1. Working world wide against HIV for the health and human rights of men who have sex with men Working world wide against HIV for the health and human rights of men who have sex with men Better Together: Using CBPAR to Understand the Predictors of HIV Service Access Among MSM Worldwide George Ayala, PsyD Executive Director, Global Forum on MSM & HIV

2. Working world wide against HIV for the health and human rights of men who have sex with men Today’s Talk About the MSMGF HIV among MSM Globally Community-based Participatory Action Research 2012 Gay Men’s Health and Rights Study – Aims and Methods – Results – Implications

3. Working world wide against HIV for the health and human rights of men who have sex with men About the MSMGF

4. Working world wide against HIV for the health and human rights of men who have sex with men About the MSMGF The Global Forum on MSM & HIV (MSMGF) works for equitable access to effective HIV prevention, care, treatment and support services to gay men and other MSM, including gay men and MSM living with HIV, while promoting their health and human rights worldwide.

5. Working world wide against HIV for the health and human rights of men who have sex with men About the MSMGF Expanded coverage of quality HIV—related services Realized promotion and protection of human rights Increased investment for effective health and rights-focused programs Improved knowledge of MSM and HIV through the promotion of research, broad-based information exchange and communication Engaged, well-prepared MSM advocates, linked to each other and to broader MSM networks at the global, regional, and national levels

6. Working world wide against HIV for the health and human rights of men who have sex with men About the MSMGF Advocacy Technical support and education Community-based research Communications Convening stakeholders

7. Working world wide against HIV for the health and human rights of men who have sex with men About the MSMGF Because we foreground: – Human rights – Self-determination – Working in coalition We employ approaches that are: – Community-led – Strengths-based – Sex positive – Critically reflexive – Action oriented

8. Working world wide against HIV for the health and human rights of men who have sex with men Community-based Participatory Action Research (CBPAR)

9. Working world wide against HIV for the health and human rights of men who have sex with men CBPAR Principles Community involvement at all stages of research Honors local knowledge Focused on questions and solutions generated by its members Strengthens local capacity Facilitates mutual learning Elevates awareness about social conditions influencing health Develops culturally appropriate measures and interventions geared to reducing inequities and promoting social justice

10. Working world wide against HIV for the health and human rights of men who have sex with men HIV Among MSM Worldwide

12. Working world wide against HIV for the health and human rights of men who have sex with men The Global Epidemic Among MSM MSM are19 times more likely to be HIV-positive than the general population in low & middle-income countries * Only 24-55% of MSM are reached by HIV prevention/care services ** Only 37% of MSM report HIV testing in the past 12 months ** *Baral, 2008 ** UNAIDS 2011

13. Working world wide against HIV for the health and human rights of men who have sex with men 2012 GMHR Survey

14. Working world wide against HIV for the health and human rights of men who have sex with men Study Aims Identify factors that hinder and facilitate access to HIV services Move beyond individual level predictors of MSM sexual health Reflect MSM voices from around the world in discourse about HIV, health and human rights

15. Working world wide against HIV for the health and human rights of men who have sex with men Methods ≈ 30-minute online survey Chinese, English, French, Georgian, Russian & Spanish Gay men & other MSM worldwide MSMGF networks, list serves, e-mail, blasts & website Administered from April to August of 2012 Data Analysis – Frequencies – Chi Square Test For Association, Wilcoxon Rank Sum Test – Regression models

16. Working world wide against HIV for the health and human rights of men who have sex with men Iterative Scale Development Identified major domains Developed scales & measures based on: – 2010 MSMGF online survey – Previous qualitative interviews with MSM globally – Other MSM online surveys Iteratively revised survey based on external reviews Beta tested online survey instrument Collected feedback from survey participants for next version of survey

17. Working world wide against HIV for the health and human rights of men who have sex with men Measures Scale Description – Hypothesized Barriers Cronbach Alpha Homophobia (e.g., In your country, how many people believe that a person who is gay/MSM cannot be trusted; how are gay men/MSM treated?) 1=None – 5=All; 1=Very well – 5=Very poorly.85 Violence MSM (e.g.., In the past 12 months, how often were you physically assaulted (slapped, punched, pushed, hit or beaten) for being gay/MSM?) 1=Never; 2=Once; 3=2-3 times; 4=4 to 5 times; 5=More than 5 times.81 Violence HIV (e.g., In the past 12 months, how often were you physically assaulted (slapped, punched, pushed, hit or beaten) for being HIV+?) 1=Never; 2=Once; 3=2-3 times; 4=4 to 5 times; 5=More than 5 times.75 Provider Stigma (e.g., In your country, has a health provider ever treated you poorly because of your sexuality?).72

18. Working world wide against HIV for the health and human rights of men who have sex with men Measures Scale Description – Hypothesized Facilitators Cronbach Alpha Outness (e.g., How many of your family members know that you are attracted to men?; Co-workers? Friends?) 1=None; 2=Few; 3=Less than half; 4=More than half; 5=All or almost all.84 Community Engagement (e.g., During the past 12 months, how often have you participated in gay social groups or activities such as a book or cooking club?) 1=Never; 2=Once or twice; 3= About 6 times; 4=About 12 times; 5=More than 12 times.76 Connection to Gay Community (e.g., How connected do you feel to the gay community where you live? How proud are you of the gay community?) 1=Extremely disconnected; 2=Somewhat disconnected; 3= Neither; 4=Somewhat connected; 5=Very connected.78 Comfort with Provider (e.g., In your country, how comfortable would you feel discussing HIV with your health care provider?) 1=Very uncomfortable; 2=Somewhat uncomfortable; 3=Neither; 4=Somewhat comfortable; 5=Very comfortable.81

19. Working world wide against HIV for the health and human rights of men who have sex with men Measures Scale Description – Hypothesized Facilitators 1=Very unhappy; 2=Somewhat unhappy; 3= Neither unhappy nor happy; 4=Somewhat happy; 5=Very happy Cronbach Alpha Sexual Happiness (Quality ) How happy would you be in a steady relationship? How happy are you with the kind of sex you are having?; How happy are you with the level of intimacy you have with your sex partners?) 0.65 Sexual Happiness (Quantity) How happy are you with your sex life? How happy are you with the amount of sex you have? How happy are you with the number of sex partners you have? 0.88

20. Working world wide against HIV for the health and human rights of men who have sex with men Measures Scale Description – Access 1=Completely inaccessible; 2=Somewhat inaccessible; 3= Neither inaccessible nor accessible; 4=Somewhat accessible; 5=Completely Accessible Condoms In your community, how accessible are free or low cost condoms? Lubricants In your community, how accessible is free or low cost condom-compatible lubricants? HIV Testing In your community, how accessible is free or low cost HIV testing? HIV Treatment In your community, how accessible is free or low cost HIV treatment?

21. Working world wide against HIV for the health and human rights of men who have sex with men GMHR 2012 Participants N=6067 71% (n=4320) participants completed the survey 165 countries represented Mean age 35 (12-90 years old) 83% self-identified as gay 18% reported living with HIV

22. Working world wide against HIV for the health and human rights of men who have sex with men Easy Access to HIV Services All U.S.Other p-value Access to Condoms 175236.3 28152%147134%<0.001 Access to Lubricants 103821.8% 16430%87421%<0.001 Access to HIV Testing 170137.2% 28354%141835%<0.01 Access to HIV Treatment* 30241.5% 5132%25144%0.014 *Access to HIV treatment analyzed only for respondents who reported being HIV-positive.

23. Working world wide against HIV for the health and human rights of men who have sex with men Easy Access to HIV Services Ethnic/Racial Minority (n=208) Other (n=421) p-value Access to Condoms 60%47%0.011 Access to Lubricants 37%26%0.020 Access to HIV Testing 57%52%0.279 Access to HIV Treatment* 33%32%0.863 *Access to HIV treatment analyzed only for respondents who reported being HIV-positive.

24. Hypothesized Predictors of HIV Service Access Among MSM by Serostatus AllHIV- MSMHIV+ MSM MeanSDMeanSDMeanSDp-value* Barriers Homophobia 3.060.753.060.762.90.740.000 Violence - MSM 1.480.761.470.751.530.790.009 Violence - HIV 3.271.15 Provider Stigma 0.20.360.180.340.320.420.000 Facilitators Outness 3.411.373.291.383.991.170.000 Community Engagement 1.630.581.60.561.770.630.000 Connection to Community 3.410.863.370.863.580.830.000 Comfort with Provider 3.130.993.060.983.430.990.000 Sexual Happiness - Qual 3.591.123.61.113.511.130.031 Sexual Happiness - Quant 3.291.173.291.173.271.150.628 *Wilcoxon Rank Sum Test

25. Predictors of Access to Condoms - AOR AllHIV- MSMHIV+ MSM AORCIAORCIAORCI Barriers Homophobia 0.70[ 0.62 - 0.78 ]0.67[ 0.59 - 0.77 ]0.86[ 0.64 - 1.14 ] Provider Stigma 0.74[ 0.59 - 0.91 ]0.79[ 0.61 - 1.01 ]0.68[ 0.44 - 1.05 ] Facilitators Outness 0.91[ 0.86 - 0.96 ]0.90[ 0.84 - 0.96 ]1.04[ 0.88 - 1.22 ] Community Engagement 1.30[ 1.13 - 1.48 ]1.27[ 1.09 - 1.48 ]1.42[ 1.06 - 1.91 ] Connection to Community 1.17[ 1.07 - 1.29 ]1.17[ 1.06 - 1.31 ]1.19[ 0.95 - 1.5 ] Comfort with Provider 1.45[ 1.33 - 1.58 ]1.43[ 1.3 - 1.58 ]1.67[ 1.35 - 2.09 ] Sexual Happiness - Quant 1.16[ 1.06 - 1.26 ]1.15[ 1.05 - 1.26 ]1.20[ 0.96 - 1.51 ]

26. Predictors of Access to Lubricants- AOR AllHIV- MSMHIV+ MSM AORCIAORCIAORCI Barriers Homophobia 0.50[ 0.44 - 0.58 ]0.50[ 0.43 - 0.58 ]0.55[ 0.39 - 0.77 ] Facilitators Outness 0.86[ 0.8 - 0.92 ]0.85[ 0.79 - 0.92 ]0.93[ 0.77 - 1.13 ] Community Engagement 1.26[ 1.08 - 1.46 ]1.26[ 1.06 - 1.5 ]1.29[ 0.92 - 1.78 ] Connection to Community 1.12[ 1 - 1.25 ]1.13[ 1 - 1.28 ]1.05[ 0.81 - 1.37 ] Comfort with Provider 1.47[ 1.33 - 1.64 ]1.48[ 1.32 - 1.66 ]1.60[ 1.24 - 2.08 ] Sexual Happiness - Quant 1.18[ 1.06 - 1.31 ]1.19[ 1.06 - 1.34 ]1.10[ 0.86 - 1.43 ]

27. Predictors of Access to HIV Testing - AOR HIV- MSM AORCI Barriers Homophobia0.59[ 0.52 - 0.68 ] Facilitators Connection to Gay Community1.23[ 1.1 - 1.37 ] Comfort with Provider1.85[ 1.67 - 2.05 ]

28. Predictors of Access to HIV Treatment – AOR HIV+ MSM AORCI Barriers Homophobia0.59[ 0.44 - 0.78 ] Facilitators Comfort with Provider1.63[ 1.32 - 2.01 ]

29. Working world wide against HIV for the health and human rights of men who have sex with men Conclusions Some predictors of access (i.e., provider stigma, community engagement, connection to gay community) may be specific to HIV service type and to subgroup Homophobia is a significant barrier to and comfort with providers is a significant facilitator of access across service type for both HIV- and HIV+ MSM

30. Working world wide against HIV for the health and human rights of men who have sex with men Implications HIV programs should be comprehensive, targeted and tailored to the needs of MSM We should work to create enabling policy and service environments to increase access to HIV services Addressing homophobia and provider sensitivity/competence should be prioritized

31. Working world wide against HIV for the health and human rights of men who have sex with men Acknowledgements Study participants and community partners Keletso Makofane, MPH Sonya Arreola, PhD, MPH Pato Hebert, MPH Jack Beck Tri D. Do, MD, MPH Milo Santos, MPH Tom Pyun, MPH Patrick Wilson, PhD

32. Working world wide against HIV for the health and human rights of men who have sex with men THANK YOU!