HIV prevalence and behavioral risk factors among men who have sex with men (MSM) in Bamako, Mali Findings from the first representative biobehavioral

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1 HIV prevalence and behavioral risk factors among men who have sex with men (MSM) in Bamako, Mali Findings from the first representative biobehavioral survey Maria Lahuerta, PhD, MPH Deputy Director, SI Unit Piku Patnaik, PhD, MS Epidemiologist (SI Specialist), SI Unit

2 Mali context Population living below $1.25 a day: 50.4% Life expectancy: 55 years Adult literacy rate: 33.4% Adult HIV prevalence: 1.1% Male in Bamako: 1.6% Female in Bamako: 1.7% Sources: UNDP Human Development Reports, DHS

3 Background In 2011, ICAP received a five-year CDC Cooperative Agreement to strengthen Strategic Information activities in Mali Sub-agreement with the International Center for Excellence in Research (ICER) from the University of Bamako to implement surveillance activities among key populations

4 Why are key populations important? Experience significant HIV burden, and influence the dynamics of HIV epidemics KPs may be important in driving the HIV epidemic, especially if they act as bridges to the general population Male partners Men who have sex with men Female partner

5 Surveillance among key populations Monitor HIV infection in KP and bridges to general population Monitor effects of intervention programs on HIV prevalence and behaviours in KP

6 Surveillance among key populations in Mali HIV prevalence among KP from the 2009 Integrated Bio-behavioral survey: female commercial sex workers (24.2%) ambulatory vendors (3.7%) taxi/bus ticket sellers (3.5%) truck drivers (2.7%) What about men who have sex with men (MSM)?

7 Men who have sex with men (MSM) MSM are disproportionally affected by HIV (3.8 times higher odds of HIV infection than other adult men in sub-saharan African countries) Other studies in West Africa showed high HIV prevalence (Cote d Ivoire: 18%, Ghana 18%) Although homosexuality is not illegal in Mali, it s highly stigmatized Two NGOs currently serving MSM in Mali: ARCAD and Soutoura Sources: Beyrer et al. 2010; Hakim et al. 2015; Aberle-Grasse et al

8 Objectives of the formative assessment among MSM in Bamako Identify specific socio-cultural factors that might limit and facilitate access to MSM Generate an ethnographic mapping of MSM hotspots Identify the operational and logistical requirements of the survey

9 Study design: Formative assessment 1. 3 focus groups with MSM 2. In-depth interviews with: 15 MSM 5 service providers 5 facilitators (individuals involved in the MSM networks) 3. Ethnographic mapping 4. Observational visits to MSM hotspots

10 Formative assessment results Socio-cultural factors: High acceptability of the survey among MSM Ethnographic mapping: Very few gathering places exclusively for MSM Logistics: Participants suggested 2 study sites, at each side of the river Recruitment through coupons was acceptable, so respondent-driven sampling was feasible

11 Objective of the bio-behavioral survey among MSM in Bamako Measure the prevalence of HIV and identify associated risk behaviors Inform HIV prevention programming in Mali

12 Protocol development 4-day protocol development workshop with Technical Working Group to: Disseminate formative assessment findings Build local capacity on respondent driven sampling (RDS) Finalize protocol and study tools for biobehavioral survey TERIYA study

13 Obtaining IRB approval Obtained approval from local ethics committee, CDC ADS and Columbia University IRB Reluctance of local ethics committee to approve study among MSM They thought the study promoted homosexuality We had to explain the importance of this study to the general population

14 Study design Cross-sectional survey among MSM in Bamako using respondent-driven sampling (RDS) Sample size needed 550 participants to: ensure sufficient power to detect the HIV prevalence in the MSM population in Bamako detect a change in HIV prevalence between the current survey and future bio-behavioral survey Two study sites

15 Respondent-driven sampling First participants (seeds) are non-randomly selected Participants recruited by peers through the use of coupons Participants were given cash: - For being interviewed (1 st incentive) - For recruited peers (2 nd incentive)

16 Coupon 3 coupons given to participants to recruit peers Coupon ID was critical to determine who recruited who

17 Respondent-driven sampling Seed

18 6 seeds were non-randomly selected Well connected among their peers Supportive of the survey s goals Diverse in regards to their characteristics Age Marital status Profession Area of residence 30 Single NGO coordinator Sexual orientation Engaged with NGO Suburb Bisexual Yes 24 Single Peer educator Commune V Homosexual Yes 38 Married Building technician Commune IV Bisexual No 48 Married Trader Commune II Bisexual No 24 Single Student Commune IV Bisexual No 31 Single Trader Commune I Bisexual No

19 Eligibility criteria Biologically male Being 18 years old Having had anal or oral sex with another man in the last 6 months Resident of Bamako or its suburbs for the past 6 months Speaking French or Bambara

20 1. Study coordinator 2. Receptionist 3. Coupon manager 4. Interviewers (2) 5. HIV counselor TERIYA study team

21 Study team trainings Good clinical practices for research Review of SOPs Practice with French and Bambara questionnaire Role playing Piloting of procedures at study sites

22 Study flow-1 st visit Screening Informed consent If not eligible, person leaves site If no consent, person leaves site Interview If participant consents to be tested Pre-test counseling HIV rapid test If participant does not consent to be tested Discussion of procedures for peer recruitment and pay primary incentive Discussion of procedures for peer recruitment and pay primary incentive Post-test counseling and referral to services Coupon manager Interviewer Counselor

23 Study flow- 2 nd visit Confirm ID 2 nd interview Pay secondary incentive Coupon manager Interviewer Counselor

24 Questionnaires First visit: socio-demographics sexual history and current sexual behaviors condom and lubricant use HIV knowledge and attitudes alcohol and drug consumption experience with health and support programs available to MSM stigma and discrimination Second visit: eligible candidate participants approached how many referral coupons he handed out why the people who refused did not accept the coupons

25 Data management SECURE SERVER

26 Lab procedures For all participants: HIV rapid testing with finger prick Dried blood spots (DBS) for quality control: all HIV-positive and 10% of HIV-negative samples were retested with ELISA by the national lab (INRSP) For HIV-positive participants: Venipuncture for additional DBS DBS were sent to CDC-Atlanta for future incidence, viral load and genotyping testing

27 Referral services 2-day training of providers treating MSM: Stigma-reduction training for services to MSM Orientation to our study and referral procedures HIV-positive participants were referred to health facilities offering HIV care and treatment Study sites Referral form Enrollment information

28 Data analysis Data were weighted by participant s network size and analyzed using the software RDS Analyst. Proportions presented are interpreted as population estimates of the true population Multivariate analyses ongoing

29 Results Between October 2014 and February 2015, 552 MSM were enrolled 550 of 552 MSM (99.6%) consented for HIV testing, while only 2 refused Laboratory quality control showed no discordance in the HIV test results Enrollment was completed without any major incident despite high stigma against MSM

30 Recruitment flow Coupons distributed n = 1551 Screened for eligibility n = 608 Not eligible, n = 56 Enrolled n=552 Consented to get tested for HIV using rapid test, n= 550

31 RDS recruitment tree

32 Participant demographics Age distribution Education level % 3% Never attended school 12% 6% 16% 13% 53% % 47% 28% Bambara alphabetization Primary Secondary Older than 35 University

33 Socio-demographic characteristics CHARACTERISTIC % 95% CI Marital status Never married 92 89, 97 Married 7 2, 12 Divorced, separated, or widowed 1 0, 3 Religion Muslim 88 85, 91 Christian 9 6, 11 Animist 0 0, 2 No religion 3 3, 4 Nationality Malian 95 93, 96 Other African nationalities 6 4, 7 Sexuality Gay/homosexual 45 39, 52 Bisexual 54 48, 60 Straight/heterosexual 0 0, 3

34 Number of sex partners Number of male sexual partners in the past 6 months Number of female sexual partners in the past 6 months 7% 12% 14% 24% 43% Plus > 4 de 4 23% 29% 48% 0 1 >1

35 Condom use during last sexual encounter 76% with male partner 55% with female partner

36 Unprotected anal sex Among men that had receptive anal sex in the past 6 months, had sex without a condom 45%

37 Lubricant use Lubricant use among those who had anal sex in the past 6 months 59%

38 HIV prevention services 45% used free condoms in the past 6 months 71% reported that access to free condoms would increase the probability of using them 72% had ever talked to a peer educator or outreach worker about HIV

39 Stigma and disclosure of orientation STIGMA & DISCLOSURE % 95% CI Thinks it is illegal to have sex with other men in Mali Yes, thinks it is illegal 73 67, 78 No, thinks it is not illegal 23 17, 28 Don't know 5 2, 8 Suffered harrassment or abuse for having sex with men Yes 23 18, 29 No 77 71, 82 Has told people other than male sex partners about having sex with men Yes 74 69, 79 No 26 21, 32

40 % HIV+ HIV prevalence in Bamako MSM 1.6 General population of adult men

41 Gaps in HIV testing overall 72% reported ever being tested for HIV Only half of these had been tested in the past 6 months

42 Awareness of status and risk perception Awareness of HIV status Risk perception 87% 13% Aware of being HIVpositive Previously unaware of being HIVpositive 30% said it was not possible for them to be HIVpositive

43 Number of persons Services: already aware of being HIV (100%) (80%) 10 9 (60%) 9 (60%) Visited Déjà Had fait tested health un test care du provider positive VIH+ for HIV Déjà Had reçu been un screened examen for TB pour TB Had Déjà initiated pris le TAR ART Currently Prends le on TAR ART maintenant

44 Services: newly identified as HIV+ Results on referral of participants who tested positive were incomplete Documentation on referrals was missing Some participants discarded their referral forms Other participants submitted their referral forms at clinics, but these referral forms were not retained at the clinic

45 Key findings HIV prevalence among MSM in Bamako was 13.7% ( ) Only 72% had ever been tested for HIV Only 36% were tested in the past 6 months 45% or just under half the population had had unprotected receptive anal sex Overall condom use at last sexual intercourse was imperfect with a male partner and low with a female partner

46 Discussion Need for enhanced HIV-related services targeted at MSM in Bamako HIV testing needs to be promoted and made easily available Free condoms need to be made easily available for MSM Peer educators/outreach workers need to reach more MSM Critical importance of using condoms during anal sex Condom use with both male and female partners Prevention messages should highlight role as a potential bridge population if they also have female partners

47 Timeline Protocol development Formative assessment IRB Dissemination Analysis Protocol development IRB Survey data Analysis collection Dissemination Political unrest in northern Mali Tuareg rebels seize control of northern Mali, declare independence Junta reasserts control after an alleged coup attempt French intervention to regain the North Attack to restaurant in Bamako Attack to Bamako hotel

48 Limitations: RDS RDS is not a perfect method, but gives us a best estimate of a representative sample Possibility of differential participation rates Older MSM who are more hidden than others; we addressed this by Closely monitoring recruitment through data collection Adding a 7 th seed mid-way through the study Mobilizing participation of older MSM Led to demonstrable increase in older MSM

49 Limitations: referrals Imperfect documentation on referrals Lessons learnt During provider training, emphasize to providers the need to train other clinic staff During visits to study site, emphasize to participants the need to submit the form at the clinic Conduct closer monitoring of forms that need to be retained at clinics and collected at frequent intervals

50 Strengths & successes First study in representative sample of MSM in Mali Smooth and timely completion despite strong stigma associated with MSM in Mali as well ongoing political unrest Major contribution to knowledge and understanding of an understudied key population MSM population profile, HIV prevalence, risk factors Generation of data for MOH to use in the design and prioritization of prevention programs

51 Continuous engagement with MOH Protocol and tool development Trainings on RDS and bio-behavioral surveys Questionnaires, forms, and SOPs were shared with MOH for future surveys Study database was shared with MOH for further analyses to inform programmatic changes

52 Data dissemination Report summarizing findings was disseminated at a workshop in Bamako International conferences Posters at ICASA and CROI Manuscripts under development including risk factors based on multivariate analyses

53 Future plans Based on UNAIDS recommendations, MSM biobehavioral surveys should be repeated every 3 years in Bamako Meanwhile, MOH will work to support prevention programming Strengthening capacity of health care systems Engaging NGOs to expand prevention, testing, care and treatment services for MSM, potentially using mobile units ICAP and partners will conduct another biobehavioral survey among artisanal gold miners in Kayes, Mali

54 Acknowledgements CSLS Tako Ballo Bouyagui Traore Ouman Dembele HCNLS Daouda Diakite INRSP Mamadou Traore Sekou Traore ICER Nouhoum Telly Seydou Doumbia Hammadoun Sango Ongoiba Aboudoullaye Oumar Sangho TERIYA study team CDC/Atlanta Avi Hakim CDC/Mali Jacques Mathieu Adama N dir Mamadou Traore Adama Sangare Tobi Saidel, Consultant ICAP-New York Batya Elul Danielle Gurr Kate Doyle Yingfeng Wu Justin Knox USAID

55 Acknowledgements This project is supported by the President s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of grant number 1U2GGH for Strengthening HIV Strategic Information in the Republic of Mali under PEPFAR. The contents are the responsibility of ICAP and do not necessarily reflect the views of the United States Government.

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