HIV-related knowledge, the basic information of respondents, service utilization and risky sexual behavior was -0.06, 0.07, -0.27, respectively, which indicated that service utilization was likely to be a major factor negatively impacting risky sexual behavior. For service utilization, the greatest item load was for distribution of lubricants and peer education, 0.69, 0.68, respectively. The factor load of HIV-related knowledge and service utilization was 0.15, which suggested that risky sexual behaviors might be indirectly reduced by improving HIV/AIDS knowledge to increase service utilization. Basic information (age, income, marital status, age at first sexual intercourse) had a greater impact on service utilization, with a load factor of 0.26. For basic information, the greatest item load was age (0.96). In terms of the intervention strategies, it is essential that public health education is provided for the young, to ultimately decrease risky behaviors in MSM.

Stigma and HIV risk among Metis in Nepal

Similar to other parts of Asia, the HIV epidemic in Nepal is concentrated among a small number of groups, including transgender people, or Metis. This study was conducted to explore the social context of stigma among Metis in Nepal to better understand their risk for HIV. Fourteen in-depth interviews were conducted with Metis in Kathmandu, Nepal. We found that stigma from families leading to rural-urban migration exposed Metis to discrimination from law enforcement, employers and sexual partners, which influenced their risk for HIV. Specific HIV-related risks identified were rape by law enforcement officers, inconsistent condom use and high reported numbers of sexual partners. These data point to an immediate need to work with law enforcement to reduce violence targeting Metis. HIV prevention, housing and employment outreach to Metis in rural areas and those who migrate to urban areas is also needed. Finally, there is a need for more research to determine the prevalence of HIV among Metis, to explore risk within sexual networks and to better understand of the relationship between Metis and their families in order to develop future programmes and interventions.

HIV/AIDS interventions in Bangladesh: what can application of a social exclusion framework tell us?

Bangladesh has maintained a low HIV prevalence (of less than 1%) despite multiple risk factors. However, recent serological surveillance data have reported very high levels of HIV infection among a subgroup of male injecting drug-users (IDUs). This suggests that an HIV/AIDS epidemic could be imminent in Bangladesh. Although biomedical and behavioural change projects are important, they do not address the root causes of observed risky behaviours among 'high-risk' groups. In Bangladesh, these groups include sex workers, IDUs, males who have sex with males, and the transgender population-hijra-who are all excluded groups. Using a social exclusion framework, this paper analyzed existing literature on HIV in Bangladesh to identify social, economic and legal forces that heighten the vulnerability of such excluded groups to HIV/AIDS. It found that poverty and bias against women are major exclusionary factors. The paper presents areas for research and for policy action so that the social exclusion of high-risk groups can be reduced, their rights protected, and an HIV epidemic averted.

HIV-related risk behaviours and the correlates among rickshaw pullers of Kamrangirchar, Dhaka, Bangladesh: a cross-sectional study using probability sampling

Background

National HIV serological and behavioural surveillance of Bangladesh repeatedly demonstrated a very high proportion of rickshaw pullers in Dhaka city, having sex with female sex workers (FSWs) and using illicit substances. However, no study has been conducted to identify the correlates of having sex with FSWs among this population. This study aimed to describe behavioural profile of rickshaw pullers in Dhaka city using probability samples and to identify the correlates for having sex with FSWs in order to focus HIV prevention intervention.

Methods

Six hundred rickshaw pullers were randomly selected from rickshaw garages in the Kamrangirchar area, the single largest slum cluster of Dhaka, Bangladesh, during March–April 2008 using the Proportion Probability to Size method. Participants were interviewed, with a response rate of 99.2% (n = 595), using a structured questionnaire and asked about illicit substance use, sexual behaviour and risk perception for HIV and sexually transmitted diseases. Independent predictors of having sex with FSWs were analysed by multivariate analysis. A qualitative study was subsequently conducted with 30 rickshaw pullers to supplement the findings of the initial survey.

Results

The proportion of survey respondents who had sex with FSWs and those who used illicit substances in the previous 12 months period were 7.9% and 24.9%, respectively, much lower than the results achieved in the 2003–04 behavioural surveillance (72.8% and 89.9%, respectively). Multivariate analysis revealed the characteristics of younger age, being never married, living alone with family remaining in other districts and using illicit substances in the previous 12 months were significantly associated with having sex with FSWs.

Conclusion

HIV-related risk behaviour of our study population of the rickshaw pullers was lower than what has been suggested by the results of behavioural surveillance. While this discrepancy should be addressed in further studies, our study emphasizes the importance of focused HIV prevention programs for rickshaw pullers as high-risk behaviour is displayed at an unacceptable level and concentrated in identifiable sub-populations.

Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003-2007 estimates

OBJECTIVES

To conduct a systematic review of published and unpublished data from research and public health information systems on the prevalence of male-to-male sex in the total male population; as well as among men who have sex with men (MSM), data on prevalence of heterosexual activity and heterosexual unions; prevalence of condom use with male and female partners; and prevalence of HIV infection and other sexually transmitted infections (STIs).

METHODS

Key indicators were defined (a) among men in the general population: prevalence of sex with a man ever and last year; (b) among MSM: prevalence of heterosexual experiences ever and last year; proportion of male-female transgenders; proportion of sex workers; prevalence of HIV and other STIs, condom use in last sexual encounter; consistent condom use with men last year; never used a condom with a man. With help from key informants, study searches were conducted in Pubmed, LILLACS, institutional databases, conference records and other sources. Methodology and quality of information were assessed, and the best data available for 2003-7 were selected. Indicator estimates from each study were used to propose regional estimate ranges.

RESULTS

A total of 83 new entries were entered into the database in addition to the previous 561, totalling 644. Of these, 107 showing 2003-7 data were selected. Many new studies came from sub-Saharan Africa, portraying hidden HIV epidemics among MSM. The most frequently reported estimate was HIV infection, with high estimate ranges in most of the regions, except for Middle East and North Africa and Eastern Europe. The next most frequently reported was lifetime frequency of heterosexual sex, showing that roughly 50% of MSM ever had sex with a woman. The small number of newer studies reporting prevalence of "sex with a man in last 12 months" between 2003 and 2007, did not warrant enough new evidence to revise our 2005 size estimates for MSM populations.

CONCLUSIONS

A considerable number of new studies with estimates of relevance to understanding sexual behaviour and HIV among MSM were identified, with an encouraging amount of new data coming from sub-Saharan Africa. However, limitations in the quality, utility and comparability of available information persist. At least three measures could be promoted for use in surveillance and academic studies: standardised indicators for MSM studies; standardised operational definitions of, and instructions to describe, variables; and standardised research designs and data gathering strategies. A prerequisite for this all is intense advocacy to ensure a social climate in which research into such matters is prioritised, resources are made available as needed and the human rights of MSM are respected.