HIV Risk and Service Use: Results of a Survey of Men in Port-au-Prince and St. Marc, Haiti, 2019
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HIV Risk and Service Use: Results of a Survey of Men in Port-au-Prince and St. Marc, Haiti, 2019
- 1. HIV Risk and Service Use: Results of a Survey of Men in Port-au-Prince and St. Marc, Haiti, 2019 The DREAMS Study Team Port-au-Prince, Haiti June 26, 2019
- 2. Five-year global cooperative agreement and USD $232M 6 partners, led by the University of North Carolina at Chapel Hill (UNC) Strategic objective: To build capacity of developing countries to collect, interpret, and use data to improve health
- 3. Local partners and capacity building Prime: UNC and partners: ICF John Snow, Inc. Management Sciences for Health Palladium Tulane University MEASURE Evaluation works with more than 72 smaller contractors in more than 27 countries More than 26% of project funding goes to smaller subcontractors
- 4. Global footprint More than 40 countries
- 5. DREAMS • A global partnership to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women • Implemented in select countries, including Haiti, where there is a high prevalence of HIV and adolescent girls and young women (AGYW) are at increased risk for HIV A global initiative
- 6. DREAMS core interventions Mobilize communities for change Empower girls and young women and reduce risk Strengthen families Reduce risk of sex partners
- 7. Male characterization studies • HIV interventions that focus on male partners in addition to AGYW may have greater impact. • Limited information exists from the perspective of male partners of AGYW globally and in Haiti. • In Haiti, women are twice as likely to acquire HIV as men, but they report less risk. Addressing the risk posed by their male partners is important. Schaefer, R., Gregson, S., Eaton, J. W., et al. (2017). Age-disparate relationships and HIV incidence in adolescent girls and young women: Evidence from Zimbabwe. AIDS, 31(10):1461−1470. Fawzi, M. C., Lambert, W., Boehm, F,, et al. (2010). Economic risk factors for HIV infection among women in rural Haiti: Implications for HIV prevention policies and programs in resource-poor settings. Journal of Women’s Health,19(5):885−892.
- 8. Study goal To increase understanding of HIV sexual risk behavior, HIV testing and treatment, and sexual partnerships from the perspective of male sexual partners of AGYW in Haiti
- 9. Methods • Cross-sectional survey • 500 male sexual partners of AGYW, Port-au-Prince • 300 male sexual partners of AGTW, St. Marc • Questionnaire (approximately 45 minutes long) was administered by interviewer, • Eligibility criteria: • 18 years of age or older • AGYW sexual partner, past 12 months • In study area past 3 months1 • Provided informed consent • Study sites: • Delmas area of Port-au-Prince • St. Marc 1 Lived, worked, or studied in area during past 3 months
- 10. Sample selection • Respondent-driven sampling (RDS) is a type of sampling that can be used when there is no sampling frame (e.g., list to select from) • Each participant is given a limited number of coupons to recruit others (3 in this study) • Analysis is done to check that respondents vary from the initial seed Respondent-driven sampling INCENTIVES Primary Haitian gourdes (HTG) 500 in phone cards. HTG 250 transport. Secondary: HTG 150
- 11. Fieldwork • Field office located in Delmas neighborhood of Port-au-Prince and St. Marc • Each team consisted of 1 supervisor, 1 coupon manager, 1 receptionist, and 3 interviewers. • Data collection period: February 6−March 22, 2019 • Sociopolitical unrest from February 8−17 affected fieldwork Mackenson Michel, coupon manager for the Port-au-Prince field site. Photo: Ralph Stevens Jeudi. Both Mr. Jeudi and Mr. Michel are with the Pentagone Consulting Group.
- 12. Recruitment • Port-au-Prince • Saint-Marc The coupon return rate was 93% (352/377). During the screening, 52 were deemed ineligible based on study criteria (14,7% or 52/352). The coupon return rate was 91% (551/605). During the screening, 51 were deemed ineligible based on study criteria (9.3% or 51/605). 605 551 500 51 Coupons distributed Coupons returned Eligible Ineligible Coupon distribution and return Port-au-Prince 377 352 300 52 Coupons distributed Coupons returned Eligible Ineligible Coupon distribution and return St. Marc
- 13. Survey instrument Sections: 1. Eligibility 2. Sociodemographics 3. Condom use 4. Sexual risk behavior 5. Alcohol and drug use 6. Partner-specific sexual risk behavior and relationship dynamics (up to 3 partners, past 12 months) 7. HIV knowledge 8. HIV testing 9. HIV treatment (for those HIV+) 10. Gender norms Approximately 45-60 minutes to complete
- 14. Data analysis • Data analyzed separately for each site* • RDS diagnostics and calculation of sampling weights** conducted in RDS Analyst • Frequencies and bivariate and multivariate analysis conducted in Stata using exported population weights * RDS data are a sample of a social network; prohibits pooling across cities ** Giles RDS-SS estimator used to calculate population weights using participant’s social network size and population estimates
- 15. RDS results Port-au-Prince, N=500 • Four seeds, each reaching 7-8 waves
- 16. RDS results St. Marc, N=300 • Two seeds, each reaching 7-8 waves
- 17. Study sample characteristics Port-au-Prince • Average age: 25 years • 81% report secondary school as highest level of education; 42% currently in school • 27% report having children─3 on average • Average monthly income Haitian gourdes (HTG) $4,734; 60% report not having enough food in past month St. Marc • Average age: 24 years • 77% report secondary school as highest level of education; 68% currently in school • 14% report having children─5 on average • Average monthly income HTG$4,873; 36% report not having enough food in past month Sociodemographics
- 18. Percentage ever participated in an HIV education activity 44% 39% 0% 100% Ever participated in an educational activity like a workshop or presentation about HIV/sexually transmitted infection (STI) Port-au-Prince St. Marc
- 19. HIV-related survey results Part 1: Sexual risk behavior, focus on condom use Part 2: HIV testing and HIV treatment Part 3: Sexual relationships, focus on intimate partner violence (IPV)
- 20. Sexual risk behavior Port-au-Prince • Age of sexual debut: 15 years (average) • Lifetime number of sexual partners: 14 (average) • Paid for sex in the past 12 months: 12% St. Marc • Sexual debut: 15 years (average) • Lifetime number of sexual partners: 12 (average) • Paid for sex in the past 12 months: 6%
- 21. Concurrent sexual partnerships 61% 39% Port-au-Prince No Yes 61% 39% St. Marc No Yes A concurrent sexual partnership is defined as one that overlaps in time with another sexual partnership. • Participants were asked to report the start and end dates of sexual partnerships for up to 3 partners in the past 12 months. Those reporting overlapping partnerships were recorded as “yes” for concurrency.
- 22. Age-discordant partnership 64% 36% Port-au-Prince No Yes 81% 19% St. Marc No Yes In this study, an age-discordant sexual partnership is defined as one in which the male participant is >5 years older than his female partner. • Participants were asked to report the age of their sexual partner for up to 3 partners in the past 12 months. Those whose age was >5 years older than any of these partners is recorded as “yes” for age discordance.
- 23. Age discordance and concurrency Port-au-Prince 55% 29% 45% 71% 0% 100% > 5 years older Same/similar age Percentage concurrent, by age discordance Yes No
- 24. Age discordance and concurrency St. Marc 69% 31% 31% 69% 0% 100% > 5 years older Same/similar age Percentage concurrent, by age discordance Yes No
- 25. “High-risk” male sexual partners 20% 80% 0% 50% 100% Age- discordant and… Lower sexual risk Port-au-Prince Age-discordant and concurrent Lower sexual risk 13% 87% 0% 50% 100% Age- discordant and… Lower sexual risk St. Marc Age-discordant and concurrent Lower sexual risk Age-discordant and concurrent
- 26. Condom use 78% 75% 16% 80% 81% 30% Condom use last sex, partner 1 Condom use last sex Condom seen by interviewer at time of interview Port-au-Prince St. Marc
- 27. Percentage reporting condom use at last sex, by education 90% 82% 64% 0% 50% 100% University Secondary None-primary Port-au-Prince University Secondary None-primary * * 77% 75% 75% 0% 50% 100% University Secondary None-primary St. Marc University Secondary None-primary • Age and income not associated with condom use at last sex • Increased education also significantly associated with condom use at last sex with partner 1, and having condom at time of interview in Port-au-Prince
- 28. Percentage reporting condom use at last sex, by purchase of sex 67% 83% 0% 50% 100% Purchased sex Did not purchase sex Port-au-Prince Purchased sex Did not purchase sex * * * 58% 76% 0% 50% 100% Purchased sex Did not purchase sex St. Marc Purchased sex Did not purchase sex • Question worded: In the last 12 months have you given someone money, drugs, clothing, food, or a place to sleep in exchange for sex?
- 29. Percentage reporting condom use at last sex, by sexual risk 79% 81% 0% 50% 100% Age- discordant and… Lower sexual risk Port-au-Prince Age-discordant and concurrent Lower sexual risk 69% 78% 0% 50% 100% Age- discordant and… Lower sexual risk St. Marc Age-discordant and concurrent Lower sexual risk
- 30. Where participants get condoms 5% 3% 9% 35% 4% 17% 69% 8% 14% 19% 28% 32% 37% 80% 0% 20% 40% 60% 80% 100% Clinic Outreach worker Mobile clinic Friend Pharmacy Store Drop-in center Port-au-Prince St. Marc Port-au-Prince
- 31. Confidence in ability to obtain and use condoms 71% 94% 95% 78% 96% 92% Have a condom if you needed one Use a condom correctly Tell your partner you want to use condoms How confident are you that you could… Port-au-Prince St. Marc Men with higher levels of confidence in these three areas were more likely to use a condom at last sex.
- 32. Perception of condom use among closest friends 52%48% Port-au-Prince None/few/half Most/All 61% 39% St. Marc None/few/half Most/All Question worded: How many of your closest friends do you think use condoms when they have sex?
- 33. Percentage reporting condom use at last sex, by perception of friend condom use 89% 74% 0% 50% 100% Most, all friends use condoms None, few, some friends use condoms Port-au-Prince Most, all friends use condoms None, few, some friends use condoms * * 89% 70% 0% 50% 100% Most, all friends use condoms None, few, some friends use condoms St. Marc Most, all friends use condoms None, few, some friends use condoms * *
- 34. Sexual communication skills 91% 82% 90% 71% It is easy to talk to my partner about condoms It is easy to talk to my partner about sex Port-au-Prince St. Marc Percentage reporting “agree” and “strongly agree” in response to the statement
- 35. Percentage reporting condom use at last sex, by sexual communication 83% 53% 0% 50% 100% Agree/ strongly agree Disagree/ strongly… Port-au-Prince * * 80% 46% 0% 50% 100% Agree/ strongly agree Disagree/ strongly… St. Marc * ** It is easy to talk about condoms with this partner…
- 36. HIV-related survey results Part 1: Sexual risk behavior, focus on condom use Part 2: HIV testing and HIV treatment Part 3: Sexual relationships, focus on IPV
- 37. HIV testing 82% 13% 55% 72% 11% 62% Intends to test for HIV next 12 months Tested for HIV past 12 months Ever tested for HIV Port-au-Prince St. Marc
- 38. Where men accessed HIV testing 19% 2% 2% 9% 32% 37% 1% 1% 8% 11% 34% 45% Health post Healthcare worker/peer… Private hospital Mobile clinic Health center Public hospital Port-au-Prince St. Marc
- 39. Percentage who tested for HIV, by sexual risk behavior 65% 81% 84% 60% 60% 57% Condom use at last sex Bought sex past 12… Age-discordant and… Port-au-Prince No Yes 55% 82% 73% 59% 53% 52% Condom use at last sex Bought sex past 12… Age-discordant and… St. Marc No Yes * * * *
- 40. Top three reasons for not having tested for HIV 48% 13% 45% 35% 35% 21% 0% 50% 100% I am not interested in HIV testing I am afraid of HIV testing I don't think I'm at risk for HIV Port-au-Prince St. Marc
- 41. Motivations for HIV testing 5% 9% 13% 9% 41% 10% 10% 9% 10% 32% 0% 50% Because I was about to marry Because I had a doubt On a doctor's request Conversation with or support from spouse/partner Part of routine healthcare Port-au-Prince St. Marc
- 42. People who influence men’s HIV testing 0% 0% 6% 4% 4% 33% 0% 6% 9% 6% 4% 37% 0% 50% Peer educator/mentor Doctor/healthcare worker Friends Parents Relatives Sexual partner Port-au-Prince St. Marc Question worded: Can your _____ influence you to test for HIV?
- 43. Sexual partner communication about HIV testing Port-au-Prince 50% 0% 50% 100% Talked about HIV testing with most recent AGYW sexual partner Yes 30% 44% 54% My HIV status Her HIV status Testing together HIV testing topic discussed with AGYW sexual partner (n=251)
- 44. Sexual partner communication about HIV testing St. Marc 47% 0% 50% 100% Talked about HIV testing with most recent AGYW sexual partner Yes 20% 59% 38% My HIV status Her HIV status Testing together HIV testing topic discussed with AGYW sexual partner (n=134)
- 45. Percentage who tested for HIV, by testing communication with sexual partner 83% 55% 0% 50% 100% Discussed HIV testing with a… Did not discuss HIV testing… Port-au-Prince * * 73% 46% 0% 50% 100% Discussed HIV testing with a… Did not discuss HIV testing… St. Marc * ** Men were asked if they discussed HIV testing with their 3 most recent sexual partners in the past 12 months. Those who discussed HIV testing with any partner are compared to those who did not.
- 46. Perception of HIV testing among closest friends 66% 34% Port-au-Prince None/few Half/almost all 75% 25% St. Marc None/few Half/almost all Question worded: How many of your closest friends do you think have tested for HIV?
- 47. Percentage who tested for HIV, by perception of friend HIV testing 85% 53% 0% 50% 100% Half to almost all friends have tested for HIV None, few friends have testd for HIV Port-au-Prince * * 75% 51% 0% 50% 100% Half to almost all friends have tested for HIV None, few friends have tested for HIV St. Marc * *
- 48. Self-reported HIV status 6% 94% HIV status Port-au-Prince Negative, don't know HIV+ 1% 99% HIV status St. Marc Negative, don't know HIV+ • 30 men self-reported as HIV+ o 29 HIV+ men in Port-au-Prince o 1 HIV+ man in St. Marc
- 49. Antiretroviral therapy (ART) HIV+ participants, n=30 • All HIV+ participants report taking ART for HIV at some point. • 4/30 HIV+ participants stopped ART at some point. • 27/30 HIV+ participants are currently taking ART. • Almost all HIV+ men (29/30) access ART from a health center; some (7/30) access ART through a hospital.
- 50. ART adherence HIV+ participants on ART, n=27 1 1 4 7 14 0 9 18 27 Number of HIV+ participants currently on ART reporting missed doses of ART in the past 4 days No days missed One day missed Two days missed Three days missed Four days missed
- 51. Sexual risk behavior among HIV+ men in the past 12 months 28 Age discordance, n=30 No Yes 11 19 Sexually concurrent partnership, n=30 No Yes HIV+ participants report: • 5 sexual partners on average (range 1−20); • 2 new sexual partners on average (range 0−15)
- 52. Condom use at last sex among HIV+ men 12 18 0 10 20 Number reporting condom use at last sex with AGYW sexual partner (n=30) No Yes
- 53. Posttest counseling for HIV+ men HIV+ participants, n=30 What were you recommended to do after receiving your HIV test result? 16 19 19 24 29 30 Talk to sexual partners about HIV testing Join a support group Remain faithful to one sex partner Get my CD4 checked Use condoms every time Start drug treatment
- 54. Disclosure of HIV status HIV+ participants, n=30 11 0 30 Does anyone in your personal life know you are HIV+? Yes 1 1 1 3 3 3 3 4 9 Mother/aunt Child Borther/sister Peer navigator Male friend Who knows you are HIV+? (n=11)
- 55. HIV-related survey results Part 1: Sexual risk behavior, focus on condom use Part 2: HIV testing and HIV treatment Part 3: Sexual relationships, focus on intimate partner violence (IPV)
- 56. Perpetration of IPV against AGYW sexual partner 4% 3% 1% 73% Ridiculed or criticized… Put down her physical… Put her down in front… Tried to control what… Emotional violence Yes 17% 8% Forced her to have sex Hit, pushed, slapped, punched, or kicked her Physical violence Yes Port-au-Prince Violence perpetration reported for most recent AGYW sexual partner
- 57. Perpetration of IPV against AGYW sexual partner 10% 7% 6% 65% Ridiculed or criticized… Put down her physical… Put her down in front… Tried to control what… Emotional violence Yes 20% 7% Forced her to have sex Hit, pushed, slapped, punched or kicked… Physical violence Yes St. Marc Violence perpetration reported for most recent AGYW sexual partner
- 58. Sexual risk behavior by physical IPV 22% 26% 16% 23% 20% 25% Condom use at last… Concurrent Age-discordant Port-au-Prince No Yes 19% 36% 28% 40% 17% 23% Condom use at last… Concurrent Age-discordant St. Marc No Yes * * * * Violence perpetration and sexual risk behavior reported for most recent AGYW sexual partner
- 59. Equity in relationship power with most recent AGYW sexual partner 66% 36% 45% 49% 34% 36% 40% 42% 26% 50% 48% 44% 50% 49% 40% 42% 8% 14% 7% 7% 16% 15% 20% 16% 0% 50% In general, who has more power? The type of sexual acts you do Whether you use condoms When you talk about serious things How often you see one another What you do together Whether you have sex Who you go out with AGYW partner Both of us Me Reported for most recent AGYW sexual partner Who usually has more say about… Port-au-Prince
- 60. Equity in relationship power with most recent AGYW sexual partner 72% 43% 62% 42% 34% 40% 42% 48% 18% 29% 29% 42% 41% 40% 32% 31% 10% 28% 9% 15% 26% 20% 26% 21% 0% 50% In general, who has more power? The type of sexual acts you do Whether you use condoms When you talk about serious things How often you see one another What you do together Whether you have sex Who you go out with AGYW partner Both of us Me Reported for most recent AGYW sexual partner Who usually has more say about… St. Marc
- 61. Sexual risk behavior by relationship equity 43% 30% 36% 51% 52% 48% Condom use at last sex Concurrent Age-discordant Port-au-Prince No Yes 37% 37% 21% 32% 35% 38% Condom use at last sex Concurrent Age-discordant St. Marc No Yes * * Reported for most recent AGYW sexual partner
- 62. Conclusions • Results confirm need for increased HIV services for male partners (education, access to condoms, testing, and treatment support) • There is a higher-risk subset of AGYW male partners not sufficiently reached with effective HIV interventions • HIV+ partners report low ART adherence and continued sexual risk behavior • An increase in condom use and HIV testing may be achieved through: • Increased access • Promotion of communication in sexual partnerships • Using social norms in messaging • Using peer groups to promote behaviors
- 63. Points for discussion • Survey results from men show an increase in condom use and HIV testing when men talk about these issues with AGYW sexual partners. • Meetings with DREAMS girls suggest that girls don’t think they can influence their male partners to get tested. I think they have to decide for themselves, they are not children. The only thing I say to him is that I am HIV- negative and wish he is also negative. If I influence him, it may be unconsciously when I told him about my HIV status.
- 64. Points for discussion • Survey results from men show that perpetration of emotional and physical violence is a common problem. Relationship power is also low for many of the AGYW. • Meetings with DREAMS girls suggest girls also think men have more power in the relationship. Some feel they are still able to influence such things as condom use. We both have power to decide on that. I would never let him force me to do sex without condoms.
- 65. Points for discussion • Survey results from men show a need for more HIV services for this group. • Meetings with DREAMS girls indicate that girls agree that men need these services and suggest replicating the DREAMS intervention with boys and men. I think they can either offer the [HIV] testing at school or within a program like DREAMS for the boys. If it were not for DREAMS and FOSREF, I would never accepted to get tested for HIV…So it can work for the boys also.”
- 66. Acknowledgments Field staff: • Suzette Etienne • Valery Michel • Ralph Stevens Jeudi • Mackenson Michel • Marie Yvelene Eliacin • Regine Noel • Linetcheli Michel • Cecile Luxamar • Rony Brignolle
- 67. Training of field staff members
- 68. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government. www.measureevaluation.org