Stakeholders dissemination meeting 31 May 2012

1. MARPS Bio-Behavioral Surveillance Survey (BSS) Results: Men Who Have Sex With Men (MSM) and Sex Workers (SW) Stakeholders dissemination meeting 31 May 2012

2. Background • Globally, men who have sex with men (MSM) and female sex workers (SW) have a higher risk of HIV infection than the general population • Considered Most-at-Risk Populations (MARPS) • Meta-analysis of previous studies: • In Africa, MSM have 3.8 times the odds of being HIV infected as the general population • In Africa, sex workers have 12.4 times the odds of being HIV infected as the general population.

3. Why Was This Study Done? • Until now, little has been known about HIV prevalence or risk factors among these populations in Swaziland • First study to examine HIV prevalence and risk factors among MSM in Swaziland • Most rigorous study to-date to examine HIV prevalence and risk factors among SW in Swaziland • Part of the Ministry of Health bio-behavioral surveillance surveys (BSS) • The first phase focused on factory workers, seasonal workers, and youth in and out of school • This information will help the Ministry of Health and partners to better plan and develop the most effective, evidence-based strategy for combating HIV in Swaziland

4. Study Design • Mixed methods study • Quantitative survey • Qualitative study • Ethical approval by the Swaziland Ministry of Health and Johns Hopkins Bloomberg School of Public Health institutional review boards • All participants provided informed consent

5. Quantitative Study Aims • Calculate a probability estimate of HIV and syphilis prevalence among sex workers and MSM in Swaziland • Describe behavioral factors associated with HIV/STI infection, including individual sexual practices, the composition of sexual networks, concurrent partnerships, substance use, and access to clinical health care and prevention services • Examine the role of social and structural factors on HIV-related behaviors and risk for HIV infection among sex workers and MSM including social inclusion, stigma and discrimination

6. Quantitative Methods • Target Populations • 328 men who have sex with men • 325 female sex workers • Accrual Methodology • Respondent-driven sampling • Behavioral Survey • Translated into SiSwati and piloted in each population • Biological Testing • HIV and syphilis • Swaziland National Guidelines with pre- and post-test counseling

7. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

8. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

9. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

10. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

11. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

12. Peer-referral system that allows for adjustment for network sizes and homophily (the concept that people recruit people who are similar to themselves) Allows for estimation of unbiased estimates from a non-probability sample Respondent-Driven Sampling

13. To examine the HIV prevention, care and treatment needs of sex workers and MSM living with HIV to better tailor programs for these populations Qualitative Study Goal

14. Qualitative Methods • One-on-one, in-depth interviews with key stakeholders (n=16) and HIV-positive sex workers (n=21) and MSM (n=20) • Most MSM and sex workers interviewed twice for more depth • Focus groups with sex workers (n=3 groups) and MSM (n=3 groups)

15. Qualitative Data Analysis • Weekly interviewer debriefing meetings • All interviews audio recorded, transcribed, and translated into English • Full day data analysis workshop held Oct. 13, 2011 at the Mountain Inn • Attended by representatives from MSM and SW groups, MOH and NERCHA staff, interviewers and members of the research team, clinicians, NGOs working with these populations, and others • Read transcripts, developed list of key themes, and discussed implications • Further coding of transcripts and analysis by 4 study team members

16. Quantitative Results

17. SW: Demographics

18. SW: Demographics

19. SW: Partners

20. SW: Condom Use and Prevention

21. SW: Reproductive Health

22. SW: Structural Risks for HIV

23. SW: Structural Risks for HIV

24. SW: Living with HIV

25. HIV Prevalence Among SW Compared to Reproductive Age Swazi Women Overall HIV prevalence among SW participants: 70.3% Source: Central Statistical Office & Macro International, 2008, p. 222

26. Higher Age Lower Education Marriage Ever Pregnant Significant Univariate Associations with HIV Among Sex Workers

27. MSM: Demographics

28. MSM: Demographics

29. MSM: Sexual Practices

30. MSM: Condom Use and Prevention

31. MSM: Structural Risks for HIV

32. MSM: Living with HIV

33. HIV Prevalence Among MSM Compared to Reproductive Age Swazi Men Overall HIV prevalence among MSM participants: 17.7% Source: Central Statistical Office & Macro International, 2008, p. 222

34. Age Syphilis Been in Prison Excessive Alcohol Use Significant Univariate Associations with HIV Among MSM

35. Qualitative Results

36. Both groups experienced dual stigma related to both HIV+ and SW/MSM identities Led to lack of disclosure of both identities SW reported violence from clients and police Some clients became violent when asked to use condoms Others would refuse to pay after sex and become violent Police round-ups, demand for sex, violence MSM reported discrimination and violence from a wide range of individuals Partners, families, general public, police raids Both groups felt they had no recourse to bring such incidents to the authorities Stigma, Discrimination, and Violence

37. Sex workers described a risk cycle of hunger & poverty driving sex work driving HIV infection. HIV in turn drives an increased need for ‘healthy foods’ Sex work leads to alienation from social networks which offer material and emotional support against hunger & poverty. Risk Cycle: Hunger, Sex Work, and HIV

39. Perceived stigma from health care settings leading to lack of care-seeking Perceived stigma from families/partners leading to lack of disclosure of HIV status Challenges with ART adherence, hiding medications, lack of social support for treatment Poverty and hunger For SW, risk cycle of hunger, sex work, and HIV MSM also reported transactional sex, challenges adhering to ART, and challenges getting to clinic due to poverty and hunger Challenges: Physical Health

40. Primary challenge of living with dual stigma Depression and self-stigma or shame Some MSM said feelings of self-stigma led MSM to drink alcohol to “forget”, which could lead to sexual risk behavior Challenges: Mental Health

41. Challenges: Preventing HIV Transmission • Questions around HIV prevention during clinical services often assume heterosexuality/one partner • Due to fear of stigma, SW/MSM often just answer the question asked (e.g., ‘I don’t have a steady partner’), rather than discuss their true risk behaviors – missed opportunity for prevention • SW offered more money for sex without condoms • Clandestine nature of MSM relationships may lead to more and more casual partnerships • MSM described many of their partners as bisexual or having female partners/wives (possibly to hide MSM behavior or to fulfill cultural expectations) • MSM relationships are kept secret and therefore families do not play a role in relationship counseling and peacekeeping

42. Sex workers appreciated the tailored HIV educational sessions provided for them MSM suggested ‘training of trainers’ model Train trusted MSM community members who could then share messages with others Both SW and MSM suggested continued/further distribution of condoms and particularly lubricant to prevent condom breakage Consider MSM/SW “expert clients” for those living with HIV Successes: Preventing HIV Transmission

43. Dual stigma and hidden identities MSM/SW have difficulty trusting outsiders until they get to know particular individuals over time MSM/SW are often unwilling to disclose their status publically to represent these groups in HIV-related activities Challenges: Increasing Agency

44. Ongoing activities by MOH, PSI, SNAP, SWAPOL, and others – including this research – suggests if approached in the right way, MSM and SW are interested in participating in HIV prevention, care and treatment decisions for their communities Successes: Increasing Agency

45. Some respondents suggested developing special clinics or services for MSM or SW living with HIV Others said targeted services would reinforce stigma Several participants said health care workers should be trained on issues related to MARPS “I would train health care workers. Even their procedures manuals should have information on how to handle MARPS … Also let’s make educational materials that also speak of MARPS.” – KI Service Delivery Models

46. Respondents emphasized the success of specific SW-friendly services (e.g. FLAS, others) Several said the “support group” model used for SW-friendly services in a few clinics worked well. “For instance . . . they come and say, ‘I’ve come to see so and so … and the health care worker will know it’s from the support group so it means she is a sex worker. [Or] she can say, ‘I’m from the support group,’ oh, then she will know she is a sex worker without announcing.” – KI “We could use some of those centres as learning sites, you know. We could share the lessons learnt from those people.” – KI Successful Models of MARPS-Friendly Services

47. Key informants consistently said that regardless of personal belief, they had an ethical responsibility to provide services to everyone, equally “As a health sector, my belief is non-discriminatory services to all the members of the population, and issues of legality and everything rest with the Ministry of Justice.” – KI “Even though I don’t approve of what they are doing … as a public health officer, I have to make sure that they have access to health services. I don’t have to judge them. I don’t have to give my views on what they are doing. But my duty is to make sure that they have access to services… whatever their sexual orientation is, they are human beings, they are Swazi.” – KI “They are human beings, they are Swazi”

48. Summary: Why This Study Was Done • Globally, MSM and SW have a higher risk of HIV infection than the general population. • Until now, little has been known about HIV prevalence or risk factors among these populations in Swaziland. • This was the first study to examine HIV prevalence and risk factors among MSM in Swaziland, and the most rigorous study to-date to examine HIV prevalence and risk factors among SW in Swaziland. • This information will help the Ministry of Health to better plan and develop the most effective overall strategy for combating HIV in Swaziland.

49. Summary: What This Study Shows • These populations exist in Swaziland. • They are at heightened vulnerability for HIV infection. • Stigma and discrimination exacerbates HIV risk among these populations and prevents them from seeking health care services. • HIV prevention, care and treatment services for these populations are sparse. • There is sexual interaction between MSM/sex workers and the general population. • To successfully combat the HIV epidemic in Swaziland, all Swazis must have access to HIV prevention, care and treatment services tailored to their needs.

50. Conclusions • While Swaziland has a highly generalized HIV epidemic, MSM and sex workers represent distinct at-risk populations • These groups are underserved, resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse targeted programming • MSM and sex workers are important populations for further scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions • The Ministry of Health will see to it that the recommendations of the study are implemented appropriately and fulfill their responsibility to all Swazis to have access to HIV prevention, care and treatment services tailored to their needs