Integrated Biological and Behavioral Surveillance Survey (IBBS) among Men who have Sex with Men (MSM)) in the Kathmandu Valley Round III – 2009

Abstract

Under the National Surveillance Plan for HIV and AIDS, the National Center for AIDS and STD Control (NCASC) has been conducting Integrated Biological and Behavioral Surveillance Surveys (IBBS) among the most at-risk populations (MARPs) at regular intervals. These surveillance studies are aimed at measuring the prevalence of HIV and sexually transmitted infections (STIs) among MARPs and assessing their health risk behaviors as well as monitoring epidemic and behavioral trends to inform the HIV response in Nepal. This report documents the findings of the third round of the IBBS conducted among 400 men who have sex with men (MSM) in the Kathmandu Valley. As in the previous round of the IBBS among the same group, the respondent-driven sampling (RDS) methodology was adopted to recruit the respondents for the study. RDS, which is one of the most effective methodologies to reach ‘hard to reach groups’, is a relatively new adaptation of chain referral sampling, where subsequent respondents are recruited by previous respondents through their network of acquaintances. This survey was conducted primarily to determine the prevalence of HIV and STIs (syphilis, chlamydia trachomatis (CT) and neisseria gonorrhoea (NG)) among MSM in the Kathmandu Valley and to assess their HIV/STI-related risk behaviors, including their sexual practices. The survey also aimed to measure their exposure to the intervention programs targeted at MSM in the valley. At the same time, it has sought to analyze trends through the comparison of data on selected variables obtained from the first, the second and the third rounds of the IBBS. A structured questionnaire (Annex 2) was used to collect information on sexual behavior, HIV/AIDS awareness, as well as the socio-demographics of the respondents. Randomly selected study participants were enrolled in the study only after getting oral informed and witnessed consent. Interview using the structured questionnaire was followed by a clinical examination by a health assistant and the collection of blood, urine and anal swab samples for biological testing of HIV, syphilis, CT and NG. The survey was carried out through one centrally-located study center at Jamal in the Kathmandu Valley. Biological samples were collected only after a pre-test counseling session and the study participants were provided syndromic treatment for STI- related problems after being examined by a health assistant. HIV and syphilis test results were provided later at STD/AIDS and Training Services (SACTS), Cruiseaids and Parichaya Samaj Voluntary Counseling and Testing (VCT) Centers along with post-test counseling delivered by experienced counselors. For the purpose of analysis, MSWs (male sex workers) and non-MSWs (non-sex workers) have been collectively defined as MSM. These two categories have been presented separately and the variables which showed marked differences between these two groups have been commented on. Finally, in this round of IBBS, although the sample was drawn using RDS method, data analysis is not done using the Respondent Driven Sampling Analysis Tools (RDAST) software. The study team analyzed the data on the network size reported in the survey, which is one of the key data needed for adjusting the sample proportions, and decided not to go for RDSAT analysis. The network size was asked twice in the questionnaire, which leads to substantial difference in reported network size that could not be reconciled and lead to substantial differences in prevalence estimates. Technical experts from FHI/Nepal and FHI Asia Pacific Regional Office (APRO) also were consulted while making this decision. In this perspective the sampling methodology used in the survey may be considered as "convenient sample obtained using RDS methodology". Below is a short summary of the findings of this study: STI/HIV/AIDS Prevalence HIV prevalence among MSM in the Kathmandu Valley in 2009 is 3.8 percent. Seven of the 135 MSWs (5.2%) and eight out of 265 non-MSWs (3%) had HIV. The overall prevalence of at least one STI was 21.5 percent among MSM in the valley. MSWs (31.9%) had significantly high prevalence of at least one STI than non-MSWs (16.2%). Moreover 1.5 percent of MSM had active syphilis, while 2.5 percent had a history of syphilis. Overall, 12.5 percent of MSM had anal NG with a relatively high prevalence among MSWs (18.5%) than non-MSWs (9.4%). In the same way, anal CT was also high among MSWs (11.1%) than non-MSWs (1.9%).The prevalence of urethral CT and urethral NG was comparatively lower than other STIs (2.5% and 0.8% respectively). Socio-demographic Characteristics MSM in the Kathmandu Valley are mostly young. The majority of respondents were below the age of 30 years (79.3% MSWs and 78.9% non-MSWs) with one in ten (12.5%) below 20 years of age (8.9% MSWs and 14.3% non-MSWs). Twenty-five percent of MSM were currently married. Not much difference was noticed in the marital status of MSWs and non-MSWs (77.8% of MSWs and 73.6% non-MSWs were unmarried). However, of those who were currently married, more MSWs (23.3%) than non-MSWs (2.9%) were married to a male partner. A relatively low proportion of MSM (22.5%) reported living with a regular partner. Among those living with a regular partner, most non-MSWs lived with female partners (69.8%), whereas the majority of the MSWs’ regular partners were male (64.9%). Almost 43 percent of MSM had attended School Leaving Certificate (SLC) or a higher level of studies. Around four percent of MSM were illiterate, while 6.8 percent could read and write but had no formal schooling. Six in ten MSM (65.3%) had lived away from home in the past 12 months. While 25.9 percent of MSWs relied on exchanging sex with a male partner for money as their main source of income, 24.9 percent of non-MSWs relied on wage labor. Use of Alcohol and Drugs The majority of MSM (80.9%) had consumed alcohol in the last month. At the same time, 38.8 percent of MSM also had used drugs in the past year. More non-MSWs (44.9%) than MSWs (26.7%) had done drugs in the year preceding the survey and the most common drugs used by them (98.7%) was marijuana, locally called ganja. Sexual Behavior, Type of Partner and Condom Use MSM reported having their first sexual encounter at a fairly young age. Six in ten (61.3%) had sex before the age of 17. More MSM (59.3%) had their first sexual experience with a male partner than with a female partner (40.8%). More MSWs than non-MSWs had their sexual debut both before the age of 17 (82.2% MSWs and 50.6% non-MSWs) and with a male partner (89.6% MSWs and 43.8% non MSWs). All the MSM had sexual contact with a male in the year preceding the survey, 49 percent of them had also maintained sexual relations with a female partner in the same period. Overall, 35.5 percent of MSM had sold sex at least once before the survey. The average age of respondents when they sold sex for the first time was 19 years. The predominant sex practice among MSM was anal sex followed by oral sex. Overall, 85.8 percent had practiced anal sex in the past month; while 71.8 percent had oral as well as anal sex in the past month. Mostly MSWs had performed receptive roles while non-MSWs had mostly performed insertive role in anal as well as oral sex in the past month. Overall, consistent condom use was highest with a paid female sex partner (78.8%) and lowest with a non-paying female sex partner (40%) in the month preceding the survey. The majority of the respondents (94.8%) could get condoms whenever necessary, and 76.6 percent of those who had obtained their last condom from various sources had got it free of cost. Almost nine in ten MSM (86.8%) had used lubricants before the survey, while 53.3 percent of those who had heard of branded/specially made lubricants had used it consistently in the past month. STI and HIV/AIDS Awareness Overall, 9.3 percent of MSM could not correctly name any symptom of STIs in men. Reportedly 22.5 percent had experienced at least one symptom of STI in the past year. Eighty-three percent of MSM (84.4% MSW and 82.7% non-MSWs) had knowledge of all three major HIV/AIDS preventive measures, such as abstinence from sexual contact , ‘A’; being faithful to one partner, ‘B’; and condom use during each incidence of sexual contact, ‘C’. Meanwhile, 64.3 percent of MSM were aware of ‘B,C,D,E,F’ (a healthy looking person can be infected with HIV, ‘D’; a person cannot get the HIV virus from a mosquito bite, ‘E’; and sharing meal with an HIV-infected person does not transmit the HIV virus, ‘F’). Eighty-three percent of the respondents were aware of a confidential HIV test facility. Moreover, 62.8 percent of MSM had taken an HIV test before the survey. Among them, 67.7 percent had taken the test within the year preceding the survey. A higher proportion of MSWs (83.7%) than non-MSWs (52.1%) had taken up HIV testing. Around two-thirds of both MSWs (65.9%) and three-fourths of non-MSWs (75.5%) perceived themselves to be at little or no risk of contacting HIV. At the same time, 34.1 percent of MSWs and 23.8 percent non-MSWs perceived that they had a high or medium risk of getting HIV. Exposure to HIV/AIDS Related Programs In the past year, seventy-eight percent of MSM had met peer/outreach educators, 54.5 percent had visited a drop-in center (DIC), and 47.5 percent had participated in at least one HIV/STI awareness program/community event. VCT centers had been visited by 43.8 percent at least once. A relatively smaller proportion of them (24.8%) had visited an STI clinic in the year preceding the survey. More MSWs than non-MSWs were exposed to or had participated in these activities.