Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur,Malaysia

INTRODUCTION

When compared with the well-studied HIV epidemic among injecting drug users, ¹ we know little about the prevalence of HIV infection in the community of men who have sex with men (MSM) in Malaysia. Of the 84,630 total reported cases of HIV infection in Malaysia from 1986 to 2008, the Ministry of Health reports that 1585, or 1.9%, were infected through homosexual or bisexual activity. ² However, such data are based on a person's voluntary declaration of a history of male-to-male sex, which is illegal in Malaysia. Homosexuality is heavily stigmatized in Malaysian society, and anal sex (or publicly advocating for the safe practice thereof) is explicitly or implicitly prohibited by law. ^3,4 No peer-reviewed research exists, but based on clinical anecdotes and unpublished internal reports, HIV incidence may be increasing and HIV-associated risk behaviour is common in the Malaysian MSM community. ^4,5

Recently, previously unrecognized HIV epidemics have been reported among MSM in urban areas throughout Asia. ^6,7 HIV prevalence among MSM was found to be 8.7% in Phnom Penh, Cambodia, ⁸ as low as 0.0% in Khanh Hoa province, Vietnam, ⁹ 7.8% in Ho Chi Minh City, Vietnam, ¹⁰ 5.6% in Vientiane, Lao People's Democratic Republic, ¹¹ 4.2% in Singapore, ¹² 10.4–12.5% in Chongquing, China, ¹³ and 0.4–5.8% in Beijing, China. ^14,15 Of particular concern is Bangkok, where HIV prevalence among MSM increased from 17.3% in 2003 to 30.8% in 2007. ^16–18 Several studies have noted inconsistent condom use, co-infection with other sexually transmitted infections (STIs), multiple male partners and the existence of female partners among MSM in south east Asia. ^19–25

Kuala Lumpur, the capital of Malaysia, is a large metropolitan area of 1,629,000 people or 6.0% of Malaysia's total population, ²⁶ which in 2008 accounted for 3.1% of the country's new HIV cases. ² Entertainment venues targeting MSM clients exist in a quasi-legal status and are often the target of police raids and public scrutiny. Public parks where men ‘cruise’ for casual sexual encounters with other men have also been identified. ^4,5 Only one registered organization, the PT Foundation (known locally as Pink Triangle Foundation), provides education, support, and HIV counselling and testing services to Kuala Lumpur's MSM community.

Socioeconomic and heath disparities exist between Malays, Indians and Chinese, the three main ethnicities that comprise Malaysian society. ^27–30 However, little is known regarding ethnic-specific differences within the MSM community. In order to direct future prevention efforts, we aim in this study to determine the HIV prevalence, transmission risk factors and level of knowledge about HIV transmission methods for the MSM community of Kuala Lumpur as a whole and among its composite ethnicities.

METHODS

We employed an adaptation of venue–day–time sampling (VDTS) ^31,32 to identify venues where men congregate for the purpose of meeting or soliciting sex from other men. In four distinct phases we: one, identified and mapped possible venues; two, enumerated foot traffic entering each venue at various times and days; three, determined logistical feasibility and venue owners' willingness to participate; and, four, enrolled MSM for HIV testing and risk behaviour assessment. Outreach workers from the PT Foundation, trained in study recruitment, data collection and rapid HIV testing procedures, conducted all phases of the VDTS protocol.

Of the 21 venues identified and mapped during phase 1 of VDTS, three were eliminated based on insufficient foot traffic. A further four venues were eliminated because of the managements' unwillingness to participate. Three clubs, two massage parlours, eight saunas and one park were selected for study participation at the completion of VDTS phase 3. Due to the sensitive nature of homosexuality in Malaysia and the ongoing threat of police raids, care was taken to keep the names and locations of selected venues confidential. Each venue was sampled during hours of peak foot traffic on two evenings, one weekday and one weekend, between May and July 2009. To be eligible, men needed to be at least 18 years of age, self-identifying as gay or bisexual (ascertained simply by asking the potential participant straightforwardly if they were gay or bisexual) or having any type of sexual interaction with another man in the past five years, and residing in Kuala Lumpur or having visited the city at least three times in the past six months for the purpose of sexual contact of any kind with another man. This arbitrary cut-off of three times in the past six months was adopted after unanimous agreement between local MSM peer staff and health-care workers. Peer staff asked potential participants verbally if they met eligibility criteria. After obtaining verbal informed consent, participants were asked to self-complete a 15-minute risk behaviour and demographic questionnaire administered on hand-held mini-PCs (Model HP 2133 Mini Note-PC, HP, Inc, Palo Alto, CA, USA), offered in the participant's language choice of English, Mandarin or Bahasa Melayu. Outreach workers made themselves available to assist participants with the questionnaire, if needed. Upon completion, outreach workers administered an oral rapid HIV test (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test, OraSure Technologies, Inc, Bethlehem, PA, USA). The tests were read by trained laboratory technicians stationed in an office within the venue or in a specially retrofitted van nearby. A participant was considered oral fluid HIV-positive if the OraQuick test was reactive for infection (99.6% sensitive and 100% specific for the detection of HIV in oral fluid based on clinical trials). ³³ HIV test results were linked to questionnaire answers via randomly generated barcodes to maintain participant anonymity. Participants were also given a bar-coded identification card, informed the location of an office to which they could return one week later for full counselling, retrieval of HIV results and HIV confirmatory testing if found reactive. Participants were allocated RM 50 (approximately USD$14) as compensation for time and transportation. Study procedures were considered complete for a participant after they provided consent, completed the questionnaire, were administered a rapid oral HIV test and received his bar-coded return-to-clinic card. Our computerized questionnaire asked for subject's specific birth date, from which we planned to calculate numerical age. As a large percentage of participants (57%) declined to provide their birth dates or provided fictional dates, we were unable to evaluate age in our analysis. The association between demographic and behavioural factors and HIV infection was evaluated using Pearson's chi-squared test (SPSS Version 16.0, SPSS, Inc, Chicago, IL, USA). Factors found to be statistically significant (P < 0.05) were examined further with multivariate analysis. Since sexual eligibility criteria differed for those residing in- and outside of Kuala Lumpur, all analyses controlled for participants' place of residence. Bivariate analysis was also used to evaluate the association between ethnicity and correct knowledge of established HIV transmission methods (sharing of needles and anal intercourse), and also between ethnicity and sexual risk behaviours found associated with HIV infection in the current study.

RESULTS

DISCUSSION

This survey found that 3.9% of MSM attending entertainment venues and parks in Kuala Lumpur were infected with HIV – a value higher than Malaysia's overall adult HIV prevalence of 0.5%. ³⁴ This prevalence is similar to that found in MSM communities in Cambodia, Laos, Vietnam and Singapore, ^11–15 but considerably less than that of neighbouring Bangkok. ¹² The large number of different partners, unprotected anal sex, anal sex while under the influence of drugs or alcohol and misconceptions about HIV transmission provide a suitable epidemiological background for a growing epidemic of HIV infection in this population in the future.

The considerable amount of misinformation about routes of HIV transmission among MSM in Kuala Lumpur underscores the need for increased prevention activities. With 20.1% and 19.5% of MSM believing HIV cannot be transmitted through insertive or receptive anal sex, respectively, we are less surprised to find that 34.8% reported having unprotected insertive anal sex and 27.9% reported unprotected receptive anal sex in the past six months. Clubs, saunas and massage parlours could serve as key sources of men's health information for the MSM community, but as many venue owners anecdotally lamented to us during preparations for this study, displaying safe-sex educational materials or distributing condoms could expose venue owners to criminal persecution due to the interpretation or misinterpretation of Malaysian law. Passages such as ‘whoever sells, lets to hire, distributes, publicly exhibits or in any manner puts into circulation, or for purposes of sale, hire, distribution, public exhibition or circulation makes, produces or has in his possession any obscene book, pamphlet, paper, drawing, painting representation or figure or any other obscene object whatsoever…’ (Section 292 of the Malaysian Penal Code) are often misinterpreted by the police to include safe-sex educational materials and condoms. Unfortunately, laws criminalizing homosexual behaviour or discouraging related safe-sex education can hinder effective HIV prevention programmes for MSM. ^4,5

Of particular concern is the high proportion of men reporting anal sex under the influence of drugs. Among MSM in the western world, use of amphetamine-type substances (ATS) during sex has been found associated with prevalent and incident HIV infection, particularly if used in combination with erectile dysfunction drugs. ³⁵ The usage of ATS is increasing in Malaysian society, a trend for which the public health sector in Malaysia seems ill-prepared to address. ³⁶

The sexual transmission of HIV among MSM can be seen as a shift away from an epidemic centred around injecting drug use, which has long been regarded as the driving force in the spread of HIV in Malaysia. ¹ Recent increases in reported cases of HIV among Malaysian women appear to signify the growing role of sexual transmission of HIV in Malaysia. ² Male-to-male transmission will continue to add to this trend. Although the heterosexual and MSM epidemics are likely separate, it should be noted that, with 34.4% of our participants not identifying as strictly homosexual, and 16.1% reporting vaginal sex with a female in the past six months, potential bridges for HIV transmission exist between this community of MSM and the general population.

One cannot ignore the role of Islamic cultural norms when exploring why Malays were more likely than their Chinese peers to be HIV-positive and to engage in key risk behaviour (unprotected anal sex with a casual male partner). Research in Islamic societies has shown that local culture can reinforce the notion that ‘HIV transmission cannot be a problem in the Muslim world’. ³⁷ This probably rises from the belief that traditional religious values regarding pre- and extra-marital sex should suffice as protection from HIV infection. In addition, MSM in Islamic countries often experience ‘social stigmatization, class discrimination, ostracization from family and friends, and…prosecution by law’. ³⁷ This may limit their access to HIV prevention information and tools, since such services may identify them as MSM or at risk for HIV infection. Future prevention initiatives would be well served to specifically address these types of cultural beliefs.

The study has a number of methodological limitations. We only examined men frequenting gay entertainment venues and cruising parks; those who are not visiting such venues may have a different HIV prevalence and risk factor profile. Men who attend venues infrequently may be under-represented, and it is possible (because this study was anonymous) that a participant may have enrolled more than once. The inclusion of a particular venue was dependent on the willingness of that venue's owner to participate; we do not know if MSM attending venues with uncooperative owners have different HIV prevalence levels or risk behaviour profiles. The small number of massage parlours included, and the possibility that some of the massage staff may have enrolled in the study, could have artificially inflated the high HIV prevalence found in this venue type. We sampled only one park, albeit the largest and most prominently associated with male ‘cruising’, according to our peer staff contacts in Kuala Lumpur. Furthermore, we did not consider Internet dating sites as potential venues. With 47.2% of our participants reporting to have found one or more male partners via the Internet in the past six months, future surveillance efforts should incorporate online recruitment. This could be accomplished within VDTS methodology by the inclusion of MSM-oriented Internet dating sites as an additional recruitment ‘venue’, or by employing a variation of respondent-driven sampling. ³⁸ A final limitation of our study is the absence of age data and our inability to control for age in our analysis. Age is a common correlate of HIV infection and behavioural risk and some of the differences between groups in our study may have been due to differences in age. Future studies may avoid this pitfall by simply asking participants to list their numerical age instead of requesting their actual birth date, since the latter could be a potential identifier.

Regardless, this study establishes a clear and urgent need to provide more effective HIV education to the Malaysian MSM community. Advocate groups like the PT Foundation have established infrastructure and maintain close, well-informed ties with the community, but their efforts are constrained by social stigma and the interpretation or misinterpretation of legal codes of Malaysia. ^3–5 Resultantly, they often lack financial and technical resources. In addition to behavioural interventions, legal and social changes are therefore necessary to more effectively combat the spread of HIV infection among MSM in Malaysia.