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Factors Affecting Treatment Seeking Behavior and Test among MSM in Asia

Factors Affecting Treatment Seeking Behavior and Test among MSM in Asia. Dr. Beena E. Thomas Social Scientist (NIRT-ICMR). Outline. MSM prevalence and epidemic in Asia MSM health needs and issues Barriers to treatment seeking behavior on MSM Our experiences The way forward.

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Factors Affecting Treatment Seeking Behavior and Test among MSM in Asia

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  1. Factors Affecting Treatment Seeking Behavior and Test among MSM in Asia Dr. Beena E. Thomas Social Scientist (NIRT-ICMR)

  2. Outline MSM prevalence and epidemic in Asia MSM health needs and issues Barriers to treatment seeking behavior on MSM Our experiences The way forward Dr. Beena Thomas,02.07.2013

  3. A note on MSM terminology • MSM is used as an ‘umbrella term’ that characterizes sexual behavior between men but encompasses a broad spectrum of multiple sexual identities and gender expressions. • Basic differences between key terms in the Clinical context: _ Homosexual or Same-Sex Sexual Behavior _ Sexual Orientation _ Sexual Identity _ Gender Identity _ Gender Expression Dr. Beena Thomas,02.07.2013

  4. MSM in Asia in the HIV AIDS context • HIV infection among MSM has been increasing in the world particularly in Asia. (Van Griensven F, 2010) • The nature of MSM activity across the continent is so diverse that it forces us to re-think the basic strategies for fighting AIDS: Awareness, outreach, education, testing. MSM and HIV/AIDS Risk in Asia: What Is Fueling the Epidemic Among MSM and How Can It Be Stopped? 2006. Special report by Treat Asia and amfar (The Foundation of AIDS Research) Dr. Beena Thomas,02.07.2013

  5. Grim realities • The Asian Epidemic Model estimates that there are 10 million MSM in Asia, some of whom have sex with women or are married [Commission on AIDS in Asia 2008] • Asian and Pacific Islander MSM have comparable high-risk sexual behaviors, number of sex partners and unprotected sex partners as MSM of other races/ethnicities [Wei C 2011] Dr. Beena Thomas,02.07.2013

  6. Grim realities-MSM in Asia • Overall, MSM are as much as 25 times more likely to be living with HIV than the general population of Asia and the Pacific [Baral 2006] • Because of stigma and ignorance, the health care issues of men who have sex with men (MSM) have often been overlooked [Makadon HJ 2006; Setia MS 2008] • Levels of sexual risk behavior in MSM have been estimated at between 40% and 60% in East Asia and Southeast Asia and 70% to 90% in South Asia [Cáceres C 2006]

  7. Data summary of MSM in AsiaUnited Nations Development Programme (UNDP) Asia-Pacific Regional Centre Dr. Beena Thomas,02.07.2013

  8. Data summary of MSM contd… Dr. Beena Thomas,02.07.2013

  9. Epidemiology of HIV-MSM in Asia United Nations General Assembly Special Session (UNGASS) Report The Global Forum on MSM & HIV: Working worldwide against HIV for the health and human rights of men who have sex with men. Dr. Beena Thomas,02.07.2013

  10. HIV Epidemiology -MSM Dr. Beena Thomas,02.07.2013

  11. Epidemiology contd… Dr. Beena Thomas,02.07.2013

  12. % of MSM reporting that condoms, lubricants, HIV testing, and HIV treatment are easily accessible, organized by country income level according to World Bank classifications Access to HIV Prevention and Treatment for Men Who Have Sex with Men. Findings from the 2012 Global Men’s Health and Rights Study (GMHR) Dr. Beena Thomas,02.07.2013

  13. MSM common Health Needs & Issues • Globally, MSM have been historically under-served and ignored in the delivery of health information and care [The Global Forum on MSM & HIV: Reaching men who have sex with men in the global HIV/AIDS epidemic, 2010]. • Sexually transmitted infections (STIs) are a serious public health concern for MSM. • There is an increased susceptibility for HIV transmission among those infected with STIs. Dr. Beena Thomas,02.07.2013

  14. Are MSM being reached? A 2006 survey of the coverage of HIV interventions in 15 Asia Pacific countries estimated that targeted intervention reached less than 8% of the estimated number of MSM, whereas 80% coverage is needed to effectively reduce the incidence of HIV infections Source: MSM-The missing piece in National response to AIDS in Asia and the pacific, Vasilaiki EI 2006, Chakrapani V2002,MannJM 1987,Commision on AIDS in Asia 2008. Dr. Beena Thomas,02.07.2013

  15. Predictors of the treatment Cascade among MSM Ensuring Universal Access to Comprehensive HIV Services for MSM in Asia and the Pacific, The Foundation of AIDS Research (amfar) Dr. Beena Thomas,02.07.2013

  16. Our Experiences……….

  17. MSM in India: Gay sexual identity and sexual behavior not necessarily linked Kothi – Feminine acting/appearing, predominantly receptive sex partner. Panthi – Masculine appearing, predominantly insertive sex partner. Double Decker – Both insertive and receptive sex partner. Gay – Similar to the identity of “out” gay men in the U.S. Bisexual – Sexual behavior with men and women. Hijra (Aravani) – Male-to-female transgender, not MSM identified. Asthana and Oostvogels, Social Science and Medicine 2001 Dr. Beena Thomas,02.07.2013

  18. Intervention strategies-What do MSM feel? • High levels of message fatigue among recipients of current MSM HIV prevention services: • “We know a lot about HIV for the past 10 years. We have had enough programs on HIV and I should take care of my personal risk - how long will NGO’s guide us about this especially. I do not think that anymore messages on condom prevention are needed. We are fed up of HIV/AIDS messages – we need more!” • The importance of ensuring safe, non-judgmental services which uphold confidentiality, professionalism and culturally sensitive facilitation • “The chances of MSM accepting a STI test at the STD clinic in a government hospital is 70-80% as they fear breach of confidentiality. It is so difficult to get MSMs with symptoms of STI to come forward to disclose their symptoms”. Dr. Beena Thomas,02.07.2013

  19. FGDs (4) Intervention Development Key Informant Interviews (5-10) CAB Meetings (4) Cultural relevance to intervention (triangulation of qualitative findings) • Lack of self-acceptance • Condom distribution and education is not enough • Un-accepting social environment • Variation in vulnerability by different sexual identities within MSM • Pressure to marry • Power differences among MSM Dr. Beena Thomas,02.07.2013

  20. HIV Risk Behavior and HIV in MSM in Chennai • N = 210 Community Recruited MSM • 22% reported unprotected anal intercourse (UAI) in past 3 months • 8% tested positive for HIV • Multivariable model: Predictors of UAI • Lower education AOR=.54 • Not having participated in a prevention program AOR=3.75 • Having clinically significant depressive symptoms AOR-2.8 • Lower self-efficacy AOR=.40 Thomas et al.,. AIDS Education and Prevention, 2009. Dr. Beena Thomas,02.07.2013

  21. Predictors for participation in HIV Prevention Intervention(N=210) 26% reported participation in HIV prevention intervention programme • MSM who are older (OR=1.04; P=0.05) • Kothis compared to Panthis (OR=5.52; P=0.004) • Higher education (OR= 1.48; P= 0.01) • Open about status (OR=4.3; P= 0.0001) • Paid for sex (OR= 2.92; P= 0.001) Dr. Beena Thomas,02.07.2013

  22. Stigma from providers • Stigma from health providers, employers and other service providers pose serious obstacles to effective HIV services provision, and hinders access to HIV and sexual health services and prevention programmes (Thomas et al. Indian J Med Res 134, 2011; 920-929). • “I do not like going to a hospital. They treat us so bad….the Drs ask us such embarrassing questions. They treat us like we are abnormal…”-Kothi-identified informant interview Dr. Beena Thomas,02.07.2013

  23. Predictors for depressive symptoms High depression and HIV risk among MSM in Chennai (55% clinically significant) • Not being married (AOR=3.10; 95% CI: 1.23-7.65) • Having paid (AOR=3.82; CI: 1.87-7.99) • Perception of risk for acquiring HIV in future (AOR=1.10; 95% CI: 1.03-1.21) • Unprotected sex with another men in past 3 months (AOR=2.04 CI: 0.91-4.48) (Safren et al and Thomas et al. Psychol Health Med 2009; 14 : 709-15. Conclusion Depression should be considered while developing HIV prevention interventions ( Safren S; Beena E 2010). Dr. Beena Thomas,02.07.2013

  24. High Alcohol use High alcohol use among MSM in Chennai (28%) associated with older age,being married, being a Panthi, weekly tobacco use, unprotected anal sex, unprotected vaginal sex (Mimiaga et al, 2010, Int. J. of HIV and STDs). Conclusion Alcohol interventions benefits in reducing the level of alcohol consumption, change harmful drinking patterns, prevent future drinking problems, improve health and reduce health care costs. Dr. Beena Thomas,02.07.2013

  25. STI Prevalence in India • Over a 3mth period 26% of MSM had one or more STIs ( Verma RK, 2004). • Over a 6th month period - At baseline 19% tested positive for STI. At the 6th month follow up, 23% tested positive for STI with 5 recurrent STIs (Ramesh K; Mayer K, 2010). • 42% reported previous participation in an HIV prevention intervention. Dr. Beena Thomas,02.07.2013

  26. Intervention strategies… • The importance of addressing self-acceptance, self-esteem, and familial and societal pressures as a part of care. • “I therefore feel a prevention program should increase self esteem and self acceptance. This would automatically influence a MSMs health seeking behavior and MSM would claim rights as an individual. I feel that only then can interventions be successful. They would want to abstain from alcohol, look after their STIs, take their medicine they need, protect themselves from HIV…” Intervention Format • Both group and individual components were recommended for an intervention • Programmatic effectiveness would be augmented by providing separate groups for different MSM identities. • “Kothis and DDs [double deckers] can be included in the same group. If panthis are in the group, kothis will not open up. They will never express their problems.” Dr. Beena Thomas,02.07.2013

  27. Psychosocial Intervention Manual Group session I: • Introduction, Self acceptance - Barriers & Strategies • Coping with pressure from family & society Group Session : II • Safer ways to meet men • Alcohol and substance use Group Session III: • HIV Education & HIV/STI Vulnerability Group Session IV: • Risk reduction skills and looking to the future

  28. Community Advisory Board ROLE OF CAB • To help safeguard and address community interests and concerns prior to and during study activities • To ensure that the study team is aware of major community concerns and adverse events • To ensure that the ethical and harm minimization guidelines are followed during the implementation of the study. CAB Meeting

  29. More information, particularly from social and operations research and from groups working successfully among MSM in Asia and the Pacific is required, Approaches on prevention-to-care including health promotion, behavior change communication, emotional and social support, and clinical care, Address challenges in reaching more vulnerable networks of MSM, lowering thresholds for accessibility to services, linking interventions and providers, and developing and achieving consistent indicators of accessibility and quality, Evidence-based service and program designs, and Demonstrable improvements in the range of interventions, quality, use, and effect. What do we need? Dr. Beena Thomas,02.07.2013

  30. How much do we invest in invoving the female partners/ family in information, education, and communication programmes? We need to continue strong advocacy campaigns to sensitize the general public and law enforcement agencies to promote a more enabling, stigma-free environment. Ensure universal access to HIV services, regardless of sexual identity, marital status, or age. We need to implement rights-based approaches to health care based on the needs of MSM Invest more in strengthening of MSM community groups and networks to promote greater community ownership of the HIV response. Some thoughts... Dr. Beena Thomas,02.07.2013

  31. The good news • The Asian HIV/AIDS epidemic has not progressed so far that it cannot be stopped. • Thailand and Cambodia have been strikingly successful in reducing HIV prevalence using campaigns based on government commitment, multi-sectoral responses, community participation, and the involvement of civil society. • We can do it if we feel, think, learn and act!! Detels R. “HIV/AIDS in Asia: Introduction.” AIDS Educ Prev. 2004; Vol 16:1-6. Dr. Beena Thomas,02.07.2013

  32. Thank you for your attention Dr. Beena Thomas,02.07.2013

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