This year has been a difficult year in some respects for me as I have lost so many friends from AIDS related deaths despite the more sophisticated anti-retroviral drugs albeit they had the HIV infection for quite a while and were surviving but like all things there has to come an end. Why is there still a high prevalence rate of HIV infection in men who have sex with men in Jamaica? Especially the younger aged men who have sex with men whether they self identify as gay, from as early as 1986 the first study done with MSM in the height of the AIDS epidemic where the prevalence was 10% and then in 1995 it jumped to 32% with a similar figure in 2007. The last study done in September 2011 through to January 2012 covering some four parishes and four hundred and forty nine men when compared to the 2007 that only captured 201 showed that there was some minor increase in the infection rate to approximately 33% although the 07 study was a snowball one covering Kingston and Mandeville while the 2011/12 was a cross sectional.
Anal sex as we know is high risk for HIV transmission and the men who are captured in most of these studies are from lower socio economic backgrounds making them socially vulnerable, we know of the exploitation within the MSM community, the power imbalance or differentials and lifestyles issues such as no life planning, low risk assessment, homelessness, living for the moment and lack of disclosure of HIV status. The prevention obviously have been ineffective over the years it seems as we are told repeatedly that MSM are driven underground and do not have access to safer sex implements but how can this be when the very agencies that have direct access to the populations do not engage said groups consistently yet claim to represent marginalized groups? Two factors came up for mention in the 2007 study:
1) Ever having a sexually infection
2) Receptive anal intercourse
These two significant risk factors came up for mention again in the 2011 study; the study was done to find the following based on my understanding of it;
To estimate the prevalence of HIV and sexually transmitted infections among MSM
To monitor program coverage and effectiveness
To look at risk factors
To explore underlined determinants
To estimate HIV incidence post the study by following a cohort of men who tested negative in the 2007 study, other items known as proximate determinants were added to the 2011 survey such as cash for sex, type of sex, number of partners, receptive anal intercourse, risk perception, use of drugs and condom usage added to that were underlined determinants in terms of social vulnerability which make some MSM more at risk and carry out risk practices than others so demographic features, socio economic status, literacy and gender issues. Outcomes that were tested for therefore were HIV, Syphilis, and other STIs. An experienced female research nurse participated in the survey via contacts from the MSM populations and persons had to be 16 years and older with written informed consent to participate. Some characteristics and results coming through were:
61% were between the age of 16 and 34
38% were 25 years of age and older
1/5 of both groups identified as “female” (possible trangender) and nearly 60% were bisexual which was what were also found in the 2007 survey; 8% of those identifying as bisexual were married.
12% of persons surveyed were of low literacy
79% had a low comfort level admitting to someone they were men who have sex with men; about a quarter of the cohort had experienced violence or ever been to jail and a fifth had spent a night outdoors; 16% of the total had expressed hints that they had been “raped”
Between 2007 and 2011 there was some improvement in the access to HIV/treatment services rate amounting to 50% a major increase; 84% of these persons were satisfied with the services received which is a smack in the face of some who continue to use an old narrative that gay men do not have access t treatment and care in the public systems. 84% is no different of the client satisfaction found in the mainstream
79% of persons had ever had an HIV test most of them had received their results and 58% had a test in the past 12 months alongside seeing the risk card as disseminated by outreach officers, 76% of the men had seen the risk card.
Risk perception was way off nearly 60% of the men thought they had little or no chance of contracting HIV which really when one assesses it is quite ridiculous because one is involved in anal receptive sex especially the risk is higher. The feeling of the young that they are invincible needs to be broken and a mindset change is urgently needed.
60% of persons who were positive had not disclosed their status to their partner(s) this is a huge problem yet still even after my absence from outreach work and certainly helps to perpetuate the transmission; aside from HIV over 8% were positive for syphilis, 3% for gonorrhoea and 9% for Chlamydia but there were no rectal swabs done for that survey so maybe the rates could be higher.
Those who were aged under twenty five a quarter of them were already positive and among those over twenty five 42% were positive, so there is a strong relationship between positivity and age.
MSM who received or paid cash for sex otherwise known as commercial sex workers those who received cash for sex just about 50% of them were positive by twenty five; the other groups who were involved in transactional sex (without cash) 26% of those persons were positive while 40% of cash for sex only were also positive, among heterosexuals transactional sex in which gifts or non cash bargaining there is a higher risk among those, bearing in mind the hierarchy
Sex work or cash for sex
Transactional sex (non cash)
All three are different but among MSM there is not much difference maybe due to the high risk of anal sex and it obviates the hierarchy. Gender and sexual orientation in as far as cash for sex persons who identify as females as much as 56% of them were positive while non cash MSM were 40% on the other hand bisexuals who did not receive or paid cash for sex 17% of them were positive which is a bit puzzling as the rate among bisexuals significantly lower than the average rate. Risk behaviour with the bisexual group and cash/noncash MSM receptive anal intercourse and cash for sex is 48%; versatile (both receptive and dominant partnered sex) the prevalence is high for those receiving cash for sex, those who gave a history of five or more one night stands 67% of those Cash for sex and 44% of other MSM were positive.
Condom use – those MSM who say that they only use boots their prevalence was significantly lower while those who ticked if they were ever told by a doctor they had an sexually transmitted infection their prevalence rate is significantly higher.
Other underlying factors also make for interesting perusal such as those who suffered violence in both cash for sex and other MSM categories – 54% in the former were positive while those who were ever raped or slept in jail while also being involved in cash for sex were four times likely to be infected than the other categories.
The 125 men of the 449 surveyed of who accepted cash for sex only 34 of the men did not have an adverse life event which means low literacy, been to jail, slept outdoors or homeless. Those who had no cash for sex but with adverse life events the rate was 27%, taking only MSM who had adverse life events their prevalence was high as 39%; men who had no adverse life event or cash for sex their prevalence was 21% so it is important to separate the categories to get a better picture. The number of life events automatically pushes the rate upwards in MSM hence homelessness is a major issue here.
The 49 men who were negative in the 2007 study the incidence estimate showed an annual rate of 6% if it were linear over five years it means it would move from 0 – 30%
The proximate determinants are well known in the conceptual model used to conduct the survey for example condom use always was protected, most of the men as said previously were poor and unemployed, adverse life events were common, transactional sex was common, Risk perception very low, STI prevalence is very high, HIV prevalence is very high but these cannot be used to generalize the rate in the broader MSM populations. The high prevalence is associated with social vulnerability, sex work and other STIs HIV among MSM is an important factor driving the epidemic in Jamaica, more ways must be found to bring down the numbers with real meaningful interventions but with recent abandonment by LGBT organizations and the lack of interest from the national program in as far as social/welfare responses then how do we expect to see the rates go down?
Bearing in mind the ending of the last round of global fund in July of 2013 yet with more agencies including faith based managed NGOs also doing HIV prevention work with sometimes the same group of MSM yet the numbers are frightening. The homeless matter has taken a turn and myself and others are watching carefully the developments in certain quarters as the lgbt reporting goes into overdrive using the homeless men in New Kingston as bait while the other populations are overlooked completely. Donations are being solicited which is good but the motive one wonders: