Transcript the presentation - IUSTI Marrakesh 2016 :: Home

« Don’t Catch Me If You Can»
MSM and Common STIs in Lebanon
Ayman Assi, Sara Abo Zaki, Diana Abou Abbas
2014-2016 Award Winner
BACKGROUND
MSM in Lebanon
• Penal Code 534 criminalizes sexual practices «against
nature».
– Commonly used against MSM.
• Penal Code 534 contributes to stigma against MSM
and is a barrier to access to medical/mental sexual
health services
– which hinders prevention & early detection of STIs.
Sexual Education
• Is not integrated in the curricula at schools and
universities
• Condom use promotion is not endorsed in Lebanon
since the 1990s
Marsa (a Dockyard in Arabic)
• A study led by Ford Foundation (El Kak F.,
2009) found that over 50% of physicians
– refused to tend to LGBT patients
– did not have relevant knowledge in STI
management among key populations.
• Marsa opened in 2010 and was launched
officially in February 2011.
• It is located in Beirut, Lebanon
• Data collection began on March 1st 2011.
• Electronic Medical Records launched in
2015
• New data is continuously being recorded
electronically and the older data
digitization is still ongoing
Services at Marsa
Holistic approach to sexual health :
• Voluntary Counseling and Testing
• Medical Consultations (STI Screening)
• Psychosocial Support (PLHIV)
• Sexual Health Education
• Sexual Health Promotion
• Tailored referral system
 Anonymous, confidential, subsidized prices
Literature
• Few data on STI/HIV prevalence and
sexual behavior of MSM in Lebanon:
– Wagner et al., 2014:
• RDS on 142 MSM
• 95 had UAI in the last 3 months
• 32 who had UAI with unknown or positive
(UAIUP) partner
• 3 men (2.1%) were HIV+
• University education was associated with
having UAI
 Population was not representative (same age
and same social class)
– Mahfoud et al, 2010 / Mumtaz et al., 2011:
• RDS on 101 MSM and other populations (Sex
workers, IDU)
• HIV prevalence : 3.7%
 No work on sexual behavior of MSM nor on STI
prevalence
AIM
• To evaluate STI, including HIV, prevalences in MSM in
Lebanon
• To examine different components of MSM’s sexual
behaviors & their possible associations with different
STI prevalences
METHODS
Methods
• VCT: Voluntary Counseling and Testing
– Rapid tests:
• HIV: 3rd generation
• HBV/HCV
• Syphilis
– Counselor-administered questionnaire
– Discussion about STI including HIV: ways of
transmission and protection
– Duration of interview with testing: 20-30
minutes
• Referral to the lab for confirmatory tests
in case of positive results (PCR, Western
Blot)
• Medical + Psychosocial support
Collected Data: Demographics
• Age
• Level of Education:
University, Primary,
Secondary, Technical
• Employment Status
Employed, Between Jobs,
Student, Jobless
• Source of Sexual Education
Marsa, Friends/Peers,
Health Care Worker,
Internet, School, University,
Various Sources
Data: Substance Use
• Type of Drug Use
NoDrugs, Various, Stimulant, Muscle Relaxant,
HalluciNogen, Depressant
• Smokes Cigarettes
No, Yes
• Smokes Water-pipe
No, Yes
• Consumes Alcohol
No, Yes
Data: Condom USe
• with Steady Partner
Always, At Times, Never, Not Applicable
• with Regular Partner
Always, At Times, Never, Not Applicable
• with Casual Partner
Always, At Times, Never, Not Applicable
• Use Lubricants During Penetrative Sex
Always, At Times, Never, Not Applicable
Data: Sexual Practices
• Performed Oral Sex On
None, Anus, Penis, Vagina,
Anus/Penis, Penis/Vagina,
Anus/Penis/Vagina
• Received Oral Sex On
None, Anus, Penis, Vagina,
Anus/Penis, Penis/Vagina,
Anus/Penis/Vagina
• Anal Sex
No Risky Exposure, Insertive RE,
Receptive RE, Insertive/Receptive
RE
Data: Knowledge and Behavior
• VCT officers assess the behavior of
the beneficiaries regarding:
Condom-Readiness, Condom
Negotiation, and Condom use
• VCT officers also assess the
knowledge of the beneficiaries on
different topics regarding their
sexual health: HIV/AIDS, HBV, HCV,
STIs, Condom Use
• These assessments of knowledge
and behavior are tracked with every
visit
Medical Consultations
• MSM seek M.C for symptoms of STIs
• Performed by medical professionals: family doctors
or dermatologists/STI specialists
• Treatment is provided based on clinical diagnosis
• Further testing is requested when necessary
• Samples collected at the center and testing is
performed at laboratory :
– Swabs: anal, oral, penile
– Urine tests
Outcome Variables
• HIV, HBV, HCV, Syphilis statuses
• Symptoms suggestive of Gonorrhea,
Chlamydia, HPV, Pubic Lice
• A general STI status variable was computed:
– if a beneficiary has one or more of the above
mentioned STIs, STI status is recorded as 1
– Otherwise, 0
• Statistics: SPSS and Xlstat
– Normality: Shapiro-Wilk
– Comparison between 2 independant samples :
• t-test or Mann-Whitney U
– Contingency : Chi-squared or Fisher
– Binary and Multinomial logistic regressions,
validated with Hosmer-Lemeshow goodness of fit
RESULTS & DISCUSSION
Results:
Demographic characteristics
Population
• 1,793 clients:
Feb 2015 till April 2016=
15 Months
Histogram : Age of MSM beneficiaries
• 757 MSM
0.4
0.3
Frequency
– 42% of all beneficiaries
– 197 returning
beneficiaries
– 560 new beneficiaries
0.35
0.25
0.2
0.15
0.1
0.05
Age Range
16 - 62 years
Median
Mean ± SD
26
26.8 ± 6.7
0
0
10
20
30
Age
40
50
60
70
Level of Education: 757 MSM
Secondary
Primary
6%
2%
Technical
3%
Not
Available
6%
University
83%
Majority of MSM beneficiaries at Marsa have a high level of education
Employment status: 757 MSM
Student
28%
Employed
26%
Between Jobs
3%
Not Available
38%
Jobless
5%
Not all of MSM disclosed their employment status
Reason for VCT: 757 MSM
Other
4%
Condomless
Sex
51%
Partner
suspected of
having STI
3%
Routine Check
30%
Partner with
STI
5%
Symptoms of
STI
6%
Most MSM seeking services at Marsa are at risk
Sources of Sexual Education: 757 MSM
Various Sources:
Friends
Family
University
School
Pornography
Internet
Marsa
Sexual Education is not
integrated in the curricula at
most of the schools and
universities in Lebanon
Marsa
16%
Various
Sources
51%
Internet
(incl. porn)
18%
School
10%
University
5%
Smoking
Cigarettes
Water pipe
No
42%
Yes
58%
Yes
52%
High prevalence of smoking among MSM in Lebanon
No
48%
Use of recreational drugs
Muscle
Relaxant
6%
Stimulant
5%
Various
0%
Hallucinogen
11%
Stimulant:
Speed
Ecstacy
Cocaine
Hallucinogen:
Hashish
Marijuana
MDMA
Depressant
3%
NoDrugs
75%
Depressant:
Heroine
GhB
Muscle Relaxant:
Poppers
¼ of MSM reported using recreational drugs
Alcohol Consumption
No
20%
Not
Available
13%
Yes
67%
High prevalence of alcohol consumption
No significant correlation between alcohol consumption and drug use
Chi2 test: p=0.92
Results:
Sexual practices
Condom use with partners
Monogamous
Not monogamous
One time
steady partner
regular partner(s)
Casual partner(s)
Never
4%
Always
17%
Not
App
51%
At
Times
20%
Never
12%
Not
App
33%
Never
5%
Always
31%
At
Times
31%
Not
App
14%
At
Times
36%
Only 31% / 46% reported Always using condoms with
their regular / casual partners resp.
Always
46%
Use of Lubricants
Not
Available
18%
Always
30%
Never
9%
At Times
43%
Only 1/3 of MSM reported always using lubricants during anal sex
Causes of condomless behavior
• Multinomial regression model
– Dependant variable: condom use with casual partner
– Independant variables: age, educational level, occupation,
sexual education source, drug use, alcohol consumption
• Result:
– Those who get their sexual education only from friends
and peers, are 8 times more likely (Adj OR: 8.2) to never
use a condom with casual partners
• (compared to those who got their sexual education from various
sources)
Reported Reasons for not using condoms
Can not
negotiate
condoms with
partner
8%
I was under the
influence
26%
Heat of the
moment – A
foreplay gone
too far
66%
Condom availability does not appear to be a reason
Reported risky exposure during anal sex
Receptive RE
23%
No risky
exposure
38%
Insertive RE
19%
Insertive/
Receptive RE
20%
Risky exposure was considered as condomless sex or condom misuse
Majority of reported anal sex was risky
Oral Sex exposure
Performed
Received
No oral
received
oral sex
23%
No Oral sex
performed
22%
Penis
69%
Anus/
Penis
9%
Penis
67%
High risk exposure to STIs: Gonorrhea, Chlamydia, HPV
Anus/
Penis
10%
Based on the tracker assessment filled by the VCT officer
Results:
Behavior and Knowledge
Behavior: Condom Readiness
Beneficiary always has a condom on him all the time
No
2%
More agency
needed
54%
Practicing
independently
44%
More than ½ of MSM do not carry a condom at all times
Behavior: Condom Negotiation
Beneficiary negotiates condom use with partner
No
2%
Practicing
independently
42%
More agency
needed
56%
More than ½ of MSM are reluctant to negotiate condom use with partners
Behavior: Oral & Anal Hygiene
Beneficiary applies correctly rules of hygiene
No
3%
Practicing
independently
21%
More agency
needed
76%
More than ¾ of MSM do not follow recommendations of
appropriate anal and oral hygiene
Knowledge: Condom use
Demonstration on a penile model
Has No info
12%
Aware/Verbalise
29%
Requires more
info
59%
The majority of MSM need further training on condom use
Knowledge: HIV
Has No
info
9%
Aware/Verbalise
28%
Requires more
info
63%
The majority requires more information about HIV
Knowledge about HBV
Aware/Verbalise
16%
Has No info
28%
Requires more
info
56%
The majority requires more information about HBV
Knowledge about HCV
Aware/Verbalise
13%
Has No info
31%
Requires more
info
56%
The majority requires more information about HCV
Knowledge about other STIs (Gonorrhea, Chlamydia, Syphilis…)
Aware/Verbalise
15%
Has No info
26%
Requires more
info
59%
Very few have enough information about other STIs
Results:
STI prevalences
STI Prevalences
• Rapid testing (followed by confirmation tests if
positive results):
–
–
–
–
HIV: 39/757 = 5.2%
HCV: 2/456= 0.4%
HBV: 2/663= 0.3%
Syphilis: 10/501= 2%
> Previous studies
• Medical consultations for 144 beneficiaries:
– Discharge: 19/144= 13%
• treated for Gonhorrea and/or Chlamydia
– Warts (HPV): 58/144 = 40%
– Pubic Lice: 5/144= 3.5%
Correlation: HIV status vs Reason for testing
Condomless Sex
Other
Partner suspected to have STI
Partner with STI
Routine Check
Symptoms of STI
HIV338
20
23
36
198
38
HIV+
15
4
1
2
12
2
Chi-squared test:
not significant p=0.3
The reason for testing could not predict whether the beneficiary was HIV+
HIV+: possible factors
• No significant difference in age between HIV+ and HIVclients (p=0.4)
No predilection for a certain age for HIV+ clients
• Level of education is not a determinant factor of HIV
(Fisher test: p=0.9)
Neither high nor low educational level
were associated with HIV status
• 39 HIV+ cases reported:
– Overly trusting their partners
– Condom compromises sensation
– Heat of the moment: a foreplay gone too far
Correlation: HIV and last exposure
All MSM (757)
Receptive RE
23%
Insertive RE
19%
Interview about last exposure
0
Insertive/
Receptive RE
20%
Insertive RE
Insertive/Receptive RE
No reported risky exposure
Receptive RE
1
136
143
276
163
6
11
10
12
No risky
exposure
38%
Transmission may have occured from previous exposure
Factors of STI status
• Binary Logistic Stepwise Model:
– Dependent variable: STI status
– Independent variables:
– Age (Covariate), Sexual Education, Occupation,
Education, type of drug used, oral sex (performed or
received), anal sex (Insertive/Receptive), Condom use :
with steady / regular or casual partner, use of
lubricants, Cigarettes, Waterpipe, Alcohol
• Results based on our sample:
– HLT: p = 0.187 not significant => there is a goodness of
fit
– Those who use stimulant drugs (Odds Ratio: 2.9) are at
a significantly higer odds of having STIs compared to
those who do not use drugs
Factors of HIV infection
• Binary Logistic Stepwise Model:
– Dependent variable: HIV status
– Independent variables:
• Age (Covariate), Sexual Education, Occupation,
Education, type of drug used, oral sex (performed or
received), anal sex (Insertive/Receptive), Condom use :
with steady / regular or casual partner, use of
lubricants, Alcohol
• Results based on our sample:
– HLT: p = 0.270 not significant => there is a
goodness of fit
– In accordance with general knowledge: those who
use condoms « at times » (Odds Ratio: 3.1) and
« never » (OR: 4.7) with casual partners are at a
significantly higher odds of having HIV compared
to those who Always use a condom
Factors of HPV infection
• Binary Logistic Model:
– Dependent variable: HPV status
– Independent variables:
• Age (Covariate), Sexual Education, Occupation,
Education, type of drug used, oral sex (performed or
received), anal sex (Insertive/Receptive), Condom use :
with steady / regular or casual partner, use of
lubricants, Alcohol
• Results:
– HLT: p>0.05 => there is a goodness of fit
– After adjusting for all variables,
– No significant associations between independant
variables and HPV
• Limitation:
– small sample: 58 HPV cases/144
Factors of Gonorrhea/Chlamydia infection
• Binary Logistic Model:
– Dependent variable: Gonorrhea and/or
Chlamydia
– Independent variables:
• Age (Covariate), Sexual Education, Occupation,
Education, type of drug used, oral sex
(performed or received), anal sex
(Insertive/Receptive), Condom use : with
steady / regular or casual partners, use of
lubricants, Alcohol
• Results based on our sample:
– HLT: p = 1.0 => there is a goodness of fit
– As expected: those who got their sexual
health education from Various sources
(Odds Ratio: 0.037) significantly Lower odds
of having Gonorrhea/Chlamydia
CONCLUSION
Conclusion
• Based on these results:
– More work has to be done in MSM
community on:
• Knowledge
• Behavior
• Work on sexual health promotion on
different levels:
–
–
–
–
–
At the center
Online media
Direct outreach
Health promotion material
Promotion of routine testing:
• On regular basis, not only when there’s
exposure
• Capture the actual prevalence of STIs
Future work
• Improving data collection methods to better capture
different possible determinants of STI transmissions
– Among MSM
– And other population groups
• Data Publication
• Advocacy among governmental institutions
TeamWork
•
•
•
•
•
•
Full timers: Lama Ftouni, Diana Abou Abbas, Sara AboZaki, Zeinab Farhat, Cynthia El Khury
VCT officers: Rabih Maher, John AbouElias, Fatima Khalil, Gisele Najm, Mohamad Khalil,
Nohra Ghaoui, Christian AbiNader, Saja Michael, Johnny Tohme, Ammar Zahreddine
Data entry: Cyril Hanna, Anthony Kassab, Ziad Bakouny & all VCT officers
Doctors: Jihane Naous, Antoine Ghanem, Ismael Maatouk, Eliane Eid, Grace AbiRizk
Therapists: Miled Abou Jaoudeh, Maha Rabbat, Pascale Kolakez
Board and Advisory board: Nizar Kinge, Georges Azzi, Mazen Khaled, Christine Tohme,
Mohamad Naja, Roland Tomb
THANK YOU
www.marsa.me
[email protected]