Ukraine’s Emerging HIV Epidemic in MSM: Unusual Geographic
* Distribution
Results From 2016 Study of The Friendly Doctor HIV Testing Program for MSM Andriy Chybisov | MPH-2017, Global Health Scholar BACKGROUND Ukraine: the highest burden of HIV in Europe: with estimated 230,000 people living with HIV, most reported cases in men [1] Prevalence: IDU* (21.9%), MSM (8.5%), FSW* (7.0%), general population (0.9%) [2] MSM have the highest HIV incidence of all key populations 0.91% but >3% in some cities (compared to 0.7% in IDU and 0.44 in FSW) [3] – the epidemic is changing from IDU-driven to sexual transmission. Strong evidence of hidden epidemic in MSM, whose reported cases are misclassified as heterosexual due to stigma and discrimination [4] Three regions based on overall HIV prevalence (colored in white, grey, and dark grey on the map) [2], but there is not enough data on how the emerging HIV epidemic in MSM alights with this IDU-driven mapping. HIV prevention programs use the general HIV prevalence map to prioritize service delivery in regions. Another gap: given the low reporting rates on MSM, which MSM subgroups are not reached with HIV prevention and testing, and how can this be improved?
The Friendly Doctor: NGO-led network-based HIV testing intervention for MSM launched in 2014: Online anonymous appointment scheduling through https://friendlydoctor.org/ (screenshots below) Separate office away from government clinics and LGBT-identified community centers. Rapid tests administered by the health worker who also works at state-run AIDS Centers to facilitate linkage to care for those who test positive:
RESULTS Positive HIV test yield: 81 (7.7%) Controlling for age, sexual orientation, and education, adult male and transgender clients receiving first test in the lowest HIV prevalence region had 2.98 (95% CI 1.80-4.93) the odds of receiving an HIV-positive result, compared to those tested in the regions with high or medium HIV prevalence. Sexual orientation was the best predictor of a positive HIV test result: bisexual men and transgender persons had 6.82 (95% CI 2.32-20.03) times, homosexual participants had 6.61 (95% CI 2.28-19.18) times, and “other” participants had 11.82 (95% CI 1.10-127.42) times the odds of getting an HIV-positive test, compared to heterosexual participants, controlling for region, age, and education. Older age was positively associated with receiving a positive HIV test result INTERVIEW FINDINGS: Number of MSM tested (columns) and positive Confidentiality – the main consideration for clients of Friendly Doctor, most of whom are “down low”. test prevalence, % (lines) in Friendly Doctor Barriers related to confidentiality that may lead to delayed HIV testing are: and comparison program, 100% 10,000 Necessity to report name when receiving a rapid test at government AIDS centers. by HIV burden region and city AIDS centers keep patients’ name and their code in different documents, Friendly Doctor, Jan-May 2016 total tests but in the same paper folder. This presents high risk of patient confidentiality breach. 90% 9,000 Alliance, Jan-Dec 2015 total tests Fear to be seen near AIDS centers or LGBT community centers: Friendly Doctor, Jan-May 2016 prevalence, % by “straight” friends near an AIDS center or LGBT NGO; 80% 8,000 Alliance, Jan-Dec 2015 prevalence, % by other LGBT community near any HIV testing point. by random people who might suspect that the person is G/B/T. Total positive results - n (%): 70% 7,000 Using peer VCT may put the client at risk of HIV status disclosure by peer counselors. Health workers in Ukraine have low level of LGBT-related knowledge and counseling skills 60% 6,000 81 LGBT health content totally absent from medical schools curricula (7.7%) Mandatory medical exams include assignments formulated in a way that pathologizes MSM In-service training on LGBT is sporadic, mostly organized by NGOs, and does not teach MSM50% 5,000 specific counseling and risk assessment 207 (1.4%) Reaching “down-low” MSM and linking them to care is not easy, but some lessons learned are: 40% 4,000 Online recruitment specific to geographic location – using those web chats, sex apps, and social Data source for comparison program: network groups that are used in a particular city (recruitment is done by LGBT community ICF “Alliance for Public Health.” (2016). 2015 Annual Report (Annual Program Report) (pp. 1–148). Kyiv, Ukraine. Retrieved from coordinators). 30% 3,000 http://aph.org.ua/wp-content/uploads/2016/07/ar2015_en.pdf Many MSM subpopulations are interested in HIV testing and risk counseling, but not in the aspect of community socialization. VCT interventions should address this need. 2,000
20%
1,000
10%
0
0%
LIMITATIONS Because clinical data collection and management tools had been designed for program purposes, a number of limitations stemmed from this. The design of intake survey contained non-mutually exclusive response categories. The data set analyzed had been exported from Friendly Doctor system with a unique identifier for each HIV testing appointment, rather than for each person, so we restricted analysis to first-time testers in order to analyze individuals. First-time testers have have systematic differences from those who test regularly.
METHODS – Qualitative Analysis 1. Select the Service and City
2. Select a Doctor (short info available)
CONCLUSIONS
3. Enter Email and Cell Phone (not attached to passport data in UA)
OBJECTIVES To examine the association between the HIV prevalence in the region where an HIV test is administered and receiving a positive test result among adult first-testers of an MSM-targeted HIV prevention program in Ukraine, based on clinical data from the Friendly Doctor program To explore the attitudes and skills of the health workers and NGO staff working with MSM to the populations they serve, to identify individual and structural barriers of reaching out to “hidden” MSM subpopulations in Ukraine, and to reveal potential promising practices in MSM-friendly HIV services.
METHODS – Clinical Records Analysis Clinical records from 7 testing locations (circled in dark black on the map) in all three HIV prevalence regions (low, medium, and high). : selected for 5 months of 2016, when most sites worked. Frequency analysis of positive test yield data, then logistic regressions using STATA v.14 . In addition, we conducted simple comparison of Friendly Doctor positive test yield to another MSM-targeted national program in Ukraine.
19 In-depth interviews in 9 cities (June-July 2016): 8 health workers, 2 NGO staff, 2 psychologists, and 7 local community coordinators Brown Human Research Protection Program protocol #1602001419, approved 4/7/2016, extended to 4/7/2018 Most interviews lasted 40-50 min. Before the interviews, health workers were asked to fill out a 27-item survey on their knowledge about HIV, substance use, and MSM-related risk assessment and counseling All interviews were sound recorded with participant consent, transcribed verbatim (in Ukrainian and Russian), and coded using QSR NVIVO Pro v. 11.4 software. We used grounded theory approach, which allows to generate a theory based on the views of a large number of participants.
HIV prevalence among MSM does not necessarily follow the same geographical patterns as the overall HIV prevalence, which is mostly driven by IDU populations. This is important to planning where HIV prevention and testing programs for target populations are delivered. Geographic areas that have traditionally been considered “low prevalence” may have high positive test yield if the intervention design is acceptable to hidden MSM population, and thus, should not be excluded or set as “low priority” for KPs. Comparing HIV-positive test prevalence and the total number of tests administered demonstrate Friendly Doctor’s higher yield of HIV-positive tests given dramatically smaller number of total people tested. Eventually, this could be a funding saving opportunity. Qualitative exploration demonstrated that targeted online recruitment, offering highly confidential HIV testing as a medical procedure, rather than an opportunity to socialize – may facilitate attracting hidden MSM subpopulations that is at high risk of HIV transmission. LGBT health content based on evidence should be introduced in Ukraine’s medical schools. Health workers must be trained in MSM-specific sexual risk counseling, as well as in identifying other potential health issues in LGBT patients. Given the lack of trust of MSM in Ukraine health care, which often leads to delayed linkage to HIV care, one solution may be in greater involvement of the health workers from AIDS centers in NGO-run VCT programs, which should simplify the linkage to care aspect (as the positive clients will already have seen the provider they would link to).
LITERATURE
ACKNOWLEDGEMENTS
1. UNAIDS. 2015. “Ukraine Harmonized AIDS Response Progress Report.” United Nations AIDS. http://www.unaids.org/sites/default/files/country/documents/UKR_narrative_report_2015.pdf. 2. PEPFAR, 2016 “Ukraine 2016 PEPFAR Country Operational Plan Strategic Direction Summary.” May 31. http://www.pepfar.gov/documents/organization/257626.pdf. 3. Simmons, R., Malyuta, R., Chentsova, N., Karnets, I., Murphy, G., Medoeva, A., … Porter, K. (2016). HIV Incidence Estimates Using the Limiting Antigen Avidity EIA Assay at Testing Sites in Kiev City, Ukraine: 2013-2014. PloS One, 11(6), e0157179. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898716/pdf/pone.0157179.pdf 4. Čakalo, J.-I., Božičević, I., Vitek, C., Mandel, J. S., Salyuk, T., & Rutherford, G. W. (2015). Misclassification of Men with Reported HIV Infection in Ukraine. AIDS and Behavior, 19(10), 1938–1940. https://doi.org/10.1007/s10461-015-1112-0
Don Operario, Ph.D. for excellent mentorship. Timothy Flanigan, M.D. for endless support of Ukraine research projects. Stephen McGarvey, Ph.D. for sharing his scholarly wisdom. Brown U. School of Public Health faculty and staff for providing me with research tools & encouragement. Charitable Organization Fulcrum, for their trust, cooperation, and collegiality: http://t-o.org.ua/ My colleagues from Brown University – Ukraine collaboration – for their support and feedback. Brown University Global Health Initiative – Elizabeth Jackvony, Eileen Wright, for their support.
*Glossary: MSM – men who have sex with men. IDU – injection drugs users, or PWID – people who inject drugs. FSW – female sex workers. VCT – voluntary HIV counseling and testing. LGBT – lesbian, gay, bisexual, transgender person. HIV – human immunodeficiency virus. AIDS – acquired immunodeficiency syndrome.