Cải thiện dịch vụ chăm sóc và dự phòng HIV cho những người tình dục đồng giới nam_Improving HIV Prevention and Care Services for MSM in Cambodia: The SAHACOM

Cải thiện dịch vụ chăm sóc và dự phòng HIV cho những người tình dục đồng giới nam_Improving HIV Prevention and Care Services for MSM in Cambodia: The SAHACOMGlobal HIV Situation among MSMChallenges in HIV programs: Greater risk for HIV, less access to intervention programs, and less understood due to their more hidden and stigmatized nature (Altman et al., 2012HIV prevalence:3.0% in the Middle East and North Africa region to as high as 25.4% in the Caribbean (Beyrer et al., 2012)HIV and STI prevalence continues to rise (Beyrer et al., 2013)– Condom use and HIV testing: Considerably low in low and middleincome countries (Oldenburg et al., 2014)HIV Situation among MSM in CambodiaHIVSTI prevalence:2010: 2.2% (BROS Khmer Study, 2010) 2015: 2.4% (NCHADS, 2015)STI symptoms in the past 12 months: 51.5% HIV risk behaviors (past 3 months): (Yi et al., 2015)Mean number of sex partners: 4 Had sex with a girlfriend: 32.2%Had sex with FSWs: 14.6%Had sex with MSWs: 9.9%Sold sex to women: 8.9% Sold sex to men: 17.4%

Improving HIV Prevention and Care Services for MSM in Cambodia: The SAHACOM Siyan Yi, MD, MHSc, PhD Director, Center for Population Health Research, KHANA Adjunct Ass Professor, Center for Global Health Research, Touro University California Co-Investigators: Pheak Chhoun, Kouland Thin, Carinne Brody Khimuy Tith, Sovannary Tuot th ICPH, Hue City, Vietnam | 26-27 September 2015 Global HIV Situation among MSM – Challenges in HIV programs: Greater risk for HIV, less access to intervention programs, and less understood due to their more hidden and stigmatized nature (Altman et al., 2012 – HIV prevalence: • 3.0% in the Middle East and North Africa region to as high as 25.4% in the Caribbean (Beyrer et al., 2012) • HIV and STI prevalence continues to rise (Beyrer et al., 2013) – Condom use and HIV testing: Considerably low in low- and middle-income countries (Oldenburg et al., 2014) Global HIV prevalence in MSM, from studies published 2007–2011 (Beyrer et al., 2012) Global prevalence of HIV in MSM compared with regional adult prevalence (UNAIDS, 2010) Map of the Study Sites Estimations and Projections of HIV Prevalence among General Population Aged 15-49 (1990-2015) 8/6/18 HIV Situation among MSM in Cambodia – HIV/STI prevalence: • • • 2010: 2.2% (BROS Khmer Study, 2010) 2015: 2.4% (NCHADS, 2015) STI symptoms in the past 12 months: 51.5% – HIV risk behaviors (past months): • • • • • • (Yi et al., 2015) Mean number of sex partners: Had sex with a girlfriend: 32.2% Had sex with FSWs: 14.6% Had sex with MSWs: 9.9% Sold sex to women: 8.9% Sold sex to men: 17.4% Condom Use among MSM in Cambodia – Always used condoms (past months): • • • • • • Girlfriends: 55.1% Boyfriends: 64.2% Female sex workers: 75.9% Male sex workers: 73.0% Female clients: 78.1% Male clients: 70.3% – Always used lubricant (past months): • • (Yi et al., 2015) (Siyan Yi et al 2015) Anal sex with boyfriends (80.8%) Selling anal sex (64.1%) Factors Associated Inconsistent Condom Use among MSM in Cambodia • Older age: ≥25 • Self-perception of higher HIV risk compared to the general population (Higher: 36%, Same: 16.4%, Lower: 46.6%) • Illicit drug use • Reported consistent lubricant use when having anal sex with men • Self-reported quality of life as good or very good (Yi et al., 2015) HIV Testing among MSM in Cambodia – HIV testing history: • • Lifetime: 83.6% Past months: 65.1% – Factors associated with HIV testing: • • • • • Receiving any form of HIV education Self-perception of higher HIV risk compared to general population Having been diagnosed with an STI Using a condom at last sex with a man or women Using a condom at last anal intercourse with a boyfriend (Yi et al., 2015) 10 The SAHACOM Activities for MSM Outreach and BCC to increase awareness of risky sexual behaviors related to HIV and STI Distribution of free condoms and lubricant HIV and STI screening by peer counselors at the community level for MSM and their partners Immediate enrolment in pre-ART/ART services for HIV-positive MSM Harm reduction intervention providing education on HIV and illicit drug overlapping risk behaviors Siyan Yi et al JIAS 2015 (In press) 12 Study Objective To review the intervention activities and measure the efficiency and effectiveness of the programs by comparing outcome indicators measured at midterm and end line 13 Study Population • MSM definition: Males who have sex with males, regardless of whether they have sex with • Inclusion criteria: women or have a personal or social gay or bisexual identity (UNAIDS, 2011) – Biological male – 18 years of age – Reporting having sex with at least one male partner in the past 12 months – Khmer speaking – Able and willing to provide oral informed consent 14 Study Sites • Provinces: Battambang & Siem Reap - 70% of the total of MSM covered by the • Hot spots and venues: SAHACOM – Night club/discotheque – Sauna/spa – Barber/beauty salon – Streets – Park/river bank – Specific community: private houses, pagoda, etc 15 Study Design & Sampling Procedures • Midterm – endline comparisons: • Sample size and sampling: – Midterm survey in 2012: 352 MSM – Endline survey in 2014: 394 MSM – Minimum required sample size: 350 – Two-stage cluster sampling method: o o Communes: Under the SAHACOM for at least 12 months Venues/hotspots: At least 20 MSM – take all approach 16 Study Population • Questionnaire: • Measures: – Standardized tools from previous studies – Back translated, consulted, pretested – Socio-demographic characteristics – Self-perception of gender identity – Sexual behaviors in different relationships – HIV and STI symptoms and care seeking behaviors – HIV and STI screening – Substance use – Access to care and support services 17 Data Analyses • • Double data entry: EpiData • Multivariable logistic regression model Bivariate analyses: – Chi-square or Fisher’s Exact test for categorical variables – Student’s t-test or ANOVA for continuous variables – Covariates: Covariates: Sites, age, venues, income, and all variables associated with outcome variables of interest at p< 0.05 – Significance level: Two-sided p< 0.05 – Soft wares: SPSS and STATA 18 Ethical Considerations • Ethical approval: – National Ethics Committee for Health Research (NECHR) • • Written informed consent: All participants Confidentiality & privacy protection: – No personal identifier collected – Interviews at private places 19 Socio-demographic Characteristics Midterm End line OR (95% CI) Mean age (in years) 23.3 ± 5.3 23.7 ± 5.2 0.84 Marital status     323 (92.0) 355 (90.3) 22 (6.0) 29 (7.4) (2.0) 10 (2.3) Characteristics   1.2 (0.7-2.0)   Never married   Married   Divorced/separated 1.2 (0.7-2.1) 1.3 (0.5-3.4)     Personal perception about own sexual identity Women 138 (39.2) 80 (20.6) 2.5 (1.8-3.5) Men 148 (42.0) 228 (57.8) 1.9 (1.4-2.5) 66 (18.8) 85 (21.6) 1.2 (0.8-1.7)     Both sex   20 HIV testing among MSM at midterm and end line Midterm End line 289 (94.1) 252 (77.1) AOR (95% CI) HIV testing experiences Tested for HIV in the past months 2.9 (1.8-3.6)   Place of the most recent HIV test     1.4 (1.1-1.8)   VCCT center 230 (74.9) 142 (43.5)   C/PITC 57 (18.6) 135 (41.2)   Private clinic/hospital (2.9) 33 (10.1) Received the last HIV test result 301 (98.1) 320 (98.2) Received the counseling for the last test 286 (94.7) 312 (95.7) 3.1 (2.2-4.5) 3.7 (1.8-7.9) 1.1 (0.3-3.3) 1.6 (0.8-3.3) 1.1 (0.8-1.3) Received HIV education in the past 12 months 292 (83.0) 333 (84.7) 21 Sexual Behaviors, STIs, and Drug Use among MSM at Midterm and Endline Sexual Behaviors & STIs Midterm End line AOR (95% CI) Sexual behaviors Number of sex partners in the past months 6.2 ± 12.4 4.0 ± 5.5 Had paying sex with men in the past month 67 (19.0) 38 (9.7) Had sex with girlfriends in the past months 59 (15.6) 118 (29.9) Always used condoms in the past three months 51 (73.9) 27 (73.0) Always used lubricant in the past months 34 (49.3) 41 (64.1) 0.03 2.0 (1.3-3.0) 1.8 (1.3-2.5) 1.1 (0.6-2.0) 1.2 (0.7-2.2) STI symptoms and illicit drug use Had at least one STI symptom in the past months 4.6 (2.9-7.4) 99 (28.1) 24 (6.1) Sought treatment for the most recent symptom 2.6 (1.1-6.9) 14 (14.1) (20.7) Illicit drug use in the past months 2.4 (1.4-4.2) 43 (12.2) 20 (5.1) 22 Limitations • No baseline data: • • • Unknown validity of the tools – Compared outcome indicators at midterm and end line – Impacts of the programs could not be fully evaluated Self-reported measures: Underreporting and over-reporting Possibility of recall bias 23 Conclusions & Recommendation • SAHACOM is successful in: –Reducing of number of sex partners –Reducing involvement in sex with male commercial sex workers –Reducing STI symptoms and illicit drug use –Improving care seeking behaviors for STI symptoms • Not successful in: –Increasing condom use rates in all relationships –HIV testing rate was even going down • Future research: –Exploring barriers preventing condom use and HIV testing –Intervention programs tailored to address these issues among MSM in Cambodia 24 Acknowledgments • • • • • • • • • NCHADS PHDs, ODs USAID US-CDC WHO UNAIDS Implementing partners and their staff members Study participants, local authorities Research team members 25 Thank you! Q&A 26 ... et al., 2015) HIV Testing among MSM in Cambodia – HIV testing history: • • Lifetime: 83.6% Past months: 65.1% – Factors associated with HIV testing: • • • • • Receiving any form of HIV education... HIV in MSM compared with regional adult prevalence (UNAIDS, 2010) Map of the Study Sites Estimations and Projections of HIV Prevalence among General Population Aged 15-49 (1990-2015) 8/6/18 HIV. ..Global HIV Situation among MSM – Challenges in HIV programs: Greater risk for HIV, less access to intervention programs, and less understood