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Abstract
Objective To assess the prevalence of unprotected anal intercourse (UAI) and its correlates among ethnic Malay men who have sex with men (MSM).
Methods In 2010, a convenience sample of 350 MSM in Penang were recruited to participate in an anonymous, computerised survey with rapid HIV testing. Participants who were not of Malay ethnicity (n=44) or who did not report sex with another man in the previous 12 months (n=22) were excluded, resulting in 284 participants in the final analysis. Correlates of UAI were examined separately for regular and casual partnerships using bivariate and multivariate logistic regression.
Results Four men (1.9%) tested HIV positive. In the past 12 months, 64.7% of participants had regular sexual partners, 77.1% had casual sexual partners and 41.9% had both. Most participants (83.1%) reported UAI, which was more common in regular partnerships. Over two-thirds of participants had never been tested for HIV. In multivariate analysis, agreement about sexual risk reduction practices was associated with a reduction in UAI with regular partners (adjusted OR (AOR)=0.14, 95% CI 0.05 to 0.40). Reporting difficulty in using condoms was associated with an increase in UAI with casual partners (AOR=9.07, 95% CI 3.35 to 24.5), and any exposure to HIV prevention was associated with a decrease in UAI with casual partners (AOR=0.22, 95% CI 0.09 to 0.54).
Conclusions Despite highly prevalent HIV risk behaviours, HIV seropositivity and prior HIV testing were low. Increasing sexual negotiation skills and access to HIV testing and other prevention services may improve future prevention efforts.
- HIV
- Homosexuality
- Prevention
- Sexual Behaviour
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Introduction
HIV prevalence is rising among men who have sex with men (MSM) in Asia.1 ,2 Though the HIV epidemic in Malaysia has historically been concentrated among people who inject drugs, there is evidence of a transition from injection-related transmission to sexual transmission.3 The rise in sexual transmission of HIV reflects increasing sexual transmission among MSM, which may be misreported as heterosexual transmission due to the illegality and stigmatisation of homosexuality. In Malaysia, sexual activities between men are forbidden by culture and religion, and are illegal under civil and Shari'a law.4 Social stigma and the lack of sentinel HIV behavioural surveillance among MSM have resulted in a lack of knowledge of this high-risk population, which in turn has resulted in minimal public health responses and few government resources allocated for this population.
The Malaysian society is multicultural and comprises several ethnic groups: Malay (50.4%), Chinese (22.2%), Indian (6.7%), indigenous (11.9%) and others (8.9%).5 The ethnicity markers include language, religion, custom and other cultural activities. Malay refers to the majority ethnic group of Malaysians who the Constitution defines culturally as Malaysian citizens who are (1) Muslim, (2) who habitually speak the Malay language and (3) who follow Malay customs.6 The Malay ethnic identity is inextricably linked to being Muslim and Malaysian Malays are forbidden to convert to other religion.
The first biobehavioural study of MSM in Malaysia, conducted in Kuala Lumpur in 2009, found that 3.9% of MSM who frequented various MSM venues were HIV positive.7 Ethnic differences in HIV risks were observed. Malay MSM were significantly more likely to test positive for HIV compared to Chinese MSM and were more likely to report unprotected anal intercourse (UAI) with casual partners. The authors hypothesised that cultural norms and religious factors may shape the sexual practices of Malay MSM. Furthermore, added stigmatisation of homosexual behaviour among Malay men may impede them from accessing HIV prevention information and services.7
Methods
Recruitment and enrolment
This cross-sectional study was conducted from July to November 2010 in Penang, the northwest state of West Malaysia that has a population of 1.56 million with 45.6% Chinese, 43.6% Malay, 10.4% Indian and 0.4% other ethnic groups.8 A MSM advisory board representing community-based organisations and local universities was established to provide guidance on study design and implementation. Universiti Sains Malaysia in Penang Island and a community-based organisation were the data collection sites. Recruitment was conducted through outreach at gay bars, cruising venues, chat rooms and websites, and peer referral by study participants.
Interested individuals were screened for eligibility as follows: age ≥18 years, residing in, or having visited Penang at least three times in the past 6 months with the aim of having sex with men, having had sex with another man in the past year, and ability to read either English, Malay or Chinese. Eligible individuals were informed of the risks and benefits of participation. The survey was anonymous, with no personal identifiers collected, and was approved by the Medical Ethics Committee of the University of Malaya Medical Centre.
Participants self-administered the survey using a computer-assisted instrument to reduce bias when reporting sensitive or stigmatised behaviours. Research assistants were unable to view the responses during the conduct of the survey unless a participant requested assistance. After survey completion, participants underwent an optional rapid oral-fluid HIV test (OraQuick ADVANCE Rapid HIV-1/2; OraSure Technologies, Inc., Bethlehem, Pennsylvania, USA). Pre-test and post-test sexual health information was provided. Participants with reactive test results were supported by research staff and referred for confirmatory testing and evaluation at an HIV clinic in Penang. Participants received RM50 (US$16) for their participation.
A convenience sample of 350 MSM was obtained. The majority of participants were ethnic Malay (n=306, 87.4%). Malays were heavily overrepresented in the sample as Chinese are the majority ethic group in Penang. Because the first MSM study found that Malay MSM were at higher risk for HIV infection compared to other ethnicities and because we were unable to adequately sample Chinese MSM, we focused on Malay MSM and excluded non-Malay MSM (n=44). Additionally, Malay MSM not reporting any sexual activity in the past year (n=22) were excluded, giving a final analytic sample of 284.
Measures
The questionnaire included demographic and behavioural items, as well as questions on HIV-related knowledge and beliefs, exposure to HIV prevention services, and testing for HIV and sexually transmitted infections (STIs). The primary outcome was UAI in the past year. UAI with regular partners and casual partners were measured separately using four items, stratified by insertive or receptive sexual roles and whether or not internal ejaculation occurred during anal sex.9 Participants were asked about difficulty in using condoms when having sex with men and, if so, the reasons for such difficulty. A regular partner was defined as a ‘boyfriend or fuck/sex buddy’ while a casual partner was someone with whom participants had sex with once or twice in the past year. Sexual intercourse with female partners and injection drug use in the past year were also assessed.
Variables specific to regular male partners
We assessed whether participants had negotiated with their regular partners on sexual risk reduction. Although it is important to examine the impact of the HIV status of an individual and his partner on the relationship between negotiating a sexual agreement and engaging in UAI,10 detailed analysis was not possible due to few cases of concordance in knowledge about HIV status. A sexual risk reduction agreement was defined as agreeing to ‘no anal sex at all’ or ‘anal sex must be with condoms’.
We also assessed three types of agreement on casual sex outside of regular partnerships. The response, ‘we are monogamous, neither of us has casual sex’ was coded as 0; ‘no agreement’ and ‘anal sex is OK and can be without a condom’ were coded as 1; and ‘no sex at all, either oral or anal,’ ‘no anal sex at all but oral is OK,’ and ‘anal sex is OK but must be with a condom’ were coded as 2. Participants were asked if they knew the HIV status of their regular partners and whether they used drugs or alcohol during sex with regular partners in the past year.
Variables specific to casual male partners
Participants were asked whether they had visited specific venues (night clubs, saunas, cruising parks) for sex over the past year Data on the number of male sex partners found on the internet were recoded as ‘0–30’ and ‘more than 30’. Additionally, data on group sex (having sex simultaneously with at least two male partners) and commercial sex (paying or receiving payment for sex with another man) in the past year were assessed. Lastly, communication with casual partners about their HIV status before sex was measured.
Knowledge about HIV transmission and exposure to HIV preventive services
Knowledge about HIV transmission was assessed using statements on 10 possible modes of HIV transmission. Cumulative knowledge scores were calculated and analysed as a continuous variable. Participants were asked about HIV and STI testing in the past year and reasons for non-testing. Three items measured exposure to HIV prevention services.
Statistical analysis
The analytic sample was 284 Malay men who reported having a regular or casual male sex partner in the past year. Potential correlates of UAI with regular and casual partners were examined separately using logistic regression. Variables associated with UAI (p≤0.05) in the bivariate analysis were further examined in multivariate analysis, controlling for demographic variables (age, education and employment) and interview site. Goodness of fit was evaluated using the Hosmer–Lemeshow test.11
Results
Table 1 shows the sociodemographic characteristics of the sample. The sample was young (mean age: 24.6), single and highly educated, and most resided in mainland Penang, either with family or male housemates. Most participants were either employed or students. None of the participants identified as heterosexual, 26% identified as bisexual, and 55% identified as gay, homosexual, ‘people like us’ or MSM (data not shown). Three-quarters of the participants had never been tested for HIV and more than half did not know where to access HIV testing. Nearly all (n=262, 92.3%) participants underwent rapid testing; only four screened positive for HIV.
Overall characteristics of the sample (N=284)
Table 2 presents data on sexual risk behaviours, exposure to HIV prevention and knowledge about HIV transmission. In the past year, one-quarter of Malay MSM (24.3%) reported sex with female partners, 64.8% with regular male partners and 77.1% with casual male partners. Multiple sexual partnerships were common: 24% had 11 or more casual sex partners and 42% had regular and casual male sex partners. In the same period, 36% reported group sex. For those who had regular male partners (n=184), 77% did not know the HIV status of their partners, 18.5% had an agreement about condom use during anal sex with their regular partners, and 10% had any agreement about casual sex outside of their regular relationship. For those who had casual partners (n=219), a majority (77%) reported that their casual partners did not talk about their HIV status before sex.
HIV-related behavioural characteristics and HIV knowledge
The most common way men located male sexual partners was through the internet, followed by nightclubs and cruising parks. About 8% reported paying for sex with male partners, and over 25% reported receiving payment for sex with other men. Exposure to HIV prevention messages or services was low. Knowledge about transmission of HIV was poor, with 20% not believing that HIV can be transmitted by receptive anal sex.
Most participants (83.1%) engaged in UAI with either regular or casual partners in the past 12 months, with higher prevalence with regular partners (83.7%) compared with casual partners (73.1%, data not shown). About 40% of participants admitted having difficulty using condoms consistently when having sex with men because ‘barebacking is more fun’, ‘sexual partners said no to condoms’ and/or they ‘did not carry any condoms’.
The independent correlates of UAI with regular partners are reported in table 3. UAI was significantly less common in the presence of a sexual risk reduction agreement (adjusted OR (AOR)=0.14, 95% CI 0.05 to 0.40). For UAI with casual partners (table 4), ‘difficulty in using condoms’ (AOR=9.07, 95% CI 3.35 to 24.5) and ‘any exposure to HIV prevention’ (AOR=0.22, 95% CI 0.09 to 0.54) were independently associated with UAI.
Correlates of unprotected anal intercourse with regular partners in the past year (N=184)
Correlates of unprotected anal intercourse with casual partners in the past year (N=219)
Discussion
This is the first surveillance study of MSM outside of Malaysia's capital. Only 1.5% of the sampled Malay MSM in Penang were HIV positive, compared to 5.4% of Malay MSM surveyed in Kuala Lumpur.7 A direct comparison, however, cannot be made because these studies were not contemporaneous and used different sampling methodologies. Similar to the previous study, UAI was highly prevalent among young, sexually active Malay MSM. Additionally, concurrent regular and casual male sex partnerships, multiple partners, group sex and selling sex were prevalent while levels of knowledge on HIV transmission were low.
In contrast to the Kuala Lumpur study, we found that UAI was more commonly practiced with regular partners than casual partners, similar to a study of Thai MSM.12 Although practicing UAI in a monogamous partnership after both partners undergo HIV testing is an effective risk-reduction strategy,13 participants’ low levels of HIV testing and knowledge of their partner's HIV status suggest that this risk-reduction strategy is not operative in this setting. Furthermore, UAI in the context of regular partnership has been shown to be a major risk factor for seroconversion.14–16 Future HIV prevention efforts should address UAI in regular partnerships as well as promoting HIV treatment among MSM in serodiscordant partnerships.
Negotiating sexual risk reduction agreements with regular partners is a common risk reduction strategy among MSM in committed relationships.17 Adherence to these agreements is influenced by relationship commitment and satisfaction.18 We found that a minority of participants (18.5%) had some form of agreement with their regular partners on condom use and anal sex, and those with agreements were 80% less likely to engage in UAI. This indicates that adherence to sexual agreements was associated with a reduction in sexual risk behaviours. We also found that men who had casual sex but no agreement about casual sex had elevated UAI compared to those had sexual agreement about casual sex and those who had no casual sex at all. Therefore, interventions should encourage communication, negotiation and agreement on sexual choices, including condom use within and outside of relationships.
The independent correlates of UAI with casual partners were ‘difficulty in using condoms’ and ‘lack of exposure to HIV prevention activities’. Participants who reported difficulty in using condoms were nine times more likely to engage in UAI with casual partners. The reported reasons for difficulty in using condoms imply that future prevention programmes should eroticise condom use, build confidence and skills in negotiating condom use, and provide, distribute and promote condoms at sexual venues for this high-risk population. Encouragingly, participants who were exposed to any HIV prevention activities or messages reported close to 80% reduction in UAI in the past year.
Access to prevention efforts and HIV testing was low. About 40% of participants had never been exposed to any kind of prevention activities or information and 70% had never been tested for HIV. Only a minority of men in regular partnerships knew the HIV status of their partners. Participants who had been tested for HIV reported a reduction in UAI, although the strength of association diminished in the multivariate analysis. Participants worried that if they were diagnosed as having HIV others might learn of their diagnosis, highlighting the importance of culturally-sensitive, anonymous and confidential testing. Engaging MSM in HIV testing is the first step in the treatment cascade,19 as studies have shown that MSM who know their status are more likely to change their behaviour20 and that antiretroviral treatment reduces the likelihood of HIV transmission.21 Increasing HIV testing and engaging HIV-positive men in treatment are critical components of the combination HIV prevention strategy.19
Limited access to HIV testing and prevention services can be explained by two structural barriers: institutionalised homophobia and criminalisation of homosexual behaviours in Malaysia.22 In addition to the anti-sodomy law, the Malay or Muslim populations are subject to Shari'a law that criminalises ‘khalwat’ (any close proximity between unmarried persons) and ‘liwat’ (anal sex) and are policed by government or religious authorities for sexual transgression or gender non-conforming behaviours.4 ,23 Many Malay gay men conceal their sexual identity because of the adverse reactions from society, including death threats from their community and accusations from religious authorities.24 The double stigma of HIV and homosexuality was recently exemplified by the Prime Minister's wife who blamed gay men for the spread of HIV.25 A human-rights-based approach and the decriminalisation of same-sex behaviours are needed before HIV prevention and treatment services can become fully effective.26
Several limitations in this study must be noted. The recruitment of MSM in Penang was difficult because of their general invisibility and because the few venues where MSM openly socialise are often raided by religious authorities. We relied on convenience sampling, so our findings are not generalisable to all Malay MSM. Additionally, the monetary incentive may have attracted a lower socioeconomic subpopulation of MSM, thus oversampling men who exchange sex for money. HIV prevalence may have been underestimated due to avoidance of participation by MSM who were afraid to be screened for HIV or who were already diagnosed as having HIV; however, there were no differences in UAI or prior history of HIV testing in those who refused to undergo HIV testing compared to those who accepted HIV testing. The study also excluded MSM below the age of 18, a subgroup of MSM who may be more vulnerable for HIV infection.27 The cross-sectional design of the study is limited in establishing temporal relationships between variables, and thus the directional relationship of the correlates with UAI cannot be determined.
Alcohol and drug use with casual partners were not assessed, neither were attitudes towards homosexuality and HIV/AIDS. The survey allowed multiple responses to the sexual identity questions so distinct mutually exclusive categories cannot be clarified. Potential conflict between Muslim and homosexual identities28 and the conservative culture in Malaysia may influence decisions to practice safer sex and should be explored in future research. Studies should also assess sexual networks sensation-seeking personalities, stigma and discrimination related to HIV risk behaviours.
Cases of HIV/AIDS by sexual transmission, including MSM, have increased since 2000 and surpassed the transmission by injection drug use in 2011.3 As the second biobehavioural surveillance study of MSM in Malaysia, this study presents the risk profile of a segment of Malay MSM who are at very high risk for HIV acquisition and transmission. Regular biobehavioural surveillance studies that include nationally representative samples of MSM are needed to monitor HIV prevalence and risk behaviours among MSM in Malaysia. Active surveillance of HIV among MSM is a critical public health need that the Ministry of Health has not yet adequately met. Given that neighbouring countries have already witnessed a growing epidemic among MSM, effective HIV surveillance and prevention efforts are urgently needed in Malaysia.
Conclusions
High levels of risky sexual behaviours, coupled with low rates of HIV testing, portend a potentially explosive HIV epidemic among MSM in Malaysia. Future prevention programmes should encourage communication and negotiation about condom use within and outside of relationships and expand HIV testing for this population. Current HIV prevention efforts for MSM are hampered by legal constraints and social stigma. A human-rights-based approach is needed to promote access to HIV prevention, treatment and care among MSM.
Key messages
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HIV seropositivity in the sampled men who have sex with men (MSM) was low.
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High rates of sexual risk behaviours (unprotected anal intercourse, multiple sex partners and group sex), coupled with low rates of HIV testing, highlight the potential for an explosive HIV epidemic among Malay MSM.
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Active HIV surveillance, expansion of testing and other prevention services for MSM are needed in Malaysia.
Acknowledgments
The authors wish to express their appreciation to the staff members at AARG (AIDS Action and Research Group) for their help in recruitment and to members of the Community Advisory Board for their advice and commitment to the study. Special thanks to Dr Philippe Adam for his helpful comments on the data interpretation and advice in the analysis. We also thank OraSure Technologies, Inc. for providing subsidised rapid tests for HIV.
References
Footnotes
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Handling editor Jackie A Cassell
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Contributors SHL conceptualised and conducted the data analysis, wrote the first draft and consolidated inputs from the other coauthors. ARB conducted preliminary data analysis and edited the manuscript. CS implemented the study and MC conducted fieldwork. FLA advised on the analysis and edited the manuscript. AK designed and supervised the implementation of the study.
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Funding This work was supported by the World Bank grant number (7153627) and through career development (NIDA K24 DA017072; FLA), research (NIDA R01 DA032106; FLA) and training (T32GM07205; ARB) grants from the National Institutes of Health.
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Competing interests None.
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Ethics approval All aspects of this study were approved by the University of Malaya Medical Centre Ethics Committee.
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Provenance and peer review Not commissioned; externally peer reviewed.