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Stefan Baral, MD MPH, JHSPH

Social and Structural Factors associated with HIV Risk among Female Sex Workers (FSW ) and Men who have Sex with Men (MSM) in Swaziland, 2011. Stefan Baral, MD MPH, JHSPH. Overview. Background HIV Epidemiology among MSM and FSW Objectives Methods Results Quantitative Qualitative

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Stefan Baral, MD MPH, JHSPH

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  1. Social and Structural Factors associated with HIV Risk among Female Sex Workers (FSW) and Men who have Sex with Men (MSM) in Swaziland, 2011 Stefan Baral, MD MPH, JHSPH

  2. Overview • Background • HIV Epidemiology among MSM and FSW • Objectives • Methods • Results • Quantitative • Qualitative • Conclusions

  3. HIV Epidemiology • UNAIDS Classifies Epidemics as: • Low level • Less than 5% Prevalence in any high risk group • Concentrated • Greater than 5% in any high risk group, but less than 1% antenatal clinics • Generalized • Greater than 1% in antenatal clinics

  4. Global HIV Prevalence IDU, SW IDU, MSM, SW, HC HC • Legend • IDU Injection Drug Use • SW Sex Work • HC High Risk Heterosexual Transmission UNAIDS. Global Update on the HIV Pandemic. 2010

  5. HIV Prevalence among MSM in Africa 6.2% (267) Egypt [90] 21.8% (501) 21.5% (463) 9.3% (713) 7.3% (406) 13.4% (1,125) 25.0% (N/A) Sudan [86] Senegal [77] Nigeria [79] 24.6% (285) Ghana [11] 12.3% (509) Kenya [78] 21.4% (201) Tanzania [80] Legend 12.4% (218) Malawi [81,82] 19.7% (117) 28.9% (249) Namibia [82] 2002 Botswana [82] 2003 30.9% (68) Soweto [83] 2004 10.6% (538) 2005 Capetown (Township) [84] 2006 Capetown [85] 2007 2008 Source: van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009

  6. Systematic Review of HIV among FSW

  7. Data Quality • Disease burden among MARPS in Africa • Data is predominantly Prevalence Data from Convenience Samples • Tells us where epidemic was and not where it is going • May not be generalizable to general population of MARPS • Samples are among young people--likely very conservative estimates of disease burden • Compared against age standardized data (15-49) in general population • HIV Incidence has been characterized in cohort studies in Kenya • ~ 10% Incidence among MSM and FSW • Prevalence of Same-Sex Practices/Sex work are unknown in most of Africa • Potential Risk Misclassification?

  8. Level of Risks Stage of Epidemic Public Policy Community Network Individual Ecological Model for HIV Risk in MSM HIV Epidemic Stage Exclusion from National Surveillance, Criminalization, Human Rights Contexts, Sexual Health Education Access to preventive services, Stigma, VCT Access, ARV Access STI Prevalence, Condom knowledge, IDUs, MSW, Transgenders Unprotected Receptive Anal Intercourse, GUD, frequency of male partners, high lifetime partners, IDU, NIDU Source: Baral and Beyrer, 2006

  9. Quantitative Study Goal • To collaborate with MOH to develop a comprehensive set of data that can be used by municipal and national government in Swaziland to design evidence-based HIV prevention programs for Most at Risk Populations.

  10. Specific Aims • Calculate a probability estimate of HIV and Syphilis prevalence among sex workers and men who have sex with men 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

  11. Methods • Target Populations • 328 Men who have had anal sex with another man in the last 12 months • 325 women who report sex work as primary form of income • Accrual Methodology • Respondent-driven sampling • Behavioral Survey • Validated and Piloted in each population • Biological Testing • HIV and Syphilis • Swaziland National Guidelines with Pre and Post-test counseling

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

  13. FSW Demographics

  14. Numbers of Partners

  15. Condom Use

  16. Structural Risks for HIV

  17. HIV Prevalence among FSW compared to Reproductive Age Women, Swaziland 2011 Source: Central Statistical Office & Macro International, 2008, p. 222

  18. Significant Univariate Associations with HIV among FSW • Higher Age • Lower Education • Marriage • Ever Pregnant

  19. MSM Demographics

  20. Sexual Practices

  21. Condom Use

  22. Structural Risks for HIV

  23. HIV Prevalence among MSM compared to Reproductive Age Men, Swaziland 2011 Source: Central Statistical Office & Macro International, 2008, p. 222

  24. Significant Univariate Associations with HIV among MSM • Age • Syphilis • Been in Prison • Excessive Alcohol Use

  25. Positive Prevention • 30 years into the HIV epidemic, new infections still outpace people initiating treatment • Historically, most HIV prevention interventions targeted uninfected individuals • Globally, little access to HIV testing • Fear of blaming the victim and adding to stigma • Recently, dramatic scale-up of HIV testing and treatment services worldwide • More PLHIV now know their status • With treatment, PLHIV living longer, healthier lives • Positive prevention helps people living with HIV lead a complete and healthy life and reduce the risk of transmission of the virus to others.

  26. WHO guidelines • In 2007, WHO issued guidelines for positive prevention interventions in resource-limited settings • However, little evidence from studies focused on PLHIV, and little focus on MARPS

  27. Study goal • To examine the prevention needs of Most at Risk Populations (MARPS) including Sex Workers (SW) and Men who have Sex with Men (MSM) in Swaziland to better tailor PHDP programs for these populations.

  28. Study Methods • Qualitative study design • One-on-one, in-depth interviews with key stakeholders (n=16) and HIV-positive SW (n=21) and MSM (n=20) • Most MSM and SW interviewed twice each for more depth • Focus groups with SW (n=3) and MSM (n=3)

  29. 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, and others • Read transcripts, developed list of key themes, and discussed implications • Further coding of transcripts and analysis by 4 study team members

  30. Stigma, discrimination, and violence • 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 violence 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

  31. Risk cycle of hunger, sex work, and HIV for SW • SW 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.

  32. Challenges keeping MSM/SW PLHIV physically healthy • 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

  33. Challenges keeping MSM/SW PLHIV mentally healthy • 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 often led to sexual risk behavior

  34. Challenges preventing further 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

  35. Successes preventing further HIV transmission • 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

  36. Challenges increasing agency of MSM/SW PLHIV • 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

  37. Successes increasing agency of MSM/SW PLHIV • 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

  38. Service delivery models • Some respondents suggested developing special clinics or services for HIV+ MSM or SW • 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

  39. Successful existing models of SW-friendly services • Respondents emphasized the success of specific SW-friendly services (e.g. FLAS, others) • Several said the “support group” code word model used for SW-friendly services in Piggs Peak, Lobamba, and a few other clinics worked well. • “For instance, Piggs Peak and Lobamba, 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. Same with Lobamba, they meet and 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

  40. “They are human beings, they are Swazi.” • 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

  41. Conclusions • FSW and MSM represent distinct high risk populations in Swaziland • These populations are underserved with only sporadic targeted program • Even in the context of countries with hyperendemic HIV prevalence rates, there is still concentration of HIV risk and prevalence • Moving Forward • Combination HIV Prevention Programs • Biomedical • Increasing HTC and Active Linkage to ART for eligible • Evaluate future strategies as they are developed • Chemoprophylaxis • Behavioral • Increasing Condom and Condom Compatible Lubricant Use • Structural • Community Systems Strengthening • Health Sector Interventions • Gender normalization strategies • Safe work spaces

  42. Next steps for Studies • Finalize findings and recommendations with MOH • Write final report • Swaziland dissemination to MOH, MARPS technical working group, stakeholders, media • Global dissemination through peer-reviewed articles and presentations for the International AIDS Conference, July 2012 • Compare with same qualitative research in the Dominican Republic (concentrated HIV epidemic)

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