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Sri Lanka has recently completed an HIV prevention project for most-at-risk populations (MARP) under the Global Fund. The intervention includes delivery of a HIV prevention package (HPP) to men who have sex with men (MSM) that includes provision of: (1) knowledge about sexually transmitted infections (STI); (2) HIV knowledge; (3) MSM-tailored leaflets; (4) condom/dildo demonstration; (5) provision of condoms; and (6) clinic escorts. MSM who received services 1–5 in the HPP are defined as ‘reached’. The final step is to escort the reached MSM to an STI clinic, and they are then defined as ‘escorted’. This HPP was delivered to MSM through peer educators (PE) scattered in four highly populated districts in the country. Each PE has contact with another 15 peers forming a peer group (PG). However, in this model, a significant number of MSM do not take up the escorting step of the HPP. Therefore, the purpose of this paper is to analyse the factors associated with clinic escorts among MSM peers in the HIV prevention project.
All the MSM peers (699 MSM) registered and retained during the project period had been reached in 2013, 2014 and 2015 and were chosen from the web-based Monitoring and Evaluation information management system (MEIMS) for analysis. The sample was divided in to two groups based on escort status (escorted peers vs non-escorted peers). Variables were compared between the two groups for the hypothesis of difference to identify significant factors associated with clinic escorts.
The study sample (699 MSM) represented four districts: Galle (37%), Colombo (35%), Gampaha (14%) and Kalutara (14%). Escort status depended on the district (P<0.001), age group of MSM (P=0.008), level of education (P=0.007) and urban/rural status (P<0.001), duration of MSM behaviour (P=0.018), experience of an HIV test during previous 12 months (P=0.050), and recent receptive anal sex (P=0.050).
Older MSM (>25 years), MSM living in urban and semi-urban areas, Nachchi MSM (effeminate males), MSM with receptive behaviours as well as less-educated MSM were less likely to be escorted and needed some extra effort to improve escort rate among MSM. In addition, performance of PEs, field supervisors and coordinators was observed to be a major factor in improving escort rate.
Sri Lanka has been categorised as a country with a low-level HIV epidemic because HIV prevalence has not consistently exceeded 5% in any of the high-risk sub-populations such as female sex workers (FSW), men who have sex with men (MSM), beach boys (BB) and people who inject drugs (PWID) . However, at the end of 2015, a cumulative total of 2308 HIV-positive persons have been reported to the National STD/AIDS Control Programme (NSACP), Ministry of Health, Sri Lanka . During 2015, the highest number of total cases (235) in a year was reported to the NSACP. In general, an estimated 10.5 new infections occur per week, while only approximately 4.5 new cases are reported to the NSACP per week .
Analysis of reported HIV cases to the NSACP during the last 5 years (2011–2015), showed that heterosexual and homosexual behaviour was the main mode of HIV transmission in the country. However, the relative proportion of HIV transmission through heterosexual behaviour reduced from 74% (2011) to 54% (2015) while the proportion of transmission via male-to-male sex increased from 20% (2011) to 41% (2016). Mother-to-child transmission remained between 3% and 7% over the same period. Injecting drug use as a mode of transmission was reported in less than 2.5% of cases. However, transmission via blood and blood products has not been identified as a method of transmission since 2004 . Therefore, the most relevant risk behaviours and key populations being considered are those associated with the main routes of HIV transmission, such as unprotected vaginal and anal sex and the use of non-sterile needles or materials .
Sri Lanka has identified different high-risk sub-populations for HIV prevention interventions such as FSW, MSM, beach boys (BB; a group of men who associate with tourists as guides or ‘animators’, and provide entertainment including sexual services, the majority of whom are bisexuals), clients of sex workers and people who inject drugs (PWID) as most-at-risk populations (MARPs) .The mapping and size estimation study carried out in 2013 provided estimates of 14,132 FSW, 7551 MSM, 1314 BBs, and 17,459 PWID in the country . HIV prevalence estimation carried out in the Integrated Biological and Behavioural Survey (IBBS) showed that HIV prevalence among FSW and MSM was 0.8% and 0.9%, respectively while among PWID and BB, the HIV prevalence was 0% .
Sri Lanka has completed a 5-year HIV activity plan under the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) at the end of 2015, which is currently being continued, with another 3-year activity plan under the GFATM New Funding Model (2016–2018). Currently, the Family Planning Association, as the non-governmental principal recipient of the GFATM grant, is carrying out HIV prevention interventions for the most-at-risk populations (FSWs, MSM, BBs and PWIDs). The main intervention is through a peer-group model. Under this model, peer educators, who are persons identified as having knowledge and leadership qualities, are trained and a monthly allowance is given to maintain a peer group of about 15 peers under the guidance of field supervisors and coordinators for different MARPs. This article examines the MSM peer model, which provides an HIV prevention package (HPP) for MSM that includes six items:
Peers are referred to as ‘reached’ if the first five services are delivered (reached peers). Once the reached peers are escorted to an STI clinic they are referred as ‘escorted’ (escorted peers) .
Although escorting of MSM to the government STI clinic for HIV testing and counselling is one of the important aspects of the HIV prevention package, the percentage of MSM escorted remained at 23–39% during the past 3 years (2013–2015). Table Table11 describes the number and percentage of MSM escorted from 2013 to 2015 against the number of MSM reached with HPP .
The details of MSM who have been reached with the HPP regularly but who failed to be escorted during 3 consecutive years needs to be examined to take programmatic decisions.
The purpose of this paper is to analyse the MSM peer cohort in order to examine the factors associated with clinic escorts (HIV testing) in peer-led HIV prevention interventions for MSM in Sri Lanka.
Web-based monitoring and evaluation information management systems (MEIMS) maintained at the Family Planning Association of Sri Lanka (FPA) are the main databases for the peer-led project and which have capacity for data filtering and export. Data for the MEIMS are entered by the project coordinators of the community-based organisation (CBO), at the district level, using peer calendars of the peer educator. A peer calendar is a sheet of paper with peer names, peer visit date and the service code of the HIV prevention package. These data are secondarily verified by the monitoring and evaluation staff at the project for quality. Furthermore, re-checking of peer calendars and on-site data verifications are carried out by the monitoring and evaluation staff to improve data quality.
The MEIMS maintain the peer cohorts from the time of peer registration with follow up data entry during the project period (from 2013 to end 2015). The system is updated by the CBOs at the district level two times per month. The clinic escort data are verified and entered in the MEIMS at the Family Planning Association using the escort slips issued by the respective STI clinics .
Details of a total of 714 MSM peers (including peer educators) registered and retained in the service during the project period (reached during 3 consecutive years 2013–2015) were filtered and exported to an Excel work sheet and then to SPSS v20 for further analysis. Fifteen records were excluded from the analysis due to data quality issues. A total of 699 MSM were considered in the final analysis.
All the categorical data were analysed to generate frequency and percentages while numerical data were analysed to present central tendency and dispersion. Both categorical and numerical variables were compared between the group of ‘reached but not escorted peers’ and the group of ‘reached and escorted peers’ (escorted to the STI clinic for HIV testing) to identify whether the variables are dependent at the level of significance of P=0.05 using chi-square tests for categorical data and using Mann–Whitney U tests for numerical data.
A total of 699 MSM peers retained in the service during the project period (2013–2015) were filtered for the analysis and sample characteristics are shown in Table Table22.
District variation among the non-escorted group and the escorted group are significant (dependent) and showing high escort rates in Galle and Gampaha (Table (Table33).
Young MSM (<25 years) were more likely to have an HIV test during the project (P<0.05). Escort status also depended on the level of education (P<0.05). Those who were educated up to GCE/’O’ level and above were more likely to be escorted for an HIV test. Rural-living MSM (79%) were also more likely to be escorted for an HIV test than semi-urban (74%) and urban MSM (69%). However, marital status and escort status were independent variables and no significant difference was observed. Nachchi MSM (effeminate males) were less likely to be escorted for HIV testing than the other MSM. This may be due to high levels of stigma from society towards Nachchi people (Table (Table44).
Duration of MSM behaviour, uptake of an HIV test during the previous 12 months (at the time of registration) and number of occasions of receptive anal sex during the previous week were dependent on escort status. MSM with a short duration of risk behaviour (<5 years) and relatively longer duration of risk behaviours (>20 years) were more likely to be escorted for an HIV test. In addition, those with a high frequency of insertive sexual encounters (>10 per week) were also more likely to be escorted. Experience of an HIV test during the previous 12 months seemed to reduce the willingness to be escorted (Table (Table55).
The peer-led HIV prevention intervention project paid a monthly allowance and trained peer educators (PE). Each PE had to maintain contact with another 15 MSM and provide the components of the HPP. There were 248 MSM peer groups scattered in four major districts (Colombo, Gampaha, Kalutara and Galle) covering 3638 MSM. Analysis and comparison of the non-escorted and escorted groups for the hypothesis of difference shows that young MSM (<25 years), rural MSM, educated MSM as well as MSM with shorter duration of risk behaviours (<5 years) and longer duration of risk behaviours (>20 years) were more likely to be escorted to an STI clinic for an HIV test. However, for older MSM (≥25 years) and MSM living in urban and semi-urban areas as well as less educated MSM, there needs to be more emphasis about the importance of attending the STI clinic for HIV testing and different innovative strategies need to be adopted to increase the rate of HIV testing among those groups. One of the important findings is that Nachchi MSM, which includes male sex workers (MSW), are less likely to be escorted for HIV testing than other MSM. The reason may be due to the high stigma prevalent in the society towards Nachchi MSM and MSW. Therefore, this warrants special strategies for Nachchi people (especially MSW) to be escorted for an HIV test. MSM with frequent insertive behaviours (>10 per week) are more likely to be escorted and attend for testing. This may be due to relatively less stigma among insertive partners. Experience of an HIV test during the previous 12 months seems to reduce the uptake of an HIV test. In addition, it has been observed that district variation of escort rates are also largely dependent on the district level implementation (CBO), performance of PE, field supervisors and coordinators who can overcome some of the difficulties found.
Escort status of MSM is dependent on number of factors. Older MSM (≥25 years), MSM living in urban and semi-urban areas, Nachchi MSM (effeminate males), MSM with receptive behaviours as well as less educated MSM require more emphasis on the importance of attending for testing to improve escorting rates among MSM in the project. It has been observed that the variation in escort rates in different districts is also dependent on the ability of the PE, field supervisors and coordinators who can overcome factors affecting escorts.
Family Planning Association of Sri Lanka, Heart to Heart Lanka, Saviya Development Foundation, Dr KAM Ariyaratne, Consultant Venereologist, National HIV/AIDS Control Programme.
There are no conflicts of interest.