1 MINISTRY OF EDUCATION MINISTRY OF AND TRAINING HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY * NGUYEN THI PHUONG HOA CURRENT SITUATION AND FACTORS AFFECTING HIV INFECTION AND The thesis was completed in: NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Scientific supervisors: Prof Nguyen Tran Hien, MD, MPH, PhD Assoc Prof Dao Thi Minh An, MD, PhD Opponent 1: SEXUALLY TRANSMITTED INFECTIONS MALE HOMOSEXUAL SEX WORKER GROUP Opponent 2: IN HANOI, 2009-2010 Opponent 3: Specialization: Public health Code : 62 72 03 01 THESIS SUMMARY 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 HA NOI - 2014 - The National Institute of Hygiene and Epidemiology Library PUBLICATIONS PREFACE Nguyen Thi Phuong Hoa, Le Minh Giang, Nguyen Tran Hien and et al (2012), “Demographic characteristics and risk 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: 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 Identify current HIV infection and sexually transmitted diseases rate in male homosexual sex worker group in Hanoi, 2009-2010 Analyze some factors affecting the risk of HIV infection and sexually transmitted diseases in Hanoi, 2009-2010 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 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 5 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 Scientific and practical significance of the thesis` Scientific significance: The thesis, which uses crosssection 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: pages; Chapter 1-Introduction: 30 pages; Chapter 2-Research subjects and methodology: 15 pages Chapter 3-The thesis’s findings: 32 pages; Chapter 4Discussion: 20 pages; Conclusion: page; Recommendations: page Thesis consists of 17 tables, 13 charts, image, and 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 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 7 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 9 10 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 drugsparticularly injecting heroin 1.5 Factors affecting the risk of HIV infection and STIs Those factors can be classified into 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 ThanhNguyen 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 p (1  p ) n = Z (1 / )  DE d2 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 11 12 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 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 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 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 13 14 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 Condom use Featuring Number Rate (%) Female sex partners Oral sex (n=159) 133 83.6 Vaginal sex (n=209) 96 45.9 Anal intercourse (n=41) 21 51.2 With male sex partners not only exchange Oral sex (n=81) 10 12.3 Anal intercouse (n=77) 32 41.6 - 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 16 - 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 to nearly 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, % 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%) 3.3 Prevalence of HIV infection and STIs in male homosexual sex worker in Hanoi 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%) 100 80 60 40 20 % 15 Testing 2.0 14.04.0 5.2 1.6 0.4 Seft report 19.2 1.6 12.0 12.8 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 17 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 ≤ 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 STI, have statistically significant (p