Abstract
Summary
In Malaysia, homosexuality is illegal; little is known about access to HIV prevention services among Malaysian men who have sex with men (MSM). We analysed PT Foundation outreach data to describe the profiles among MSM who accessed PT Foundation services and to examine factors associated with being aware of PT Foundation and having visited the organization. A survey was administered during weekly outreach throughout Kuala Lumpur from March–December 2012. Pearson's Chi square tests were used to compare demographic and behavioural characteristics of participants who were and were not aware of the PT Foundation. Binary logistic regression was used to identify correlates of MSM visiting the PT Foundation among those who had heard of the organization. Of 614 MSM, this study found significantly higher awareness of the PT Foundation among MSM who perceived they had “good” HIV knowledge (p = .026) and participants who reported always using condoms (p = .009). MSM who reported being paid for sex were 2.81 times as likely to visit the PT Foundation compared to men who did not. A subgroup of MSM known to be at high risk for HIV infection is accessing prevention services. Future studies should uncover motivations and barriers of accessing these services among MSM in Malaysia.
Keywords
Introduction
In many parts of the world, HIV prevalence is increasing among men who have sex with men (MSM). 1 In Malaysia, homosexuality is heavily stigmatized, and anal sex is explicitly or implicitly prohibited by law.2–4 Consequently, few studies have described the profiles of Malaysian MSM with regards to their specific knowledge and behaviours related to HIV risks and access to HIV prevention services. The Malaysian Ministry of Health reported that between 2008 and 2009, government-sponsored HIV prevention services have only reached 22.3% of MSM in Malaysia and only 29.7% of MSM have received an HIV test and know their results. 5 In a venue-based study in Kuala Lumpur, Kanter et al. (2011) highlighted considerable misinformation about the routes of HIV transmission among MSM in Kuala Lumpur, 3 with 20.1% of MSM in Kuala Lumpur believing that HIV cannot be transmitted through insertive or receptive anal sex. Additionally, the most recent study among Malay MSM in Penang (Lim et al. 2013) has found that 83.1% of sampled Malay MSM reported having unprotected anal intercourse and over two-thirds had never been tested for HIV. 6
Targeted outreach is an integral part of HIV prevention for MSM in developing countries because peer outreach can improve HIV knowledge and increase prevention behaviours among MSM. 7 It has also been shown that motivational outreach can encourage MSM to participate in voluntary testing and counseling (VCT), 8 which can also reduce sexual risk taking, thus reducing the likelihood of virus transmission.9–11
The PT Foundation (previously known as Pink Triangle Foundation), which has offered HIV prevention services to MSM since 1987, is among very few community-based organizations in Kuala Lumpur providing education, support and HIV testing and counseling services to the MSM community (and other socially marginalized groups such as transgender individuals and sex workers). The organization, which has a drop-in centre, provides services to as many as 200 MSM clients every day. 12 In 2007, PT Foundation began a community outreach programme in which volunteers go to public venues frequented by MSM to distribute safer sex kits, promote safer sex practices and advertise their services. Outreach by this organization may be reaching MSM who may not be linked to HIV prevention services provided by the Malaysian government, potentially bridging gaps in VCT by providing these men with the information, motivation and skills needed for maintaining positive health behaviours. The Information, Motivation, and Behavioural Skills (IMB) model postulates that health-related information, motivation and behavioural skills are fundamental determinants of the performance of health behaviours. With this framework, we analysed data collected by the PT Foundation to describe the profiles among MSM that accessed PT Foundation services and to examine factors associated with being aware of PT Foundation and having visited the organization.
Methods
Data analysis was conducted using data collected during PT Foundation weekly outreach sessions from March to December 2012. PT Foundation volunteers approached men at parks and saunas throughout Kuala Lumpur where MSM are known to frequent to complete a short written questionnaire. All men who were approached were encouraged to visit the PT Foundation for VCT services and were provided a safe sex kit including a packet of two condoms and water-based lubricant, regardless of survey completion. Data were available for 674 men who were given the questionnaire; of them 671 men completed the survey. Analysis was limited to men who reported having at least one male sexual partner within the past six months, resulting in 614 MSM who were included in this analysis.
Measures
PTF awareness
All participants were asked to specify their exposure to the PT Foundation prior to outreach, noting whether they had (1) ever heard of PT Foundation and (2) ever visited PT Foundation if they had ever heard of the organization. Participants were considered having awareness of PT Foundation if they reported having ever heard of the organization (regardless of whether they had visited the organization).
HIV knowledge
Participants were asked, ‘What is your HIV knowledge’ to identify their perceived knowledge of HIV information from one of three options as either ‘don't know’, ‘average’, or ‘good’. Due to low responses of individuals reporting that they ‘Don't know’ much information about HIV, responses of ‘Don't know’ and ‘Average’ were combined in the analysis to indicate having a lower level of perceived HIV knowledge in relation to individuals who report having ‘Good’ perceived knowledge.
Statistical analysis
Pearson's Chi square tests were used to compare demographic and behavioural characteristics of participants who were aware and who were not aware of PT Foundation. Binary logistic regression was used to identify correlates of MSM visiting PT Foundation among those who had heard of the organization. This secondary data analysis was reviewed and approved by Perdana University Graduate School of Medicine Institutional Review Board.
Results
Demographics and behavioural characteristics of MSM contacted during outreach sessions March–December 2012.
Characteristics among MSM who are aware and unaware of PTF in Kuala Lumpur, Malaysia.
Determinants of visiting the PT Foundation among those aware of the organization.
Discussion
The present study examined social and behavioural differences among MSM who were aware of PT Foundation compared to MSM unaware of the organization and described the correlates of MSM who accessed services at the PT Foundation drop-in centre. There were statistically significant differences among MSM who were aware and who were unaware of PT Foundation with regard to age (p = .029), ethnicity (p < .001), self-perceived HIV knowledge (p < .026) and condom use for anal or vaginal sex in the past six months (p < .01). The study also observed that MSM who report having been paid for sex in the past six months were more likely to have accessed PT Foundation services compared to those who had not been paid for sex.
This study found that being aware of the AIDS organization was associated with older age. This may be because older MSM have more life experience and larger social networks which may have led to greater exposure to information about sexual health and HIV prevention services. It is also possible that older MSM, although having greater awareness of PT Foundation, may access other private clinics for sexual health services. However, there were no statistically significant differences among younger and older men with regard to visiting the PT Foundation of the organization if they were aware. Outreach efforts should not only increase exposure of PT Foundation among younger men, but also encourage older MSM to visit the organization.
There was a significantly higher report of PT Foundation awareness among Chinese MSM in this sample compared to all other ethnic groups in Kuala Lumpur, but there were no ethnic differences with respect to visiting the organization. In a venue-based study in Kuala Lumpur, Kanter et al.(2011) 3 found that Malay MSM have a higher rate of HIV infection compared to other Malaysian ethnic groups, and high levels of unprotected anal intercourse (UAI) were reported by a recent study of Malay MSM in Penang.3,6 This finding suggests that PT Foundation efforts must target Malay MSM and encourage them to use their VCT services.
Not surprisingly, men who perceived they had ‘good’ HIV knowledge were significantly more aware of PT Foundation than those who reported ‘don't know’ or had ‘average’ HIV knowledge. These men were more aware of the organization, maybe because they might have been exposed to relevant HIV-related information that also informed them about PT Foundation services, or they might have gathered more HIV related information as a result of accessing PT Foundation information or services.
While MSM who reported always using condoms in the past six months had the highest level of awareness of PT Foundation compared to MSM who reported never using condoms or inconsistently using condoms, there were no statistically significant differences in visiting the organization by condom use in the past six months. Possibly, MSM who reported consistently using condoms had a higher level of awareness because they have been exposed to more HIV-related information.
The analysis of this study showed that men who were paid for sex in the past six months were significantly almost three times as likely to visit PT Foundation compared to men who did not report being paid for sex. This finding suggests that PT Foundation is indeed reaching a subgroup of MSM who are known to be at high risk for HIV transmission. Perhaps MSM who reported being paid for sex in the past six months may be more likely to visit the organization because they knew they were ‘at-risk’ and might be seeking HIV prevention services (e.g. voluntary testing and counseling, condoms). Outreach efforts should increase exposure of this organization among sex workers which may subsequently increase VCT among those who report being paid for sex.
In summary, the present study found that a segment of MSM populations, namely younger MSM, non-Chinese MSM and MSM who perceive they have low knowledge of HIV, have lower levels of awareness of this HIV prevention organization. This study also found that men who have been paid for sex in the past six months were more likely to visit the organization if they were aware of it. Outreach efforts should target and increase awareness of the services available at PT Foundation among these high risk men and link them to HIV testing, treatment and care. PT Foundation (and other similar organizations) should also attempt to increase knowledge of HIV transmission during outreach.
As a secondary data analysis, this research was limited in that the data were collected by a survey during outreach. This study was cross-sectional in nature and cannot make any causal inferences. We also do not have data on survey response or completion rates among MSM approached during outreach. Additionally, data on the specific services utilized by men who visited PT Foundation were not available, and motivation for visiting the organization could not be identified. Other issues such as logistical barriers to accessing services at the largest AIDS community-based organization in Kuala Lumpur may exist, but such data were not collected in the survey. Evaluation of HIV knowledge among MSM is also limited as HIV knowledge was measured using one item and was noted using self-perceived level of knowledge instead of objective testing of knowledge on HIV transmission, which may not be a reliable proxy for true knowledge of HIV information.
More research on how MSM access services in Malaysia is needed as homosexuality remains a social taboo and is highly stigmatized. A significant proportion of our sample were young MSM specifically between the ages of 15 and 30, a vulnerable subpopulation of MSM who are especially vulnerable for HIV.1,3 PT Foundation is uniquely managed by members of the MSM community and is not only sensitive to the needs of this community in Kuala Lumpur, but is also a trusted HIV service provider among the community as all data collected at VCT are kept strictly confidential. Still, as one of few non-governmental organizations targeting groups including the MSM community in Malaysia, PT Foundation's primary messages during outreach sessions remain two-fold: to encourage reduction in sexual risk taking through the use of condoms and to visit their drop-in centre for VCT. Future research should include a longitudinal study to evaluate the impact of the outreach programme on behavioural change and uptake of HIV testing. Qualitative methods such as focus group discussion or in-depth interviews may be considered to uncover motivations for and barriers to accessing HIV prevention services among MSM in Malaysia.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by the US Department of State Fulbright Program, the PT Foundation, the High Impact Research Grant of the University of Malaya (E000001-20001), and the UJMT Fogarty Global Health Fellows Training Program #5R25TW009340.