Report - Outreach HIV testing Project in venues frequented by men who have sex with men (MSM) - August 2013 to October 2013 Roy Chan, Martin Chio, Sean Lim Kevin Poh, Avin Tan, Bryan Loh, James Foong Introduction This is the sixth consecutive year that the Outreach HIV testing project at MSM venues was carried out. The first project was first conducted in November 2007, recurring every year betweenthat and 2013. Each project lasted two and a half months and was conducted by Action for AIDS, singapore. Objectives For the sixth project, the objectives are: Method
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.
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 red ribbon pin (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.
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Venues Project 2010
2009
2008
2007
2011/2012
2013
Venues Saunas Bars/Clubs MSM events Saunas Bars/Clubs MSM events Saunas Bars/Clubs MSM events Saunas Bars/Clubs MSM events Saunas Bars/Clubs MSM events Saunas Bars/Clubs MSM Events
Approached 9 6 1 9 8 3 7 5 1 6 5 1 7 6 7 7 -
Participated 9 6 1 8 8 3 5 4 1 4 4 1 7 5 7 6 1
Declined 1 2 1 2 1 1 1 -
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. 2013 Results – Tests done (n=1293) 5 bar/clubs participated Total samples: 629
Made 23 visits
7 saunas participated Total samples: 649
Made 37 visits
Others Total samples: 15
Made 2 visits
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Participant
Figure 1 – Venues (overall) 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
2013 Study
629
649
15
1293
Great care was taken to make sure there are equal participants from both bars/clubs & saunas. Figure 2 – Age Group by venue
As in the previous projects, bar/club patrons were younger than those in saunas.
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Figure 3 – Race by venue 1000 900 800 700 600 500 400 300 200 100 0 Chinese
Eurasian
Indian
Malay
Others
Not answers
Bars & clubs
409
14
12
30
60
101
Sauna
463
4
22
53
65
24
Events
15
0
0
0
0
1
Total
887
18
34
83
125
126
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 – Nationality
PR 7%
Others 22%
Malaysian 7%
Filipino 4%
Other 7% Chinese 3%
Singaporean 57%
Foreigners are forming a larger part of the MSM community.
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Figure 5 – Age Groups 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
48.83%
27.58%
18.26%
5.81%
0.92%
2013 Age Group
56.04%
27.18%
12.16%
4.03%
0.59%
The age groups of participants were similar.
Figure 5a – Age Groups 2013 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 2013 Age Group
<=29
30-39
40-49
50-59
>=60
56.04%
27.18%
12.16%
4.03%
0.59%
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Figure 6 â&#x20AC;&#x201C; 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
2013
69.68
6.52
2.67
21.13
Racial distribution is similar.
Figure 6a â&#x20AC;&#x201C; Race by venue 2013 1000 900 800 700 600 500 400 300 200 100 0 Chinese
Eurasian
Indian
Malay
Others
Not answers
Bars & clubs
409
14
12
30
60
101
Sauna
463
4
22
53
65
24
Events
15
0
0
0
0
1
Total
887
18
34
83
125
126
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Figure 7 â&#x20AC;&#x201C; 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
2013 Nationality
63.12
8.05
28.83
Nationality distribution was similar over the years
Figure 8 â&#x20AC;&#x201C; Results collected by Year 2013 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
2013
79.12
7.73
13.15
In 2013 similar number of clients collected their results as per previous years.
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Figure 9 – First time testers by Age Group 250 200 150 100 50 0 <18 18-25 26-29 30-39 40-49 50-59 I have never had a HIV test
3
138
23
42
19
3
(blan >59 k) 5
2
Figure 10 – First time testers by Race and Year 90 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
2013
76.59574468
8.085106383
6.382978723
8.94
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Gran d Total 235
Figure 11 – First time testers by Nationality and Year 90 80 70 2007
60
2008
50
2009
40
2010
30
2011
20
2013
10 0 Singaporeans
Malaysians
Others
Figure 12 – Last HIV 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
2013 Test Done
First Time
46.77
27.27
23.08
20.33
20.03
19.63
6 months
17.51
37.22
28.37
36.78
25.50
26.07
12 months
10.94
23.84
25.24
22.64
23.50
26.40
> 1yr
24.78
11.67
23.32
20.25
30.97
27.90
In 2013 there were fewer first time testers than in previous years (20.03%) This suggests that more MSM had been tested than previously.
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Figure 12 â&#x20AC;&#x201C; Last HIV test by Age Group 2013 500 450 400 350 300 250 200 150 100 50 0 <18 18-25 26-29 30-39 40-49 50-59
(blan >59 k)
Gran d Total
Grand Total
3
138
23
42
19
3
5
2
235
I have never had a HIV test
3
138
23
42
19
3
5
2
235
Most participants are testing at least once every 6 months.
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HIV positive 40 participants were tested positive by Oraquick HIV1/2 tests. Overall prevalence of 3.14% (40 positives) - Bars/Clubs: Prevalence 2.29% (14 positives) - Saunas: Prevalence 4.30% (26 positives) Figure 13 – Prevalence by Venues 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00
Bars and clubs
Saunas
2.29
4.30
Details of 40 individuals testing HIV positive -
40 individuals had a previous negative HIV test 3 individuals were first time testers 13 were below 29 years of age 50% are Singaporean
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Figure 14 – HIV-positive by Age Group and 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%
2013 40 HIV+ve
46.00%
33.00%
16%
5.00%
0.00%
Figure 14b – HIV-positive by Age Group 2013
50-‐59 5%
2013 40 HIV+ve >60 0%
40-‐49 16%
<30 46%
30-‐39 33%
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Figure 15 – HIV-positive by Race and 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
2013 40 +vw
20
10
2
8
Figure 16 – Overall HIV-positivity by Year 1600
10.00%
1400
9.00% 8.00%
1200
7.00%
1000
6.00%
800
5.00%
600 400
3.13%
2.75%
2.61% 1.64%
3.14% 2.06%
HIV +ve
4.00%
Total test Done
3.00%
Prevalence Rate
2.00%
200
1.00%
0
0.00% 2007 2008 2009 2010 2011 2013 Study Study Study Study Study Study
The number of positive cases detected in 2013 increased compared to the previous three years.
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56Figure 16a – HIV-positivity in Bars/Clubs by Year 700
10.00% 9.00%
600
8.00%
500
7.00%
400
6.00%
300
4.00%
5.00% 3.00%
200
2.00%
100 0 Bar/Club Prevalence Rate
1.00% 2007 Study
2008 Study
2009 Study
2010 Study
2011 Study
2013 Study
532
532
589
487
295
612
2.60%
1.50%
1.50%
2.70%
1.69%
2.29%
0.00%
Figure 16b – HIV-positivity in Saunas by Year 1200
10.00% 9.00%
1000
8.00% 7.00%
800
6.00% 600
5.00% 4.00%
400
3.00% 2.00%
200
1.00% 0 Saunas Prevalence Rate
2007 Study
2008 Study
2009 Study
2010 Study
2011 Study
2013 Study
363
655
645
761
1008
605
4.10%
3.70%
2.70%
2.90%
2.17%
4.30%
0.00%
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 Page 15 of 24
collected with emphasis on condom usage. Additional fields were added to the questionaire for further refinement. Please refer to the attached form for all the questions. Figure 17 â&#x20AC;&#x201C; Where do you meet your sexual partners (survey form n=1335) Participants can circle more than one option on where they meet their sexual partners.
Through mobile device apps
126
Through Internet sites and chat rooms
83
Through friends
97
Sauna Private parties Paid sex e.g. Masseurs; Escorts
43 12 9
No hook ups
240
In saunas In Public spaces e.g. Parks; toilets; gyms; swimming pools
520 3
In bars and clubs
202
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Figure 18a â&#x20AC;&#x201C; Condom use in the last 6 months with regular partners (survey form n=1331) Sometimes 13%
No regular male partner(s) 25%
All the time 38%
Most of the time 17%
No hook ups 2% Never used condoms 5%
Figure 18b â&#x20AC;&#x201C; Condom use in the last 6 months with casual partners (survey form n=1335) No hook ups 2%
No casual male partner(s) 30%
Sometimes 8%
All the time 44%
Never used condoms 1%
Most of the time 15%
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Figure 18c â&#x20AC;&#x201C; Condom use in the last 6 months with paid sex partners (survey form n=1335) No hook ups 4%
Sometimes Most of the 2% time All the 3% time 12%
Never used condoms 0%
Never paid for sex 79%
Figure 19a â&#x20AC;&#x201C; When did you have your last (most recent) voluntary HIV test? (survey form n=1197)
312
Within the past six months
More than 1 year ago
334
I have never had a HIV test
235
316
Between 6 months to 12 months
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Figure 19b – Have you ever had a mandatory (not voluntary) HIV test e.g. in NS, for medical insurance or employment? (survey form n=1328)
Yes - More than 1 year ago
Yes - Within the past six months
Yes - Between 6 months to 12 months
369
171
135
No
653
National service is the main point where participants were required to take a mandatory test. Figure 20a – How long would you wait before you take a HIV test if you thiunk you were exposed to HIV? (survey form n=1337)
Not sure 25% Not applicable 0%
6 months 10%
1 week 22%
3 months 29%
4 weeks 8% 3 weeks 6%
Figure 20b – If you never had an anonymous HIV test, what is the main reason? (survey form n=1337)
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800 688
700 600 500 400 300
221
200 100
140 92
85 19
0
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45
Discussion Demographics The majority of those tested were between 18 to 29 years, similar numbers seen through the 5 rounds. 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 Saunas/bath houses remain as the main venue where participants meet their sexual partners, followed by the internet and then clubs. The 2013 survey introduced additional data fields which includes mobile devices and public spaces. These were included based on feedbacks and reccomendations from 2010 study. However, unlike 2011, "mobile devices and internet are separated this round, to provide a clearer insight and because people do not perceive mobile app as accessing information through the internet. Condom use with regular partners (n=1308) Fig 18.a - 502 (37.7%) condom use always - 228 (17%) uses condom most of the time - 171 (12.8%) sometimes - 73 (5.5%) are not using condoms with regular sex partners - 357 answered no regular sex partners Condom use with casual partners (n=1335) fig 18b - 593 (44.4%) condom use always - 196 (14.7%) uses condom most of the time - 102 (7.6%) sometimes - 20 (1.5%) are not using condoms with casual sex partners - 424 answered no casual sex partners Condom use with paid sex partners (n=1322) fig 18c - 159 (12%) condom use always - 35 (2.6%) uses condom most of the time - 27 (2%) sometimes - 7 (0.5%) are not using condoms with casual sex partners - 1094 (82.6) answered no casual sex partners
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HIV testing A total of 1293 samples were collected. Bars & Clubs - 629 samples from clubs/bars - 138 (21.9%) were first time testers - 345 (54.8%) had tested in the last 12 months - 180(28.6% tested more than 12 months ago or did not answer this question) Sauna - 649 samples from saunas - 113 (17.4%) were first time testers - 367 (56.5%) had tested in the last 12 months - 181 (27.9% tested more than 12 months ago or did not answer this question) HIV positivity 40 tested HIV positive - 3 individuals were first time testers - 13 (32.5%) were below 29 years of age - Over 50% are Singaporean - 0 were known HIV +ve (did test due to peer pressure)
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Conclusion and Reccomendations A total of 1293 MSM participated and took the HIV test. Of these 40 tested HIV positive (overall HIV positivity of 3.14%). Number of samples taken were similar, number of positive cases detected increased by 48% (27 positive notifications in 2011, incidence rate of 2.06%). It is believed that the jump in new notification might be caused by the hiatus of this project in 2012. HIV positivity figures has also increased in saunas (4.3% vs. 2.17% [2011]) and in bars/clubs ( 2.29% vs. 1.69% [2011]). 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 successfully 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. A staff of AfA or appointed coordinator is present at every session and prompt feedback was given to volunteers after each session. This can help make sure confidentiality is not broken when a participants test positive while these information can be useful for the rest. 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. Reccomendations form 2011 to data collection sheet and generic information slip have been implimented in the 6th round of sero-prevalence. The data collection sheet is digitized and the questions in the sexual behavior category is syncronized with the MSM BSS that is ocnducted by AfA to continous tracking of community.
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