Results
- Condom use with different sex partners and genders varied significantly ; While 78% of MSM used condoms consistently when buying sex from women, only 47% did so when buying sex from men;
- Sera results showed HIV and reactive syphilis serology prevalence amongst MSM was 14.4 % and 5.5%, respectively;
- Other diagnosed STIs were urethral Neisseria gonorrhoeae 4.8%, anal Neisseria gonorrhoeae 0.3%, urethral chlamydial infection 7.2%, and anal chlamydial infection 1.0%.
- Overall, 26.5% of the respondents tested positive for at least one STI, including HIV ;
- Among only those MSM who reported selling sex, HIV prevalence was 15.0%. This is very similar to the national HIV prevalence among female indirect sex workers in 2000 (16.1%), though it still remains well below those female sex workers in brothels (31.1%)
- Risk factors for HIV infection were:
- anal sex with multiple partners (OR 3.3, CI 1.3 – 8.5),
- unprotected vaginal sex with female commercial partners in the past month (OR 3.3, CI 1.2 – 9.0),
- current syphilis infection (OR 9.0, CI 2.0 – 40.2), and
- any STI (OR 5.9, CI 1.5 – 23.6).
While the study strove to include as many MSM in Phnom Penh as possible, there were some limitations to the representativeness of the sample. 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).
Conclusions
In Phnom Penh, Cambodia, MSM should be considered are a group at high risk of HIV infection because of a significant proportion who reported unprotected anal intercourse and multiple sexual partners. A large proportion of MSM were also found to have penetrative sex with both males and females. This indicates that MSM could be serving as a "bridge group" of HIV transmission to the general population.
It can be concluded that male-to-male sexual behavior, which is often of a hidden nature, does represent a link in the spread of HIV and STIs in Cambodia. However, more research is necessary to determine the size of ther MSM population in both Phnom Penh and other parts of the country. This information would help in understanding both the possible contribution of this high risk population to the continued spread of the HIV epidemic, as well as the scale of resources needed to successfully reach MSM with interventions. Additional research would also provide a more knowledge about other MSM sub-populations not included in this study such as youth and some clients of male sex workers.
Interventions should be a priority among this group as HIV and syphilis have entered the population in a significant way, and programs should be tailored to the hidden and vulnerable nature of this group, as well as to their sexual risk taking activities which are different from other at risk male populations in Cambodia.
I Background
Cambodia has the highest national HIV prevalence in Asia. In 1999, the Cambodian national estimates suggest that 3.8%2 of the population was infected with HIV. In Cambodia HIV is largely transmitted sexually, and most interventions and resources have been focused on reducing heterosexual transmission. The epidemic is fuelled by a large sex industry, poorly developed health and education infrastructures, and the increasing mobility of the population as the country resumes normal economic activity after decades of war.
Prevention efforts in Cambodia have focused on reducing risky behavior in heterosexual sex by targeting a reduction in multiple sex partners and increased condom use in commercial sex encounters. Behavioral surveillance data collected in several locations in 1999 suggested that annually around one-third3 of the high risk male populations (police, military, moto drivers) continue to have sex with sex workers, with about one quarter of them not protecting all of their commercial sex acts with condoms.
Despite the intensive HIV research and surveillance that has been conducted in Cambodia, little was known about sexual behavior and HIV prevalence among men who have sex with men (MSM) 4, and there were no significant HIV prevention services for MSM. This follows a similar pattnern to other countries in Asia where there is limited data related to prevention programs focusing on male-to-male sexual behavior.5 To date, the only data available on the existence of male-to-male sexual behavior in Cambodia were reported in a study among university students6 showing that 8% of male students reported male-to-male sex behavior, and in an anthropological study about gender and sexuality among Cambodian youth,7 which described the existence of male-to-male sexual behavior among youth. In 2000-2001, Family Health International noted the considerable gaps in understanding of MSM behavior and HIV prevalence and undertook the following study to gain a better understanding of overall HIV risk among MSM in order to better provide interventions to this community.
2 NCHADS 1999, BSS 3 NCHADS 1999, BSS
4 The term "MSM" refers to biological males who engage in sex with other biological males, irrespective of their motivation for their sexual behavior and irrespective of their self-identification and even irrespective of whether they regard themselves as "men".
5 Roy Chan et al, 1998 6 Glaziou, 1999 7 Chou Meng Tarr, 1996
