AIDS and Behavior

pp 1–15

Sociodemographic Factors, Sexual Behaviors, and Alcohol and Recreational Drug Use Associated with HIV Among Men Who Have Sex with Men in Southern Vietnam

Authors

    • Pasteur Institute Hochiminh City
  • Nghia Van Khuu
    • Pasteur Institute Hochiminh City
  • Phuc Duy Nguyen
    • Pasteur Institute Hochiminh City
  • Hau Phuc Tran
    • Pasteur Institute Hochiminh City
  • Huong Thu Thi Phan
    • Vietnam Authority of HIV/AIDS Control
  • Lan Trong Phan
    • Pasteur Institute Hochiminh City
  • Roger Detels
    • Department of EpidemiologyUCLA School of Public Health
Original Paper

DOI: 10.1007/s10461-015-1265-x

Cite this article as:
Nguyen, T.V., Van Khuu, N., Nguyen, P.D. et al. AIDS Behav (2016). doi:10.1007/s10461-015-1265-x

Abstract

A total of 2768 MSM participated in a survey in southern Vietnam. Univariate and multivariate logistic regression analyses were performed to determine predictors of HIV infection. The prevalence of HIV among MSM was 2.6 %. HIV infection was more likely in MSM who were older, had a religion, had engaged in anal sex with a foreigner in the past 12 months, previously or currently used recreational drugs, perceived themselves as likely or very likely to be infected with HIV, and/or were syphilis seropositive. MSM who had ever married, were exclusively or frequently receptive, sometimes consumed alcohol before sex, and/or frequently used condoms during anal sex in the past 3 months were less likely to be infected with HIV. Recreational drug use is strongly associated with HIV infection among MSM in southern Vietnam. HIV interventions among MSM should incorporate health promotion, condom promotion, harm reduction, sexually transmitted infection treatment, and address risk behaviors.

Keywords

HIVRisk factorsMSMVietnam

Introduction

It is estimated that there were 35 million people worldwide living with HIV/AIDS by the end of 2013, of whom 16 million were women and 19 million were men [1]. Among men, people who inject drugs (PWIDs) and men who have sex with men (MSM) were recognized as high-risk groups in many countries.

MSM bear a disproportionately higher burden of HIV infection than the general population. In Asia, MSM are as much as 18.7 times more likely to be infected with HIV than the general adult population [2]. Adult men who report having sex with men account for 3–5 % of male cases in East Asia, 6–12 % in South and Southeast Asia, 6–15 % in Eastern Europe, and 6-20 % in Latin America [3].

By the end of 2012, there were approximately 209,000 people living with HIV in Vietnam. The national prevalence rate was estimated to be 0.37 % [4]. The southern region accounted for almost 50 % of total cases, and had the highest number of cases compared to the other three regions of Vietnam: northern, central and highland. Vietnam is still facing an HIV epidemic that has occurred primarily in PWIDs and female sex workers (FSWs). Recently, the epidemic has been rising significantly among MSM (e.g., from 9.4 % in 2006 to 19.9 % in 2009 in Hanoi and from 5.3 % in 2006 to 14.4 % in 2009 in Ho Chi Minh City [5], and interventions have been implemented to reduce HIV infections in this hidden population [6].

Although two quantitative studies of MSM in Ho Chi Minh city and An Giang province in southern Vietnam have reported the HIV prevalence rates of 8 and 6.4 % respectively, these studies were implemented in just one province or city, and the sample size was not large enough to investigate different risk factors [7, 8]. The study reported herein had a larger sample size and was conducted in eight provinces in southern Vietnam to assess the risk profile for HIV infection among MSM.

Methods

Participants and Data Collection

A mapping team was established that included health-care workers and local MSM or peer educators who identified all known active MSM “hotspots” (where MSM often gather to meet, talk, exercise, drink, etc., such as coffee bars, clubs, restaurants, hotels, movie theaters, parks, swimming pools, gyms, etc.). The team visited these hotspots to estimate the numbers of MSM in each. With the assistance of MSM and hotspot owners, additional hotspots were identified, yielding a total of 745. Local health staff, with the help of MSM peers, accessed these venues and conducted rapid interviews of hotspot owners and several MSM to get information for estimating the size of the MSM population and how to approach MSM in each hotspot.

The number of hotspots per province was 247 in Tay Ninh, 54 in Dong Nai, 96 in Ba Ria-Vung Tau, 21 in Ben Tre, 119 in Vinh Long, 110 in Dong Thap, 58 in Hau Giang, and 40 in Soc Trang. The proportion of the total MSM populations (from mapping data) recruited was 64 % in Tay Ninh, 81.3 % in Dong Nai, 98.3 % in Ba Ria-Vung Tau, 71.6 % in Ben Tre, 70.3 % in Vinh Long, 48.6 % in Dong Thap, 75.9 % in Hau Giang, and 87.7 % in Soc Trang. Based on the mapping information obtained, several surveys among MSM were conducted between June 2010 and June 2012 in eight southern provinces of Vietnam, including three in the southeastern region (Tay Ninh (400), Dong Nai (360), and Ba Ria-Vung Tau(400)), and five in the southwestern region (Ben Tre (380), Vinh Long (338), Dong Thap (290), Hau Giang (300), and Soc Trang (300).

MSM were invited to participate in this survey if they were at least 16 years old and self-reported having had oral and/or anal sex with another male in the past 12 months. Those with any history of poor blood clotting were excluded due to the risk of prolonged bleeding after drawing of blood, and those with hearing disorders were excluded due to the difficulty for them to clearly hear and understand the questions being asked and responding to them correctly.

Based on the estimated prevalence of HIV among MSM in each province, the sample size was calculated as follows:
$$N = Z^{2}_{1 - \alpha } \frac{p(1 - p)}{{d^{2} }}$$
  • + HIV prevalence estimate: P

  • + Alpha level (α) = 5 %

  • + Desired precision: d

  • + Sample size N

Sample sizes are shown in the following table

No

Province

Sample size

Notes

1

Tay Ninh

400

P = 4 %

2

Ba Ria Vung Tau

400

P = 4 %

3

Dong Nai

360

P = 4 %

4

Ben Tre

380

P = 4 %

5

Dong Thap

290

P = 3 %

6

Hau Giang

300

P = 3 %

7

Vinh Long

338

P = 3 %

8

Soc Trang

300

P = 3 %

Total

 

2768

 

There were differences between provinces in sample sizes because of variations in prevalence estimates and/or limited funding. The HIV prevalence among MSM per site was estimated using proxy data of nearby provinces (e.g., 6.4 % in An Giang province whose risk for HIV infection among MSM was thought to be higher than in our study provinces). We also had personal communications with peer educators and staff of provincial AIDS centers from the study provinces to gain insights into the probable HIV prevalence and risk behaviors among MSM to estimate the HIV prevalence for selecting suitable sample sizes. The prevalence of HIV in MSM in southern Vietnam was estimated to be approximately 4 %, and the desired precision was set at 2 %, indicating that a sample size of 369 was needed; allowing 10 % for incomplete data and specimen damage, the sample size was rounded to 400. However, since funding was insufficient, the sample size was lower (360) for four provinces, where the estimated prevalence was approximately 3 %, and the desired precision was set at 2 %. The sample size needed was 279, rounded to 300. For Vinh Long, a sample size of 338 was obtained, since more individuals were willing to participate.

The surveys were conducted in the listed hotspots in each province (mapping), in which the number of MSM was estimated. The sample size in each province was stratified based on the estimated size of MSM population in each district, then in each hotspot. All interviewers, medical technicians, and physicians attended a three-day training course specific for conducting the study.

Informed consent was obtained prior to face-to-face interviews to collect data on sociodemographic characteristics, sexual identity, sexual behaviors, knowledge related to HIV and sexually transmitted infection (STIs), history of STIs, alcohol and recreational drug use, and access to HIV/STI intervention programs. After the interview, four ml of blood and 50 ml of urine were collected. Interviews were conducted by health staff or staff with a background in social sciences who were trained to administer the questionnaire. Biological samples were taken by trained phlebotomists according to national protocols.

HIV testing was performed using ELISA (Genscreen HIV ½) and a rapid test (Determine, SFD). All specimens were tested at provincial AIDS centers. Syphilis was screened using RPR (SD Bioline Syphilis 3.0; Standard Diagnostics, Kyonggi-Do, Korea) at the AIDS centers. Positive specimens were transported to the Pasteur Institute in Hochiminh City (PIHCM) for further confirmation by the Treponema pallidum haemagglutination assay (TPHA, Bio-Rad, Marnes La Coquette, France). If positive for both tests, the specimen was considered positive for syphilis. Due to limited funding, syphilis testing was only performed in seven provinces (not Soc Trang). Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were tested by PCR (Amplicor NG/CT, Roche) at the PIHCM for only six provinces (not Dong Thap or SocTrang).

The test results were returned to the participants through local voluntary HIV counseling and testing clinics. Men infected with syphilis, NG, and/or CT were referred to local STI centers for free treatment according to national STI treatment syndrome guidelines [9]. HIV-positive individuals were referred to local outpatient clinics. Ethical approval for this study was granted by the institutional review board in each province (at provincial AIDS centers and/or Departments of Health).

Data Management and Analysis

All interview answer sheets were checked by the interviewers for any missing information, then sent to the supervisors for futher checking before being sent to PIHCM. Interview answer sheets were stored in locked cabinets in the Provincial AIDS Centers (PACs) and sent to PIHCM. Data were entered using Epi-Data version 3.1 (EpiData Association, Odense, Denmark), and all statistical analyses were carried out using Stata version 13.0 (StataCorp, TX).

Frequency distributions and percentages were used to describe the HIV infection rate and several qualitative variables. Mean, median and variance were estimated for quantitative continuous variables. These parameters were also used to clean data before further analysis. To partially reduce the effect of temporal relationships between HIV and risk behaviors, those who had been tested for HIV previously and knew they were HIV-positive were removed from the univariate and multivariate analyses, because they might have altered their risk behaviors, and this could possibly cause an inverse association if binary logistic regression analysis was used. Potential covariates were first identified in the existing literature or by subjective prior knowledge plus those variables with p values of ≤0.25 in univariate analysis, and were entered in the full model [10]. Backward elimination was used. Any variable which had a p value over 0.05 was removed from the model. A log likelihood ratio test was performed to compare the “bigger” and “reduced” models. If the log likelihood ratio test gave a p value of ≤0.05, the corresponding variable was retained in the model. The procedure was repeated until no other variables in the model yielded p values of > 0.05. The final estimates were also adjusted for cluster effects (8 provinces).

Results

Sociodemographic Features (Table 1)

Over three-quarters of the MSM participating in the study were 30 years or younger. The median age was 22 years. Approximately one-fifth (19.2 %) of participants had low education (grade 1–5 or illiterate), and nearly 95 % were Kinh ethnicity (the major ethnic group in Vietnam). Eighty five percent of participants had never married, 65.6 % had a religion, and 13 % were unemployed. The majority of participants were blue collar workers (34.6 %), and 16.7 % were students. MSM in this study had an average income of VNĐ 2,000,000/month (approximately US $100).
Table 1

Socio-demographic characteristics, sexual behaviors and HIV/STI knowledge among MSM in eight southern provinces of Vietnam

Characteristics

Ba Ria-Vung Tau

Dong Nai

TayNinh

Ben Tre

Vinh Long

Dong Thap

HauGiang

SocTrang

Overall

n

%

n

%

n

%

N

%

n

%

n

%

n

%

n

%

n

%

Age (years)

400

 

358

 

400

 

380

 

338

 

289

 

300

 

300

 

2765

 

 16–18

 

9.3

 

6.4

 

29.7

 

31.8

 

24.6

 

15.9

 

26.3

 

19.3

 

20.5

 19–24

 

45.0

 

27.7

 

39.0

 

44.7

 

42.0

 

50.2

 

34.3

 

34.3

 

39.7

 25–30

 

28.3

 

23.7

 

16.0

 

9.8

 

12.4

 

22.5

 

25.7

 

23.7

 

20.0

 31–61

 

17.4

 

42.2

 

15.3

 

13.7

 

21.0

 

11.4

 

13.7

 

22.7

 

19.8

 Mean

25.9

30.0

23.6

22.7

24.9

24.0

24.2

26.0

25.2

 Median

24.0

28.0

20.5

20.0

21.0

22.0

23.0

24.0

22.0

 Range

16–61

16–57

16–56

16–54

16–59

16–55

16–53

16–56

16–61

Education

394

 

358

399

380

338

290

300

300

2759

 Illiterate/primary school

 

18.3

 

24.6

 

15.3

 

8.2

 

16.0

 

26.2

 

14.3

 

34.3

 

19.2

 Secondary school

 

40.1

 

45.5

 

35.8

 

38.2

 

30.8

 

33.8

 

34.3

 

47.7

 

38.3

 High school

 

33.0

 

27.7

 

40.4

 

38.3

 

33.1

 

35.2

 

33.1

 

17.0

 

32.6

 Vocational/tertiary or higher

 

8.6

 

2.2

 

8.5

 

15.3

 

20.1

 

4.8

 

18.3

 

1.0

 

9.9

Kinh ethnicity

398

 99.3

353

 97.7

400

 99.0

380

99.5 

337

 99.1

287

 98.6

300

 93.0

300

 67.0

2755

94.8

Marital status

400

 

357

 

400

 

380

 

338

 

290

 

300

 

300

 

2765

 

 Never married

 

89.2

 

87.1

 

90.5

 

91.3

 

86.3

 

84.1

 

85.0

 

64.6

 

85.4

 Never married but co–habiting with a male partner

 

2.8

 

3.6

 

5.0

 

1.3

 

3.0

 

3.8

 

1.0

 

24.7

 

5.3

 Married/cohabiting with a female partner

 

4.5

 

1.7

 

1.8

 

4.0

 

7.1

 

8.6

 

11.7

 

6.0

 

5.4

 Separated/divorced/widowed

 

3.5

 

7.6

 

2.7

 

3.4

 

3.6

 

3.5

 

2.3

 

4.7

 

3.9

Having a religion

400

 79.0

358

 79.6

400

65.8

380

50.8 

335

50.2 

288

 59.0

299

 49.2

300

 89.7

2760

65.6

Residing in the local area

400

 88.8

354

 75.1

397

 91.7

380

 79.2

338

 79.3

289

89.6 

300

91.3 

300

 98.0

2758

 83.4

Occupation

400

 

360

 

400

 

380

 

338

 

290

 

300

 

300

 

2768

 

 Unemployed

 

4.5

 

6.1

 

17.5

 

25.5

 

14.5

 

7.9

 

6.7

 

20.0

 

13.0

 Small business/vendors

 

18.3

 

15.6

 

10.8

 

11.6

 

18.6

 

13.1

 

21.7

 

16.3

 

15.6

 Singers/barbers

 

16.8

 

31.4

 

20.0

 

2.6

 

6.8

 

14.8

 

9.7

 

10.3

 

14.3

 White collar workers

 

3.0

 

2.5

 

1.3

 

0.3

 

2.1

 

4.2

 

10.7

 

1.0

 

2.9

 Students

 

11.0

 

3.6

 

18.0

 

27.4

 

31.1

 

15.2

 

23.0

 

3.7

 

16.7

 Blue collar workers and others

 

46.4

 

40.8

 

32.4

 

32.6

 

26.9

 

44.8

 

28.2

 

48.7

 

37.5

Average income/month (million VND)

400

 

353

 

400

 

380

 

334

 

290

 

299

 

297

 

2753

 

 ≤2

 

29.8

 

33.4

 

70.7

 

77.3

 

77.0

 

61.7

 

63.2

 

40.7

 

56.7

 Between 2 & 4

 

49.2

 

47.6

 

26.0

 

19.0

 

18.8

 

31.4

 

33.4

 

46.8

 

33.9

 >4

 

21.0

 

19.0

 

3.3

 

3.7

 

4.2

 

6.9

 

3.4

 

12.5

 

9.4

 Mean

3.4

3.3

1.8

1.8

1.8

2.1

2.0

2.7

2.4

 Median

3.0

3.0

2.0

1.5

1.5

2.0

2.0

2.5

2.0

 Range

0.0–15.0

0.0–35.0

0.0–15.0

0.15–20.0

0.0–10.0

0.0–10.0

0.2–7.0

0.45–10.0

0.0–35.0

Currently living with

400

 

357

 

400

 

380

 

338

 

290

 

300

 

300

 

2765

 

 Alone

 

14.3

 

19.9

 

8.5

 

5.5

 

12.4

 

9.3

 

6.3

 

9.7

 

10.9

 Parents/relatives

 

60.0

 

57.1

 

77.2

 

82.4

 

60.1

 

60.0

 

76.3

 

51.0

 

66.0

 Male partners/friends

 

20.7

 

21.3

 

12.5

 

9.2

 

21.3

 

20.7

 

6.1

 

32.0

 

17.7

 Wife/female partner

 

5.0

 

1.7

 

1.8

 

2.9

 

6.2

 

10.0

 

11.3

 

7.3

 

5.4

Age at sexual debut

397

 

352

 

399

 

380

 

338

 

290

 

300

 

300

 

2756

 

 ≤15 years old

 

9.6

 

8.5

 

10.8

 

10.5

 

11.8

 

1.4

 

13.0

 

6.3

 

9.2

 Mean

18.2

18.6

17.8

17.7

18.5

18.1

17.8

18.2

18.1

 Median

18.0

19.0

17.0

17.0

18.0

18.0

17.0

18.0

18.0

 Range

12.0–33.0

11.0–41.0

8.0–35.0

12.0–27.0

12.0–44.0

12.0–26.0

13.0–33.0

12.0–35.0

8.0–44.0

Self-reported type of sexual identity

399

 

358

 

399

 

379

 

336

 

289

 

298

 

300

 

2758

 

 Transvestite gay

 

15.5

 

29.1

 

19.8

 

10.3

 

11.9

 

22.5

 

24.8

 

14.0

 

18.3

 Non-transvestite gay

 

72.4

 

51.7

 

63.9

 

68.6

 

59.8

 

50.9

 

35.2

 

67.3

 

59.6

 Bisexual

 

12.0

 

19.3

 

16.3

 

21.1

 

28.3

 

26.6

 

39.9

 

18.7

 

22.1

Sexual roles in past 12 months

345

 

236

 

285

 

338

 

229

 

243

 

273

 

209

 

2158

 

 Exclusively insertive

 

16.2

 

12.7

 

22.1

 

23.7

 

39.7

 

25.1

 

38.8

 

31.1

 

25.6

 Frequently insertive

 

22.9

 

15.3

 

9.1

 

10.4

 

7.9

 

8.2

 

12.8

 

8.1

 

12.3

 Versatile

 

55.9

 

35.1

 

43.2

 

49.4

 

26.2

 

48.2

 

35.2

 

23.4

 

41.1

 Frequently receptive

 

3.8

 

30.1

 

5.6

 

11.2

 

8.7

 

11.9

 

4.8

 

18.7

 

11.1

 Exclusively receptive

 

1.2

 

6.8

 

20.0

 

5.3

 

17.5

 

6.6

 

8.4

 

18.7

 

9.9

Typical meeting places/past 12 months

                  

 Pubs/restaurants

394

22.3

356

39.9

400

22.8

379

21.6

337

51.6

289

50.9

300

58.3

298

31.9

2753

36.1

 Guest houses/motels

394

53.1

356

62.4

400

52.5

380

31.6

337

41.5

289

40.5

300

13.0

298

24.5

2754

41.0

 Hotels

394

12.4

356

30.9

400

5.5

380

2.4

337

3.0

289

8.3

300

0.0

298

2.4

2754

8.4

 Swimming pools

394

0.5

356

4.2

400

2.5

380

1.8

337

0.0

289

0.4

300

0.0

298

1.7

2754

1.5

 Fitness/aerobic centers

394

1.8

356

2.0

400

0.0

380

1.3

337

0.3

289

0.4

300

0.0

298

1.3

2754

0.9

 Internet

394

16.2

356

9.0

400

9.8

380

16.6

337

4.2

289

10.4

300

3.0

298

3.4

2754

9.5

 Match-makers

394

1.0

356

7.6

400

2.3

380

1.8

337

0.0

289

2.8

300

0.0

298

5.4

2754

2.6

 Massage/sauna

394

4.8

356

1.7

400

1.8

380

0.5

337

0.3

289

6.6

300

0.3

298

1.3

2754

2.1

 Bars/discotheques

394

20.3

356

2.8

400

8.3

380

7.4

337

4.5

289

12.8

300

2.7

298

4.7

2754

8.2

 Theaters

394

1.5

356

0.3

400

2.3

380

1.1

337

0.6

289

2.4

300

0.0

298

0.3

2754

1.1

 On streets, parks, lake/river shores

394

19.0

356

21.6

400

14.8

380

34.0

337

11.3

289

24.6

300

37.0

298

52.4

2754

26.0

 Cafés, billiards

394

32.5

356

11.2

400

53.5

380

64.0

337

50.5

289

73.4

300

80.7

298

43.6

2754

50.1

 Others (home, workplace, school)

394

12.2

356

8.2

400

12.5

380

14.7

337

17.8

289

9.7

300

9.0

298

4.4

2754

11.3

Number of male oral sex partners in past 3 months

396

 

349

 

400

 

380

 

337

 

290

 

300

 

299

 

2751

 

 Mean

2.0

 

6.8

 

2.5

 

2.1

 

1.9

 

2.0

 

2.3

 

4.6

 

3.0

 

 Median

2.0

 

5.0

 

2.0

 

1.0

 

1.0

 

1.0

 

2.0

 

3.0

 

2.0

 

 Range

0.0–30.0

 

0.0–60.0

 

0.0–30.0

 

0.0–30.0

 

0.0–50.0

 

0.0–8.0

 

0.0–15.0

 

0.0–30.0

 

0.0–60.0

 

Number of male anal sex partners in past 3 months

398

 

356

 

399

 

380

 

336

 

290

 

300

 

299

 

2758

 

 None

 

16.3

 

44.9

 

37.3

 

20.5

 

37.5

 

18.3

 

9.3

 

33.4

 

27.5

 1

 

35.4

 

10.5

 

24.1

 

33.2

 

27.7

 

42.1

 

32.7

 

18.7

 

27.9

 2–4

 

45.2

 

26.1

 

30.8

 

39.7

 

27.7

 

29.3

 

46.0

 

33.4

 

34.9

 ≥5

 

3.1

 

18.5

 

7.8

 

6.6

 

4.1

 

10.3

 

12.0

 

14.5

 

9.7

 Mean

1.7

 

2.4

 

1.8

 

1.9

 

1.6

 

1.9

 

2.4

 

2.3

 

2.0

 

 Median

1.0

 

1.0

 

1.0

 

1.0

 

1.0

 

1.0

 

2.0

 

1.0

 

1.0

 

 Range

0.0–13.0

 

0.0–22.0

 

0.0–30.0

 

0.0–25.0

 

0.0–21.0

 

0.0–8.0

 

0.0–12.0

 

0.0–20.0

 

0.0–30.0

 

Having sex in the past 12 months with

 Foreigners

400

2.3

360

3.1

400

2.8

380

2.6

338

1.2

290

5.5

300

0.0

300

0.7

2768

2.3

 Females/girlfriends

400

19.5

350

10.3

400

19.3

380

35.8

338

40.5

290

46.6

300

50.7

297

32.0

2755

30.7

 Wife/cohabiting partner

400

18.0

350

8.6

400

16.8

380

25.8

338

34.3

290

42.4

300

49.7

296

29.7

2754

27.0

 Female sex workers

400

7.5

350

1.7

400

3.0

379

6.6

336

4.8

290

10.7

300

6.0

295

5.1

2750

5.6

 Female clients

400

0.3

348

0.0

400

0.0

379

1.6

336

0.6

290

2.8

300

2.0

296

1.0

2749

1.0

 Voluntary male partners

399

91.2

357

73.1

400

90.3

380

90.8

337

95.9

290

91.0

300

99.7

299

88.3

2762

89.8

 Male clients

399

24.8

356

35.7

400

20.5

380

40.8

337

16.6

290

13.5

300

6.0

299

42.1

2761

25.4

 Male sex workers

398

10.1

357

15.4

400

11.3

380

14

337

2.1

290

6.9

300

2.7

299

19.4

2761

10.4

Condom use during anal sex with male partners in past 3 months

328

 

205

 

257

 

295

 

189

 

234

 

272

 

202

 

1982

 

 Never

 

14.6

 

21.0

 

20.6

 

36.6

 

28.0

 

20.1

 

20.2

 

21.3

 

22.7

 Sometimes

 

17.7

 

35.6

 

6.6

 

10.9

 

9.1

 

14.5

 

8.8

 

15.8

 

14.5

 Often

 

35.1

 

17.1

 

23.0

 

14.7

 

16.9

 

13.3

 

11.4

 

17.8

 

19.3

 Always

 

32.6

 

26.3

 

49.8

 

38.0

 

46.0

 

52.1

 

59.6

 

45.1

 

43.5

Use of condoms when having sex with female sex workers/past 12 months

29

 

6

 

12

 

25

 

16

 

31

 

18

 

15

 

152

 

 Never

 

0.0

 

0

 

50.0

 

12

 

12.5

 

0.0

 

27.8

 

13.3

 

11.8

 Sometimes

 

10.3

 

0

 

0.0

 

4

 

18.8

 

16.2

 

16.7

 

6.7

 

10.5

 Often

 

0.0

 

17

 

8.3

 

8

 

12.4

 

16.1

 

16.7

 

0.0

 

9.3

 Always

 

89.7

 

83

 

41.7

 

76

 

56.3

 

67.7

 

38.8

 

80.0

 

68.4

Lubricant use when having anal intercourse in past 12 months

345

 

236

 

285

 

335

 

228

 

241

 

273

 

209

 

2152

 

 Never

 

69.9

 

29.7

 

60.0

 

60.6

 

66.2

 

32.4

 

60.4

 

70.8

 

57.0

 Saliva

 

2.6

 

2.1

 

4.2

 

3.9

 

1.8

 

13.7

 

0.8

 

1.0

 

3.7

 Water

 

22.6

 

18.2

 

9.8

 

17.3

 

12.3

 

9.1

 

0.0

 

5.7

 

12.5

 Oil/cream

 

4.9

 

50.0

 

26.0

 

18.2

 

19.7

 

44.8

 

38.8

 

22.5

 

26.8

Self-assessment of HIV risk among those who had ever heard about HIV/AIDS

383

 

304

 

328

 

336

 

287

 

220

 

268

 

211

 

2337

 

 Not at all

 

56.7

 

44.1

 

69.8

 

48.2

 

67.2

 

69.5

 

62.7

 

63.0

 

59.4

 Not likely

 

15.9

 

11.8

 

16.5

 

14.0

 

17.1

 

15.0

 

19.4

 

4.8

 

14.6

 Likely

 

22.7

 

38.8

 

12.5

 

28.9

 

13.6

 

10.9

 

16.0

 

24.6

 

21.4

 Very likely

 

4.7

 

5.3

 

1.2

 

8.9

 

2.1

 

4.6

 

1.9

 

7.6

 

4.6

Ever tested for HIV

400

12.8

360

6.9

400

3.5

380

9.2

338

8.3

290

4.5

300

1.0

300

16.7

2768

7.9

Had heard about HIV

400

95.8

358

85.2

400

82.0

380

88.4

338

84.9

290

75.9

300

89.3

300

70.3

2766

84.5

Correct knowledge about HIV prevention

400

 

358

 

400

 

380

 

338

 

290

 

300

 

300

 

2766

 

 Always using condoms during sex can reduce HIV transmission

 

77.3

 

68.4

 

77.8

 

85.3

 

78.1

 

71.4

 

76.7

 

65.7

 

75.5

 A healthy-looking person can be infected with HIV

 

64.0

 

69.8

 

70.8

 

71.3

 

70.4

 

59.0

 

70.3

 

56.0

 

66.8

 Sharing food with PLWHIV does not transmit HIV

 

91.0

 

74.3

 

74.5

 

77.4

 

75.4

 

48.6

 

82.3

 

65.3

 

74.5

 Mosquitoes do not transmit HIV

 

58.3

 

65.9

 

56.5

 

67.9

 

57.4

 

50.3

 

63.3

 

61.3

 

60.3

 Having only one partner can reduce the risk of HIV infection

 

68.0

 

63.7

 

68.5

 

73.4

 

70.1

 

64.1

 

70.7

 

57.3

 

67.3

Necessary knowledge about HIV (National AIDS preventive indicator-21) (×)

400

30.8

358

41.9

400

38.3

380

44.2

338

41.1

290

29.3

300

42.3

300

43.3

2766

38.9

Heard or knew about STIs

400

64.8

357

65.6

400

65.3

380

76.3

337

69.1

290

54.1

300

57.3

299

31.4

2763

61.5

Knew at least one male STI-related symptom

400

58.3

360

60.8

400

27.5

380

39.2

338

53.0

290

43.1

300

43.0

300

25.0

2768

44.0

Ever had an STI

400

0.8

360

1.9

400

1.8

380

4.2

338

1.5

290

5.9

300

1.0

300

2.0

2768

2.3

n number of MSMs;  % percentage. Not all questions were answered by all participants, but there were very few questions that were not answered by the participants

(×): Having necessary knowledge about HIV including: 1. Being faithful with a partner who is not infected HIV reduces the risk of HIV infection; 2. Condom use reduces the risk of HIV infection; 3. A healthy-looking person can be infected with HIV, 4. Mosquito bite does not transmit HIV, 5. Sharing food with PLWHIV does not transmit HIV

The majority (66 %) of the participants currently lived with parents/relatives, whereas 5.4 % were living with wives/female partners and 17.7 % with male partners/friends.

The proportion of MSM who thought that they were very likely, likely, not likely, or not at all likely to be infected with HIV were 4.6, 21.4, 14.6 and 59.4 %, respectively. Only 7.9 % of MSM in the survey had previously been tested for HIV.

Basic knowledge of HIV was also assessed. The majority was able to recognize safe sex behaviors in general, but only 38.9 % correctly answered all five questions on knowledge related to HIV transmission. Nearly two-third (61.5 %) of the participants had ever heard about STIs and 44 % knew at least one male STI-related symptom; 2.3 % of MSM reported ever having an STI (Table 1).

Sexual Behaviors (Table 1)

The median age of sexual debut was 18 years, with little variation across sites. Overall, 9.2 % of participants initiated sexual activity when they were 15 years of age or younger. Sexual identity was self-reported as 18.3 % transvestite gay (who dress like women, known as “bong lo”), 59.6 % “non-transvestite gay” (wear male attire, known as “bong kin”), and 22.1 % bisexuals who had both male and female partners. As expected, gay (transvestite and non-transvestite) men were less likely to have sex with females compared to bisexuals in the past 12 months (21.8 vs. 61.5 %, p < 0.001); however, those who identified themselves as gay were more likely to always use a condom when having sex with wife/partner (45.4 vs. 31.8 %, p < 0.001) (data available upon request). Sexual role was reported as 25.6 % exclusively insertive, 12.3 % versatile but frequently insertive, 41.1 % versatile, 11.1 % versatile but frequently receptive, and 9.9 % exclusively receptive. The most common places where MSM met were reported to be café/billiard establishments (50.1 %), guest houses/motels (41.0 %), pubs/restaurants (36.1 %), and streets/parks or lake/river shores (26.0 %); the internet was not as popular a means for MSM to meet (9.5 %).

The median number of male oral sex partners in the past 3 months was two, while more than one-third (34.9 %) of participants reported having 2–4 male anal sex partners in the past three months. The majority of participants (85.4 %) were unmarried, and 89.8 % engaged in sex with male partners, but 30.7 % also had sex with females/girlfriends. Few (2.3 %) had engaged in sex with a foreigner in the past 12 months. We found that 49.2 % of those who had ever engaged in sex with a foreigner had ever had transactional sex with male or female clients. Additionally, 24.9 % of those who never engaged in sex with a foreigner ever had transactional sex with male or female clients (not shown in Table 1). One-fourth had had sex with male clients, and 10.4 % had had sex with a male sex worker in the past 12 months. Only 43.5 % had consistently used condoms with any anal sex partners, and 22.7 % never used condoms. Unprotected anal intercourse was slightly higher among unmarried MSM (57.3 %) than ever-married MSM (49.4 %) (not shown in Table 1). Participants also engaged in sex with their wives/cohabiting partners (27 %) or female sex workers (5.6 %) in the past 12 months, and female clients (1.0 %) in the past three months. The rate of consistent condom use with female sex workers was 68.4 %. Lubricant was also used by almost 40 % for anal sex with either males or females (26.8 % oil or cream, 12.5 % water-based).

Cigarette, Alcohol, and Recreational Drug Use (Table 2)

Daily cigarette smoking among participants was quite prevalent (49.1 %), 7.8 % reported consuming alcohol on a daily basis, and 31.5 % reported frequent drinking (a few times per week). One-fifth of the participants reported never drinking in the past month (for the questions asked about behavior in the past month, not in lifetime). Among participants who had sex in the past three months, 75 % reported alcohol consumption before sex; the proportion was 23.7 % reporting always, 21.1 % frequently, 30.0 % sometimes, and 25.2 % never.
Table 2

Cigarette, alcohol and recreational drug use among MSM in eight southern provinces of Vietnam

Characteristics

Ba Ria-Vung Tau

Dong Nai

TayNinh

Ben Tre

Vinh Long

Dong Thap

HauGiang

SocTrang

Overall

N

%

n

%

n

%

n

%

N

%

n

%

n

%

n

%

n

%

Cigarette smoking in the last month

400

 

358

 

400

 

379

 

338

 

285

 

300

 

299

 

2759

 

 Daily

 

38.2

 

51.1

 

46.0

 

55.9

 

51.2

 

43.2

 

34.3

 

74.5

 

49.1

 Sometimes

 

27.3

 

18.2

 

8.8

 

9.3

 

9.8

 

13.0

 

8.0

 

6.4

 

12.9

 Never

 

13.5

 

30.7

 

45.2

 

34.8

 

39.0

 

43.8

 

57.7

 

19.1

 

38.0

Consuming alcohol in the past month

400

 

353

 

399

 

380

 

338

 

290

 

269

 

300

 

2756

 

 Every day

 

10.5

 

18.7

 

5.3

 

2.4

 

8.6

 

5.5

 

6.5

 

4.3

 

7.8

 A few times a week

 

36.0

 

41.1

 

14.8

 

32.6

 

47.0

 

25.9

 

35.8

 

18.7

 

31.5

 A few times a month

 

26.5

 

23.8

 

42.8

 

39.5

 

32.5

 

29.6

 

40.5

 

35.0

 

33.8

 Only one time per month

 

8.0

 

2.8

 

6.0

 

0.8

 

2.7

 

10.7

 

17.2

 

5.7

 

6.4

 Never

 

19.0

 

13.6

 

31.1

 

24.7

 

9.2

 

28.3

 

0.0

 

36.3

 

20.5

Consuming alcohol before sex in the past 3 months

327

 

194

 

242

 

279

 

211

 

234

 

272

 

199

 

1958

 

 Never

 

27.8

 

17.5

 

33.0

 

28.7

 

22.3

 

24.8

 

19.9

 

24.6

 

25.2

 Sometimes

 

41.6

 

40.7

 

23.6

 

15.8

 

13.3

 

44.9

 

27.2

 

32.2

 

30.0

 Frequent

 

19.6

 

18.1

 

26.0

 

19.0

 

19.9

 

17.5

 

31.6

 

15.1

 

21.1

 Always

 

11.0

 

23.7

 

17.4

 

36.5

 

44.5

 

12.8

 

21.3

 

28.1

 

23.7

Recreational drug use

400

 

360

 

400

 

380

 

338

 

290

 

300

 

300

 

2768

 

 Never

 

89.2

 

96.4

 

94.9

 

86.6

 

90.8

 

95.5

 

98.7

 

92.3

 

92.9

 Previously, but no longer using

 

7.0

 

1.1

 

4.3

 

10.5

 

6.5

 

3.1

 

0.3

 

3.3

 

4.7

 Current use via smoking/inhaling/drinking

 

2.0

 

0.8

 

0.5

 

2.6

 

1.5

 

1.4

 

0.7

 

2.7

 

1.5

 Current use via injecting

 

1.8

 

1.7

 

0.3

 

0.3

 

1.2

 

0.0

 

0.3

 

1.7

 

0.9

Types of recreational drug use

42

 

13

 

20

 

51

 

31

 

13

 

4

 

23

 

197

 

 Heroin

 

19.1

 

7.7

 

25.0

 

7.8

 

16.2

 

7.7

 

0

 

30.4

 

15.7

 Opium

 

4.8

 

0.0

 

5.0

 

2.0

 

0.0

 

0.0

 

0

 

0.0

 

2.0

 Sedative

 

0.0

 

15.4

 

0.0

 

2.0

 

0.0

 

7.7

 

25

 

0.0

 

2.6

 Cannabis

 

64.2

 

53.8

 

65.0

 

62.8

 

29.0

 

46.1

 

50

 

52.1

 

54.8

 Ecstasy

 

11.9

 

23.1

 

0.0

 

21.5

 

29.0

 

30.8

 

25

 

13.1

 

18.3

 Ice (methamphetamine)

 

0.0

 

0.0

 

5.0

 

3.9

 

25.8

 

7.7

 

0

 

4.4

 

6.6

N number of participants; % percentage

Recreational drug use is strictly prohibited in Vietnam. When asked about recreational drug use, 7.1 % reported ever using them. This proportion included 4.7 % who had previously but no longer used, 1.5 % who were currently using drugs that could be inhaled or swallowed, and 0.9 % currently injecting drugs. The most common drug of use was cannabis (54.8 %), “shaking drug” (ecstasy; 18.3 %), heroin (15.7 %), and methamphetamine (6.6 %). The prevalence of men who previously but no longer used drugs, currently inhaled or swallowed drugs, and injected among participants who were exclusively or frequently insertive were 1.1, 2.6, and 5.3 %, respectively, whereas for participants who were exclusively or frequently receptive, 0.4, 1.6 and 2.9 %, respectively (not shown in Table 2).

HIV and Selected STIs Among MSM (Table 3)

The overall prevalence of HIV among participants was 2.6 % (95 % CI 2.0–3.2), ranging from 0 % (95 % CI 0.0–1.2) in Hau Giang to 8.64 % (95 % CI 5.7–11.6) in Dong Nai. The prevalence of syphilis, urethral gonorrhea, urethral chlamydia, urethral gonorrhea, and/or chlamydia were 1.6 %, ranging from 0 % in Ben Tre to 5.8 % in Dong Nai; 2.4 % (from 1.1 % in Dong Nai to 4.0 % in Hau Giang), 4.3 % (from 2.2 % in Dong Nai to 6.5 % in Vinh Long), and 6.3 % (from 3.3 % in Dong Nai to 8.3 % in Vinh Long), respectively.
Table 3

Prevalence of HIV and selected STIs among MSM in eight southern provinces of Vietnam

Characteristics

Ba Ria-Vung Tau

Dong Nai

Tay Ninh

Ben Tre

Vinh Long

Dong Thap

Hau Giang

Soc Trang

Overall

N

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

n

%

HIV

400

2.25

359

8.64

395

1.01

380

1.05

337

3.86

290

1.72

300

0.00

300

2.00

2761

2.61

95 % CI

0.8–3.7

5.7–11.6

0.3–2.6a

0.3–2.7a

1.8–5.9

0.6–4.0a

0.0–1.2a

0.4–3.6

2.0–3.2

Syphilis

400

1.00

360

5.83

400

0.25

380

0.00

337

0.89

290

0.00

300

3.67

2467

1.62

95 % CI

0.3–2.5a

3.4–8.3

0.01–1.4a

0.0–1.0a

0.2–2.6a

0.0–1.3a

1.5–5.8

  

1.1–2.1

Urethral gonorrhea

400

2.75

360

1.11

400

3.00

380

1.58

338

2.07

299

4.01

2177

2.39

95 % CI

1.1–4.4

0.3–2.8a

1.3–4.7

0.3–2.8

0.5–3.6

  

1.8–6.3

  

1.7–3.0

Urethral chlamydia

400

4.50

360

2.22

400

3.50

380

4.47

338

6.51

299

4.68

2177

4.27

95 % CI

2.5–6.5

0.7–3.8

1.7–5.3

2.4–6.6

3.9–9.2

  

2.3–7.1

  

3.4–5.1

Urethral gonorrhea and/or chlamydia

400

6.75

360

3.33

400

6.00

380

5.79

338

8.28

299

8.03

2177

6.29

95 % CI

4.3–9.2

1.5–5.2

3.7–8.3

3.4–8.1

5.3–11.2

  

4.9–11.1

  

5.3–7.3

N number of participants; % percentage; CI confidence interval

aBinomial exact

Factors Associated with HIV Infection (Table 4)

In univariate analysis, HIV infection was more prevalent among older MSM, those residing in the southeastern provinces (versus southwestern), small businessmen/vendors or freelance singers/barbers, those reporting having a religion, ever having sex with a foreigner, consuming alcohol on a daily basis, ever using recreational drugs (previously but no longer using, currently inhaling/swallowing, currently injecting), and those who thought that they were likely or very likely to be infected with HIV. HIV was less prevalent among those who had higher education levels, and/or never or only sometimes consumed alcohol immediately before having sex.
Table 4

Factors associated with HIV among MSM in eight southern provinces of Vietnam

Characteristic

N

% HIV

Univariate

Multivariateb

OR (95 % CI)

p value

aOR (95 %CI)

p value

Age (years)

2752

 

1.06 (1.04–1.09)

<0.001

1.13 (1.081.18)

<0.001

Region

2754

     

 Southwestern

1604

1.6

1

   

 Southeastern

1150

3.5

2.28 (1.37–3.77)

0.001

Educational level

2746

     

 Low (illiterate/primary school)

525

5.0

1

   

 Secondary school

1053

1.9

0.37 (0.21–0.67)

0.001

 High school

894

1.9

0.37 (0.20–0.69)

0.002

 Vocational/college/university

274

0.7

0.14 (0.03–0.60)

0.008

Occupation

2754

     

 Unemployed

357

1.7

1

   

 Small business/vendor

430

4.4

2.70 (1.07–6.85)

0.036

 Singer/barber shopper

393

4.1

2.48 (0.96–6.42)

0.06

 White collar

81

2.5

1.48 (0.29–7.47)

0.634

 Students

461

0.4

0.25 (0.05–1.27)

0.095

 Other (worker, laborer, farmer)

1032

1.9

1.16 (0.46–2.90)

0.757

Marital status

2752

     

 Never married

2497

2.4

1

 

1

 

 Ever married

255

2.0

0.81 (0.32–2.04)

0.658

0.10 (0.030.29)

<0.001

Income (per month)

2740

     

 ≤2 VND million

1552

1.6

1

 

1

 

 2–4 VND million

931

3.4

2.27 (1.33–3.87)

0.003

1.27 (0.55–2.93)

0.574

 >4 VND million

257

3.5

2.31 (1.06–5.03)

0.035

3.85 (0.75–19.63)

0.105

Having a religion

2747

     

 No

945

1.4

1

 

1

 

 Yes

1802

2.9

2.13 (1.15–3.93)

0.016

3.56 (2.215.73)

<0.001

Residing in the local area

2745

     

 No

453

1.6

1

   

 Yes

2292

2.5

1.65 (0.75–3.65)

0.212

Currently living with

2752

     

 Alone

297

4.0

1

   

 Parents/relatives

1816

2.3

0.55 (0.28–1.06)

0.073

 Friends/male partners

489

2.0

0.50 (0.21–1.16)

0.107

 Wife/cohabiting/girl friend

150

1.3

0.32 (0.07–1.45)

0.14

Age at sexual debut (years)

2743

     

 >15

2490

2.4

1

   

 ≤15

253

2.0

0.82 (0.32–2.05)

0.666

Sexual identity

2745

     

 Transvestite gay

502

4.0

1

   

 Non transvestite gay

1637

2.3

0.56 (0.32–0.97)

0.038

 Bisexual

606

1.3

0.32 (0.14–0.74)

0.007

Sexual role

2148

     

 Exclusively or frequently insertive

815

1.8

1

 

1

***

 Versatile (equally insertive and receptive)

882

1.8

0.99 (0.48–2.01)

0.968

0.38 (0.11–1.33)

0.130

 Exclusively or frequently receptive

451

2.4

1.33 (0.61–2.93)

0.474

0.28 (0.130.62)

0.002

Basic HIV knowledge (national indicator–20)a

2753

     

 No

1684

2.2

1

   

 Yes

1069

2.6

1.20 (0.73–1.97)

0.478

Number of male anal sex partners in past 3 months

2745

     

 1

767

1.2

1

   

 2–4

957

2.2

1.89 (0.86–4.15)

0.113

  

 ≥5

267

2.3

1.94 (0.68–5.49)

0.214

Engaged in sex with a foreigner in past 12 months

2754

     

 No

2692

2.3

1

 

1

 

 Yes

62

6.5

2.97 (1.05–8.45)

0.041

9.24 (1.8346.64)

0.007

Consumed alcohol before anal sex in past 3 months

1950

     

 Always

463

3.2

1

 

1

 

 Frequently

413

0.7

0.22 (0.06–0.76)

0.017

0.19 (0.02–1.45)

0.108

 Sometimes

583

1.4

0.42 (0.17–0.99)

0.047

0.15 (0.060.34)

<0.001

 Never

491

1.6

0.49 (0.21–1.18)

0.11

0.46 (0.09–2.32)

0.345

Condom use during anal sex in past 3 months

1943

     

 Never

441

2.5

1

 

1

 

 Sometimes

283

2.8

1.14 (0.45–2.86)

0.785

0.97 (0.34–2.78)

0.959

 Frequently

377

0.8

0.31 (0.09–1.13)

0.077

0.07 (0.010.90)

0.041

 Always

842

1.4

0.56 (0.25–129)

0.176

0.42 (0.08–2.22)

0.306

Lubricant used during anal sex in past 12 months

1984

     

 No

1174

1.4

1

   

 Yes

810

2.4

1.74 (0.89–3.40)

0.106

Cigarette smoking during past month

2746

     

 Never

1043

2.4

1

   

 Sometimes

355

2.3

0.94 (0.42–2.10)

0.878

 Daily

1348

2.4

0.99 (0.58–1.68)

0.971

Consumed alcohol during past month

2743

     

 Never

560

1.8

1

 

1

 

 One or a few times/month

1104

2.1

1.17 (0.55–2.48)

0.681

2.14 (0.51–8.92)

0.297

 One or a few times/week

864

2.6

1.44 (0.68–3.06)

0.347

1.19 (0.15–9.61)

0.871

 Daily

215

4.7

2.68 (1.10–6.54)

0.03

0.32 (0.01–7.21)

0.474

Recreational drug use

2754

     

 Never

2558

2.0

1

 

1

***

 Previously but no longer

129

5.4

2.77 (1.23–6.21)

0.014

7.37 (2.2224.52)

0.001

 Currently inhaling/swallowing

42

7.1

3.71 (1.11–12.38)

0.033

19.29 (4.6080.92)

<0.001

 Currently injecting

25

12.0

6.57 (1.91–22.64)

0.003

63.58 (28.20143.38)

<0.001

Types of recreational drug use +++

2754

     

 Never

2559

2.0

1

 

1

***

 Cannabis and others

117

1.7

0.84 (0.20–3.48)

0.808

2.90 (0.49–17.14)

0.239

 ATS

47

14.9

8.44 (3.61–19.71)

<0.001

28.87 (5.10163.54)

<0.001

 Heroin

31

12.9

7.14 (2.41–21.15)

<0.001

48.16 (25.2391.90)

<0.001

HIV risk self-assessment

1899

     

 Not at all likely to be infected

1100

2.6

1

 

1

***

 Unlikely to be infected

297

1.7

0.91 (0.37–2.21)

0.828

0.42 (0.12–1.45)

0.170

 Likely to be infected

424

1.7

1.88 (1.03–3.45)

0.04

2.48 (1.006.18)

0.050

 Very likely to be infected

78

1.3

3.08 (1.24–7.63)

0.015

3.76 (1.2011.79)

0.023

Syphilis-positive

2454

     

 No

2414

2.3

1

 

1

 

 Yes

40

10

4.77 (1.64–13.85)

0.004

8.12 (2.5925.53)

<0.001

Urethral infection with either gonorrhea or Chlamydia

2164

     

 No

2029

2.5

1

 

1

 

 Yes

135

3.0

1.18 (0.42–3.33)

0.748

3.18 (0.71–14.24)

0.131

Full model includes: age, region, education level, occupation, marital status, income, having a religion, residing in the local area, whom currently living with, sexual identity, sexual role, number of male anal sex partners in past three months, ever engaging in sex with a foreigner in past 12 months, consuming alcohol before anal sex in past three months, condom use during anal sex in past three months, lubricant use during anal sex in past 12 months, drinking last month, recreational drug use, types of recreational drug use, self HIV risk assessment, syphilis, urethral infection with either gonorrhea or chlamydia (Four HIV cases previously tested for HIV were removed from the model)

N sample size; OR odds ratio; aOR adjusted OR; CI confidence interval; +++: recreational drug use was replaced by types of recreational drug use in the full model (to see the effect of types of recreational drug use on HIV)

***p for trend <0.05

aHaving necessary HIV knowledge includes correct answers to the all 5 as below: 1. Having only one partner who is not infected HIV can reduce the risk of HIV infection; 2. Condom use can reduce the risk of HIV infection; 3. A healthy-looking person can be infected with HIV; 4. Mosquito bites do not transmit HIV; 5. Sharing food with PLWHIV does not transmit HIV

bAdjusted for cluster effect in the final model

In multivariate analysis, 10 factors were associated with HIV in the final model, including having ever married, having a religion, exclusively/frequently receptive, engaging in sex with a foreigner in past 12 months, consuming alcohol before anal sex in the past 3 months, using condoms during anal sex in the past three months, ever using recreational drugs, using amphetamine-type stimulants (ATS)/heroin, perceiving oneself to be likely/very likely to be infected, and testing positive for syphilis. When age was increased by one year (between 16 and 61 years), the risk of HIV infection increased by 13 % (OR 1.13, 95 % CI 1.08–1.18). HIV infection was higher among MSM who had a religion (OR 3.56; 95 % CI 2.21–5.73), ever engaged in anal sex with a foreigner (OR 9.24, 95 % CI 1.83-46.64), and/or were syphilis-seropositive (OR 8.12, 95 % CI 2.59–25.53). Compared with those who had never used recreational drugs, those who reported previously but no longer using (OR 7.37, 95 % CI 2.22–24.52), currently inhaling/swallowing drugs (OR 19.29, 95 % CI 4.60–80.92), or currently injecting drugs (OR 63.58, 95 % CI 28.20–143.38) were at significantly increased risk of HIV. When the drug use route was replaced by types of drug in the final model, compared with those who had never used recreational drugs, those who reported using ATS (OR 28.87, 95 % CI 5.10–163.54) or heroin (OR 48.16, 95 % CI 25.23–91.90) were at a higher risk of HIV infection. Moreover, MSM who thought that they were likely (OR 2.48, 95 % CI 1.00–6.18) or very likely (OR 3.76, 95 % CI 1.20–11.79) to be infected with HIV were at a higher risk of HIV infection.

MSM who had ever married (OR 0.10, 95 % CI 0.03–0.39), were exclusively or frequently receptive (OR 0.28, 95 % CI 0.13–0.62), sometimes consumed alcohol immediately before having sex (OR 0.15, 95 % CI 0.06–0.34), and/or frequently used condoms during anal sex in the past three months (OR 0.07, 95 % CI 0.01–0.90) were less likely to be infected with HIV.

Discussion

The observed prevalence of HIV among MSM in the eight provinces was low compared with other provinces in Vietnam [>5 % in Hanoi, Hochiminh City, Can Tho and An Giang (bordering with Cambodia)], except for Dong Nai (8.6 %) [6, 8, 11]. The prevalence of HIV in the southwestern provinces was lower than that observed in southeastern provinces, including Dong Nai (8.6 %). Dong Nai borders with Hochiminh City, which has amongst the highest prevalence of HIV in Vietnam in all high-risk groups, including those who inject drugs, MSM, and female sex workers. Previous studies among MSM in Vietnam were carried out in urban populations, whereas our study was conducted in rural or small urban areas, except for Dong Nai which is an industrial province where HIV prevalence may be lower [8, 12]. The prevalence of HIV in the current study, 2.6 %, was lower than in other countries, including 13.6 % in Brazil [13], 12.9 % in northern Thailand [14], and 4.8 % in Beijing, China [15].

Several correlates of HIV infection were identified in this study. Increasing age was found to be correlated with a higher likelihood of HIV infection, perhaps due to cumulative exposure, as was observed in studies in Malawi, Namibia, and Botswana [16] and China [17, 18]. Ever being married was associated with a lower likelihood of HIV, similar to that observed in China; unmarried and homosexual MSM who did not have female sex partners were six-fold more likely to be infected with HIV compared to married or non-homosexual MSM with a female partner(s) [15]. Both that study and ours found that unprotected anal intercourse among married MSM was lower than among those who had never married. The association between having a religion and HIV infection found in this study might be due to infected individuals seeking consolation with religion. However, it is possible that people may believe that their destinies are decided by God and therefore take fewer precautions. It has been shown that personal sexual behaviors and cultures are sometimes related to religion [1921]. Hence, education about HIV transmission and prevention should be discussed with religious leaders so they can deliver appropriate messages to MSM and their partners or families.

Recreational drug use, especially injecting, was shown to be highly associated with HIV, consistent with a number of other studies [7, 8, 22, 23]. Drug injection was associated with a higher risk of HIV than inhalation, smoking, or swallowing drugs. The fact that those who had previously but no longer used drugs had higher rates of HIV infection suggests either under-reporting current drug use or quitting drug use when learning they were HIV-positive. The risk of HIV infection was different according to drug used: cannabis (lowest, OR = 2.9; not statistically significant), ATS (OR = 28.9), and heroin (highest, OR = 48.2).

Receptive anal intercourse was found to be an important risk factor for sexual HIV transmission in several studies [18, 2426]. However, in our study, receptive anal intercourse was associated with a lower likelihood of HIV infection than for those who were exclusively or frequently insertive. This could be partly explained by a higher rate of recreational drug use (both injection and non-injection) in the “insertive” group than the “receptive” group in our study. Although a low proportion of MSM engaged in sex with foreigners, this was significantly associated with a higher risk of HIV infection. Another study amongst migrant MSM in Beijing, China found that having a foreign MSM friend was significantly associated with HIV infection [27]. It is possible that foreigners who have sex with Vietnamese MSM may have higher risks of HIV infection, since they may also have sex with other MSM in other countries where they travel. We also found that nearly half of MSM who had ever engaged in sex with a foreigner also had transactional sex with male or female clients. It has been reported in Hochiminh City and Hanoi that a foreigner pays much more for sex than local clients, and financial power influences decision-making about using condoms [28]. In that same study, MSM thought that not using condoms was a way to show hospitality to foreign clients.

Alcohol use was frequent among participants. Alcohol consumption immediately before having sex “sometimes” was significantly associated with a lower risk for HIV infection than “always”. In fact, heavy alcohol use has been shown to be a risk for HIV infection [29], since it often leads to unsafe sex and a disregard for safe sexual behavior. In this study, condom use was protective for HIV; however, only “frequent condom use” was a significant protective factor. The role of condom use in protecting MSM from HIV infection has been shown in a number of studies [18, 3032]. However, consistent condom use in our study was only 43.5 %, which is similar to that in other provinces in Vietnam [4], suggesting a need to expand and strengthen condom programmes for MSM in Vietnam. Condom use helps prevent both HIV and STIs. Self-assessment of their risk of HIV infection was associated with HIV infection, suggesting it is a good indicator for MSM at risk for HIV. It is possible that MSM recognize that they are at risk of HIV if they use drugs, engage in unsafe sex, and have multiple partners. Therefore, HIV risk perception may be a useful way to prioritize which MSM to target for intervention. Strengthening HIV education and counseling programs for MSM to increase their knowledge and awareness of HIV transmission and related risk behaviors may be beneficial.

STIs are recognized as a facilitating factor for HIV transmission [33, 34], although the prevalence of STIs among MSM in this study was not high, though possibly underestimated, since chlamydia and gonorrhea were only tested for in urine samples, not from rectal specimens. In this study, the prevalence of syphilis was low, but it was highly correlated with HIV infection. Syphilis may increase the risk of HIV transmission, because it shares the same sexual route of transmission, or is facilitated by HIV infection [15, 27, 35, 36]. Consistent condom use can effectively reduce sexual transmission of both HIV and STIs.

This study had certain limitations. The study population was very young and may not be representative of all MSM in the study area. Since “mapping” was used for the sampling frame, only those frequenting the mapped areas would be captured by mapping and be invited into the study. Perhaps the sampling strategy is why the majority of the participants identified as “bong kin” (non-transvestite gay). As such, it would be hard to generalize to MSM in Vietnam more broadly unless the proportion in this study is similar to others. However, the results here could be extrapolated to the gay population in southern Vietnam. Moreover, we do not know the refusal rates, since peer educators distributed the invitation cards to participants at each hotspot. It is possible that some MSM refused to participate and/or gave the invitation cards to other MSM who wanted to take part in the study. If the invitees and non-invitees differed in HIV prevalence and risk behaviors, the association could be under- or over-estimated. Moreover, sensitive topics such as drug use and anal sex might have been under-reported, and under-estimation of the association between these behaviors and HIV could have occurred. Last but not least, the cross-sectional design cannot define temporal relationships between exposures and HIV (a chronic infection).

Our findings suggest that recreational drug use is strongly associated with HIV infection among MSM in southern Vietnam. This is similar to findings among female sex workers in Vietnam, where drug use played a very important role in HIV transmission in this high-risk population [12, 37, 38]. This study also supports the evidence of the protective role of condom use in preventing HIV transmission among MSM. Consumption of alcohol, HIV risk self-assessment, and other risk factors found in the study may be useful for recognizing MSM groups with a higher risk for HIV for implementation of interventions.

HIV interventions among MSM should incorporate several components (health promotion, condom promotion, drug harm reduction programs, methadone maintenance treatment, and STI treatment) and address risk behaviors (inconsistent condom use, consuming alcohol and/or recreational drug use) and having a STI(s).

Acknowledgments

We thank colleagues from eight Provincial AIDS Centers of the eight above stated provinces in southern Vietnam and the staff of the HIV/AIDS Program and the Microbiology and Immunology Department of PIHCM for assisting in the data collection and testing of specimens. Funding for this work was supported by The World Bank Project entitled “Prevention and Control of HIV/AIDS in Vietnam” and NIH UCLA/Fogarty International Center D43 TW000013. We thank Wendy Aft for editing.

Copyright information

© Springer Science+Business Media New York 2015