HIV prevalence and behavioral risk factors among men who have sex with men (MSM) in Bamako, Mali

Findings from the first representative bio-behavioral survey

Maria Lahuerta, PhD, MPHDeputy Director, SI Unit

Piku Patnaik, PhD, MSEpidemiologist (SI Specialist), SI Unit

Mali context• Population living below

$1.25 a day: 50.4%

• Life expectancy: 55 years

• Adult literacy rate: 33.4%

• Adult HIV prevalence: 1.1%– Male in Bamako: 1.6%– Female in Bamako: 1.7%

Sources: UNDP Human Development Reports, DHS 2012-13

Background• In 2011, ICAP received a five-year CDC

Cooperative Agreement to strengthen Strategic Information activities in Mali

• Sub-agreement with the International Center for Excellence in Research (ICER) from the University of Bamako to implement surveillance activities among key populations

Why are key populations important?

• Experience significant HIV burden, and influence the dynamics of HIV epidemics

• KPs may be important in driving the HIV epidemic, especially if they act as “bridges” to the general population

Men who have sex with menMale partners

Female partner

Surveillance among key populations

• Monitor HIV infection in KP and bridges to general population

• Monitor effects of intervention programs on HIV prevalence and behaviours in KP

Surveillance among key populations in Mali

• HIV prevalence among KP from the 2009 Integrated Bio-behavioral survey: – female commercial sex workers

(24.2%)–ambulatory vendors (3.7%) – taxi/bus ticket sellers (3.5%)– truck drivers (2.7%)What about men who have sex with men (MSM)?

Men who have sex with men (MSM)

• MSM are disproportionally affected by HIV (3.8 times higher odds of HIV infection than other adult men in sub-Saharan African countries)

• Other studies in West Africa showed high HIV prevalence (Cote d’Ivoire: 18%, Ghana 18%)

• Although homosexuality is not illegal in Mali, it’s highly stigmatized

• Two NGOs currently serving MSM in Mali: ARCAD and Soutoura

Sources: Beyrer et al. 2010; Hakim et al. 2015; Aberle-Grasse et al. 2013.

Objectives of the formative assessment among MSM in Bamako

• Identify specific socio-cultural factors that might limit and facilitate access to MSM

• Generate an ethnographic mapping of MSM hotspots

• Identify the operational and logistical requirements of the survey

Study design: Formative assessment

1. 3 focus groups with MSM 2. In-depth interviews with:

15 MSM 5 service providers 5 facilitators (individuals involved in

the MSM networks)3. Ethnographic mapping4. Observational visits to MSM hotspots

Formative assessment results

• Socio-cultural factors: High acceptability of the survey among

MSM• Ethnographic mapping:

Very few gathering places exclusively for MSM

• Logistics:• Participants suggested 2 study sites, at

each side of the river• Recruitment through coupons was

acceptable, so respondent-driven sampling was feasible

Objective of the bio-behavioral survey among MSM in Bamako

• Measure the prevalence of HIV and identify associated risk behaviors

• Inform HIV prevention programming in Mali

Protocol development• 4-day protocol development

workshop with Technical Working Group to:• Disseminate formative assessment

findings• Build local capacity on respondent

driven sampling (RDS) • Finalize protocol and study tools for

bio-behavioral surveyTERIYA study

Obtaining IRB approval• Obtained approval from local ethics

committee, CDC ADS and Columbia University IRB

• Reluctance of local ethics committee to approve study among MSM– They thought the study promoted homosexuality– We had to explain the importance of this study

to the general population

Study design• Cross-sectional survey among MSM in

Bamako using respondent-driven sampling (RDS)

• Sample size needed 550 participants to: ensure sufficient power to detect the HIV prevalence

in the MSM population in Bamako detect a change in HIV prevalence between the

current survey and future bio-behavioral survey

• Two study sites

Respondent-driven sampling

• First participants (seeds) are non-randomly selected

• Participants recruited by peers through the use of coupons

• Participants were given cash:- For being interviewed (1st incentive)- For recruited peers (2nd incentive)

Coupon

• 3 coupons given to participants to recruit peers

• Coupon ID was critical to determine who recruited who

Respondent-driven sampling

Seed

6 seeds were non-randomly selected

Age Marital status Profession Area of

residenceSexual

orientationEngaged with

NGO30 Single NGO

coordinator Suburb Bisexual Yes

24 Single Peer educator Commune V Homosexual Yes

38 Married Building technician Commune IV Bisexual No

48 Married Trader Commune II Bisexual No

24 Single Student Commune IV Bisexual No

31 Single Trader Commune I Bisexual No

• Well connected among their peers• Supportive of the survey’s goals• Diverse in regards to their characteristics

Eligibility criteria• Biologically male

• Being ≥18 years old

• Having had anal or oral sex with another man in the last 6 months

• Resident of Bamako or its suburbs for the past 6 months

• Speaking French or Bambara

TERIYA study team

1. Study coordinator2. Receptionist3. Coupon manager4. Interviewers (2)5. HIV counselor

Study team trainings

• Good clinical practices for research

• Review of SOPs• Practice with French and

Bambara questionnaire• Role playing • Piloting of procedures at study

sites

Study flow-1st visitScreening

Informed consent

Interview

If not eligible, person leaves site

If no consent, person leaves site

Coupon manager

Interviewer

Counselor

Pre-test counseling

HIV rapid test

Post-test counseling and referral to services

If participant consents to be

tested

Discussion of procedures for peer recruitment and

pay primary incentive

If participant does not

consent to be tested

Discussion of procedures for peer recruitment and

pay primary incentive

Study flow- 2nd visit

Confirm ID

2nd interview

Pay secondary incentive

Coupon manager

Interviewer

Counselor

Questionnaires• First visit:

– socio-demographics– sexual history and current

sexual behaviors – condom and lubricant use– HIV knowledge and

attitudes– alcohol and drug

consumption – experience with health

and support programs available to MSM

– stigma and discrimination

• Second visit:– eligible candidate

participants approached

– how many referral coupons he handed out

– why the people who refused did not accept the coupons

Data management

SECURE SERVER

Lab procedures• For all participants:

– HIV rapid testing with finger prick– Dried blood spots (DBS) for quality control: all HIV-

positive and 10% of HIV-negative samples were retested with ELISA by the national lab (INRSP)

• For HIV-positive participants:– Venipuncture for additional DBS– DBS were sent to CDC-Atlanta for future incidence,

viral load and genotyping testing

Referral services• 2-day training of providers treating MSM:

• Stigma-reduction training for services to MSM• Orientation to our study and referral procedures

• HIV-positive participants were referred to health facilities offering HIV care and treatment

Study sites

Referral form

Enrollment information

Data analysis

• Data were weighted by participant’s network size and analyzed using the software RDS Analyst.

• Proportions presented are interpreted as population estimates of the true population

• Multivariate analyses ongoing

Results

• Between October 2014 and February 2015, 552 MSM were enrolled

• 550 of 552 MSM (99.6%) consented for HIV testing, while only 2 refused

• Laboratory quality control showed no discordance in the HIV test results

• Enrollment was completed without any major incident despite high stigma against MSM

Recruitment flow Coupons distributedn = 1551

Screened for eligibilityn = 608

Enrolledn=552

Not eligible , n = 56

Consented to get tested for HIV using rapid test, n= 550

RDS recruitment tree

Participant demographics Age distribution

13%

53%

16%

7%12% 18-19

20-2425-2930-34Older than 35

Education level

5% 3%

28%

47%

16%

Never at -tended school

Bambara alphabeti-zation

Primary

Secondary

University

Socio-demographic characteristics

CHARACTERISTIC % 95% CIMarital statusNever married 92 89, 97Married 7 2, 12Divorced, separated, or widowed 1 0, 3Religion

Muslim 88 85, 91Christian 9 6, 11Animist 0 0, 2No religion 3 3, 4

NationalityMalian 95 93, 96Other African nationalities 6 4, 7

SexualityGay/homosexual 45 39, 52Bisexual 54 48, 60Straight/heterosexual 0 0, 3

Number of sex partners

43%

24%

12%

7%

14%

Number of male sexual partners in the past 6

months

1

2

3

4

Plus de 4> 4

48%

29%

23%

Number of female sex-ual partners in the past

6 months

0

1

>1

Condom use during last sexual encounter

76% with male partner 55% with female partner

Unprotected anal sex

Among men that had receptive anal sex in the past 6 months, had sex without a condom

45%

Lubricant use

Lubricant use among those who had anal sex in the past 6 months

59%

HIV prevention services

• 45% used free condoms in the past 6 months

• 71% reported that access to free condoms would increase the probability of using them

• 72% had ever talked to a peer educator or outreach worker about HIV

Stigma and disclosure of orientation

STIGMA & DISCLOSURE % 95% CIThinks it is illegal to have sex with other men in MaliYes, thinks it is illegal 73 67, 78No, thinks it is not illegal 23 17, 28Don't know 5 2, 8Suffered harrassment or abuse for having sex with menYes 23 18, 29No 77 71, 82Has told people other than male sex partners about having sex with menYes 74 69, 79No 26 21, 32

HIV prevalence in Bamako

MSM General population of adult men

0

5

10

15 13.7

1.6% H

IV+

Gaps in HIV testing overall

• 72% reported ever being tested for HIV

• Only half of these had been tested in the past 6 months

Awareness of status and risk perception

30% said it was not possible for them to be HIV-positive

13%

87%

Awareness of HIV status

Aware of being HIV-pos-itive

Previously unaware of being HIV-posi-tive

Risk perception

Services: already aware of being HIV+

Déjà fait un test du VIH+

Déjà reçu un examen pour TB

Déjà pris le TAR Prends le TAR maintenant

0

2

4

6

8

10

12

14

16 15 (100%)

9 (60%)

12 (80%)

9 (60%)

Num

ber o

f per

sons

Had tested posi-tive for HIVHad tested posi-tive for HIVHad tested posi-tive for HIV

Had been screened for TB

Visited health care provider

Currently on ARTHad initiated ART

Services: newly identified as HIV+

• Results on referral of participants who tested positive were incomplete

• Documentation on referrals was missing– Some participants discarded their referral

forms

– Other participants submitted their referral forms at clinics, but these referral forms were not retained at the clinic

Key findings

• HIV prevalence among MSM in Bamako was 13.7% (2014-2015)

• Only 72% had ever been tested for HIV

• Only 36% were tested in the past 6 months

• 45% or just under half the population had had unprotected receptive anal sex

• Overall condom use at last sexual intercourse was imperfect with a male partner and low with a female partner

Discussion

• Need for enhanced HIV-related services targeted at MSM in Bamako– HIV testing needs to be promoted and made easily

available – Free condoms need to be made easily available for MSM– Peer educators/outreach workers need to reach more

MSM • Critical importance of using condoms during anal

sex• Condom use with both male and female partners

– Prevention messages should highlight role as a potential bridge population if they also have female partners

Timeline

2011 2012 2013 2014 2015

Attack to Bamako hotel

Tuareg rebels seize control of northern Mali, declare independence

Junta reasserts control after an alleged coup attempt

French intervention to regain the North

Attack to restaurant in Bamako

Political unrest in northern Mali

Survey data collection

Formative assessmentProtocol

development

Protocol development

DisseminationIRBIRB

Dissemination

Analysis Analysis

Limitations: RDS• RDS is not a perfect method, but gives us a

best estimate of a representative sample• Possibility of differential participation rates

– Older MSM who are more hidden than others; we addressed this by

• Closely monitoring recruitment through data collection

• Adding a 7th seed mid-way through the study• Mobilizing participation of older MSM

– Led to demonstrable increase in older MSM

Limitations: referrals • Imperfect documentation on referrals • Lessons learnt

– During provider training, emphasize to providers the need to train other clinic staff

– During visits to study site, emphasize to participants the need to submit the form at the clinic

– Conduct closer monitoring of forms that need to be retained at clinics and collected at frequent intervals

Strengths & successes • First study in representative sample of MSM in Mali • Smooth and timely completion despite strong stigma

associated with MSM in Mali as well ongoing political unrest

• Major contribution to knowledge and understanding of an understudied key population– MSM population profile, HIV prevalence, risk

factors

• Generation of data for MOH to use in the design and prioritization of prevention programs

Continuous engagement with MOH

• Protocol and tool development • Trainings on RDS and bio-behavioral surveys

• Questionnaires, forms, and SOPs were shared with MOH for future surveys

• Study database was shared with MOH for further analyses to inform programmatic changes

Data dissemination• Report summarizing

findings was disseminated at a workshop

in Bamako

• International conferences Posters at ICASA and CROI

• Manuscripts under development including risk factors based on multivariate analyses

Future plans• Based on UNAIDS recommendations, MSM bio-

behavioral surveys should be repeated every 3 years in Bamako

• Meanwhile, MOH will work to support prevention programming– Strengthening capacity of health care systems– Engaging NGOs to expand prevention, testing, care

and treatment services for MSM, potentially using mobile units

• ICAP and partners will conduct another bio-behavioral survey among artisanal gold miners in Kayes, Mali

Acknowledgements• CSLS

– Tako Ballo– Bouyagui Traore– Ouman Dembele

• HCNLS– Daouda Diakite

• INRSP– Mamadou Traore– Sekou Traore

• ICER– Nouhoum Telly– Seydou Doumbia– Hammadoun Sango– Ongoiba Aboudoullaye– Oumar Sangho– TERIYA study team

• CDC/Atlanta– Avi Hakim

• CDC/Mali– Jacques Mathieu– Adama N’dir– Mamadou Traore– Adama Sangare

• Tobi Saidel, Consultant• ICAP-New York

– Batya Elul– Danielle Gurr– Kate Doyle– Yingfeng Wu– Justin Knox

• USAID

Acknowledgements

This project is supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of grant number 1U2GGH000398-01 for “Strengthening HIV Strategic Information in the Republic of Mali under PEPFAR”. The contents are the responsibility of ICAP and do not necessarily reflect the views of the United States Government.