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Background A systematic assessment was done to examine the effect of HIV interventions among MSM in Dhaka, Bangladesh. MSM were defined as males having sex with males but did not sell sex in the last year. MSM are hidden, marginalized and stigmatized population groups not only in Bangladesh but also globally. In 2010, HIV interventions for MSM were expanded in 40 districts of Bangladesh through 65 drop-in-centres (DICs) and peer outreach workers. Methods Data from two surveys on MSM in Dhaka in 2010 (baseline) and 2013 (midline) were used to analyse the effect of ongoing HIV prevention services. Both surveys used time location sampling to randomly select MSM for risk behaviour interviews. Two outcome variables were considered; condom use in the last anal sex act and consistent condom use during anal sex in the last month. Univariate and multivariate logistic regression methods were used to determine factors associated with condom use. Results Condom use significantly increased at the midline than baseline (p<0.001 for both). Multivariate analysis showed that having comprehensive knowledge of HIV and participation in HIV prevention programme were positively associated with both last time and consistent condom use. MSM who had comprehensive knowledge of HIV were 1.9 times (95% CI: 1.3–2.8, p = 0.002) and 2.1 times (95% CI: 1.4–3.2, p<0.001) more likely to use condoms than those who did not have comprehensive knowledge of HIV. The likelihood of using condoms among MSM was more than double at the midline than the baseline (p<0.01 for both). However, odds of condom use was significantly lower among those who perceived themselves to be at risk or were not able to assess their own risk of HIV. Conclusion To sustain positive changes in HIV risk behaviours, HIV prevention programmes for MSM need to be continued and strengthened.

Comparison of socio-demographics between baseline and midline.

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RESEARCH ARTICLE

Changes in condom use among males who

have sex with males (MSM): Measuring the

effect of HIV prevention programme in Dhaka

city

Md. Masud Reza

, AKM Masud Rana

, Tasnim Azim

, Ezazul Islam Chowdhury

Gorkey Gourab

, Md. Sha Al ImranID

, Md. Aminul Islam

, Sharful Islam KhanID

1Programme for HIV and AIDS, Infectious Disease Division, International Centre for Diarrhoeal Disease

Research, Bangladesh (icddr,b), Dhaka, Bangladesh, 2 Regional Advisor for Research Policy and

Cooperation (RPC), Department of Communicable Diseases, WHO South-East Asia Regional Office, Delhi,

India, 3 HIV/AIDS Program, Save the Children International, Dhaka, Bangladesh

*sharful@icddrb.org

Abstract

Background

A systematic assessment was done to examine the effect of HIV interventions among MSM

in Dhaka, Bangladesh. MSM were defined as males having sex with males but did not sell

sex in the last year. MSM are hidden, marginalized and stigmatized population groups not

only in Bangladesh but also globally. In 2010, HIV interventions for MSM were expanded in

40 districts of Bangladesh through 65 drop-in-centres (DICs) and peer outreach workers.

Methods

Data from two surveys on MSM in Dhaka in 2010 (baseline) and 2013 (midline) were used

to analyse the effect of ongoing HIV prevention services. Both surveys used time location

sampling to randomly select MSM for risk behaviour interviews. Two outcome variables

were considered; condom use in the last anal sex act and consistent condom use during

anal sex in the last month. Univariate and multivariate logistic regression methods were

used to determine factors associated with condom use.

Results

Condom use significantly increased at the midline than baseline (p< 0.001 for both). Multivar-

iate analysis showed that having comprehensive knowledge of HIV and participation in HIV

prevention programme were positively associated with both last time and consistent con-

dom use. MSM who had comprehensive knowledge of HIV were 1.9 times (95% CI: 1.3–

2.8, p = 0.002) and 2.1 times (95% CI: 1.4–3.2, p< 0.001) more likely to use condoms than

those who did not have comprehensive knowledge of HIV. The likelihood of using condoms

among MSM was more than double at the midline than the baseline (p< 0.01 for both).

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 1 / 15

a1111111111

OPEN ACCESS

Citation: Reza M.M, Rana AM, Azim T, Chowdhury

EI, Gourab G, Imran M.SA, et al. (2020) Changes in

condom use among males who have sex with

males (MSM): Measuring the effect of HIV

prevention programme in Dhaka city. PLoS ONE 15

(7): e0236557. https://doi.org/10.1371/journal.

pone.0236557

Editor: Tendesayi Kufa, National Institute for

Communicable Disease (NICD), South Africa,

SOUTH AFRICA

Received: September 12, 2019

Accepted: July 8, 2020

Published: July 24, 2020

access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: The data and

materials used and analyzed during this research

are not publicly available due to ethical restrictions,

data confidentiality, and the International Centre for

Diarrheal Disease Research, Bangladesh data

policy. Data are available, on reasonable request for

researchers who meet the criteria for access to

confidential data, from Armana Ahmed

(armana@icddrb.org ), Head of Research

However, odds of condom use was significantly lower among those who perceived them-

selves to be at risk or were not able to assess their own risk of HIV.

Conclusion

To sustain positive changes in HIV risk behaviours, HIV prevention programmes for MSM

need to be continued and strengthened.

Introduction

Males having Sex with Males (MSM) are at elevated risk of HIV infection in most countries

around the world [1 ]. In the cities of Southern and South-eastern Asia, prevalence of HIV

among MSM ranges from 6–29% [2 ] and 4–81% [3–12 ] of MSM received HIV prevention

services. The hidden nature of MSM and the criminalisation of MSM behaviours in many

countries makes accessing MSM for services a challenge [13 ] and in South Asia including Ban-

gladesh and Pakistan, the Penal Code 377 is one such act that states "Whoever voluntarily has

carnal intercourse against the order of nature with any man, woman or animal, shall be pun-

ished with imprisonment for life, or with imprisonment of either description for a term which

may be extended to ten years, and shall also be liable to fine" [14 , 15 ]. Furthermore, police can

arrest persons without any warrant based on information provided by a third party who are

involved with such offences [16 ]. Bail for this offence is at the discretion of the courts and can

take up to two years to obtain [15].

In Bangladesh, HIV prevalence among MSM is still low. The last HIV serological surveil-

lance conducted in 2015 among MSM in Dhaka city showed that the prevalence of HIV was

only 0.3% and the prevalence of active syphilis was 1.5% [17 ]. The data also showed that, risky

sexual behaviours were highly prevalent with 46% of MSM not using a condom in the last sex

act and only 34–50% using condoms consistently with male sex partners during the last month

[17 ]. Moreover, 13.5% of MSM reported that they were beaten and/or raped in the last year,

only 10.6% ever accessed HIV testing services (HTS) and 35.5% had comprehensive knowl-

edge of HIV [17 ]. Given these data there is concern that HIV may rise among MSM if preven-

tion efforts are not strengthened.

In Bangladesh HIV prevention services for MSM started in 1997 [18 ] and since then ser-

vices have expanded with support from various sources. In 2010, the estimated number of

MSM was 110,581 [19 ] and the HIV prevention services expanded to 18,231 (16.5% of the esti-

mated number) MSM in 40 districts of Bangladesh through 65 drop-in-centres (DICs). At the

end of December 2012, in Dhaka city, ~1,000 (0.9% of the estimated number) received services

through five DICs. The current HIV prevention services (from 2010 and onwards) to MSM

build on the previous design of November 2009 [18 ] with a few differences. The services are

implemented through static DICs and peer outreach workers in cruising spots where MSM

congregate. The services include behaviour change communication (BCC), condom and lubri-

cant promotion and distribution, HIV testing and services (HTS), referral for HIV positive

MSM to care, support and treatment and management of sexually transmitted infections

(STIs) including counselling. Each peer educator provides HIV prevention services to ~140

MSM at the cruising spots five days a week. To ensure availability of condoms and lubricants

during holidays and weekends, condoms and lubricants are made available at fixed sites,

known as depot holders (DH), in the localities frequented by MSM. Advocacy with commu-

nity and law enforcement agencies are conducted locally to promote an enabling environment.

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 2 / 15

Administration of icddr,b, and as per the data

policy of icddr,b.

Funding: The surveys were funded by The Global

Fund through the Grant 'Expanding HIV/AIDS

Prevention in Bangladesh' under the terms of Grant

Agreement NO. BAN-202-G13-H-00 with icddr,b.

We acknowledge with gratitude the commitment of

the Global Fund to its research efforts. icddr,b is

also grateful to the governments of Bangladesh,

Canada, Sweden and the UK for providing core/

unrestricted support.

Competing interests: The authors declare that they

have no competing interests.

There are provisions for legal support, if required. In addition, a participatory monitoring and

evaluation (PM&E) is in place that has served to enhance the quality of the programme data

and provide a better understanding of the underlying context and to ensure rapid action for

improvement of programme performance [20].

Prior to the upscaling of HIV prevention programme for MSM in Bangladesh, a risk behav-

iour survey was conducted in Dhaka, the capital city in 2010 (referred to as the baseline survey)

[21 ] and this was repeated later, in 2013 (referred to as the midline survey) [22 ]. The objective

of the midline survey was to compare the progress of the HIV prevention programme in-

terms of impact and outcome indicators, i.e. HIV prevalence and safer sex behaviours with

MSM and transgender women (hijra) over time. Hijra or transgender women refer to those

who identify themselves as belonging to a traditional hijra sub-culture [19 ]. Dhaka was selected

for the baseline survey because of two reasons: i) at that time, 35,355 MSM [19 ] (32% of the

total MSM in Bangladesh) were living in Dhaka city and ii) of 2,228 HIV positive cases that

were detected from key populations (KPs) at risk of HIV from 2007–2013 in Bangladesh,

mostly (19.2%) were detected in Dhaka [23].

Here we present an analysis of data obtained from the two surveys (baseline and midline)

that was conducted to determine changes in key risk behaviours and correlates of condom

use in MSM in Dhaka following implementation three years of HIV prevention services. Such

evaluation of behavioural interventions is pertinent in generating evidence for outcome-ori-

ented interventions [24 , 25].

Materials and methods

Setting

Both the baseline 2010 and midline 2013 was conducted in Dhaka, the capital city of Bangla-

desh. Furthermore, in 2010, an assessment was conducted to estimate the size of MSM in

Dhaka city before starting HIV prevention program for MSM. The data showed that the esti-

mated size of MSM was 110,581 [19 ]. Based on the fund available, during the phase-1 of the

project (2010–2012), 18,230 (16.0%) and the phase-2 (2013–2015), 22,448 (20.0%) MSM

received HIV prevention services. This is to be mentioned that in Dhaka city, there was no

HIV prevention services for MSM by any other agencies and since 2010, it is being running by

a single donor. Male to male sex is still prohibited in Bangladesh and therefore, they are hidden

and hard to reach. There are 9,379 MSM in Dhaka city [26 ] and only 17.7% (1,659; program

data, Jul-Dec, 2019) received HIV prevention services. There is also a lack of research data on

MSM population that can contribute to increase HIV prevention services. Therefore, the find-

ings from this analysis are still important for program managers and policy makers.

Study design

Both surveys (baseline in 2010 and midline in 2013) were conducted in Dhaka city and fol-

lowed a similar cross-sectional design aimed at collecting HIV risk behavioural data from

MSM 18 years and older [21 , 22 ]. MSM were defined as males having sex with males but did

not sell sex in the last month.

Standard guideline was followed to conduct both the baseline and midline surveys as sug-

gested by USAID and DFID [27 ]. Time Location Sampling (TLS), which is a two-stage proba-

bility sampling method [27 ] was used in both surveys. Both in 2010 and 2013, a place to be

defined as a 'spot' where at least 3 MSM were seen during mapping.

In 2010, social mapping was conducted in 211 places in Dhaka city. At least one MSM was

seen during mapping in 160 places. To make the sampling frame of spots, which was the first

stage of sampling, 126 places were filtered (considered as spots) from 160 places where at least

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 3 / 15

2 MSM were seen during mapping. This is to be noted that to be in the safe side we filtered the

spots where at least 2 or more MSM were seen during mapping. Then from 126 spots, 114

spots were chosen using systematic random sampling technique.

In 2013, social mapping was conducted in 234 places in Dhaka city. At least one MSM was

seen during mapping in 182 places. To make the sampling frame of spots, which was the first

stage of sampling, 164 places were filtered (considered as spots) from 182 places where at least

2 MSM were seen during mapping. This is to be noted that to be in the safe side we filtered

the spots where at least 2 or more MSM were seen during mapping. Then from 164 spots, 119

spots were chosen using systematic random sampling technique.

In both surveys, interviews were conducted randomly during a suitable time of day from 5

PM to 11 PM assuming a fixed 4 MSM to be interviewed from each spot, which was the second

stage of sampling. Besides interviewing of MSM, the data collectors also collected information

on the number of MSM available in a particular spot during 5 PM to 11 PM which referred to

as seen during interview. This information was used in the calculation of sampling weights.

Data were collected for the baseline and midline surveys between February-March, 2010 and

January-February, 2013, respectively.

Sample size calculation

Both in the baseline and midline, the sample sizes were calculated using a standard formula

shown below [27].

n¼ Df z 1α ﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ

2�

pð1  �

pÞ

pþz1β ﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ

p1 ð1  p1 Þ þ p2 ð1  p2 Þ

pg2

ðp2 p1 Þ 2

In the above formula:

D = Design effect.

p1 = Estimated proportion of risk behaviour at the time of previous survey.

p2 = The target proportion at some future date, so that (p2-p1) is the magnitude of change

that we want to be able to detect.

pðbarÞ ¼ ð p1 þp2Þ= 2

1-α

= The Z-score corresponding to desired level of significance = 1.645.

1-β

= The Z-score corresponding to desired level of power = 0.83.

In the baseline, two risk behavioural indicators from the last round of behavioural survey

and surveillance (BSS) conducted in 2006–07 among MSM in the Dhaka were used [28].

These indicators were: condom use in the last anal sex act while buying sex from males (not

transgender) and condom use in the last anal sex act while having sex with non-commercial

male/transgender sex partners in the last month. The sample size was calculated to detect 11–

14% (1-way change detectable) changes in these risk behaviours over time for the population

group. In the calculation of sample size, we also used the inflation rates (percent of the popula-

tion that is eligible to be considered for the indicators) from BSS 2006–07 for MSM population

and a design effect of 2, 95% confidence level and 80% power. The calculated sample sizes

were also adjusted for 5% non-response. For the first indicator, the calculated sample size was

439 and for the second indicator, 454.

In the midline 2013 [22], similar indicators and approach were used to calculate sample

sizes. The estimates of the indicators were taken from baseline 2010 [21 ]. For the first indica-

tor, the calculated sample size was 476 and for the second indicator, 387. Finally, the largest

sample size was chosen for interview both in the baseline and midline.

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 4 / 15

Survey tool

Face to face interviews were conducted using semi-structured questionnaires by experienced

interviewers at public spots where some privacy could be assured [28–30 ]. The questionnaire

included information on socio-demographic characteristics sexual history, sexual risk-behav-

iour, mobility, knowledge of male condoms and lubricants, knowledge of STIs and HIV, self-

reported symptoms of STIs, knowledge and uptake of HTS, violence, HIV risk self-assessment

and participation in HIV prevention programmes. Before each interview, verbal informed

consent was obtained from the respondents. Because, same-sex sexual acts are criminalized in

Bangladesh under Section 377 of the Penal Code and punishable by life imprisonment. Our

experiences of working with MSM and transgender women (known as hijra ) with such sensi-

tive topic suggest that many of them do not like to disclose their identity (e.g. sexual orienta-

tion, involvement in sex trade) in written form due to the fear of identity disclosure. Structural

barriers such as religious prohibition; criminalization of sex work and same-sex behaviour;

and social stigma hinders getting written consent from them. Also, most often, requesting for

written consent make them suspicious about the purpose of the study. This process not only

influences their participation in the study but also their responses to the sensitive questions.

Hence, we collected verbal consent from the research participants. Our trained research team

members carefully obtained verbal informed consent and sought permission through verbal

approval before each interview. The studies, findings of which were analysed in this manu-

script, were approved by the Ethical Review Committee (ERC) at icddr,b.

Measures

In this analysis, two key risk behaviours of MSM were considered as outcome variables. The

first outcome variable was 'used condom in the last sex act with any transactional/non-transac-

tional males/hijra sex partners in the last month' and the second outcome variable was 'used

condoms consistently in all anal sex acts with any transactional/non-transactional males/hijra

sex partners in the last month'.

Statistical analysis

A composite indicator was computed to measure the comprehensive knowledge of HIV who

correctly identified two ways to prevent HIV and rejected three misconceptions regarding

HIV transmission implies that 1) Can the risk of HIV transmission be reduced by having sex

with only one uninfected partner who has no other partners?, 2) Can a person reduce the risk

of getting HIV by using a condom, every time they have sex?, 3) Can a healthy-looking person

have HIV?, 4) Can a person get HIV from mosquito bites? and 5) Can a person get HIV by

sharing food with someone who is infected? [31]. Uptake of HTS was computed based on who

received HIV testing as well as received the test result in the last 12 months [31 ]. Categorical

variables were measured by percentage points and numerical variables by means along with

95% conficence intervals (CIs) for both. All variables between the two survey periods were

compared using Chi-square statistics and any 5% was used as a level of significance. To identify

the factors associated with using condom in the last sex act and using condoms consistently in

the last month, bivariate analysis was carried out initially using univariate logistic regression

models [32 ]. Thereafter, the net association of the factors associated with using condom in the

last sex act and consistently with male/hijra sex partners, was determined by using multiple

logistic regression models [32 ]. Factors that were significant at the 10% level in the bivariate

analysis were included in the multivariate analysis [33 , 34 ]. Results from the bivariate analysis

were reported as unadjusted odds ratios (UOR) and from multivariate analysis as adjusted

odds ratios (AOR). Before running multivariate analysis, pair-wise correlation coefficients

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 5 / 15

were checked among the factors that were significant at p-value of <0.10 in the bivariate

analysis [35 ]. In all analysis, appropriate sampling weights and clustering of observations were

incorporated [27 ]. In this analysis, data from two-time points were appended. Data were ana-

lysed with Stata using complex survey design commands, Version 13.1 [36 ]. In the baseline,

data were collected from 457 MSM and in the midline, from 487 MSM. The analysis was con-

ducted among those who were 18 or above years of old. Finally, at both time points some of

which were also married to women, a total of 457 MSM participated at the baseline were com-

pared with 475 MSM at the midline. This is to be noted that after appending two data sets,

sampling weights were modified [37 ] and then standard formula was used [27 ] to make it stan-

dardised so that in the analysis, the total number of observations become equal to the sum of

sampling weights. Hence, for the sake of completeness in the analysis, all results in the manu-

script are reported based on the modified sampling weights. After incorporating clustering of

observations in the analysis, the calculation of standard error of estimates was based on cluster

sampling design that was been automatically modified by Stata and based on that 95% confi-

dence intervals were calculated in the univariate, bivariate and multivariate analyses.

Results

Comparison between the baseline and midline surveys

Comparisons between the two surveys are shown in Table 1 . There were no differences in

sociodemographic characteristics including age, years of schooling, marital status however,

income significantly increased at the midline than the baseline (p< 0.001) (Table 1 ). This is to

be mentioned that 30–32% of MSM in both time points were married that indicates they were

bisexual.

Condom use (both last time and consistent) significantly increased at the midline compared

to the baseline (p< 0.001 for both, Table 2 ). Risk perception changed significantly between the

Table 1. Comparison of socio-demographics between baseline and midline.

Variables Baseline (2010) Midline (2013) Comparison

n, Col% (95% CI) n, Col% (95% CI) (p-value)

(N = 457) (N = 475)

Age

18–24 years 183, 39.4 (34.1–45.0) 197, 40.1 (35.1–45.3) NS

>= 24 years 274, 60.6 (55.0–65.9) 278, 59.9 (54.7–64.9) NS

Years of schooling

0 36, 7.9 (5.6–11.1) 44, 9.4 (5.8–14.9) NS

1–5 120, 26.6 (21.4–32.6) 107, 23.1 (18.9–28.0) NS

6–10 214, 46.0 (40.9–51.3) 183, 38.5 (33.5–43.8) NS

>10 86, 19.4 (15.0–24.7) 139, 28.9 (23.7–34.8) NS

Income in the last month (USD)

<= 91 296, 66.3 (60.4–71.7) 195, 40.1 (35.4–45.0) <0.001

>91 161, 33.7 (28.3–39.6) 280, 59.9 (55.0–64.6) <0.001

Current marital status

Unmarried 295, 65.0 (59.9–69.8) 323, 67.0 (61.9–71.7) NS

Married 144, 31.8 (27.2–36.9) 136, 29.6 (25.2–34.3) NS

Divorced/Separated/Widower 18, 3.1 (1.9–5.1) 16, 3.5 (2.1–5.6) NS

Based on median value (1 USD = 91.0 BDT); NS indicates a non-significant comparison at the 5% level.

N = 456, one observation was missing in 2010 and N = 473, 2 observations were missing in 2013.

https://doi.org/10.1371/journal.pone.0236557.t001

Changes in condom use among MSM in Dhaka city

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two time points; significantly more MSM at the midline versus the baseline survey did not con-

sider themselves to be at risk of HIV (63%, 95% CI: 58.1–67.6 and 43%, 95% CI: 36.8–49.4;

p< 0.001) respectively. At the same time, fewer participants were not able to assess their

own risk of HIV with 34.3% (95% CI: 27.9–41.3) at the baseline to 11.3% (95% CI: 7.7–16.2;

p< 0.001) at the midline. Two questions were asked to assess the knowledge of HIV prevention

and three questions were asked to assess knowledge of HIV transmission. Use of condom

(properly and consistently) as a mode of HIV prevention was reported by 82.4% (95% CI:

78.0–86.1) at the baseline and 88.5% (95% CI: 84.0–91.9) at the midline. At the baseline, 66.2%

(95% CI: 61.2–70.8) and at the midline, 64.2% (95% CI: 58.1–69.9) mentioned avoiding multi-

ple sex partners to prevent HIV. At both time points, almost half of the MSM rejected the mis-

conception that HIV can be transmitted by mosquito bites and a little more than half rejected

the misconception that HIV can be transmitted by sharing food with HIV infected persons.

More MSM at the midline compared to the baseline rejected the misconception that one can

tell by looking at someone whether he/she is infected with HIV (57.6%, 95% CI: 51.6–63.3 vs.

78.2%, 95% CI: 73.1–82.5; p< 0.001). Only 23.5% (95% CI: 18.9–29.0) at the baseline and

Table 2. Comparison of sexual risk, vulnerabilities and programmatic variables between baseline and midline.

Variables Baseline (2010) Midline (2013) Comparison

n, Col% (95% CI) n, Col% (95% CI) (p-value)

(N = 457) (N = 475)

Age at first sex (anal/vaginal)

12 years 31, 7.7 (5.1–11.5) 70, 14.8 (11.3–19.3) <0.01

13–19 years 373, 79.6 (74.2–84.0) 356, 75.4 (70.5–79.6) NS

20 years 53, 12.8 (9.7–16.6) 49, 9.8 (7.2–13.2) NS

Had anal sex with males/hijra in the last month 342, 74.7 (69.3–79.4) 400, 84.7 (80.0–88.5) <0.01

Used condom in the last anal sex act with a male in the last month (denominator is who had anal sex

with a male in the last month)

92, 24.8 (20.3–29.8)

N = 342

197, 48.6 (42.4–54.7)

N = 400

<0.001

Used condom consistently during all anal sex acts with males in the last month (denominator is who

had anal sex with males in the last month)

61, 16.7 (12.7–21.6)

N = 342

143, 35.1 (29.4–41.2)

N = 400

<0.001

Reported at least one STI symptoms in the last year 80, 17.7 (13.4–23.2) 62, 13.3 (10.3–17.1) NS

Mentioned condom use (correctly and consistently in any type of sex) as a mode of prevention 377, 82.4 (78.0–86.1) 417, 88.5 (84.0–91.9) NS

Mentioned avoiding multiple sex partners as a mode of prevention 293, 66.2 (61.2–70.8)

N = 448

305, 64.2 (58.1–69.9) NS

Rejected misconception that HIV can be transmitted by mosquito bites 228, 50.6 (44.9–56.2)

N = 450

227, 46.7 (40.2–53.3) NS

Rejected misconception that HIV can be transmitted by sharing food with an HIV infected person 261, 59.3 (53.5–64.8)

N = 450

265, 54.7 (48.1–61.2) NS

Rejected misconception that one can tell by looking at someone whether he/she is infected with HIV 266, 57.6 (51.6–63.3)

N = 448

371, 78.2 (73.1–82.5) <0.001

Had comprehensive knowledge of HIV 108, 23.5 (18.9–29.0) 130, 26.6 (21.6–32.3) NS

HIV risk perception

At risk (high or medium) 114, 22.7 (18.4–27.7) 128, 25.7 (21.1–31.0) NS

Not at risk 192, 43.0 (36.8–49.4) 296, 63.0 (58.1–67.6) <0.001

Not able to assess 146, 34.3 (27.9–41.3) 51, 11.3 (7.7–16.2) <0.001

NS indicates a non-significant comparison at the 5% level.

9 observations were missing.

7 observations were missing.

N = 452, 5 observations were missing at baseline.

https://doi.org/10.1371/journal.pone.0236557.t002

Changes in condom use among MSM in Dhaka city

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26.6% (95% CI: 21.6–32.3) at the midline had comprehensive knowledge of HIV and no differ-

ence was observed.

Factors associated with condom use in the last sex act and consistently with

a male/hijra sex partner in the last month

In the bivariate analysis, condom use in the last sex act was significantly associated (p<0.10)

with income in the last month, having STI symptoms in the last year, HIV risk perception,

having comprehensive knowledge of HIV and year of survey (Table 3 ). In the multivariate

analysis, HIV risk perception, having comprehensive knowledge of HIV, having STI symp-

toms in the last year and year of survey retained significance at p< 0.05 (Table 3 ). The likeli-

hood of using a condom in the last sex act was significantly lower among those who perceived

themselves to be at risk (high or medium) of HIV or were not able to assess their own risk

compared to those who perceived themselves to be at no risk (p< 0.05 for both). Concomi-

tantly, comprehensive knowledge of HIV was positively associated with last time condom use

Table 3. Factors associated with condom use in the last sex act.

Factors Bivariate analysis Multivariate analysis

Yes No UOR (95% CI) p-value AOR (95% CI) p-value

n/N (Row %) n/N (Row %)

Age

18–24 years 115/296 (36.6) 181/296 (63.4) 0.9 (0.7–1.3) NS -- --

>24 years (RC) 174/446 (38.3) 272/446 (61.7) 1.0 - -

Years of schooling

0 (RC) 20/67 (31.0) 47/67 (69.0) 1.0 - - - - - -

1–5 58/164 (35.1) 106/164 (64.9) 1.2 (0.6–2.3) NS

6–10 123/319 (36.7) 196/319 (63.3) 1.3 (0.7–2.5) NS

>10 88/190 (44.1) 102/190 (55.9) 1.8 (0.9–3.4) NS

Income in the last month (USD)

<= 91 120/375 (31.2) 255/375 (68.8) 1.0 - - 1.0 - -

>91 169/367 (44.3) 198/367 (55.7) 1.8 (1.3–2.4) 0.001 1.4 (1.0–1.9) NS

Current marital status

Unmarried (RC) 201/496 (38.9) 295/496 (61.1) 1.0 - - - - - -

Married 80/217 (35.9) 137/217 (64.1) 0.9 (0.6–1.3) NS

Divorced/Separated/Widower 8/29 (29.4) 21/29 (70.6) 0.7 (0.3–1.6) NS

Age at first sex (anal/vaginal)

12 years (RC) 31/83 (36.1) 52/83 (63.9) 1.0 - - - - - -

13–19 years 230/581 (38.3) 351/581 (61.7) 1.1 (0.7–1.9) NS

20 years 28/78 (35.1) 50/78 (64.9) 1.0 (0.4–2.1) NS

HIV risk perception

At risk (medium or high) 75/206 (34.8) 131/206 (65.2) 0.6 (0.4–0.9) 0.009 0.7 (0.4–1.0) 0.04

Not at risk (RC) 185/378 (47.2) 193/378 (52.8) 1.0 - - 1.0 - -

Not able to assess 28/154 (18.1) 126/154 (81.9) 0.2 (0.1–0.4) < 0.001 0.4 (0.2–0.6) 0.001

Reported at least one STI symptoms in the last year 32/120 (24.6) 88/120 (75.4) 0.5 (0.3–0.8) 0.002 0.5 (0.4–0.9) 0.009

Had comprehensive knowledge of HIV 108/204 (50.7) 96/204 (49.3) 2.1 (1.4–3.1) < 0.001 1.9 (1.3–2.8) 0.002

Year of survey

2010 (baseline) (RC) 92/342 (24.8) 250/342 (75.2) 1.0 - - 1.0 --

2013 (midline) 197/400 (48.6) 203/400 (51.4) 2.9 (2.0–4.1) < 0.001 2.3 (1.6–3.3) <0.001

In the bivariate analysis NS indicates a non-significant result at the 10% level and in the multivariate analysis, at the 5% level; RC = reference category.

https://doi.org/10.1371/journal.pone.0236557.t003

Changes in condom use among MSM in Dhaka city

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(AOR: 1.9, 95% CI: 1.3–2.8, p = 0.002). Having a symptom of STI in the last year was negatively

associated with last time condom use (AOR: 0.5, 95% CI: 0.4–0.9, p = 0.009). The year of inter-

vention (2013) showed a positive impact on condom use in the last sex act (AOR: 2.3, 95% CI:

1.6–3.3, p<0.001).

Consistent use of condoms was significantly lower among those who perceived themselves

to be at risk (AOR: 0.4, 95% CI: 0.3–0.7, p< 0.001) or were not able to assess their own risk of

HIV compared to those who perceived themselves to be at no risk (AOR: 0.3, 95% CI: 0.2–0.5,

p< 0.001, Table 4 ). Significant positive associations with consistent condom use were observed

with having comprehensive knowledge of HIV (AOR: 2.1, 95% CI: 1.4–3.2, p< 0.001) and year

of survey (AOR: 2.1, 95% CI: 1.4–3.4, p = 0.001).

Discussion

Condom use, especially consistent condom use, is a cornerstone in the behavioural prevention

programme against sexual transmission of HIV [38 ]. Condom use can be improved with

Table 4. Factors associated with consistent use of condoms.

Factors Bivariate analysis Multivariate analysis

Yes No UOR (95% CI) p-value AOR (95% CI) p-value

n/N (Row %) n/N (Row %)

Age

18–24 years 80/296 (25.3) 216/296 (74.7) 0.9 (0.6–1.3) NS -- --

>24 years (RC) 124/446 (27.5) 322/446 (72.5) 1.0 - -

Years of schooling

0 (RC) 15/67 (23.1) 52/67 (76.9) 1.0 - - 1.0 - -

1–5 41/164 (23.0) 123/164 (77.0) 1.0 (0.5–2.0) NS 1.0 (0.5–2.0) NS

6–10 78/319 (24.1) 241/319 (75.9) 1.1 (0.5–2.1) NS 1.0 (0.5–2.0) NS

>10 70/190 (35.6) 120/190 (64.4) 1.8 (0.9–3.6) 0.08 1.0 (0.5–2.1) NS

Income in the last month (USD)

<= 91 83/375 (21.5) 292/375 (78.5) 1.0 - - 1.0 - -

>91 121/367 (31.9) 246/367 (68.1) 1.7 (1.2–2.4) 0.003 1.3 (0.9–1.9) NS

Current marital status

Unmarried (RC) 138/496 (26.7) 358/496 (73.3) 1.0 - - - - - -

Married 60/217 (27.0) 157/217 (73.0) 1.0 (0.7–1.5) NS

Divorced/Separated/Widower 6/29 (23.7) 23/29 (76.3) 0.9 (0.3–2.3) NS

Age at first sex (anal/vaginal)

12 years (RC) 20/83 (22.6) 63/83 (77.4) 1.0 - - - - - -

13–19 years 164/581 (27.2) 417/581 (72.8) 1.3 (0.7–2.3) NS

20 years 20/78 (27.3) 58/78 (72.7) 1.3 (0.6–3.0) NS

HIV risk perception

At risk (medium or high) 43/206 (19.6) 163/206 (80.4) 0.4 (0.3–0.6) < 0.001 0.4 (0.3–0.7) <0.001

Not at risk (RC) 145/378 (36.9) 233/378 (63.1) 1.0 - - 1.0 - -

Not able to assess 15/154 (10.2) 139/154 89.8) 0.2 (0.1–0.4) < 0.001 0.3 (0.2–0.5) <0.001

Reported at least one STI symptoms in the last year 21/120 (16.1) 99/120 (83.9) 0.5 (0.3–0.8) 0.008 0.6 (0.3–1.0) NS

Had comprehensive knowledge of HIV 84/204 (39.9) 120/204 (60.1) 2.4 (1.6–3.5) < 0.001 2.1 (1.4–3.2) <0.001

Year of survey

2010 (baseline) (RC) 92/342 (24.8) 250/342 (75.2) 1.0 - - 1.0 - -

2013 (midline) 197/400 (48.6) 203/400 (51.4) 2.7 (1.8–4.1) < 0.001 2.1 (1.4–3.4) 0.001

In the bivariate analysis NS indicates a non-significant result at the 10% level and in the multivariate analysis, at the 5% level; RC = reference category.

https://doi.org/10.1371/journal.pone.0236557.t004

Changes in condom use among MSM in Dhaka city

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effective programmes as has been shown in several cohort studies in China, Vietnam and Thai-

land [39–41 ] and in randomised control trials [42–44 ] in India, China, Russia and Hungary.

The analysis presented here shows that condom use increased following three years of pro-

gramming suggesting that the prevention programme for MSM in Dhaka had a positive effect

in promoting safer sexual behaviours. These findings are consistent with other studies con-

ducted in various countries globally. For example, similar findings were observed among

MSM in Andhra Pradesh, Maharashtra and Tamil Nadu in India where HIV prevention pro-

gramme had a positive impact on increasing condom use [45–47 ] as was the case in Anhui and

Sichuan Provinces in China [48 , 49 ] and in Senegal [50].

Although condom use increased after three years of intervention, the level of improvement

is not sufficient to prevent a future HIV epidemic as half of the interviewed MSM still did not

use a condom in the last sex act and about three in every five were not using condoms consis-

tently. It is fortunate that HIV prevalence is still low among MSM in Bangladesh but recent

data on the number of reported cases of HIV shows a consistent annual rise and MSM show

the greatest rise in numbers after people who inject drugs [51 ]. Moreover, reports of STI symp-

toms within the last year did not decline significantly between 2010 and 2013. The reasons for

this cannot be gauged from this analysis but it does raise concerns about the future of the epi-

demic if it is not better understood and dealt with.

Relationship of condom use and HIV prevention programmes has also been assessed by

using AIDS Epidemic Model (AEM) [52 ] in many countries. The results of AEM among MSM

in China showed a positive association between condom use and increased coverage of HIV

intervention programme and concluded that the HIV prevention programme needed to be

continued and strengthened to control the AIDS epidemic in MSM [53 ]. Findings of AEM in

Peru, Ukraine, Kenya, and Thailand showed the positive impact of increased HIV prevention

programme in reducing new HIV infections among MSM [54 ]. A modelling exercise con-

ducted among MSM of Dhaka city using AEM showed that new HIV infections would be

increasing in 2020 through various risk behaviours particularly male-to-male sex due to con-

dom-less anal sex [55 ]. The findings also showed that 54% of the total new HIV infections will

occur among MSM in 2020 compared to 12% in 2000 and hence recommended to increase

coverage of HIV prevention for MSM in Dhaka city.

Several factors affect condom use and a major one is having comprehensive knowledge

about HIV [56 ] that was reported to be low and did not improve in MSM over the three-year

intervention period. The BCC leaflet that the peer-educators use to improve knowledge of HIV

among MSM contains all correct information regarding HIV prevention and transmission.

This analysis has revealed some important findings that need the attention of the programme

implementers. At both time-points, a substantial percentage of MSM reported HIV can be pre-

vented by using condoms correctly and consistently while on the other hand avoiding multiple

sex partners as a mode of HIV prevention was reported to be low. Having correct knowledge

that HIV is not transmitted by mosquito bites and not by sharing food with HIV infected per-

sons was also reported to be low. These findings signal that when PEs conduct sessions to

change risk behaviours using BCC with MSM, one-to-one or in a group, they stress only on cor-

rect and consistent use of condoms as a mode of HIV prevention and may ignore or do not

stress enough on other ways of HIV prevention and transmission. However, misconception

regarding HIV transmission that requires testing to know the status of HIV has increased at the

midline compared to the baseline that highlights the benefit of HTS. In this analysis, since the

prevalence of active-syphilis was low, self-reported symptoms of STIs was used as a proxy vari-

able for prevalence of STIs. The association of self-reported STIs was found significant only

with condom use in the last sex act. Those who used condom in the last sex act was less likely to

report symptoms of STIs. Similar finding was observed in a study among MSM in Africa [57].

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 10 / 15

An outcome of knowledge is risk perception. In this analysis, more MSM at the midline

perceived themselves to not be at risk, not because of lack of knowledge but because they used

their knowledge on condoms and were therefore more likely to use condoms. It is essential

to get everyone participating in the HIV prevention programme to be fully knowledgeable

regarding routes of HIV transmission and means of prevention. In order to achieve this,

assessment of the knowledge transfer techniques using BCC materials by the PEs need to be

evaluated and improved.

This analysis is limited only to the outcome variables, condom use in the last sex act and

consistently. The prevalence of HIV (< 1%) and active syphilis (< 2%) was very low among

MSM in Dhaka city both at the baseline and midline [21 , 22 ] and therefore, were not consid-

ered as outcome measures. Time location sampling encompassed to those MSM who were

visible at the public cruising spots, therefore, results cannot be generalised to those who

were hidden [58 ]; behavioural data may also be affected by social desirability and recall bias

[59 ]. Furthermore, uunfortunately, we do not have data on what percentage of MSM partici-

pated in both baseline and in midline. Hence, pre-post design statistical analysis could not

be performed.

Conclusions

In summary, the results of the current analysis provide an evidence of positive changes in HIV

risk behaviours among MSM in Dhaka city. However, the time gap between baseline and mid-

line is only for three years therefore, a proper longitudinal study using similar methodology

could better substantiate evidence to measure such sustainability. In sum to endure positive

changes in HIV risk behaviours and end HIV in Bangladesh by 2030 [23 ], HIV prevention for

MSM needs to be continued, strengthened and scaled up.

Supporting information

S1 File.

(ZIP)

Acknowledgments

A large number of individuals participated at the baseline and midline survey by providing

blood and giving their time in responding to questions and without their active participa-

tion these surveys would not have been possible and they are therefore acknowledged grate-

fully. We are grateful to AIDS/STD Programme (ASP) for overall support, coordination and

monitoring of field activities. We also thank other NGOs for their support in conducting

the surveys.

Author Contributions

Conceptualization: Md. Masud Reza, AKM Masud Rana, Sharful Islam Khan.

Data curation: Md. Masud Reza, Md. Sha Al Imran, Md. Aminul Islam.

Formal analysis: Md. Masud Reza, Md. Sha Al Imran, Md. Aminul Islam.

Funding acquisition: Sharful Islam Khan.

Investigation: Md. Masud Reza, AKM Masud Rana, Tasnim Azim, Ezazul Islam Chowdhury,

Gorkey Gourab, Md. Sha Al Imran, Md. Aminul Islam, Sharful Islam Khan.

Changes in condom use among MSM in Dhaka city

PLOS ONE | https://doi.org/10.1371/journal.pone.0236557 July 24, 2020 11 / 15

Methodology: Md. Masud Reza, AKM Masud Rana, Tasnim Azim, Md. Sha Al Imran, Md.

Aminul Islam, Sharful Islam Khan.

Project administration: Md. Masud Reza, Tasnim Azim, Sharful Islam Khan.

Resources: Tasnim Azim, Sharful Islam Khan.

Software: Md. Masud Reza.

Supervision: Md. Masud Reza, AKM Masud Rana, Tasnim Azim, Ezazul Islam Chowdhury,

Gorkey Gourab, Sharful Islam Khan.

Validation: Md. Masud Reza, AKM Masud Rana, Tasnim Azim, Sharful Islam Khan.

Visualization: Md. Masud Reza, AKM Masud Rana, Sharful Islam Khan.

Writing – original draft: Md. Masud Reza.

Writing – review & editing: Md. Masud Reza, AKM Masud Rana, Tasnim Azim, Ezazul Islam

Chowdhury, Gorkey Gourab, Md. Sha Al Imran, Md. Aminul Islam, Sharful Islam Khan.

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... In most HIV research in Bangladesh prior to 2007, hijra only mentioned a high-risk HIV transmission group. Both NGOs', government's HIV prevention projects, and scholars, therefore, significantly only emphasized their concern to develop an awareness of using condom and lubricants during anal sex (Azim et al., 2008(Azim et al., , 2009Chan & Khan, 2007;Islam & Conigrave, 2008;Reza et al., 2020;. Issues like-hijra exclusion, vulnerability, socio-cultural gender, sexuality, identity crisis remains undisclosed in those HIV intervention research. ...

Rezwana Karim Snigdha

Hijra, a category often considered to be beyond the woman/man binary, has been officially recognized as a separate gender in Bangladesh since 2013. However, there has been little research exploring the lived experiences of hijra. This Ph.D. explores what it means to identify as hijra. To do this, I adopted a postmodern framework and conducted 12 months of ethnographic fieldwork. During this year, I got to know twenty hijra who lived in Dhaka. I also conducted two focus groups among NGO workers and undertook four in-depth interviews with government officials. Such an exploration allowed insight into the complexity of hijra categorization, sexuality, gender, and government perceptions of hijra. To assist in the analysis of this primary data, I drew on Foucault's concept of sexuality as discourse and Butler's idea of gender performativity. Based on field data, this Ph.D. has four key findings. First, I found that hijra in Bangladesh are not a homogenous category. Instead, understanding the complexity of hijra identity needs an intersectionality lens. Second, I found that hijra sexual acts and practices can be fluid and, in some ways, are less regulative than heterosexuality. Here I trouble the popular understanding of hijra as 'sexually disabled' or 'asexual' or as having sexual desire only for men. I found that hijra can enjoy a variety of sexual partners and that this does not preclude them from identifying as hijra. Third, I found that for many hijra in Bangladesh, gender is performative, as Butler suggests. Further, gender can involve fun and play and a variety of code-switching from performing as a man to hijra, then hijra to woman, and as hijra to a man depending on what is most strategic for accessing certain rights, and as the situation, context, and circumstance demand. Fourth, I found that hijra is dehumanized in contemporary Bangladesh society and that this dehumanization is, in part, an outcome of the lack of understating of hijra, which has antecedents in Bangladesh's colonial past.

... The variable has been used in other representative surveys and yielded similar results to other methods of assessing condom use (Abara, Oraka, Jeffries, Chavez, Nasrullah, & DiNenno, 2017). Condom use at last sexual encounter was significantly associated with income in the last month, having STI symptoms in the last year, HIV risk perception, having comprehensive knowledge of HIV, and the year survey was conducted (Reza et al, 2020). Condom use was also predicted by the MSM's health beliefs regarding HIV (Calaguas, 2020), and social and behavioral norms (Wang, Tucker, Liu, Zheng, Tang, & Ling, 2018). ...

James Montegrico

Purpose: This scoping review aims to describe the factors affecting the National Council for Licensure Examination for Registered Nurses (NCLEX-RN) performance of internationally educated nurses (IEN). Background: The United States relied heavily on IEN to help address the nursing shortage. However, IEN face challenges in passing the NCLEX-RN with almost half failing the NCLEX-RN the first time. There is lack of studies on IEN, in general, and factors affecting their NCLEX-RN performance, in particular. Method: A literature review of IEN NCLEX-RN studies from 1994 to 2019 was conducted. The Preferred Reporting for Items for Systematic Reviews and Meta-Analysis (PRISMA) was used to describe the search process. Findings: Based on the review of the available literature, the factors affecting IEN NCLEX-RN performance include proficiency with the English language, differences in nursing education, and unfamiliarity with the NCLEX-RN are the most common identified factors. Language, country of nursing education, healthcare experience, support system, the Commission on Graduates of Foreign Nursing Schools certification exam, (CGFNS CE), and time lag between graduation or initial licensure and NCLEX-RN are statistically significant predictors of NCLEX-RN performance. Conclusion: Individual, academic, and environmental factors influence IEN NCLEX-RN performance. Identifying these factors can help in designing individual and multi-level interventions to assist IEN pass the NCLEX-RN. Keywords: internationally educated nurses, NCLEX-RN, nursing education

Noriel Calaguas

The steady rise in newly-diagnosed cases of Human Immunodeficiency Virus (HIV) has been historically associated with Men-who-have-sex-with-men (MSM) in the Philippines. This has been attributed to low condom use despite longstanding guidance on their efficacy in preventing the spread of HIV among other sexually transmitted diseases. The objective of the study was to describe the sociodemographic and sexual characteristics of an online sample of Filipino MSM, and identify which factors are significantly associated with condom use at last sexual intercourse. Purposive sampling through referrals within the MSM community resulted in a sample of 491 Filipino MSMs. Bivariate analysis revealed that MSM's civil status, gender expression, relationship status, their predominant sexual position, and the sexes of their sexual partners are significantly associated with the use or non-use of condoms during their last sexual intercourse. The study may prove to be beneficial to public health leaders in the implementation of a comprehensive group of interventions to increase condom use.

Introduction: The epidemic in Dhaka, capital city of Bangladesh, was believed to be driven by injecting drug use as human immunodeficiency virus (HIV) has been concentrated among people who injected drugs since 2006. However, the needle/syringe program coupled with other prevention interventions among the key populations (KPs) and may have limited HIV spread from people who inject drugs (PWID) altering the modes of transmission (MOT). Material and methods: The AIDS Epidemic Model was used to assess probable HIV transmission modes, which used data and information on indicators and co-factors from national behavioral surveys, serological surveillances, and other relevant studies including program data from 2000-2013. Results: The distribution of HIV infections by MOT reveals that in 2000, needle sharing was the major source of HIV infection (48%) in Dhaka, followed by (female) sex work (30%), male-to-male sex (12%), heterosexual relationships (husband to wife, 9%), and other sources (1%). In 2014, needle sharing as a mode of transmission dropped to 28%. In the same year, male-to-male sex accounted for 42% of new HIV infections. It is projected that male-to-male sex will be responsible for 54 percent of new infections by 2020 in Dhaka. Conclusions: The needle/syringe exchange program and other interventions among KPs have shifted the MOT in Dhaka city. Human immunodeficiency virus intervention strategies and coverage in Dhaka should be revised and focused to address the evolving epidemic.

Alaa Althubaiti

As with other fields, medical sciences are subject to different sources of bias. While understanding sources of bias is a key element for drawing valid conclusions, bias in health research continues to be a very sensitive issue that can affect the focus and outcome of investigations. Information bias, otherwise known as misclassification, is one of the most common sources of bias that affects the validity of health research. It originates from the approach that is utilized to obtain or confirm study measurements. This paper seeks to raise awareness of information bias in observational and experimental research study designs as well as to enrich discussions concerning bias problems. Specifying the types of bias can be essential to limit its effects and, the use of adjustment methods might serve to improve clinical evaluation and health care practice.

Matthew Mimiaga
Elizabeth F Closson
Katie B. Biello
Donn J Colby

An emerging HIV epidemic can be seen among men who have sex with men (MSM) in Vietnam. There are currently no evidence-based behavioral sexual risk reduction interventions for MSM in this setting. Between October 2012 and June 2013, 100 high-risk MSM from Ho Chi Minh City were enrolled in an open pilot trial to assess feasibility and acceptability of a group-based, manualized sexual risk reduction intervention, and to preliminarily examine changes in primary and secondary outcomes. Participants completed a behavioral assessment battery and HIV testing at baseline, 3, and 6 months post-baseline. Over 80.0 % of the sample was <25 years old and 77.0 % identified as Bong kin ("hidden," masculine-appearing). Feasibility and acceptability of the program was evidenced by 87.0 % retention for the intervention sessions, 78.0 % completion of the 6 month assessment, and positive responses on evaluation forms and qualitative exit interviews. There was a decline in the number of condomless anal sex acts from baseline (6.32) to 3 month (2.06) and 6 month (2.49) follow-up (p < .0001). These data support the need for further testing of this group-based, behavioral HIV prevention intervention to reduce sexual risk behavior among MSM in Vietnam in a randomized controlled efficacy trial.

The HIV incidence among Thai men who have sex with men (MSM) enrolled in the Bangkok MSM Cohort Study (BMCS) has remained high since its inception in 2006. The purpose of this BMCS analysis was to determine: (1) changes in three HIV-risk behaviors (unprotected anal intercourse (UAI), recreational drug use, and multiple sexual partners i.e., more than four male/transgender partner) over time; and (2) factors associated with each one separately. Thai MSM aged 18 years or older and living in Bangkok were eligible to participate in the BMCS. At each follow-up visit, participants were asked to report their sexual and drug behaviors in the previous 4 months. We conducted a longitudinal analysis using generalized estimating equations logistic regression that included 1,569 MSM who were enrolled from 2006 to 2010 and contributed at least one follow-up visit. For each four-month visit increase, we found a 2, 1, and 1 % decrease in odds for reported UAI, recreational drug use, and multiple sexual partners, respectively. We found significant predictors associated with three HIV-risk behaviors such as binge drinking, participation in group sex, and use of erectile dysfunction drugs. The statistically significant decrease in odds of HIV-risk behaviors among the participants is encouraging; however, continued vigilance is required to address the factors associated with HIV-risk behaviors through currently available interventions reaching MSM.

Background Consistent and correct condom use and suppressive antiretroviral therapy for the infected partner are two of the primary strategies recommended for prevention of heterosexual HIV transmission in serodiscordant couples today. The applied effectiveness of treatment as a prevention strategy in China is still under investigation, and much less is known about its effects in the presence of other prevention strategies such as consistent condom use. Methods We conducted a systematic search in PubMed and three Chinese language databases to identify relevant articles for the estimation of relative effectiveness of a) consistent condom use and b) ART use by index partners for preventing HIV transmission in serodiscordant couples. We also estimated the prevention effectiveness of ART stratified by condom use level and the prevention effectiveness of consistent condom use stratified by ART use level. Results Pooled results from the eleven eligible studies found a pooled HIV seroconversion incidence of 0.92 cases per 100 person years (PY) among HIV-negative spouses whose index partners were taking ART versus 2.45 cases per 100 PY in untreated couples. The IRR comparing seroconversion in couples where the index-partner was on ART versus not on ART was 0.47 (95%CI: 0.43, 0.52), while stratified by condom use, the IRR was 0.33(0.17,0.64). The IRR comparing incidence in couples reporting "consistent condom use" versus those reporting otherwise was 0.02(95%CI:0.01,0.04), after stratified by ART use level, the IRR was 0.01(95%CI: 0.00, 0.06). Conclusions ART use by index partners could reduce HIV transmission in serodiscordant couples, and the effectiveness of this prevention strategy could be further increased with consistent condom use.

To test a novel social network HIV risk-reduction intervention for MSM in Russia and Hungary, where same-sex behavior is stigmatized and men may best be reached through their social network connections. A 2-arm trial with 18 sociocentric networks of MSM randomized to the social network intervention or standard HIV/STD testing/counseling. St. Petersburg, Russia and Budapest, Hungary. Eighteen 'seeds' from community venues invited the participation of their MSM friends who, in turn, invited their own MSM friends into the study, a process that continued outward until eighteen three-ring sociocentric networks (mean size = 35 members, n = 626) were recruited. Empirically identified network leaders were trained and guided to convey HIV prevention advice to other network members. Changes in sexual behavior from baseline to 3-month and 12-month follow-up, with composite HIV/STD incidence, measured at 12 months to corroborate behavior changes. There were significant reductions between baseline, first follow-up, and second follow-up in the intervention versus comparison arm for proportion of men engaging in any unprotected anal intercourse (UAI) (P = 0.04); UAI with a nonmain partner (P = 0.04); and UAI with multiple partners (P = 0.002). The mean percentage of unprotected anal intercourse acts significantly declined (P = 0.001), as well as the mean number of UAI acts among men who initially had multiple partners (P = 0.05). Biological HIV/STD incidence was 15% in comparison with condition networks and 9% in intervention condition networks. Even where same-sex behavior is stigmatized, it is possible to reach MSM and deliver HIV prevention through their social networks.

William D Dupont

For biomedical researchers, the new edition of this standard text guides readers in the selection and use of advanced statistical methods and the presentation of results to clinical colleagues. It assumes no knowledge of mathematics beyond high school level and is accessible to anyone with an introductory background in statistics. The Stata statistical software package is used to perform the analyses, in this edition employing the intuitive version 10. Topics covered include linear, logistic and Poisson regression, survival analysis, fixed-effects analysis of variance, and repeated-measure analysis of variance. Restricted cubic splines are used to model non-linear relationships. Each method is introduced in its simplest form and then extended to cover more complex situations. An appendix will help the reader select the most appropriate statistical methods for their data. The text makes extensive use of real data sets available online through Vanderbilt University.

Source: https://www.researchgate.net/publication/343197004_Changes_in_condom_use_among_males_who_have_sex_with_males_MSM_Measuring_the_effect_of_HIV_prevention_programme_in_Dhaka_city

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