Report - Outreach HIV testing Project in venues frequented by men who have sex with men (MSM) - November 2010 to January 2011 Roy Chan Martin Chio Sean Lim Donovan Lo Introduction This is the fourth consecutive year that the Outreach HIV testing project at MSM venues was carried out. The first project was conducted in November 2007 and followed by November 2008 and November 2009. Each project lasted two and a half months and was conducted by AfA. Objectives For the fourth project, the objectives are: -
To provide a proven and innovative outreach method to increase HIV/AIDS awareness by the provision of free and anonymous HIV testing. To compare HIV prevalence with the project undertaken in 2007, 2008 and 2009. To collect additional data on sexual behaviour and practices.
Method HIV test kit The OraQuick rapid HIV-1/2 test kits were used -
The test kit is for single-use Time required for test completion & test result is 20 minutes
OraQuick test kit
Sample identification and result collection Each participant was given a serial numbered ID card, which had information on: - Interpretation of negative or positive results - Where to go for confirmatory tests, if positive - Telephone number to call for test results and counselling ID card
Serial numbers were printed on stickers and these were stuck on both the test kits and ID cards that were handed out. Participants were given the option to call back after one hour or to collect their result personally by showing their ID card to the volunteers on site. The tests was done anonymously to minimise the fear of stigmatisation and loss of confidentiality, and to maximise uptake. A souvenir collar pin was given to each participant as thanks for taking part in the project. Tests was offered free of charge to all participants. Collar pin
Project Management and Data Collection Before commencing the test, volunteers checked if the participant had already taken part in the project, repeat testing was not allowed. A short survey form was given out to collect basic demographic information such as, Nationality, Age group and Race, as well as additional data on sexual behaviour and practices.
Testing in a bar/club venue
Survey form
Venues 9 MSM saunas and 6 MSM bars/clubs participated. Testing was also offered at 1 MSM event. Project
Approached 9 6 1
Participated 9 6 1
Declined
2010
Venues Saunas Bars/Clubs MSM events
9 8 3
8 8 3
1
2009
Saunas Bars/Clubs MSM events
2008
Saunas Bars/Clubs MSM events
7 5 1
5 4 1
2 1
2007
Saunas Bars/Clubs MSM events
6 5 1
4 4 1
2 1
With increased awareness of HIV/AIDS and the continuity of this project, there was no difficulty in getting the venue proprietors to participate. Results from the individual venues are known only to the project coordinators and relevant AfA officers. Aggregated data is presented here. 2010 Results – Tests done (n=1273) 6 bar/clubs participated Total samples: 487
Date commenced: 05 Nov’10 Date concluded: 30 Jan’11 Made 11 visits
9 saunas participated Total samples: 761
Date commenced: 01 Nov’10 Date concluded: 23 Jan’11 Made 38 visits
1 MSM event Total samples: 25
Held on: 04 Dec ‘10
Figure 1 – Venues (overall) 800 700 600 500 400 300 200 100 0
Bar/Club
Sauna
Event
2007 Study
532
363
65
2008 Study
532
655
38
2009 Study
589
645
43
2010 Study
487
761
25
Figure 2 – Age Group by venue 250
200
150
100
50
0
Club
Sauna
Event
2
3
18-‐25
208
201
26-‐29
106
113
2
30-‐39
126
220
10
40-‐49
37
161
9
50-‐59
5
49
1
>60
2
13
Not a nswered
1
1
<18
3
As in the previous projects, bar/club patrons were younger than those in saunas.
Figure 3 – Race by venue 700 600 500 400 300 200 100 0
Club
Sauna
Event
Chinese
348
576
17
Malay
37
42
2
Indian
24
32
Eurasian
23
9
1
Others
55
102
6
Racial mix was similar in the 2 types of venues.
Figure 4 – Nationality by venue 600 500 400 300 200 100 0
Club
Sauna
Event
Singaporean/PR
370
534
22
Malaysian
48
79
2
Others
69
147
1
Not a nswered
1
Saunas have greater proportion of non-Singaporeans than bars/clubs.
Figure 5 – Age Groups by Year
Percentage (%)
60 50 40 30 20 10 0
<=29
30-‐39
40-‐49
50-‐59
>=60
2007 Age Group
51.77
30.94
14.27
2.81
0.21
2008 Age Group
49.14
31.51
14.37
3.67
0.24
2009 Age Group
50.52
32.24
13.97
2.87
0.4
2010 Age Group
50.2
28.01
16.29
4.33
1.18
The age groups of participants were similar.
Figure 5a – Age Groups 2010
50-‐59 4.33%
>60 1.18%
40-‐49 16.29%
<18 0.39%
18-‐25 32.42% Other 50.20%
26-‐29 17.39% 30-‐39 28.01%
<18
18-‐25
26-‐29
30-‐39
40-‐49
50-‐59
>60
Figure 6 – Race by Year 100 Percentage (%)
80 60 40 20 0
Chinese
Malay
Indian
Others
2007 Race
79.79
7.5
4.38
8.33
2008 Race
77.96
6.61
2.69
11.59
2009 Race
76.19
6.3
3.63
13.88
2010 Race
73.92
6.36
4.4
15.32
Racial distribution was similar.
Figure 6a – Race 2010
Malay, 6.36% Indian, 4.40%
Eurasian, 2.59% Caucasian, 0.39% Australia, 0.08% Filipino, 0.31% Myanmar, 0.16% Thai, 0.31%
Other, 15.32% Others, 11.47% Chinese, 73.92%
Chinese
Malay
Indian
Eurasian
Caucasian
Australia
Filipino
Myanmar
Thai
Others
Figure 7 – Nationality by Year
Percentage (%)
100 80 60 40 20 0
Singaporean
Malaysian
Others
2007 Nationality
76.56
12.29
11.15
2008 Nationality
73.63
10.12
15.59
2009 Nationality
68.74
12.95
18.31
2010 Nationality
72.8
10.14
17.06
Nationality distribution was similar over the years
Figure 8 – Called back for results by Year
Percentage (%)
100 80 60 40 20 0
Same Day
Another Day
Did Not Call
2007 Call Back
68.54
10.21
21.25
2008 Call Back
70.78
12.16
17.06
2009 Call Back
68.36
11.12
20.52
2010 Call Back
76.83
7.78
15.4
In 2010 more clients called back for their results than previous years
Figure 9 – First time testers by Age Group and Year 70 60 50
Percentage (%)
40 30 20 10 0
<30
30-‐39
40-‐49
50-‐59
>60
2007 First Time Tester
64.09
21.62
11.97
2.32
0
2008 First Time Tester
58.98
19.16
13.17
5.99
0
2009 First Time Tester
64.56
20.7
12.98
1.05
0.7
2010 First Time Tester
64.17
16.14
11.81
5.51
2.36
Figure 9a – First time testers by Age group 2010 50-‐59 5.51%
>60 2.36%
<18 0.39%
40-‐49 11.81%
18-‐25 50.79%
Other 64.17%
26-‐29 12.99%
30-‐39 16.14%
<18
18-‐25
26-‐29
30-‐39
40-‐49
50-‐59
>60
Figure 10 – First time testers by Race and Year
Percentage (%)
100 80 60 40 20 0
Chinese
Malay
Indian
Others
2007 First Time
77.22
11.58
6.18
5.02
2008 First Time
78.14
8.68
4.49
6.29
2009 First Time
72.95
11.39
3.56
12.1
2010 First Time
74.61
9.38
6.25
9.77
Figure 10a – First time testers by Race 2010 Malay 9.38% Indian 6.25%
Eurasian 3.13%
Other 9.77%
Others 6.64%
Chinese 74.61%
Chinese
Malay
Indian
Eurasian
Others
Figure 11 – First time testers by Nationality and Year 100
Percentage (%)
80 60 40 20 0
Singaporean
Malaysian
Others
2007 First Time
84.17
10.04
5.79
2008 First Time
82.63
6.89
8.08
2009 First Time
75.09
8.06
16.85
2010 First Time
78.13
10.16
11.72
Figure 12 – Last HIV test by Year
Percentage (%)
50 40 30 20 10 0
First Time
6 months
12 months
> 1yr
2007 Test Done
46.77
17.51
10.94
24.78
2008 Test Done
27.27
37.22
23.84
11.67
2009 Test Done
23.08
28.37
25.24
23.32
2010 Test Done
20.33
36.78
22.64
20.25
In 2010 there were fewer first time testers than in previous years (20.33%) This indicates that more MSM had been tested than previously.
HIV positive 35 participants were tested positive by Oraquick HIV1/2 tests. Overall prevalence of 2.7% (35 positives) - Bars/Clubs: Prevalence 2.7% (13 positives) - Saunas: Prevalence 2.9% (22 positives) - MSM event: no positive
Figure 13 â&#x20AC;&#x201C; Prevalence by Venues 800 700 600 500 400 300 200 100 0 Grand  Total Positive Prevalence
Club
Sauna
Event
487
761
25
13
22
2.7%
2.9%
0.0%
Details of 35 individuals testing HIV positive -
31 individuals had a previous negative HIV test 4 individuals were first time testers 4 individuals attended AfA ATS for confirmatory test (as at time of writing) 2 known HIV+ve came forth for testing (peer pressure)
Figure 14 – HIV-positive by Age Group and Year 20 15 10 5 0
<30
30-‐39
40-‐49
50-‐59
>60
2007 30 HIV +ve
12
12
4
2
0
2008 32 HIV +ve
14
10
4
4
0
2009 21 HIV +ve
11
7
3
0
0
2010 35 HIV +ve
18
9
7
1
0
Figure 14a – HIV-positive by Age Group and Year 60%
Percentage (%)
50% 40% 30% 20% 10% 0%
<30
30-‐39
40-‐49
50-‐59
>60
2007 3 0 HIV +ve
40%
40%
2008 3 2 HIV +ve
44%
31%
13%
7%
0%
13%
13%
2009 2 1 HIV +ve
52%
0%
33%
14%
0%
0%
2010 3 5 HIV +ve
51%
26%
20%
3%
0%
Figure 14b – HIV-positive by Age Group 2009 40-‐49 20.00%
50-‐59 2.86%
18-‐25 22.86%
18-‐25 26-‐29 30-‐39 40-‐49 50-‐59 30-‐39 25.71%
26-‐29 28.57%
Figure 15 – HIV-positive by Race and Year 25 20 15 10 5 0
C hines e
Malay
Indian
O thers
2007 30 HIV + ve
21
5
0
4
2008 32 HIV + ve
23
5
0
4
2009 21 HIV + ve
12
3
0
5
2010 35 HIV + ve
18
7
1
9
Figure 15a – HIV-positive by Race and Year
P erc entag e(% )
80% 60% 40% 20% 0%
C hines e
Malay
Indian
O thers
2007 30 HIV + ve
70%
17%
0%
13%
2008 32 HIV + ve
72%
16%
0%
13%
2009 21 HIV + ve
60%
15%
0%
25%
2010 35 HIV + ve
51%
20%
3%
26%
Figure 16 – HIV-positive by Nationality and Year 25 20 15 10 5 0 S ingaporean
Malays ian
O thers
Not ans wered
2007 30 HIV + ve
21
3
6
0
2008 32 HIV + ve
22
4
6
0
2009 21 HIV + ve
11
2
6
2
2010 35 HIV + ve
20
5
10
0
Figure 16a – HIV-positive by Nationality and Year
P erc entag e(% )
80% 60% 40% 20% 0% S ingaporean Malays ian
Others
Not ans wered
2007 30 HIV + ve
70%
10%
20%
0%
2008 32 HIV + ve
69%
13%
19%
0%
2009 21 HIV + ve
52%
10%
29%
10%
2010 35 HIV + ve
57%
14%
29%
0%
Figure 17 – Overall HIV-positivity by Year 1400
n =12 7 7
n =12 2 5
n =12 7 3
1200 n =9 6 0
1000 800 600
3 . 1%
2.7%
2.6%
400
1. 6 % 200 0
2007
2008
2009
2010
Ov erall MS M t ested
960
1225
1277
1273
% H IV+v e a mong MS M
3.1
2.6
1.6
2.7
tested
The number of positive cases detected in 2010 increased compared to the previous two years. HIV positivity was 1.6% (21 positive) in 2009 and 2.6% (32 positive) in 2008. Figure 17a – HIV-positivity in Bars/Clubs by Year 700 600
n =5 8 9 n =5 3 2
n =5 3 2 n =4 8 7
500 400 300 200
2.7%
2.6% 1. 5 %
1. 5 %
100 0
2007
2008
2009
2010
MS M t ested i n B ars/C lubs
532
532
589
487
% H IV+v e a mong MS M
2.6
1.5
1.5
2.7
tested
Figure 17b – HIV-positivity in Saunas by Year n =7 6 1
800 n =6 5 5
700
n =6 4 5
600 500 n =3 6 3 400
4 . 1%
300
3.7%
200
2.9% 1. 7 %
100 0
2007
2008
2009
2010
MS M t ested i n S aunas
363
655
645
761
% H IV+v e a mong MS M
4.1
3.7
1.7
2.9
tested
Data of survey form Besides questions on the basic demographics, additional data on sexual behaviour and practices among MSM that patronised the saunas and bars/clubs were also collected with emphasis on condom usage. 1280 survey forms were collected with the following questions: 1. Where do you meet your sexual partners (last 6 months) - Bar - Club - Sauna - Internet - Massage parlor - Paid sex 2. Do you practice anal sex and condom usage (last 6 months) a. With regular partners b. With casual partners 3. When was your last HIV test? - Where have you done the test?
Figure 18 – Where do you meet your sexual partners (survey form n=1280) 700 600 500 400 300 200 100 0 c ount
B ar
C lubs
S auna
Internet
104
214
629
358
Mas s age P aid S ex 35
34
Participants can circle more than one option on where they meet their sexual partners.
Figure 19 – Do you practice anal sex (survey form n=1280) Do not practice anal sex 107 8%
Practice Anal Sex 1173 92%
Figure 20 – Condom use in the last 6 months with regular partners (survey form n=1221) 700 600 500 400 300 200 100 0
Total
10.2%
53.9%
24.2%
10.2%
I do not have Y es , 100% Y es , No c ondom regular s ex c ondom us e c ondom us e never us ed partner with regular s ometimes with regular 125
658
296
125
1.4%
Not ans wered 17
Figure 21 – Condom use in the last 6 months with casual partners (survey form n=1221) 900 800 700 600 500 400 300 200 100 0
Total
11%
65%
16%
6%
I do not have Y es , 100% Y es , No c ondom c as ual s ex c ondom us e c ondom us e never us ed partner with c as ual s ometimes with c as ual 138
781
194
78
2%
Not ans wered 30
Figure 22 â&#x20AC;&#x201C; Condom use and HIV testing among MSM who had casual sex partners (n=1037) 100%
36 103
80%
13
27
41 44
60%
40%
No condom never used with casual sex partners Yes, condom use sometimes with casual sex partners
507
Yes, 100% condom use with casual sex partners
154 112
20%
0% Less than 12 months ago
more than 12 months ago
First Time Testing
646 tested less than 12months (36+103 = 139, n=646, 22% unsafe sex) 208 tested more than 12months (13+41 = 54, n=208, 26% unsafe sex) 183 first time testers (27+44 = 71, n=183, 39% unsafe sex) Higher percentage (39%) of first time testers reported unsafe sex with casual partners compared with those who had tested before.
Figure 22a â&#x20AC;&#x201C; Condom use and HIV testing among MSM who had regular sex partners (n=1062) 100% 90% 80%
56
24
176
55
70%
42
60
60% 50% 40% 30%
427
130
20%
No condom never used with regular sex partners Yes, condom use sometimes with regular sex partners
92
10%
Yes, 100% condom use with regular sex partners
0% Less than 12 more than 12 months ago months ago
First Time Testing
659 tested less than 12months (56+176 = 232, n=659, 35% unsafe sex) 209 tested more than 12months (24+55 = 79, n=209, 38% unsafe sex) 194 first time testers (42+60 = 102, n=194, 53% unsafe sex) Higher percentage (53%) of first time testers reported unsafe sex with regular partners compared with those who had tested before.
Figure 23 â&#x20AC;&#x201C; Condom use and HIV testing among MSM who met sex partners in saunas (n=556) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
17 50
4 21
11 No condom never used with casual sex partners
27
287
Yes, condom use sometimes with casual sex partners
87 52
Yes, 100% condom use with casual sex partners Less than 12 more than months ago 12 months ago
First Time Testing
354 tested less than 12months (17+50 = 67, n=354, 19% unsafe sex) 112 tested more than 12months (4+21 = 25, n=112, 22% unsafe sex) 90 first time testers (11+27 = 38, n=90, 42% unsafe sex) First time testers reported more unsafe sex in saunas comparing to those who had tested before.
Figure 23a â&#x20AC;&#x201C; Condom use and HIV testing among MSM who met sex partners in clubs/bars (n=190) 100% 80%
4
2
24
5
4 10
60% 40%
90
21
30
20% 0% Less than 12 months ago
more than 12 months ago
First Time Testing
Condom Usage with Casual Partners No condom never used with casual sex partners Condom Usage with Casual Partners Yes, condom use sometimes with casual sex partners Condom Usage with Casual Partners Yes, 100% condom use with casual sex partners
118 tested less than 12months (4+24 = 28, n=118, 24% unsafe sex) 28 tested more than 12months (2+5 = 7, n=28, 25% unsafe sex) 44 first time testers (4+10 = 14, n=44, 32% unsafe sex) First time testers reported more unsafe sex in clubs/bars comparing to those who had tested before
Discussion Demographics The majority of those tested were between 18 to 29 years, similar numbers seen in the 2009 project. Noticeable increase of 200% for those above 60 years (15 samples compared to 5 in 2009). The main ethnic group is Chinese, followed by Other races, then Malay. A similar clientele pattern was observed as with the other three projects, participants who took the HIV test were different; those from saunas were older and had a greater proportion of non-Singaporeans/PRs than those in clubs/bars Sexual behaviour (survey form, n=1280) Saunas are the main venue where participants meet their sexual partners, followed by the internet and then clubs. Out of the 1280 survey forms collected (Fig.18 to 23) - 1173 (92%) practice anal sex (Fig.19) - Anal sex - 1163 participants answered yes to having anal sex either with casual or regular partner (10 did not indicate casual or regular) - 660 (57%, n=1163) condom use always - 487 (42%, n=1163) no condom use - 16 (1%, n=1163) condom use not indicated - Condom use with regular partners (n=1221) - 1079 participants had anal sex with regular partners (Fig.20) - 658 (61%) condom use always - 421 (39%) sometimes or never use condoms - 125 answered no regular sex partners - 17 did not answer this question - Condom use with casual partners (n=1221) - 1053 participants had anal sex with casual partners (Fig.21) - 781 (74%) condom use always - 272 (26%) sometimes or never use condoms - 138 answered no casual sex partners - 30 did not answer this question - Last HIV test - First time testers show a higher percentage (39%) of no condom use with casual partners comparing to those who have ever tested before (Fig.22), similar pattern seen with regular partners (Fig.22a) - First time testers also show a higher percentage (43%) of no condom use in saunas with casual partners comparing to those surveyed in clubs/bars (Fig.23/23a)
HIV testing A total of 1273 samples were collected. - 487 samples from clubs/bars - 105 (22%) were first time testers - 286 (59%) had tested in the last 12months (19% tested more than 12months ago or did not answer this question) - 761 samples from saunas - 142 (19%) were first time testers - 454 (60%) had tested in the last 12months (21% tested more than 12months ago or did not answer this question) - 25 samples from MSM events - 9 (36%) were first time testers - 8 (32%) had tested in the last 12months (32% tested more than 12months ago or did not answer this question) HIV positivity 35 tested HIV positive - 31 individuals had a previous negative HIV test - 4 individuals were first time testers - 18 (51%) were below 29 years of age - Over 50% are Singaporean Chinese - 2 were known HIV +ve (did test due to peer pressure)
Known HIV positive - Confidential Survey From pass outreach projects we have noticed known HIV+ve patrons in these venues. A separate survey containing questions on basic demographic, ARVs taken, latest CD4 counts and Viral load, and safer sex behaviour was discreetly conducted by volunteers who recognised these individuals. Five were approached and 2 agreed to participate. Survey HIV+ve case 1 Nationality
Singaporean
Race
Chinese
Age group
18-25
Number of visit to venue
Once a week
ARV Medication
No
Physician follow up
No
CD4 count
320
Viral load
Not sure
Other STI
No
Sex with regular partner
- No condom for oral - Sometimes condom for anal
Sex with casual partner
No casual partner
Survey HIV+ve case 2 Nationality
Singaporean
Race
Chinese
Age group
50-59
Number of visit to venue
Once a month
ARV Medication
Truvada and Stocrin
Physician follow up
Overseas
CD4 count
170
Viral load
18,000
Other STI
Syphilis
Sex with regular partner
No regular partner
Sex with casual partner
Hand job
Conclusions A total of 1273 MSM participated and took the HIV test. Of these 35 tested HIV Typical sauna set up positive (overall HIV positivity of 2.7%). Number of samples taken were similar, number of positive cases detected increased by 67% (21 positive in 2009, prevalence 1.6%). HIV positivity figures were almost similar in saunas (2.9%) and in bars/clubs (2.7%). Higher percentage of first time testers did not use condoms consistently with their casual or regular partners compared with those who had previous HIV test (figure 22). This repeat project was well received. All the venues gave their full cooperation to the volunteers and feedback that their clients have been asking when the next HIV testing will take place. The high visibility of this project is effective in reminding the MSM community not to be complacent about HIV/AIDS and has contributed to normalizing HIV testing. Correct information about the window period and the potential risk for other STIs was always provided in order to prevent clients engaging in unprotected sex on the basis of one negative rapid test result. Participants were also reminded that one cannot be certain about a sexual partnerâ&#x20AC;&#x2122;s last sexual exposures or HIV status. As with every project, we found that it was more conducive to conduct the study in saunas than in bars/clubs. Saunas often have lounge areas, which offer a private relaxing atmosphere, whereas bars/clubs are noisy, cramp, crowded and dark, which makes communication very difficult.