D7 Prevention Manual and Training

Transcription

1 D7 Prevention Manual and Training Formative Research Report Sandra Dudareva-Vizule, Ulrich Marcus Robert Koch Institut, Berlin Prevention Training Manual Peter de Grot, Wim Vanden Berghe Institut of Tropical Medicine, Antwerp

2 "This document has been produced with the support of the SIALON project funded by the European Commission under the European Commission Public Health Programme The contents of this document are the sole responsibility of the authors and can under no circumstances be regarded as reflecting the position of the European Commission." Prevention Manual and Training 2

3 Formative Research Report

4 Glossary EMIS European MSM Internet Survey FR formative research FRR formative research report FSW female sex workers HBV hepatitis B virus HCV hepatitis C virus HIV human immunodeficiency virus IDU intravenous drug users IQR interquartile range Q quartile MSM men who have sex with men RDS respondent driven sampling STI sexually transmitted infection TLS time location sampling Prevention Manual and Training 2

5 Content 1. Overall information on the formative research process and the data sources 2. Background information on the study area and MSM population 2.1. Legislative background in SIALON II countries 2.2. Proportion of MSM population by the study area 2.3. Characterisation of the target population (EMIS data) Age distribution Education Employment Migrations status Current relationship status Who are you sexually attracted to? Outness Gay friends Self-reported HIV and STI positivity 3. Gay/gay friendly commercial and non-commercial sites 3.1. Overview of gay friendly commercial and non-commercial sites in the study areas 3.2. MSM population attending gay venues (EMIS results) 3.3. Characteristics of the MSM population that can be reached in gay venues (EMIS data for TLS countries) Who can be reached in bars, pubs, or cafes? Who can be reached in community centres, organisations or social groups? Who can be reached in gay saunas? Who can be reached in gay discos or night-clubs? Who can be reached in backrooms, sex-clubs, and sex-parties? Who can be reached in cruising sites? How many MSM can be reached in porn cinemas? 4. Recency of visiting a website for MSM (EMIS data) 5. The prevention activities 6. HIV, Syphilis and Viral hepatitis B (HBV) and C (HCV), testing and therapy 7. Overall information about the experience with study methodology and studies among MSM 8. Formative research report annexes 8.1. FRR Annex 1. Formative research questionnaire for study sites 8.2. FRR Annex 2. Commercial gay venues by study sites 8.3. FRR Annex 3. Non-commercial gay venues by study sites 8.4. FRR Annex 4. HIV testing and counselling sites by study site 8.5. FRR Annex 5. Presentation of the FR results in the Project meeting, Berlin, Prevention Manual and Training 3

6 1. Overall information on the formative research process and the data sources This formative research (FR) was carried out for 13 SIALON II countries performing the study. Each country preselected the study area as well as recruitment methodology and target sample size (n=400). Altogether 9 countries will recruit study participants by using time location sampling (TLS) and 4 countries by using respondent driven sampling (RDS). Main questions and aspects FR had to cover were decided in the Kick-Off-Meeting (Luxemburg, ) and Steering Committee meeting (Verona, ). Further consultation with project partners and steering committee members followed per and in Telephone conferences. Project partners commented and agreed on the FR questionnaire. For FR purposes we used information from both FR questionnaires and EMIS data. The questionnaires (see formative research report (FRR) Annex 1) were filled out by each project partner from the respective study country and queried information on: the study site previous experience with different study methodologies and target groups gay-friendly commercial and non-commercial sites prevention activities HIV, STIs, HBV, and HCV testing and therapy legislation and stigmatisation In addition to the information provided by each country we used EMIS data to further characterise the MSM population in each respective study area. We describe demographic characteristics, outness, gay-venue attendance, and HIV and STI history by study area. Information on the SIALON II study area, type of sampling and how good the EMIS data fit these study areas are summarised in Table 1.1. In Italy the survey will be complemented by a national survey that is covered by national funds and will include Rome, Milan, Catania and Napoli in addition to the SIALON II study area Verona. We extracted the data containing all the relevant information for SIALON II countries from the EMIS data set. Altogether 3.6% (4,505/126,289) of all respondents had discrepancies in two or more question sets. In concordance with the approach of the EMIS research team we excluded these participants from further analysis. The proportion of participants excluded from analysis due to discrepancy did not differ significantly between SIALON study areas (p-value=0.38). Note that for FR purposes we analysed only a part of EMIS results. Detailed analysis of all EMIS data on country and region level is available in the EMIS report (The EMIS Network. EMIS 2010: The European Men-Who- Have-Sex-With-Men Internet Survey. Findings from 38 countries. Stockholm: European Centre for Disease Prevention and Control, 2013) as well as in national reports available at Altogether 119,557 records from the EMIS data base were available for the SIALON II countries. From these records altogether 17,160 were further selected for the SIALON II study areas. Table 1.2 summarises the information of EMIS records per country, number and proportion of records with missing information about the place of residence of participants, number and proportion of EMIS records matching SIALON study area. In some of the study sites the size of the sample available for the analysis is small (for example in Lithuania, Slovakia, Slovenia, United Kingdom, and Italy (Verona). This should be taken into account when interpreting the results of the EMIS data. And, more Prevention Manual and Training 4

7 important, this indicates that in these countries (Lithuania, Slovakia, Slovenia, United Kingdom, and Verona, Catania and Napoli in Italy) there might be challenges to motivate a higher proportion of potential study participants than EMIS (where approximately 10% of those who were approached eventually participated). Possibilities to expand the study area/engagement of alternative venues should be considered and implemented if needed. For the data generated from EMIS results, we are able to provide estimates for all potential study sites in Italy (Verona, Rome, Milan, Catania, Napoli). For the data generated from FR questionnaires we can only provide information on Verona in Italy. All the calculations from EMIS data observations with missing values were excluded. Table 1.1. Study area in each SIALON II partner country, correlation with EMIS data, sampling methodology Country Study area Abbreviation Does it fit well to EMIS study Sampling methodology regions? Belgium Brussels city centre BE Yes TLS Bulgaria Sofia BG Yes TLS Germany Hamburg DE Yes TLS Spain Barcelona ES Yes TLS Lithuania Vilnius LT Yes (Vilnius district) RDS Poland Warsaw PL Yes (Mazowieckie TLS district) SIALON catchment TLS Portugal Lisbon and Setubal regions PT area will be smaller than these two districts Romania Bucharest RO Yes RDS Yes (Stockholm, TLS Sweden Stockholm SE Södermanland, Uppsala county) Yes TLS Slovenia Ljubljana SI (Osrednjeslovenska district) Slovakia Bratislava SK Yes RDS United Kingdom Brighton and Hove UK Yes TLS Italy, Verona Verona IT (Verona) Yes RDS Italy, Rome* Rome IT (Rome) Yes Italy, Milan* Milano IT (Milano) Yes Italy, Catania* Catania IT (Catania) Yes Italy, Napoli* Napoli IT (Napoli) Yes *Cities where the survey will be implemented as part of a national survey Prevention Manual and Training 5

8 Table 1.2. EMIS records per country, number and proportion of records with missing information about the place of residence of participants, number and proportion of EMIS records matching SIALON study area Country Total N EMIS data at country level Missing information on area SIALON study area EMIS participants corresponding study area N % N % Belgium 3, % 1, % Bulgaria 1, % % Germany 54,387 4, % 2, % Spain 13,111 1, % 1, % Lithuania % % Poland 2, % % Portugal 5, % 2, % Romania 2, % % Sweden 3, % 1, % Slovenia % % Slovakia % % United Kingdom 15,494 1, % % Italy, Verona 15,984 1, % % Italy, Rome 15,984 1, % 1, % Italy, Milan 15,984 1, % 1, % Italy, Catania 15,984 1, % % Italy, Napoli 15,984 1, % % 2. Background information on the study area and MSM population 2.1. Legislative background in SIALON II countries The number of years since when homosexuality is legal in the SIALON II countries ranges between 10 (Romania) and 220 (Belgium) years. In Bulgaria, Lithuania, Romania, and Slovakia homosexuality is legal since less than 25 years. Gay marriage is possible in Belgium, Portugal, Spain, Sweden, and will be introduced by 2015 in UK. Currently, in UK, Germany, Slovakia, and Slovenia other types of an officially recognized partnership are possible. In Bulgaria, Italy, Lithuania, Poland, and Romania same sex unions are not recognised. With the exception of Italy, in these countries homosexuality has become legal only recently. Almost in all the countries legislation forbids discrimination regarding sexual orientation. This is partially implemented in Italy and Poland. In Italy the regulation is related only to workplace. The table 2.1 summarises the year since when homosexuality is legal in each country, at what level homosexual relationship is legal, as well as if and since when the national legislation forbids discrimination by sexual orientation, and if there lately have been studies assessing discrimination, stigmatization, or hate towards LGBT population. Based on this information we might expect that the gay communities in Bulgaria, Lithuania, Poland and Romania might be less open, thus harder to reach. Prevention Manual and Training 6

9 Table 2.1. Background information on legislation and stigmatization in the study areas Other type of official partnership possible (date Legislation (persons should not be discriminated by sexual orientation) - date since Studies assessing discrimination, stigmatization, or hate towards LGBT population in last 24 months Country Homosexuality is Marriage Homosexuality legal since legal but same sex unions are not recognised since when) performed (date since when) Adoption possible (date since when) when BE Y BG 1990 Y 2004 Y DE Step-child adoption only (full joint adoption proposed) 2006 Y IT 1887 Y 2003 partially Y LT 1993 Y 2008 Y PL 1932 Y 2004 (2010) partially Y PT Y RO 2002 Y 2002 Y SK 1991 * N N SL Y ES Y SE N UK /2005 by Y *date since when missing Prevention Manual and Training 7

10 2.2. Internalised homonegativity in the study countries The Reactions to Homosexuality scale, first developed by Ross and Rosser in 1996 and recently revised (Smolenski et al., 2010), was presented to EMIS respondents in order to measure internalised homonegativity. Here we present EMIS data at country level from the EMIS report. According to EMIS results the mean internalised homonegativity score for all respondents with a valid score was 1.50 (range 0-6; SD=1.23). Mean scores for countries ranged from 1.22 in the Netherlands (lowest) to 2.58 in Bulgaria (highest) (figure 2.1). Figure 2.1. Internalised homonegativity scores across Europe (EMIS report) As concluded by Ross et al. internalised homonegativity is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with outness and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. EMIS data on internalised homonegativity are published in: Michael W. Ross; Rigmor C. Berg; Axel J. Schmidt; Harm J. Hospers; Michele Breveglieri; Martina Furegato; Peter Weatherburn (2013): Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia. BMJ Open 2013;3:e (doi: /bmjopen ) Proportion of MSM population by the study area Each SIALON II partner provided the most recent available information on the proportion of MSM among the adult male population in their country and study area (if available). This proportion ranged between less than 2% to almost 10% by country. Some of the countries, like Belgium, Sweden, United Kingdom, and Poland could provide a good reference for this estimate. While in Bulgaria the estimate is based on experts opinion and there are three countries that were not able to provide this estimate (Romania, Slovakia, and Slovenia). The information on proportion of MSM population by the country together with comments and references is summarised in table 2.2. It should be taken into account that these data have been estimated by using a variety of Prevention Manual and Training 8

11 methodologies and might over or under-estimate the size of the MSM population. For instance the estimate for Bulgaria is based on expert opinion, while there are two comparable estimates reported for Sweden. Table 2.2. Proportion of MSM among adult male population by the country, comments and the references Study area BE MSM (among adult male population), % 1.9% (Country) Comments, references Survey Gelijke Kansen 2007, Steven Lenaers (Steunpunt Gelijkekansenbeleid) sexual attraction was measured, not behaviour. BG 3% For country and study area, based on expert opinion DE IT 6% (Country) 6.7% (Country) In the city probably more (8%). M. Bochow (1997), Aids-Forum DAH, Bd 26, 20 Statistikamt Nord (Hamburg/Schleswig-Holstein) Survey on families in Italy in Estimate of the prevalence of sexual orientation regards all the LGB population, considering dimension such as self identification, sexual attraction and having ever had sex with someone of the same sex. La popolazione omosessuale nella società italiana, National Statistical Institute (ISTAT), 2011, LT % UNDP. Reversing the epidemics. Facts and Policy options. Bratislava, 2004; PL 9.7% (Country) 2.3% (Country) Men had ever sexual contact with men (internet survey 2010). Men had ever sexual contact with men (self-administered questionnaire as part of face-to-face interview on random sample from voting districts 2001). Izdebski Z. Selected Aspects of Evaluation of the National HIV/AIDS Prevention Program within the Scope of Society's Knowledge, Sexual Behaviour and Condom Availability in Poland. Warsaw 2002: UNDP, National AIDS Centre PT 10.2% (Country) 350,000 MSM reported by study partner. For calculation used data on adult male population (3.420,859) from World databank ( RO. Up to 4000 present in gay scene in Bucharest registered MSM profiles on gayromeo.org for Bucharest. SK. SL. ES 3-6% (Country) LGBT report, Spain, % SE (Country) Nationella folkhälsoenkäten, % UngKAB study, 2009 UK 2.8% (Country) 13% (Study area) National Survey of Sexual Attitudes and Lifestyles (NATSAL II) from Only takes into account adult males aged years, so likely to be an underestimate. New data for 2010 due in 2013 which will include older age bracket and this new estimate likely to be much higher. 564,760 (calculated 2.8%) Brighton and Hove City Council (2011). Health and Wellbeing Joint Strategic Needs Assessment Summary. 35,000 (calculated 13%). The data does not break down into MSM, rather LGBT. Although the denominator in this case is not clear, it is likely to be the total adult population of Brighton (not just male population). Brighton population in 2009 estimated at 256,300 (Office for National Statistics). Gender break down for Brighton: 51% female; 49% male Prevention Manual and Training 9

12 2.4. Characterisation of the target population (EMIS data) Age distribution The age distribution of the MSM reached by EMIS in the SIALON study areas significantly differed by study region (Kurskal Wallis test, p-value<0.001). The MSM population in the study sites in Bulgaria, Lithuania, Poland, Romania, Slovenia, Slovakia, as well as Napoli and Catania in Italy is younger than the MSM population in Belgium, Germany, Spain, Portugal, Sweden, United Kingdom, and Italy (Rome, Milano and Verona). See table 2.3 and figure 2.2. This might be related to the differences in the time span since when an openly accessible gay scene exists, age of homosexual consent, the level of openness and the differences in populations that use internet and are eager to participate in online surveys. In order to reach better representation of older MSM population in SIALON II study Bulgaria, Poland, and Slovenia (study sites using TLS methodology) should - if possible - identify and include venues in the sampling that are more frequently visited by older MSM. Table 2.3. Median age, interquartile range (IQR), minimum and maximum age, and the proportion of population younger than 30 years of age <30 years of age Study area Median IQR Minimum Maximum N % BE % BG % DE % ES % LT % PL % PT , % RO % SE % SI % SK % UK % IT (Verona) % IT (Rome) % IT (Milano) % IT (Catania) % IT (Napoli) % Prevention Manual and Training 10

13 Figure 2.2. Age distribution by study site Education According to EMIS, the information on the level of education was gathered by asking participants What is your highest education qualification?. The response set for this question varied by survey language; however, all answer categories were grouped according to the International Standard Classification of Educational Degrees (ISCED). Please note that this grouping may still generate larger discrepancies between countries (particularly Germany is an outlier compared with the other SIALON and EMIS countries). Therefore although ISCED has been constructed to improve comparability - these parameters cannot be compared equally well between the countries. However, it can be used for comparison of the MSM population reached by EMIS and the population that will be reached by SIALON II. Prevention Manual and Training 11

14 Table 2.4. Number and proportion of MSM with low/middle and high education by study area Low/middle (ISCED I+II) High (ISCED III+) Study area N % N % BE % % BG % % DE 1, % % ES % 1, % LT % % PL % % PT % 1, % RO % % SE % % SI % % SK % % UK % % IT (Verona) % % IT (Rome) % % IT (Milano) % 1, % IT (Catania) % % IT (Napoli) % % Employment The percentage of unemployed men ranged between 2.6% (Romania and Lithuania) and 9.2% (Spain and Napoli in Italia). The Proportion of employed and unemployed men by study area is summarised in table 2.5. Table 2.5. Number and proportion of employed, unemployed, and men with other occupation by study area Employed Unemployed Other occupation Study area N % N % N % BE % % % BG % % % DE 1, % % % ES 1, % % % LT % 7 2.6% % PL % % % PT 1, % % % RO % % % SE 1, % % % SI % % % SK % % % UK % % % IT (Verona) % % % IT (Rome) 1, % % % IT (Milano) 1, % % % IT (Catania) % % % IT (Napoli) % % % Prevention Manual and Training 12

15 Migration status The proportion of MSM that were born in another country than the current country of residence differed substantially by study area. Lithuania, Poland, Romania, Slovenia, and Catania and Napoli in Italy had less than 6% of MSM population that was born in another country. Contrastingly in Belgium, Spain, Portugal, Sweden, and the United Kingdom this proportion was nearly or slightly over 20%. The proportions of MSM born in country of residence and in another country are displayed in table 2.6. Table 2.6. Number and proportion of MSM born in country of residence and in another country by study area Born in country of residence Born in another country Study area N % N % BE % % BG % % DE 2, % % ES 1, % % LT % % PL % % PT 1, % % RO % % SE 1, % % SI % % SK % % UK % % IT (Verona) % % IT (Rome) 1, % % IT (Milano) 1, % % IT (Catania) % 6 3.4% IT (Napoli) % % Current relationship status In the total sample, 55.5% were single (currently no steady partner), 39.4% were in a steady relationship with a man, 4.6% were in a steady relationship with a woman, and 0.5% had both male and female steady partners. The proportion of single men, men in a steady relationship with men, woman, and both varied by study area and are displayed in table 2.7. Prevention Manual and Training 13

16 Table 2.7. Number and proportion of MSM who are single, are in a steady relationship with men only, with women only or both, by study area Single Steady relationship With men only With men and women With women only Study area N % N % N % N % BE % % 4 0.4% % BG % % 5 1.0% % DE 1, % % 6 0.2% % ES 1, % % 1 0.1% % LT % % 3 1.1% % PL % % 4 0.4% % PT 1, % % % % RO % % 7 1.1% % SE % % 8 0.6% % SI % % 1 0.2% % SK % % 0 0.0% 6 2.4% UK % % 1 0.3% 6 2.1% IT (Verona) % % 1 0.3% % IT (Rome) 1, % % 6 0.3% % IT (Milano) 1, % % 4 0.2% % IT (Catania) % % 1 0.6% % IT (Napoli) % % 4 0.8% % Average 55.5% 39.4% 0.5% 4.6% Who are you sexually attracted to? In all the countries the vast majority of MSM reported that they are sexually attracted only to men. However, the proportions of men attracted also to women varied between countries (see Figure 2.3). The proportion of men also attracted to women were higher in Bulgaria, Lithuania, and Romania compared to Belgium, Germany, Spain, Poland, Sweden, UK, and Italy, where the proportion of men attracted only to men was around and above 80%. Bulgaria, Lithuania, and Romania also belong to the countries where MSM are less out (see chapter ) about their sexual orientation and with higher homonegativity scores >2 (see Chapter 2.2.). Prevention Manual and Training 14

17 Figure 2.3. Distribution of MSM sexually attracted to men and to women by study area. Prevention Manual and Training 15

18 Outness According to EMIS, outness was defined as the degree to which men are open about their sexual attraction to others. The level of outness differed substantially between the study areas. The proportion of men being out about their sexual orientation to all or most people ranged between 26.8% (Romania) and 86.9% in UK. In Bulgaria, Lithuania, Poland, Portugal, Romania, Slovakia, and some sites in Italy the proportion of MSM who are out only to some people were over 30% (with 53% in Lithuania and 52% in Bulgaria). In the SIALON II context this indicates that in these countries the MSM population will be harder to reach, as well as the reached population will most probably represent the men who are more out about their sexual orientation; this is particularly true for countries planning TLS sampling. The level of outness might be associated to the network size and strength of the ties in the network, i.e. men who are less out about being attracted to men might have weaker networks. Lithuania, Slovakia, Italy, and Romania are planning to use RDS methodology. Therefore these countries should consider extra seeds with large number of MSM acquaintances. Proportions of men out to most, some, and only few people by study site are summarised in table 2.8. Table 2.8. Number and proportion of MSM by level of outness and study site Out to most people Out to no-one or only few people Out to some people, but not to most Study area N % N % N % BE % % % BG % % % DE 1, % % % ES 1, % % % LT % % % PL % % % PT 1, % % % RO % % % SE 1, % % % SI % % % SK % % % UK % % % IT (Verona) % % % IT (Rome) % % % IT (Milano) 1, % % % IT (Catania) % % % IT (Napoli) % % % Average 53.0% 34.4% 12.6% Prevention Manual and Training 16

19 Gay friends The proportion of the men with gay friends differed substantially between study areas. In Bulgaria, Romania, Slovenia and some sites in Italy the proportion of men who had none or only few gay friends was nearly or more than 30% (see table 2.9). This finding is in line with the proportion of men being out about their sexual orientation and again indicates that there is some proportion of MSM that probably will not be reached in the SIALON II study. The high proportion of men with no or only few gay friends can influence the recruitment process in the countries performing RDS as these men will be less likely recruited and, if recruited, to enrol further participants in the study. Therefore it is highly important to preselect seeds with a wide network of gay friends, as well as in advance to account that not all recruited participants will be productive (i.e. consider larger number of seeds). Table 2.9. Number and proportion of MSM whose friends most or all are gay, some are gay, none or few are gay, by study area Most or all Some None or few Study area N % N % N % BE % % % BG % % % DE % 1, % % ES % 1, % % LT % % % PL % % % PT % 1, % % RO % % % SE % % % SI % % % SK % % % UK % % % IT (Verona) % % % IT (Rome) % % % IT (Milano) % 1, % % IT (Catania) % % % IT (Napoli) % % % Average 16.8% 57.7% 25.5% Self-reported HIV and STI positivity Self-reported HIV positivity rate versus those tested negative or untested ranged between less than 2% (Bulgaria, Lithuania, and Slovakia) and 21% (UK). HIV positivity rate by study site is summarised in table Prevention Manual and Training 17

20 Table Number and proportion of HIV positive MSM (versus those diagnosed negative or untested) Diagnosed positive Study area N % (95% CI) BE % ( %) BG 9 1.9% ( %) DE % ( %) ES % ( %) LT 4 1.5% ( %) PL % ( %) PT % ( %) RO % ( %) SE % ( %) SI % ( %) SK 4 1.6% ( %) UK % ( %) IT (Verona) % ( %) IT (Rome) % ( %) IT (Milano) % ( %) IT (Catania) 7 4.0% ( %) IT (Napoli) % ( %) Table Proportion of MSM who tested positive for HIV among those with known HIV test result Not tested Tested Last test negative Diagnosed positive Study area N % N % N % BE % % % BG % % 9 2.7% DE % 1, % % ES % 1, % % LT % % 4 2.9% PL % % % PT % 1, % % RO % % % SE % 1, % % SI % % % SK % % 4 2.6% UK % % % IT (Verona) % % % IT (Rome) % 1, % % IT (Milano) % 1, % % IT (Catania) % % 7 6.5% IT (Napoli) % % % Average 28.2% 90.5% 9.5% Prevention Manual and Training 18

21 In the table are displayed proportions of MSM diagnosed positive with at least one bacterial STI or 1st diagnosis of anal or genital warts or herpes in the last 12 months. The lowest positivity rates were observed in Lithuania and Slovakia and the highest in Belgium, Spain, Romania, and UK. Figure 2.4 displays proportion of MSM with positive HIV status and proportion diagnosed positive with at least one bacterial STI or 1st diagnosis of anal or genital warts or herpes in the last 12 months. Table Number and proportion of MSM diagnosed positive with at least one bacterial STI (Syphilis, Gonorrhoea, or Chlamydia) or 1st diagnosis of anal or genital warts or herpes in the last 12 months Diagnosed positive Study area N % (95% CI) BE % ( %) BG % ( %) DE % ( %) ES % ( %) LT % ( %) PL % ( %) PT % ( %) RO % ( %) SE % ( %) SI % ( %) SK 8 3.2% ( %) UK % ( %) IT (Verona) % ( %) IT (Rome) % ( %) IT (Milano) % ( %) IT (Catania) % ( %) IT (Napoli) % ( %) Prevention Manual and Training 19

22 Figure 2.4 displays proportion of MSM with positive HIV status (versus HIV negative or unknown) and proportion diagnosed positive with at least one bacterial STI or 1st diagnosis of anal or genital warts or herpes in the last 12 months. Table Percentage of MSM who have tested positive for syphilis within last 12 months among those with blood test for STIs (other than HIV) within the last 12 months Not tested Tested Negative Positive Study area N % N % N % BE % % % BG % % 4 3.6% DE 1, % % % ES % % % LT % % 0 0.0% PL % % % PT 1, % % % RO % % % SE % % % SI % % 6 7.0% SK % % 1 2.0% UK % % 4 2.7% IT (Verona) % % 8 7.1% IT (Rome) 1, % % % IT (Milano) 1, % % % IT (Catania) % % 2 6.9% IT (Napoli) % % % Average 70.4% 92.7% 7.3% Prevention Manual and Training 20

23 3. Gay/gay friendly commercial and non-commercial sites Each study site collected information on commercial and non-commercial gay (friendly) venues. Cafés, bars, discos, sex-clubs, saunas, porn-shops and similar venues were classified as commercial venues. Community centres and cruising areas were classified as non-commercial sites. We did not provide a specific definition for the commercial and non-commercial sites. As lives of gay communities are often organized around venues and social structures, this information can be used to better understand the community in each respective study area, as well as the opportunities for the TLS sampling. It should be taken into account that the study areas differ by their size (in respect of population and geographic region), therefore direct comparison of the numbers of the venues between these sites is not possible Summary of gay friendly commercial and non-commercial sites in study areas The number of different commercial venues ranged between 4 (Romania and Slovakia) and 39 (Spain). Sexual contact was facilitated on average in almost half (46%) of the commercial venues. The proportion of venues among all commercial venues where sexual contact is facilitated was highest in Bulgaria, Italy (Verona), Poland, and Slovenia; lowest in Sweden and UK. In Romania sexual contact is not facilitated in any of the 4 reported commercial venues. Approximately in half of the venues condoms and lubricants are available (if available, then almost always both are available). Prevention leaflets are available on average in 62% of all the commercial venues. This, however, varies substantially between countries. In Bulgaria, Germany, Portugal, Romania, Slovenia, and UK prevention materials are available in all or almost all the commercial venues. Contrastingly, in Italy (Verona), Lithuania, and Slovakia prevention materials are not available at all in these venues (in Lithuania available in 1 venue out of 7). Outreach workers are visiting all or almost all the commercial venues in Belgium, Bulgaria, Germany, Portugal, Slovenia, and UK. While only few or no venues in Italy (Verona), Lithuania, Romania, Slovakia, Spain, and Sweden are visited by outreach workers. The overview of commercial venues is summarised in Table 3.1. Table 3.1. Overview of commercial venues by study site Country N Sexual contact facilitated Condoms available Lubricants available Prevention leaflets available Visited by outreach worker N % N % N % N % N % BE % 14 50% 13 50% 24 88% 20 73% BG % 7 100% 7 100% 7 100% 7 100% DE % 17 47% 17 47% 35 97% % IT (Verona) % 4 50% 4 50% 0 0% 2 25% LT % 4 57% 3 43% 1 14% 1 14% PL % 10 63% 10 63% 11 69% 9 56% PT % 20 71% % % 27 96% RO 4 0 0% 4 100% 0 0% 4 100% 0 0% SK % 1 25% 1 25% 0 0% 1 25% SL % 5 83% 5 83% 5 83% 6 100% ES % 15 38% 0 0% 30 77% 6 15% SE % 9 36% 9 36% 9 36% 7 28% Prevention Manual and Training 21

24 UK % 23 96% 23 96% % 22 92% Average 46% 63% 53% 62% 56% The number of different non-commercial venues ranged between none (Slovakia) and 12 (Sweden). Sexual contact was facilitated in almost none or only few of the venues, except Bulgaria, Germany, Slovenia, and Sweden. The non-commercial venues where sexual contact is facilitated were usually gay cruising sites. Condoms and lubricants were available in none or only few of these venues, except study sites in Bulgaria, Sweden and UK, where almost in all of the sites condoms and lubricants were available. Prevention leaflets were available approximately in half of the venues and more than half of the venues were visited by outreach workers. Again this varies substantially by study site. Overview of non-commercial venues is summarised in Table 3.2. Table 3.2. Overview of non-commercial venues Country N Commu nity centre Category Cruisin g site Oth er Sexual contact facilitated Condoms available Lubricants available Prevention leaflets available Visited by outreach worker N % N % N % N % N % BE % 0 0% 1 50% 1 50% 2 100% BG % 9 90% % % % DE % 2 33% 2 33% 2 33% 6 100% IT (Verona) % 0 0% 1 33% 1 33% 1 33% LT % 0 0% 1 33% 1 33% 1 33% PL % 0 0% 1 14% 2 29% 0 0% PT % 0 0% 1 25% 1 25% 4 100% RO % 0 0% 0 0% 1 20% 1 20% SK SL % 0 0% 0 0% 0 0% 0 0% ES % 0 0% 6 60% 7 70% 9 90% SE % 6 50% 10 83% 10 83% 5 42% UK % 2 29% 6 86% 5 71% 6 86% Average 29% 17% 19% 46% 59% Among the countries applying TLS methodology for sampling the lowest number of gay-venues is in Slovenia (together 7 venues). However, according to FR research in all of these venues sampling would be possible. The average number of clients in the 6 commercial venues is 20 (range 10-30) in weekdays and 30 (range ) on weekends. However, in the average only 60% of the population in these venues are MSM. This should be particularly taken into account when planning the sampling frame for Slovenia. The country specific information on type of commercial and non-commercial venues for the TLS countries, and details on number of clients, etc. are reported in FRR Annex 2 and MSM population attending gay venues (EMIS results) Prevention Manual and Training 22

25 The proportion of MSM who ever have visited gay social venue community centre, organisation or social group, bar, pub, cafe, disco) in their country of residence varied by study site. In Bulgaria, Lithuania, Romania, Slovenia, and Italy (Napoli) only 70 to 80% of MSM have ever visited gay social venues in their country of residence. In Belgium, Spain, and UK this proportion was over 95%. In the table 3.3 there is information summarised on the proportion of MSM reached by EMIS that have attended gay social venues ever, in the last 12 and 6 months, and last 4 weeks. Since the SIALON II study is planned for a time period of approximately 3 months, the best estimate about MSM population we can reach in the venues is last 6 months. According to these data we can conclude that SIALON II will reach only part of the population reached by EMIS and this varies by study site. Sampling in the gay social venues in Bulgaria and Slovenia (proportion of MSM who visited gay social venues in the last 6 months) might reach only half of the MSM population (reached by EMIS). Table 3.3. Recency of visiting any gay social venue in the country of residence (community centre, organisation or social group, bar, pub, cafe, disco) Never Ever Last 12 months Last 6 months Last 4 weeks Study area N % N % N % N % N % BE % % % % % BG % % % % % DE % 2, % 2, % 1, % 1, % ES % 1, % 1, % 1, % 1, % LT % % % % % PL % % % % % PT % 2, % 1, % 1, % 1, % RO % % % % % SE % 1, % 1, % 1, % % SI % % % % % SK % % % % % UK 2 0.7% % % % % IT (Verona) % % % % % IT (Rome) % 1, % 1, % 1, % % IT (Milano) % 1, % 1, % 1, % 1, % IT (Catania) % % % % % IT (Napoli) % % % % % Gay community centre, organisation or social group altogether were the least attended venues. On average only nearly half of MSM have ever attended this kind of venue. The situation varied by study site and in the last 12 months was highest in Belgium, Spain, Sweden, Italy (Verona) and UK (over 30% of MSM visited these venues in last 12 months) and lowest in Bulgaria and Slovakia. The information on proportion of MSM reached by EMIS that attended gay community centres or organisations, or social groups ever, in the last 12months, and last 4 weeks is summarised in table 3.4 and displayed in figure 3.1. Prevention Manual and Training 23

26 Table 3.4. Visited gay community centre or organisation, or social group in country of residence Never Ever Last 12 months Last 4 weeks Study area N % N % N % N % BE % % % % BG % % % % DE 1, % 1, % % % ES % % % % LT % % % % PL % % % % PT 1, % % % % RO % % % % SE % % % % SI % % % % SK % % % % UK % % % % IT (Verona) % % % % IT (Rome) % % % % IT (Milano) 1, % % % % IT (Catania) % % % % IT (Napoli) % % % % Figure 3.1. Proportion of MSM who have visited gay community centre or organisation, or social group in country of the residence ever, in the last 12 months and in the last 4 weeks, by study site Prevention Manual and Training 24

27 Altogether 86% of MSM population have attended gay commercial venues like bar, pub, disco, etc. at least once ever. Again this varied by study site and in the last 6 months was highest in Belgium, Spain, and UK (over 80% of MSM visited these venues in last 6 months) and lowest in Bulgaria, Lithuania, Romania, and Slovakia (less than 60%). The information on proportion of MSM reached by EMIS that attended gay commercial venues ever, in last 12 and 6 months, and last 4 weeks is summarised in table 3.5 and displayed in figure 3.2. Table 3.5. Visited gay commercial venue in the country of residence Last 12 Never Ever months Last 6 months Last 4 weeks Study area N % N % N % N % N % BE % % % % % BG % % % % % DE % 2, % 2, % 1, % 1, % ES % 1, % 1, % 1, % 1, % LT % % % % % PL % % % % % PT % 2, % 1, % 1, % 1, % RO % % % % % SE % 1, % 1, % 1, % % SI % % % % % SK % % % % % UK 2 0.7% % % % % IT (Verona) % % % % % IT (Rome) % 1, % 1, % 1, % % IT (Milano) % 1, % 1, % 1, % 1, % IT (Catania) % % % % % IT (Napoli) % % % % % Prevention Manual and Training 25

28 Figure 3.2. Proportion of MSM who have visited any gay commercial venue in country of residence ever, in the last 12 months, in the last 6 months and in the last 4 weeks, by study site (Please note that minimum value on X axis is 30%) The Sex-focused venues have ever been visited by an average of 68% of MSM population and in the last 6 months it has been 42%. Again this varied by study site and in the last 6 months was highest in Belgium, Spain, and UK (over 50% of MSM visited these venues in last 6 months) and lowest in Slovenia and Slovakia (around 25%). The information on the proportion of MSM reached by EMIS that attended sex-focused venue for MSM ever, in last 12 and 6 months, and last 4 weeks is summarised in table 3.6. The proportion of MSM who in the last 4 weeks have visited more than one sex-focused venue was on average 11%, however, varied by country (table 3.6). Figure 3.3 displays distribution of proportions of MSM who visited one and more than one sex-focused venues in the last 4 weeks. Prevention Manual and Training 26

29 Table 3.6. Visited a sex-focused venue for MSM in their country of residence Never Ever Last 12 months Last 6 months Last 4 weeks In the last 4 weeks visited more than 1 sex-focused venue Study area N % N % N % N % N % N % BE % % % % % % BG % % % % % % DE % 1, % 1, % 1, % % % ES % 1, % 1, % % % % LT % % % % % % PL % % % % % % PT % 1, % 1, % 1, % % % RO % % % % % % SE % % % % % % SI % % % % % % SK % % % % % 6 2.4% UK % % % % % % IT (Verona) % % % % % % IT (Rome) % 1, % % % % % IT (Milano) % 1, % 1, % % % % IT (Catania) % % % % % % IT (Napoli) % % % % % % Figure 3.3. Proportions of MSM who visited one and who visited more than one sex-focused venue among those who visited these venues in the last 4 weeks Prevention Manual and Training 27

30 3.3. Characteristics of MSM population that can be reached in gay venues (EMIS data for TLS countries This chapter describes MSM by outness, HIV and STI positivity, and age who visited particular types of venues. These data should help to better understand who can be reached in venues and how to interpret the data gathered in the study sites performing TLS. This analysis is performed only for sites performing TLS. We compared the proportions of MSM who visited these sites in the last 6 months stratified by level of outness (out to all or almost all, some, and few or none), HIV status (HIV+ and HIV negative or unknown), and STI positivity (diagnosed positive with at least one bacterial STI (Syphilis, Gonorrhoea, or Chlamydia) or 1st diagnosis of anal or genital warts or herpes in the last 12 months). As well as compared mean age between those who visited these venues and those who did not. Overall we observed that: MSM who are not out about being attracted to men are less present in: bars, pubs, or cafes community centre, organisation or social group gay disco or night-club backroom, sex-club, sex-party (in some countries only) MSM population did not differ by level of outness in: gay saunas cruising sites We will potentially reach proportionally more HIV+ MSM (than we would reach in a populationrepresentative sample) in: bars, pubs, or cafes (in some countries only) gay saunas gay disco or night-club (in some countries only) backroom, sex-club, sex-party cruising sites MSM population did not differ regarding HIV status in: community centre, organisation or social group We will reach proportionally more recently tested positive for STI MSM (than we would reach in a population-representative sample) in: bars, pubs, or cafes (in some countries only) gay saunas gay disco or night-club (in some countries only) backroom, sex-club, sex-party cruising sites MSM population did not differ regarding STI status in: community centre, organisation or social group Prevention Manual and Training 28

31 MSM population is younger in comparison to MSM population reached by EMIS in: bars, pubs, or cafes (in some countries only) gay disco or night-club MSM population is older in comparison to MSM population reached by EMIS in: gay saunas backroom, sex-club, sex-party cruising sites MSM population did not differ in comparison to MSM population reached by EMIS in: bars, pubs, or cafes (in some countries only) community centre, organisation or social group The study site specific results by type of the venue are summarised in tables 3.7 to Additional comments are included after each table. In table 28 are displayed proportion of MSM that can be reached in porn cinemas (due to small number we did not stratify this analysis). It should be taken into account that the measure of association is related to the sample size. Therefore for some countries, in particular for Bulgaria, Slovenia and UK, we were not able to detect significant differences. Each country should take both - overall result (the measure of association) and country specific estimate (difference in proportions) into account. Prevention Manual and Training 29

32 Who can be reached in bars, pubs, or cafes? Table 3.7. Number and proportion of MSM, who visited bars, pubs, or cafes in the last 6 months overall and stratified by outness, HIV and STI status and age TLS study area Proportion of MSM, who visited bars, pubs, or cafes in the last 6 months overall and stratified by outness, HIV and STI status Overall Outness HIV STI (in last 12 months) N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Comparison of mean age between those who visited these venues and those who did not, mean (IQR) Visited Did not visit p- value** BE % 86.2% 82.4% 50.4% % 83.8% % 83.8% (28-42) 35 (27-47) BG % 54.2% 58.5% 28.9% % 33.3% % 48.6% (23-33) 30 (24-35) DE 1, % 80.7% 75.6% 33.3% % 82.7% % 85.8% (28-44) 34 (25-43) ES 1, % 88.2% 85.3% 66.0% % 88.8% % 89.4% (27-39) 34 (26-43) PL % 81.5% 71.1% 48.5% % 66.1% % 76.4% (25-34) 29 (24-34) PT 1, % 77.6% 73.9% 43.4% % 72.6% % 77.5% (25-39) 32 (25-41) SE % 80.4% 66.5% 31.6% % 83.3% % 82.7% (29-45) 36 (27-47) SI % 59.3% 53.2% 17.7% % 53.9% % 48.5% (24-35) 30 (23-38) UK % 89.2% 92.4% 41.2% % 91.7% % 93.6% (29-45) 42 (34-46) Overall 7, % 82.0% 74.6% 41.0% % 80.8% % 82.0% (26-41) 32 (25-42) *Chi2 test (or Fishers exact test where applicable) **Wilcoxon-Mann-Whitney test 1) The proportion of MSM who visited gay pub, bar or cafe in the last 6 months differs by level of outness, i.e. those who are not out about being attracted to men are less presented in these venues 2) In some of the countries the proportion of HIV+ MSM that visited gay bars, pubs or cafes was higher than proportion of HIV- or untested MSM, i.e. in gaysaunas we will potentially reach proportionally more HIV+ MSM (than we would reach in a population-representative sample) 3) In some of the countries the proportion of MSM tested positive for any STI (excluding HIV) in the last 12 months that visited gay bar, pub or cafe was higher than proportion of those not tested positive, i.e. in some countries in gay-bars, pubs and cafes we will potentially reach proportionally more recently tested positive for STI MSM (than we would reach in a population-representative sample) 4) In some study sites MSM population visiting gay-bars, pubs or cafes is older or younger in comparison to MSM population reached by EMIS, i.e. in other countries there is no difference in age. This might be explained by different profile of gay bars Prevention Manual and Training 30

33 Who can be reached in community centre, organisation or social group? Table 3.8. Number and proportion of MSM, who visited community centre, organisation or social group in the last 6 months overall and stratified by outness, HIV and STI status, and age Proportion of MSM, who visited community centre, organisation or social group in the last 6 months overall and stratified by outness, HIV and STI status TLS study area Overall Outness HIV STI (in last 12 months) N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Comparison of the mean age between those who visited these venues and those who did not, mean (IQR) Visited Did not visit BE ,6% 32.8% 29.2% 17.4% % 31.6% % 31.6% (27-42) 35 (28-43) BG 45 9,3% 13.9% 10.7% 7.0% % 0.0% % 11.4% (23-35) 29 (23-35) DE ,8% 22.3% 21.6% 6.4% % 21.0% % 19.8% (27-45) 35 (27-43) ES ,1% 31.3% 25.0% 18.2% % 33.6% % 33.1% (27-39) 33 (27-40) PL ,2% 30.6% 20.8% 8.9% % 22.6% % 18.1% (24-32) 29 (25-34) PT ,3% 20.8% 16.3% 8.1% % 16.4% % 21.7% (23-38) 32 (25-40) SE ,2% 41.5% 26.1% 20.2% % 53.1% % 42.3% (29-45) 36 (28-45) SI 71 17,7% 33.3% 21.8% 6.5% % 7.7% % 24.2% (24-37) 29 (24-37) UK 75 25,9% 26.8% 26.6% 11.8% % 33.3% % 27.7% (31-47) 38 (29-44) Overall ,7% 29.0% 21.4% 10.1% % 27.2% % 26.9% (26-42) 33 (26-41) *Chi2 test (or Fishers exact test where applicable) **Wilcoxon-Mann-Whitney test p- value** 1) The proportion of MSM who visited community centres in the last 6 months differs by the level of outness, i.e. those who are not out about being attracted to men are less presented in these venues 2) In majority of the study sites the proportion of MSM who visited community centres or similar did not differ by HIV status or being tested positive for STI in last 12 months. In some though. This probably can be explained by the type of community centres (i.e. a community centre for HIV+ MSM) Prevention Manual and Training 31

34 Who can be reached in gay saunas? Table 3.9. Number and proportion of MSM, who visited the gay saunas in the last 6 months overall and stratified by outness, HIV and STI status, and age Proportion of MSM, who visited the gay saunas in the last 6 months overall and stratified by outness, HIV and STI status Comparison of the mean age between those who visited these Overall Outness HIV STI (in last 12 months) venues and those who did not, mean (IQR) TLS study area N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Visited Did not visit p- value** BE % 25.8% 23.8% 29.2% % 30.3% % 35.0% (29-43) 34 (27-43) BG % 26.4% 23.3% 30.0% % 22.2% % 34.3% (25-36) 28 (23-33) DE % 23.9% 22.0% 21.9% % 38.5% % 35.3% (32-46) 33 (26-42) ES % 28.3% 28.3% 26.1% % 39.6% % 35.1% (29-40) 32 (26-39) PL % 12.8% 14.3% 17.1% % 36.7% % 30.0% (26-36) 28 (24-34) PT % 39.4% 38.1% 31.8% % 61.5% % 51.4% (28-43) 29 (23-38) SE % 24.8% 22.9% 24.6% % 43.5% % 37.3% (32-48) 34 (27-44) SI % 17.4% 13.4% 15.6% % 30.8% % 30.3% (27-40) 29 (24-36) UK % 36.1% 35.9% 20.0% % 51.7% % 51.1% (33-47) 38 (28-44) Overall % 26.9% 26.4% 26.1% % 43.6% % 38.6% (29-43) 32 (25-40) *Chi2 test (or Fishers exact test where applicable) **Wilcoxon-Mann-Whitney test 1) The proportion of MSM who visited gay-saunas in the last 6 months does not differ by level of outness 2) In most of the countries the proportion of HIV+ MSM that visited saunas was higher than proportion of HIV- or untested MSM, i.e. in gay-saunas we will potentially reach proportionally more HIV+ MSM (than we would reach in a population-representative sample) 3) In most of the countries the proportion of MSM tested positive for any STI (excluding HIV) in the last 12 months that visited saunas was higher than proportion of those not tested positive; i.e. in gay-saunas we will potentially reach proportionally more recently tested positive for STI MSM (than we would reach in a population-representative sample); i.e. in SIALON sample (in TLS study areas) potentially proportion of MSM who had unprotected sex in the last 12 months will be larger than in the general MSM population 4) MSM population visiting gay-saunas is older in comparison to MSM population reached by EMIS Prevention Manual and Training 32

35 Who can be reached in gay disco or night-club? Table Number and Proportion of MSM, who visited gay disco or night-club in the last 6 months overall and stratified by outness, HIV and STI status, and age TLS study area Proportion of MSM, who visited gay disco or night-club in the last 6 months overall and stratified by outness, HIV and STI status Overall Outness HIV STI (in last 12 months) N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Comparison of the mean age between those who visited these venues and those who did not, mean (IQR) Visited Did not visit p- value** BE % 65.8% 61.3% 35.6% % 62.6% % 72.4% (27-40) 38 (30-47) BG % 56.3% 64.8% 28.9% % 50.0% % 55.9% (23-33) 30 (23-35) DE 1, % 61.9% 59.5% 22.9% % 60.8% % 73.0% (27-41) 37 (28-45) ES 1, % 77.0% 75.6% 52.3% % 75.1% % 81.9% (26-38) 36 (29-44) PL % 76.9% 69.6% 51.6% % 66.1% % 73.6% (25-33) 30 (24-35) PT 1, % 71.0% 66.6% 36.9% % 62.8% % 70.0% (25-38) 33 (25-42) SE % 72.7% 57.4% 30.5% % 74.7% % 78.4% (28-43) 39 (28-48) SI % 64.0% 52.1% 16.6% % 41.7% % 39.3% (24-34) 31 (25-38) UK % 65.0% 68.4% 41.2% % 60.0% % 72.3% (27-42) 44 (38-51) Overall 6, % 68.9% 65.0% 35.1% % 65.7% % 73.7% (26-39) 35 (27-44) *Chi2 test (or Fishers exact test where applicable), **Wilcoxon-Mann-Whitney test 1) The proportion of MSM who visited gay disco or night-club in the last 6 months differs by the level of outness, i.e. those who are not out about being attracted to men are less presented in these venues 2) In some of the countries the proportion of HIV+ MSM that visited gay disco or night-club was higher than proportion of HIV- or untested MSM, i.e. in Germany, Portugal and Sweden in these venues we will potentially reach proportionally more HIV+ MSM (than we would reach in a population-representative sample) 3) In most of the countries the proportion of MSM tested positive for any STI (excluding HIV) in the last 12 months that visited gay disco or night-club was higher than proportion of those not tested positive; i.e. in these venues we will potentially reach proportionally more recently tested positive for STI MSM (than we would reach in a population-representative sample); 4) MSM population visiting gay disco or night-club is younger in comparison to MSM population reached by EMIS Prevention Manual and Training 33

36 Who can be reached in backroom, sex-club, and sex-party? Table Number and proportion of MSM, who visited backroom, sex-club, sex-party in the last 6 months overall and stratified by outness, HIV and STI status, and age TLS study area Proportion of MSM, who visited backroom, sex-club, sex-party in the last 6 months overall and stratified by outness, HIV and STI status Overall Outness HIV STI (in last 12 months) N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Comparison of the mean age between those who visited these venues and those who did not, mean (IQR) Visited Did not visit p- value** BE % 36.9% 33.9% 25.6% % 52.5% % 54.7% (30-42) 33 (27-43) BG % 9.9% 10.7% 10.3% % 0.0% % 11.4% (22-33) 29 (24-35) DE % 33.0% 28.3% 19.3% % 54.1% % 54.2% (32-45) 33 (26-42) ES % 39.8% 37.0% 30.4% % 59.0% % 50.0% (28-41) 32 (25-39) PL % 31.2% 20.6% 22.7% % 46.8% % 40.9% (26-36) 28 (24-34) PT % 17.8% 15.1% 8.5% % 23.6% % 26.4% (29-45) 31 (24-39) SE % 22.1% 19.3% 19.8% % 45.8% % 33.3% (32-48) 34 (28-44) SI % 9.2% 2.8% 2.4% % 7.7% % 3.0% (28-40) 29 (24-36) UK % 26.0% 29.0% 23.5% % 48.3% % 42.6% (34-48) 38 (28-44) Overall 2, % 30.0% 23.3% 15.7% % 46.2% % 41.7% (30-44) 32 (25-40) *Chi2 test (or Fishers exact test where applicable) **Wilcoxon-Mann-Whitney test 1) In most study sites the proportion of MSM who visited backroom, sex-club, sex-party in the last 6 months differs by the level of outness, i.e. those who are not out about being attracted to men are less presented in these venues 2) In most of the study sites the proportion of HIV+ MSM that visited backroom, sex-club, sex-party was higher than proportion of HIV- or untested MSM, i.e. in these venues we will potentially reach proportionally more HIV+ MSM (than we would reach in a population-representative sample) 3) In most of the countries the proportion of MSM tested positive for any STI (excluding HIV) in the last 12 months that visited backroom, sex-club, sex-party was higher than proportion of those not tested positive; i.e. in these venues we will potentially reach proportionally more recently tested positive for STI MSM (than we would reach in a population-representative sample); 4) MSM population visiting backroom, sex-club, sex-party is older in comparison to MSM population reached by EMIS Prevention Manual and Training 34

37 Who can be reached in cruising sites? Ttable Number and proportion of MSM, who visited the cruising sites in the last 6 months overall and stratified by outness, HIV and STI status, and age TLS study area Proportion of MSM, who visited the cruising sites in the last 6 months overall and stratified by outness, HIV and STI status Overall Outness HIV STI (in last 12 months) N % All or almost all Some Few or none p- value* HIV- HIV+ p- value* STI- STI+ p- value* Comparison of the mean age between those who visited these venues and those who did not, mean (IQR) Visited Did not visit p- value** BE % 25.8% 23.7% 29.2% % 30.3% % 35.0% (29-43) 34 (27-43) BG % 26.4% 23.3% 30.0% % 22.2% % 34.3% (25-36) 28 (23-33) DE % 23.9% 22.0% 21.9% % 38.5% % 35.3% (32-46) 33 (26-42) ES % 28.3% 28.3% 26.1% % 39.6% % 35.1% (29-40) 32 (26-39) PL % 12.8% 14.3% 17.2% % 36.7% % 30.0% (26-36) 28 (24-34) PT % 39.4% 38.1% 31.8% % 61.5% % 51.4% (28-43) 29 (23-38) SE % 24.7% 22.9% 24.6% % 43.5% % 37.3% (32-48) 34 (27-44) SI % 17.4% 13.4% 15.6% % 30.8% % 30.3% (28-40) 29 (24-36) UK % 36.1% 35.9% 20.0% % 51.7% % 51.0% (34-47) 38 (28-44) Overall 2, % 30.0% 26.4% 26.1% % 43.6% % 38.6% (29-43) 32 (25-40) *Chi2 test (or Fishers exact test where applicable) **Wilcoxon-Mann-Whitney test 1) In most of the study sites the proportion of HIV+ MSM that visited cruising sites was higher than proportion of HIV- or untested MSM, i.e. in these venues we will potentially reach proportionally more HIV+ MSM (than we would reach in a population-representative sample) 2) The proportion of MSM tested positive for any STI (excluding HIV) in the last 12 months that visited cruising sites was higher than proportion of those not tested positive; i.e. in these venues we will potentially reach proportionally more recently tested positive for STI MSM (than we would reach in a populationrepresentative sample); 3) MSM population visiting cruising sites is older in comparison to MSM population reached by EMIS Prevention Manual and Training 35

38 4. Recency of visiting a website for MSM (EMIS data) Almost in all study sites nearly and more than 90% of MSM population have visited a website for MSM in the last 7 days (over 70% in the last 24 hours). These proportions differed by study sites, however the differences were much less pronounced in comparison to proportion of MSM attending venues. It should be taken into account that these data are acquired from an online-survey that was advertised in websites for MSM. General MSM population might visit websites for MSM less frequently. Table 4.1. Recency of visiting a website for MSM Last 7 days Last 24h Study area N % N % BE % % BG % % DE 2, % 2, % ES 1, % 1, % LT % % PL % % PT 2, % 1, % RO % % SE 1, % 1, % SI % % SK % % UK % % IT (Verona) % % IT (Rome) 1, % 1, % IT (Milano) 1, % 1, % IT (Catania) % % IT (Napoli) % % 5. Prevention activities Almost in all the SIALON II study areas outreach work and prevention activities have been carried out (see table 5.1). Major types of the prevention activities are summarised in table 5.2. Prevention Manual and Training 36

39 Table 5.1. Prevention activities and outreach work in the study area in the last 12 months Country Outreach work Prevention activities Evaluation of prevention activities BE Y Y Y BG Y Y N DE Y Y Y IT (Verona) Y Y N LT.. Y PL Y Y N PT Y Y N RO Y Y N SK N Y. SL Y Y N ES Y Y Y SE Y Y Y UK Y Y Y Table 5.2. Major types of prevention activities Information campaigns on various topics, including poster campaigns, mass media campaigns, social media campaigns (Facebook, Twitter), websites, videos, leaflets. Partially connected with distribution of condoms and lubricants as well as linking target group with specific services (i.e. counseling). Campaigns in World AIDS Day and other mass events. Distribution of condoms and lubricants in gay venues. Usually connected with distribution of information material and/or in frame of outreach work. BE, BG, DE, RO, ES, UK BE, PT, RO, SL, ES, IT Websites containing information on various topics as well as forums for exchange of opinions, information and as platform for online consultations. BE, UK, PL, DE Consultation (and testing) services for MSM. Providing face to face health promotion and counselling on various topics. At some services also VCT and testing for other Infections. Support groups. Harm reduction. Outreach work and mobile medical units. Telephone, online and Skype consultations Peer education, education for bar-tenders or other leaders Advocacy, open podium discussions / interviews in media. Gay pride Activities for communities of PLWHIV BE, BG, DE, PL, ES, UK BE, BG, IT, PL, PT, RO, SL, ES, SE, UK BE, ES, PL, UK BE, DE, PL, PT, UK BE, DE, SK, ES, UK BE, UK Prevention Manual and Training 37

40 Major lessons learned from prevention activities For information campaigns: focus group pre-testing with the target audiences was crucial Working closely with venues to establish mutually beneficial outcomes for both customers & service providers. Free condom & lube provision to venues was crucial to encourage engagement of venue management. Gay community is open to participate in prevention activities, and surprisingly open to discuss openly. There is a lack of knowledge about the basics and stigma among the community. Campaigns only in World AIDS Day or other special events is insufficient and should be implemented during whole year HIV and Safer messages don t need to be clever. Simple and to the point messages such as THINK were rated well by MSM PEP training seminars for outreach workers, volunteers and helpline workers was needed. Awareness on PEP among MSM doubled in 4 years Major challenges to implement prevention activities The lack of economic resources for prevention activities and/or for free condoms and lubricants Lack of human resources (partially linked to the lack of economic resources) Negotiating delivery of services in gay venues To involve MSM that are not already motivated or integrated in prevention activities Prevention Manual and Training 38

41 6. HIV, Syphilis and Viral hepatitis B (HBV) and C (HCV), testing and therapy Table 6.1. Proportion of HIV positive persons among population in general and among MSM receiving antiretroviral therapy by study area Community MSM MSM EMIS Data* % of HIV+ receiving ARV treatment % of HIV+ MSM receiving ARV treatment % of HIV+ MSM receiving ARV treatment Country Country Study area Country Study area Country Study area BE 79% 79% 74% 74% 64% 59% BG 2 30% 63%.. 67% 67% DE 3 78% 78% 78% 78% 75% 78% IT (Verona) % 52% LT 5 12%. 35%. 73% 50% PL 6 38% 81% 61% 69% 56% 48% PT 7 57%. 69%. 73% 70% RO % 70% SK 45% 47% 45% 49% 50% 25% SL 10 82% 88% 68% 46% ES 11 85% 89% 80% 36% 70% 74% SE 90% 91% 90% 90% 74% 69% UK 13 87% 79% 87% 79% 74% 82% *Note that for Bulgaria, Lithuania and Slovakia calculations on country level are based on <15 and on study area level on <10 HIV+ respondent EMIS data reflect the treatment situation in Due to higher treatment uptake and the trend to recommend starting treatment earlier, treatment rates may be higher in Prevention Manual and Training 39

42 Table 6.2. Guidelines and standards for the management of HIV+ patients by country Country Guidelines exist Screening Exist Syphilis Gonorrhoea Chlamydia HCV Other HBV vaccination recommended Under which conditions ARV is recommended CD4 count, cells/mm3 HBV infection AIDSdefining illness Frequency of monitoring visits for HIV+, times per year On treatment BE Y*** <350 Y Y BG Y N N <350 N N 6 2 DE Y N # Y Y Y Y Y <350 Y Y 4 4 IT (Verona) Y N. <350 Y Y LT Y N N <200 N Y 4 4 PL Y Y Y Y HBV Y <350 Y Y PT Y N. <350 Y Y 2 $ 2 RO SK Y Y Y Y Y Y HBV Y <350 Y Y 4 2 SL Y Y Y Y Y <350 Y Y ES Y Y Y Y N <350 N Y 4 4 SE Y N* Y** <350 Y Y 2 2 UK Y Y Y Y Y Y Y <350 N Y SE * There are other testing routines in place in each respective clinic; ** All MSM are recommended vaccination against HBV BE *** European guidelines, no Belgian guidelines; PT $ If patient stable DE # included in quality assurance (is recommended and can be provided for HIV+ patients (without extra costs for patients)) Not yet on treatment Prevention Manual and Training 40

43 Table 6.3. Availability of ARV drugs by country, treatment interruptions because of stock-out of drugs ARV groups and drugs BE BG DE IT (Verona) LT PL PT RO SK SL ES SE UK NRTI combinations Abacavir/Lamivudine/Zidovudine Y N Y Y Y Y Y. Y Y Y Y Y Abacavir/Lamivudine Y Y Y Y Y Y Y. Y Y Y Y Y Tenofovir/Emtricitabine Y N Y Y Y Y Y. Y Y Y Y Y Zidovudine/Lamivudine Y Y Y Y Y Y Y. Y Y Y Y Y NRTI/NNRTI combinations - Tenofovir/Emtricitabine/Efavirenz NRTI Y Y Y Y Y Y Y. Y Y Y Y Y Abacavir Y N Y Y Y Y Y. Y Y Y Y Y Tenofovir Y Y Y Y Y Y Y. Y Y Y Y Y Didanosine Y Y Y Y Y N Y. Y Y Y Y Y Lamivudine Y Y Y Y Y Y Y. Y Y Y Y Y Emtricitabine N Y Y Y Y Y Y. Y Y Y Y Y Zidovudin Y Y Y Y Y Y Y. Y Y Y Y Y NNRTI Efavirenz Y Y Y Y Y Y Y. Y Y Y Y Y Nevirapin Y Y Y Y Y Y Y. Y N Y Y Y Etravirin Y Y Y Y Y Y Y. Y Y Y Y Y Rilpivirine N N Y Y N N N. N Y N Y Y Protease Inhibitor combination Lopinavir/ Ritonavir Y Y Y Y Y Y Y. Y Y Y Y Y Protease Inhibitors Darunavir Y Y Y Y Y Y Y. Y Y Y Y Y Atazanavir Y Y Y Y Y Y Y. Y Y Y Y Y Saquinavir Y Y Y Y Y Y Y. Y N Y Y Y Fosamprenavir Y Y Y Y Y Y Y. Y N Y Y Y Ritonavir Y Y Y Y Y Y Y. Y Y Y Y Y Tipranavir Y N Y Y Y Y Y. Y N Y Y Y Integrase inhibitor - Raltegravir Y Y Y Y Y Y Y. Y Y Y Y Y CCR5 inhibitor - Maraviroc Y Y Y Y Y Y Y. Y Y Y Y Y Fusion inhibitor - Enfuvirtide N Y Y Y Y Y Y. Y Y Y Y Y Treatment interruptions because stock-outs of drugs Y N N N N N Y. N N N N N Prevention Manual and Training 41

44 7. Overall information about the experience with the study methodology and studies among MSM Overall information about the experience with the study methodology and studies among MSM are summarised in tables 7.1 and 7.2. All of the study countries already have the experience with at least one type of MSM study. From TLS countries Belgium, Slovenia, Spain and UK have already experience with TLS methodology in study among MSM. From RDS countries none of the countries have experience with RDS methodology among MSM, however, Lithuania have experience with this methodology in study among IDUs. Table 7.1. Experience with studies among MSM and other target groups by study methodology Country TLS RDS Other study methodology (among MSM only) in previous 24 months (for example internet based studies like EMIS) BE MSM FSW Y BG Y DE IDU Y IT MSM Y LT IDU Y PL IDU Y PT IDU, DU Y RO MSM Y SK MSM Y SL MSM Y ES MSM Youth Y SE IDU Y UK MSM MSM (1) Y Prevention Manual and Training 42

45 Table 7.2. Number of studies among MSM by type of the study Country TLS RDS Internet based (EMIS) Other (In last 24 months) BE BG 1 1 DE 1 1 IT (Verona) LT 1 PL 1 PT 1 1 RO 1 1 SK 2 1 SL ES SE 1 UK Prevention Manual and Training 43

46 8. Formative research report annexes 8.1. FRR Annex 1. Formative research questionnaire for study sites 8.2. FRR Annex 2. Commercial gay venues by study sites 8.3. FRR Annex 3. Non-commercial gay venues by study sites 8.4. FRR Annex 4. HIV testing and counselling sites by study site 8.5. FRR Annex 5. Presentation of the FR results in the Project meeting, Berlin, Prevention Manual and Training 44

47 Prevention Training Manual Prevention Manual and Training 45

48 Content 1. General introduction 2. Theoretical background and current situation 2.1 Theoretical background 2.2 Situation analysis Participating countries 3. Training manual 3.1 Introduction 3.2 Training of data-collectors 3.3 Didactics of training 3.4 Training program 3.5 Data collection and prevention activities on site 3.6 Factsheets Annex 1 : Info/prevention package Annex 2 : Scratchcards/Barcodecards Prevention Manual and Training 46

49 Glossary DGSANCO Directorate General for Health and Consumers (of the European Commission) Downer Drugs taken to relax or to feel less pain/irritations during sexual activities ECDC European Centre for Disease Prevention and Control EFTA European Free Trade Association EU European Union FAQ Frequently Asked Question GBL Gamma ButyroLactone. Drug, usually taken to relax and be more sexually aroused. Also sold as a strong cleansing product. The human body transforms GBL into GHB GHB Gamma-HydroxyButyrate. Less concentrated than GBL, with lesser effect Hallucination A sense perception (sight, touch, sound, smell, or taste) that has no basis in external stimulation HCV Hepatitis C HIV Human Immunodeficiency Virus MDMA The activating substance in Ecstasy, drug with hallucinating effects, also a an upper (activating effect) MSM Men who have Sex with Men NGO Non-Governmental Organization PEP Post Exposure Prophylaxis PrEP Pre Exposure Prophylaxis RSP Regular sex partner: A partner you regularly meet for sexual encounters SGSS Second Generation HIV Surveillance System SSP Steady (sex) partner, the partner you have a relationship with CSP Casual sex partner, one night stand RDS Respondent-Driven Sampling: The sampling method that relies on social network properties to sample hardto-reach populations RUOI Receptive unprotected oral intercourse with ejaculation STI Sexually transmitted infection TLS Time-location sampling: A sampling method that recruits individuals from specific locations during specific time periods UAI Unprotected anal intercourse Upper Popular term for any amphetamine or neurostimulant. Drugs taken to enable longer lasting and more intense experiences, e.g. dance all night Venue Locations where the target population, in our case MSM, congregates VDT Venue-day-time periods: Manageable 4-hour units of time that are venue, day, and time specific. VDTs are identified through a-priori staff knowledge, community interviews, owners and type I (if necessary) enumerations XTC Abbreviation of Ecstasy, drug with hallucinating effects, also a an upper (activating effect) Sero discordant couple Couple existing of one HIV positive and one HIV negative partner Prevention Manual and Training 47

50 1. General introduction The purpose of this prevention manual is to provide project partners in participating countries with a theoretical and concrete basis for the prevention framework and prevention activities of the Sialon II project. In the first part the underlying theoretical principles and current situation concerning MSM and HIV prevention are described. The second part is the training manual to be used by project partners to train data collectors in preparation of onsite prevention activities during the data collection. 2. Theoretical background and current situation analysis 2.1 Theoretical background 1 The Sialon II prevention activities are rooted in two complementary theoretical models. Firstly, a multilevel model predicting health outcomes among minority groups such as LGBT s called the minority stress model. Secondly, at the more individual and cognitive level, the informationmotivation- behavioural skills model. The concept of minority stress refers to the determinants of these mental health outcomes. Minority stress, based on Social Stress theory, was first conceptualized as a result of a marginal minority status. LGBT specific minority stress differs from other kinds of minority stress because of the potentially hidden character of sexual identity.more recent research conceptualizes the broader term minority stress as the excess stress individuals from stigmatized minority groups experience as a result of being part of that group. This excess stress is brought about through minority-specific determinants or stressors. Concerning sexual minorities, the following types of stressors are noted: (a) external, objective stressful events and conditions, e.g., discrimination at work; (b) expectations of such stressful events e.g. stigma consciousness; and (c) the internalization of negative societal attitudes regarding sexual minorities e.g. internalized homonegativity, as well as the perceived need to conceal one s sexual orientation. These different types of LGB-specific minority stress cause negative mental health outcomes but also affect different types of risk behavior and applied to the current framework, sexual risk behavior. The elements of this model are reflected in parts of the formative research for Sialon II and depict a country-specific contextual framework for the different prevention activities. At the more individual and social-cognitive level, the Sialon II prevention discours aims at interaction between data collectors and the respondents. As the data collectors are part of the target population this prevention activity can be seen as a form of peer education. Bandura s social-cognitive learning theory is a general theory of self-regulatory agency, defined as perceived self-efficacy. Within this model personal change requires that people believe in their ability to control their motivation (will), thoughts (knowledge), affective states and behaviours (power). Through practice and receiving feedback individuals develop self efficacy in taking preventive action. In this context social or peer support for the desired personal changes will be essential. Building on the former model we come to the Information-Motivation-Behavioural (IBM) skills model. Information has a positive influence on behaviour only when aligned with active, behavioural strategy. 1 Meyer IH Minority stress and mental health in gay men. J Health Soc Behav Mar;36(1): Bandura A Social cognitive theory and exercise of control over HIV infection in Preventing AIDS: theories and models of behavioural interventions. DiClemente RJ & Peterson JL Eds, Plenum Press, New York, 1994 Fisher JD and Fisher WA Theoretical approaches to individual-level change in HIV risk behaviour. In JL Peterson and CC diclemente (eds.), Handbook of HIV Prevention, pp New York: Springer, 2000 Prevention Manual and Training 48

51 The IMB model provides a multi-dimensional approach. The information component of the model targets the cognitive domain providing knowledge in supporting the behavioral change. The motivation aspect addresses affect and allows opportunity for developing a favorable attitude towards preventive behavior building on existing social support systems to enhance motivation. The third component, the behavioural aspect of the model implies that through practice, individuals acquire certain physical skills necessary to maintain the behavior change in time. Within Sialon II we will be mostly focusing on the information or knowledge and the motivation components through a peer interaction preventive activity. 2.2 Current situation analysis - Hiv prevention among MSM in participating countries See the Formative Research Report in the first section of this Manual 3. Training Manual 3.1 Introduction ( 3.4 of data collection manual WP5) 3.2 Training of data-collectors (text data collection manual WP5) One month before data collection, coordinators will be trained by the WP5, WP6 and WP8 leaders in a training session during the general meeting in Berlin. Later, a training session should be provided by the coordinator to data collectors in their countries following the instructions detailed in section 4 of this handbook. Training should be provided a few days before data collection in order to be sure that trainees can remember the procedure. The training session will be developed according to the SIALON I experience and will include a summary of the data collection and prevention manuals: 1. Information on HIV and STI prevention, testing and counselling. 2. Strategies for giving prevention messages and information of gay health services in approaching men in venue settings. 3. Data collection process: - Respect the planned time, setting and positioning - Safety rules - Getting tools ready before approaching - Approach and invite - Data collection - Collection, transportation and storage of oral fluid samples - Delivery of oral fluid samples and questionnaires to coordinator. - Prevention activities 3.3 Didactics of training The training will help you to develop skills and attitudes useful for data-collection. Awareness of certain individual emotions and being assured of support during and after the training and data-collecting are important subjects as well. Knowledge: During the training, the data-collectors gather the required knowledge. Attitude: After having gathered knowledge, the trainer and data-collectors, as a team, will stimulate the individual data-collector to reflect about his beliefs, opinions and vision and how this affect his own acting or judging towards himself or others. Skills: Data-collectors need to have good communication skills. During the training the datacollectors practice to speak about (individual) sexual behaviour without judgment, convince people in a friendly way to participate in the survey and shape borders to limit the contact, when needed. Prevention Manual and Training 49

52 Emotions: Data-collectors have to recognize and respect their own emotions as well as the emotions of the respondents and fellow data-collectors. Support: Data-collectors must have the skills to reassure respondents. If respondents worry about their health they should have an address for a follow-up. The data-collector should be able to support the co-data-collectors and be supported by the coordinator during and after data collection. 3.4 Training program Objectives The data-collector should be able to answer questions of the local visitors of gay-venues about: 1. The actual state of HIV and STIs: which STIs are present in the local MSM-scene, symptoms, transmission, prevention of transmission and treatment. 2. The relation between substance use and sexual behaviour at a physical, mental and social level. 3. Talking easily about personal wishes and boundaries in relationships and sex. 4. The local LGBT and sexual health center mapping. The data-collector training is constructed as follows: Table 1 Nr. Subject Activity Objective Done by 1. Explaining Sialon II, construction of training Presentation 2. Quiz Data-collectors participate in a quiz about HIV/STI, alcohol, drugs in relation to sexuality 3. Sex carousel Talking about sex to (relative) strangers 4. HIV/STI: facts and figures 5. Relation between substance use and sex Interactive presentation Interactive presentation Break 6. Proposition Take up a position in the room, showing your point of view to the trainer 7. The real life of prevention working Role-play how to speak out your wishes and limitations For data-collectors to know background of testing and prevention at the venue To determine what the data-collectors know themselves about the content of the training; warming up to content Experience how it is to talk about sex in public, experience your own talents and limitations Acquiring knowledge about HIV/STI Acquiring knowledge about the effects of alcohol and drugs on your body, mind and social interactions Getting aware of your own ideas on relationships, sexuality and hiv/sti prevention The trainers show a role play of a possible practical situation: the data-collectors are Trainer Datacollectors Trainer and datacollectors Trainer and datacollectors Trainer and datacollectors. Trainer and datacollectors Prevention Manual and Training 50

53 Nr. Subject Activity Objective Done by invited to participate and take over; getting experienced in skills necessary for being a host as well as prevention worker 8. Evaluation Results of the quiz; who s the winner? Evaluation (strengthts and weaknesses for yourself, trainers as well as the training) 9. Evaluation of the results of the training Meeting Remark: check the factsheets for interesting links per item. Further elaboration and items to be used in the training: Being aware of your strength- and weaknesses in order to improve your skills To formulate points of improvement for trainers and data-collectors Trainer and datacollectors Trainers 1 Explanation Sialon II, construction of training. The trainer gives a short overview of the Sialon I project, the data of Sialon I according to the conclusion of the Qualitative and Quantitative report. Think of (e.g.): Number of sex partners during the last 12 months Condom use during latest (anal) intercourse, separately for steady vs. csp/rsp partners When tested for HIV, within the last 12 months or before that; year and result of the latest test Condom use with different types of partners Exposure to risk (during the last 12 months) Types of drugs consumed Access to gay-specific information Access to/experience with condoms Access to testing (HIV/STI) Relation to Sialon II 2 Quiz Questions to test your knowledge about HIV/STI, sex and health, substance use and the local LGBT map. The quiz is a pleasant icebreaker and compares what you think you know to what you really know. The trainer checks the answers of the quiz and the winner will be announced after the break or at the end of the training. The quiz is found as an annex. 3 HIV/STI: facts and figures The trainer shows by means of a presentation (for example PowerPoint, Prezi) the actual local state of prevalence of HIV and STI, the symptoms, ways of transmission ways to prevent transmission and treatment. The trainer invites the data-collectors to share their knowledge and experiences. Information about facts and figures: see factsheet on HIV/STI, for local data: see formative research report, EMIS output. Prevention Manual and Training 51

54 4 Relation of substance use and sex We start with an exercise. The trainer draws a body outline on a flip chart or white board. The trainer asks the data-collectors to name all areas of the body (male/female) where there are mucous substances and how these areas can be an entry point for STI s. List of areas to be mentioned: mouth, throat, penis (gland, urethra, rectum). The trainer explains how substance use in can influence HIV/STI transmission. After the exercise, the trainer gives an overview of the popular local (party) drugs, the physical, mental and social effects of these drugs and the possible influence of these effects on sexual risk behaviour. The trainers use a flip- chart and asks the data-collectors if they know the effects of substances considering the anaesthetic, stimulating or hallucinating effects. The trainer makes the link between the effects and social sexual activities. E.g.: cocaine makes you overwhelmingly self-confident, which results in getting into contact with other people easier and change your attitude towards: what can happen to me, I don t need a condom. Cocaine as well, it makes anal sex is less painful. Other examples: see factsheet on substance abuse 5 Speak out sex carrousel Talking about sex: a practical exercise to speak out easily and respectfully on HIV/STI facts, sexual behaviour, test behaviour, substance use and ways of transmission. The exercise offers tools to maintain a comfortable discussion with respondents. 6 Propositions Showing your views increases your awareness as a data-collector and informs your colleagues of what your thoughts are on relationships, sex, substance use and prevention. You learn to share your views, to speak openly about safe sex and to create a safe environment, where you can be open and respectful towards others. These are very important qualities to have as data-collector. The trainer offers propositions. Per proposition the data-collectors give a rating from 1-10 (depending on local views). By positioning you as data collector make your point of view visible. The trainer can invite you to motivate your point of view. The propositions: 1. I m not only responsible for my own health but also my friends health. 2. I m not only responsible for my own health but also for my sex partner s health. 3. My sex partner is also responsible for my health. 4. My friends are also responsible for my health. 5. When I see my friends are drunk, I should warn them to stop drinking. 6. When I see a drunk person I don t know in a bar I visit, I should prevent him to order more alcohol. 7. When I see other people have unprotected sex it is my duty to make them stop. 8. Using drugs is a bad thing. 9. Drinking alcohol is a bad thing. 10. Condom use is not important anymore; there are other strategies to prevent HIV transmission. 11. Condom use is not important anymore; HIV is a chronic disease 12. Young people that are HIV positive are stupid, they should have known how to prevent themselves. 13. I always have 100% safe sex. 14. When I go out, I always carry condoms with me. 7 Real life role play: practical exercise Before setting up the role-play, the group brainstorms on how to act to facilitate a good prevention conversation. Think of body language, presentation, looks etc; The trainer notes these different Prevention Manual and Training 52

55 aspects. Then you and the group choose which of the mentioned items remain important. The trainer refers to the basics of interview techniques, see factsheets Skills to talk about sex. The trainer and a data-collector act a role-play. The trainer takes up the role of the data-collector and the data-collector that of the participant. The role-play starts with a scene where everything goes wrong. The data-collector is not respectful, not listening etc. The participant is given a short description of what he should say and how he should react. The role-play is restarted again and the fellow data-collectors may take over and show the right interventions. Description role-play: Situation The participant just finished the survey and is hesitant to leave. It is obvious that he wants to ask something. The data-collector doesn t pick up the signs. The respondent wants to know if he needs to have an STI test and where he should go, without being judged. The datacollector should know at the end of the role play: 1. The exact questions of the participant do I need a test? where can I get an anonymous test? 2. Provide him with the information where to go to for the test. 3. Let the participant leave with a good feeling. The observing group members note for themselves what they should do differently and why. After the first play they are invited to use their notes. During the replay, people can interchange roles. The trainer coordinates this part (besides acting as data-collector in case there is only one trainer). The play D = Data-collector P = participant, visitor of the venue D: Data collector to respondent in a very enthusiastic way: Thank you for your participation, enjoy your evening! P: Takes a few hesitating steps to leave the room, waits a few seconds and returns. D: Looks up a bit surprised and says; Thanks again and bye again in a friendly way. P: Obviously he wants to ask something about the questionnaire. I aaahh, I.aaaah. D: Remains busy arranging his paperwork and says; Oh yes, the questionnaire yeah I have it here, no worries. without looking at the respondent. P: (hesitatingly) I want to ask you a question about the questionnaire.. While I was filling it in I D: Oh yes, I know, It was much too long and it s a bit noisy here as well. The conditions should have been much better; sorry for that! P: No no no, it s just when I was filling it in I got a little worried about my number of dates, I don t remember all my dates anymore, you know, sometimes I drink a bit too much and. D: Ah, don t we all, you know going out is fun! P: Indeed, but I wonder if maybe I ve run a certain risk, you know D: Of course, always go for a test at the Center X in Y street, you know where it is don t you?! While the next person enters: Ah, a new respondent. Bye! Oh, hi handsome! I m so happy you want to participate. Just wait a second till the other gentleman has made some space. Evaluation role-play The participants share their experiences in the role-play: what they experienced (not) being in contact with the other person, what was positive and negative. Also the participants share Prevention Manual and Training 53

56 what they experienced emotionally. The evaluation ends with general conclusions: what did the data-collectors learn? Time indication Preparing role-play: 5 minutes Role-play itself: 10 minutes Replay of the role-play: 30 minutes Evaluation: 10 minutes 8 Evaluation training Finally the evaluation provides you with an overview of your talents and challenges being the datacollector, as well as for your team. The winner of the quiz is announced and the answers are read by the trainer. The trainer refers to the content of the training where possible. The data-collectors are asked to write down: What is the most important thing you have learned during this training? Which important question for you has not been answered during this training? The trainer writes down (e.g. on a blackboard or flip-chart) the replies and discusses possible answers with the group. This evaluation can take about 45 minutes. 3.5 Data collection and prevention activities onsite Prevention activities The data-collection activities are combined with HIV/STI prevention activities. The prevention consists of: Personal interaction Personal interaction makes it possible to adapt the information to the personal needs of the client. When the interaction is appealing, it will be more likely that the client will be motivated by the content and outcome of the interaction. A scratchcard (see annex 2) is offered to a client after having filled in the Sialon II survey. The scratchcard may contain a question on sex behaviour, test behaviour, substance use and the transmission of HIV-STI. The data collector reads the question and the possible answers. The client chooses and scratches one answer and then knows if it is the right answer. The data-collector explains the right answer briefly. Distribution of personal interaction supporting materials (see annex 1 and 2) Interactive distribution is a way of being in contact with a client and recruits him as participant. A sachet with condom and lube is handed over, with web-address of the local NGO and the Sialon website for more information about LGBT health and the Sialon project itself (info-packs). Condoms in combination with lube are handed out because they are an effective way to protect against HIV and STI s. Sweets are handed out because they attract people. Passing on an unfolded scratch card with a sexual health quiz question and the barcode card with brief information about health is also a way to increase knowledge and raise awareness. The barcode card: this card provides the participant with his personal code to obtain the test result and one short item of information (sex behaviour, test behaviour, substance use and the transmission of HIV-STI). Prevention Manual and Training 54

57 The project website The project website provides links and up to date info about gay health: after a party night it gives the respondent the possibility to review the information and go to other websites and institutes for help. In this way the prevention activities can be prolonged after the night out Safety rules (see text data collection manual WP5) Monitoring and evaluation The prevalence of HIV and the data received from the questionnaire are to be published at the website The evaluation of and debriefing on the data collection and prevention activities will be done after the data-collection itself or the day after. We refer to the data-collection manual for more specific information on monitoring and evaluation. 3.6 Factsheets Factsheet condoms Condoms are the most effective way to safeguard your sexual health as they provide a very thin barrier that stops sperm, bacteria and viruses getting from one person to another. The benefits of condoms Compared to other products that protect against pregnancy and STIs, condoms are: affordable available everywhere only needed during sex without side effects useable without help of a health worker When it comes to sex either he can put it on himself or his partner can. Here are some tips: Check the condom is not past its expiration date (a condom can be kept for five years if stored correctly; the date is printed on the wrapper). Take care not to rip the condom (e.g. with your teeth) when taking it from its wrapper. To be sure you have the condom the right way up, place it over your finger tip. If you can t roll it down, you need to turn it over before putting it on. The penis must be fully erect before the condom goes on; if not, it s more likely to come off (1.). Try not to stretch or unroll the condom before it goes on as this can weaken it. If the condom has a teat at the tip, squeeze the air out of it. Make sure no air or lubricant is trapped under the condom. Roll the condom all the way down to the base of the penis (otherwise it s more likely to come off). Grip the base of the penis to help it stay hard (2.). Prevention Manual and Training 55

58 If the condom gets stuck, roll back up a bit and try again. If lubrication is needed (e.g. for anal sex), apply water-based or silicone-based lube to the condom once it s on. Don t use oil-based lubes they can make a condom split. Hand cream, oils from the kitchen, massage oils, Vaseline, hair and bath products are all oil-based. Don t use spit as this also weakens the condom. Be sure to use water-based or silicone-based lube (3.). A condom is more likely to split if sex lasts over 30 minutes: check it from time to time and after half an hour change it for a new one. After the man has ejaculated, he should grip the base of his penis before pulling out of his partner to ensure the condom doesn t come off inside him. Put used condoms in a bin, not the toilet as they can block it. A condom should never be used more than once. It's worth mentioning that using a femidom and condom together is not recommended - it's more likely to cause either or both to split. Source: Factsheet HIV/STI facts and figures HIV Cause Human Immunodeficiency Virus. Immunodeficiency refers to how this virus weakens a person s immune system, the part of the body that fights off diseases. Some people notice no symptoms when they re first infected with HIV. But within six weeks of infection most people suffer a short illness (lasting around two weeks) as their body reacts to the virus. This involves at least two of the following symptoms: body rash, sore throat or fever. Once this passes an infected person usually feels fine for a number of years. However, unless they start treatment before the virus causes too much damage, as years go by they will usually start to suffer life-threatening illnesses such as cancer, TB and pneumonia. This is because HIV is destroying cells (CD4 or T-cells) that our immune system needs. HIV is usually transmitted in the following ways: Prevention Manual and Training 56

59 An infectious body fluid (such as blood, semen and vaginal or anal secretions*) gets inside another person. This can happen during vaginal, anal and oral sex or when an object (e.g. a sex toy) that has bodily fluid on it, goes from one person to another. When inside the body, the virus, present in the fluid, can enter the blood stream of the host. The virus entering the body via anal and vaginal sex is much more likely than via oral sex. HIV can also be passed on if drug users share injecting equipment (needles, syringes, swabs, spoons and other items) that has been used by someone with HIV. Although HIV could be passed on any time during unprotected sex with an infected person happens, it doesn t get passed on every time. These matters make HIV more likely to be transmitted: High viral load (the amount of HIV in someone s blood and other body fluids) it s very high in the first weeks or months after someone is infected. Taking HIV drugs will lower viral load considerably. If either partner has a sexually transmitted infection (they make it easier for HIV to leave one body and enter another). The type of exposure to the virus: anal sex is higher risk than vaginal sex, both are higher risk than oral sex. Sharing drug injecting equipment is higher risk than all of them. Source; Symptoms per stage 1. Primary infection; no complaints to flu 2. Chronicle stage: no complaints to fatigue 3. AIDS (Acquired Immuno-Deficiency Syndrome): low resistance, opportunistic infections; 1. Herpes 2. Fungal infection 3. Pulmonary diseases PCP 4. Cancer (Carposi) 5. Chronicle diarrhea Development: Treatment A combination of drugs can keep HIV under control by stopping it from reproducing itself. The goal is to keep levels of HIV so low that in tests they are undetectable ( undetectable doesn t mean HIV is not there, just that the level is too low for tests to pick up). The lower the amount of HIV, the better for someone s health (it also means they are less infectious). But the drugs are not a cure for HIV because they cannot completely rid the body of the virus as it lives on in parts of the body that drugs can t reach. For this reason lifelong treatment is needed. Thanks to HIV treatment doctors now see the infection as something that people can live very well with for a life time. This is especially true if they are diagnosed in good time and start medication (before the virus does too much damage to their immune system). In that case a person can expect Prevention Manual and Training 57

60 to live more or less as long as someone who doesn t have HIV. Thanks to medication, HIV-related illnesses and deaths have dropped dramatically. When to start treatment Someone tested HIV positive may not need treatment straight away. It may be several years before medication is necessary but sooner or later most people need to start treatment. Doctors monitor the level of a person s CD4 cells (blood cells which help the body fight off disease but are attacked by HIV). Once the level of CD4 cells drops below a certain point, treatment is strongly advised. Treatment is working well if tests show someone has a high number of CD4 cells and a low level of HIV in their body. Adherence People take far fewer pills now than in the past, sometimes just one or two a day. However many pills are needed, once treatment starts they must be taken every day. Sticking to the daily dose is called adherence and good adherence is vital if treatment is to work. If even just a few doses are missed, levels of drugs in the body fall, allowing HIV to develop resistance to them, meaning they stop working as they should. That s why it s so important that the pills are taken every day and on time; the drugs need to be taken as instructed at least 95 per cent of the time. If a dose is missed take another as soon as you remember. But repeatedly missing doses risks your treatment to fail and the need to switch to a different drug. Side effects HIV drugs have become more effective and easier to take. Earlier problems with side effects (such as visible changes to the face and body) are less present. People may experience side effects during the first weeks of treatment (eg, headache, diarrhea, or feeling sick or tired) but once your body gets used to the drugs these should improve or go away. Prognosis Chronic disease, normal life expectancy. Side effect on long term not known yet. Possible threats: Stigma Fatigue of medication Affected liver and kidney functions Increased chance of (viral) disorders Faster getting older Mental problems Long term prognosis unclear Prevalence The outcomes of Sialon I show alarming findings concerning undiagnosed HIV infections. Over half the respondents were unaware of their HIV positive status. This proportion was slightly lower in Barcelona but very high in some Eastern-European cities (nearly 80% in Ljubljana and Bucharest). Moreover, nearly one third of the MSM, found to be HIV-positive through oral fluid samples, reported a negative HIV test result over the last 12 months, so the undiagnosed infections were recent. Chlamydia Cause: Chlamydia trachomatis (bacterium) Transmission Chlamydia is spread during oral or anal sex without condoms. It can also spread on fingers when you touch an infected part of the body and then touch other parts of your or someone else s body. Complaints: Symptoms might show within one to three weeks of infection, but around half of men and most women have no symptoms. Chlamydia in the penis can cause a whitish discharge and a burning feeling, especially when urinating. Prevention Manual and Training 58

61 Irritation of the anus Ascending infections, possibly causing infertility When One till three weeks after contact. Test and treatment There is a urine test for chlamydia, or a sample can be taken from the infected part of your body using a swab. Chlamydia is treated with antibiotics. LGV Cause Type of Chlamydia trachomatis (bacterium) Transmission LGV bacterium usually enters the body through the delicate, moist skin of the rectum and penis. Gay and bisexual men have contracted LGV from having anal sex without condoms and from 'fisting' - when a hand is inserted into a partner's rectum. The bacteria can also be carried from one rectum to another during group sex, on objects such as sex toys, fingers, enema equipment, condoms or latex gloves. Cover anything which is moved from one rectum to another with a fresh condom or fresh latex glove for each new person it enters, or clean it with warm water and anti-bacterial soap. Enema equipment should not be shared. Complaints: Important: A small sore might appear where the bacteria got into the body but most people don t get or notice one. Left untreated LGV can cause lasting damage in the rectum that may require surgery. Local ulcer Severe inflammation of the anus with secretion (blood, pus) Constipation Formation of fistula Severe inflammation of lymph nodes, especially in groin Fever LGV in the penis may cause a discharge and pain when urinating LGV in the mouth or throat is rare but it can cause swollen glands in the neck When A few days after infection. Test and treatment If you re a gay or bisexual man with possible LGV symptoms, a sexual health clinic will use a swab (a small cotton bud) to take a sample from your rectum and penis. This is initially tested for Chlamydia. If it tests positive it is then also tested for LGV. Antibiotics cure LGV with no lasting effects, as long as the infection is treated early enough. Gonorrhea Cause Neisseria gonorrhea (bacterium) Complaints: Green/yellow secretion out of penis, urethritis Secretion from the anus Throat complaints (irritation, pain) Irritation, especially when urinating When Symptoms in men usually show within 10 days. Test and treatment Prevention Manual and Training 59

62 There is a urine test for gonorrhoea, or a sample is taken from the infected part of your body using a swab. Gonorrhea is treated with antibiotics (be aware: there could be problems with resistant strains). Syphilis Cause Spirochete Treponema pallidum (bacterium) Transmission Syphilis bacterium spread during unprotected oral, vaginal or anal sex through contact with the sores of the first stage or the rash of the second stage. Unless this is treated, a person can pass on syphilis for up to two years. Complaints; 3 stages: First stage (primary syphilis) two to four weeks after becoming infected a painless sore ( chancre ) may appear on the penis, in the mouth, rectum or vagina. This heals over. Glands near the sore may swell. Second stage (secondary syphilis) a few weeks or months later you may get a rash on your body, often on palms of hands or soles of feet. You may feel ill, with a fever or headache, get ulcers, grey patches or growths of skin on or around your mouth or genitals. Hepatitis A Third or late stage (tertiary syphilis) years later, syphilis can seriously damage your heart, brain and nervous system. The infection is usually detected by then. Test and treatment There is a blood test for syphilis, and if you have a sore the fluid inside it will also be tested. Penicillin, given by intramuscular of intravenous injection. Cause Hepatitis A virus Transmission Someone with hepatitis A is most infectious two weeks before the symptoms appear. The virus lives in faeces and minute traces of it carry the infection on the hands or on food prepared by an infected person. Water can also be contaminated, especially abroad. The virus needs to get into the mouth to infect someone. This can happen during sex when tiny amounts of faeces get on fingers and into mouths through: rimming fingering anal sex without condoms handling used condoms and sex toys that have not been cleaned since previous use by someone else. Prevent Vaccination. Complaints A wide range from no complaints to fatigue, listlessness, inflammation of the liver, jaundice, vomiting, dark skin and pale faeces. When Hepatitis A symptoms can be so mild you may not realise you have it, but up to six weeks after infection it can cause mild flu-like symptoms. Test and treatment A blood test will confirm whether you have been infected with the virus. Rest is the usual treatment for hepatitis A. You may need several weeks off work and will be advised to avoid alcohol until your liver recovers. Smokers often avoid smoking as it can make them feel sick. Recreational drugs should Prevention Manual and Training 60

63 be avoided to allow the liver to recover. Once you have had the infection you will be immune, but you can get infected with other types of hepatitis. Hepatitis B Cause Hepatitis B virus (HBV) Transmission You are most infectious to others in the two weeks prior to symptoms. The virus can be passed on in these body fluids: blood, semen, pre-cum, and vaginal secretions. It is passed on through oral anal sex without a condom or rimming. Prevent Vaccination Complaints A wide range from no complaints to fatigue, listlessness, inflammation of the liver, jaundice, vomiting, dark skin and pale faeces. Symptoms can last several weeks, taking months to get back to normal. Most people make a full recovery but up to 1 in 10 become carriers with chronic infection. They feel fine but stay infectious to others, with a small risk of developing liver disease. When Two to six months after contact. Treatment Sometimes spontaneous clearance Rest (acute stage) Treatment (chronic stage- peg interferon, nucleosiden) without guarantee of success Hepatitis C Cause Hepatitis C virus (HCV) Transmission The hepatitis C virus is found in blood and is passed on when infected blood gets into another person s blood stream. It is seen as unlikely (but not impossible) that the virus could be passed on in semen. Complaints Wide range from no complaints to fatigue, listlessness, inflammation of the liver, jaundice, vomiting, dark skin and pale faeces. Symptoms can last several weeks, taking months to get back to normal. Most people make a full recovery but up to 1 in 10 become carriers with chronic infection. They feel fine but stay infectious to others, with a small risk of developing liver disease. Severe liver damage on the long term, unpredictable progress. When From several weeks after risk behaviour, especially in combination with (existing) HIV transmission. Treatment Possible spontaneous clearance by resting, treatment (peg interferon, ribavirine) without guarantee of success. Treatment could last for six months and involves tablets and injections into the stomach. Avoiding alcohol and recreational drugs is advised. Sources : Loek Elsenburg, hiv-consulent VU Hospital Amsterdam, presentation update hiv and soa barmantraining Schorer, Amsterdam 2011 Amsterdam and Prevention Manual and Training 61

64 Factsheet PEP and PrEP: explanation, counter-effects, who has to take it? PEP Explanation PEP (Post Exposure Profylaxis) is a one month lasting treatment of HIV-inhibitors to prevent the HIVvirus to implant itself in the body after having been at risk for HIV transmission. PEP should be started as soon as possible, preferably within two hours, at the very latest within 72 hours after having had unprotected sex. The earlier you start, the bigger the chances of success. Counter effect It is very likely that PEP prevents you to become HIV positive. A PEP treatment is considered as severe in most cases, because of the counter effect and the emotions of becoming aware of the personal possible consequences after having had unsafe sex. Who has to take it Not everybody who had unsafe sex behaviour needs PEP. It depends on plural factors; Sexual technique: for example; having undergone passive anal penetration is more risky than being the active partner. The serostatus of the partner: being positive or negative. The presence of little wounds on anus or penis. Violent behaviour during sex, which increases the risk of wounds. If possible: both partners should take rapid HIV testing. If one partner is negative (and the other didn t have other unsafe sexual encounters in the last 72 hours) it saves him from taking treatment for a month. PrEP Explanation PrEP(Pre-Exposure Prophylaxis) is an HIV-inhibitor treatment for HIV-negative people to prevent them from becoming HIV-positive. The outcomes of PrEP -trials are very fluctuant. Some trials show an effectiveness of 73%, others studies show no effect. In this matter, therapy adherence is decisive. The PrEP trials didn t investigate the effectiveness of PrEP apart from condoms, but in addition to (not always consequent) condom use. The present result of research is based on continually used PrEP-pills (brand name; Truvada). There is no information of the effectiveness of intermittent use of Prep (some days before and after unprotected sex). Therefore intermittent use is strongly discouraged. Different treatments PrEP is available in different treatments. It can be found as pills and as vaginal gels. Anal gels are in research. Danger: possible resistance Truvada is not considered as a full combination therapy. Therefore, it is very important that people who use PrEP are HIV-negative. If users of Truvada are positive without knowing and not on ART there is a big chance the virus will become resistant to the HIV-inhibitors in Truvada. Because of this danger, it is important to be tested on HIV on a regular base. It is possible that PrEP failed to do its job, and that the person has become HIV-positive. Also the counter effects on Truvada need to be explored. Who has to take it? PrEP is used supplementary to and not replacing condoms. Condoms are very effective to prevent the transmission of HIV. PrEP can be used by men who have many sex partners or serodiscordant couples. Concerning the latter, it is more effective to treat the HIV-positive partner than to use PrEP. If the positive partner uses HIV-medication; PrEP-use is not necessary, according the European Medicines Agency: Prevention Manual and Training 62

65 Factsheet behaviour The results of Sialon I show that 2 out of 10 respondents reported Unprotected Anal Intercourse (UAI) the last time they had sex with a casual partner while 4 out of 10 reported having had UAI during the last six months. Almost 2 out of 10 participants) reported Receptive Unprotected Oral Intercourse (RUOI) during the last encounter with a casual partner, whilst 3 out of 10 reported RUOI during the last six months with casual partners. Young people under 25 had riskier behaviour than men over 25. Drug use is an important factor in risk increasing behaviour. For information about sexual behavior among MSM in your own country, visit the EMIS website: Testing behaviour According to the Sialon I quantitative report, 92.7% of participants of the overall sample knew where to go to have an HIV test. E.g.: 97.2% of participants of Ljubljana knew the test site(s) and 86.9% the test site(s) in Bucharest (the highest and the lowest percentages). HIV testing during the last 12 months Almost half of the participants (49.9%) of the overall sample had been tested in the last 12months. In order to monitor HIV testing uptake, UNGASS indicator number eight was used. This indicator comprises of the percentage of MSM tested for HIV over the last 12months, who also collected their results. Fig.7 presents the UNGASS 8 indicator estimate percity. Southern European cities had the highest percentage of tested people, who received their HIV test result (56.3% in Barcelona and 53.0% in Verona), while the Eastern European cities had the lowest percentages, ranging from 31.6% in Bratislava to 42.6% in Bucharest. This indicator was higher for people of 25 years of age (46.5%) than for people < 25 (38.4%), showing that people <25 tend to be tested less, although this is not confirmed when processing data for individual cities. Type of sexual act and the risks besides the pleasure Besides using a condom during anal sex with or without ejaculation, or oral sex with ejaculation there are other ways to be intimate without running the risk to get HIV. Having sex though, means you can get an STI, even if you protect. Below you find a list of several techniques and their risks on becoming infected with HIV or STI and what you can do to prevent transmission (as much as possible). Kissing and French kissing : Herpes and Hepatitis B. Cuddling and caressing: Scabies. Masturbating each other (jerk off- to finger): only risky when there is contact between sperm and mucous (gland, anus) Anal sex (penis inserting anus): condom use protects against HIV, Chlamydia, Gonorrhea and Hepatitis B and reduces the chance to other STI. Anal sex in combination with toys holds more risk the bigger the toy is and depends on the construction of the toy itself. Using a condom around the toy and avoiding to share the toy, gives protection. If fisting is practiced, always use medical gloves and put on new gloves with each partner. Oral sex (mouth penis/anus): less risk behaviour than anal sex unless the mucous in the mouth is damaged. A condom or dam protects completely against HIV, Chlamydia, Gonorrhea and Hepatitis B. Golden shower and scat: only risk behaviour for Hepatitis A. When blood is present also holds risk for Hepatitis C and HIV. Translated from Prevention Manual and Training 63

66 Factsheet Substance Use Definition of drugs Drugs are substances influencing the normal way of functioning of the central nervous system and are consumed for that specific reason. The influencing is sought by the user and there is no medical purpose to use that drug. Drug use and HIV-medication HIV-medication, alcohol and drugs may influence each other. The effect of HIV medication can be weakened or strengthened. Both can lead to complications and resistance of the HIV-virus against the medication. Because there is a wide range of HIV-treatments, there is still a lot of work to be done, before we know what the effects are on the specific combinations. Moreover, drugs are (partly) illegal, which complicates the investigation. Besides the effects in the body, alcohol and drug use can influence the regimen of treatment. When you are stoned, you could forget the time, and because of that, miss a dose of treatment. Categories according to effects: Anesthesia (downers); diminishes conscience and body functions. Relaxes the person, diminishes fear, tempers heartbeat and breath, relaxes muscles en diminution of senses. Could have an effect on decision making about having sex: less fear of the possible dangers of unsafe sex, more dilatation possible of the anus: more risk behaviour and les awareness of pain. Less resistance, mentally and physically to do things you wouldn t do in a clear state of mind. Stimulants (uppers); Could increase arousal of consciousness, and decrease hunger and fatigue. Provide an energetic, alert en cheerful mood. Increases self-confidence and concentration. Accelerates heartbeat and breathing. Could have an effect on decision making about having sex: More risks are taken as the person considers himself not harmful, exhausted, focused on sexuality. Acting happy without really being happy, signals agreement to behaviour you could possibly regret afterwards. Hallucination (trippers); Change the perception of the environment around someone. Accelerates heartbeat and increases blood pressure. Could have an effect on decision making about having sex: as the deviant perception of everything keeps this person from taking reasonable decisions. It gives you the feeling that everything around you is love and good. Examples of drugs of each category; Anesthesia Stimulating Hallucinating Alcohol Tabacco Cannabis (both stimulating and hallucinating) Sleeping pills, tranquillizers Caffeine Some species of cactus GHB/GBL XTC (both stimulating and hallucinating) Opiate (morphine, heroine, Coke, crack Mushrooms methadone). Volatiles (poppers) Speed Drugs and body Drugs do their job in the brain. By influencing the transmission of stimuli they sort their effect. The brains send information to your body to react, e.g. widen pupils or faster heartbeat. Therefore drugs causes physical consequences concerning safer sex as well. For example XTC causes less rectal fluids. When having anal sex after having taken XTC, more lube is needed. Depending on the way of taking the drug, someone can possibly damage the mucous in throat, nose or rectum, damage to lungs or skin. This gives easy access to the blood system for bacteria and viruses. Besides damage to the actual surface where the drug is taken, drugs can also have the effect of sedating pain and arousing lust, with the possible effect when practicing anal interceptive sex to Prevention Manual and Training 64

67 not feel pain; A possible consequence can be ruptures of rectal veins or of the intestine itself, without noticing (in time). Party drugs in general make someone willing to dance all night, with the possible effect of not feeling the fatigue or thirst of the body. Exhaustion and dehydration are a possible result. Drugs like alcohol, XTC and cocaine have dehydration as effect. Because of sweating due to restless behaviour and urinating more (the effect of alcohol) your body dehydrates. The result is less mucous. Less mucous means more friction and therefor potentially more (little) ruptures whilst having oral or anal sex. Description of popular party drug, mental and physical effects and relation to HIV and STI transmission Poppers Poppers are sold in small bottles, containing a liquid. In earlier days these were sold in capsules, which, on opening, made a popping noise. Poppers are very comustible, evaporate quickly, have a strong and for most people unpleasant smell. Poppers are very irritating to the skin. Application Nasal inhaling via the liquid dipped on a tissue or directly from bottle. Effects After 10 seconds a 1-2 minutes lasting feeling of being high. Relaxation of the sphincter. It gives a boost to sexual experience and gives a stronger erection. On the contrary it can also, because of the dilating effect on blood vessels, cause a dizzy or fainting feeling, as well as diminished erection. The heart has to make more effort to circulate the blood. Strong headache. Risks Low risk, when sporadically used. Frequent use can lead to brain damage because of damaged vessels and visual problems, due to high pressure behind the eyeball. Studies have shown that using poppers, when being penetrated without a condom, increase the risk of HIV transmission. This may be caused by the opening of blood vessels in the lining of the anus, making this lining more susceptible to bleeding during anal sex. It is also more likely that rough sex will be performed, which will cause the anus to bleed. Poppers may have the effect of weakening the immune system temporarily, leaving someone more vulnerable to become infected with HIV. Poppers in combination with Viagra Poppers contain nitrates. Nitrates have the same effect on blood pressure as Viagra. Combined use can lead to extreme low blood pressure, cerebral vascular accident, heart attack and death. Poppers in combination with XTC/Speed Extreme effect on the vascular system. Cocaine Cocaine is a powerful stimulant, (it speeds the body up), it is the white powder, from ground leaves of the South American coca shrub. It's usually mixed or cut with things like sugars, talc, baking soda, painkillers, toxins or amphetamine. Application The most common way of using cocaine (coke) is sniffing. Passing the nasal mucous is takes 3 minutes to reach the brains. The effect lasts minutes. Other ways of use are injecting and smoking, which is hardly ever seen in the party scene. Effects Prevention Manual and Training 65

68 Cocaine gives energy and self-assurance. Contacting others is easy, creativity flows and thinking is easier. It can even give an euphoric feeling. Suppresses hunger. Low doses can stimulate erotically. Risks Cocaine is often mixed with other substances. Because you don t know the exact mix, you don t know the exact consequences. The upper effect can lead to exhaustion. In combination with a suppressed hunger feeling, it leads to weight loss and less immunity against diseases. The effects on the vascular system could lead to heart problems and cerebral vascular accidents. Long term effects could be loss of smell and decreased libido. Cocaine combined with alcohol The use of alcohol and cocaine can diminish the feeling of drunkenness, which makes people think they can drive, whereas in reality they are too intoxicated to do so. The combination of alcohol and cocaine results in coca-ethylene which can cause extra damage to the liver. Cocaine combined with XTC This can more likely cause dehydration and overheating, which can lead to a diminution of memory, concentration and mood. Cocaine combined with cannabis This causes a higher risk of mental effects like fear and being restless MDMA MDMA is the substance which gives XTC its stimulating and hallucinating effect. Application XTC can be used in the form of pills or powder. Powder can be licked or swallowed in tobacco paper as bombs. The exact mix is never clear, neither are the effects. Effects The first effects of MDMA show 20 till 60 minutes after having taken the substance. Tingly feeling, glow, love feeling. Quickly, these feelings become stronger, what results in the hitting in feeling. This feeling last for about five minutes. After 2 hours the effects decrease and after 4-6 hours the effects fade away. Taking an new dose to relive the strong first effect is of no use, it won t give the same effect again. On the contrary, it reinforces the counter effects of a dry mouth, muscle tension and teeth grinding, which can cause damage to your teeth. Other effects of XTC are feeling strongly attached to others, need for talking, intimacy, hugging (hug drug), urge to dance, be more alert. On the other hand it gives trouble to focus and concentrate and it can even lead to fear and being confused and short memory. Physical effects are fast eye movement, widened pupils, difficulty to urinate, higher body temperature and difficulty to sleep. Risks Hyperthermia, brain damage because of drinking too much water, damage to liver, mental illness. Cannabis Cannabis (hash and weed) is made from the leaves of a plant, the Cannabis sativa. Application Hash and weed can be smoked, eaten (space cake), drunk (tea) of vaporised. Effects In general the use of hash and weed gives relaxation. It increases creativity and thoughts pop-up easily. Sometimes it can give a restless feeling or it can cause fear or uncontrollable laughing. Well known is the urge to eat sweet things, indolence, red eyes, dry mouth, tension, low blood pressure. Effects depend very much on the moment and on your state of mind; it can cause damage to lungs. Amphetamine Prevention Manual and Training 66

69 Amphetamine (Speed) is a chemical substance with a stimulating effect. It is available in powder form or pills. Application Speed can be sniffed or swallowed as a bomb or pill. Effects Amphetamine stimulates breathing; heartbeat, blood pressure and body temperature. It gives an energetic feeling. Talking goes easy and quickly. Pupils are dilated, a dry mouth because of less saliva, increased urinating and grinding of the teeth due to high muscle tension in the cheek. Viagra Viagra is a prescription drug, treating erectile dysfunction. Application Viagra is available in pills. Effect Viagra increases the erection while being sexually aroused. It makes the erection harder and longer lasting. It also makes it possible to ejaculate more often in a longer time. It also may have the effect of less sensibility in the penis with the effect of having difficulties to ejaculate. Viagra can be taken as a counter treatment of erection loss due to other drugs. Risks Poppers contains nitrates. Nitrates have the same effect on blood pressure as Viagra. Combined use with Viagra can lead to extreme low blood pressure, cerebral vascular accident, heart attack en death. Factsheet skills to talk about sex Starting to talk about using condoms is not always easy. For instance, it could interrupt the aroused atmosphere or your partner could turn you down while you like him so much. Nevertheless, condom use remains a cheap and safe way to have safe sex and, when properly used, contributes to HIV/STI prevention. As a data-collector, at the evening of HIV-screening you communicate with at least three different types of people; your screening-team members, the staff and the visitors. The choice of words, the tone of voice and physiology (body language) you choose, need to be adapted to the language used by the people you speak with. Accepted and commonly used aspects of verbal and non-verbal communication are different, depending on the (sub-) culture you are in. Nevertheless, there are general aspects which facilitate being in contact with others. The following items can help you to make your communication a feel good experience. Verbal aspects: Verbal aspects which can influence the communication between you and the person you are talking with: Speak the language of the person(s) in front of you. The kind of words you use depends on your social background, education or state of mind of the moment. Try to use the words the other person feels comfortable with. Check if the other person understood you, or speak out if you have not understood the other person. Pre-suppositions in language Our daily language is full of pre-suppositions. For example, the questions How expensive was your new shirt presumes that the shirt is expensive. Asking What did your new shirt costs? is a much more neutral way to get to know the price. People could not be aware of the presuppositions they use. As data-collector, using presuppositions, could lead to social desirable answers. Saying: you use condoms - off course!, makes it more likely the respondent doesn t want to oppose your view, while the question: Do you use condoms?, or even more neutral: Do you use techniques to prevent the transmission of HIV?, could be answered more openly. It is important to leave out presuppositions as much as possible. Honest answers lead to more tailor-made prevention. Prevention Manual and Training 67

70 Space It is important to create space for the visitor to speak out. Instead of asking questions each time, being silent can invite the other person to talk. If the other person remains silent you could try asking open questions. An example of an open question is; How do you like it in here? Open questions usually start with: a. Who? b. Why? c. When? d. Where? e. Which? f. How? If your main goal is to gather specific information you can use yes or no questions. An example of a yes or no question is: Do you have to pay money to visit the toilet? Volume Volume is an instrument you can use in many ways. Speak out loud, shouting or whispering are methods to emphasise what you mean. As a data-collector, a loud voice in prevention activities could be very intimidating. Speaking softly to a respondent could be not very appropriate in a venue, because of the noises around you, like music, footsteps, or machines. Screaming: You don t use condoms!!!!!!!!???????? may lead to a different interpretation (e.g. intimidating) than whispering You don t use condoms? (e.g. shame) Most of the time a neutral tonality leads to an open conversation. Nevertheless, whether you speak normal, shout or whisper, interpretation is always personal. Some people are not intimidated by shouting or feel attracted when you speak in a neutral voice. Intonation Intonation can make the difference to let people listen to you or not. Although a question can be highly intelligent or super relevant, spoken out on a monotone manner, no accents at all, has as result that people lose their attention. On the contrary, messages, which perhaps are less intelligent or irrelevant, but spoken out in an enthusiastic way, keep the attention. Speaking in positive words Talking to somebody in positive words motivate. Speaking in negative words demotivate. I appreciate you having bought condoms after your unprotected encounter sounds different than You better should have thought of buying these condoms before your last encounter. Positive attitude In general to get into contact with potential respondents, will be more successful if you approach them, standing straight up, in eye contact and with a smile. There are gay venues were people come for sex in an anonymous way where this open attitude is not always appropriate. Experience learns though, that even in these kinds of venues, this approach works for the majority of visitors. Looks Being a data-collector you may be asked to use the dress code of that night in that specific venue. Sportswear at a sportswear party, rubber at a rubber party etc. Check in advance with the coordinator and staff what would be necessary and what would be possible. Helpful links and addresses Links of websites and addresses of local organisations promoting (gay) health and wellbeing. Per country (see Sialon II project website : Prevention Manual and Training 68

71 Annex 1 : Info/prevention package (example lay-out and text) Prevention Manual and Training 69

72 Prevention Manual and Training 70

73 Sialon infopack text : translation document Anal sex without a condom is the most risky practice for both you and your partner, even before or without ejaculation, due to possible micro lesions in the rectum and/or on the penis. For anal sex always use water-based or silicon-based lubes. Do not use oil based lubes like salve, lotion or baby-oil because this may damage the condom. The overall objective of the SIALON II project is to obtain reliable and valid information on HIV prevalence, risky behaviour and cultural factors among MSM (men who have sex with men), combining targeted prevention with a meaningful surveillance system in Europe. The whole project has been developed in collaboration with local gay associations in Belgium, Bulgaria, Germany, Italy, Slovak Republic, Spain, Lithuania, Poland, Portugal, Slovenia, Sweden, Romania, UK. This info-pack, with its content, has been conceived by the gay associations of all participating countries and is being distributed within a European prevention campaign. People can have HIV without any (or major) symptoms and some don t know they have HIV. Even if they know, it could be difficult for them to tell you. Protect yourself: use a condom and get tested! Always keep a condom with you! To maintain condom strength, store it in a cool, dry place. Do not use after the expiry date written on the condom package. Unroll the condom directly on the penis. Never re-use a condom. To disperse any trapped air, pinch the nipple of the condom and simultaneously roll the condom down the shaft of the penis. Prevention Manual and Training 71

74 Annex 2 : Scratchcards and barcodecards (on flip side) Prevention Manual and Training 72

75 Prevention Manual and Training 73

76 Prevention Manual and Training 74