HIV prevention among MSM and transgender people who use drugs in Asia and the Pacificadmin
HIV prevention among MSM and transgender people who use drugs in Asia and the Pacific
HIV Australia | Vol. 11 No. 4 | November 2013
By Sin How Lim, with Thomas E Guadamuz and Frederick L Altice
Drug use among men who have sex with men (MSM) in Asia is an established trend.
Evidence shows that using club drugs, such as cocaine, ecstasy, gamma hydroxy butyrate (GHB), ketamine and methamphetamine, taking erectile dysfunction medications1, 2, 3and binge drinking4 place a subgroup of Asian MSM at high risk for HIV infection.
These findings link to international evidence showing substance use among MSM is associated with increased sexual risk-taking.5
Strong evidence indicating escalating HIV epidemics among MSM in Asia and the Pacific has emerged, with increasing HIV prevalence among MSM in China6 and Thailand7 – 30.8% in Bangkok in 2007.
Parallel to the increase in HIV prevalence among Thai MSM is an increase in recreational drug use.
The use of amphetamine-type stimulants increased from 3.6% in 2003 to 17.5% in 2005, and to 20.8% in 2007.8
High rates of amphetamine-type stimulant use have also been reported among MSM in other parts of Asia, including Indonesia (15.0%),9 Malaysia (23.9%),10 Thailand (32.0%),11 and China (13.3%).12
These findings are of concern for HIV prevention as there is a strong predictor between amphetamine-type stimulant use and HIV seroconversion among MSM.13
However, there are other major obstacles to HIV prevention among MSM and transgender people who use drugs in Asia and the Pacific:
Criminalisation of drug use and MSM and transgender people
Given the legal restrictions on drug use and in some cases the criminalisation of male-to-male sex in Asia and the Pacific, multiple challenges remain in enrolling MSM and transgender people who use drugs into HIV testing, treatment and care programs.
Overlapping vulnerabilities to HIV
Drug use may be more prevalent among MSM who engage in sex work.14, 15, 16
However, it is particularly challenging to reach marginalised MSM sex workers who remain hidden for legal reasons.
Substance use is likely to be part of the overlapping health problems (“syndemics”) that put Asian MSM at high risk for HIV infection and transmission.17, 18
An understanding of the individual, social, and societal effects of drug use among MSM and transgender people is needed so that evidence-based interventions can be developed to reduce HIV transmission among these subgroups.
Gay social media and social networking applications may be useful in reaching some of these populations.
Lack of evidence-based interventions for MSM and transgender people who use drugs
Although there is a range of evidence-based HIV prevention interventions available for MSM, for transgender people and for people who use drugs, there is a lack of documentation of evidence-based interventions specifically for MSM and TG who use drugs in the Asian context.
Interventions for MSM and transgender people who use drugs and alcohol must not only be culturally congruent, they must also be comprehensive and focus on both prevention and treatment.
An understanding of the risks associated with drug use, especially amphetamine-type stimulants, need to be integrated into current prevention messages targeting MSM and transgender people.
Lack of data on MSM and transgender people who use drugs
Despite data from a cohort study that demonstrated the association between illicit drug use and HIV incidence in Thailand,19 drug use among MSM in Asia remains under-studied.
Drug-use patterns and HIV-related risks among transgender people are even more poorly understood because such studies are extremely rare, despite a recent systematic review and meta-analysis of global studies showing that transgender people bear a much higher HIV burden (50-fold higher) than the general adult population.20
New, innovative ways to recruit drug-using MSM and transgender people21 need empirical testing in Asian populations.
New data collection modalities, such as Internet/smartphone surveys or automated telephone interviewing systems may offer alternatives to the collection of sensitive data on drug use and sexual behaviours.
1 Hidaka, Y., Ichikawa, S., Koyano, J., Urao, M., Yasuo, T., Kimura, H., et al. (2006). Substance use and sexual behaviours of Japanese men who have sex with men: a nationwide internet survey conducted in Japan. BMC Public Health, 6, 239.
2 van Griensven, F., de Lind van Wijngaarden, J. (2010). A review of the epidemiology of HIV infection and prevention responses among MSM in Asia. AIDS, 24(suppl 3), S30–40.
3 Wei, C., Guadamuz, T., Lim, S., Huang, Y., Koe, S. (2012). Patterns and levels of illicit drug use among men who have sex with men in Asia. Drug and Alcohol Dependence, 120(13), 246-0.
4 Lu, H., Han, Y., He, X., Sun, Y., Li, G., Li, X., et al. (2013). Alcohol use and HIV risk taking among Chinese MSM in Beijing. Drug and Alcohol Dependence. Epub 24 July 2013.
5 Stall, R., Purcell, D. (2000). Intertwining epidemics: a review of research on substance use among men who have sex with men and its connection to the AIDS epidemic. AIDS and Behavior, 4(2), 181–92.
6 Ma, X., Zhang, Q., He, X., Sun, W., Yue, H., Chen, S., et al. (2007). Trends in prevalence of HIV, syphilis, hepatitis C, hepatitis B, and sexual risk behavior among men who have sex with men. Results of 3 consecutive respondent-driven sampling surveys in Beijing, 2004 through 2006. J Acquir Immune Defic Syndr, 45(5), 581–7.
7 van Griensven, F., de Lind van Wijngaarden, J. (2010). A review of the epidemiology of HIV infection and prevention responses among MSM in Asia. AIDS, 24(suppl 3), S30–40.
9 Morineau, G., Nugrahini, N., Riono, P., Nurhayati, Girault, P., Mustikawati, D., et al. (2011). Sexual risk taking, STI and HIV prevalence among men who have sex with men in six Indonesian cities. AIDS and Behavior, 15(5), 1033–44
10 Kanter, J., Koh, C., Razali, K., Tai, R., Izenberg, J., Rajan, L., et al. (2010, September). Risk behaviour and HIV prevalence among men who have sex with men in a multiethnic society: a venue-based study in Kuala Lumpur, Malaysia. AIDS, 24(suppl 3), S30–40
11 Newman, P., Lee, S., Roungprakhon, S., Tepjan, S. (2012). Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention. Prevention Science: The Official Journal of the Society for Prevention Research, 13(5), 483–92.
12 Feng, Y., Wu, Z., Detels, R., Qin, G., Liu, L., Wang, X., et al. (2010). HIV/STD prevalence among men who have sex with men in Chengdu, China and associated risk factors for HIV infection. J Acquir Immune Defic Syndr, 53 (suppl 1), S74–80.
13 Plankey, M., Ostrow, D., Stall, R., Cox, C., Li, X., Peck, J., et al. (2007). The relationship between methamphetamine and popper use and risk of HIV seroconversion in the multicenter AIDS cohort study. J Acquir Immune Defic Syndr, 45(1), 85–92.
14 Nguyen, T., Nguyen, H., Le, G., Detels, R. (2008). Prevalence and risk factors associated with HIV infection among men having sex with men in Ho Chi Minh City, Vietnam. AIDS and Behaviour, 12(3), 476–82.
15 Wong, F., He, N., Huang, Z., Young, D., O’Conor, C., Ding, Y., et al. (2010). Migration and illicit drug use among two types of male migrants in Shanghai, China. Journal of Psychoactive Drugs, 42(1), 1–9.
16 Liu, S., Detels, R. (2012). Recreational drug use: an emerging concern among venue-based male sex workers in China. Sexually Transmitted Diseases, 39(4), 251–2.
17 McCarthy, K., Wimonsate, W., Guadamuz, T., Varangrat, A., Thienkrua, W., & Chaikummao, S. (2010). Syndemic analysis of co-occurring psychosocial health conditions and HIV infection in a cohort of men who have sex with men (MSM) in Bangkok, Thailand. In Vienna: International AIDS Conference.
18 Wu, J., Lu, C., Deng, X., Wang, H., Hong, L. A Syndemic of Psychosocial Problems Places the MSM (Men Who Have Sex with Men) Population at Greater Risk of HIV Infection. PloS one. 2012;7(3): e32312.
19 van Griensven, F., Varangrat, A., Wimonsate, W., Tanpradech, S., Kladsawad, K., Chemnasiri, T., et al. (2010). Trends in HIV prevalence, estimated HIV incidence, and risk behavior among men who have sex with men in Bangkok, Thailand, 2003–2007. J Acquir Immune Defic Syndr, 53(2), 234–9.
20 Baral, S., Poteat, T., Stromdahl, S., Wirtz, A., Guadamuz, T., Beyrer, C. (2013). Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. The Lancet Infectious Diseases, 13(3), 214–22.
21 Jenkins, R. (2012). Recruiting substance-using men who have sex with men into HIV prevention research: current status and failure. AIDS Behav, 16, 1411–9.
Sin How Lim is a Post Doctorate Associate, Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia