International http://std.sagepub.com/ Journal of STD & AIDS
HIV knowledge and risks among Vietnamese men who have sex with men travelling abroad Huyen Nguyen, Hoang Quan Nguyen and Donn Joseph Colby Int J STD AIDS 2014 25: 643 originally published online 18 December 2013 DOI: 10.1177/0956462413516098 The online version of this article can be found at: http://std.sagepub.com/content/25/9/643
Published by: http://www.sagepublications.com
Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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Original research article
HIV knowledge and risks among Vietnamese men who have sex with men travelling abroad
International Journal of STD & AIDS 2014, Vol. 25(9) 643–649 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413516098 std.sagepub.com
Huyen Nguyen, Hoang Quan Nguyen and Donn Joseph Colby
Abstract Rapid economic and social development in Vietnam has resulted in increased opportunities for travel and new potential routes of HIV transmission. We conducted a cross-sectional study examining demographics, knowledge, and sexual risk behaviour amongst 100 Vietnamese men who have sex with men who traveled abroad in the previous 12 months. Men who have sex with men surveyed were mostly university-educated, single, and under 30. Most travel (73%) was within Southeast Asia and was undertaken for tourism (51%) or for work (29%). Casual sex with a foreign partner occurred on 39% of trips. Only four were reported to have involved in unsafe sex with a casual partner. Four reported illicit drug use. Alcohol was widely consumed. Multivariate analysis showed that two variables, travelling alone (OR ¼ 5.26, p < 0.001) and a university education (OR ¼ 4.05, p ¼ 0.004), were significantly associated with casual sex abroad. More HIV prevention education on the risks of sex while travelling abroad is needed for men who have sex with men in Vietnam.
Keywords HIV, AIDS, sexually transmitted infection, homosexual, men who have sex with men, MSM, sexual behaviour, travel, Asia Date received: 16 August 2013; accepted: 17 November 2013
Introduction In the past decade, Vietnam has undergone major socioeconomic changes that have opened up Vietnamese society, increased living standards, and further integrated the country into a globalized world.1 These changes have affected the lifestyles of men who have sex with men (MSM), particularly in the major cities of Hanoi and Ho Chi Minh City (HCMC). This can be seen in increasing numbers of gay bars, greater public awareness of the existence of sexual minorities, and a growing number of Vietnamese-language websites that target gay and bisexual men.2 As more people move into the middle class there has been an increase in regional and international travel among the Vietnamese population.3 The explosion of cheap budget airlines in the region as well as relaxed visa regulations for travel within the Association of South East Asian Nations (ASEAN) have made international trips much more accessible and popular. This is a concern as travel has been implicated as one reason why HIV infection rates among MSM in the developed world are not declining.4 These reduced barriers to travel combined with Internet interconnectivity pose new potential opportunities for HIV transmission.
Many Vietnamese, MSM included, travel to nearby Cambodia and Thailand, countries known for sex tourism.5 Thailand has an adult HIV infection rate of around 1.3%, triple Vietnam’s 0.4% prevalence rate. Cambodia also experienced a large spike in HIV infections in the 1990s and has an adult HIV prevalence rate of 0.5%.6 Throughout the world MSM have higher HIV infection rates than other men and the countries of South East Asia are no exception.7 Recent estimates of the HIV prevalence rate of MSM in major Vietnamese cities place it at 14.3% and 19.8% in HCMC and Hanoi, respectively.8 MSM in Bangkok have a reported seroprevalence of 30%.9 MSM in Vietnam exhibit high rates of unsafe sexual behaviour. In fact, integrated biological and behavioural surveys (IBBS) between 2006 and 2009 have Center for Applied Research on Men and Health, Ho Chi Minh City, Vietnam Corresponding author: Huyen Nguyen, Center for Applied Research on Men and Health (CARMAH), Ho Chi Minh City, Vietnam. Email: [email protected]
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
644
International Journal of STD & AIDS 25(9)
shown a drop from 38% to 30% in consistent condomuse during anal sex among HCMC MSM.8,10 A survey of MSM in Malaysia showed similarly inadequate safe sex practices and knowledge.11 This indicates potential new risks as poorly informed and high-risk MSM populations increasingly intermingle amongst the Southeast Asian countries. Unsafe sex among MSM is the cause of a growing percentage of new HIV infections in East and Southeast Asia.12 Rising use of alcohol and illicit drugs in the region compound the risk for HIV transmission.13,14 By 2020, it is projected that more than 50% of all new infections in Asia will be due to homosexual sex between men.12 Increased travel combined with lagging knowledge amongst MSM poses a major source for new HIV infections in Vietnam, particularly if travelling to regional countries with similarly poor safe sex practices and higher HIV infection rates. There have been no published data about the sexual behaviour, knowledge, and habits of travelling MSM in Southeast Asia. This survey, the first of its kind for the region, evaluates the knowledge about HIV transmission and sexual risk behaviour while travelling amongst Vietnamese MSM who had been abroad within the prior 12 months.
Methods Study participant selection This is a cross-sectional study of 100 Vietnamese MSM. Their inclusion criteria were: self-identified as MSM (having had oral/anal sex or masturbated with another man within the prior 12 months), over 15 years of age, and had travelled abroad at least once in the prior 12 months. These MSM were selected by the snowball method: an initial 10 Vietnamese MSM who met these criteria were surveyed, who in turn contacted MSM they knew to refer to our study. The snowball method was chosen due to the difficulty of finding MSM who met the criteria. Existent NGO-linked MSM social networks were used to reach out to potential participants. The initial 10 MSM were chosen from different age groups and geographic areas of HCMC in order to recruit a diversity sample of MSM. Subsequent waves were surveyed until the sample size was reached. The response rate was high, as 90% of MSM contacted agreed to participate. All subjects received written and verbal information about the study and signed a written informed consent form prior to participation.
Study design Subjects were interviewed using a standardized questionnaire that asked basic demographic information,
recent travel activity, sexual behaviour while travelling, condom use, and knowledge about the HIV virus and how it is transmitted. Each participant could provide information on up to three trips taken within the previous 12 months. Data from multiple trips was collected because this was an exploratory study and the researchers planned to analyze both inter-individual and intertrip variability in sexual behaviour. A limit of three trips was imposed as to prevent data skewing by a single frequently-travelling individual. Participants may have opted not to report on the questionnaires on all of the trips they took, thus the total number of trips reported was greater than the number of trips with data presented in the findings. Average participation lasted 45 minutes and subjects received 100,000 Vietnam Dong (VND, about US$5.00) upon completion of the survey.
Data analysis We analyzed data on behaviour for each reported trip as well as for each individual. This allowed us to more thoroughly look at each individual’s travel sexual behaviour as a whole. Other studies ask about their most recent or current trip, which fails to take into consideration variation in behaviour between trips.15,16 The responses underwent descriptive data analysis to yield percentages and frequencies. Differences between variables were measured using Chi square tests for categorical variables and t-tests for continuous variables. Logistic regression using a backward stepwise method was performed to determine independent predictors of sex with foreign casual sex partners while travelling, defined as a sex partner who had not traveled with the subject from Vietnam. Statistic analysis and testing was done using Stata SE 12.
Funding and ethical concerns Funding for the study was provided through a grant from the Purple Sky Network and its MSM Leadership Program. The study was conducted in collaboration with a newly established and independent Vietnamese community-based organization, the Center For Applied Research on Men and Health (CARMAH). The authors certify that the study was developed and conducted following the Ethical Principles for Medical Research Involving Human Subjects as written in the World Medical Association Declaration of Helsinki.
Results Demographic information is shown in Table 1. The median age was 27 and 70% were aged 20 to 30 years. Almost all had at least a high-school education and twothirds had some university; 21% were current students.
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Table 1. Demographic characteristics of MSM in HCMC who travelled abroad within the prior 12 months.
Age
Education
Occupation
Marital status
Monthly income Self identity
Time travelled abroad in the prior year
Characteristics
Frequency (n ¼ 100)
30 Less than secondary school Secondary schools University Office worker Student Entrepreneur Other (tour guide, entertainment) Civil servant Unskilled worker Single Married Divorced Living with male partner Median (range) in VNDa Gay-male gender (Bong Kin) Gay-transgender (Bong Lo) Gay-alternating Roles (50/50) Straight 1 time 2 times More than 2 times
7 70 23 1 35 64 50 21 18 7 3 1 89 4 3 4 6,000,000 (1,000,000–60,000,000) 89 6 3 2 66 21 13
MSM: men who have sex with men; HCMC: Ho Chi Minh City. a In Vietnamese Dong (US$1 ¼ 20,800 VND).
The median income was 6,000,000 Vietnam Dong (VND) or about US$288 per month, marginally higher than the reported mean income for HCMC of 265 per month.17 Only a third reported more than one trip in the prior year. Characteristics of individual trips are shown in Table 2. Three-quarters of trips were taken in Southeast Asia, with Thailand as the most common destination. Half of all trips were taken for tourism or leisure and 29% were related to work. Most trips (40%) were taken with a colleague or friend, but 37% of trips were taken alone.
Knowledge Knowledge on HIV transmission was fair, with 62%–97% correctly answering five questions on HIV transmission, including knowing that HIV can be prevented by being sexually monogamous or by using protection during anal sex, and that sharing meals and mosquito bites do not transmit HIV. Of most concern, only 62% knew that HIV-infected people can appear
healthy on the outside. Only 48% answered all five questions correctly. Also, 62% knew that MSM are at a higher risk of HIV infection compared to other Vietnamese men. Although 98% knew where to get an HIV test, only 45% had ever been tested.
Risk behaviour In all, 41% reported having had sex with a new or casual partner while abroad. There were 54 trips out of the reported 139 (39%) during which sex with a new or casual partner occurred. Within the 41 individuals, 48.8% reported meeting their sexual partners on the Internet, 43.4% from a prior meeting, 34.1% in saunas, 26.8% via mutual friends, 24.4% in bars, and 2.4% from encounters in the street or park. Only 1 participant (1%) reported paying for sex with a male sex worker on one trip. During 83% of the trips alcohol was reported to have been consumed. Only 3% (4 trips) had reported illicit drug use. Of these, two reported ecstasy use while the other two reported marijuana use.
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
646
International Journal of STD & AIDS 25(9) Table 2. Characteristics of international trips taken by participants (n ¼ 139 trips). Characteristics Destination
Time spent abroad
Reason travelled abroad
Travelling companion(s)
Southeast Asia Thailand Singapore Cambodia Other Other Asia Hong Kong Taiwan Mainland China Other N. America/Europe/Aus. Less than 3 days 3 to 5 days More than 5 days Tourism/Leisure Work Visiting family/friends Study Other Friend/Colleagues None (went alone) Male Partner Family
Frequency
Percent (%)
102 52 20 18 12 26 12 6 5 3 11 10 72 54 70 40 9 6 13 56 52 18 15
73.4 37.4 14.4 12.9 8.6 18.7 8.6 4.3 3.6 2.2 7.9 7.2 51.8 38.8 50.5 28.8 6.5 4.3 9.4 40.3 37.4 12.9 10.8
The vast majority (n ¼ 37 or 90.2% of those reporting having sex with a new casual partner while abroad) reported as only having protected anal sex or no anal sex at all during these encounters. Four people, or 9.8% of those reporting having had sex with a new or casual partner while abroad, reported sometimes not using a condom with foreign sex partners. All four men reported unsafe sex with foreigners that they had previously known before that trip abroad. Of these four, three reported not using a condom due to trust in their partner while the fourth reported not consistently using condoms due to loss of sensation. Three of the four further cited bars, saunas, and the Internet as places to meet sexual partners while abroad.
trip. Higher income and travelling more than once in the prior year were also significantly associated with casual sex, while students were less likely to have casual sex than non-students. Backward stepwise logistic regression was used to analyze independent predictors for casual sex while abroad. All variables demonstrating a p value under 0.20 in addition to age were included in the model. Upon multivariate analysis, only two variables were shown to be statistically significant: travelling alone (odds ratio: 5.26, 95% CI: 2.44–11.50, p value < 0.001) and having a university education (odds ratio: 4.05, 95% CI: 1.55–10.62, p value: 0.004).
Risk factors for casual sex while abroad
While 41 individuals (41%) reported having a casual or new sex partner while being abroad, only four individuals within these 41 reported having unsafe sex with these partners. Looking at the 139 trips abroad the participants reported, the vast majority of trips (73%) took place within Southeast Asia. This is of concern as the region is a hub for sex tourism with relatively high rates of HIV infection. Bangkok, with the largest and most diverse gay entertainment scene in all of Asia, is only a
We analyzed the data to determine which factors were associated with having casual sex with a foreign partner while abroad. Data for 139 reported trips is shown in Table 3. The variables are ranked in ascending order by p value. Travelling alone, having a university education, and travelling outside of Asia were most strongly associated with having a casual sex partner during that
Discussion
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
Nguyen et al.
647
Table 3. Univariate analysis of association with casual sex partner(s) during trip (n ¼ 139 tripsa).
Variable Travelling aloneb Education levelb b
Region of Travel
Monthly incomeb Student
b
Times traveled abroad in prior yearb Correctly answered first five questions about HIV/AIDS Have been tested for HIV before Alcohol use during trip Age Trip length Tourism as purpose Illicit drug use during trip
Yes No No University University Degree SE Asia Rest of Asia Rest of World 8,000,000 VNDc >8,000,000 VND No Yes ¼1 >1 No Yes No Yes No Yes 30 >30 5 days >5 days No Yes No Yes
Had new/casual sex partner during trip n (%)
No new/casual sex partners during trip n (%)
33 21 7 47 32 14 8 24 30 50 4 19 35 31 23 22 32 6 48 36 18 29 25 29 25 52 2
19 66 33 52 70 12 3 56 29 65 20 47 38 36 49 45 40 17 68 64 21 53 32 40 45 83 2
(63) (24) (18) (47) (31) (54) (73) (30) (51) (43) (17) (29) (48) (46) (32) (33) (44) (26) (41) (36) (46) (35) (44) (42) (36) (39) (50)
(37) (76) (82) (53) (69) (46) (27) (70) (49) (57) (83) (71) (52) (54) (68) (67) (56) (74) (59) (64) (54) (65) (56) (58) (64) (61) (50)
Odds ratio
95% Confidence interval
p Value
5.46
2.56–11.5
HIV knowledge and risks among Vietnamese men who have sex with men travelling abroad Huyen Nguyen, Hoang Quan Nguyen and Donn Joseph Colby Int J STD AIDS 2014 25: 643 originally published online 18 December 2013 DOI: 10.1177/0956462413516098 The online version of this article can be found at: http://std.sagepub.com/content/25/9/643
Published by: http://www.sagepublications.com
Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Jul 12, 2014 OnlineFirst Version of Record - Dec 18, 2013 What is This?
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
Original research article
HIV knowledge and risks among Vietnamese men who have sex with men travelling abroad
International Journal of STD & AIDS 2014, Vol. 25(9) 643–649 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462413516098 std.sagepub.com
Huyen Nguyen, Hoang Quan Nguyen and Donn Joseph Colby
Abstract Rapid economic and social development in Vietnam has resulted in increased opportunities for travel and new potential routes of HIV transmission. We conducted a cross-sectional study examining demographics, knowledge, and sexual risk behaviour amongst 100 Vietnamese men who have sex with men who traveled abroad in the previous 12 months. Men who have sex with men surveyed were mostly university-educated, single, and under 30. Most travel (73%) was within Southeast Asia and was undertaken for tourism (51%) or for work (29%). Casual sex with a foreign partner occurred on 39% of trips. Only four were reported to have involved in unsafe sex with a casual partner. Four reported illicit drug use. Alcohol was widely consumed. Multivariate analysis showed that two variables, travelling alone (OR ¼ 5.26, p < 0.001) and a university education (OR ¼ 4.05, p ¼ 0.004), were significantly associated with casual sex abroad. More HIV prevention education on the risks of sex while travelling abroad is needed for men who have sex with men in Vietnam.
Keywords HIV, AIDS, sexually transmitted infection, homosexual, men who have sex with men, MSM, sexual behaviour, travel, Asia Date received: 16 August 2013; accepted: 17 November 2013
Introduction In the past decade, Vietnam has undergone major socioeconomic changes that have opened up Vietnamese society, increased living standards, and further integrated the country into a globalized world.1 These changes have affected the lifestyles of men who have sex with men (MSM), particularly in the major cities of Hanoi and Ho Chi Minh City (HCMC). This can be seen in increasing numbers of gay bars, greater public awareness of the existence of sexual minorities, and a growing number of Vietnamese-language websites that target gay and bisexual men.2 As more people move into the middle class there has been an increase in regional and international travel among the Vietnamese population.3 The explosion of cheap budget airlines in the region as well as relaxed visa regulations for travel within the Association of South East Asian Nations (ASEAN) have made international trips much more accessible and popular. This is a concern as travel has been implicated as one reason why HIV infection rates among MSM in the developed world are not declining.4 These reduced barriers to travel combined with Internet interconnectivity pose new potential opportunities for HIV transmission.
Many Vietnamese, MSM included, travel to nearby Cambodia and Thailand, countries known for sex tourism.5 Thailand has an adult HIV infection rate of around 1.3%, triple Vietnam’s 0.4% prevalence rate. Cambodia also experienced a large spike in HIV infections in the 1990s and has an adult HIV prevalence rate of 0.5%.6 Throughout the world MSM have higher HIV infection rates than other men and the countries of South East Asia are no exception.7 Recent estimates of the HIV prevalence rate of MSM in major Vietnamese cities place it at 14.3% and 19.8% in HCMC and Hanoi, respectively.8 MSM in Bangkok have a reported seroprevalence of 30%.9 MSM in Vietnam exhibit high rates of unsafe sexual behaviour. In fact, integrated biological and behavioural surveys (IBBS) between 2006 and 2009 have Center for Applied Research on Men and Health, Ho Chi Minh City, Vietnam Corresponding author: Huyen Nguyen, Center for Applied Research on Men and Health (CARMAH), Ho Chi Minh City, Vietnam. Email: [email protected]
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
644
International Journal of STD & AIDS 25(9)
shown a drop from 38% to 30% in consistent condomuse during anal sex among HCMC MSM.8,10 A survey of MSM in Malaysia showed similarly inadequate safe sex practices and knowledge.11 This indicates potential new risks as poorly informed and high-risk MSM populations increasingly intermingle amongst the Southeast Asian countries. Unsafe sex among MSM is the cause of a growing percentage of new HIV infections in East and Southeast Asia.12 Rising use of alcohol and illicit drugs in the region compound the risk for HIV transmission.13,14 By 2020, it is projected that more than 50% of all new infections in Asia will be due to homosexual sex between men.12 Increased travel combined with lagging knowledge amongst MSM poses a major source for new HIV infections in Vietnam, particularly if travelling to regional countries with similarly poor safe sex practices and higher HIV infection rates. There have been no published data about the sexual behaviour, knowledge, and habits of travelling MSM in Southeast Asia. This survey, the first of its kind for the region, evaluates the knowledge about HIV transmission and sexual risk behaviour while travelling amongst Vietnamese MSM who had been abroad within the prior 12 months.
Methods Study participant selection This is a cross-sectional study of 100 Vietnamese MSM. Their inclusion criteria were: self-identified as MSM (having had oral/anal sex or masturbated with another man within the prior 12 months), over 15 years of age, and had travelled abroad at least once in the prior 12 months. These MSM were selected by the snowball method: an initial 10 Vietnamese MSM who met these criteria were surveyed, who in turn contacted MSM they knew to refer to our study. The snowball method was chosen due to the difficulty of finding MSM who met the criteria. Existent NGO-linked MSM social networks were used to reach out to potential participants. The initial 10 MSM were chosen from different age groups and geographic areas of HCMC in order to recruit a diversity sample of MSM. Subsequent waves were surveyed until the sample size was reached. The response rate was high, as 90% of MSM contacted agreed to participate. All subjects received written and verbal information about the study and signed a written informed consent form prior to participation.
Study design Subjects were interviewed using a standardized questionnaire that asked basic demographic information,
recent travel activity, sexual behaviour while travelling, condom use, and knowledge about the HIV virus and how it is transmitted. Each participant could provide information on up to three trips taken within the previous 12 months. Data from multiple trips was collected because this was an exploratory study and the researchers planned to analyze both inter-individual and intertrip variability in sexual behaviour. A limit of three trips was imposed as to prevent data skewing by a single frequently-travelling individual. Participants may have opted not to report on the questionnaires on all of the trips they took, thus the total number of trips reported was greater than the number of trips with data presented in the findings. Average participation lasted 45 minutes and subjects received 100,000 Vietnam Dong (VND, about US$5.00) upon completion of the survey.
Data analysis We analyzed data on behaviour for each reported trip as well as for each individual. This allowed us to more thoroughly look at each individual’s travel sexual behaviour as a whole. Other studies ask about their most recent or current trip, which fails to take into consideration variation in behaviour between trips.15,16 The responses underwent descriptive data analysis to yield percentages and frequencies. Differences between variables were measured using Chi square tests for categorical variables and t-tests for continuous variables. Logistic regression using a backward stepwise method was performed to determine independent predictors of sex with foreign casual sex partners while travelling, defined as a sex partner who had not traveled with the subject from Vietnam. Statistic analysis and testing was done using Stata SE 12.
Funding and ethical concerns Funding for the study was provided through a grant from the Purple Sky Network and its MSM Leadership Program. The study was conducted in collaboration with a newly established and independent Vietnamese community-based organization, the Center For Applied Research on Men and Health (CARMAH). The authors certify that the study was developed and conducted following the Ethical Principles for Medical Research Involving Human Subjects as written in the World Medical Association Declaration of Helsinki.
Results Demographic information is shown in Table 1. The median age was 27 and 70% were aged 20 to 30 years. Almost all had at least a high-school education and twothirds had some university; 21% were current students.
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
Nguyen et al.
645
Table 1. Demographic characteristics of MSM in HCMC who travelled abroad within the prior 12 months.
Age
Education
Occupation
Marital status
Monthly income Self identity
Time travelled abroad in the prior year
Characteristics
Frequency (n ¼ 100)
30 Less than secondary school Secondary schools University Office worker Student Entrepreneur Other (tour guide, entertainment) Civil servant Unskilled worker Single Married Divorced Living with male partner Median (range) in VNDa Gay-male gender (Bong Kin) Gay-transgender (Bong Lo) Gay-alternating Roles (50/50) Straight 1 time 2 times More than 2 times
7 70 23 1 35 64 50 21 18 7 3 1 89 4 3 4 6,000,000 (1,000,000–60,000,000) 89 6 3 2 66 21 13
MSM: men who have sex with men; HCMC: Ho Chi Minh City. a In Vietnamese Dong (US$1 ¼ 20,800 VND).
The median income was 6,000,000 Vietnam Dong (VND) or about US$288 per month, marginally higher than the reported mean income for HCMC of 265 per month.17 Only a third reported more than one trip in the prior year. Characteristics of individual trips are shown in Table 2. Three-quarters of trips were taken in Southeast Asia, with Thailand as the most common destination. Half of all trips were taken for tourism or leisure and 29% were related to work. Most trips (40%) were taken with a colleague or friend, but 37% of trips were taken alone.
Knowledge Knowledge on HIV transmission was fair, with 62%–97% correctly answering five questions on HIV transmission, including knowing that HIV can be prevented by being sexually monogamous or by using protection during anal sex, and that sharing meals and mosquito bites do not transmit HIV. Of most concern, only 62% knew that HIV-infected people can appear
healthy on the outside. Only 48% answered all five questions correctly. Also, 62% knew that MSM are at a higher risk of HIV infection compared to other Vietnamese men. Although 98% knew where to get an HIV test, only 45% had ever been tested.
Risk behaviour In all, 41% reported having had sex with a new or casual partner while abroad. There were 54 trips out of the reported 139 (39%) during which sex with a new or casual partner occurred. Within the 41 individuals, 48.8% reported meeting their sexual partners on the Internet, 43.4% from a prior meeting, 34.1% in saunas, 26.8% via mutual friends, 24.4% in bars, and 2.4% from encounters in the street or park. Only 1 participant (1%) reported paying for sex with a male sex worker on one trip. During 83% of the trips alcohol was reported to have been consumed. Only 3% (4 trips) had reported illicit drug use. Of these, two reported ecstasy use while the other two reported marijuana use.
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
646
International Journal of STD & AIDS 25(9) Table 2. Characteristics of international trips taken by participants (n ¼ 139 trips). Characteristics Destination
Time spent abroad
Reason travelled abroad
Travelling companion(s)
Southeast Asia Thailand Singapore Cambodia Other Other Asia Hong Kong Taiwan Mainland China Other N. America/Europe/Aus. Less than 3 days 3 to 5 days More than 5 days Tourism/Leisure Work Visiting family/friends Study Other Friend/Colleagues None (went alone) Male Partner Family
Frequency
Percent (%)
102 52 20 18 12 26 12 6 5 3 11 10 72 54 70 40 9 6 13 56 52 18 15
73.4 37.4 14.4 12.9 8.6 18.7 8.6 4.3 3.6 2.2 7.9 7.2 51.8 38.8 50.5 28.8 6.5 4.3 9.4 40.3 37.4 12.9 10.8
The vast majority (n ¼ 37 or 90.2% of those reporting having sex with a new casual partner while abroad) reported as only having protected anal sex or no anal sex at all during these encounters. Four people, or 9.8% of those reporting having had sex with a new or casual partner while abroad, reported sometimes not using a condom with foreign sex partners. All four men reported unsafe sex with foreigners that they had previously known before that trip abroad. Of these four, three reported not using a condom due to trust in their partner while the fourth reported not consistently using condoms due to loss of sensation. Three of the four further cited bars, saunas, and the Internet as places to meet sexual partners while abroad.
trip. Higher income and travelling more than once in the prior year were also significantly associated with casual sex, while students were less likely to have casual sex than non-students. Backward stepwise logistic regression was used to analyze independent predictors for casual sex while abroad. All variables demonstrating a p value under 0.20 in addition to age were included in the model. Upon multivariate analysis, only two variables were shown to be statistically significant: travelling alone (odds ratio: 5.26, 95% CI: 2.44–11.50, p value < 0.001) and having a university education (odds ratio: 4.05, 95% CI: 1.55–10.62, p value: 0.004).
Risk factors for casual sex while abroad
While 41 individuals (41%) reported having a casual or new sex partner while being abroad, only four individuals within these 41 reported having unsafe sex with these partners. Looking at the 139 trips abroad the participants reported, the vast majority of trips (73%) took place within Southeast Asia. This is of concern as the region is a hub for sex tourism with relatively high rates of HIV infection. Bangkok, with the largest and most diverse gay entertainment scene in all of Asia, is only a
We analyzed the data to determine which factors were associated with having casual sex with a foreign partner while abroad. Data for 139 reported trips is shown in Table 3. The variables are ranked in ascending order by p value. Travelling alone, having a university education, and travelling outside of Asia were most strongly associated with having a casual sex partner during that
Discussion
Downloaded from std.sagepub.com at UNIV OF WISCONSIN MILWAUKEE on October 15, 2014
Nguyen et al.
647
Table 3. Univariate analysis of association with casual sex partner(s) during trip (n ¼ 139 tripsa).
Variable Travelling aloneb Education levelb b
Region of Travel
Monthly incomeb Student
b
Times traveled abroad in prior yearb Correctly answered first five questions about HIV/AIDS Have been tested for HIV before Alcohol use during trip Age Trip length Tourism as purpose Illicit drug use during trip
Yes No No University University Degree SE Asia Rest of Asia Rest of World 8,000,000 VNDc >8,000,000 VND No Yes ¼1 >1 No Yes No Yes No Yes 30 >30 5 days >5 days No Yes No Yes
Had new/casual sex partner during trip n (%)
No new/casual sex partners during trip n (%)
33 21 7 47 32 14 8 24 30 50 4 19 35 31 23 22 32 6 48 36 18 29 25 29 25 52 2
19 66 33 52 70 12 3 56 29 65 20 47 38 36 49 45 40 17 68 64 21 53 32 40 45 83 2
(63) (24) (18) (47) (31) (54) (73) (30) (51) (43) (17) (29) (48) (46) (32) (33) (44) (26) (41) (36) (46) (35) (44) (42) (36) (39) (50)
(37) (76) (82) (53) (69) (46) (27) (70) (49) (57) (83) (71) (52) (54) (68) (67) (56) (74) (59) (64) (54) (65) (56) (58) (64) (61) (50)
Odds ratio
95% Confidence interval
p Value
5.46
2.56–11.5
