Multiple Sexual Partnerships and Elevated HIV Risks among Men Who Have Sex with Men in Southwest China APHA Annual Meeting November 3, 2015 Hongyun Fu, PhD, Eastern Virginia Medical School Kai Wang, MA, FHI 360 Lisa G. Johnston, PhD, Tulane University Kim Longfield, PhD, Population Services International Gary Mundy, MA, Helen Keller International

No relationships to disclose

Presentation Overview Background Objectives Methods Results Conclusions and Discussion

Background: HIV/AIDS in China Historically, China’s HIV epidemic was primarily driven by injecting drug use (IDU). The first HIV/AIDS cases were reported in 146 heroin users in 1989 in Yunnan province in Southwest China. Sexual transmission surpassed IDU and became the predominant mode of HIV transmission in 2007. Over 90% of new HIV cases identified in 2014 were due to sexual transmission. HIV sentinel surveillance data revealed a ten-fold increase in male-to-male sexual transmission (rising from 0.9% in 2003 to 7.7 % in 2014), although HIV rates in other key populations overall demonstrated a decreasing trend in last decade. Male-to-male sexual transmission accounted for over 45% new HIV/AIDS cases (N= 9,601) reported in Yunnan between January and October 2014. HIV rate in men who have sex with men (MSM) in Kunming reached 13.2% in 2014.

Background: HIV/AIDS in China (cont.) Source: http://www.unaids.org/sites/default/files/country/documents/CHN_narrative_report_2015.pdf Source:: http://www.globaltimes.cn/content/894536.shtml

Background: HIV/AIDS in China (cont.) Source: http://www.unaids.org/sites/default/files/country/documents/CHN_narrative_report_2015.pdf

Background: USAID-Funded HIV Program in China Program Period: 2004 – 2010 (Phase I); 2011 - 2013 (Phase II) Program Sites: Hotspots in Yunnan and Guangxi in Southwest China Target Populations: Most-at-risk populations (MARPs) for HIV infection, including people who inject drugs (PWID), MSM, female sex workers (FSWs), people living with HIV/AIDS (PLHIV) Collaborating Organizations: Population Services International (PSI), FHI 360, International HIV/AIDS Alliance (Alliance), Research Triangle Institute (RTI), and Pact, in collaboration with local governmental departments and NGOs (including peer-led grassroots organizations) Key Program Objectives: Improved access to prevention, care and treatment, using behavioral change communication (BCC) strategy. Improved strategic Information collection and use to support evidence-based programming Strengthened technical assistance and capacity building linked to local ownership and scale up

Background: Comprehensive HIV Prevention Package (CPP) Model Policy Behavioral Change communication Community Mobilization Stigma and Discrimination HIV Counseling and Testing STI Screening and Treatment MARPs PLHIV Condom Distribution Harm Reduction Strategic Information Livelihood Development Linkages to Care and Support Capacity Building 8

Background: MSM Targeted Program Activities/Services BCC intervention through peer-led education, including drop-in center activities, venue-based and online outreach events (FHI360 & Alliance) Peer-led HIV counseling & rapid testing, community-based STI diagnosis and syndromic management (FHI360) Referrals for HIV confirmatory testing and Antiretroviral treatment, other care and support services (FHI360 & Alliance) MSM community mobilization, capacity building, stigma and discrimination reduction, peer-led psychosocial support for ARV adherence for HIV+ MSM) (Alliance) Distribution of condoms/lubricants and HIV rapid test kits, conducting routine behavioral tracking (RBT) surveys to support evidenced-based program design, monitoring & evaluation, providing trainings on social marketing, collecting and using strategic information (PSI) 9

Objectives of the Study Describe the characteristics of MSM population in Southwest China, including demographic, socioeconomic background, patterns of sexual behaviors, condom use, and STI Explore what factors influence patterns of sexual behaviors and HIV-related behavioral and health outcomes among MSM Examine the associations between sexual partnership patterns and HIV risk/resilience among MSM Discuss the findings and implications for future research and public health programming

Methods A cross-sectional behavioral survey was conducted in Jan/March 2013 in MSM in Kunming and Nanning in Southwest China Respondent-driven sampling (RDS) was employed to recruit 780 adult males who reported having anal sex with a male in past 3 months Participants recruitment criteria: (1) age ≥ 18 years old, (2) biologically male at birth, (3) had anal sex with a male in past 3 months, (4) residence in Kunming/Nanning ≥ 1 month, (5) speak and comprehend mandarin Chinese to a sufficient level to respond to survey questions, and (6) give informed consent Interviews were conducted face-to-face using a structured questionnaire. The study was reviewed by the Institutional Review Board at Yunnan CDC

Methods (cont.) Seeds selection criteria: (1) peer social network ≥ 15 MSM; (2) age groups: <24; 24-40; >40; (3) educational levels; (4) type of sexual partners in past 3 months; (5) participation in program activities Number of seeds:10 for each site Recruitment coupons: 3 coupons for each participant for use to recruit peers from their social networks for participation in the survey Final sample: Total N = 780 MSM (290 in Kunming and 490 in Nanning) Data analyses used RDS Analysis Tool and STATA 13, adjusting for RDS weights and city weights

Results: Sample Characteristics

Results: Sample Characteristics (cont.)

Results: Sample Characteristics (3)

Results: Sample Characteristics (cont.)

Results: Sample Characteristics (cont.)

Results: Sample Characteristics (cont.) Notes: ** P significant at p<0.01. # STI symptoms: (1) ulcers or sores in the penile and/or scrotal area (2) extreme burning pain when urinating; (3) discharge from the penis, (4) discharge from the anus. # Correct knowledge about HIV/AIDS: (1) sharing food with an HIV-infected person,(2) shaking hands with an HIV-infected person,(3) having sex without condoms (4) being bitten by a mosquito, (5) blood transfusion, (6) sharing needles, (7) transmitting from an HIV-infected pregnant woman to her baby (8) using condoms during anal sex is an effective means of preventing HIV infection.

Results: Correlates of Bisexual Partnership Currently married: OR = 36***; 95% CI = 16-84 (Ref: never married & ever married) Homosexuality disclosure: OR = 0.44*; 95% CI = 0.20-0.98 (Ref: Only to male sexual partners) Using internet to seek gay friends: OR = 0.28*; 95% CI = 0.10-0.79 (Ref: not using internet) Role in anal sex with males: OR_receptive = 0.20***, 95% CI = 0.08-0.51; OR_insertive = 1.82, 95% CI = 0.67- 4.92 (Ref: versatile) Alcohol drinking ≥3 times weekly: OR = 0.18**, 95% CI = 0.08-0.51 (Ref: not drinking/drinking < 2 times weekly) Had sex with females in past 3 months Notes: Statistical analysis used binary logistic regression. Other control variables in the model included: age, education, income, ethnicity, city of residence, migration status, age at first anal sex with a male, transgender, drug use, knowledge about HIV/AIDS, participation in program intervention. *** P significant at p<0.001, ** at P<0.01, ** at P<0.05.

Results: Correlates of Multiple Male Sexual Partnership Notes: Statistical analyses used multinomial logistic regression model. Base outcome: one male partner only. Other confounding variables included: age, ethnicity, migration status, age at first anal sex with a male, knowledge about HIV/AIDS. ** P significant at p<0.01, * at P<0.05, ^ at P<0.10

Results: Associations between Sexual Partnerships, Condom Use and STI Sexual partnerships in past 3 months Consistent condom use with female partners (N=193) Consistent condom use with regular male partners (N=512) Consistent condom use with casual male partners (N = 469) Experienced STI symptoms (N=780) OR (95% CI) Bisexual partnership (no sex with females as ref) Had sex with females ------ 0.31 ** (0.10 – 0.90) 1.13 (0.40 - 3.20) 1.95 (0.53 - 7.27) Multiple male sexual partnership (had sex only with 1 male as ref group) Had 2-5 male partners 0.14 ** (0.03 - 0.63) 0.84 (0.34 - 2.08) 0.24* (0.06 - 0.98) 2.67 ^ (0.89 - 7.98) Had ≥ 6 male partners 0.89 (0.13 - 6.24) 0.38^ (0.12 - 1.20) 0.28 ^ (0.06 – 1.29) 5.84 * (1.46 - 23.30) Notes: statistical analyses used multivariate logistic regression. Other control variables in the model included: age, ethnicity, education, marital status, using internets to seek gay friends, migration status, age at first anal sex with a male, disclosure of homosexuality, role in anal sex with males, HIV knowledge, drug use, alcohol drinking. ** P significant at p<0.01, * at P<0.05, ^ at P<0.10

Results: Other Correlates of Consistent Condom Use and STI Independent Variables Consistent condom use with female partners (N=193) Consistent condom use with regular male partners (N=512) Consistent condom use with casual male partners (N = 469) Experienced STI symptoms (N=780) OR (95% CI) Drug/stimulant use (Non drug users as ref) Yes 0.09 * (0.05 - 0.70) 0.16 * (0.04 – 0.66) 5.82 ** (1.56 – 21.23) 4.13^ (0.77 - 22.50) Role in anal sex with males (Versatile role as ref) Insertive only 3.95^ (0.87 - 17.96) 4.08 ** (1.46 – 11.40) 2.69 ^ (0.95 - 7.61) 0.37 (0.09 - 1.45) Receptive only 0.16 (0.03 – 2.99) 1.11 (0.43 - 2.90) 0.99 (0.32 - 3.08) 0.42 (0.12 - 1.42) Program Intervention (No participation in peer-led program services as ref) Lower level exposure 1.45 (0.36 - 5.83) 2.31 ^ (0.90 - 5.88) 1.05 (0.30 – 3.63) 0.56 Higher level exposure 5.88^ (0.75 - 46.19) 4.29 * (1.12 - 16.91)* 1.81 (0.44 - 7.38) 1.96 (0.49 - 7.86) Notes: ** P significant at p<0.01, * at P<0.05, ^ at P<0.10

Conclusions and Discussions A high level of bisexual partnership and low level of consistent condom use with females -- the role of MSM as a “bridge” for HIV transmission to heterosexual women A high rate of multiple male partnerships (involving multiple types of male sexual partners) – a driving engine which facilitates HIV transmission in MSM A syndemic of drug use and STI among MSM – the needs for targeted services which integrate HIV and drug use intervention Differential associations between drug use and consistent condom use by types of sexual partners -- more in-depth understanding of the mechanism of relationship between drug use, sexual behaviors, and HIV risk/resilience among MSM. A strong association between anal sex role, sexual partnerships and condom use -- MSM’s adoptive sexual behaviors and HIV risk/resilience.

Conclusions and Discussions (cont.) Cross-sectional study Small sample size Data on sensitive behaviors (e.g. sexual behaviors and drug use) collected through self-reports and face-to-face interviews Future research: longitudinal design audio-computer assisted self-interviewing method a linked behavioral and biological survey event-level data on alcohol/drug use and sexual behaviors ……

Acknowledgement USAID and USAID-supported international organizations under CAP-3D in China: PSI, FHI 360, Alliance, RTI, and Pact Local partners: Yunnan HIV and STI Prevention Association, CDCs, PHBs, Yunnan and Guangxi MSM technical working groups MSM community and our study participants in Kunming and Nanning The Colorful Sky in Kunming Bright Color Sky in Kunming The Spring Ring in Kunming Green City Rainball in Nanning Shanshui Qinghua in Nanning Health Action in Nanning Field data collection and data entry team: graduate students at Yunnan University, Yunnan Normal University and Yunnan University of Nationalities

Thank you! Questions? page 26