Capacity building in combining targeted prevention with meaningful HIV surveillance among MSM

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1 Capacity building in combining targeted prevention with meaningful HIV surveillance among MSM Global AIDS Response Progress Reporting GARPR indicators in Barcelona, Bratislava, Brighton, Brussels, Bucharest, Hamburg, Lisbon, Ljubljana, Sofia, Stockholm, Verona, Vilnius, and Warsaw among MSM This document is based on data from the Sialon II project, funded under the European Commission s (EC) Public Health Programme (Work Plan 2010). The sole responsibility lies with the authors of this report and the Commission is not responsible for any use that may be made of the information contained therein 1

2 SIALON II project summary In line with the last Communication on combating HIV/AIDS in the European Union and neighbouring countries ( ) 1, the overall objective of this project was to carry out and promote combined and targeted prevention complemented by a meaningful surveillance among MSM. More specifically, the aim was to develop capacity building and know-how through both training and on-site coaching under the active supervision of, and in collaboration with, the ECDC, WHO and UNAIDS on: i) prevention needs assessment and prevention actions, and; ii) innovative surveillance methodologies for hard to reach populations such as MSM (Time Location Sampling, Respondent Driven Sampling, HIV and STI testing). The SIALON II project was implemented using the same methodologies as defined by WHO/UNAIDS and ECDC (research protocols, GARPR/ECDC indicators, epidemiological algorithms) and prevention strategies across the participating countries. SIALON II was funded under the European Commission s (EC) Public Health Programme (Work Plan 2010). Background The project s strategic relevance lies in the fact that it addresses the need for an effective response in priority regions such as the EU Member States most affected by HIV. In line with the Health Programme 2010 Work Plan objective, SIALON II targeted MSM as one of the most at risk populations with the active involvement and participation of gay communities in all phases of the project actions. This included the development and implementation of targeted, culturally sensitive strategies of communication for the prevention of HIV and promotion of Voluntary Counselling and Testing (VCT) among MSM. Moreover, the project was in line with the implementation of the WHO and UNAIDS recommendations on Second Generation Surveillance Systems (SGSS), where the collection of behavioural and biological data as well the assessment of prevention needs are foreseen. Methods and means Formative research was carried out in each participating country in order to collect information on the local contexts and for assessing the prevention needs of MSM (Work Package 4). Data collectors (recruited through gay associations / NGOs) were trained locally on prevention issues using a jointly developed prevention protocol adopting a theory-based approach (i.e. the Minority-stress model 2 and the Information-Behavioural Skills model 3 ). Prevention activities were carried out concomitantly to data collection in community-based settings in the context of a broader prevention campaign supported by the project s website featuring gay-friendly services. The Sialon II prevention campaign consisted of a standardised approach to community-based prevention activities that were delivered during data collection, i.e. a community-based settings approach, which has inherent limitations in terms of what prevention can realistically achieve in venue-based settings. The tailored prevention activities included: (a) dissemination of prevention packages during data collection (containing 1 Communication from the Commission to the European Parliament, the Council, the European economic and social Committee and the Committee of the Regions. Combating HIV/AIDS in the European Union and neighbouring countries, , {SEC(2009) 1403}, {SEC(2009) 1404}, {SEC(2009) 1405}. Available at: 2 Meyer IH Minority stress and mental health in gay men. J Health Soc Behav Mar;36(1): Fisher, J.D. & Fisher, W.A. (1992). Changing AIDS-risk behaviour. Psychological Bulletin, 111,

3 condoms, lubricants), and distribution of leaflets with specifically tailored information; (b) interactive peer-to-peer health education activities delivered when recruiting study participants (this included using an interactive quiz to increase information on HIV and other STIs and promotion of HIV testing in a playful way). In addition, at RDS data collection sites, individual HIV-test counselling was conducted, promoting collection of test-results and linkage to care. These activities focused on improving knowledge and building motivation for safer-sex and uptake of HIV-testing among the participants (WP8). The project website supported the prevention activities by featuring gay-friendly services in selected study sites (through providing links to local community-based organisations). A bio-behavioural survey (WP5-WP6) was then implemented using standardised procedures for data collection in community-based settings. The Time-Location Sampling method (TLS) was adopted in nine countries including: Belgium, Bulgaria, Germany, Poland, Portugal, Slovenia, Spain, Sweden, and the UK. The Respondent-Driven Sampling (RDS) method was implemented in four countries including: Italy, Lithuania, Romania, and the Slovak Republic. In the latter settings, prevention activities focused additionally on sexual health promotion in the context of VCT and linkage to care. Data on MSM related prevention needs and behaviour were collected through an anonymous questionnaire linked to biological samples (serum for RDS countries and oral fluid for TLS countries). When needed, an online training programme was provided for laboratory technicians on testing (virology) at country level. Standardised testing procedures were implemented in each site for laboratory data analysis (WP7). An aliquot of HIV positive serum samples (only for countries where the RDS method was implemented) was then sent to a specialised laboratory for the calculation of HIV antibodies avidity index, and incidence estimation. Data were analysed in line with the GARPR indicators guidelines 4. Prior to any data collection, approval from all partners ethics and governance committees were obtained. The SIALON II research protocols were also approved by the WHO Research Project Review Panel (RP2-WHO) and by the Research Ethics Review Committee (WHO-ERC) in February Outcomes The project's results feed directly into HIV-related public health and health promotion practice and policy. Moreover, through the implementation of the project s processes, capacity has been built for all partners and their networks for both venue-based bio-behavioural surveillance and targeted prevention activities. This was achieved through expert training, coaching and the adoption of participatory approaches, and interactive dissemination methods. In concrete figures, a total of 99 trained data collectors/outreach prevention workers from 18 local prevention organisations disseminated about 9000 prevention packages and 3000 leaflets. About 1500 scratch-cards were used during prevention activities to sensitize MSM in the venues. Preliminary findings of the study were discussed with all partners involved in the preventionand data collection activities at a community-based prevention meeting. This has translated into a sustainable prevention outcome as partners have been able to utilise the results in their own prevention activities. Prevention initiatives have been taken over by local NGOs, such as 4 Global Aids Response Progress Reporting Construction of Core indicators for monitoring the United Nations Political declaration on HIV and Aids, Available at: 3

4 the continued condom-distribution, the continued use of prevention material produced within Sialon II, the initiation of rapid HIV testing in Bratislava, the creation of local NGO prevention networks, and the extension of office hours at HIV-testing sites to reduce thresholds (as in the case of Warsaw). In total, 14 such new prevention activities were reported by the partners of the Sialon II network. In addition, the involvement of the ECDC, WHO and UNAIDS has brought substantial added value to the project and has been directly and effectively connected to practical use of the research results. Finally, the use of outreach strategies and complementary methodologies maximised the validity and effectiveness of preventive interventions. In terms of project deliverables, specific reports have been produced including: a formative research report with information on target group characteristics, social contexts and prevention practices and gaps across the different study sites; a manual for data collection and surveillance among MSM; a prevention report describing the prevention activities that were conducted, lessons learned and major challenges to prevention activities. This report also includes examples of practice-based evidence of HIV/STI prevention and sexual health promotion targeting MSM; a summary report on the findings from the bio-behavioural surveys conducted via TLS and RDS (in press). In conclusion, the SIALON II project has contributed to the harmonisation of surveillance methodologies, and generated comparable data on behavioural and epidemiological indicators for MSM communities (ECDC and GARPR indicators). In doing so, the project has identified unmet prevention needs through the formative research conducted, and built communitybased capacity to carry out research and prevention in venue-based settings. While the Sialon II prevention campaign was designed to take place in the context of the TLS and RDS data collection venues, implementation of prevention activities went beyond the data collection as such. The project s close ties with local implementers of prevention activities have contributed to the sustainability of the project. Sialon II adopted a community-based, participatory approach throughout the whole project, which contributed to identify the shortcomings of existing prevention policies and measures (see also the Sialon II prevention report for more information), and strengthened a Europe-wide network of international (UNAIDS, WHO) and European (European Commission, ECDC) organisations, National Institutes of Public Health, Universities, and civil society organisations (NGOs working with and for MSM). Partners Main Partner AOUI Azienda Ospedaliera Universitaria Integrata Verona Italy Associated Partners IGTIP Fundació Institut d'investigació en Ciències de la Salut Germans Trias i Pujol, ICO - Institut Catala d'oncologia, Barcelona Spain INBI Institutul National De Boli Infectioase Prof. Dr. Matei Balș Bucharest Romania ACCEPT, LBGT NGO, Bucharest Romania IHMT/UNL Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa - Portugal ISS Istituto Superiore di Sanità, Rome Italy ITG Prins Leopold Instituut voor Tropische Geneeskunde, Antwerpen Belgium NCIPD National Centre of Infectious and Parasitic Diseases, Sofia - Bulgaria NIJZ National Institute of Public Health, Ljubljana Slovenia 4

5 NIZP-PZH - National Institute of Public Health - National Institute of Hygiene Warszawa Poland RKI - Robert Koch-Institut, Berlin - Germany Folkhälsomyndigheten Public Health Agency of Sweden, Stockholm Sweden SMU - Slovak Medical University, Bratislava - Slovakia ULAC - Centre for Communicable Diseases and AIDS, Vilnius - Lithuania UOB - University of Brighton, Brighton United Kingdom Collaborating Partners ECDC World Health Organisation UNAIDS London School of Hygiene and Tropical Medicine Local NGO s in different participating countries Contacts Massimo Mirandola (project coordinator): massimo.mirandola@ospedaleuniverona.it - Infectious Diseases Section - Department of Pathology - University Hospital; Lorenzo Gios (project manager): lorenzo.gios@ospedaleuniverona.it - CReMPE - Regional Coordination Centre for European Project Management, Veneto Region - Department of Health, C/O The Verona University Hospital, p.le Aristide Stefani Verona (VR) Italy, Tel: fax Website: 5

6 The SIALON II surveys Data collection was conducted in 2013 for the TLS arm of the project, and in 2014 for the RDS arm. The table 1 below presents the overall number of MSM enrolled in the study across countries according to the specific sampling method adopted for each study site. All estimates were calculated using specialised survey software and sampling weights. According to the GARP reporting guidelines, estimates should be reported disaggregated by age ( 25 and 25). Thus, the indicators below are reported by city as global estimates and disaggregated by both city and age. The age distribution of samples varied across the cities. Table 1.0: MSM enrolled in the study by city Sampling method City and Country Overall sample Time-Location Sampling Brussels, Belgium 406 (TLS) Sofia, Bulgaria 411 Hamburg, Germany 408 Warsaw, Poland 408 Lisbon, Portugal 409 Ljubljana, Slovenia 416 Barcelona, Spain 408 Stockholm, Sweden 377 Respondent-Driven Sampling (RDS) Brighton, UK 418 Verona, Italy 400 Vilnius, Lithuania 322 Bratislava, Slovakia 400 Bucharest, Romania 183 TOTAL SIALON II survey data Indicator Men who have sex with men: prevention programmes (percentage of men who have sex with men reached with HIV prevention programmes) This indicator is measured using two questions: one on knowledge regarding HIV testing facilities and the other on whether free condoms have been received over the last 12 months. Only positive answers to both questions were considered valid for the inclusion in the numerator of the indicator. In the TLS-cities, more than half of the men answered yes to both questions in all cities with the exception of Warsaw where less than one third of the participants answered yes to both questions. Conversely, less than half of the men in the RDScities answered yes to both questions, with the exception of men aged 25 years in Bucharest and men younger than 25 in Vilnius. The highest proportions were seen in Sofia and Hamburg with more than 80% reached through HIV prevention programmes. The lowest levels reached through HIV prevention programmes were seen in Bratislava and Warsaw with less than 30%. 6

7 In all thirteen cities (except Brighton, Hamburg, and Lisbon) men aged 25 years were reached to a higher extent compared with younger men ( 25 years) despite the differences between the age groups being small in most cities. Most men (>80%) in the survey reported knowing where to go to get an HIV test. However, there were differences between the age groups indicating that in general, men younger than 25 years are less aware about where to go for an HIV test. In young men aged 25 years, 80 90% reported knowing where to go. In two cities, Brighton, and Ljubljana, the proportions knowing where to go were higher in this age group (>92%). In men aged 25 years, 90% or more in all cities reported knowing where to get an HIV test. Most men report having been given condoms as part of HIV prevention activities during the last 12 months, except in Bratislava, Warsaw, and Verona. In these three cities, less than half of men (regardless of age) reported being given condoms. In the other cities for men aged 25 years, variations were observed ranging from 51% (CI 95% ) in Ljubljana to 95% (CI 95% ) in Sofia. For men aged 25 years, the highest proportions reporting having received condoms as part of HIV prevention activities during the last 12 months were seen in Hamburg and Sofia with 94% (CI 95% ) and 86% (CI 95% ) respectively. The lowest proportions were seen in Bratislava and Verona with 24.4% (CI 95% ) and 29.2% (CI 95% ) respectively. Differences were evident between the participating cities when comparing the type of venues and settings where men had been given condoms. In Sofia, Barcelona, Brussels, Lisbon, and Vilnius, the most common venues where men received condoms included saunas and night clubs/discos. For Hamburg, Bucharest, Verona, and Warsaw, outreach services and gay organisations were the most common channel for receiving condoms. Table 1.11 Weighted percentage of MSM having been reached by prevention programmes, 95% confidence intervals, design effect and number of participants, by city and age group (GARPR 1.11). In most cities, HIV prevalence was higher among BARCELONA BRATISLAVA Age BRIGHTON Point Estimate 95% Lower Bound 95% Upper Bound Estimated Design Effect Sample Size

8 BRUSSELS BUCHAREST HAMBURG LISBON LJUBLJANA SOFIA STOCKHOLM VERONA

9 VILNIUS WARSAW Indicator Men who have sex with men: condom use (percentage of men reporting the use of a condom the last time they had anal sex with a male partner) Condom use during last anal sex ranged between 68.7% in Barcelona to 45.2% in Bratislava. In most cities, higher proportions of condom use were reported by men aged 25 years. Exceptions were noted in Bratislava, Bucharest, Lisbon, Verona, and Warsaw. Variability was larger in men aged 25 years: condom use was reported by 84.6% of young MSM in Barcelona and 34.6% in Bucharest. In men aged 25 years, proportions varied between 72.0% in Lisbon to 46.7% in Bratislava. However, the small sample sizes for the younger age group in many of the study cities should be considered when interpreting these findings. Differences between cities can be explained partly by different proportions of men having their last anal intercourse with a steady partner. Condom use was much lower when the last anal sex partner was a steady partner compared to a non-steady partner. Condom use during last anal sex when the partner was the steady partner and the respondent was younger than 25 years was high in Brussels (60%), Sofia (63%) and Barcelona (69%), and low in Hamburg (26%) and Ljubljana (25%). Among older respondents with steady partners condom use increased among men from Warsaw, Lisbon, Ljubljana, and Stockholm. Condom use declined in older men from Brussels, Sofia, Hamburg, Barcelona, and Brighton. When the last anal sex partner was a non-steady partner, condom use during the last anal sex episode was generally high. Condom use with non-steady partners was usually higher among respondents aged 25 years than in respondents aged 25 years. Sexual roles during last anal intercourse were distributed equally between insertive, receptive, and both (versatile), with only minor variations between cities. Considering the last steady anal sex partner, serosorting with a presumed HIV serostatus -concordance between partners was reported very frequently in all cities. However, a lack of knowledge of the partner s sero-status was reported most frequently in Central European cities. HIV serostatus concordance before sex with non-steady anal sex partners was rarely established across all cities. 9

10 Table 1.12 Weighted percentage of MSM reporting condom use during last anal intercourse with a male partner, independent of type of partner, 95% confidence intervals, design effect and number of participants, by city and age group (GARPR 1.12). In most cities, HIV prevalence was higher among Age Point Estimate 95% Lower Bound 95% Upper Bound Estimated Design Effect Sample Size < BARCELONA BRATISLAVA BRIGHTON < < BRUSSELS BUCHAREST HAMBURG < < < LISBON <

11 LJUBLJANA < < SOFIA STOCKHOLM VERONA VILNIUS < < < < WARSAW Indicator 1.13 HIV testing in men who have sex with men (percentage of men who have sex with men who received an HIV test in the past 12 months and know their results) HIV testing over the last 12 months period and the collection of the test result is an important indicator to be used for monitoring testing and counselling availability. At city level, the indicator ranged from 37% in Bratislava to 74% in Sofia. Using the estimates of this composite indicator, it is possible to aggregate the cities into two main groups: testing rates under 50% (Bratislava, Brighton, Bucharest, Ljubljana, Verona, and Vilnius) and above 50% (Barcelona, Brussels, Hamburg, Lisbon, Sofia, Stockholm, and Warsaw). Considering the age disaggregation, in Brighton, Brussels, and Warsaw more than 50% of the older men ( 25 years) 11

12 reported a known HIV test within the last 12 months while among the younger men ( 25 years) it was less than 50%. In Lisbon only 21% of the younger men reported a known HIV test over the last 12 month period, which represents the lowest level in the study. In several cities, large differences were apparent between the age groups. Brighton, Brussels, Lisbon, and Warsaw all reported a difference greater than 20% for the two age groups. Only in Hamburg younger men reported a clearly higher level of this indicator. However, the precision of the estimate for the younger age group is questionable in many cities because the sample sizes were relatively small (<50). Table 1.13 Weighted percentage of MSM who received an HIV test in the past 12 months, 95% confidence intervals, design effect and number of participants, by city and age group (GARPR 1.13). In most cities, HIV prevalence was higher among BARCELONA BRATISLAVA BRIGHTON BRUSSELS BUCHAREST Age Point Estimate 95% Lower Bound 95% Upper Bound Estimated Design Effect Sample Size

13 HAMBURG LISBON LJUBLJANA SOFIA STOCKHOLM VERONA VILNIUS WARSAW

14 Indicator 1.14_ HIV prevalence in men who have sex with men (percentage of men who have sex with men risk who are living with HIV) Weighted HIV prevalence ranged from 10% to 20% in five cities: Brussels, Barcelona, Lisbon, Brighton, and Bucharest; whilst in Hamburg, Warsaw, and Verona it ranged from 5% to 10%. In Stockholm, Vilnius, Ljubljana, Bratislava, and Sofia HIV prevalence was estimated below 5% (see Table 1.14). This distribution across countries reflects the distribution of new HIV diagnoses reported among MSM in 2013 by the ECDC 5, except for Bratislava (Slovakia) that is shown to have a very high rate of new HIV diagnoses in the ECDC report. The highest prevalence was observed in Bucharest: this could, however, be due partially to the RDS recruitment process in that particular study site where specific sub-populations of MSM who inject drugs were enrolled. In most western European cities, the proportion of young MSM aged 25 years in the samples is smaller than in the central/eastern European cities. This has an impact on the precision of the estimates when subgroups disaggregated by age are used. This is evident when the 95% confidence intervals (CIs) are considered together with the prevalence estimates (Table 1.14). In all cities, HIV prevalence was higher among men aged 25 years compared to men aged 25 years, except in Bucharest where it was similar in both groups. The absence of HIV positive participants younger than 25 in Stockholm and Vilnius can be due to the low HIV prevalence and small sample size in these cities. Table 1.14 HIV weighted prevalence among MSM, 95% confidence intervals, design effect and number of participants, by city and age group (GARPR 1.14). In most cities, HIV prevalence was higher among BARCELONA Age Point Estimate 95% Lower Bound 95% Upper Bound Estimated Design Effect Sample Size BRATISLAVA BRIGHTON ECDC HIV/AIDS surveillance in Europe, 2013, available at: b960-af70113dbb90&id=

15 BRUSSELS BUCHAREST HAMBURG LISBON LJUBLJANA SOFIA STOCKHOLM VERONA

16 VILNIUS WARSAW Limitations Sampling methods Two different sampling strategies were used in the SIALON II study: Time Location Sampling in nine cities, and Respondent Driven Sampling in four cities. It has been shown in other studies that these two sampling methods can result in different sample characteristics, and the differences may persist also after applying weighting corrections to the result estimates. Age composition In specific cases, the precision of the estimate for the younger age group is questionable as the sample sizes were relatively small (<50). The proportion of study participants younger than 25 years was larger in central/eastern European than in western European cities. This is most likely explained by the different age structure of the MSM population approachable by surveillance studies. It does probably not reflect a more difficult access to young MSM in Western Europe, but rather a more difficult access to older MSM in central/eastern Europe. Older MSM in central/eastern Europe have grown up in a much more homophobic environment with a lack of gay infrastructure like commercial and non-commercial gay venues. Some of the differences in the GARP indicators between western and central/eastern Europe are associated with these age differences, and also with the different time-points of onset of the HIV epidemic among MSM. Comparability and generalizability of the samples A closer look at behavioural variables in different TLS cities and a comparison with the samples from the same study areas in the European MSM Internet Survey (EMIS) suggests that different segments of the total MSM population were reached in the gay venues which were selected for the recruitment of study participants. For example, gay bars/cafes where gay couples go out for socialising rather than for seeking sex partners are less present in the central/eastern European cities than in the western European cities. This may affect the composition of the relatively small younger age groups ( years) in western European cities, but may also affect the sample from Sofia. While the high self-reported testing rates and scores for the having been reached by prevention indicator are indicative of the good work of the NGO which recruited the participants for the study, this sample is probably less representative for the general MSM population of the study city/country as compared to the TLS samples from other cities. 16

17 Another aspect is the inclusion of tourists from other countries and nationals not residing in the study city in the samples. The proportion of tourists varies considerably between TLS cities, and tourists are nearly absent in the RDS samples. However, since the weighting procedure was based on the frequency of venue visits (less frequent visits are associated with higher weights), tourists may get disproportional high weights which may bias weighted estimates according to the proportion of tourists. 17

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