Heterosexual men who patronise entertainment establishments versus brothels in an Asian urban setting - which group practises riskier sexual behaviours?

Application of the network scale-up method to estimate the sizes of key populations for HIV in Singapore using online surveys

INTRODUCTION

Singapore lacks robust data on the sizes of the key populations that are most at risk for HIV. Using the network scale-up method for hidden or hard-to-reach populations, we estimate the sizes of five key populations-male clients of female sex workers (MCFSW), men who have sex with men (MSM), female sex workers (FSW), people who inject drugs (PWID) and transgender people-and profile the ages and ethnicities of respondents with the high-risk contacts they report knowing.

METHODS

We conducted a cross-sectional online survey between March and May 2019 (n = 2802) using a network scale-up instrument previously developed for Singapore. Participants were recruited using an existing panel and online advertising, and the sample reweighted by age, sex, ethnicity and education attained to represent the general adult population. We built a Bayesian hierarchical model to estimate the sizes of the five key populations for HIV in Singapore.

RESULTS

After adjustment, the sizes of the at-risk populations are estimated to be: 76,800 (95% credible interval [CI]: 64,200-91,800) MCFSW; 139,000 (95% CI: 120,000-160,000) MSM; 8030 (95% CI: 3980-16,200) FSW; 3470 (95% CI: 1540-7830) PWID and 18,000 (95% CI: 14,000-23,200) transgender people. Generally, men reported knowing more people in all the high-risk groups; older people reported knowing more MCFSW, FSW and transgender people; and younger people reported knowing more MSM. There was a bimodal effect of age on those who reported knowing more PWIDs: people in their 20s and 60s reported more contacts.

CONCLUSIONS

This study demonstrates that a size estimation study of hidden populations is quickly and efficiently scalable through using online surveys in a socially conservative society, like Singapore, where key populations are stigmatized or criminalized. The approach may be suitable in other countries where stigma is prevalent and where barriers to surveillance and data collection are numerous.

Perceptions of an HIV self-testing intervention and its potential role in addressing the barriers to HIV testing among at-risk heterosexual men: a qualitative analysis

Objectives

Voluntary HIV testing rates are still low in several Asian countries including Singapore. HIV self-testing (HIVST) has the potential to increase testing, leading to earlier diagnosis and better prognosis. However, the views of at-risk individuals, especially heterosexual men (HSM), who are not coming forward for testing are still poorly understood. In this study, we examined the barriers and facilitators to and delivery preferences for HIVST in order to implement an effective intervention in Singapore.

Methods

From May 2017 to June 2018, 48 in-depth interviews were conducted with HSM aged 21–66 years and at risk of HIV infection. Participants were purposively sampled based on ethnicity, age and testing behaviour. Recruitment was done mainly at brothels and entertainment establishments in Singapore. Participants gave their views on HIV testing, factors affecting HIVST use and their preferred HIVST service delivery model.

Results

Most participants preferred HIVST over conventional testing for its convenience, privacy, anonymity and autonomy, but older men still preferred conventional testing. Low self-perceived risk, low awareness and self-efficacy for HIVST, and non-comprehensive test for other STIs were reported as barriers to HIVST. There were mixed opinions on kit preference. A blood-based kit was favoured for higher accuracy, while the oral-fluid-based kit was favoured for ease of use. Participants wanted a human touch for post-test counselling and linkage to care only if they self-tested positive. Traditional media, internet and social media, and venue-based outreach were potential advertising platforms mentioned.

Conclusions

A locally acceptable and feasible HIVST intervention must address the barriers and facilitators of using HIVST in order to improve HIV testing rates among this at-risk population who might otherwise delay or fail to present for testing.

Socioecological differences in factors associated with inconsistent condom use with female sex workers and casual partners: an observational study of heterosexual men attending an anonymous HIV testing clinic in Singapore

Sexual practices among heterosexual men may differ between female sex workers (FSWs) and casual partners. We surveyed 203 heterosexual men and investigated the attributes associated with inconsistent condom use among them. Lower educational attainment was positively associated with inconsistent condom use with FSWs (adjusted prevalence ratio (aPR) 2.63; P = 0.018) and casual partners (aPR 1.55; P = 0.022), whereas early age of sexual debut (aPR 3.00; P = 0.012) and alcohol use during sex (aPR 7.95; P < 0.001) were positively associated with inconsistent condom use with FSWs. Socioecological factors may explain such differences.

"I have HIV but I'm not the HIV" - the experiences of heterosexual Chinese men living with HIV in Singapore

As HIV is widely acknowledged as a stigmatized chronic condition which impacts the self, it is important to study the experiences of people living with HIV in relation to their selves and identities. According to extant literature on HIV and identity, the incorporation of an HIV identity is essential to adapting to the diagnosis. However, most of the participants in this study reject HIV as an identity. Using qualitative in-depth interviews, this paper explores the experiences of twelve heterosexual Chinese men living with HIV in Singapore. This paper is anchored by identity concepts from identity theory to examine the impact of HIV on self and identities and how various identities are reworked in the face of a stigmatized chronic medical condition. Thematic analysis shows varying impact of HIV on self, the role of normative identities and the location of HIV in their lives. The findings shed light on the importance of normative identities and the manner in which participants locate HIV in their lives.

Reported oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa: a systematic review

BACKGROUND

Oral and anal sexual behaviours are increasingly reported among adolescents and adults reporting heterosexual sex in peer-reviewed journals in high income countries, but less is known about these behaviours in low and middle-income countries, especially in sub-Saharan Africa. The aim of this systematic review is to describe the prevalence of, and motivations for, oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa.

METHODS

A systematic review of published articles that reported oral and or anal sex in sub-Saharan Africa was conducted from seven databases up to and including 30th August 2018.

RESULTS

Of 13,592 articles, 103 met the inclusion criteria. The prevalence of reporting ever practising oral sex among adolescents, university students and a combined population of adolescents/adults ranged from 1.7-26.6%, 5.0-46.4% and 3.0-47.2% respectively. Similarly, prevalences of reported ever practising anal sex ranged from 6.4-12.4% among adolescents, 0.3-46.5% among university students and 4.3-37.8% amongst combined population of adolescents and adults. Higher prevalences of oral and anal sex were reported among populations at high-risk for sexually transmitted infections and HIV and university students and, in most studies, both behaviours were more commonly reported by males than females. Heterosexual oral and anal sexual acts were associated with some high-risk behaviours such as inconsistent condom use and multiple sexual partners.

CONCLUSION

Reported oral and anal sex between men and women are prevalent behaviours in sub-Saharan Africa. Health professionals and policy makers should be aware of these behaviours and their potential associated health risks.

A Public Health Communication Intervention Using Edutainment and Communication Technology to Promote Safer Sex among Heterosexual Men Patronizing Entertainment Establishments

It is a challenge to reach out, develop and implement a communication intervention for heterosexual men (HSM) patronizing entertainment establishments (EEs) to promote safer sex. We described the theoretical basis and process from assessment to implementation where edutainment (talk shows) and communication technology (interactive web portal) was implemented. A female comedian hosted the talk shows. The portal contained an HIV risk profile calculator with individually tailored strategies to lower risk; two videos on real-life stories of unsafe sex and exit strategies to avoid casual or paid sex; as well as online support. We integrated edutainment, social cognitive theory (SCT) and the elaboration likelihood model (ELM). Edutainment techniques like humor through jokes, fun through games, and narrative persuasion through real-life accounts were applied. The SCT focused on modifying attitudes and social norm on sexual well-being, increasing self-perceived HIV/STI risk as well as building self-efficacy and skills in condom use. We applied the ELM to guide communication strategies and message development. For peripheral processing, we used cues like comedian delivery and charisma. For central processing, we focused on argument framing, issue involvement, argument quality, and modeling. The intervention was effective in promoting condom use with casual partners among the target group in Singapore.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Trial on Condom Use Among Heterosexual Men Patronizing Entertainment Establishments Who Engaged in Casual or Paid Sex in Singapore

BACKGROUND

We assessed the efficacy of a multi-component sexual health promotion program on condom use and human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing among heterosexual men (HSM) patronizing entertainment establishments who engaged in casual or paid sex in Singapore.

METHODS

This was a quasi-experimental trial with a comparison group using cross-sectional surveys at baseline and 6 months postintervention. A locality patronized by local HSM was assigned the intervention, a comparable and distant area served as the comparison site. Using time location sampling, cross-sectional samples of these men were assessed on sexual behaviors using an anonymous questionnaire at baseline (n = 604) and 6 months postintervention (n = 360) in both groups. The coprimary outcomes were condom use at last vaginal and oral sex with casual partner respectively. Mixed effects Poisson regression model accounting for clustering by establishment was used to compute the adjusted prevalence ratio (aPR) of the outcomes postintervention.

RESULTS

At postintervention, the intervention group was more likely than the comparison group to report condom use at last vaginal (aPR, 1.41; 95% confidence interval [CI], 1.05-1.89) and oral (aPR, 1.70; 95% CI. 1.11-2.61) sex, respectively, with casual partner. Similar findings were found for consistent condom use in the last 6 months for vaginal (aPR, 1.67; 95% CI, 1.13-2.48) and oral (aPR, 1.97; 95% CI, 1.16-3.32) sex, respectively, with casual partner. The HIV/STI testing was not significantly higher in the intervention than the comparison group (aPR, 1.43; 95% CI, 0.98-2.09).

CONCLUSIONS

This trial was effective in promoting condom use with casual partners but not HIV/STI testing among HSM in Singapore.

Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore

Background

There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention.

Methods

In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation.

Results

We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group.

Conclusions

The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction.

Trial registration

ClinicalTrials.gov, NCT02780986. Registered 23 May 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0358-5) contains supplementary material, which is available to authorized users.

Efficacy of multicomponent culturally tailored HIV/ STI prevention interventions targeting foreign female entertainment workers: a quasi-experimental trial

OBJECTIVES

We assessed the efficacy of a multicomponent culturally tailored HIV/STI prevention intervention programme on consistent condom use and STI incidence among foreign Thai and Vietnamese female entertainment workers (FEWs) in Singapore.

METHODS

We conducted a quasi-experimental pretest and post-test intervention trial with a comparison group. We recruited 220 participants (115 Vietnamese and 105 Thai) for the comparison group, followed by the intervention group (same number) from the same sites which were purposively selected after a 3-month interval period. Both groups completed a self-administered anonymous questionnaire and STI testing for cervical gonorrhoea and Chlamydia, as well as pharyngeal gonorrhoea at baseline and 6-week follow-up. The peer-led intervention consisted of behavioural (HIV/STI education and condom negotiation skills), biomedical (STI screening and treatment services) and structural components (access to free condoms). We used the mixed effects Poisson regression model accounting for clustering by establishment venue to compute the adjusted risk ratio (aRR) of the outcomes at follow-up.

RESULTS

At follow-up, the intervention group was more likely than the comparison group to report consistent condom use for vaginal sex with paid (aRR 1.77; 95% CI 1.71 to 1.83) and casual (aRR 1.81; 95% CI 1.71 to 1.91) partners. For consistent condom use for oral sex, this was aRR 1.50; 95% CI 1.23 to 1.82 with paid and aRR 1.54; 95% CI 1.22 to 1.95 with casual partners. STI incidence at follow-up was significantly lower in the intervention (6.8 per 100 FEWs) than the comparison (14.8 per 100 FEWs) group (aRR 0.42; 95% CI 0.32 to 0.55).

CONCLUSIONS

This trial was effective in promoting consistent condom use for vaginal and oral sex as well as reducing STI incidence among the foreign Thai and Vietnamese FEWs in Singapore. The feasibility of scaling up the interventions to all entertainment establishments in Singapore should be assessed.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0-2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8-1.3, p 0.84) partner than the control/comparison group post-intervention.

Geographic Distribution and Temporal Trends of HIV-1 Subtypes through Heterosexual Transmission in China: A Systematic Review and Meta-Analysis

Background: Heterosexual transmission (HST) has become the current predominant transmission pathways of the HIV-1 epidemic in China. The aim of this study was to explore the geographic and dynamic change of HIV-1 subtypes through HST in China from published studies. Methods: Several electronic databases were searched to identify the studies, and the overall prevalence of HIV-1 subtypes was estimated by a meta-analysis method. Subgroup analysis was conducted by study region and time period. Publication bias was evaluated using Egger's test. The χ² test was used to evaluate the proportion differences among subgroups. Sensitivity analysis was carried out to assess the stability of the overall prevalence estimates. Results: 42 studies were included in our final analysis. The overall prevalence of CRF01_AE was 46.34% (95% CI: 40.56-52.17%), CRF07_BC was 19.16% (95% CI: 15.02-23.66%), B/B' was 13.25% (95% CI: 9.68-17.25%), CRF08_BC was 10.61% (95% CI: 7.08-14.70%), and C was 4.29% (95% CI: 1.85-7.48%). In subgroup analysis, the prevalence of CRF01_AE and CRF07_BC increased, while the prevalence of B/B' decreased over time, whereby the prevalence of CRF07_BC and CRF08_BC have exceeded that of B/B' since 2010. A significant higher prevalence of CRF01_AE was found in the South provinces, CRF07_BC in East provinces, CRF08_BC and C in Southwest provinces, and B/B' in North provinces. Conclusions: The HIV-1 prevalent strains have evolved into complicated and diverse subtypes, and the proportion of HIV-1 subtypes through HST has changed constantly in different regions and periods in China. This highlights the urgent need to vigorously strengthen the prevention and control of the HIV-1 epidemic.

What are the factors associated with human immunodeficiency virus/sexually transmitted infection screening behaviour among heterosexual men patronising entertainment establishments who engaged in casual or paid sex? - Results from a cross-sectional survey in an Asian urban setting

Background

Late presentation of human immunodeficiency virus (HIV) is associated with heterosexual transmission, particularly among heterosexual men in Asia. Although data on HIV/sexually transmitted infection (STI) testing behaviour is increasing, information is still lacking among heterosexual men who receive far lesser attention and are generally invisible in HIV/ STI prevention, particularly in the Asian urban setting. The aim of this study was to assess the prevalence of HIV/STI testing among heterosexual men patronising entertainment establishments (EEs) who engaged in casual or paid sex in Singapore, and the factors associated with this behaviour.

Methods

This was a cross-sectional survey involving 604 participants using time location sampling between March and May 2015. For multivariable analysis, we used a mixed effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratio (aPR) for the association of various factors with HIV/STI testing.

Results

Among 604 at-risk participants, only 163 (27.0%) had gone for HIV or STI testing in the past 6 months. Of this, 83.4% of them specifically underwent HIV testing. In multivariable analysis, HIV/STI testing increased with being non-Chinese (aPR 1.50; 95% CI: 1.08–2.06), having engaged in anal sex with casual or paid partner in the past 6 months (aPR 1.80; 95% CI: 1.27–2.57), number of partners in the past 6 months (aPR 1.03; 95% CI: 1.01–1.05) and HIV knowledge score (aPR 1.11; 95% CI: 1.05–1.16). Among those who reported non-consistent condom use with casual or paid partner, almost half of them (47.9%) perceived that they were at low risk for HIV/STI. Sigmatisation and discrimination was another common barrier for non-testing.

Conclusions

Despite being at risk of HIV/STI, the low prevalence of testing coupled with a high prevalence of risky sexual behaviour among this group of heterosexual men in Singapore calls for a need for HIV/STI prevention interventions in the EE setting. Other than promoting testing and safer sex, the interventions should address the discordance between perceived risk and actual sexual behaviour, in addition to the stigma and discrimination associated with testing for this group.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-2088-8) contains supplementary material, which is available to authorized users.

Factors associated with consistent condom use and STIs among foreign female entertainment workers: results from a cross-sectional survey in Singapore

OBJECTIVES

We assessed the prevalence of consistent condom use and laboratory-confirmed STIs among foreign female entertainment workers (FEWs) who engaged in paid or casual sex in Singapore and the factors associated with these characteristics.

METHODS

A cross-sectional survey, using time-location sampling, was conducted on 220 FEWs (115 Vietnamese and 105 Thai) in 2015. For multivariable analysis, we used a mixed-effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratios (aPRs) of factors associated with consistent condom use and STI positivity, respectively.

RESULTS

Consistent condom use with paid or casual partners in the past month was 39.6% and 36.2% for vaginal and oral sex, respectively. The prevalence of STI (cervical chlamydia, cervical gonorrhoea or pharyngeal gonorrhoea) positivity was 13.6%. In multivariable analysis, consistent condom use for both vaginal and oral sex increased with high self-perceived risk of getting STI/HIV (vaginal: aPR 2.09; 95% CI 1.26 to 3.46; oral: aPR 2.41; 95% CI 1.23 to 4.69) and condom negotiation (vaginal: aPR 3.74; 95% CI 2.07 to 6.75; oral: aPR 2.81; 95% CI 1.51 to 5.26). STI positivity decreased with consistent condom use for vaginal sex (aPR 0.22; 95% CI 0.07 to 0.75) and increased with number of sexual partners (aPR 1.43; 95% CI 1.07 to 1.92).

CONCLUSION

In addition to advocating for policy decisions to provide a safer work environment, behavioural interventions on condom negotiation skills and condom use and biomedical interventions on STI/HIV testing and treatment interventions are needed among the FEWs in Singapore.

TRIAL REGISTRATION NUMBER

NCT02780986; pre-results.