HIV infection among men having sex
with men in Kampala, Uganda
Joseph Barker
US Centers for Disease Control and Prevention
Division of Global HIV/AIDS
Co-authors:
Wolfgang Hladik, Danstan Bagenda, Tom Tenywa,
Michael Muyonga, John Ssenkusu, Jordan Tappero
Men having Sex with Men (MSM) and
HIV in sub-Saharan Africa
• In sub-Saharan Africa men having sex with men:
– Criminalized behavior
– Highly stigmatized
– Often not included in national AIDS control programs
• MSM often have female sex partners
– “Bridging” population
2
HIV Epidemic in Kampala
• HIV in Kampala
– Population 1.4 million
– HIV prevalence: 8.5%†
– HIV prevalence among adult males: 4.5%†
– Heterosexual transmission
– Little data on hidden populations considered most-atrisk for HIV infection, including MSM
• Sex among men is illegal
† Uganda HIV/AIDS Sero-Behavioural Survey 2004-05
3
Survey Design
• CDC, Makerere University SPH, MOH-Uganda
• May 2008 – April 2009: concurrent sampling of six mostat-risk-populations (MARP) groups
– Central survey office
• Respondent-driven sampling (RDS)
– “Chain referral sampling” - survey participants refer (recruit) their
peers
– Probability sample
• Projects sample characteristics to target population
• Eligibility criteria – MSM
– Age 18+ years
– Resident in greater Kampala
– Reported anal sex with a man in last 3 months
4
Data Collection and Biomarkers
• Audio Computer-Assisted Self-Interview (ACASI)
– Increased validity for sensitive questions
– Focus on behavioral risk
– English, Luganda
• Biological Measures
Specimen
type
Rectal swab
Urine
Agent
Chlamydia trachomatis
Neisseria gonnorhea
Test
Cobas Amplicor or
Amplicor PCR test
HIV
EIA in parallel
(StatPack – tiebreaker)
T. pallidum
TPHA  RPR
Venous blood
5
Statistical Analysis
• Descriptive analysis – RDS Analysis Tool (RDSAT)
– Weighted population estimates, adjusted for nonrandom sampling frame
– Version 5.6
• Bivariate and multivariate analysis – STATA
– Associations between respondent characteristics with
HIV infection
– Logistic regression modeling
• Backwards elimination
6
Sampling
• Sample size: 303 participants
Survey
start
May ‘08
Sampling
slumps
Sampling
recovers
May-Jun
Jul-Aug
Arrests
of LGBT rights
activists (Kampala
Implementers
Meeting)
Sampling Sampling Sampling
slumps remains low effort cease
Sep
Oct-Mar
Arrests
of gay persons,
alleged abuse by
police
7
Apr ‘09
Baseline demographics
Characteristic
n
% (95% CI)
Age
18-24 years
25+ years
Median (IQR)*
Years of School
None
1-7 years (Primary)
8 -13 years (Secondary)
14+ years (Tertiary)
Median (IQR)*
143
50 (40 – 57)
152
50 (43– 60)
25 years old (21 – 29)
21
8 (4 – 12)
72
27 (20 – 36)
108
38 (31 – 46)
88
27 (20 – 34)
11 years (7 – 14)
*Unweighted median and IQR
94% of MSM in Kampala are Ugandan
8
Marriage, female partners, children
• Ever married:
31%
• Currently married:
20%
• Living with female sex partner
– Ever:
– Currently:
44%
16%
• Ever sex with women: 78%
• Fathered children:
29%
9
Sexual orientation and attraction
Straight/Heter
osexual
Bisexual
Gay/Homosex
ual
Mostly/onl
y women
7%
37%
56%
19%
Both men
and
women
12%
Mostly/onl
y men
70%
57% had disclosed their same sex activity to other people
10
Prevalence (95% CI) of selected STIs
22.1%
Any STI (including HIV)
1.9%
NG (rectal)
CT (rectal)
1.1%
NG (urethral)
1.4%
One in five MSM has
at least one STI
1.2%
CT (urethral)
8.3%
Syphilis
13.7%
HIV
0%
10%
20%
30%
CT: Chlamydia trachomatis
NG: Neisseria gonorrhea
11
11
HIV prevalence by age group
22.4%
Age 25+
Age <25
3.9%
Older MSM substantially
more likely to be HIV+ than
younger MSM
HIV prevalence ratio: 5.7
0%
5%
10%
15%
20%
12
25%
Perceived vs. actual HIV status
Perceived
Actual
Neg
Pos
D/K
Neg
35%
9%
44%
Pos
6%
1%
5%
D/K: Don’t know
Most HIV-pos MSM think
they are HIV-neg or don’t
know their status
Most MSM who think
they are HIV-pos are
not
Ever tested for HIV: 44%
13
Ever forced to have sex,
blackmailed, or physically abused
Ever forced
to have sex
26%
Ever
blackmailed
37%
Ever
physically
abused
37%
14
Median number (IQR) of male sex
partners by type in last 3 months
Men recruits bought sex
from*
2
Men recruits
sold clients
sex to*
Commercial
2
*
Commercial /
transactional sex
frequent:
42% ever sold sex
Casual sex partners
2
Steady sex partners
4
0
5
10
* Among those engaging in commercial sex
15
Median number (IQR) of female sex
partners by type in last 3 months
Women recruits bought
sex from**
1
Commercial
Women recruits
sold clients
sex to*
0
Casual sex partners
0
Steady sex partners
24% ever sold sex to
women
On average, MSM report
one female steady
partner in last 3 months
1
0
5
10
* Among those engaging in commercial sex
16
Median proportion of condom use in
last 3 months by partner type
Commercial
partners
33%
Female casual
partners
40%
Female steady
partners
39%
Male casual
partners
Male steady
partners
43%
Sub-optimal
condom use
across all
partner types,
especially for
commercial sex
26% never use
condoms
50%
Most MSM used lubricants, although
17
most lubricants were oil based
17
“What kind of anal sex (insertive, receptive)
do you think is more dangerous to get HIV?”
Both no
risk
11%
Both equal
Insertive
Receptive
65%
13%
11%
18
Multivariate analysis
Factors associated with HIV serostatus among MSM
Characteristic
Unadjusted OR
(95% CI)
Age
18-24 years
Ref
25+ years
5.7 (2.0 - 16.0)
P
6.4 (2.5 – 16.4)
P
Ref
0.001
History of violence
or abuse
Never
Ref
Ever
Adjusted OR
(95% CI)
4.3 (1.5 - 12.8)
0.008
Ref
< 0.001
4.8 (1.8 – 13.1) 0.002
Factors non-significant in multivariate analysis but adjusted for: sexual orientation,
alcohol consumption, use of lubricants, reported STD symptoms.
Discussion
• Arrests and allegations impeded sampling
• Almost all MSM in Kampala are Ugandan
• Most MSM in Kampala had sex with women
• Poor knowledge of HIV risk with anal sex
• Sub-optimal condom use, high number of partners
• Reports of history of violence and abuse
20
Discussion
• HIV prevalence (14%) 3x higher than among
Kampala men
– AIS 2004/5: 4.5%
• Older MSM are 4x more likely to be HIV infected
than younger MSM
• MSM reporting abuse 5x more likely to be HIV
infected than those who are not abused
21
Recommendations
• Include MSM in national strategic AIDS control
planning and gender based violence initiatives in
Uganda
• Work with MOH, NGOs, advocacy groups to
initiate tailored interventions
–
–
–
–
Counseling to address anal sex
Promote condom use
Make safe lubricants available
Increase access to diagnose and treat anal STDs
22
Acknowledgments
(Courageous) Survey respondents
CDC Uganda
Makerere University
Ministry of Health
Wolfgang Hladik
Frank Kaharuza
John Ssenkusu
Simon Kyazze
Sylvia Nakayiwa
David Katuntu
Suzanne Theroux
Stephen Ssebagala
Kelly Bartholow
Brad Bartholow
Jordan Tappero
David Serwadda
Alex Opio
Danstan Bagenda
Michael Muyonga
Susan Mawemuko
Tom Tenywa
Rachel Kwezi
George Lubwama
Other Crane Survey staff
UCSF
Rachel King
The findings and conclusions in this presentation are those of
the author(s) and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
23
Thank you
Contact:
Joseph Barker: jbarker1@cdc.gov
Wolfgang Hladik: wfh3@cdc.gov
Types of lubricants used
Also: "Blue Band", ghee,
10%
Butter
cooking oil
11%
Baby oil
25%
Vaginal gel
15%
Hand lotion
35%
Petroleum jelly
4%
Saliva
15%
Other
78% ever
used lubricants
0%
5%
Green font: oilbased lubricants
10% 15% 20% 25% 30% 35% 40%
25
Type of sex partner at first MSM
episode
Friend
70%
Relative
7%
Acquaintance
7%
Stranger
6%
Prison inmate
Median age at first
sex: 18 years
3%
8%
'Authority figure'
0%
20%
40%
60%
80%
26
Survey Procedures
• Coupon-based peer referral to central survey office
• 1st visit to survey office
– Quantitative data collection
– Specimen collection
– Peer referral
• Interim (2 weeks)
– Laboratory testing
• 2nd visit to survey office
– Return of test results
– Interview on peer referral efforts
27
Significant associations (95% CI)
with HIV infection*
6.1
Age 25+
Recreational drug use
0.2
Never used lubricants
0.1
6.7
Ever been abused
STI-positive (any)
0
3.1
5
10
15
20
Odds ratio
*Bivariate analysis
28
28
Type of sex partner at first MSM
episode
Friend
70%
Relative
7%
Acquaintance
7%
Stranger
Prison inmate
'Authority figure'
Median age at first
0%
sex: 18 years
Authority figure categories:
6%
3%
8%
20%
Religious leader:
50%
Teacher:
22%
Military:
11%
Police:
17%
40%
60%
80%
29
Reported STD symptoms in last 12
months
Anal warts
Anal discharge
Anal ulcer or sore
Genital ulcer
Genital discharge or
burning
19%
36% report
at least one
anal STD
problem
14%
26%
32%
29%
30
30
Abuse and HIV infection
• Did you ever suffer any violence or abuse because
you have sex with other men?
• MSM reporting any violence or abuse were 6.4
times as likely to test positive for HIV
– 95% CI 2.5 – 16.3, p <0.001
31
RDS: A chain starts with a seed
Wave 1 Wave 2 Wave 3 Wave 4
Seed
Wave 5
- Person fulfilling eligibility criteria
- Purposively chosen
- Can be one or several
32
This seed then recruits others
Wave 1 Wave 2 Wave 3 Wave 4
Wave 5
Seed
33
…and these recruit others…
Wave 1 Wave 2 Wave 3 Wave 4
Wave 5
34
…and these do likewise…
Wave 1 Wave 2 Wave 3 Wave 4
Wave 5
35
…and so on…
Wave 1 Wave 2 Wave 3 Wave 4
Wave 5
36
…until sample size is reached
Wave 1 Wave 2 Wave 3 Wave 4
Wave 5
37
Factors not associated with HIV
infection
•
•
•
•
•
Education
Marital status
Unemployment
Alcohol use
Circumcision status
• HIV testing history
• No. lifetime partners
• History of rape
•
•
•
•
Reported STD symptoms
Sex with women
Condom use
Mainly receptive anal sex
GAP Brown Bag
HIV infection among MSM in
38
Sampling characteristics
Sampling duration:
Seeds:
No. coupons issued:
Highest wave achieved:
Equilibrium (HIV), wave No.:
Recruits screened:
Ineligible recruits:
Eligible recruits:
10 months
14
1,706
11
2
454
146
303
39
What do you think is your HIV
status?
Don't
know
45%
Negative
Positive
44%
12%
40