V. Discussion
Although it was not the intention of the sampling strategy, the majority of those included as respondents in this survey were male sex workers (82.8%), a group of men at very high risk for HIV and other STIs. The sites identified in the mapping exercise were locations where men go to meet other men, which may account for the disproportionate number of men selling sex. Due to legal and social reasons, MSM who reported being under age 18 were not recruited for the study. However, a considerable number were identified during the mapping. Some locations where MSM could be located were not accessible to the research team such as exclusive entertainment establishments or telephone networks for commercial sex. The refusal rate was 37%, and upon inquiry the study team found that a majority of those men who refused were the clients of male sex workers (MSW). Hence, the group described in this survey may represent the group of MSM in Phnom Penh with the highest risk behavior, and may not be representative of all MSM.
However, this study has demonstrated that the MSM interviewed are vulnerable because of their risk behaviors, and their complex sexual networks do contribute to sexual mixing between high and low prevalence groups in Cambodia. MSM may serve as a "bridge group" in Cambodia – that is a higher risk population that can link HIV to the general population. In the past month, 13.0% of MSM reported unprotected penetrative sex with both male and female partners, and 9.5% reported having sex with both MSW and FSW, as well as with regular female partners. However, because the absolute size of the MSM population in Phnom Pehn and nationally remains unknown, it is difficult to estimate how influential MSM would be in contributing to the general population epidemic.
When MSM bought sex from women, far fewer used condoms than when buying sex from men. In fact, all high risk and general population male groups in the surveillance system reported using condoms more consistently than MSM with female commercial sex partners.10
11 At the same time that condom use was lower among MSM than the police, HIV prevalence among MSM was a good deal higher than the police12 in 2000 (14.4% of MSM in Phnom Penh versus 3.1% of police nationally). The proportion of MSM with another STI was also higher across the board than it was for police in five provinces in a 2001 study13 (syphilis -5.5% MSM, 0.0% police; chlamydia - 7.2% MSM, 1.8% police; gonorrhea - 4.8% MSM, 0.0% police).
This risk taking behavior also extended to the MSM selling sex. Fully 30% more MSM reported not using condoms every time with their male clients than did direct female sex workers. While the prevalence among MSM who reported selling sex was significantly lower than that of direct female sex workers, it was almost the same as that of indirect female sex workers (15.0% versus 16.1%).
10 Cambodian Household Male Survey, BSS IV, NCHADS 2000
11 Cambodian Behavioral Surveillance Survey, NCHADS 1999
12 Report on HIV Sentinel Surveillance in Cambodia, NCHADS 2000
13 Cambodia STI Prevalence Survey, NCHADS 2001
HIV was associated with some sexual behaviors and STI status among MSM. Anal sex with multiple male partners, unprotected sex with commercial female partners, any diagnosed STI and biological evidence of syphilis were independently associated with HIV.
Few studies have been done in South East Asia that target MSM. In the north of Thailand, one study conducted in 1995 targeted male sex workers and found a high turnover of partners with low consistent condom use. The HIV prevalence rate was 16.6% and the syphilis rate was 7.6%.14 Another study, done in the north of Thailand, found that MSM with more than one male sex partner, compared with those with only one partner, were more likely to be HIV infected; the HIV prevalence rate found was 12.1%15. The common point found in these studies was the high number of reported partners and the common factors associated with HIV i.e. biological evidence of syphilis and anal sex with multiple partners.
The existence of MSW sexual networks suggests the existence of of male-to-male sex behavior in Phnom Penh. In a study amongst conscripts from northern Thailand, male-to-male sexual behavior was reported by 6.5% of conscripts16 and by 10.9% of conscripts in another study using self-administered questionnaires. 17 In both studies, the majority of respondents reporting male-to-male sexual behaviors also had female sex partners. While some limited comparison of studies done in Thailand can be drawn based on of the proximity of these countries and the similarity in the religious and socio-cultural context, the actual proportion of men in Cambodia who have sex with other men in still largely known.
It is clear is that the MSM studied in Phnom Penh are at high risk for HIV and STI infection, and risky sex behaviors persist even as sexual behavior amongst heterosexual males in Cambodia is becoming safer. In addition, many of these men have unprotected sex with both high and low risk female partners and therefore they may act as an efficient conduit for the virus between populations with different levels of risk behavior.
14 Kunanararak, 1995
15 Beyrer, 1995
16 Beyer, 1995
17 Tawesak Nopkerson, 1993
VI Recommendations
In light of these findings, it is not possible to ignore the existence of high-risk male-to male sexual behavior in Cambodia nor is it acceptable to neglect this group when planning HIV prevention interventions. Recommendations for appropriate interventions and additional research include the following:
- Male sexual health program including appropriate STI services, should be targeting different segments of the MSM population with a priority on male sex workers and transgender.
- Appropriate IEC material should be developed and based on sexual behavior and practices rather than solely on sexual identity and self- labeling.
- New and appropriate messages should be developed and integrated into IEC materials targeting male populations in Cambodia
- Water-based lubricant should be promoted through social marketing e.g., kit promotion including condoms, lubricant and IEC material
- Health care providers, counselors and health educators should be sensitized to the existence of male to male sexual behaviors in Cambodia and trained to provide appropriate care / education
- Policy makers, Program managers, Donor Agencies should also be sensitized on these issues
- Health Care Providers working in STI clinics should be trained to be able to talk with their clients about male to male sexual behavior and its risks
- Further research, especially qualitative research, is needed to gain a more in-depth understanding of the male to male sexual behavior in the Cambodia context; and
- Size estimations of the MSM population in Phnom Penh and nationally are needed.
