w w w . e l s e v ie r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Original
article
HIV
testing
and
HIV
knowledge
among
men
who
have
sex
with
men
in
Natal,
Northeast
Brazil
Monica
Baumgardt
Bay
a,∗,
Marise
Reis
de
Freitas
a,
Marcia
Cavalcante
Vinhas
Lucas
b,
Elizabeth
Cristina
Fagundes
de
Souza
b,
Angelo
Giuseppe
Roncalli
baUniversidadeFederaldoRioGrandedoNorte,DepartamentodeDoenc¸asInfecciosas,Natal,RN,Brazil
bUniversidadeFederaldoRioGrandedoNorte,Natal,RN,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received15August2018 Accepted13January2019 Availableonline10February2019
Keywords:
HIVtesting
Menwhohavesexwithmen(MSM) HIVknowledge
a
b
s
t
r
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c
t
Background:Menwhohavesexwithmen(MSM)accountforthehighestprevalenceofHIV
inBrazil.HIVtestingallowstoimplementpreventivemeasures,reducestransmission, mor-bidity,andmortality.
Methods:Weconductedacross-sectionalstudytoevaluateHIVtestingduringlifetime,
fac-torsassociatedwiththedecisiontotest,knowledgeaboutHIVtransmission,anduseof condomsbetweenMSMfromthecityofNatal,northeastBrazil.
Results:Outof99participants,62.6%hadbeentestedforHIVduringlifetime,46.2%inthelast
year.ThemostfrequentreportedreasontobetestedforHIVinfectionwascuriosity(35.5%). CorrectknowledgeaboutHIVwasobservedinonly9.2%ofparticipants.Inmultivariate analysis,age(PR0.95;95%CI,0.91–0.99;p=0.041)andprevioussyphilistest(PR4.21;95%CI, 1.52–11.70;p=0.006)wereassociatedwithHIVtesting.
Conclusions:ThefrequencyofHIVtestingamongMSMfromNatalisratherlow,especially
inyoungerMSM,andknowledgeaboutHIVtransmissionisinappropriate.
©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
TheoverallprevalenceofHIVinfectioninBrazilisestimated at0.4%,butthe epidemicishighlyconcentratedin vulner-ablepopulations, with5.3%prevalenceamongsexworkers and19.8%inmenwhohavesexwithmen(MSM)accordingto thelastreports.1ThehigherriskofHIVinfectionamongMSM
∗ Correspondingauthor.
E-mailaddress:monibay@gmail.com(M.B.Bay).
maybepartlyexplainedbythepracticesandbehaviors associ-atedwithanalsexandtheguttropismofHIV.2,3Besidesthat,
behavioralvulnerabilitiesacttogetherincreasingthechances ofHIVinfectionbetweenMSM,suchasnocondomuse, prac-ticeoftransactionalsex,useofdrugsduringsex,andsexwith casualpartners.4
In 2015, the Joint United Nations Program on HIV/AIDS (UNAIDS) proposedthat by2020,90% ofpeoplelivingwith HIVshouldbeawareoftheirHIVstatus,asthefirstpartof 90-90-90strategytoendAIDSepidemic.5 Earlydetectionof
HIVallowsinitiatingcareforpropertreatment,whichimpacts inmorbidity,mortality,andreducesfurthertransmission.2In
https://doi.org/10.1016/j.bjid.2019.01.003
1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Brazil,HIVtestingisrecommendedforallpregnantwomen andpatientswithdiagnosisoftuberculosis,visceral leishma-niasis,orsexuallytransmittedinfections.6Studiesestimated
thatthedelaybetweeninfectionandfirstCD4countinBrazil was4.3years,showingthatalargeproportionofindividuals stillstartedtreatmentlateinthecountry.7InNortheastBrazil
8800newcasesofAIDSaredetectedperyearandinNatalthe meanCD4countatdiagnosisis269cells/mm3,pointingtolate
diagnosisofHIV.1
Although the group of MSM accounts for the highest prevalenceofHIVinthecountry,thereisnospecific recom-mendationforHIVtestinginthispopulationinBrazil.6Data availablefromdevelopedcountriesshowthattheproportion ofMSMnevertestingforHIVisgenerallybelow30%.8,9Since
fewstudiesevaluatedHIVtestingamongMSMinBrazil, espe-ciallyinNortheastregion,ourstudyaimedtoaccesstherate and factors associated withHIV testing among MSM from Natalcity,NortheastBrazil.
Materials
and
methods
Studydesign
Thisisacross-sectionalstudy,conductedinthecityofNatal, betweenAugust2011andDecember2012.Theprimary objec-tivewastoevaluatepreviousHIVtestingamongMSMfrom Natalduringlifetime.Basedonpreviousstudiesweanticipate thatyoungerage andlower educationwould beassociated withlackoftesting,10,11
Studysample
Participantswere MSMaged18 yearsold ormore,residing orworkinginNatal.Theywererecruitedusing respondent-driven sampling (RDS) approach initially.12 Six MSM were
selected asinitial seeds, chosenthrough focus group. The focusgroupwasconductedwith15MSMrepresentativesof artisticscene,student activismand socialmovement from Natal,theinitialseedswereselectedconsideringdemographic characteristics,likeageandsocioeconomicstatus,and net-worksize.Eachseedwasallowedtorecruitthreeparticipants, usingstudycouponspre-printedwiththestudycenterphone numberandlocation.Staffscreenedsubjectsinthestudysite forthefollowingeligibilitycriteria:ageover18years,livingor workinginthecityofNatal,andhavingengagedinanal inter-coursewithanothermaninthepreviousyear.Eachincluded participantreceivedthreecouponstoinvitemorepeoplefor thestudy.
Procedures
Thestudywasconductedatahealthcarefacilityinsidethe university. The study questionnaire consisted of objective questionstobeself-administeredandbasedonabehavioral instrumentusedpreviouslywiththispopulationinBrazil.13
Participantsrespondedto thequestions ina privateoffice. Questions included socioeconomic and demographic char-acteristics,historyofHIVtesting,reasonstodothetest,use ofcondominthelast sexualrelation,HIVstatus ofsexual
partners,transactionalsex,previoussyphilistest,knowledge ofplaceswere HIVtesting isfree,andadequateknowledge about HIVprevention,according toUnitedNations General AssemblySpecial Sessionon HIV/AIDS(UNGASS)indicator, defined as the percentage of respondents giving correct answerstoallthefollowingfivequestions14:
Canhavingsexwithonlyonefaithful,uninfectedpartner reducetheriskofHIVtransmission?(yes);
Can usingcondoms reducethe riskof HIVtransmission? (yes);
Canahealthy-lookingpersonhaveHIV?(yes) CanapersongetHIVbyusingpublictoilets?(no)
CanapersongetHIVbysharingamealwithsomeonewho isinfected?(no)
A rapid test for HIV using hole blood was offered for the participantsat study site (Rapid Check HIV-1/2 and/or Bio-ManguinhosHIV-1/2),withpre-andpost-testcounseling andtheresultwasgivenimmediately,accordingtoBrazilian guidelines.15
Statisticalanalysis
Sample size was calculated tobe 95 subjects, assuming a prevalenceof60% forprevious HIVtesting duringlifetime, 95%confidenceanda10%error,basedonpreviousdatafrom Adam et al. for 10 countries in Latin America.16
Descrip-tiveanalysisincludedcentraltendencymeasurescalculated forcontinuousvariablesandproportionswerecalculatedfor categoricalvariables.TheassociationbetweenpreviousHIV testingandexplanatoryvariableswasassessedbyunivariate analysisusingPearson’sChi-squareorFischerexacttestwhen appropriate.Forcontinuousvariables,Student’s“t”testwas performed. Associationswithap-valueless than0.05were consideredsignificant.Inordertoverifytheadjustedeffect, PoissonRegressionModelingwithrobustvariancewere per-formed,includingthosevariableswithp-valueslessthan0.2. DatawereanalyzedusingSPSS(StatisticalPackageSoftware forSocialScience)version20.0.
Ethics
ThestudywasapprovedbytheEthicResearchCommitteeof FederalUniversityofRioGrandedoNorte(number136/11).All participantssignedawritteninformedconsent.
Results
By November 2012, 70 subjects were included using RDS, despitemany effortsofthestudy teamtoimprove recruit-ment, including increase in the hours of operation of the studysiteandaddingsixmoreseeds.Asourplanedsample was95MSM,wedecidedtoincludeavenue-basedsampleof additional31subjectsrecruitedduringthegayprideeventin NatalcityinDecember2012.From101participants,twowere excludedbecausetheyansweredlessthan70%ofthe ques-tionnaire,totalingasampleof99subjects.Sociodemographic characteristicsofparticipantsareshowninTable1.Themean
Table1–Sociodemographiccharacteristicsof99MSM fromNatal.
Variables Mean/n SD/%
Age(years) 29.1 9.7
Yearsofstudy 11.5 2.2
Monthincome(USdollars) 494 465
Race White 25 27.5 Mulatto/black 66 72.5 Occupation Employed 62 62.6 Unemployed 37 37.4
Useofcondominlastanalsex
Yes 68 71.9
No 27 28.1
PreviousHIVtest
Yes 62 62.6
No 37 37.4
Previoussyphilistest
Yes 34 35.4
No 62 64.6
HIVtestinthestudy
Positive 6 9.2
Negative 59 90.8
KnowwheretotestforHIVforfree
Yes 72 73.5
No 26 26.5
Table2–ReasonforhavingdoneHIVtestamongMSM.
Reason n %
Curiosity 22 35.5
SelfperceptiontobeatriskforHIVinfection 11 17.7
Medicalrecommendation 10 16.2
Blooddonation 7 11.3
Requestedatwork 6 9.7
Partnerwish 3 4.8
Total 62 100
agewas29.1years(SD9.7years),73.3%identifiedthemselves asmulattoorblack,meanmonthlyincomewas494USdollars (SD465dollars),and61.5%wereemployed.Participantshada meanof11.5yearsofschooling(SD2.2years).
Outof99participants,62.6%(CI95%52.5–71.7%)hadbeen testedforHIV,46.2%(CI35.5–57%)inthelastyear.Themost
frequent reason to be tested was curiosity (35.5%), 17.7%
because they perceived themselves to be at risk for HIV
infection,and16.2%wereaskedtobetestedbyahealth pro-fessional(Table2).Themostfrequentplacefortestingwas publicservicesmentionedby52.4%(Table3).Only9.2%of par-ticipantshad adequate knowledgeaboutHIVtransmission. Thequestionswiththehighestpercentagesofwronganswers were“CanapersongetHIVbysharingamealwithsomeone whoisinfected?”(66.7%marked‘yes’)and“Canapersonget HIVbyusingpublictoilets?”(22.9%marked‘yes’)[Table4].
Transactionalsexwas frequent,as42% reported having received money in exchange for sex in the previous six months. Use of condom in the last anal intercourse was
Table3–PlacesofHIVtestingreportedbyMSM.
Places n % Publicservice 32 51.6 Bloodbank 6 9.7 Privateservice 11 17.7 Workplace 5 8.1 Other 8 12.9 Total 62 100
mentionedby71.9%.Only13.1%wereawareoftheHIVstatus ofsexualpartners.Ofthe63MSMwhoagreedtoperforman HIVtest,sixturnedoutpositive(9.5%)[Table1].
In univariate analysis, age (PR 0.93; 95% CI, 0.88–0.97;
p<0.001)andprevioussyphilistest(PR1.85;95%CI,1.41–2.44;
p<0.001)wereassociatedwithHIVtesting.Knowingaplace wheretheHIVtestcouldbedonefree-of-chargewasalso asso-ciatedwithHIVtesting(PR1.69;95%CI,1.05–2.71;p=0.017),as mostMSMdidthetestinpublicservices(Table5).Inadjusted analysis,resultedfromPoissonmodeling,thevariables“age”, “previous syphilistest”,and “knowing whereHIVtest was free”whereincludedinastepwiselogisticregressionanalysis. Inthefinalpredictivemodelonly“age”and“previoussyphilis test” remainedindependentlyassociatedwithpreviousHIV testing(Table5).
Discussion
Ourstudyfoundthat62.6%ofMSMfromNatalhadbeentested forHIVbefore.Thisratewashigherthanthenational aver-age of 37% estimatedfor the generalpopulation in 201113
andthe51.6%foundbyBritoetal.inMSMfrom10Brazilian citiesin2009.10TheseratesareratherdisappointingasMSM
isagroupwithahighprevalenceofHIVinfection.TheWorld HealthorganizationandtheCentersforDiseaseControland Prevention(CDC)inUnitedStates,recommendthatpersons athighriskforHIVinfectionshouldbescreenedforHIVat leastannually.17,18Itshouldbepointedoutthattestingatany
timewasaccountedfor,ratherthanbeingrestrictedtothelast year.Ifonlytestinginthepreviousyearwereconsideredthe ratewouldbeevenlower(46.2%).Previousstudiesconducted inArgentina,Peru,andChinashowedHIVtestingrates vary-ingbetween48%and58%,9,11,19butstudiesfromUnitedStates
andPuertoRicohadamuchbetterresult(82–90%).20,21
LackofknowledgeaboutHIVtransmissionisoneofthe rea-sonsthatleadtolowperceivedriskofbeinginfected.Halletal. foundthat testingwas higheramonghigh schoolstudents iftheyweretaughtatschoolaboutAIDSorHIV.22Although
adequateknowledgeaboutHIVtransmissionwasnot signif-icantlyassociatedwithHIVtesting,itisnoteworthythelow levelofknowledge,despitethehigheducationallevel.The per-centageofadequateknowledgeinastudywiththeBrazilian generalpopulationwas muchhigher,reaching57.1%,13 but
Guimarãesetal.indicateadecreaseintheproportionofMSM withadequate HIVknowledgefrom 35.2%in2009to23.7% in2016.23 Campaignscarried outbythe MinistryofHealth
inBrazilhavefocusedprimarilyoncondomuseasawayto avoidHIVinfection,leavingasideclarificationonsituations thathavenoriskoftransmission,suchassharingamealor
Table4–KnowledgeaboutHIVbyMSMfromNatalcity,Brazil,2012.
Question n %
CanapersongetHIVbyusingpublictoilets?
Yes 22 22.9
No 57 59.4
Don’tknow 17 17.7
Total 96 100
Canhavingsexwithonlyonefaithful,uninfectedpartnerreducetheriskofHIVtransmission?
Yes 78 78.8
No 16 16.2
Don’tknow 5 5.1
Total 99 100
Canahealthy-lookingpersonhaveHIV?
Yes 94 94.9
No 2 2.0
Don’tknow 3 3.0
Total 99 100
CanusingcondomsreducetheriskofHIVtransmission?
Yes 96 97.0
No 2 2.0
Don’tknow 1 1.0
Total 99 100
CanapersongetHIVbysharingamealwithsomeonewhoisinfected?
Yes 66 66.7
No 17 17.2
Don’tknow 16 16.2
Total 99 100
useofpublictoilets.Inourcountry,AIDSisstillatopicrarely addressedinschools,andevenwhenthisapproachiscarried out,itisusuallynotsystematic.Theschoolisoftentheonly placewhereyoungpeoplecanreceive reliableinformation. However,mostoftenschoolteachersareNOTwellprepared, andmayendupdeliveringincompleteinformation. Alterna-tiveinterventionslikepeereducationandinternetandsocial mediastrategiestoaccessMSMhaveproventobeusefulin studiesfromPeruandUnitedStates.19,24 In2015,ateamof
governmental,research,andnon-governmentalorganizations inthecityCuritibainSouthBrazillaunchedandevaluateda multi-componentimplementationscienceprojecttoimprove HIVoutcomesforMSM.Thisproject,called“AHoraéAgora” (“TheTimeisNow”)implementedaweb-basedplatformand associatedmobile applicationdesignedtoprovideHIV pre-ventioninformation,allowingforself-assessmentofriskand deliveringHIVself-testkits.Theprojectexceededall expecta-tionswith7352HIVself-testrequestsover24months,asthe initialgoalwastodistribute1000testkitsperyear,andwas abletoreachalargepercentage(31%)ofMSMwhohadnever beentestedbefore,withthosebetween18and28yearsold reportingahigherpercentageoffirst-timetesters(36%)than those29yearsorolder(18%).25Thesameprojectisnowbeing
implementedinthecityofSãoPaulo.26
YoungeragewasassociatedwithnevertestingforHIVin this study,which isworrisomesince thelast national epi-demiological report datashowed that the HIV epidemic is increasinginthisgroup.1Astudyevaluatingsexualrisk behav-ioramongMSMfrom10Braziliancitiesshowedthattobeaged
25 years or less wasindependently associatedwith higher scoresofriskybehavior.27ArecentstudyfromGermanyalso
showedthatyoungerage(<25years)wasassociatedwithlower ratesofHIVtesting.28Theveryabsenceoftestingcouldbea
contributingfactortotheincreasednumberofinfectionsin thispopulation,sincepeoplewithHIVonantiretroviralsare lesslikelytotransmitthevirus thanthosewhodonotuse them,acategorywhichincludeHIVcarriersthathavenotbeen diagnosed.29,30Theproposaloftreatmentaspreventionrelies
onamodelofuniversal testing,reinforcing thatbarriersto HIVtestingwillbecomemorerelevanttothefullspectrumof HIVcare.Maximizingtestingopportunitiesandreducing bar-rierstoregulartestingshouldbeacentralcomponentofHIV preventionprograms.31
Thisstudyhassomelimitations.TheRDStechniquewas noteffectiveforthepopulationofMSMfromNatal,asithas notreachedthesamplesizeinitiallycalculated.Fewseedshad enoughwavestodispersethesampleandmakeitclosertoa probabilisticsample,evenwithalleffortsfromtheresearch teamtoimproverecruitment.Similardifficultieshavebeen reported with the use of RDS technique by researches in Singapore.32 We ended up analyzingour entiregroup asa
non-probabilisticsampleasaconsequenceofthese difficul-ties. Therefore, these resultsmay notbe representative of the entireNatalMSM population. Someofthe resultsthat did not show statistical significance may have been influ-encedbythesamplesizethatmayhavenotbeensufficient toshowassociations.However,thereisrelevancetothestudy becauseitrepresentsapopulationthatisdifficulttoaccessin
Table5–UnivariateanalysisofselectedcharacteristicsofMSMandpriorHIVtestinginNatalcity,Brazil,2012.
Variables PreviousHIVtest Total Unadjusted Adjustedb
Yes No n % pa PR p PR
n % n % Mean SD (CI95%) (CI95%)
Mean SD Mean SD Occupation Employed 39 66.1 20 33.9 59 61.5 0.48 1.23 Unemployed 21 56.8 16 43.2 37 38.5 (0.76–2.13) Total 60 62.5 36 37.5 96 100 Age 31.8 10.0 24.4 6.9 29.1 9.7 <0.001 0.93 0.041 0.95 (0.88–0.97) (0.91–0.99) Race White 15 62.5 9 37.5 24 26.7 0.97 1.01 Non-White 41 62.1 25 37.9 66 73.3 (0.55–1.84) Total 56 62.2 34 37.8 90 100 Yearsofschooling 11.5 2.1 11.4 2.4 11.5 2.2 0.714
Monthlyincome(USdollars) 528 511 434 370 494 465 0.359
KnowledgeaboutHIV
Correct 6 66.7 3 33.3 9 9.2 0.82 1.11 Incorrect 56 62.9 33 37.1 89 90.8 (0.42–2.91) Total 62 63.3 36 36.7 98 100 Transactionalsex No 38 69.1 17 30.9 55 57.9 0.34 1.37 Yes 23 57.5 17 42.5 40 42.1 (0.80–2.34) Total 61 64.2 34 35.8 95 100
Previoussyphilistest
Yes 31 91.2 3 8.8 34 35.8 <0.001 5.76 0.006 4.21
No 30 49.2 31 50.8 61 64.2 (1.90–17.45) (1.52–11.70)
Total 61 64.2 34 35.8 95 100
KnowwhereHIVtestisfree
Yes 50 71.4 20 28.6 70 72.9 0.017 1.69
No 11 42.3 15 57.7 26 27.1 (1.05–2.71
Total 61 63.5 35 36.5 96 100
Useofcondominlastanalsex
Yes 46 67.6 22 32.4 68 71.9 0.27 1.37
No 15 55.6 12 44.4 27 28.1 (0.79–2.37)
Total 61 64.2 34 35.8 95 100
a Forcategoricalvariables,Chi-SquareorFisherExacttest;forcontinuousvariables,Student’s“t”test.
b PoissonRegressionModeling
alocationwherenosimilarstudyhadbeenperformed previ-ously.
Conclusion
Thestudy showsthatHIVtesting ratesarelowamongthis sampleofMSM,andyoungerageandprevioussyphilistest wereassociatedwithnevertestinginmultivariateanalysis. KnowingaplacewheretheHIVtestcanbedonefree-of-charge wasassociatedwithHIVtestinginunivariateanalysisbutlost significanceinthemultivariatemodel.Actionsthatprioritize thedisseminationofplaceswhereHIVtesting canbedone forfreeandtargetedatyoungpeopleseemtobemost suit-ableforscalingupHIVtestingamongMSMinourreality.Also importantisthefactthatknowledgeaboutHIVtransmission waslow,despitethehigheducationalleveloftheparticipants, emphasizingtheneedforinnovativeapproachesto dissemi-natepreventioninformationforMSM.
Sources
of
support
NationalFundofHealth,MinistryofHealth,Brazil.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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