Report -‐ Outreach HIV testing Project in venues frequented by men who have sex with men (MSM) -‐ November 2011 to February 2012 Roy Chan, Martin Chio, Sean Lim Donovan Lo, Avin Tan, Joe Wong, Bryan Loh Introduction This is the fifth 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, 2009, 2010 and 2011. Each project lasted two and a half months and was conducted by Action for AIDS. Objectives For the fifth 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 from 2007 to 2011. To collect additional data on sexual behaviour and practices.
Method HIV test kit The OraQuick rapid HIV-1/2 test kits were used (Annex A) -
The test kit is for single-use Time required for test completion & test result is 20 minutes
Sample identification and result collection Each participant was given a serial numbered ID card (Annex B), 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 counseling
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 pen (Annex C) was given to each participant as thanks for taking part in the project. Tests was offered free of charge to all participants. 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 (Annex D) 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.
Venues 7 MSM saunas and 4 MSM bars/clubs participated. Project Venues Approached Participated 2010
2009
2008
2007
2011
Declined
Saunas
9
9
-
Bars/Clubs
6
6
-
MSM events
1
1
-
Saunas
9
8
1
Bars/Clubs
8
8
-
MSM events
3
3
-
Saunas
7
5
2
Bars/Clubs
5
4
1
MSM events
1
1
-
Saunas
6
4
2
Bars/Clubs
5
4
1
MSM events
1
1
-
Saunas
7
7
-
Bars/Clubs
6
5
1
MSM events
-
-
-
With increased awareness of HIV/AIDS and the continuity of this project, there was no difficulty in getting the venue proprietors to participate. Only the project coordinators and relevant AfA officers know results from the individual venues. Aggregated data is presented here. 2011/12 Results – Tests done (n=1309) 5 bar/clubs participated Total samples: 297
Date commenced: 04 Nov’ 11 Date concluded: 26 Feb’ 12 Made 7 visits
7 saunas participated Total samples: 1012
Date commenced: 04 Nov’11 Date concluded: 26 Feb’ 11 Made 44 visits
Figure 1 – Venues (overall)
Participants
1400 1200 1000 800 600 400 200 0
Bar/Club
Sauna
Event
Total
2007 Study
532
363
65
960
2008 Study
532
655
38
1225
2009 Study
589
645
43
1277
2010 Study
487
761
25
1273
2011 Study
297
1012
0
1309
A new sauna (Cruise Club) opened towards the end of the project and the venue owner requested the project to be held in conjunction with its many events. Thus, skewing the number in sauna.
Figure 2 – Age Group by venue
Figure 2 - Age Group by Venue 1400 1200 1000 800 600 400 200 0 <18
18-25
26-29
30-39
40-49
50-59
>60
Not Grand answer Total ed
Age Club
1
144
63
72
15
1
0
1
297
Sauna
5
274
126
289
224
75
12
7
1012
Grand Total
6
418
189
361
239
76
12
8
1309
As in the previous projects, bar/club patrons were younger than those in saunas.
Figure 3 â&#x20AC;&#x201C; Race by venue
Count of Race by Venue Type 1200 1000 800 600 400 200 0 Chinese
Eurasian
Indian
Malay
Others
Not Answered
Club
231
3
15
15
30
3
Sauna
735
17
30
69
132
29
Grand Total
966
20
45
84
162
32
Racial mix was generally similar in the 2 types of venues, and reflects the population breakdown in Singapore. However, project ICs have reported an increase of foreigners in saunas.
Figure 4 â&#x20AC;&#x201C; Nationality by venue
Count of Nationality by Venue 600 500 400 300 200 100 0
Malaysian
Others
PR
Singapore
Club
24
40
21
210
Sauna
123
212
101
560
Saunas have greater proportion of non-Singaporeans than bars/clubs. Mostly made up of Chinese nationals and Pilipino.
Figure 5 – Age Groups by Year
Age group by Year 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
<=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%
0.40%
2010 Age Group
50.20%
28.01%
16.29%
4.33%
1.18%
2011 Age Group
46.83%
27.58%
18.26%
5.81%
0.92%
The age groups of participants were similar. A raising trend of participants aged between 50-59 is recorded.
Figure 5a – Age Groups 2011
2011 Age Group
28%
<=29
18%
30-39 7%
6%
40-49 50-59
47%
1%
>=60
Percentage %
Figure 6 – Race by Year
90 80 70 60 50 40 30 20 10 0
Chinese
Malay
Indian
Others
2007
79.79
7.5
4.38
8.33
2008
77.96
6.61
2.69
11.59
2009
76.19
6.3
3.63
13.88
2010
73.92
6.36
4.4
15.32
2011
73.8
5.27
2.29
11.38
Racial distribution is similar.
Figure 6a – Race 2011
Race 2011 Eurasian Indian 3% 2% Malay 6%
Other 15%
Others 12%
Chinese 74% Not Answered 3%
Figure 7 – Nationality by Year 90 80 70 60 50 40 30 20 10 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
2011 Nationality
69.09
11.39
19.52
Nationality distribution was similar over the years
Figure 8 – Called back for results by Year 2011 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
Same day
Another day
Did not call
2007
68.54
10.21
21.25
2008
70.78
12.16
17.06
2009
68.36
11.12
20.52
2010
76.83
7.78
15.40
2011
81.49
7.23
11.28
In 2011 more clients called back for their results than previous years.
Figure 9 – First time testers by Age Group
First time tester by age group 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
Never taken a test
<6mths Ago
<18
0.38%
1.92%
>60
0.38%
18-25
6-12mths ago
>12mths Ago
1.15%
0.38%
2.68%
49.43%
47.89%
34.10%
28.35%
26-29
9.58%
26.05%
20.31%
15.71%
30-39
19.54%
47.13%
36.40%
33.72%
40-49
13.79%
21.07%
27.59%
28.35%
50-59
6.13%
7.66%
8.05%
7.66%
Not answered
0.77%
1.92%
0.77%
1.15%
Figure 10 – First time testers by Race and Year 90
Percentage %
80 70 60 50 40 30 20 10 0
Chinese
Malay
Indian
Other
2007
77.22
11.58
6.18
5.02
2008
78.14
8.68
4.49
6.29
2009
72.95
11.39
3.56
12.1
2010
74.61
9.38
6.25
9.77
2011
72.97
10.42
5
11.58
Figure 10a – First time testers by Race 2011 120 100 80 60 40 20 0
Chinese
Indian
Malay
Others
(blank)
99
3
13
17
1
26-29
20
2
3
30-39
33
4
5
10
40-49
22
2
6
1
50-59
13
<18
1
>60
1
18-25
Eurasian
1
2
4
1
(blank)
2
Percentage %
Figure 11 – First time testers by Nationality and Year 90 80 70 60 50 40 30 20 10 0
Singaporeans
Malaysians
Others
2007
84.17
10.04
5.79
2008
82.63
6.89
8.08
2009
75.09
8.06
16.85
2010
78.12
10.16
11.72
2011
67.69
11.92
20.38
Figure 12 â&#x20AC;&#x201C; Last HIV test by Year
Last test by year 50 45 40 35 30 25 20 15 10 5 0
2007 Test Done
2008 Test Done
2009 Test Done
2010 Test Done
2011 Test Done
First Time
46.77
27.27
23.08
20.33
20.03
6 months
17.51
37.22
28.37
36.78
25.50
12 months
10.94
23.84
25.24
22.64
23.50
> 1yr
24.78
11.67
23.32
20.25
30.97
In 2011 there were fewer first time testers than in previous years (20.33%) This indicates that more MSM had been tested than previously.
HIV positive 27 participants were tested positive by Oraquick HIV1/2 tests. Overall prevalence of 2.06% (27 positives) - Bars/Clubs: Prevalence 1.69% (5 positives) - Saunas: Prevalence 2.17% (22 positives) Figure 13 â&#x20AC;&#x201C; Prevalence by Venues
Prevalence by Venue 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Series1
Club
Sauna
1.69%
2.17%
Details of 27 individuals testing HIV positive -
23 individuals had a previous negative HIV test 4 individuals were first time testers 12 (46.15%) were below 29 years of age Over 60% are Singaporean
Figure 14 – HIV-positive by Age Group and Year
HIV+ve Age by Year 30 25 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
27
9
7
1
0
2011 27 HIV +ve
12
10
4
0
0
Figure 14a – HIV-positive by Age Group and Year
Percentage
HIV+ve Age by Year 70% 60% 50% 40% 30% 20% 10% 0%
<30
30-‐39
40-‐49
50-‐59
>60
2007 30 HIV +ve
40%
40%
13%
7%
0%
2008 32 HIV +ve
44%
31%
13%
13%
0%
2009 21 HIV +ve
52%
33%
14%
0%
0%
2010 35 HIV +ve
61%
20%
16%
2%
0%
2011 27 HIV +ve
46.15%
38.46%
15.38%
0.00%
0.00%
Figure 14b – HIV-positive by Age Group 2011
2011 27 HIV +ve 0% 15%
<30 30-‐39
46%
40-‐49 50-‐59
39%
>60
Figure 15 – HIV-positive by Race and Year
HIV +ve Race by Year 25 20 15 10 5 0
Chinese
Malay
Indian
Others
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
2011 27 HIV +ve
15
4
2
6
Figure 15a – HIV-positive by Race and Year
HIV +ve Race by Year 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%
Chinese
Malay
Indian
Others
2007 30 HIV +ve
70.00%
16.67%
0.00%
13.33%
2008 32 HIV +ve
71.88%
15.63%
0.00%
12.50%
2009 21 HIV +ve
60.00%
15.00%
0.00%
25.00%
2010 35 HIV +ve
51.43%
20.00%
2.86%
25.71%
2011 27 HIV +ve
55.56%
14.81%
7.41%
22.22%
Figure 16 – HIV-positive by Nationality and Year
HIV-‐positivity by Nationality and Year 25 20 15 10 5 0
Singaporean
Malaysian
Others
Not Answered
2007
21
3
6
0
2008
22
4
6
0
2009
11
2
6
2
2010
20
5
10
0
2011
17
4
5
1
Figure 16a – HIV-positive by Nationality and Year 100 90 80 70 60 50 40 30 20 10 0
Singaporean
Malaysian
Others
Not Answered
2011
17
4
5
1
2010
20
5
10
0
2009
11
2
6
2
2008
22
4
6
0
2007
21
3
6
0
Figure 17 – Overall HIV-positivity by Year 1400 1200 1000 800 600 400 200 0
1277
1309
10.00% 9.00% 8.00% 960 7.00% 6.00% 5.00% 4.00% 3.13% 3.00% 2.75% 2.61% 2.06% 2.00% 1.64% 1.00% 0.00% 2007 2008 2009 2010 2011 Study Study Study Study Study 1225
1273
Total test Done
960
1225
1277
1273
1309
Prevalence Rate
3.13%
2.61%
1.64%
2.75%
2.06%
Prevalence Rate
3.13%
2.61%
1.64%
2.75%
2.06%
The number of positive cases detected in 2011 decreased compared to the previous three years.
Figure 17a – HIV-positivity in Bars/Clubs by Year 700 600 500 400 300 200 100 0 Bar/Club Prevalence Rate
10.00% 9.00% 532 532 8.00% 487 7.00% 6.00% 295 5.00% 4.00% 3.00% 2.70% 2.60% 1.69% 2.00% 1.50% 1.50% 1.00% 0.00% 2007 2008 2009 2010 2011 Study Study Study Study Study 589
532
532
589
487
295
2.60%
1.50%
1.50%
2.70%
1.69%
Figure 17b – HIV-positivity in Saunas by Year 1200 1000 800 600 400 200 0 Saunas Prevalence Rate
10.00% 9.00% 8.00% 761 7.00% 655 645 6.00% 363 5.00% 4.10% 4.00% 3.70% 3.00% 2.90% 2.70% 2.17% 2.00% 1.00% 0.00% 2007 2008 2009 2010 2011 Study Study Study Study Study 1008
363
655
645
761
1008
4.10%
3.70%
2.70%
2.90%
2.17%
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. Additional fields were added to the questionaire for further refinement. 1271 survey forms were collected with the following questions: 1. Where do you meet your sexual partners (last 6 months) - Bar - Club - Sauna/bath houses - Internet/Mobile Devices - Public Spaces - 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 â&#x20AC;&#x201C; Where do you meet your sexual partners (survey form n=1271)
Where do you meet your sexual partners in the last 6 months 1000 800 600 400 200 0
Series1
Bar
Clubs
Sauna/ Bath Houses
Internet/ Mobile Devices
Public Spaces
82
174
841
325
53
Massage Paid Sex parlor 49
22
Participants can circle more than one option on where they meet their sexual partners.
Figure 19a â&#x20AC;&#x201C; Condom use in the last 6 months with regular partners (survey form n=1308)
Condom use (regular partner) 7%
11%
15%
No Regular Partner 15%
No Anal Sex
1.4%
Condoms all the time Condoms Sometimes No Condoms
52%
Figure 19b â&#x20AC;&#x201C; Condom use in the last 6 months with casual partners (survey form n=1283)
Condom use (Casual Partners) 2% 14%
7%
19%
No Casual Partner No Anal Sex Condoms all the time Condoms Sometimes No Condoms
58%
Figure 20a – Condom use and HIV testing among MSM who had casual sex partners (n=953) 100%
12
80%
37
8 104
3 37
124
457
171
Never taken a test
within 12 months
> 12 months
60% 40% 20% 0% Condoms all the time
Condoms sometimes
No condoms
569 tested within 12months (104+8 = 112, n=569, 19.68% unsafe sex) 211 tested more than 12months (37+3 = 40, n=211, 18.96% unsafe sex) 173 first time testers (37+12 = 49, n=172, 28.49% unsafe sex) Higher percentage (28.49%) of first time testers reported unsafe sex with casual partners compared with those who had tested before. Figure 20b – Condom use and HIV testing among MSM who had regular sex partners (n=967) 100% 80%
19 44
44 112
23 48
60% 40%
110
418
149
within 12 months
> 12 months
20% 0% Never taken a test Condoms all the time
Condoms sometimes
No condoms
574 tested within 12months (112+44 = 156, n=574, 27,18% unsafe sex) 220 tested more than 12months (48+23 = 71, n=220, 32.27% unsafe sex) 173 first time testers (44+19 = 63, n=173, 36.41% unsafe sex) Higher percentage (36.41%) of first time testers reported unsafe sex with regular partners compared with those who had tested before. Comparitively, more practice unsafe sex with regular partners.
Discussion Demographics The majority of those tested were between 18 to 29 years, similar numbers seen in the 2010 project. The main ethnic group is Chinese, followed by Other races, then Malay. A similar clientele pattern was observed as with the other four 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=1313) Saunas/bath houses remain as the main venue where participants meet their sexual partners, followed by the internet and then clubs. The 2011 survey introduced additional data fields which includes mobile devices and public spaces. These were included based on feedbacks and reccomendations from 2010 study. Mobile devices and internet are goruped together because they access information through the same channels. Out of the 1313 survey forms collected (Fig.18 to 20) -
962 (74%) practice anal sex with regular partners (Fig.19a) 951 (74%) practice anal sex with casual partners (Fig.19b)
Condom use with regular partners (n=1308) Fig 19.a - 674 (52%) condom use always - 288 (22%) sometimes or never use condoms - 144 answered no regular sex partners - 202 are not having anal sex with regular partners - 5 did not answer this question Condom use with casual partners (n=1283) fig 19b - 750 (58,46%) condom use always - 201 (15.67%) sometimes or never use condoms - 94 answered no casual sex partners - 283 are not having anal sex with casual partners - 30 did not answer this question Last HIV test - First time testers show a higher percentage (36.41%) of no condom use with casual partners comparing to those who have ever tested before (Fig.20b), similar pattern seen with regular partners (Fig.20a)
HIV testing A total of 1307 samples were collected. - 297 samples from clubs/bars - 70 (24%) were first time testers - 78 (49%) had tested in the last 12months (27% tested more than 12months ago or did not answer this question) - 1012 samples from saunas - 190 (19%) were first time testers - 589 (58%) had tested in the last 12months (19% tested more than 12months ago or did not answer this question) HIV positivity 27 tested HIV positive - 23 individuals had a previous negative HIV test - 4 individuals were first time testers - 12 (46.15%) were below 29 years of age - Over 60% are Singaporean - 0 were known HIV +ve (did test due to peer pressure)
Conclusion and Reccomendations A total of 1307 MSM participated and took the HIV test. Of these 27 tested HIV positive (overall HIV positivity of 2.06%). Number of samples taken were similar, number of positive cases detected decreased by 22.8% (35 positive notifications in 2010, incidence rate of 2.75%). HIV positivity figures has also decreased in saunas (2.17%) and in bars/clubs (1.69%). This could be due the skewed number of participants in saunas. Inconsistent condom use happens more frequently amoungst participants who are first time testers when compared to participants who have taken a test previously. This happens with both casual and regualr partners, while more frequently with regular partners. However, it is also noted that it is common for MSMs to have concurrent regular sex partners. This repeat project was well received by all partners and participating venues gave their full cooperation and support towards staff and volunteers. The projectâ&#x20AC;&#x2122;s high visibility also serve as an effective reminder to the MSM community to remain vigilant and not to be complacent. Judging from anedoctel feedbacks and incresed demand for such projects, sero prevalence has successcfully normalized HIV testing within the MSM community. To increase the confidence of participants, volunteers and IC on duty have taken extra precaution to make sure that information about the testing procedure, window period and after care services are accurate. This also serves as a timely reminder that potential risk for contracting other STIs and HIV still remain even after one negative rapid HIV test. 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. Participants usually feel more confident and comfortable when it is conducted in a more relaxing environment such as the lounge area. Further improvements can be made to the data collection sheet, such as including more fields to better refine the data. Reccomendations to better close the loop for referral and follow up includes a generic information slip containing contact details of the positive living center can be made available to all participants. This can help make sure confidentiality is not broken when a participants test positive while these information can be useful for the rest.