HIV prevalence is significantly higher amongst men who have sex with men in Laos (Lao People’s Democratic Republic) than any other group in the country, according to a study published in the January 28th edition of AIDS.
The study was conducted in the capital, Vientiane, and found that 6% of men who have sex with men were HIV-positive, and that attempted suicide was associated with HIV infection, a finding that the investigators believe “may point to the mental health needs of men who have sex with men.”
HIV prevalence in Laos is low compared to neighbouring countries such as Cambodia, Thailand and Vietnam. Research has suggested that 0.1% of the adult population in Laos is HIV-positive, and that approximately 1% of female sex workers are infected with HIV.
Investigators were concerned that there were no data on HIV prevalence amongst men who have sex with men in the country. They therefore designed a cross-sectional (or snapshot) study involving men reporting sex with other men recruited from commercial venues in Vientiane in 2007.
Men attending these venues were approached by trained peer educators and asked to complete a questionnaire. All the men in the study reported oral or anal sex with another man in the previous six months.
After completing the questionnaire, the men had oral HIV tests. Participants were instructed how to obtain their test result from a clinic one week later. All the men who returned received counselling and HIV-positive men were referred for confirmatory testing and medical follow-up.
A total of 540 men were included in the study. Exclusive sexual attraction to men was reported by 40% of participants, 58% reported ever having sex with a woman, and 39% reported sex with a woman in the previous three months. Sex with more than one male partner in the previous three months was reported by 42% of men.
Anal sex with another man was reported by 84% of men and, of these, 42% said they were usually the insertive partner and 44% reported usually being the receptive partner.
Receiving money for sex was reported by 22%, and 28% said they had paid for sex. Sex with a foreigner was reported by 16% of men and 29% said that they had been coerced into having sex.
Condom use was low. Only 14% of men reported using condoms with a regular partner, 24% with a casual partner and 50% when having sex with a foreigner.
Alcohol had been used by 96% of men in the previous three months; 59% smoked and 21% reported the use of illegal drugs.
Attempted suicide was reported by 17% of men. A history of symptoms of a sexually transmitted infection was reported by 42% of men; 81% expressed concern about contracting HIV, but only 6% of men had ever had an HIV test.
A total of 30 men (6%) were HIV-positive, but only four of these men returned for their test result.
The investigators’ first set of statistical analyses found that two factors were associated with a higher risk of testing HIV-positive: suicidal ideation (p = 0.02) and inconsistent condom use when selling sex (p = 0.03). However, in subsequent multivariate analysis, only suicidal ideation remained significant (OR = 2.91, 95% CI = 1.26 to 6.72, p = 0.01).
“HIV prevalence of 5.6% is the highest documented HIV prevalence for any group in the country. This elevated HIV prevalence compared with the general population is consistent with data from neighbouring countries,” comment the investigators.
A number of factors are noted by the investigators that suggest that the HIV epidemic could accelerate amongst men who have sex with men in Laos. These include the number of reported sexual partners, the number of men reporting anal sex, high levels of drug and alcohol use, frequent buying and selling of sex, large numbers of reported sexually transmitted infections, and low rates of condom use.
Suicidal ideation was the only significant factor associated with HIV infection. The investigators believe that this indicates the mental health needs of men who have sex with men in Laos. They do not believe that prior knowledge of HIV infection could explain this association “as only one HIV-positive person in our study reported having previously tested for HIV”.
Recruitment of the men participating in the study from public entertainment venues means that the men may not be representative of the wider population of men who have sex with men in the country, caution the investigators.
Nevertheless, they conclude, “this survey documents an HIV epidemic among men who have sex with men in Vientiane. The risky behaviours exhibited by these men indicate the potential for further transmission within this group. The sexual networking with women suggests that there may be transmission of HIV to the broader community unless action is taken.”
Sheridan S et al. HIV prevalence and risk behaviour among men who have sex with men in Vientiane Capital, Lao People’s Democratic Republic, 2007. AIDS 23: 409-14, 2007.