the 6 th national scientific conference on hiv/aids male sex workers in vietnam: risk factors &...

THE 6TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS

Male Sex Workers in Vietnam:Risk Factors &

Preliminary Findings from a Sexual Health Intervention

(SHEATH)Scientific Symposium on HIV and HCV Infections in Key Populations

Hanoi, Vietnam

November 2015

The 6th National Scientific Conference on HIV/AIDS

ACKNOWLEDGEMENTS

National Institute on Drug Abuse

Grant Number: DA022170

National Institute on Drug Abuse / PEPFAR

Grant Number: 033673


RESEARCH COLLABORATION

New York University, College of Nursing

Lloyd Goldsamt, PhD

Hanoi Medical Univ., CREATA

Le Minh Giang, MD, PhD

Center for Applied Research on Men and Community Health (CARMAH)

Donn Colby, MD

Bao Le, MSW

Univ. of Puerto Rico, School of Public Health

Michael Clatts, PhD


SUMMARY• YMSWs in Vietnam evidence multiple, complex, and interacting sources of risk and

multiple poor health outcomes.

• YMSW have limited contact with health services (including HIV testing and

treatment)

• Lack of knowledge and stigma are key barriers to engagement and retention in

care.

• It is possible to identify, reach, and engage YMSWs for participation in HIV & health

services interventions.

• Targeting YMSW in these types of interventions may be expected to yield

substantial individual and community level benefits across the full spectrum of HIV

prevention and care.


HIV IN SE ASIA• Global Burden of HIV: 35 million (2.1 million new infections in 2013

• Asia/Pacific region has a “concentrated” HIV epidemic

• 350,000 new infections in Asia/Pacific region 2013 (little change in

incidence in last 5 years)

• MSM populations account for a rapidly growing proportion of new STI/HIV

infections throughout the region

• Behavioral risk is especially high among among young male sex workers

(YMSW)

Source: HIV and AIDS in the Pacific: UNAIDS Report 2013.


INCREASING STI/HIV MSM/MSW IN VIETNAM


EPIDEMIOLOGICAL STUDY YMSW IN VIETNAM

• 2010 – 2011

• Community-based ethnographic mapping in Hanoi, Nha Trang, and Ho Chi Minh City

• Targeted/venue-based sampling (n=654)

• Cross-sectional survey and biological screening

• Eligibility:

Age 16-35 years of age

Sex with a male client partner <90 days


DEMOGRAPHIC CHARACTERISTICS

• Mean Age: 22 (39% under the age of 21)

• Education: 58% had no completed high school

• 50% of monthly income from sex work

• Unstable housing <30 days: 88%

• Migrant: 53%

• 47% attracted to both men and women, 30% attracted exclusively to women, only 14% identify as “Gay”


HIGH RATES OF DEPRESSION

Source: L Goldsamt, M Clatts, Le MG, G Yu (2014) Prevalence and Behavioral Correlates of Depression and Anxiety Among YMSW in Vietnam, Internat J. Sex. Hlth


SUBSTANCE USE (<30DAYS)

Tobacco: 80%

Alcohol: 98%

Amphetamines: 38%

MDMA: 37%

Ketamine: 10%

Opium: 8%

Heroin (smoking): 8%

Heroin (injection): 8%Source: Yu, G., et al. Substance use among male sex workers in Vietnam: Prevalence, onset, and interactions with sexual risk.

International J. of Drug Policy (2014)


MULTIPLE, CONCURRENT SEX PARTNERS

Source: Clatts MC, Giang LM, Goldsamt LA, Yu G. 2015. Sexual Practices, Partner Concurrency, & Prevalence of STIs/HIV Among Male Sex Workers in Vietnam. Sexual

Health

9%

18%

47%

26%

654 Vietnamese MSWs by sex partner type

Sex work clients, female elective partners and male elective partnersSex work clients and male elective partnersSex work clients and female elective part-nersSex clients only


HIGH RATES OF UNPROTECTED SEX & CONCURENT MULTIPLE PARTNERS


Health

Male elective partners Female elective partners Sex clients

34%

57%

32%

Unprotected Anal or VaginaI In-tercourse in the last 30 days


HIGH RATES OF STI/HIV


Health http://dx.doi.org/10.1071/SH14101.


COMPLEX (“SYNDEMIC”) SOURCES OF RISK

SUBSTANCE USE

DEPRESSION & ANXIETY

BEHAVIORAL RISKS

STI/HIV & POOR HEALH OUTCOMES

POVERTY & LACK OF

OPPRTUNITY

LIMITED UNDERSTANDING OF HIV RISK

STIGMA & ALIENATION FROM CARE


• SHP interventions originally emerged as a challenge to risk factor model (placing greater emphasis on situational, contextual, & structural factors to understand dynamics of risk).

• SHP has been widely applied in structural, community, and individual level interventions, including HIV prevention and care, sexual decision-making, and health services

• SHEATH is a composite intervention in which we bundled content from multiple intervention sources, including Sexual Health Promotion (education) and Harm Reduction (risk reduction)

• Locally adapted for use in targeted YMSW populations and environments in Hanoi and HCMC

• Delivered by specially trained Health Educators, using Motivational Interviewing to enhance personalization and with an emphasis on protective factors and sources of resiliency

SHEATH INTERVENTION(Sexual Health Education And Targeted Harm reduction)


CORE COMPONENTS

1. Sexual Health2. Sexual Diversity and Sexual Rights3. Detailed education STI/HIV (including symptoms, sources of transmission risk, interactions, and treatment options4. Sexual Harm Reduction (including the full range of strategies to behavioral risk, including role selection, sero-sorting, partner selection strategies, condom use, etc.)5. Substance Use (education about alcohol and drug use, modes of administration, interactions with sexual decision-making)6. Stigma, bias, and social barriers to health care (including skills development in stigma management)7. Role of health services in protecting sexual health, including habituation of HIV testing at 4-6 months intervals, HBV vaccination


STUDY DESIGN

Two cites: Hanoi and Ho Chi Minh City Delivered by health educators using motivational interviewing techniques to increase personalization Community/venue-based outreach education (11,993 community interventions delivered)Random selection from the community for the clinic-based interventionIndividual-level intervention using a 2-session format (matching conventional pre/post HIV testing infrastructure) (>1,000 interventions delivered)Community level evaluation: Repeated cross-sectional survey in diverse YMSW venuesClinic evaluation: Pre & post test measures


ACCEPTABILITY:Helpfulness & Relevance of Intervention Content


SIGNIFICANT IMPACT ON A BROAD RANGE OF HEALTH SEEKING INTENTIONS


MOST YMSWS HAVE NEVER HAD CONTACT WITH HEALTH SERVICES & LESS THAN HALF HAVE HAD AN HIV TEST

Community Sample Community Sample


SIGNIFICANT IMPACT ON KNOWLEDGE OF HIV STATUS---(Critical Step in the HIV test & treat cascade)

Community Sample Clinic Sample

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