HIV knowledge and risks among Vietnamese men who have sex with men travelling abroad

Abstract

Rapid economic and social development in Vietnam has resulted in increased opportunities for travel and new potential routes of HIV transmission. We conducted a cross-sectional study examining demographics, knowledge, and sexual risk behaviour amongst 100 Vietnamese men who have sex with men who traveled abroad in the previous 12 months. Men who have sex with men surveyed were mostly university-educated, single, and under 30. Most travel (73%) was within Southeast Asia and was undertaken for tourism (51%) or for work (29%). Casual sex with a foreign partner occurred on 39% of trips. Only four were reported to have involved in unsafe sex with a casual partner. Four reported illicit drug use. Alcohol was widely consumed. Multivariate analysis showed that two variables, travelling alone (OR = 5.26, p < 0.001) and a university education (OR = 4.05, p = 0.004), were significantly associated with casual sex abroad. More HIV prevention education on the risks of sex while travelling abroad is needed for men who have sex with men in Vietnam.

Keywords

HIV AIDS sexually transmitted infection homosexual men who have sex with men MSM sexual behaviour travel Asia

Introduction

In the past decade, Vietnam has undergone major socioeconomic changes that have opened up Vietnamese society, increased living standards, and further integrated the country into a globalized world.¹ These changes have affected the lifestyles of men who have sex with men (MSM), particularly in the major cities of Hanoi and Ho Chi Minh City (HCMC). This can be seen in increasing numbers of gay bars, greater public awareness of the existence of sexual minorities, and a growing number of Vietnamese-language websites that target gay and bisexual men.²

As more people move into the middle class there has been an increase in regional and international travel among the Vietnamese population.³ The explosion of cheap budget airlines in the region as well as relaxed visa regulations for travel within the Association of South East Asian Nations (ASEAN) have made international trips much more accessible and popular. This is a concern as travel has been implicated as one reason why HIV infection rates among MSM in the developed world are not declining.⁴ These reduced barriers to travel combined with Internet interconnectivity pose new potential opportunities for HIV transmission. Many Vietnamese, MSM included, travel to nearby Cambodia and Thailand, countries known for sex tourism.⁵ Thailand has an adult HIV infection rate of around 1.3%, triple Vietnam’s 0.4% prevalence rate. Cambodia also experienced a large spike in HIV infections in the 1990s and has an adult HIV prevalence rate of 0.5%.⁶

Throughout the world MSM have higher HIV infection rates than other men and the countries of South East Asia are no exception.⁷ Recent estimates of the HIV prevalence rate of MSM in major Vietnamese cities place it at 14.3% and 19.8% in HCMC and Hanoi, respectively.⁸ MSM in Bangkok have a reported seroprevalence of 30%.⁹

MSM in Vietnam exhibit high rates of unsafe sexual behaviour. In fact, integrated biological and behavioural surveys (IBBS) between 2006 and 2009 have shown a drop from 38% to 30% in consistent condom-use during anal sex among HCMC MSM.^8,10 A survey of MSM in Malaysia showed similarly inadequate safe sex practices and knowledge.¹¹ This indicates potential new risks as poorly informed and high-risk MSM populations increasingly intermingle amongst the Southeast Asian countries.

Unsafe sex among MSM is the cause of a growing percentage of new HIV infections in East and Southeast Asia.¹² Rising use of alcohol and illicit drugs in the region compound the risk for HIV transmission.^13,14 By 2020, it is projected that more than 50% of all new infections in Asia will be due to homosexual sex between men.¹² Increased travel combined with lagging knowledge amongst MSM poses a major source for new HIV infections in Vietnam, particularly if travelling to regional countries with similarly poor safe sex practices and higher HIV infection rates.

There have been no published data about the sexual behaviour, knowledge, and habits of travelling MSM in Southeast Asia. This survey, the first of its kind for the region, evaluates the knowledge about HIV transmission and sexual risk behaviour while travelling amongst Vietnamese MSM who had been abroad within the prior 12 months.

Methods

Study participant selection

This is a cross-sectional study of 100 Vietnamese MSM. Their inclusion criteria were: self-identified as MSM (having had oral/anal sex or masturbated with another man within the prior 12 months), over 15 years of age, and had travelled abroad at least once in the prior 12 months. These MSM were selected by the snowball method: an initial 10 Vietnamese MSM who met these criteria were surveyed, who in turn contacted MSM they knew to refer to our study. The snowball method was chosen due to the difficulty of finding MSM who met the criteria. Existent NGO-linked MSM social networks were used to reach out to potential participants. The initial 10 MSM were chosen from different age groups and geographic areas of HCMC in order to recruit a diversity sample of MSM. Subsequent waves were surveyed until the sample size was reached. The response rate was high, as 90% of MSM contacted agreed to participate. All subjects received written and verbal information about the study and signed a written informed consent form prior to participation.

Study design

Subjects were interviewed using a standardized questionnaire that asked basic demographic information, recent travel activity, sexual behaviour while travelling, condom use, and knowledge about the HIV virus and how it is transmitted. Each participant could provide information on up to three trips taken within the previous 12 months. Data from multiple trips was collected because this was an exploratory study and the researchers planned to analyze both inter-individual and inter-trip variability in sexual behaviour. A limit of three trips was imposed as to prevent data skewing by a single frequently-travelling individual. Participants may have opted not to report on the questionnaires on all of the trips they took, thus the total number of trips reported was greater than the number of trips with data presented in the findings. Average participation lasted 45 minutes and subjects received 100,000 Vietnam Dong (VND, about US$5.00) upon completion of the survey.

Data analysis

We analyzed data on behaviour for each reported trip as well as for each individual. This allowed us to more thoroughly look at each individual's travel sexual behaviour as a whole. Other studies ask about their most recent or current trip, which fails to take into consideration variation in behaviour between trips.^15,16

The responses underwent descriptive data analysis to yield percentages and frequencies. Differences between variables were measured using Chi square tests for categorical variables and t-tests for continuous variables. Logistic regression using a backward stepwise method was performed to determine independent predictors of sex with foreign casual sex partners while travelling, defined as a sex partner who had not traveled with the subject from Vietnam. Statistic analysis and testing was done using Stata SE 12.

Funding and ethical concerns

Funding for the study was provided through a grant from the Purple Sky Network and its MSM Leadership Program. The study was conducted in collaboration with a newly established and independent Vietnamese community-based organization, the Center For Applied Research on Men and Health (CARMAH). The authors certify that the study was developed and conducted following the Ethical Principles for Medical Research Involving Human Subjects as written in the World Medical Association Declaration of Helsinki.

Results

Demographic information is shown in Table 1. The median age was 27 and 70% were aged 20 to 30 years. Almost all had at least a high-school education and two-thirds had some university; 21% were current students. The median income was 6,000,000 Vietnam Dong (VND) or about US$288 per month, marginally higher than the reported mean income for HCMC of 265 per month.¹⁷ Only a third reported more than one trip in the prior year.

Table 1.

Demographic characteristics of MSM in HCMC who travelled abroad within the prior 12 months.

	Characteristics	Frequency (n = 100)
Age	<20 years	7
	20–30	70
	>30	23
Education	Less than secondary school	1
	Secondary schools	35
	University	64
Occupation	Office worker	50
	Student	21
	Entrepreneur	18
	Other (tour guide, entertainment)	7
	Civil servant	3
	Unskilled worker	1
Marital status	Single	89
	Married	4
	Divorced	3
	Living with male partner	4
Monthly income	Median (range) in VND^a	6,000,000 (1,000,000–60,000,000)
Self identity	Gay-male gender (Bong Kin)	89
	Gay-transgender (Bong Lo)	6
	Gay-alternating Roles (50/50)	3
	Straight	2
Time travelled abroad in the prior year	1 time	66
	2 times	21
	More than 2 times	13

MSM: men who have sex with men; HCMC: Ho Chi Minh City.

In Vietnamese Dong (US$1 = 20,800 VND).

Characteristics of individual trips are shown in Table 2. Three-quarters of trips were taken in Southeast Asia, with Thailand as the most common destination. Half of all trips were taken for tourism or leisure and 29% were related to work. Most trips (40%) were taken with a colleague or friend, but 37% of trips were taken alone.

Table 2.

Characteristics of international trips taken by participants (n = 139 trips).

Characteristics		Frequency	Percent (%)
Destination	Southeast Asia	102	73.4
	Thailand	52	37.4
	Singapore	20	14.4
	Cambodia	18	12.9
	Other	12	8.6
	Other Asia	26	18.7
	Hong Kong	12	8.6
	Taiwan	6	4.3
	Mainland China	5	3.6
	Other	3	2.2
	N. America/Europe/Aus.	11	7.9
Time spent abroad	Less than 3 days	10	7.2
	3 to 5 days	72	51.8
	More than 5 days	54	38.8
Reason travelled abroad	Tourism/Leisure	70	50.5
	Work	40	28.8
	Visiting family/friends	9	6.5
	Study	6	4.3
	Other	13	9.4
Travelling companion(s)	Friend/Colleagues	56	40.3
	None (went alone)	52	37.4
	Male Partner	18	12.9
	Family	15	10.8

Knowledge

Knowledge on HIV transmission was fair, with 62%–97% correctly answering five questions on HIV transmission, including knowing that HIV can be prevented by being sexually monogamous or by using protection during anal sex, and that sharing meals and mosquito bites do not transmit HIV. Of most concern, only 62% knew that HIV-infected people can appear healthy on the outside. Only 48% answered all five questions correctly. Also, 62% knew that MSM are at a higher risk of HIV infection compared to other Vietnamese men. Although 98% knew where to get an HIV test, only 45% had ever been tested.

Risk behaviour

In all, 41% reported having had sex with a new or casual partner while abroad. There were 54 trips out of the reported 139 (39%) during which sex with a new or casual partner occurred. Within the 41 individuals, 48.8% reported meeting their sexual partners on the Internet, 43.4% from a prior meeting, 34.1% in saunas, 26.8% via mutual friends, 24.4% in bars, and 2.4% from encounters in the street or park. Only 1 participant (1%) reported paying for sex with a male sex worker on one trip.

During 83% of the trips alcohol was reported to have been consumed. Only 3% (4 trips) had reported illicit drug use. Of these, two reported ecstasy use while the other two reported marijuana use.

The vast majority (n = 37 or 90.2% of those reporting having sex with a new casual partner while abroad) reported as only having protected anal sex or no anal sex at all during these encounters. Four people, or 9.8% of those reporting having had sex with a new or casual partner while abroad, reported sometimes not using a condom with foreign sex partners. All four men reported unsafe sex with foreigners that they had previously known before that trip abroad. Of these four, three reported not using a condom due to trust in their partner while the fourth reported not consistently using condoms due to loss of sensation. Three of the four further cited bars, saunas, and the Internet as places to meet sexual partners while abroad.

Risk factors for casual sex while abroad

We analyzed the data to determine which factors were associated with having casual sex with a foreign partner while abroad. Data for 139 reported trips is shown in Table 3. The variables are ranked in ascending order by p value. Travelling alone, having a university education, and travelling outside of Asia were most strongly associated with having a casual sex partner during that trip. Higher income and travelling more than once in the prior year were also significantly associated with casual sex, while students were less likely to have casual sex than non-students.

Table 3.

Univariate analysis of association with casual sex partner(s) during trip (n = 139 trips^a).

Variable		Had new/casual sex partner during trip n (%)	No new/casual sex partners during trip n (%)	Odds ratio	95% Confidence interval	p Value
Travelling alone^b	Yes	33 (63)	19 (37)	5.46	2.56–11.5	<0.001
Travelling alone^b	No	21 (24)	66 (76)
Education level^b	No University	7 (18)	33 (82)
Education level^b	University Degree	47 (47)	52 (53)	4.26	1.72–10.5	0.001
Region of Travel^b	SE Asia	32 (31)	70 (69)
	Rest of Asia	14 (54)	12 (46)	2.55	1.06–6.13	0.006
	Rest of World	8 (73)	3 (27)	5.83	1.45–23.4
Monthly income^b	≤8,000,000 VND^c	24 (30)	56 (70)
Monthly income^b	>8,000,000 VND	30 (51)	29 (49)	2.41	1.20–4.86	0.012
Student^b	No	50 (43)	65 (57)
Student^b	Yes	4 (17)	20 (83)	0.26	0.08–0.81	0.014
Times traveled abroad in prior year^b	=1	19 (29)	47 (71)
Times traveled abroad in prior year^b	>1	35 (48)	38 (52)	2.28	1.13–4.60	0.02
Correctly answered first five questions about HIV/AIDS	No	31 (46)	36 (54)
Correctly answered first five questions about HIV/AIDS	Yes	23 (32)	49 (68)	0.55	0.27–1.09	0.083
Have been tested for HIV before	No	22 (33)	45 (67)
Have been tested for HIV before	Yes	32 (44)	40 (56)	1.63	0.82–3.26	0.16
Alcohol use during trip	No	6 (26)	17 (74)
Alcohol use during trip	Yes	48 (41)	68 (59)	2.00	0.73–5.44	0.16
Age	≤30	36 (36)	64 (64)
Age	>30	18 (46)	21 (54)	1.52	0.72–3.22	0.27
Trip length	≤5 days	29 (35)	53 (65)
Trip length	>5 days	25 (44)	32 (56)	1.43	0.72–2.85	0.31
Tourism as purpose	No	29 (42)	40 (58)
Tourism as purpose	Yes	25 (36)	45 (64)	0.77	0.39–1.52	0.45
Illicit drug use during trip	No	52 (39)	83 (61)
Illicit drug use during trip	Yes	2 (50)	2 (50)	1.60	0.22–11.7	0.65

139 was the number of trips taken by 100 Vietnamese MSM. The data was entered per trip such that the maximum possible n for each variable was 139, including for individual level data.

Statistically significant.

Equivalent to about 385 USD.

Backward stepwise logistic regression was used to analyze independent predictors for casual sex while abroad. All variables demonstrating a p value under 0.20 in addition to age were included in the model. Upon multivariate analysis, only two variables were shown to be statistically significant: travelling alone (odds ratio: 5.26, 95% CI: 2.44–11.50, p value < 0.001) and having a university education (odds ratio: 4.05, 95% CI: 1.55–10.62, p value: 0.004).

Discussion

While 41 individuals (41%) reported having a casual or new sex partner while being abroad, only four individuals within these 41 reported having unsafe sex with these partners. Looking at the 139 trips abroad the participants reported, the vast majority of trips (73%) took place within Southeast Asia. This is of concern as the region is a hub for sex tourism with relatively high rates of HIV infection. Bangkok, with the largest and most diverse gay entertainment scene in all of Asia, is only a 75-minute flight away and has a higher HIV prevalence rate amongst MSM.

Half of reported trips were for tourism or leisure. While 40% of trips were with friends or colleagues, 37% were taken alone (Table 2). There were only four reported trips where unsafe sex with a casual partner occurred, although this figure may be artificially low due to response bias, a common phenomenon in sexual behaviour surveys.¹⁸

With multivariate logistic regression analysis, only two variables were shown to be significantly associated with having casual sex while abroad: travelling alone and having a university education.

While it may seem understandable that MSM travelling alone are more likely to seek a new and/or casual sex partner during a trip than those travelling with someone, the relationship between casual sex and a university education seems less obvious. A study of HIV infection amongst Thai MSM showed a correlation between HIV infection and a lower education level.¹⁹ However, we should not directly link having new/casual sexual partners with HIV infection, since having a casual sex partner does not necessarily mean having unsafe sex. Testing for interaction between variables eliminated the possibility that education level was confounded with age, salary, or any other tested variable (data not shown). We might postulate that a university education level is related to English proficiency, which may make foreign sexual relations easier to seek out. However, further data are needed to support this hypothesis.

Only 48% of participants were able to correctly answer five basic questions about HIV transmission. While nearly everyone knew that condoms help prevent HIV prevention, 38% did not know that HIV-infected men could have a healthy appearance and another 38% did not know that gay men were at a higher risk of HIV infection compared to other men. Thus, although there is knowledge about the benefits of protected sex, travelling MSM may decide to have risky sex based off the potential partner’s appearance and first impressions, particularly if they do not perceive that MSM have a higher infection rate than the general population. These numbers are similar to those reported in the past, which showed that only half of MSM in Vietnam knew that outwardly healthy-looking men could in fact carry HIV.²⁰ This lack of awareness may be due to a past government HIV prevention campaign, which concentrated on drug users and female sex workers as the only high-risk groups for HIV.¹⁸ It is only recently that HIV prevention programmes in Vietnam have acknowledged and targeted MSM as a distinct high-risk group.

This study has several limitations. We used a convenience sample rather than a representative sampling methodology. The MSM we surveyed were young, well-educated, and relatively affluent and therefore are not representative of the MSM population as a whole in HCMC or Vietnam. However, travelling abroad is still relatively expensive and would be less accessible for men from poorer backgrounds. It may be that the MSM in this survey are more representative of the richer and more educated portion of society that has access to international travel. The interviews were conducted in person by one of the authors (HQN), who had experience in peer education with MSM. The low rate of reported unsafe sexual behaviour in the survey may be due to reporting bias and a reluctance to admit to unsafe sex in the presence of a health educator. Future studies might use different data collection techniques, such as computer-assisted interviews or online surveys, to remove this potential bias.

We found a very low rate of reported sex with sex workers while traveling, despite the fact that Thailand, which has a large and open commercial sex industry, was the single country reported most frequently for travel. There may have been some underreporting bias because purchasing sex is illegal and stigmatized in Vietnam. However, this finding may indeed be accurate in that the sample of MSM was relatively young with a median age of 27, and that the typical client of sex workers in Thailand is much older. In addition, there is also a very large sex work industry in Vietnam, albeit less open and less known outside of the country than the industry in Thailand. Repeated surveys of MSM in HCMC have reported that up to 20–50% of MSM engage in sex work.^8,10,20 Therefore, it may be that the availability of commercial sex is less of a motivating factor for travel to Thailand from Vietnam than it is for visitors from other countries.

The reliance of MSM, Vietnamese included, on the Internet in meeting new partners presents challenges to more traditional peer-based interventions. However, social media or website-directed interventions may overcome these difficulties.²¹ Many MSM in HCMC have already voiced a preference for the Internet as a means for receiving health and HIV-prevention information.²²

Conclusion

A combination of a growing and increasingly mobile Vietnamese middle class with inadequate knowledge about HIV transmission makes travelling MSM an important group for HIV prevention programming. Higher HIV prevalence rates among MSM in neighboring countries means that Vietnamese MSM may be at higher risk for HIV transmission when travelling outside of their home country. More attention in the form of directed outreach and education needs to be targeted towards Vietnamese MSM who travel abroad.

Footnotes

Acknowledgements

We warmly thank amfAR, TREATAsia, and the Purple Sky Network for supporting the MSM Leadership Program and the funds for this survey. This survey would not have been possible without the guidance of Dr Nguyen Anh Thuan. Our thanks also go to the MSM peer education network in HCMC for introducing us to this survey’s respondents. We also thank Corinne Thompson at the Oxford University Centre for Tropical Medicine for help with statistical analysis.

Conflict of interest

The authors declare no conflict of interest.

Funding

The project was funded by a grant from the Purple Sky Network as part of the Southeast Asia MSM Leadership Development Program with support from TREATAsia and the American Foundation for AIDS Research (amfAR).

Participant consent

Obtained.

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