current situation and factors affecting hiv infection and sexually transmitted diseases in male homosexual sex worker group in hanoi, 2009-2010”

Epidemiological and social researches of HIV infection and sexually transmitted infections STIs among male homosexual sex worker/MSM have shown that: Male homosexual sex worker group has

NATIONAL INSTITUTE OF HYGIENE AND

EPIDEMIOLOGY -* -

NGUYEN THI PHUONG HOA

CURRENT SITUATION AND FACTORS

AFFECTING HIV INFECTION AND

SEXUALLY TRANSMITTED INFECTIONS

MALE HOMOSEXUAL SEX WORKER GROUP

IN HANOI, 2009-2010

Specialization: Public health

Code : 62 72 03 01

THESIS SUMMARY

HA NOI - 2014

NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

Scientific supervisors:

1 Prof Nguyen Tran Hien, MD, MPH, PhD

2 Assoc Prof Dao Thi Minh An, MD, PhD

Opponent 1:

Opponent 2:

Opponent 3:

The thesis will be defended at the Institute‘s PhD Assessment committee at National Institute of Hygiene and Epidemiology

Time: date: month 2014

The thesis can be found at:

- The National library

- The National Institute of Hygiene and Epidemiology Library

PUBLICATIONS

1 Nguyen Thi Phuong Hoa, Le Minh Giang, Nguyen Tran

Hien and et al (2012), “Demographic characteristics and risk

behaviors for HIV/STIs of men having sex with men (MSM)

sex workers in Ha noi, 2009-2010”, Journal of Preventive

Medicine, Volume XXII, No 6(133), page 39-46

2 Nguyen Thi Phuong Hoa, Le Minh Giang, Nguyen Tran

Hien and et al (2012), “Risk factors for HIV/STIs among

MSM sex workers in Ha noi, 2009-2010”, Journal of

Preventive Medicine, Volume XXII, No 6(133), page 47-54

PREFACE

1 The thesis’s urgency

Male homosexual sex worker group is a branch of Men who have sex with men (MSM) group Epidemiological and social researches of HIV infection and sexually transmitted infections (STIs) among male homosexual sex worker/MSM have shown that: Male homosexual sex worker group has higher risk of HIV infection and STIs Other researches also pointed out the results of unsafe sexual intercourse with many type of partners, numerous sex partners and using drugs

Those researches have shown the importance of studying male homosexual sex worker group in limiting HIV infection and STIs However, in Vietnam and particularly in Hanoi, there are not much specific studies on male homosexual sex worker group; therefore, we conducted this thesis in order to:

1 Describe sexual identity, knowledge about HIV/STIs, sexual behaviors, use of addictions and use of medical services among male homosexual sex worker in Hanoi, 2009-2010

2 Identify current HIV infection and sexually transmitted diseases rate in male homosexual sex worker group in Hanoi, 2009-2010

3 Analyze some factors affecting the risk of HIV infection and sexually transmitted diseases in Hanoi, 2009-2010

2 New findings of the thesis

This is the first systematic research on demographic

characteristics, HIV infection and STIs rate, risk factors of HIV

infection and STIs in male homosexual sex worker group in Hanoi

The thesis has identified current HIV infection and STIs

rate in male homosexual sex worker group in Hanoi as well as

has found some factors to forecast the risk of infected at least

one STI in this group

The results have supported planning process to prevent

HIV infection and STIs among male homosexual sex worker

group in Hanoi

3 Scientific and practical significance of the thesis`

Scientific significance: The thesis, which uses

cross-section descriptive research included quantitative and

qualitative research, trusted data collection methods and precise

analyzing methods, has concluded that male homosexual sex

worker group in Hanoi is the group with high risk of HIV

infection and STIs as well as identified some factors to forecast

the risk of infected at least one STI in male homosexual sex

worker group

Practical significance: The results imitated some

solutions to prevent and control HIV infection and STIs in male

homosexual sex worker group

The thesis also provided various practical data for

teaching purposes or reference for other researches

Thesis arrangement: The thesis was presented on over

102 pages (excluded references, table of contents) and divided

into; Preface: 2 pages; Chapter 1-Introduction: 30 pages; Chapter 2-Research subjects and methodology: 15 pages Chapter 3-The thesis’s findings: 32 pages; Chapter 4-

Discussion: 20 pages; Conclusion: 2 page; Recommendations:

1 page Thesis consists of 17 tables, 13 charts, 1 image, and 1

diagram The appendix includes 77 references (16 Vietnamese,

61 English), list of sampling sites, the deep interview questionnaire guidance, adventure screening, agreed to participate in research, questionnaires, and card for promissory test results

CHAPTER 1: INTRODUCTION 1.1 Introduction and basic concepts

1.1.1 Sex and gender

1.1.1.1 Sex: is the concept which implies biological

characteristics of male and female body

1.1.1.2 Gender: is social concept of role, behaviors, activities and

other features which are considered suitable for male or female

1.1.2 Sex and related concepts

1.1.2.1 Sexual orientation: Imply a long-term sexual or

emotional attraction by a same gender, different gender or both Therefore, there are 3 general sexual orientations: heterosexual, homosexual and bisexual

1.1.2.2 Concepts of Transgender, Transsexual, Intersex, Gay, Men who have sex with men, Male homosexual sex worker

1.1.2.3 Transgender: the situation in which a person with

normal body characteristics about sex but believe that he/she belong to other sex and live as he/she thought

1.1.2.4 Transsexual: The use of surgery or hormone

treatment… to change biological sex from man to woman or

vice versa

1.1.2.5 Intersex: A person has extraordinary strange about sex

differentiation, body and genital organs because of unusual

genes, endocrine… The person would have biological

characteristics of both male and female or unidentified sex

1.1.2.6 Gay: A male individual is attracted or has sexual desire

with another male individual Gay infer to homosexual

orientation of a male individual

1.1.2.7 MSM: the term infer to sexual intercourse of a male

with another in any situation regardless sexual orientation,

sexual identity

1.1.2.8 Male homosexual sex worker: Prostitution is the coitus

behaviors of a person with another in order to exchange money

or other benefits Male homosexual sex worker is defined as a

male has sexual intercourse with another man to get money or

benefits (accommodation, foods, drugs…)

1.1.2.9 Other terms, concept (Gay, straight men), Pê – đê

1.1.3 Concept of sexually transmitted infections

Infections due to bacteria, virus, monocle, fungus,

parasitic and can be transmitted between people through sexual

intercourse

1.2 Demographic characteristics of MSM/Male

homosexual sex worker group worldwide and in Vietnam

1.2.1 Population size

The proportion of male homosexual sex worker in MSM group fluctuates between 20.0% and 74.0%, depending

on each country In Vietnam, this proportion is about 22.0% to 52.4%, depending on each province

1.2.2 Socio-Demographic characteristics, sexual identity and gender identity

Worldwide and Vietnamese studies have shown that male homosexual sex worker group does not uniform, they diverse as ages but popular in young men, educational background, nationalities, and jobs…Most male homosexual sex worker are immigrations from other areas Male homosexual sex worker group consists of gay, intersex and heterogeneous

1.3 Current situation of HIV infection and STIs rate in male homosexual sex worker group

Until now, there is not any international organization introduce statistics data on level of HIV infection and STIs rate

in male homosexual sex worker group worldwide This ratio fluctuate proximately between 2.1% - 33.3%, and the ratio of infected at least one STI is about 2.0% - 60.0%

1.4 Sexual behaviors and the use of addictions

1.4.1 Sexual behaviors

There were a number of studies on risks of infecting HIV and STIs in male homosexual sex worker group which depend on the number of sex partners as well as their diversity The male homosexual sex worker member not only has sexual intercourse with male but also with female In other words, inter-gender sex among male homosexual sex worker group is quite popular in recent years which increases the risk of infecting

Although oral sex is very popular in male homosexual sex

worker/MSM group, the proportion of using condoms is seldom

Besides, anal sex is the main reason for infecting HIV and STIs in

male homosexual sex worker group Many specific researches on

male homosexual sex worker have concluded that the proportion

of anal sex with out protection is pretty high, from 13.0% to 78.5%,

much higher than that of non male homosexual sex worker group

(22.4% compared with 4.6%)

1.4.2 The use of addictions

The use of addictions among male homosexual sex

worker is quite popular Studies have shown that there are vast

addiction types used, included: alcohol, tobaco, marijuana, cocain,

heroin, benzodiazepines, pain retriever, ecstasy….In the world,

research in Kenya in 2008 showed the relationship between alcohol

and unprotected-anal sex (OR=1.63; 95%CI=1.05-2.54) Among

male homosexual sex worker group, the number of IDUs

fluctuates between 1.5% - 11.1%.Vu Ngoc Bao’s research in 2009

also proved the relationship between prostitution and using drugs-

particularly injecting heroin

1.5 Factors affecting the risk of HIV infection and STIs

Those factors can be classified into 3 categories: individual

factor, socio-environmental factors and the specific situation of

prostitution

1.6 Medical services

In Vietnam, medical services assessibility of male

homosexual sex worker group has not been concerned, some

studies have shown this limitation Among male homosexual sex

worker group, self-admitted HIV tested ratio of group prostitution only is about 12.5%, much lower than average ratio (19.5%) Besides, only 39.0% was received condoms, in which, the ratio of group prostitution only is lowest (22.2%)

CHAPTER 2: METHODOLOGY 2.1 The thesis object

The study objects are men who have homosexual prostitution in Hanoi, from 16 to 35 years old and admitted having anal sex or oral sex with another man in the last previous month

2.2 Time and location of the thesis

2.2.1 Time: from 01/2009 to 12/2010

2.2.2 Location

Places are gathering points of male homosexual sex worker group in Hanoi, which are chose through qualitative social research, included: Hoan Kiem lake, Thien Quang lake, Water resources university park, massage street Quan Thanh-Nguyen Truong To, steam room Quan Tho-Kham Thien street, Hale club in Nguyen Du street, Bar GC-Bao Khanh

2.3 Structure of the thesis

Cross-section research combines with qualitative research (social research) and quantitative research

2.4 Sample size and sampling methods

n = Z(21/2) DE

d

p p





2

) 1 (

Which include:p is current rate of HIV infection and sexually transmitted infection rate in male homosexual sex worker group in Hà Nội, 2006 (p= 0,088), Z1-α/2 = 1,96, d = 0,044, DE=1,5

Countable sample size was rounded to 250 observation

Sample was chose through time-location method

2.5 Variations and index: Based on the research purposes

2.6 Means of the thesis

Deep interview questionnaire guidance, interviewees

screening sheets, study enrollment’s agreement, interview

questionnaire; blood, or pharyngeal, genitals and fundament tests

2.7 Data collecting methods

2.7.1 Qualitative social research

Using observation method combine with daily field

records, deeply interview 12 male homosexual sex worker

objects and 7 objects who have relationship, knowledge of male

homosexual sex worker group and inspected locations in order

to collect data on the location which male homosexual sex

worker appear frequently (characteristics of location and types

of objects), collect information on male homosexual sex worker

group (approaching methods, estimated number according to

time periods and dates, types of sexual intercourse, risky

behaviors, health problems…) and design suitable

questionnaire for targeted subjects of the research

2.7.2 Quantitative Cross-section research

Aim to select appropriate objects in inspected locations

When a qualified object is read and signed agreement to

participate the research, the object would be asked to answer

the designed questionnaire, and took 3 ml blood,

oropharyngeal, genitals and fundament to test

Sampling procedures preservation and transportation were carried out legally and directly sent to experimental lab by officers in that day

2.8 Testing techniques

HIV, HBV, HCV và syphilis tests were conducted in Microbian faculty of Bạch Mai hospital

Contraband, Chlamydia and HPV tests were conducted in Laboratory of the Hospital of Hanoi Medical University

All these technical tests were carried out under the guidance of the Ministry of Health

2.9 Processing and analyzing data

2.9.1 Qualitative data

Depth interviews records were decode and saved into computer through word documents Other information noted in STIs and Depth interviews were encoded thematically All is analyzed through Nvio8 software

2.9.2 Quantitative data

The data was cleaned before putted in Epi Data 6.04 software, analyzed by SPSS 16.0 The test used 2 test and Logistics regression model

2.10 Research ethics

The thesis was proved by ethics council of Hanoi Medical University

CHAPTER 3: RESULT OF RESEARCH

3.1 Demographic characteristics of male homosexual sex

worker group in Hanoi

According to research’s result, the mass of the participants

are in young age between 20-24 (52.0%), Most objects are still

single (94.4%) 87.2% have high school qualification or above,

the majority of them are immigrants (78.0%), and main income

from 2-5 million VND (53.6%)

3.2 Sexual identity, knowledge about HIV/STIs, sexual

behaviors, using addictions and using medical services of

the study group

3.2.1 Sexual identity

Most participants declared to be male (68.8%); only 5.2%

participants declared to be female and 5.2% participants

declared to be transgenders; prefer having sex with female

(56.0%), over 1/3 of objects likes have sex with male and

12.4% likes to have sex with both male and female

3.2.2 Knowledge about HIV/STIs

The research results showed that the proportion of objects

with results correctly answer questions of knowledge about

HIV/STIs high Still a small percentage of object wrong answer

questions about HIV transmission through mosquito bites and

sharing a cup of HIV infected persons

3.2.3 Sexual behavior and use addictions

3.2.3.1 Sexual behavior

- The objects have sex with male, female partners and

male client, not only sex selling but also sex purchasing

Table 3.6 Forms of sexual intercourse and condom use with

sexual partners in the first time

Number Rate (%) Female sex partners

With male sex partners not only exchange

- Table 3.6 showed: the proportion of condom use differ between forms of sex and between sexual partners

Chart 3.2 Condom use during sexual intercourse with the most recent with Vietnamese and foreign clients

- Chart 3.2 shows: The percentage of condom use objects

in the forms sex is low

- On average, objects had 9.5 and 11.7 times that they have sex with their clients in the last 30 days

- The everage number of clients who oral sex is 9.2; The

everage number of clients who give anal sex is 3.5 and to

receive anal sex is 3.9

Characteristics of selling sex: Most (52.8%) selling sex

male objects take part in this activity at the first time in age

from 20-24 (average at 20 years old), the majority of

participants have experience from 1 to nearly 5 years (54.0%),

and the reason is for money (86.8%); In the last 30 days,

research objects often meet male clients at various locations

Most of their first time and latest clients are Vietnamese (95.2%

and 77, 6 % in counterpart) Nonetheless, More than 70.0% of

Vietnamese buyers is older than the subjects (5 years or more)

3.2.3.2 Use addictions

- 52.0% of objects had used at least one drug, up to

42.2% of objects have ever use synthetic drugs 8.4% users

injecting drug and only 0.4% (1 person) is declared multiple

shared needles in the past 90 days Most of the study objects

used wine/beer (97.6%)

3.2.4 Use of medical services

The majority of objects had used health services

(80.4%); However, only 1/4 (20.8%) talk to the medical staff

about MSM; Percentage of objects vaccinated with hepatitis B

vaccine relatively low (25.6%); Percentage of HIV tested object

is not high (47.8%); Percentage examination and treatment of

STIs is low (6,8%); Percentage examination and treatment of

HIV is low ( 9,6%)

3.3 Prevalence of HIV infection and STIs in male homosexual sex worker in Hanoi

0 20 40 60 80

Chart 3.7 Prevalence of HIV infection and STIs through test

results and self report

Graph 3.7 showed that: Prevalence of HIV infection and STIs through some test of the study are much higher than declaration questionnaire (48.8% compared with 7.6%)

Chart 3.8 The prevalence of STIs by organs tested

Result of the 3.8 diagram shows: own review in three parts

of infiltration sex ban, 20.4% of objects infected at least one STI at

anal, 15.6% at oropharynx and 12.8% in the genitals

Analysing the rate of objects who infected at least one

STI according to demographic characteristics has shown that:

in the group of candidates from 25 years old, more than a half

of them has at least one STI, illiterate or low knowledge

background group hold the highest proportion, about 68.8%

Although, candidates who have already had wife or a lover

account for the lowest proportion in research objects (4.4%),

the rate among this group is very high (72.7%) The proportion

of male homosexual sex worker who originally was born in Ha

Noi has infected at least one STI is relatively high (54.5%)

3.4 Some risk factors of HIV infection and STIs in Hanoi

3.4.1 Factors related to behavior of anal sex without condom

for the last time

Research results showed that: factors associated with anal

intercourse sex no condom use is adulterers, those who have the

tendency of homosexuality and have incomes ≤ 2 million VND

in the last month

3.4.2.Risk factors of HIV infection and STIs

To analyze the factors related to susceptibility to at least

one STI, researchers used logistic regression analysis in which

the dependent variable is infected with at least one STI and

independent variables are the variables after univariate analysis

with at least 1 STI, have statistically significant (p <0.05)

Table 3:16 Logistic regression model

The dependent variable for at least one STI; parity coefficient:

-1.7; Significance level: 0.006, R2 = 0.1

Independent variable Regression

coefficients

Significance level OR 95%

Education level

Less primary 1

0.007

2.5 1.3-4.8

From junior

The Average number of male clients in the last 30 days

≥ 10 clients 1,1

0.025

2.6 1.5-3.9

After logistic regression analysis, from primary or less education levels and the average number of male clients from

10 guests or more in the last 30 days the variables related to infection with at least one STI

CHAPTER 04: DISUSSION 4.1 Demographic characteristics

The results of demographical characteristic of research objects in our study are quity similar to other studies conducted

by Hanoi Medical University and LIFE center In comparison with IBBS in 2009, male homosexual sex worker group in Hanoi are younger, higher level of education and income than their counterparts in Can Tho, Hai Phong and Ho Chi Minh city These findings are also similar with other studies conducted in China, Russia, Indonesia, Pakistan and India Studies in other countries and in Vietnam show that a large number of gay sex workers come from other areas In our

study, a lot of male homosexual sex worker come from

neibouring provinces and they do not have a fixed house to

sleep over night The results reflect the difficulties this group of

person are facing with while they live in Hanoi and a lot of

them operate at public areas

4.2 Sexual identity, knowledge about HIV/STIs, sexual

behaviors, using addictions and using medical services of

the study group

4.2.1 Sexual identity

Majority of male homosexual sex worker group in

Hanoi are male (68.8%) and be attracted to have sex with

female (56%) The sexual attractiveness can be different among

research objects Although they may have sexual attractiveness

with male or female both, they still have sex with other male

partner due to economic purpose In addition, the results reveal

that diversified population of male individuals are participating

in gay sex working activity

4.2.2 Knowledge about HIV/STIs

The results show that there are a large number of male

homosexual sex worker have not understood correctly and

sufficiently about ways of tranmission and risk-factors of HIV

and STIs

4.2.3 Sexual behavior and drug use

Having sex with both male and female partners

Male homosexual sex worker group in our study not only

have sex with male, but also with female including female sex

partners and female sex worker, not only sex selling but also

sex purchasing Number of clients and frequency of sex selling

of research objects are reflected through their risk factors In average, each have 9.5 clients over the last 30 days, number of sex buyers is correspond to the number of sex intercourse The average number of sexual intercourse with male clients over the last 30 days is 11.7 Therefore, diversity of sex partner, the average number of sex partner, the average number of sexual intercourse over the last 30 days in our study reveal that they have high risk of being infected with HIV and STIs

Forms of sexual intercourse and condom use

The forms of sexual intercourse of sex worker for gay in our study are quite diversified: oral sex, anal sex and intercourse 1/3 of research objects have been experienced with oral sex and anal sex with male sex partner not due to exchange purpose

Oral sex is quite popular among research objects HIV can still be infected to receiver through oral sex without using condom and the risk of HIV will be increased if having sperm

in mouth and wounded throat/mouth For other STIs, oral sex without condom will have very high rate of infection while directly touching with sexual fluid even having not scratch Around one third of research objects in our study used condoms when having anal sex with Vietnamese and foreign customers Having anal sex with foreigner, especially when being done without condom, will increase HIV infection; it is because of that HIV transmission is mainly due to gay men in the developed countries