HIV prevalence and risk behaviors amongst men who have sex with. men in Hong Kong: a systematic review. (Ref. No.: R05-12)

Transcription

1 HIV prevalence and risk behaviors amongst men who have sex with men in Hong Kong: a systematic review (Ref. No.: R05-12) (Report for CUHK I CARE Program ) Jinghua LI Ph.D. Student School of Public Health and Primary Care

2 HIV prevalence and risk behaviors amongst men who have sex with men in Hong Kong: a systematic review INTRODUCTION The HIV/AIDS epidemic in Hong Kong is still in a concentrated phase, which is similar to the situation in the mainland, with the highest prevalence rates found amongst injecting drug users (IDU), men who have sex with men (MSM) and female sex workers (FSW). Especially, attentions should be given to the high-risk population of MSM, which accounted for over 40% of the newly reported HIV infections in 2011 (1). It is projected that the number of reported HIV cases that are accountable by MSM will continue to increase gradually in Hong Kong (2). Homosexual contact has been identified as an important route of HIV transmission nearly 30 years ago. In the past decade, emerging and increasing HIV epidemics among MSM has been reported in both developed and developing countries (3-6). It was estimated that there were over 96,000 MSM in Hong Kong in the year of Among them, 42,000 were active MSM (had sex with another men in the last six months) and 10,000 were MSM with recent anal sex (2). The findings of the 2010 Asia Internet MSM Sex Survey (AIMSS) have shown that approximately 6% of the MSM also had sex with their female partners in the past 6 months, which might be a potential bridge of transmitting HIV from the high-risk group to the general population. Many researchers suggested that the high rates of HIV prevalence among MSM were due to their high risk behaviors, such as unprotected sex, group sex, and multiple sexual

3 partners. Low HIV testing rates among this at-risk population is another concern. Knowing one s HIV status and combined counseling have been proved to be associated with decreases in high-risk sexual activities (7). Rapidly rising prevalence rates of HIV among MSM in Hong Kong have drawn concerns from the government and the researchers. Although many epidemiological and behavioral studies have been conducted amongst MSM in Hong Kong, to our knowledge, there is no comprehensive and systematic review on these researches. OBJECTIVES AND SYGNIFICANCES With our concerns about the increasing HIV epidemic among MSM in Hong Kong, the present study intends: 1) to investigate the prevalence rates of HIV amongst MSM and 2) to identify the significantly associated risk behaviors, by reviewing and analyzing previous published studies conducted in Hong Kong. There is no comprehensive and systematic review of researches on MSM and risk factors for HIV in Hong Kong. As the HIV epidemic continues to disproportionately affect MSM in Hong Kong, understanding the evaluated HIV epidemiological situation and the significant risk factors are essential for the researchers and other stakeholders to develop effective and cost-effective interventions and programs to control and eliminate HIV infections among this high-risk group. METHOD Search strategy

4 Systematic literature review was used for this study. Previous studies exploring HIV prevalence and risk behaviors among MSM in Hong Kong were identified by searching both electronic databases (PubMed and MEDLINE) and government and international institutes databases (department of health, UNAIDS) from 01 January 1980 onwards. The following key words were used as keywords when we conducted database searches: HIV, men who have sex with men, and Hong Kong. Inclusion and exclusion criteria Inclusion criteria includes: 1) studies investigating HIV prevalence and/or risk behavior among MSM groups (including homosexual, bisexual, male sex workers and transgender women) in Hong Kong; 2) reported in English; and 3) published in peer-reviewed journals or commissioned by the government of Hong Kong and/or international organizations, e.g. UNAIDS and WHO. Studies with a sample size of less than 50, selfreported HIV status rather than serologic testing, were excluded (3). Data extraction The following characteristics will be extracted from each included study: Study details: 1) first author and year of publication; 2) year in which study was conducted; 3) study design and study site; 4) sampling size and age range of participants; and 5) sampling methods; Outcome details: 1) rates of HIV prevalence; 2) reported risk behaviors (e.g. number of sexual partners, unprotected anal intercourse); and 3) outcome measures.

5 RESULTS Study selection process Figure 1 shows the process of the study selection and the reasons for excluding studies. Original searches resulted in 29 studies that were examined for potential relevance to this review, including 17 studies from electronic database and 12 reports from government database. By reading titles and abstracts, 8 citations were judged irrelevant to this review. The full texts of the remaining 21 articles that were potentially eligible to be included were retrieved and examined. By careful and thorough reading, a number of 12 articles did not meet the inclusion criteria, including one study that had a sample size less than 50; one study that analyzed the same dataset used in another included study; one study that recruited Hong Kong MSM who seek sex partner in Shenzhen from the venues located in Shenzhen; and nine studies that present the same results included in another included government report. Therefore, a total of nine eligible articles were included in the final review, and the data interested were extracted. All included studies were conducted after the year of Table 1 shows characteristics and outcomes interested of the studies included in this review. HIV prevalence among MSM One major source to estimate HIV prevalence in MSM was AIDS Concern s voluntary HIV testing service among MSM, although the data was largely affected by participant bias. Since 2001, a rising pattern in HIV prevalence has been observed among MSM who attended AIDS Concern s HIV voluntary counseling and testing services, from 0.93% in 2001 to 2.11% in 2010 (8). The 2010 Asia internet MSM Sex Survey (AIMSS) and the

6 three rounds of HIV Prevalence and Risk Behavioural Survey of Men who have sex with men (PRiSM) have reported higher HIV prevalence among Hong Kong MSM, compared to AIDS Concern s results. Three community-based PRiSM s conducted in 2006, 2008 and 2011 have revealed a relatively stable HIV prevalence of around 4% among MSM in Hong Kong (9-11). The 2010 internet-based AIMSS showed the highest HIV prevalence of 5.46%, which might be biased as the was based on selfreporting data (12). Figure 1 Flow diagram of study selection for the systematic review Search Results Electronic databases (n=17), government report (n=12) Total (N=29) Full text retrieved for potential articles, N=21 Irrelevant citations judged by reading title or abstract, N=8 Studies included in final review, N=9 Ineligible studies by careful reading, N= 12 Articles excluded from systematic review (N=12) for the following reasons: same dataset used in another included study (n=1) clinical trial, and sample size less than 50 (n=1) sample recruited from Shenzhen (n=1) same results presented in another included report (n=9)

7 Condom use among MSM The findings of PRiSM in 2008 and 2011 revealed that consistent condom use rates among MSM with regular sexual partners (RP) and non-regular sexual partners (NRP) have slightly increased from 45% to 52% and from 75% to 80% respectively during the period of (10, 11). There were still 39% of MSM engaged in unprotected anal intercourse (UAI) with either RP or casual sexual partners (CaSP) in the previous six months in 2009, and consistent condom use rate was only 35% for RP in 2010, according the results of AIMSS in 2009 and 2010 (12). Although the situation has been improved since the year of 2000, in which year, according to the study conducted by Lau and his colleagues (13, 14), over 60% of MSM had had UAI in the previous six months, inconsistent condom use was still common (15), especially during anal sex with RP. Number of sexual partners among MSM No difference has been observed in the pattern of having multiple sexual partners among MSM in the past decade. The findings derived from the MSM who attended AIDS Concern s HIV testing services reported that the participants had a median number of one RP, 1.5 commercial sexual partners (CoSP) and 3.5 CaSP in AIMSS 2010 showed that a quarter of MSM had sex with more than five partners in the previous six months, similar to the findings of the study conducted by Lau and his colleagues in 2001 (13). VCT uptake rate among MSM The pattern of a rising VCT uptake rates has been reported in the last decade. In 2001, only around 14% of MSM had had HIV testing in previous six months (13). The

8 percentage of MSM who had tested HIV in previous one year has increased to around 40% in 2008 (15). Other risk behaviors In addition to the aforementioned risk behaviors, AIMSS in 2009 and 2010 have revealed three other risk behaviors for MSM, including low HIV disclosure rate, consumption of drugs and alcohol before or during sex, and engaging in commercial sex works (12): 73% of MSM had never disclosed their HIV status; 13% and 29% consumed drugs and alcohol before or during sex; and 5% were money boys (12).

9 Table 1 Outcomes of HIV and risk behavior studies in Hong Kong through April 2013 Study Year Study design Sample (N) Gu et al, 2011(15) Lau et al, 2002(14) Lau et al, 2002(16) Lau et al, 2003(13) DH, 2007(9) DH, 2009(10) DH, 2012(11) Jul-Oct, 2008 Nov Jan 2000 Nov Jan 2000 Jul-Oct 2001 Dec Jan 2007 Dec Jan 2009 Jul Feb 2012 Cross-sectional 389 None Population based telephone Population based telephone Population based telephone Venue-based Venue-based Venue-based Internet-based 85 None HIV prevalence Condom use Multiple partners Other risk behaviors 29.1% had had UAI with at least one RP; 16.5% had had UAI with at least one NRP in P6M; 66.7% use condom inconsistently during anal sex in P6M. None 85 None None None 283 None 60% had had UAI in P6M; 47.1% had at least one male sex partner in P6M; 29.4% had more than one male sex partner in P6M; 24.7% had 3 or more sex partners in P6M Lifetime and 12-month uptake rates of VCT were 56.5% and 39.4% None % None None None % % % Consistent condom use rates was 45% for RP and 75% for NRP in P6M Consistent condom use rates was 52% for RP and 80% for NRP Consistent condom use rates was 42% for RP and 61% for NRP None None None 15.5% had had a HIV test in P6M 17.7% had successfully found a partner via the Internet in P6M; 13.9% had had HIV testing in P6M; 36% had had HIV testing in previous one year Lifetime and 12-month uptake rates of VCT were 67% and 40% Lifetime and 12-month uptake rates of VCT were 63% and 41%

10 Table 1 continued Study Year Study design Sample (N) HIV prevalence Condom use Multiple partners Other risk behaviors 73% did not disclose; 5% as money boy; 13% and 29% Consistent used drugs and alcohol Jan- condom use rate 25% had sex with more respectively before or Feb, Internet 1, % was 35% in RP; than 5 partners in P6M during sex; 6% with any % in CaSP; Koe, STIs; Lifetime and 12-60% in CoSP 2010(12) month uptake rates of VCT were 57% and 37% DH, 2011(8) 2009 Internet % Prevalence among MSM tested by AC or behavioral among MSM attending ACTS % in 2010; 1.98% in 2009; 1.66% in 2008; 2.26% in 2007; 1.64% in 2006; 2.48% in 2005; 1.81% in 2004; 0.90% in 2003; 0.77% in 2002; 0.93% in 2001; 39% had UAI with either RP or CaSP in P6M 40-60% used condom consistently with any sex partners 32% had sex with more than 5 partners in P6M Median no. of RP, CoSP, and CaSP were: 1, 2, and 3 in 2002; 1, 2.5, and 3 in 2003; 1, 2, and 4 in 2004; 1, 1, and 3 in 2005; 1, 1.5, and 3 in 2006; 1, 1, and 3 in 2007; 1, 2, and 4 in 2008; 1, 3, and 4 in 2009; 1, 1.5, and 3.5 in 2010; 6-month uptake rates of VCT was 30%; 18% used drugs before or during sex in P6M; Remarks: UAI unprotected anal intercourse; RP regular partners; NRP Non-regular partners; CoSP commercial sex partners; CaSP causal sex partners; AC AIDS concern; ACTS AIDS counseling and testing service; VCT voluntary counseling and testing; P6M previous six months None

11 CONCLUSION Although HIV prevalence among the general population in Hong Kong was estimated to remain at less than 0.1%, HIV epidemic among MSM was still increasing and predominantly affected the epidemic in Hong Kong. HIV prevalence among MSM has increased from 0.93% in 2001 to over 4% in The highest HIV prevalence of 5.46% among MSM was derived from the findings of the internet-based AIMSS in After a decade s efforts, VCT uptake rate among MSM has been improved largely and the consistent condom use rate has also increased in Hong Kong. However, the common situation of having multiple sexual partners has not been changed and there are still around 40% of MSM engaging in UAI with either RP or CaSP. In addition to the risk behaviors of having multiple sexual partners, HIV testing and UAI, professionals, governments, non-governmental organizations, and other stakeholders should also give attentions to other risk behaviors identified in this review, including HIV disclosure status, consumption of drugs and alcohol, and commercial sex.

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13 15. Gu J, Lau JT, Tsui H. Psychological factors in association with uptake of voluntary counselling and testing for HIV among men who have sex with men in Hong Kong. Public Health May;125(5): Lau JT, Wong WS. HIV antibody testing among male commercial sex networkers, men who have sex with men and the lower-risk male general population in Hong Kong. AIDS Care Feb;14(1):55-61.