Sex, drugs and health of men who have sex with men in Vietnam

Sex, drugs and health of men who have sex with men in

Vietnam

Nga Thi Thu Vu

M.D.

A thesis in the fulfilment of the requirements for the degree of

Doctor of Philosophy

Centre for Social Research in Health

Faculty of Arts and Social Sciences

November, 2017

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PLEASE TYPETHE UNIVERSITY OF NEW SOUTH WALES

Thesis/Dissertation Sheet

Surname or Family name: VU

First name: NGA THI THU Other name/s:

Abbreviation for degree as given in the University calendar: Ph.D

School: Centre for Social Research in Health Faculty: Arts and Social Sciences

Title: SEX, DRUGS AND HEALTH OF MEN WHO HAVE SEX WITH MEN IN VIETNAM

Abstract 350 words maximum: (PLEASE TYPE)

This thesis assessed patterns of amphetamine-type-stimulants (ATS) use and their association with condomless anal intercourse (CAI), HIV infection and mental health issues, particularly depression, among men who have sex with men (MSM) in Vietnam. The thesis employed a socio-ecological framework with a community-based survey conducted in 2014 in Hanoi and Ho Chi Minh City, Vietnam and a systematic review and meta-analysis of the relationship between ATS use and HIV infection in MSM. A substantial proportion of Vietnamese men (30.4%) had used ATS and 20.3% had used ATS recently. Methamphetamine was the most popular substance. The majority of recent methamphetamine and ecstasy users were classified as moderate to high-risk users, according to WHO guidelines. Methamphetamine use was associated with higher sexual sensation seeking, engagement in recent sex work and the perception that methamphetamine use was popular among other MSM. A high prevalence of CAI with male partners in the last three months (75.7%) was reported. CAI was associated with methamphetamine use before or during sex, higher sexual sensation seeking, and belief in the safety of withdrawal as an HIV prevention strategy. Voluntary HIV tests conducted for 210 men in Hanoi found a moderate HIV prevalence of 6.7%. Men who used methamphetamine before or during sex, who had engaged in sex work and perceived more homosexuality-related stigma were more likely to have an HIV positive test. A sizable proportion of men (11.3%) were classified as having major depression which was associated with ever having used ATS and higher enacted (i.e. experienced) homosexuality-related stigma. The systematic review and meta-analysis demonstrated a significant pooled estimate of ATS use and HIV infection in MSM across longitudinal, case-control and cross-sectional studies, but not for ecstasy use in cross-sectional studies. Methodological shortcomings of current studies of drug use and sexual behaviour were identified. This thesis suggests a comprehensive HIV prevention package, that includes treatment for methamphetamine use, is needed for MSM in Vietnam to address drug use and the risks of HIV at the individual, community and societal levels. Recommendations for further research on drug use and sexual behaviours are suggested, including periodic assessment of ATS use.

Declaration relating to disposition of project thesis/dissertation

I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation.

I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only).

…………………………………………………………… Signature

……………………………………..……………… Witness Signature

……….……………………...…….… Date

The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research.

FOR OFFICE USE ONLY Date of completion of requirements for Award:

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ORIGINALITY STATEMENT

‘I hereby declare that this submission is my own work and to the best of my knowledge, it

contains no materials previously published or written by another person, or substantial

proportion of material which have been accepted for the award of any other degree or diploma

at UNSW or any other educational institution, except where due acknowledgement is made in

the thesis. Any contribution made to the research by others, with whom I have worked at

UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual

content of this thesis is the product of my own work, except to the extent that assistance from

others in the project’s designs and conception or in style, presentation and linguistic

expression is acknowledged.’

Nga Thi Thu Vu

27th June, 2017

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Submission of a doctoral thesis as a series of publications

Publications in this thesis arise from a systematic review and meta-analysis and a

community-based cross-sectional study conducted in two major cities in Vietnam in

late 2014. In recognition of the study’s collaborators’ contributions (and as is typical

with standard journal publications), multiple co-authors are listed.

However, the author of this thesis was primarily responsible for all of these

publications, including leading the work on study design, conducting the data analyses

and preparing the manuscripts. This contribution is recognised by the candidate’s

primary author role on all of these publications. For each publication, all the co-authors

have acknowledged that the author of this thesis was responsible for at least 50% of

the contribution to the paper, and have agreed to the submission of the papers as part

of this doctoral thesis.

Given four publications included in this thesis are from the cross-sectional survey in

Vietnam, the readers are advised that there is some repetition in these publications in

the methods sections, as would be expected in a series of papers from a single study.

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COPYRIGHT STATEMENT

‘I hereby grant the University of New South Wales or its agents the right to archive and

to make available my thesis or dissertation in whole or part in the University libraries

in all forms of media, now or here after known, subject to the provisions of the Copyright

Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use

in future works (such as articles or books) all or part of this thesis or dissertation.

I also authorise University Microfilms to use the 350 word abstract of my thesis in

Dissertation Abstract International (this is applicable to doctoral theses only).

I have either used no substantial portions of copyright material in my thesis or I have

obtained permission to use copyright material; where permission has notbeen granted

I have applied/will apply for a partial restriction of the digital copy of my thesis or

dissertation.'

Nga Thi Thu Vu

27th June, 2017

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AUTHENTICITY STATEMENT

‘I certify that the Library deposit digital copy is a direct equivalent of the final officially

approved version of my thesis. No emendation of content has occurred and if there are

any minor variations in formatting, they are the result of the conversion to digital format.’

Nga Thi Thu Vu

27th June, 2017

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SUPERVISOR STATEMENT

I hereby certify that the student (Nga Thi Thu Vu) is responsible for at least 50% of the

contribution to all papers included as chapters in this thesis; all co-authors of the published

papers agree to Nga Thi Thu Vu submitting those papers as part of her Doctoral Thesis.

Professor John De Wit

27th June, 2017

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Table of contents

Thesis dissertation sheet…………………………………………………………………………i

Originality statement……………………………………………………………………………...ii

Submission of a doctoral thesis as a series of publications………………………………….iii

Copyright statement……………………………………………………………………………..iv

Authenticity statement……………………………………………………………………………v

Supervisor statement…………………………………………………………………………….vi

Thesis abstract…………………………………………………………………………………...ix

Thesis structure…………………………………………………………………………………...x

List of publications and presentations from this thesis………………………………………xiii

List of abbreviations……………………………………………………………………………..xv

List of tables……………………………………………………………………………………..xvi

List of figures…………………………………………………………………………………...xviii

Acknowledgement……………………………………………………………………………...xix

Chapter 1. Introduction and literature review…………………………………………………1

Amphetamine-type-stimulants (ATS)………………………………………………………3

Health vulnerabilities of MSM……………………………………………………………….6

Correlates of health vulnerabilities among MSM………………………………………..11

Sex, drugs use and the HIV epidemic among MSM in Vietnam……………………….21

A socio-ecological approach to studying health and well-being……………………….31

Research questions and study objectives………………………………………………..36

Chapter 2. Methodology of the cross-sectional survey in Vietnam and the systematic

review and meta-anlysis………………………………………………………………………..70

The community-based, cross-sectional survey of MSM in Hanoi and Ho Chi Minh City,

Vietnam……………………………………………………………………………………...71

The systematic review and meta-analysis of the association between ATS use and HIV

infection……………………………………………………………………………………...80

Chapter 3. Amphetamine-type-stimulant use among men who have sex with men (MSM)

in Vietnam: Results from a socio-ecological, community-based study…………………….85

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Chapter 4. The relationship between methamphetamine use, sexual sensation seeking and

condomless anal intercourse among men who have sex with men in Vietnam: results from

a community-based, cross-sectional study……………………………………………………95

Chapter 5. Amphtamine-type-stimulants and HIV infection among men who have sex with

men: implications on HIV research and prevention from a systematic review and meta-

analysis…………………………………………………………………………………………109

Chapter 6. The prevalence and correlates of HIV and undiagnosed infection among men

who have sex with men in Hanoi, Vietnam: findings from a cross-sectional, biobehavioural

study…………………………………………………………………………………………….124

Chapter 7. Amphetamine-type-stimulants (ATS) use and homosexuality-related enacted

stigma are associated with depression among men who have sex with men (MSM) in two

major cities in Vietnam in 2014………………………………………………………………136

Chapter 8. Discussion and Conclusion………………………………………………………147

Key findings………………………………………………………………………………..148

Lessons learned, limitations and future directions……………………………………..154

Recommendations for HIV interventions in Vietnam…………………………………..157

Conclusion…………………………………………………………………………………164

Appendix 1. Support letter…………………………………………………………………………176

Appendix 2. Participants information statement and consent forms………………………….181

Appendix 3. Ethical approvals…………………………………………………………………….192

Appendix 4. The community-based, cross-sectional survey’s questionnaire……………….. 195

Appendix 5. Quality assessment checklists for the systematic review and meta-analysis..217

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Thesis abstract

This thesis assessed patterns of amphetamine-type-stimulants (ATS) use and their

association with condomless anal intercourse (CAI), HIV infection and mental health issues,

particularly depression, among men who have sex with men (MSM) in Vietnam.

This study employed a socio-ecological framework with a community-based survey conducted

in 2014 in Hanoi and Ho Chi Minh City, Vietnam. As part of the thesis, a systematic review

and meta-analysis of the relationship between ATS use and HIV infection in MSM was also

conducted. The survey results showed that a substantial proportion of Vietnamese men

(30.4%) had ever used any ATS and 20.3% had used ATS recently. Methamphetamine was

the most popular substance. The majority of recent methamphetamine and ecstasy users were

classified as moderate to high-risk users, according to WHO guidelines. Methamphetamine

use was associated with higher sexual sensation seeking, engagement in recent sex work and

the perception that methamphetamine use was popular among other MSM. A high prevalence

of CAI with any male partners in the last three months (75.7%) was reported. CAI was

associated with methamphetamine use before or during sex, higher sexual sensation seeking,

and belief in the safety of withdrawal as an HIV prevention strategy. Voluntary HIV tests

conducted for 210 men in Hanoi found a moderate HIV prevalence of 6.7%. Men who used

methamphetamine before or during sex, who had engaged in sex work and perceived more

homosexuality-related stigma were more likely to have an HIV positive test. Lastly, a sizable

proportion of men (11.3%) were classified as having major depression which was associated

with ever using ATS and higher enacted (i.e. experienced) homosexuality-related stigma. The

systematic review and meta-analysis demonstrated a significant pooled estimate of ATS use

associated with HIV infection in MSM across longitudinal, case-control and cross-sectional

studies, but not for ecstasy use in cross-sectional studies. The review found several

methodological shortcomings of current studies of drug use and sexual behaviour.

This thesis suggests a comprehensive HIV prevention package, that includes treatment for

methamphetamine use, is needed for MSM in Vietnam to address drug use and the risks of

HIV at the individual, community and societal levels. The thesis also recommends the inclusion

of MSM in HIV prevention, care and treatment provision. From the systematic review and

survey findings, several recommendations for further research on drug use and sexual

behaviours are suggested, including periodic assessment of ATS use.

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THESIS STRUCTURE

Other than the introduction (Chapter 1), the thesis consists of a methods chapter (Chapter

2), five chapters based on articles published in peer-reviewed journals (Chapters 3-7) and a

discussion and conclusion chapter (Chapter 8). The articles were written by the candidate

and have all been published. At the beginning of each chapter, the citation and copyright

permission for the article is included. Where possible, supplementary materials are also

provided. As each publisher requires a different formatting style, some discrepancies in

terminology and citations may appear across chapters. The outline of the thesis is:

Chapter 1

This chapter provides an overview of ATS, including their physiological effects and

prevalence of use in different countries and regions in the world, an overview of the health

and social vulnerabilities of MSM and a review of correlations with these vulnerabilities. The

chapter also provides an overview of the evolution of a multilevel approach to understanding

health and behavioural issues, followed by a socio-ecological framework for the study of

drug use, particularly ATS use and associated harms in MSM in Vietnam. The chapter ends

by identifying research gaps and specific research questions for the thesis.

Chapter 2

This chapter provides a description of the study design, measures and fieldwork for the

community-based cross-sectional study and the systematic review and meta-analysis on

ATS use and HIV infection in MSM. Each of the published papers also includes a description

of the method used for that analysis.

Chapter 3

This chapter represents a published, original article in Drug and Alcohol Dependence with the

following details: Vu, N. T., M. Holt, H. T. Phan, H. T. Le, L. T. La, G. M. Tran, T. T. Doan, T.

N. Nguyen and J. de Wit (2016). "Amphetamine-type stimulant use among men who have sex

with men (MSM) in Vietnam: Results from a socio-ecological, community-based study." Drug

Alcohol Depend 158: 110-117.

In this chapter, with data from the community-based cross-sectional study, I assessed the

magnitude, patterns and severity of ATS use among MSM in Hanoi and Ho Chi Minh City. I

analysed the prevalence and patterns of ATS use, including methamphetamine,

amphetamine and ecstasy use. Following a socio-ecological approach, by logistic

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regression, I identified the individual, community and societal correlates of

methamphetamine use (the most popular substance) in the sample. From the findings, I

suggested relevant public health recommendations for methamphetamine use prevention

and treatment.

Chapter 4

This chapter represents a published, original article in AIDS and Behavior with the following

details: Vu, N. T., M. Holt, H. T. Phan, L. T. La, G. M. Tran, T. T. Doan, T. N. Nguyen and J.

de Wit (2017). "The Relationship Between Methamphetamine Use, Sexual Sensation Seeking

and Condomless Anal Intercourse Among Men Who Have Sex With Men in Vietnam: Results

of a Community-Based, Cross-Sectional Study." AIDS Behav 21(4): 1105-1116.

In this chapter, I analysed patterns of HIV-related risky sexual behaviours of MSM in Hanoi

and Ho Chi Minh City. Correlates of CAI Prevalence Ratios (PR) are analysed by generalised

linear models with modified Poisson regression and robust error variances. Since sexual

sensation seeking has been found to modify the association between alcohol use and risky

sexual behaviours, in this analysis I also hypothesized that sexual sensation seeking may be

a modifier of the association between methamphetamine use and CAI in the sample.

Accordingly, I incorporated the interaction term of methamphetamine use and sexual

sensation seeking in the model. Based on the findings, I suggested public health

recommendations for both HIV research and prevention targetting MSM in Vietnam.

Chapter 5

This chapter represents a published, original article in the Journal of International AIDS

Society (JIAS) with the following details: Vu, N. T., L. Maher and I. Zablotska (2015).

"Amphetamine-type stimulants and HIV infection among men who have sex with men:

implications on HIV research and prevention from a systematic review and meta-analysis." J

Int AIDS Soc 18: 19273.

In this chapter, I provided the results of my systematic review and meta-analysis on the

association between ATS use and HIV infection in MSM from English language, peer-reviewed

published articles. I presented the pooled estimates of the relationship between each ATS

substance, i.e. methamphetamine, amphetamine and ecstasy, with HIV infection in MSM, by

each study design, i.e. cross-sectional, case-control and longitudinal. I also conducted meta-

regression to identify the causes of heterogeneity in the findings. I discussed the shortcomings

of current drug use studies and provided recommendations for future research.

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Chapter 6

This chapter represents a published, original article in Frontiers in Public Health with the

following details: Vu, N. T., M. Holt, H. T. Phan, L. T. La, G. M. Tran, T. T. Doan and J. de Wit

(2016). "The Prevalence and Correlates of HIV and Undiagnosed Infection among Men Who

Have Sex with Men in Hanoi, Vietnam: Findings from a Cross-sectional, Biobehavioral Study."

Front Public Health 4: 275.

In this chapter, I analysed the correlates of HIV infection in a sub-sample of MSM from Hanoi.

This is an embedded bio-behavioural sub-component of my cross-sectional study. I presented

HIV prevalence identified via laboratory testing and the correlates with HIV-related risky sexual

and drug use behaviours, particularly ATS use. I analysed societal, community and individual

correlates of HIV infection and suggest relevant interventions for methamphetamine use and

HIV prevention targetting MSM.

Chapter 7

This chapter represents a published, original article in Substance Use and Misuse with the

following details: Vu, N. T., M. Holt, H. T. Phan, L. T. La, G. M. Tran, T. T. Doan, T. N. Nguyen

and J. de Wit (2017). “The Prevalence and Correlates of HIV and Undiagnosed Infection

among Men Who Have Sex with Men in Hanoi, Vietnam: Findings from a Cross-sectional, Bio-

behavioural Study”. Substance Use and Misuse (In Press).

This chapter presents my work on depression and its associated factors in the sample. I

analysed the prevalence of depression classified by the Patient Health Questionnaire (PHQ-

9) and correlates of depression using logistic regression. From the findings, I suggested

relevant changes to a comprehensive HIV prevention and provide recommendations for future

research targetting MSM in Vietnam.

Chapter 8

In this chapter, I summarised the major findings of my study. I compare my findings with the

results of previous studies in other settings and in Vietnam and discuss any discrepancies and

divergent findings. I also discussed the strengths and weaknesses of my current study and

provide suggestions for future research. Based on my findings, I made recommendations for

interventions to address ATS use and HIV prevention among MSM in Vietnam.

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List of publications and presentations arising from this thesis

Journal paper publications

1. Vu, N. T., M. Holt, H. T. Phan, H. T. Le, L. T. La, G. M. Tran, T. T. Doan, T. N.

Nguyen and J. de Wit (2016). "Amphetamine-type stimulant use among men who

have sex with men (MSM) in Vietnam: Results from a socio-ecological, community-

based study." Drug Alcohol Depend 158: 110-117.

2. Vu, N. T., M. Holt, H. T. Phan, L. T. La, G. M. Tran, T. T. Doan, T. N. Nguyen and J.

de Wit (2017). "The Relationship Between Methamphetamine Use, Sexual Sensation

Seeking and Condomless Anal Intercourse Among Men Who Have Sex With Men in

Vietnam: Results of a Community-Based, Cross-Sectional Study." AIDS Behav 21(4):

1105-1116.

3. Vu, N. T., L. Maher and I. Zablotska (2015). "Amphetamine-type stimulants and HIV

infection among men who have sex with men: implications on HIV research and

prevention from a systematic review and meta-analysis." J Int AIDS Soc 18: 19273.

4. Vu, N. T., M. Holt, H. T. Phan, L. T. La, G. M. Tran, T. T. Doan and J. de Wit (2016).

"The Prevalence and Correlates of HIV and Undiagnosed Infection among Men Who

Have Sex with Men in Hanoi, Vietnam: Findings from a Cross-sectional,

Biobehavioral Study." Front Public Health 4: 275.


de Wit (2017). “The Prevalence and Correlates of HIV and Undiagnosed Infection

among Men Who Have Sex with Men in Hanoi, Vietnam: Findings from a Cross-

sectional, Bio-behavioural Study”. Substance Use and Misuse (In Press).

Conference presentations


de Wit (2016). Methamphetamine use increases the likelihood of condomless anal

intercourse (CAI) among Vietnamese men who have sex with men (MSM) who have

low sexual sensation seeking score. Paper presented at the 2016 Australasian

HIV/AIDS Conference, Adelaide, Australia


de Wit (2016). Amphetamine-type-stimulant use and HIV infection: Findings from a

cross-sectional, bio-behavioural survey of men who have sex with men in Hanoi,

Vietnam. Paper presented at the 2016 Australasian HIV/AIDS Conference, Adelaide,

Australia


de Wit (2016). Methamphetamine use increases the likelihood of condomless anal

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intercourse (CAI) among Vietnamese men who have sex with men (MSM) who have

low sexual sensation seeking score. Paper presented at the 21st International AIDS

Conference. Durban, South Africa.

4. Vu NT, Maher L, Zablotska I. (2013). The association between Amphetamine-typed-

stimulants with HIV infection among men who have sex with men: A systematic

review and Meta-analysis from cross-sectional studies. Paper presented at The 19th

Social Research in HIV, HBV and other infectious diseases, Centre for Social

Research in Health, UNSW Australia.

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LIST OF ABBREVIATIONS

ATS Amphetamine-type-stimulants

MSM Men who have sex with men

CAI Condomless anal intercourse

US United States

UNODC The United Nations Office on Drugs and Crime

LMIC Low and middle income countries

UK United Kingdom

LGBT Lesbian, gay, bisexual and transgender

STI Sexual transmitted infections

UNAIDS The Joint United Nations Programme on HIV/AIDS

IBBS Integrated Behavioural and Biological Surveillance

RCAI Receptive condomless anal intercourse

ICAI Insertive condomless anal intercourse

EDM Erectile dysfunction medications

RDS Respondent Driven Sampling

VAAC Vietnam Administration HIV/AIDS Control Office

IDU Injecting drug users

Hanoi PAC Hanoi HIV/AIDS Prevention Centre

CHP Centre for Community Health Promotion

Life Center Centre for Promotion of Quality of Life

CBO Community-based organisations

ASSIST Alcohol, smoking and substance involvement screening test

CI Confidence Interval

PRR Prevalence Rate Ratio

OR Odds Ratio

HR Hazard Risk

RR Relative Risk

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LIST OF TABLES

In this thesis, the table numbers are firstly identified by the chapter number and then

by their sequential number within each chapter.

Table 3.1: Demographic and behavioural characteristics of the full sample and by

study locations for men who have sex with men in Hanoi and Ho Chi

Minh City, Vietnam, 2014 ……….........................................................92

Table 3.2: Socially involvement with other MSM and perception of the popularity

of ATS substance use among MSM network’s friends of the full sample

and by study location for men who have sex with men in Hanoi and Ho

Chi Minh City, Vietnam, 2014…………………………………………….93

Table 3.3: Patterns of amphetamine-type stimulants (ATS) and other substances

among men who have sex with men sampled in Ho Chi Minh City and

Hanoi, Vietnam, 2014……………………………………………………..93

Table 3.4: Bivariate and multivariate regression analyses of covariates of recent

methamphetamine use among men who have sex with men sampled in

Ho Chi Minh City and Hanoi, Vietnam, 2014……………………………94

Table 4.1: Demographic characteristics of MSM recruited in Hanoi and HCMC,

Vietnam, 2014…………………………………………………………….103

Table 4.2: Sexual and drug use behaviours among MSM in Hanoi and HCMC,

Vietnam, 2014…………………………………………………………….104

Table 4.3: Bivariate and multivariate analyses of any CAI with male partners in the

last 3 months among MSM recruited in Hanoi and HCMC, Vietnam,

2014………………………………………………………………………..105

Table 5.1: Articles in the analysis: description of studies and their

participants………………………………………………………………..116

Table 5.2: Stratification analysis for cross-sectional studies……………………. 121

Table 6.1: Participant characteristics……………………………………………….132

Table 6.2: Sexual and drug use behaviours………………………………………..133

Table 6.3: Bivariate and multivariate analysis of associations with HIV

infection…………………………………………………………………... 134

Table 7.1: Characteristics of MSM recruited in Hanoi and Ho Chi Minh City,

Vietnam, 2014…………………………………………………………….144

Table 7.2: Sexual and drug use behaviours of MSM recruited in Hanoi and Ho Chi

Minh City, Vietnam, 2014………………………………………………..144

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Table 7.3: Bivariate and multivariable analysis of correlates of depression among

MSM recruited in Hanoi and Ho Chi Minh City, Vietnam, 2014……..145

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LIST OF FIGURES

In this thesis, the figure numbers are firstly identified by the chapter number and

then by their sequential number within each chapter.

Figure 1.1: Hanoi prevalence among MSM by region from 2007-2011.........9

Figure 1.2: Trends in HIV prevalence among MSM in Vietnam from 2005-

2013 from Integrated Biological and Behavioural Surveillance

(IBBS)……………………………………………………………….30

Figure 1.3: Socio-ecological framework for the study of HIV risk and alcohol

environment………………………………………………………...34

Figure 1.4: The proposed Socio-Ecological Framework for the study of ATS

use and associated harms in Vietnam…………………………..36

Figure 2.1: Participant interview protocol……………………………………..77

Figure 4.1: Differences in the probability of involving in CAI in the last three

months for sexually-related methamphetamine use versus no

methamphetamine use by sexual sensation seeking………...106

Figure 5.1: Flow chart for selection of studies with number of articles…..115

Figure 5.2: Summarized effect measure of the association between ATS

use and HIV infection, by study design………………………...119

Figure 5.3: Summarized effect measure of the association between ATS

use and HIV infection, by study design and drug type. (a) cross-

sectional study; (b) case-control studies; (c) longitudinal

studies……………………………………………………………..120

Figure 8.1: Recommendation for a comprehensive HIV prevention package

for MSM in Vietnam………………………………………………165

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ACKNOWLEDGEMENT

Finally, I have completed my Ph.D. study after a challenging four-year journey. I could not

have accomplished this work without the assistance and support of my supervisors,

colleagues, friends and relatives.

First of all, I want to especially extend my sincere gratitude to Professor John De Wit and

Associate Professor Martin Holt for their courageous decision to get on board with me,

knowing that I am an international student whose English is not her mother tongue. I could not

have gone through this long, difficult journey without your extraordinary support, assistance,

guidance, and patience. I remember how patient you were with my messy drafts with lots of

grammatical and typing errors, your instructions to help me develop critical thinking and writing

skills and your attention to even the smallest of details in my writing. I have learned a lot from

you and these valuable lessons will go with me for the rest of my life. I am also very thankful

for your compassion during the times when my mother went away and there was chaos in my

family back in Vietnam. Additionally, I would also like to extend my sincere thanks to Professor

Lisa Maher and Associate Professor Iryna Zablotska, my ex-supervisors at the Kirby Institute,

UNSW. Though they were only with me for a short period of my Ph.D. journey, the systematic

review and meta-analysis I did with them was the first real challenge within my doctoral

candidature and it was an extremely exciting task. I am thankful for the opportunity they gave

me to acquire a new powerful statistical analysis technique and the overall understanding of

the topics of my research at the very beginning of my Ph.D. The skills and knowledge I gained

from this particularly helped me in my research.

Secondly, I want to express my great thanks to my colleagues in Vietnam, who supported me

to conduct my research in Vietnam: Dr. Lan Thi La, Deputy Director of Hanoi HIV/AIDS

Prevention and Control Center; Dr. Gioi Minh Tran, Director of the Centre for Community

Health Promotion and Ms Trang Nguyen Nhu Nguyen, Director of the Centre for Quality of

Life Promotion. I want to especially thank Tung Thanh Doan, Thanh Le and members of all

COBs in Ho Chi Minh City for their wonderful contributions, collaboration and support during

my survey work in Hanoi and Ho Chi Minh City. I could not have conducted my fieldwork

without their agreement to collaborate with me in this study, their referral to the networks of

community-based-organisations of MSM in Hanoi and Ho Chi Minh City, and their kind offer

of various locations for meetings, interviewer training, and interviews, and most importantly,

their thoughtful contributions to this study. It is so inspiring to have come in contact with their

work and to have got to know them all on a personal basis. I also want to send my sincere

thanks to all the men who bravely came and shared their information and their life experiences.

I am grateful for the opportunity they gave me to gain an insight into the difficulties of being in

Page| xxv

a minority and how brave they are in constructing their identity in a heterosexist-dominant

society. I thank my colleagues and students at Hanoi Medical University and Ho Chi Minh

University of Pharmacy and Medicine for their great work with me during my fieldwork. Their

enthusiasm, time, hard work and wonderful interviews with the men in my study meant a lot to

me.

Thirdly, I am very much thankful to the staff and other academics at the Centre for Social

Research in Health, UNSW, particularly Carla Treolar, Christy Newman, Loren Brener, Limin

Mao and Ann Whitelaw for their great administrative and academic support, their constructive

advice, and the wonderful study conditions that they gave me. I also want to thank my fellow

Ph.D. candidates who created a friendly and supportive learning environment in our 206 lab,

at level 2 of the John Goodsell Building, UNSW Kensington campus. All of the fun moments I

spent with them helped to reduce my stress levels during the course of my research.

Last but not least, I am very grateful for the support of my ex-husband- Duy Trung Nguyen,

my little sons-Hieu and Chip and other loved ones in my extended family. Many thanks to Duy

for taking care of our sons when I had to go away. Although we are not able to spend the rest

of our lives together, I feel very relieved that we will share the endless love, caring, and

responsibilities of our children, Hieu and Chip. I know it was not easy for the children when I

was not with them and they missed me so much. Nothing can compensate for the fact they

had to grow up without their mother, especially as they were entering their teenage years.

Finally, to my mother and father, thank you so much for your encouragement and support of

me. I feel guilty that I could not take care of you and be with you, especially when you were

sick or during our traditional Tet. Mum, I love you and I hope you rest in peace now. This work

is my compliment to you and I hope you feel proud of me.

CHAPTER 1

INTRODUCTION AND LITERATURE REVIEW

1

My study focuses on the use of amphetamine-type-stimulants (ATS) and its potential

associated harms, including risky sexual behaviours, HIV infection and psychological

problems, particularly depression, among men who have sex with men (MSM) in

Vietnam. In this chapter, I provide a rationale for why I conducted this study and I assess

previous research and gaps in the existing knowledge.

In the first section of this chapter, I provide an overview of ATS including their

physiological effects and the prevalence of their use in different countries. Following this,

I explain the particular social and health vulnerabilities of MSM. I discuss homosexuality-

related stigma and discrimination, how stigma and discrimination affects MSM and the

prevalence of common health issues, including depression, risky sexual behaviours and

HIV infection. Next, I present a literature review of recent research, mostly published in

the past five years, on the correlates of drug use, particularly ATS use, risky sexual

behaviours, notably condomless anal intercourse (CAI), HIV infection and depression

among MSM.

I continue the chapter with an overview of the theoretical framework I used in my study

of ATS use and its associated harms among MSM. Specifically, I report a brief review of

previous public health research approaches and how these approaches were adapted

to develop frameworks for the study of health-related issues. I then propose an adapted

theoretical framework for my study of ATS use and its associated harms among MSM in

Vietnam.

Next, I consider the context of Vietnam and current knowledge about ATS use and

associated harms in Vietnamese MSM, including risky sexual behaviours, HIV infection

and depression. In this section, I describe how homosexuality is situated in

contemporary Vietnamese society, as well as illicit drug use in Vietnam and the

Vietnamese HIV epidemic. I then review recent research on ATS use, risky sexual

behaviours, HIV infection and depression among Vietnamese MSM. After this literature

review, I discuss the gaps and limitations of recent research in Vietnam.

I then present my overall research objective and specific research aims, as well as my

research questions, and briefly describe the study design. I conclude the chapter with an

outline of the other chapters in the thesis.

2

AMPHETAMINE-TYPE-STIMULANTS (ATS)

This section begins with background information about ATS, their classification, how they

are referred to by drug users, and a description of the biological mechanisms of the

action of ATS. The section continues with an explanation of the various physical,

psychological and sexual effects of ATS, followed by epidemiological evidence regarding

their use globally. The section concludes with information regarding the extent of ATS

use among MSM in different parts of the world.

What are ATS?

ATS are synthetic psycho-stimulants (1), that are often classified into two groups: the

amphetamine-group substances which includes ephedrine, methylphenidate, ∆-

amphetamine, L-amphetamine, amphetamine sulphate, amphetamine hydrochloride,

methamphetamine, and methcathinone, and the ecstasy-group substances which

include 3, 4-methylenedioxy-N-methylamphetamine (MDMA), N-ethyl-3, 4-methylene-

dioxyamphetamine (MDEA) and 3, 4-methylenedioxyamphetamine (MDA) (1-3). In the

amphetamine substance group, amphetamine and methamphetamine are the most

commonly used drugs (4). Methamphetamine has different street names in different parts

of the world, including “meth”, “speed”, “crystal meth”, “ice”, “batu”, “shabu”,”glass”, “tina”,

”crank”, ”go-fast”, “stove top”, and “yaba” (5). In Vietnam, methamphetamine’s street

names include (but are not limited to) “hồng phiến”, “ viên chúa” for tablets/pills and “hàng

đá” or “ice” for crystal (6). Ecstasy is the most commonly used drug in the ecstasy

substance group, with various street names, including “eva”, “adam” and “love” (3). In

Vietnam, ecstasy is called “thuốc lắc” or “ viên tình yêu” (6), or referred to by the icon

stamped on the tablets.

Between the 1940s and 1980s, methamphetamine was prescribed for various medical

conditions, particularly weight reduction (5). Currently, methamphetamine is still

indicated for the treatment of narcolepsy, and for treatment of the symptoms of attention

deficit hyperactivity disorder in children (3). Ecstasy group substances have never been

officially prescribed for medical purposes (1). Since the late twentieth century,

amphetamine and ecstasy group substances have been labelled as club or party drugs

as they are often used in dance clubs, circuit parties or raves (7). This type of recreational

use is typically classified as illegal.

In many illicit drug markets, including Vietnam, ecstasy is commonly produced as a

tablet, normally containing MDMA and other ecstasy-type substances, often stamped

with a symbol (1, 8, 9). Methamphetamine is available in the market in various forms

3

such as crystals, crushable tablets, liquids or powder, usually combined with other

substances and with varying purity (5). Both amphetamine and ecstasy substances can

be used in various ways, including oral ingestion, injection, inhalation, smoking or

“shafting” (inserting in the anus) (4, 5, 7).

How do ATS substances work and what are their effects?

Both amphetamine and ecstasy-group substances are classified as neuro-stimulants,

while ecstasy-group substances are also classified as hallucinogenic (1, 3, 5). In the

central nervous system, amphetamine substances affect the release of

neurotransmitters (i.e. dopamine), and inhibit the re-uptake of catecholamines (i.e.

adrenaline) (3), while ecstasy substances increase the release of serotonin, which is

responsible for psychological effects, and inhibit the uptake of adrenaline, which is

responsible for physical effects (1, 3). Because of their long half-life, both amphetamine

and ecstasy-type stimulants can have physiological and psychological effects which may

last up to 3-6 hours for ecstasy or 10-12 hours for methamphetamine (3, 7, 10). The

effects of ATS may be affected by the individual’s physiology and psychological state,

the dose taken, the route of administration of the drug, the user’s prior experience with

the drug, expectations of what it will do, and contextual and environmental factors, such

as where and with whom the drug is used (11, 12).

ATS tend to increase heart rate, blood pressure, body temperature, alertness,

wakefulness, endurance and energy, and decrease feelings of fatigue and sleepiness

(1, 3, 9). Users of amphetamine substances tend to report experiences of euphoria,

arousal, positive mood, behavioural disinhibition, enhancement of cognition and

increased self-esteem (11, 13). Ecstasy substance users also report experiences of

euphoria and a positive mood, as well as a sense of wellbeing, sociability, extraversion,

and closeness to other people (1, 9). Potential adverse effects of amphetamine

substances include convulsions, coma, cerebral haemorrhage and death (3), and those

of ecstasy substances include muscle pain, heighted body temperature, headache,

nausea, reduced appetite, blurred vision, dry mouth, insomnia, anxiety and psychosis (1,

9). Long-term use of methamphetamine can result in toxic effects and a variety of

psychological and/or psychiatric conditions, such as psychosis, depression, anxiety,

violent behaviour and suicide (3, 5, 11, 14). Long-term use of ecstasy substances can

result in neurotoxic effects and adverse physical, psychological and psychiatric

conditions, such as tooth grinding, muscle ache, circulatory problems, cognitive

impairment, greater impulsivity, paranoia, hallucinations, psychosis, depression and

death (1, 9).

4

A number of qualitative studies have described the motivations for methamphetamine

use and its effects on sexual behaviour from the user’s perspective. Narratives from both

HIV-positive and HIV-negative MSM in major cities in the United States (US) described

the sexual effects of methamphetamine as some of the most important reasons for MSM

to use the drugs (15-22). However, studies have also revealed numerous personal,

interpersonal and social reasons for its use. Methamphetamine can be used to enhance

sexual experience and achieve prolonged sexual encounters, heighten sexual feelings,

reduce anxiety and sexual inhibitions and increase openness about homosexuality (16,

18, 20-22). Methamphetamine may be used by MSM to socialize with other gay men or

to approach sexual partners in gay-oriented venues (16, 18, 21), and to avoid or reduce

social pressure, conflicts or rejection because of being homosexual or HIV positive (16,

18, 20-22). It may also be used to avoid psychological distress (23), and for functional

purposes, including losing weight, improving work performance, enhancing mood and

reducing fatigue (4).

In relation to ecstasy use, there are contradictory reports about its sexual effects from

both gay and bisexual men and other users in high-income countries. Qualitative

research with gay and bisexual men in New York and ecstasy users in Belfast described

some users feeling enhanced sensitivity to touch, increased affection or sensuality,

emotional closeness to others (24, 25) or just relaxation or enhanced socialisation (26).

It may also improve a sense of well-being, relationship satisfaction or increased

enjoyment of music and dancing (27) . However, other men reported sexual arousal,

increased sexual desire, and sexual disinhibition (24, 25, 28). A review of both

quantitative and qualitative studies with young recreational ecstasy users found similar

effects on sexual sensation and arousal (29).

ATS use globally and among MSM

In the recent World Drug Reports, the United Nations Office on Drugs and Crime

(UNODC) has identified ATS as the second most commonly used type of illicit drug

during the period 2011 to 2015, after cannabis (30-34). The agency estimated that

during 2011-2015, approximately 0.6% -1.3% of the global population aged 15 to 64

years used amphetamines in the previous year and 0.2% - 0.6% used ecstasy (30, 34).

Since the late 2000s, the use of ATS has been stable or has decreased slightly in North

America, Europe and some Southeast Asian countries, such as Thailand, Malaysia and

Singapore. However, ATS use has increased substantially in other countries in

Southeast Asia (30), such as Vietnam, Laos, Cambodia and Myanmar (35) and there

may be emerging markets in Africa (32). East and Southeast Asia have been identified

5

as the regions with the biggest markets for amphetamine substances, particularly

methamphetamine during the first part of the 2010s (30-34, 36).

Drug use in general and ATS use in particular have been reported at relatively high levels

among MSM in high-income countries, particularly in America, Australia and Western

Europe. It has consistently been found that ATS use is more prevalent among MSM

compared to other population groups (4, 7, 37). National and large-scale surveys in high

income countries have found relatively high rates of ATS use among MSM. In the early

2000s, national and large-scale studies in the US reported amphetamine substance use

ranging from 6% to 20% and ecstasy use from 10% to 19% among MSM (38, 39). In

some cities, such as New York City, the rate of life-time ecstasy use among MSM was

found to be as high as 84% (40). In England, a national survey of MSM in 2004 found

that the rate of ecstasy use in the last year was 18.5%, while amphetamine use was

reported as 7.2% and methamphetamine use as 2.8% (41). A large-scale survey

conducted in 2010 among gay and bisexual men in 44 cities in Europe found relatively

high life-time rates of ATS use, among which amphetamines were the most commonly

used ATS (40.0%), followed by ecstasy (20.0%) and crystal methamphetamine (10.0%)

(42). In Australia, behavioural surveys in major cities in 2014 found a high level of ATS

use among MSM, in which the prevalence of recent amphetamine (speed) use was

10.2% and 11.4% for methamphetamine (43). Recent studies in high income countries

have found inconsistent trends in ATS use. A repeated cross-sectional study that

followed 5599 substance-using MSM in the US from 2008 to 2011 reported an upward

trend in methamphetamine use in the last 30 days, from 23.7% in 2008 to 27.4% in 2011

(44). However, behavioural surveillance in Australia has observed a downward trend in

methamphetamine use from 15.6% in 2005 to 11.4% in 2014 (43, 45).

Most studies on ATS use among MSM to date have been conducted in English-speaking

high-income countries, notably the United States (US), England, other European

countries and Australia. Evidence from low and middle income countries (LMIC) is

lacking (4, 7). There has been only one published study addressed drug use among

MSM in 12 countries in Asia. This study reported an overall prevalence of any

recreational drug use of 16.7%, with ecstasy being the most commonly used drug,

reported by 8.1% (46).

HEALTH VULNERABILITIES OF MSM

MSM may experience adverse physical and mental health outcomes related to social

stigma and discrimination, as well as from specific sexual and drug-related practices. In

6

this section, I present the health vulnerabilities that MSM may face, beginning with

homosexuality-related stigma and discrimination, followed by mental health disparities

and sex and drug use behaviours which may increase the risk of HIV. The section

concludes with a consideration of the HIV burden faced by MSM.

Homosexuality-related stigma and discrimination

MSM include homosexual or gay men, bisexual men, heterosexual men who have sex

with men and any other men who have sex with men. The term only reflects the

behavioural aspect of sexuality while ignoring sexual attraction and sexual identity.

Despite continuous efforts to advocate for homosexual rights across the globe,

particularly in high-income countries, homosexuality-related stigma and discrimination

towards gay men and other MSM remain prevalent in many parts of the world (47, 48).

Even in high income countries such as the US, United Kingdom (UK) and Australia, many

MSM still experience negative stereotypes, prejudice and discrimination in various social

settings, including the home, school, workplace, health care services and the community

(49-51). Homosexuality-related stigma and discrimination toward MSM can be

expressed in various ways, including unpleasant treatment, verbal abuse and physical

violence (52, 53) and have been outlawed in some countries (47). In the literature,

homosexuality-related stigma and discrimination are often referred to as homophobia,

meaning the dislike or fear of homosexuality and beliefs that homosexuality is wrong or

abnormal (51, 54). Homosexuality-related stigma may be classified into three main types

(55): experienced or enacted stigma, perceived stigma and internalised homophobia.

Enacted stigma includes men’s experiences of stigmatising or discriminating behaviours

by others, perceived stigma refers to men’s perceptions of societal attitudes towards

homosexuality, and internalised homophobia is men’s self-blaming or stigmatising of

their homosexuality as a result of hostile societal attitudes (56).

Homosexuality-related stigma and discrimination can affect many aspects of MSM’s

lives, and adversely affect their physical and mental health. Importantly, MSM who

experience internalised stigma, typically referred to as internalised homophobia, have

been found to be more likely to have a higher risk of acquiring HIV, because they may

be more likely to engage in HIV-related risky sexual behaviours (57), including CAI (58)

and having sex under the influence of drugs (52, 58). Additionally, MSM who experience

internalised homophobia are less likely to be aware of or utilise HIV prevention programs,

including individual, group and community behavioural change interventions and HIV

testing, and are less likely to change their behaviours when participating in such HIV

prevention programs (57, 59). At the same time, experienced stigma and/or internalised

7

homophobia can adversely affect MSM’s mental health. Studies have reported that MSM

who report internalised homophobia are more likely to be socially isolated (60), have

higher rates of depression and lower self-esteem (57, 60), and are more likely to use

illicit drugs (61).

Depression

MSM are disproportionately affected by mental health problems, including depression

and anxiety (50, 62). Generally, sexual minority populations, including lesbian, gay,

bisexual and transgender (LGBT) people, report higher rates of suicide attempts,

depression, anxiety disorders and illicit drug use, compared to their heterosexual peers

(63). In the US, the prevalence of depression among MSM is up to ten times higher than

among heterosexual men (64), and, together with other health concerns such as HIV

and other sexually transmitted infections (STIs), depression and other mental health

problems have been noted as major health issues among MSM (65).

High rates of depression among MSM have been reported in a range of settings. Recent

studies of MSM in in the US have found that rates of depression ranged from 23% to

34% (66-68), and up to 42% among HIV-positive MSM (69). In Europe, the prevalence

of depression was reported to be 32% among MSM in Estonia (70) and 29% among

MSM in Belgium (71). In Australia, one third of MSM attending general medical practices

in Sydney and Adelaide were found to experience major depressive disorder (72). In

Africa, major depression was found to affect 16% of MSM in Lesotho and Kenya (73, 74)

and over half of MSM in Cape Town, South Africa (75). In Asia, recent studies have

investigated psychological disorders and sexual behaviours among MSM and male sex

workers in a number of countries, including India, Nepal, China, Taiwan, Cambodia,

Thailand and Vietnam (55, 76-82). While the prevalence of depression among MSM in

India was moderate (11%) (76), in East and Southeast Asia countries, several studies

targetting subgroups of MSM such as HIV-positive MSM or male sex workers (MSW),

reported a high proportion (43%-58%) suffering from depression (78, 79, 81, 82).

HIV infection

MSM are disproportionately affected by HIV in all countries where data are available. In

the period from 2000 to 2006, the global pooled HIV prevalence among MSM in LMIC

reportedly was 12.8%, with the prevalence of HIV among MSM in Central and South

America ranging from 7.9%-25.6%, in Africa from 0.01%-21.5%, and in Southeast Asia

from 2.8%-24.6% (83). In the period from 2007 to 2011, the pooled HIV prevalence

among MSM was reported to be as high as 25.4% in the Caribbean region, and the HIV

8

prevalence among MSM was consistently found to be between 14-18% in all regions of

America, South and Southeast Asia and sub-Saharan Africa (figure 1) (84).

Figure 1.1. HIV prevalence among MSM by region from 2007-2011

(Source: Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet.

2012;380(9839):367-77.)1

Despite efforts to control the HIV epidemic among MSM, from the late 1990s onwards,

the epidemic has been regarded as re-emerging or increasing in many settings in the

world, including both high-income countries and LMIC (83-85). The number of cases of

HIV infection among MSM increased during late 1900s and early 2000s by 10%-25% in

the US, Canada and Australia and a two- to threefold increase in the number of infections

in MSM occurred between 2002-2007 in Hong Kong, Taiwan, Singapore and Japan (85).

A trend analysis of HIV infections among MSM in six countries in North America, Western

Europe and Australia showed an annual increase of HIV notifications of 3.3% from 2000-

2005 (86). A trend analysis of HIV infections among MSM in six countries in North

America, Western Europe and Australia showed an annual increase of HIV notifications

of 3.3% from 2000-2005 (87). While the Joint United Nations Programme on HIV/AIDS

(UNAIDS) estimated a 35% decrease in annual HIV infections worldwide from 2000 to

2014 (87), MSM still accounted for up to half of new HIV infections in 2014 in some

regions (88).

In East Asian countries, a continued increase in HIV transmission via sex between men

was reported from the middle of the 2000s to the early 2010s (89). A review of trends in

HIV infections during the 2000s among MSM in South and East Asian countries found a

1 The candidate received the agreement from Elsevier, license number 4092760201754 dated

19th April, 2017, for the reproduction of this figure in this thesis.

9

two-digit HIV prevalence in many major cities in the region: 14% in Taiwan in 2000-2001,

10%-13% in Chongqing, China, in 2006-2007, 9%-25% in several districts of India in

2006-2007, and 24%-35% in Yangon and Mandalay, Myanmar, in 2007 (90) . In

Southeast Asia, HIV was found to be highly prevalent among MSM in Cambodia (14%

in Phnom Penh in 2000), Thailand (increasing from 17% to 30% during 2003-2007 in

Bangkok; 15% in Chiang Mai in 2005), and Vietnam (9% in Hanoi in 2006) (90). From

2006 to 2011, the number of all HIV cases diagnosed in MSM increased from 2.5% to

13.7% in China, and from 23.5% to 77.2% in Taiwan (89). Since 2004, the HIV epidemic

has re-emerged among MSM in Hong Kong and a new HIV epidemic has been reported

in MSM in Mongolia (91). In Vietnam, HIV prevalence among MSM has increased

significantly, from 9% in 2006 to 20% in 2011 (92). Integrated behavioural and biological

surveillance (IBBS) conducted in Vietnam in 2009 found that HIV was most prevalent

among MSM in major cities, ranging from 14% to 20% (93).

Risky sexual behaviours

A considerable amount of research has found a high prevalence of risky sexual

behaviours, particularly CAI among MSM across the globe, both in high-income countries

and LMIC (84). A recent online survey among more than ten thousand MSM in twelve

Asian countries found that more than two fifths of MSM practiced insertive or receptive

CAI with their male partners, although the review did not distinguish between casual and

regular partners (94). A recent systematic review of studies of HIV and sexual risk

behaviours among MSM in the Mekong subregion and China conducted during the

2000s reported that the rate of CAI ranged from 31% to 72% in Cambodia, China,

Thailand and Vietnam, across different types of sexual partners and recall periods (90).

Furthermore, sizeable proportions of MSM in these countries reported having multiple

male sexual partners (31%-54%), engaging in sex work (9%-24%) and having female

sexual partners (25%-33%) (90). In China, a recent review of national and international

studies and grey literature found that only 20%, 30% and 58% of MSM practiced

consistent condom use with their regular, casual and commercial sex partners,

respectively (95). The pooled estimates from recent studies in China indicate that the

majority of HIV-positive MSM (>70%) engaged in some CAI with men and 68% had

condomless vaginal sex with women (96). A systematic review of research conducted

between 2003 and 2007 regarding homosexual behaviours among MSM in LMIC found

that the rate of condom use during the last anal sex encounter with another man was

limited and varied by geographical setting, ranging from 6%-47% in Southeast Africa,

32%-63% in East Asia, 30-82% in Southeast Asia, 37-58% in Eastern Europe and

Central Asia, and 47-61% in Latin America. Consistent condom use with another man in

10

the previous year ranged from 12-18% in Southeast Africa, 0-40% in East Asia, 54% in

the Caribbean, and 64% in Latin America (97).

The research presented above indicates high levels of high infection and low levels of

consistent condom use by MSM in LMIC, particularly East and Southeast Asia. To

improve HIV prevention, it is necessary to understand the influences on HIV infection

and sexual behaviour among MSM in these settings.

CORRELATES OF HEALTH VULNERABILITIES AMONG MSM

This section provides an overview of research published mostly in the last five years on

correlates of drug use, in particular ATS use, and associated health-related harms,

including CAI and other sexual behaviours, HIV infection and psychological distress,

notably depression, among MSM.

For each health vulnerability of interest (drug use, CAI, HIV infection and depression),

associations with these conditions are grouped into the following categories (depending

on the availability in the literature): i) socio-demographic factors, ii) personal

dispositions including mental health problems (i.e. depression) and personal traits such

as sexual sensation-seeking, iii) behavioural correlates such as drug use and sexual

behaviour, iv) environmental or contextual correlates such as access to gay venues or

HIV services, v) community/interpersonal factors (i.e. men’s involvement in a MSM

community) and lastly, vi) societal and cultural factors (i.e. homosexuality-related

stigma and discrimination).

Correlates of drug use, including ATS

Drug use has been a great concern in research with MSM because of its potential

association with risky sexual behaviours and, consequently, HIV infection. During the

past three decades of the HIV epidemic, a great deal of literature has suggested that

substance use, particularly ATS use, is a multifaceted problem which involves personal,

interpersonal, contextual, cultural and societal factors.

Socio-demographical characteristics

Previous studies reported diverse demographic profiles of MSM who used recreational

drugs, including ATS. Depending on the study’s contexts and sampling methods, the

demographic characteristics of men who used drugs varied in terms of age, education,

occupation and income. However, many studies in different settings have consistently

11

found that drug use is more likely common in younger men compared to older men (98-

105) and among HIV-positive men compared to HIV-negative men (99, 101, 105-109).

Dispositions correlates

Drug use by MSM may be shaped by personal dispositions such as comorbid health

conditions (e.g. depression) or personality characteristics such as sexual sensation

seeking or sexual compulsivity. A number of studies have found that MSM who

experienced depression or depressed mood are more likely to use drugs, including

methamphetamine (101, 105, 107, 110). Several studies have found that personal traits,

such as sexual sensation seeking, the propensity to seek novel, optimal sexual

excitement and to engage in novel sexual experiences (111), was directly associated

with both drug use and risky sexual behaviours and can mediate the association between

the two (112-116). There has also been research that has found that the sexual

compulsivity scale, which measures preoccupations with sexual acts and episodes, is

associated with an increased likelihood to use drugs in MSM (105). Drug use or sexual

behaviours could be seen as an expression of personal traits, or on the other hand,

personal traits, might affect the relationship between drug use and risky sexual

behaviours (117). However, the exploration of these factors’ effects in relation to sexual

or drug use behaviours has not received substantial attention in the literature.

Behavioural correlates

Consistently, previous studies conducted in different settings have found that MSM are

more likely than their heterosexual peers to use different drugs, such as marijuana,

inhalants, (crack) cocaine, psychedelics or hallucinogens, tranquilisers or heroin (20-22,

40, 43, 107, 118-121). Alcohol consumption and poly-drug use in the context of

methamphetamine use is very common in different populations of MSM (22, 101, 106,

107, 122, 123). Concurrent use of multiple drugs could, of course, make it difficult to

understand the effect of individual drugs, particularly the effects on risky sexual

behaviours and HIV infection. However, most of this research on the correlates of ATS

use has been conducted in high-income countries, while evidence from LMIC is lacking.

Environmental or contextual correlates

Much of the current literature has explored the influences of environmental and

contextual factors on drug use behaviours of MSM. Thus far, available evidence

highlights the widespread use of recreational drugs in gay-specific, sexual-oriented

venues and events such as gay bars, bathhouses, dance clubs, circuit or sex parties (4,

20, 22, 37, 101, 106, 124, 125). Notably, for example, in the sexual subculture of gay-

specific venues and events in New York, researchers have found that recreational drug

12

use, particularly methamphetamine use is very prevalent (18, 20, 22, 126). A study of

MSM in four cities in the US in the early 2000s also found that men who go to sex venues

were more likely to use party drugs, including methamphetamine, ecstasy and poppers

compared to men who frequent these venues less often (127).Besides physical venues,

there has been an increasing use of the internet and mobile phones by MSM to

communicate, make friends and find sexual partners (128-132). Studies have found that

drug use, including ATS use, is more prevalent among MSM who use the internet to seek

sexual partners compared to men who seek partners from other channels (102, 103,

129-132). Exploring how MSM engage with and meet other MSM in particular locations

may assist in understanding patterns of drug use and sexual behaviours by MSM.

Community/Interpersonal correlates

Studies have found that gay men who have a strong attachment to the gay community

may be more likely to take drugs to enhance sexual performance and subsequently

might engage in risky sexual behaviours (133). High involvement in the gay community

and more socialising with gay friends can also be associated with more drug use and

poly drug use (134). How interpersonal relationships among MSM and the local MSM

subculture influence drug use and sexual behaviours should therefore be taken into

account in studies of drug use and other MSM’s health behaviours.

Societal and cultural correlates

As suggested by the minority stress model (50), MSM may experience social stigma and

discrimination in relation to homosexuality, including internalised homophobia, which can

contribute to a stressful social environment, resulting in a greater risk of mental health

issues, including alcohol and substance use problems. Men who experience

discrimination against their sexual orientation alone or in combination with racism and

gender discrimination, have been found to have higher rates of substance use and

alcohol use (135-137). Furthermore, homosexual men who have internalised

homophobia have been found to be more likely to use drugs than other men (50, 138).

Nonetheless, the assessment of homosexuality-related stigma and discrimination has

not been widely included in previous studies of drug use, both in high-income countries

and in LMIC.

Correlates of condomless anal intercourse (CAI)

MSM who practice risky sexual behaviour are at risk of acquiring STI, including HIV.

These risky practices include having multiple regular and casual sexual partners,

participating in group sex, transactional sex, and having receptive condomless anal

13

intercourse (RCAI) or insertive condomless anal intercourse (ICAI). CAI, particularly

RCAI is consistently identified as a risk factor for HIV infection. Understanding local risk

factors and the correlates of CAI can assist in the formulation of HIV prevention

interventions targetting MSM in specific contexts. This section compiles the available

evidence on the correlates of risky sexual behaviours among MSM.


Associations between socio-demographic characteristics and engaging in CAI among

MSM vary, depending on the design of studies, sampling methods and recruitment

locations. Some studies have found that CAI is less frequent among men who are older,

highly educated or with higher incomes (77, 139, 140), while other studies report

opposing findings or find no associations (141, 142). Some studies have found that CAI

is more frequently reported by homosexual or gay-identified men compared to bisexual

or heterosexual MSM (143, 144). (143, 144). A number of studies have found that HIV-

positive MSM are more likely to practise CAI compared with HIV-negative or status

unknown MSM (94, 99, 140, 145, 146). An understanding of how CAI practice is

distributed by socio-demographic correlates is one of the essential steps in studies of

sexual behaviour since it provides important information about who safe sex

interventions should target.

Dispositions correlates

Few studies have assessed the association between personality traits (i.e. sexual

sensation seeking) or comorbid conditions (i.e. depression) and the likelihood of

participating in CAI by MSM. Nonetheless, findings suggest men who are more sexual

sensation seeking are more likely to engage in risky sexual behaviours, particularly CAI,

and that sensation seeking may moderate the relationship between alcohol or drug use

and CAI (113, 115, 116). Furthermore, previous studies have also found that having a

risk-taking personality (147), a higher level of sexual impulsivity (148), or having higher

trait anxiety (characterised by feelings of apprehension, tension, nervousness, or worry)

(149) were associated with a higher odds of CAI with HIV-positive or unknown status

partners. However, to the best of my knowledge, there has not been assessment of the

role of sexual sensation-seeking on the relationship between ATS use, particularly

methamphetamine use, and CAI in MSM.

Moreover, MSM who have comorbid mental health conditions, such as stress and

depression, are more likely to practice CAI (68, 149, 150). A recent study found that

depression was a significant modifier of the association between methamphetamine use

and CAI (151). While some previous findings reflect the fact that while some men engage

14

in CAI for enjoyment or enhanced sexual pleasure purposes, other practiced CAI

because they were anxious or depressed. Exploring the underlying cause of CAI,

therefore, is important to HIV prevention.


A handful of literature has assessed the behavioural correlates of CAI, including

recreational or club drug use and alcohol consumption. Most studies, including those

from both high-income countries and LMIC, have found a statistically significant

association between CAI and alcohol consumption, including ‘binge drinking’ (141, 145,

152-155). Previous studies have also found that MSM who drink large quantities of

alcohol (‘binge drinking’) have more CAI partners and are more likely to engage in

transactional sex (4, 156).

Previous studies using different designs, i.e. cross-sectional or longitudinal studies or

studies using event-level measurement of drug use, have found that club drug use,

including methamphetamine and amphetamine use was associated with higher rates of

practicing RCAI and ICAI among both HIV negative and HIV positive MSM (4, 15, 23,

37, 68, 77, 94, 98, 122, 140, 143-149, 152, 156-171). Studies from high-income countries

indicate that methamphetamine use increases the likelihood of practicing RCAI or ICAI

with male partners (4, 15, 37, 43, 120, 122, 139, 149, 153, 165-167, 171-174). As such,

drug use, including ATS use, could facilitate the transmission of HIV and STIs.

It has been also reported that recreational or club drug use, including ATS use was

related to other sexual behaviours, such as having a higher number of sexual partners

(4, 37, 43, 98, 120, 121, 165, 166, 173, 175), and having sex with HIV positive partners

(107, 119-121, 165, 166, 172). Methamphetamine use in particular has been found to be

associated with having a higher number of sexual partners (4, 37, 43, 120, 121, 165,

166, 173), engaging in sexual marathons (4, 16, 18, 20, 37, 176) and participating in

group sex (16, 37, 43), having risky sex with casual or anonymous sexual partners with

whom they would never have had sex without the drugs (15, 16, 18, 43, 120, 166, 173)

and engaging in transactional sex or selling sex (4, 7, 37, 166). Co-administration of

methamphetamine with other illicit drugs may increase the likelihood of having sex with

many casual partners, anonymous or paid sexual partners (118), and having more RCAI

or ICAI with unknown status casual partners (119). Several studies suggest that gay or

bisexual men who use ecstasy are more likely to have more partners, have more one

night stand sex and practiced CAI (25, 177, 178). Furthermore, MSM who practiced CAI

are more likely to have high number of sexual partners, particularly having many casual

15

sexual partners (141, 142, 145, 147, 149, 174), participate in sex work (140, 169, 174,

179) and participate in group sex (145).

Overall, this research suggests a significant association between drug use and CAI and

other sexual behaviours, although evidence of causal relationships is lacking. However,

the findings can be variable, with some studies finding no evidence of an association

between drug use and CAI (4), possibly because of the difference in study designs,

sampling methodology, measurement of drug use and sexual behaviour and the potential

for underlying factors, such as contextual influences on drug use or confounding (117).

Nonetheless, understanding the association between drug use, particularly ATS use and

CAI practice, and other sexual behaviours is one of the essential components of any

study of drug use in MSM.

Environmental and situational factors

A number of studies have reported that MSM who frequent gay-specific sex venues,

such as bathhouses, saunas, gay bars and public cruising areas, are more likely to

engage in CAI (127, 140, 147, 180-182). Additionally, in the context of the popular

availability of the internet and social networking applications on smartphones, recent

studies have found that MSM who find sexual partners online are more likely to report

CAI, and have more sexual partners, particularly casual partners (73, 94, 131, 143, 183-

189). A recent meta-analysis of 11 observational studies found that MSM who initiated

sexual encounters online were more likely to participate in CAI or group sex (190). At the

environmental level, evidence has demonstrated that accessing HIV testing and other

HIV prevention services can be associated with a reduced likelihood of risky sexual

behaviours by MSM, if they receive safe sex counselling, (141, 191), while other studies

find that men who access HIV testing may report higher levels of CAI (142, 168, 192). In

either case, access to or uptake of HIV prevention and testing appears to be an influence

on the likelihood of CAI by MSM (193).

Cultural, societal correlates

Studies have analysed the relationships between societal and cultural factors and CAI.

Several studies have found that MSM who experienced homosexuality-related stigma

and discrimination (140, 194-196), internalised homophobia (197) or social isolation

(146) were more likely to report CAI. Additionally, MSM who suffered from social stress

(149) were more likely to report CAI. Moreover, MSM who perceived higher social norms

of condom use were less likely to report CAI (146), while MSM who had weaker safe-

sex norms were more likely to practice CAI (158, 198, 199). Lastly, research has shown

that MSM’s beliefs in the effectiveness of different HIV prevention strategies (such as

16

serosorting, strategic positioning and withdrawal) may affect their sexual practices. MSM

who practice strategic positioning and withdrawal or who believe that HIV treatment

reduces transmission are more likely to report CAI (140).

Correlations of HIV infection

This sub-section provides an overview of recent research regarding factors associated

with the risk of HIV infection among MSM. This includes studies with different designs,

including longitudinal, case-control and cross-sectional studies.


Studies from both high-income countries and LMIC have found socio-demographic

differences between HIV-positive and HIV-negative MSM. Some studies found that HIV-

positive MSM are more likely to be older (200-210), from lower socio-economic

backgrounds, including lower education levels (200, 202, 211-217), are unemployed

(206), or have low incomes (203). Conversely, some other studies found that HIV was

more prevalent among MSM younger than 25 years (200, 213, 218, 219) or MSM who

have higher incomes (220). Research more consistently finds that identifying as

homosexual or gay or exclusively having sex with men is associated with a higher risk of

HIV infection (203, 220-222). These findings suggest a diversity of socio-demographical

correlates of HIV infection, reflecting different epidemiological distributions of HIV

infection and variations in the ways studies were designed.

Sexual risk behaviours

Many studies have assessed the relationship between risky sexual behaviours, notably

CAI, and HIV infection. Both prospective and retrospective longitudinal studies have

consistently found that CAI, particularly RCAI, is the main risk factor for HIV

seroconversion among MSM (200, 205, 209, 214, 219, 221, 223) and it is also a strong

covariate of HIV prevalence in cross-sectional studies (203, 204, 206, 222, 224-230).

Position during anal sex may also be associated with HIV infection risk; longitudinal

studies have reported that MSM who practice receptive or versatile positions during anal

sex are more likely to get HIV infection than men who are exclusively insertive (200, 212,

231). Other behavioural risks of HIV infection in high-income and LMIC include having

a higher number of male sexual partners (205, 213, 214, 219, 231), participation in group

sex (200, 221), having sex with HIV-positive or unknown status partners (205, 219, 232)

and engaging in sex work (212). All of these risk factors have also been identified as

covariates of HIV prevalence in cross-sectional studies (203, 208, 215, 222, 224, 227,

233-237).

17

Previous studies have further found that MSM with a recent history of STIs and other

blood-borne infections, including syphilis, gonorrhoea, signs of genital ulcers and

hepatitis B or C virus are more likely to be infected with HIV (200, 205, 212-214, 221).

Findings from a number of cross-sectional studies also show a significantly higher rate

of STIs among HIV-positive MSM (203, 209, 210, 222, 228, 236, 238, 239), although

these STIs may occur after diagnosis of HIV.

Drug use behavioural correlates

Other widely reported behavioural correlates of HIV infection in MSM include drug use.

Longitudinal studies have found that MSM who use drugs generally or use drugs before

or during sex are associated with a higher likelihood of HIV infection (200, 240). Further,

evidence from longitudinal and case-control studies has demonstrated that erectile

dysfunction medications (EDM) and poppers (amyl nitrite) use increased the likelihood

of HIV seroconversion (200, 217, 219, 240). There is also some evidence that alcohol,

particularly binge drinking, increases the likelihood of getting HIV (241) and that

hazardous alcohol consumption in the last year was associated with HIV prevalence

(215). Additionally, drug use behaviour has been found to be correlated with HIV

prevalence in a number of cross-sectional studies (203, 210, 211, 226, 229, 242, 243),

although it is not clear if this drug use occurred before or after HIV infection. Injecting

drug use has also been found to be a risk factor of HIV seroconversion in a longitudinal

study (205) or a covariate of HIV prevalence in cross-sectional studies (83, 229, 236).

Regarding the association of ATS use and HIV infection, studies in the early period of

the HIV epidemic reported inconsistent findings. While almost all longitudinal and case-

control studies find that methamphetamine or amphetamine was a risk factor for HIV

seroconversion (200, 217, 219, 229, 239, 244-253), some cross-sectional studies did not

find this relationship (254, 255). In regard to ecstasy use and HIV infection, some studies

found significant associations between ecstasy use and HIV infection (196, 250-252),

while others found no relationship (217, 223, 247, 254, 256). The mechanism of how

drug use, particularly ATS use, may be associated with HIV infection is unclear.

However, because drug use and CAI are often associated, studying the influence of drug

use and particularly ATS use on HIV infection in MSM is still needed for informed HIV

interventions. Lastly, almost all studies of ATS use and HIV infection have been

conducted in high-income countries, while the evidence from LMIC is limited.

Other correlations

While the majority of studies focus on behavioural correlates, which could identify how

HIV is transmitted in a particular population, there have been few studies exploring other

18

correlates of HIV infection, which include interpersonal, environmental and cultural and

societal correlates of HIV infection.

As regards to interpersonal influences, some studies have shown that MSM who have

older sexual partners tended to have a higher risk of HIV infection (204, 223). Moreover,

disclosure of HIV status or agreement to have unprotected sex with sexual partners has

been found to be associated with a higher probability of HIV infection (223, 224). Studies

also found that HIV infection was more likely among men who had disclosed their sexual

orientation to family members or health care providers (220, 226).

In relation to environmental factors, HIV testing is regarded as one of the most important

components of a comprehensive HIV prevention package (257). Available evidence

suggests that accessibility to and uptake of HIV testing services or other HIV prevention

services increases the rate of diagnosis of HIV infection (200, 204, 211, 218, 220, 226).

Additionally, some studies have found that MSM recruited from parks and other venues

are more likely to be infected with HIV (232) possibly because MSM recruited in these

locations may be more likely to engage in sex work (258). Lastly, studies indicate that

MSM who have experienced sexual abuse or coercion may be more likely to be infected

with HIV (200, 206, 215).

Last but not least is how cultural and societal factors affect risks of HIV infection. Previous

studies have found that experiencing HIV- or homosexuality-related stigma and

discrimination or internalised homophobia is positively correlated with HIV infection (201,

215). Experience or perception of either HIV- or homosexuality-related stigma and

discrimination may prevent MSM from practising safe sex, or accessing HIV prevention

and treatment services (193, 257, 259), thus fuelling the transmission of HIV in this

population

Correlations of depression among MSM

Numerous studies have been conducted to understand the correlates of depression in

MSM. Many studies focus on exploring the correlation between socio-demographic,

behavioural, interpersonal and cultural, and societal factors with depression.

Socio-demographic characteristics

Although findings have been mixed, studies in both high-income countries and LMIC

have found that depression is more prevalent among MSM who are younger (55, 72,

260, 261), have lower levels of education (66, 67, 262, 263), are unemployed (263), have

low incomes (66, 72, 263) or are experiencing financial hardship

19

(70), are single (262, 264) or married to a woman (74, 262). Other personal

characteristics that have been found to be associated with depression among MSM

include being HIV-positive (68, 73, 76, 105, 262, 265, 266), not having any recent sex or

reporting sexual dysfunction (72, 262, 264), experiencing significant adverse events (72),

having a history of attempted suicide (264) and having low levels of self-esteem (261).


A number of studies have been conducted to explore the relationship between

depression and HIV-related risky sexual and drug use behaviours. Findings have been

mixed in term of the significance of the association, however, numerous studies in MSM

in different settings have found an association between depression and CAI (55, 66, 68,

69, 71, 80, 265, 267-270). MSM who have depression have been found to have more

regular sexual partners than other MSM (70), to be more likely to have engaged in sex

work (269) or perceive themselves to be at high risk of HIV infection (269).

Additionally, MSM who have depression, particularly men who are also HIV-positive, are

more likely to consume alcohol or other drugs (67, 68, 73, 76, 82, 105, 271). Specifically,

in a recent comprehensive review, depression was identified as one of the psychological

harms of regular methamphetamine use (14). Syndemic conditions, where there is a

comorbidity of several psychological disorders, may have synergistic effects on risky

sexual behaviours (265, 272-274). Lastly, some studies have found a significant

association between depression and being diagnosed with STIs, particularly syphilis (73,

275).

MSM with depression and other mental health problems may be less likely to benefit

from HIV prevention interventions (276). Further, mental health problems, particularly

depression can also compromise MSM’s access to and uptake of HIV prevention and

treatment services (272, 274).

Interpersonal correlates

Several studies focused on exploring community or interpersonal-related correlations of

depression in the MSM population. One of the most interpersonal factors which have

been studied relatively widely is the level of engagement with and social support received

from the gay community and network. The level of connection to the gay community and

emotional or social support received from other MSM peers in their gay friend network

have been found to be protective factors for depression in the MSM population (72, 73,

79, 261, 264, 277). On the other hand, there has been evidence that men who suffer

interpersonal isolation or withdraw from social opportunities have a higher probability of

having depression symptomology (72). Additionally, some available evidence has

20

reported that MSM who experienced CSA or maltreatment during childhood were more

likely to experience depression in their adult years (67, 264, 265, 278). Moreover, CSA

can result in long term adverse physical health problems such as negative perceptions

of overall well-being. CSA may also result in psychological disorders, such as anxiety,

low self-esteem and feelings of helplessness, anger, fear, shame, isolation, and a

negative perception of self (279-281). Several studies also reported that depression was

associated with disclosure of being MSM to other people (277) or disclosure of being

HIV-positive (76). As already presented, interpersonal factors, particularly engagement

or attachment with the gay community and gay friendship networks, may strengthen or

promote men practicing safe or risky drug use or sexual behaviours. Attending to the

specifics of these relationships is therefore important.

Cultural, societal correlates

Numerous studies have paid attention to the cultural and societal correlates of

depression. Previous studies in both high-income countries and LMIC consistently report

that MSM who suffer from racism, HIV-or homosexuality-related stigma, are more likely

to report depression and anxiety, maybe because of subsequent associated hostile

environments (55, 67, 69, 73, 74, 264, 277, 282-286). A recent study in China found that

homosexuality-related stigma was indirectly associated with depression and anxiety

among MSM (283). Another study in Australia found that internalised homophobia and

perceived and experienced stigma were related to psychological distress and suicidal

ideation among LGBT people (286). One study in India found that gender-nonconformity

stigma and HIV-related stigma were associated with a higher degree of depression

among MSM (285). A study in the US found that experiencing racism was associated

with depression among ethnic minority MSM (282).

To summarise, stigma and discrimination, including that related to homosexuality, is

correlated with HIV infection and risky drug use and sexual behaviours. Stigma and

discrimination may also be associated with mental health problems, particularly

depression, among MSM.

SEX, DRUGS USE AND THE HIV EPIDEMIC AMONG MSM IN VIETNAM

Vietnam at a glance

Vietnam is a country located in the Southeast Asia region, bordering China, Cambodia

and Laos. The estimated population in 2013 was 92.5 million, with 47% of people working

in the agricultural sector and 21% working in the industrial sector. The reported Gross

21

Domestic Product (GDP) per capita in 2013 was US$1785(287). As of 2014, Vietnam

had 64 provincial or cities level administrative units and approximately 33% of the

population was estimated to be living in urban areas. The literacy level among people

aged 15 years or older was 94.7%, with slightly higher levels of literacy among men than

women (96% versus 93%). In 2014, the unemployment rate among working-aged people

was 3.4% with lower rates in urban areas (1.2%), particularly Hanoi (0.99%) and Ho Chi

Minh City (0.3%) (288).

Vietnam was under Chinese imperial rule for approximately 1000 years until it reclaimed

its independence in 938 AD. In 1867, France colonised Vietnam and set about ‘civilising’

and modernising what the colonial regime perceived to be Vietnam’s old and primitive

society. During this time, Vietnam underwent dramatic political, economic and social

changes (289). Vietnam retained a feudal regime until 1945, when Vietnam’s Revolution

Movement, under the leadership of the Vietnamese Communist party, liberated Vietnam

from French Colonial governance and the Nguyen dynasty. During the feudal regime

period, Vietnamese culture and society were profoundly influenced by Chinese

Confucian ideology and culture (289). After the 1945 revolution, Vietnam was at war with

France until the1954 Geneva Agreement divided the country into the North (following

socialist ideology and supported by the Soviet Union and China) and the South (ruled by

a US-backed government). In the 1960s a war broke out between the Vietnam

Democratic Republic Government in the North and the Government of the Republic of

Vietnam in the South, in which the US government became involved. This war is known

as either the Vietnam War or, in Vietnam, the American war. During the Vietnam war,

South Vietnam experienced significant economic and social changes toward capitalism

and Western freedoms (289). However, traditional Confucian beliefs and practices were

still observed in both parts of the country.

After the national reunion in 1975, when the American war ended, until the middle of the

1980s, Vietnam had a subsidised, centrally managed, state-owned economy. This

changed substantially after 1986 when a socialism oriented, open-market economy was

introduced in the reform period known as “Doi Moi” (290). This reform, together with the

lifting of economic embargoes imposed on Vietnam after the reunification of the country

in 1975 until the late 1990s, has resulted in dramatic social and economic changes, with

increased cultural exchanges and trade between Vietnam and other countries, increased

production, growth of gross domestic product, reduced poverty, and increased life

expectancy (291) . These dramatic changes in recent years have substantially affected

the position of male homosexuality in Vietnamese society.

22

Male homosexuality history in Vietnam

Over a decade ago, Blanc published a seminal analysis of the historical position of male

homosexuality in Vietnamese society (292). Blanc noted that throughout Vietnam’s

history from the ancient period under Chinese rule until today , Vietnamese culture,

family and gender roles have been profoundly influenced by Chinese Confucian

ideology, particularly in rural provinces (293). With regard to gender, Vietnam has

traditionally been a patriarchal society that assumes there are two genders (male and

female) and in which men have more power than women. Historically, homosexuality

was largely invisible because of Confucian influences, according to which

heterosexuality was normative in order to maintain families and bloodlines (292).

Therefore, during Chinese rule and the Vietnamese feudal period, there was little visibility

or discussion of homosexuality. Some “shaman” and “medium” roles in spiritual and/or

religious settings appear to have been exceptions to this limited visibility. These

“shamen” or “mediums” performed ritual worship and songs and dances to communicate

with God or ancestral spirits in temples. In these roles, men could adopt non-gender-

conforming roles that allowed for expression of homosexuality. At the same time, these

men acquired relatively high social and religious status and earnings. However, there

was little discussion or recording of sexual relationships or behaviours of these “shamen”

and “mediums” (292).

Vietnam was exposed to Western ways of living and concepts with the arrival of the

French in the mid-19th century and the Americans in South Vietnam during the mid-20th

century. The contemporary globalisation process has also contributed to significant

social and cultural changes, including changes in perceptions and practices of

homosexuality (292). During the French colonial period, and subsequently in

contemporary Vietnam, exposure to Western modernity increased the visibility and

expression of homosexuality. However, at the same time, gender inequality set out in

Confucian ideology was reinforced with the introduction of Judeo-Christian moral

standards. Since the colonial period, male homosexuality was seen as a disease or

disability, or a moral failing or deviance, imported by Western men. Homosexuality was

sometimes misunderstood by both the general public and health providers to be limited

to emotional closeness between men, without sexual relations (292). Homosexuality

remained relatively invisible before Doi Moi and was not particularly discussed or

stigmatised. Since its visibility increased, however, people who express their

homosexuality have become targets for social stigma and discrimination (294).

23

From the Doi Moi period, Vietnam has rapidly increased the extent of social, cultural and

economic exchange with the rest of the world. Homosexuality has also become more

visible in society. Gay-specific venues such as cafés, bars and discotheques have been

established, and road sides and parks where men meet are easier to recognise in urban

settings, particularly in big cities such as Ho Chi Minh City and Hanoi, These various

venues attract local MSM as well as foreign visitors (292). Websites, online forums and,

more recently, social media such as Facebook, are easy for gay men and other MSM to

access and have become important channels for men to network, exchange information

and date, as well as to advertise or obtain sex work.

In recent years, there has been a movement to promote and advocate for the rights of

LGBT people in Vietnam. LGBT people have become visible in mainstream Vietnamese

media and on the websites of government agencies. As an alternative to derogatory,

slang words to describe homosexual practices and identities, some non-governmental

organisations such as The Institute for Studies of Society, Economics and Environment

(http://www.isee.org.vn/en/Home/About) or ICS (https://www.facebook.com/icsvn) have

promoted a classification that is aligned with Western typology. According to this system,

sexual orientations in Vietnam are defined as dong tinh (gay/homosexual), song tinh

(bisexual) and di tinh (heterosexual). Currently, almost all published studies about MSM

in Vietnam use this sexual orientation classification system, as it is readily understood

overseas (266, 295-297). I have used this classification system in my research with MSM

in Vietnam as Vietnamese gay, bisexual and MSM regard these labels as acceptable

and non-stigmatising

Drug use in Vietnam

Vietnam is located in a region that is recognised for the production, smuggling and use

of illicit drugs, including opium, heroin and, increasingly in recent years, ATS (30-34,

298). As reported by UNODC, in almost all countries in the South East Asia region, the

smuggling and use of methamphetamine pills, crystal methamphetamine and ecstasy

has increased steadily in the period from 2008 to 2012 (298).

Like other countries in the region, Vietnam has viewed the use and production of illicit

drugs as important problems for decades (299). In 2012, it was reported that there were

172,000 current drug users in Vietnam, mostly using heroin or opium, followed by

synthethic drugs (i.e. ATS) and other illicit drugs (298). A recent Government report

noted that the number of reported recent illicit drug users in Vietnam had increased from

143,196 in 2010 to 204,377 in 2014 (300). The 2012 UNODC report, which drew on data

24

https://www.facebook.com/icsvn

provided from the Vietnam Government, noted that nearly half of the drug users were

young people (16 to 30 years old) and most of the drug users (96%) were male (298).

The dominance of men in drug use in Vietnam probably reflects gender norms and

prejudice against women using alcohol, tobacco and other substances. The UNODC

(2012) also highlighted that the most popular routes of administration of illicit drugs in

Vietnam included smoking and injecting, with injecting being the most common method

for heroin use.

The use of opium has been dominant in the country, especially in the Northern

mountainous areas, from the 19th century until the middle of the 1990s. Since then, a

shift has occurred to heroin use and then from the early 2000s, to ATS use (299). In

2010, ATS, including methamphetamine pills, crystal methamphetamine and ecstasy,

were ranked the second most commonly used drugs in Vietnam, after heroin (298). The

drug use reporting and monitoring system in Vietnam has typically focused on the harder,

more potent drugs such as morphine and heroin. However, conversations with key

informants and experts suggest that many new drug users in Vietnam are perceived to

be ATS users. Therefore, the drug monitoring and reporting system may have

underreported the use of ATS and other recreational drugs. Nevertheless, the prevention

and treatment of ATS use have been recognised as key objectives of Vietnam’s Illicit

Drugs Prevention and Control Program for the period 2016 to 2020 (300).

MSM and drug use in Vietnam

There was little information about drug use among MSM in Vietnam, particularly before

2010. Studies conducted in early the 2000s in Ho Chi Minh City found a low prevalence

of lifetime drug use, of 2% to 6%, in MSM (296, 301). In the late 2000s, studies in different

parts of the country found levels of drug use, including ecstasy and methamphetamine

use, ranging from 16% to 30%, reflecting different recall periods (81, 297, 302).

Since 2006, the Vietnam Government has implemented periodic monitoring of HIV

behavioural and biological indicators called IBBS in Vietnam. Three rounds of IBBS have

been conducted. The IBBS is different from community-based and online studies in the

way it recruits participants. Participants of IBBS are recruited by Respondent Driven

Sampling (RDS). Additionally, participants who engage in sex work are targetted.

Reports from IBBBs found higher levels of lifetime drug use in MSM samples in Hanoi

and Ho Chi Minh City, ranging from 21-23% in 2006 and 25-32% in 2011 (303, 304).

Although data from IBBS also showed a relatively low proportion of men who had injected

drugs (less than 10%), the sampling approach appeared more likely to reach subgroups

25

of MSM who used illicit drugs than that of community-based studies. All of these earlier

studies, however, used nonspecific indicators of drug use (i.e. ‘any drug use’) that does

not provide information on use of ATS or specific types of drugs.

From 2010 onwards, studies began reporting on ATS use in MSM. A study of male sex

workers in three cities reported a prevalence of amphetamine or methamphetamine use

in the last 30 days of 17% and of ecstasy use of 12% (305). Another study conducted

among MSM in 12 Southern provinces who reported ever having used drugs found that

18% had ever used ecstasy and 7% had ever used methamphetamine (210). Studies

also found a high prevalence (>50%) of lifetime or current alcohol use in MSM, across

time and geographical locations (210, 296, 305, 306).

Despite using different measures and designs, the data suggests that drug use by MSM

in Vietnam has increased during the past 20 years, particularly in the Southern provinces

and larger cities. It may also reflect the fact that recent studies, particularly IBBS,

sampled subgroups of MSM who consumed more drugs. Nevertheless, data on drug use

by MSM remains scarce.

Correlates of drug use in MSM in Vietnam

There are relatively few accessible, published studies on the correlates of drug use,

particularly ATS use, by MSM in Vietnam. There have only been two published

quantitative studies in which drug use is the primary outcome found in PubMed. A study

conducted with MSM in a Southern province of Vietnam found only a few significant

behavioural covariates of injection drug use, including having partners who injected

drugs, alcohol use, and having sex with non-paying female sexual partners in the last six

months (307). Another study found that any recent drug use in MSM was significantly

associated with depression (81). A qualitative study on substance use among drug-using

MSM in Vietnam found that participating MSM used different types of drugs, including

heroine, methamphetamine, ecstasy, ketamine, and marijuana. Any drug use was

related to not using condoms during sex and overcoming social stigma towards

homosexuality and sex work in those who were involved in selling sex (308).

In the context that drug use by MSM appears to have increased in recent years,

particularly the use of ATS, evidence regarding the magnitude of drug use and its

correlations is urgently needed to provide information for effective and targetted drug use

interventions for MSM in Vietnam.

26

HIV-related risky sexual behaviours in MSM

There is a body of literature on the extent of HIV-related risky sexual behaviours,

particularly CAI, among MSM in Vietnam. At least 16 quantitative studies have reported

various measures of risky sexual behaviours (81, 295-297, 301, 302, 305-307, 309-315).

Data on HIV-related sexual behaviours is also available from IBBS reports. Some

qualitative research provides valuable supplementary insights on HIV-related sexual

behaviours among MSM in Vietnam.

In the early 2000s, community-based studies with MSM in big cities in Vietnam (i.e. Ho

Chi Minh City and Hanoi), as well as studies conducted in smaller provincial towns, found

a relatively high proportion (41-67%) of men had engaged in CAI with different sexual

partners in the last month and a high proportion (32-71%) reported CAI at their last sexual

encounter (295, 296, 301). A study reported in 2010 found that many (50%) young MSM

in Hanoi men scored high on a combined index of risky sexual practices which included

the number of sexual partners, use of condom during anal sex and consistent use of

condom during any sexual intercourse in the last 30 days (307). More recent studies

conducted online find high proportions (64-69%) of MSM reporting CAI with casual and

regular partners in the last month (311), in the last six months (41-63%) (310) (310), as

well as with any male partners in the last three months (36%) (36%) (312). Studies have

also found that rates of CAI during recent transactional sex, either with paid or paying

partners, are generally lower (21-33%) (81, 311).

IBBS findings in Hanoi and Ho Chi Minh City suggest that reports of CAI with regular and

casual partners in the last month have reduced from 63-71% in 2006 to 46-70% in 2011,

and 41%-60% in 2013, as has CAI with transactional sexual partners in the last month,

from 77-96% in 2006 to 41%-85% in 2011, and 1%-44% in 2013 (303, 304, 316).

However, findings from community-based studies, online studies and IBBS may not be

directly comparable because of different study designs and sampling methods. Because

IBBS surveys in Vietnam recruit participants by RDS and by sex work status, these

surveys may reach networks of MSM who are more likely to report high levels of CAI

(although rates have declined in the IBBS rounds). Community-based and online studies

suggest rates of CAI may have remained high in other groups of MSM in Vietnam.

Correlates of CAI practice

Correlates of CAI among MSM population in Vietnam are not well researched. Some

studies found that there were higher rates of CAI among MSM in Vietnam with higher

income level (312), more alcohol consumption before or during sex (305, 311), higher

27

perceived risk of HIV infection (311), and a history of sexual violence and childhood

sexual abuse (81). CAI was less likely among MSM who found casual sexual partners

on the internet, who had paid sexual partners in the last six months and who had multiple

casual sexual partners in the last six months (311).

When being treated as a covariate in the analysis of other health outcomes, CAI has

been found to be positively associated with enacted (i.e. experienced) homosexuality-

related stigma, being classified as having depression and having used drugs in the last

30 days (302), alcohol dependence and childhood sexual abuse (81). However, CAI was

not found to be associated with having never tested for HIV, willingness to use the

internet for seeking HIV prevention services or sex work related stigma (309, 310, 317).

In addition, several qualitative and review papers provide valuable insights into the

sexual practices of MSM in Vietnam. Qualitative data showed that MSM in Vietnam tend

to have concurrent, short-term sexual relationships and casual partners when they are

seeking new and interesting sexual experiences, or when they are not in a romantic

relationship with another man (318-322). MSM’s narratives from qualitative studies also

suggest that inconsistent condom use is pervasive among MSM because condoms are

perceived as a sign of a lack of trust between sexual partners, particularly men who are

in long-term relationships (318, 320, 321). Condoms are also perceived with a loss of

sexual pleasure and are less likely to be used with sexual partners who are perceived to

be healthy (319-321). A review of Vietnamese MSM vulnerabilities to HIV infection

reported similar findings (323).

Apparently, there is a lack of knowledge in terms of the correlations associated with CAI

by MSM in Vietnam, particularly in relation to evidence from quantitative studies.

HIV epidemic among MSM in Vietnam

HIV was first reported in Vietnam in the early 1990s (324), and since then the epidemic

has rapidly spread in different parts of the country during the last 30 years, being reported

in all provinces and cities from 1999 (325). In its early stages, the HIV epidemic was

concentrated in specific key populations, in particular people who inject drugs and female

sex workers. Injection drug use initially was the dominant route of HIV transmission,

accounting for over 88% of new cases during the late 1990s (325, 326). As reported by

the Vietnam Administration HIV/AIDS Control Office (VAAC), at the end of 2015, the

national, cumulative number of people diagnosed with HIV was 227,154, of whom 85,194

had progressed to AIDS and 86,176 had died of AIDS (327).

28

MSM were not identified as a key population for HIV in Vietnam until the mid-2000s, and

were largely ignored in Vietnam’s HIV surveillance and intervention efforts (292, 328).

Nevertheless, in the early 2000s, there were initial warning signs of HIV spreading

among MSM in Vietnam (323). An early study of MSM in Ho Chi Minh City pointed out

that MSM had inaccurate knowledge about HIV prevention and transmission and

engaged in risky sexual behaviours such as having multiple sexual partners and CAI

(296). Despite this, it was only in the late 2000s that MSM were officially identified as a

key population for HIV (329). Since the mid-2000s, several reports and published papers

drawing on National HIV/AIDS Sentinel Surveillance, IBBS or community-based studies

have assessed the magnitude of HIV infection among MSM in Vietnam. While IBBS

found an increasing HIV prevalence in MSM in major cities during 2005-2009 (304, 330),

there was a declining trend from 2013. Meanwhile, both recent community-based studies

and IBBS have found a lower HIV prevalence in smaller provinces: 0.0% in Khanh Hoa

in the central region (295), 2.6% in eight Mekong delta provinces (210), 1.1% in a

Southern provincial town(316), 6.3% in another Southern provincial town (297) and 5.4%

in a Northern city(316). The trend of HIV prevalence in four major cities in Vietnam is

summarised in figure 2.

29

Figure 1.2. Trends in HIV prevalence among MSM in Vietnam from 2005-2013 from

Integrated Biological and Behavioural Surveillances (IBSS)

(Source: National Institute of Hygiene and Epidemiology (Vietnam Ministry of Health).

HIV/STI Integrated Biological and Behavioural Surveillance (IBBS) in Vietnam. Results

from Round III and trends across three rounds (2005-2009-2013) of the survey)2

Because of different study designs, sampling methods, different subjects’ inclusion

criteria, findings from IBBSs and community-based studies are hard to compare. Other

factors such as HIV–related mortality and migration might have affected the HIV

prevalence. Therefore, it is difficult to conclude if there has truly been a decrease of HIV

prevalence among the MSM population in Vietnam, particularly in big cities (i.e. Hanoi

and Ho Chi Minh City).

Correlates of HIV infection among MSM in Vietnam

Because MSM in Vietnam were only considered as a population at risk of HIV infection

during the mid-2000s (328, 331), there have been few published studies exploring the

associated factors and/or risk factors of HIV infection among this population. Though

IBBS have collected both behavioural data and delivered HIV testing, there has only

been one analysis of the relationship between behavioural data and HIV prevalence

among MSM (332). A systematic review of available papers in PubMed found five

published papers that analysed the correlations of HIV infection in MSM since the

beginning of the epidemic in Vietnam (295, 301, 314, 332, 333). All of these studies were

conducted in Southern provinces and cities; two were conducted during early 2000s

(295, 301) and the other three were conducted during the late 2000s (297, 332) and/or

early 2010s (314).

In the first study of the correlations of HIV infection among MSM in Ho Chi Minh City

conducted in 2004 (301), Nguyen et al found being older, having lower education levels,

currently participating in selling sex, injecting drugs in the past 12 months and having

more than five male sexual partners in the past month were associated with HIV

infection. Another analysis using IBBS data for MSM in Ho Chi Minh City in 2009 (332)

reported similar findings of the association between older age, lower education levels

and a high number of sexual partners with HIV infection. Studies in the late 2000s

reported that HIV was more prevalent among men who had sexual partners who injected

drugs, who felt at risk of HIV infection, or who were injecting drug users (IDU) (297, 314).

Other factors positively associated with HIV infection among MSM in Vietnam include

2 The candidate received agreement from the National Institute of Hygiene and Epidemiology, Vietnam Ministry of Health for the reproduction of this figure in this thesis.

30

ever having used recreational drugs, particularly ATS and heroin, alcohol consumption

in relation to sex, ever having had sex with foreign sexual partners, being diagnosed with

syphilis (314), having CAI with female sexual partners and being transgender versus

cisgender (297). In agreement with other studies, consistent condom use during anal sex

was associated with a lower risk of HIV infection (314). While published research has

found no evidence of associations between HIV infection and occupation, employment,

or income levels among MSM, findings have been mixed with respect to associations

between HIV infection and sexually transmitted infections (STI), sex work and sexual

orientation (210, 297, 301, 332). In agreement with other studies, consistent condom use

during anal sex was associated with a lower risk of HIV infection (314).

As of note, all published literature on the associations with HIV among Vietnamese MSM

was conducted in the Southern provinces and cities during the 2000s. Updated evidence

is needed on the correlations of HIV infection, for example ATS use, particularly in the

Northern provinces and cities of Vietnam.

A SOCIO-ECOLOGICAL APPROACH TO STUDYING HEALTH AND WELL-BEING

Multilevel influences on health outcomes

Health conditions are often caused by multiple factors at different levels from individual

characteristics and pre-conditions to cultural and societal influences. Therefore, a holistic

understanding of the range of influences over health conditions can assist us in designing

effective interventions. It has been already argued that any study of people’s health

behaviours conducted in separation from the study of the wider environment and the

societal and cultural context is incomplete and insufficient to comprehend the complex

causes of human health and illness (334). Several epidemiologists have advised that

without considering structural factors that include societal and cultural influences, the

application of behavioural interventions to solve public health problems is unlikely to

result in successful outcomes (334, 335). Additionally, the heterogeneity of disease

patterns and socioeconomic variations in disease distribution found in previous studies

highlights the fact that there are rarely single, explanatory determinants or interventions

for health problems and as such, a multilevel approach is useful for understanding poorly

researched health issues (336). Lastly, it has been proposed that patterns of health and

disease in the population can be explained by a complex matrix of various interconnected

risks and protective factors, sometimes referred to as a “web of causation” (337).

31

In response to the need to understand the multifaceted influences of disease and well-

being, during the late twentieth century, social epidemiologists started to pay attention

to the societal and cultural determinants of health and illness (338). These

epidemiologists proposed multilevel, ecological perspectives, containing multiple factors

at different levels. These perspectives were described with various names, including eco-

social theory (337), eco-epidemiology (339), and the social-ecological perspective (338).

In this section, I focus on core principles of the eco-epidemiology perspective proposed

by Susser and Susser (339). This perspective proposes that the influences on health,

disease and well-being may occur in localised systems or organisations, as well as

interactively across multiple levels, ranging from individual biological characteristics to

the surrounding physical, societal, and cultural environment. Therefore, to better

understand population health and changing patterns of disease, modern epidemiology

should analyse the organisation of health and illness from molecular research to:

comprehend disease pathology and aetiology, biological studies of tissues, cells and

physiology, behavioural studies, and the identification of environmental, societal, cultural

and political influences in different locations, nations and populations. Additionally, this

eco-epidemiology perspective also encourages the assessment of the interaction of

factors across these levels. The authors proposed this approach to be seen as a “skeletal

framework” (339), from which a specific and localised conceptual framework could be

developed for each particular health condition or disease in a particular population at a

particular time. The evolving of a social-ecological framework from multilevel, ecological

perspectives for health behavioural studies is described in the following paragraph.

During the early 2000s, multi-level, ecological perspectives were adapted to understand

various health behaviours, including physical exercise among young children (340),

violence (341), prevention and control of STIs in adolescents (342), and HIV-related risky

sexual behaviours related to alcohol consumption (343). For each of these frameworks,

individual behaviours are examined in the context of the influences of the surrounding

social and physical environment. As such, this conceptual perspective is often called the

socio-ecological framework. The framework has common features such as concentric

spheres of influence, in which the innermost sphere is the individual. The spheres that

come after this may be labelled family, interpersonal, community and neighbourhood

where the interactions of an individual with his/her family members, intimate partners

and peers have strong influences on beliefs and social norms about drug use and sexual

behaviours, for example, and consequently affect behaviour. The outermost sphere is

the societal environment which may include policy and gender or racial discrimination

(homosexuality-related stigma and discrimination, for example), which may have potent

32

influences on an individual’s behaviour. In the next paragraph, I describe the socio-

ecological framework for the study of HIV-related risky sexual behaviours and alcohol

consumption by Scribner (343) from which my conceptual framework is adapted.

In 2010, Scribner et al (343) proposed an adaptation of a socio-ecological framework for

their study of HIV risk behaviours in relation to alcohol consumption. In their proposed

framework, they underscored the importance of understanding risk behaviours at

multiple levels that could affect individuals’ HIV risk behaviours, in which individuals are

embedded within interpersonal networks, neighbourhoods, environments and a societal

structure influenced by policy. Individual factors included personal characteristics,

alcohol consumption, substance use and sexual behaviours. Interpersonal factors

included social and sexual networks in which the target population was embedded.

Sexual network factors included network size, density, network member characteristics

and the roles that alcohol played in shaping social and sexual networks. Interpersonal

factors include the roles of alcohol outlets where people meet, and social norms about

alcohol consumption and safe sex. Neighbourhood factors included the density of

available alcohol outlets. Societal factors included policies that regulated alcohol’s

availability and thus consumption. The framework suggests core principles of a socio-

ecological framework in which HIV infection is a product of multiple influences, from

individual-level risk factors to societal and cultural factors. Of note, the multilevel

framework suggests that environmental and social factors do not directly affect health

outcomes or behaviours but these macrosocial factors (including alcohol consumption

policy, neighbourhood alcohol outlet environments) and microsocial factors (social

networks and social norms) can interact to either prevent or promote individual-level

behaviours such as alcohol consumption, drug use and sex. The framework is illustrated

in figure 3. Of note, researchers have become increasingly interested in what is referred

to as ‘syndemics’ of multiple health problems and risk factos that may increase the HIV

risk of MSM. Briefly, the syndemic approach assesses the synergistic and cumulative

effects of multiple adverse life experiences that may be experienced by MSM, reducing

resilience and increasing the risk of HIV, such as childhood sexual abuse, depression,

anxiety and drug use (265, 272-274). In particular, Stall et al (some of the primary

proponents of the syndemic approach) argue that co-occurring social stressors and

negative life experiences may amplify each other, increasing the likelihood of risky sexual

behaviour and HIV infection (272).

33

Figure 1.3. Socio-ecological framework for the study of HIV risk and alcohol

environment

(Source: Scribner R, Theall KP, Simonsen N, Robinson W. HIV Risk and the Alcohol

Environment: Advancing an Ecological Epidemiology for HIV/AIDS. Alcohol Research

& Health. 2010;33(3):179-83.)3

A socio-ecological approach for ATS use and impacts among MSM in

Vietnam

Most of the previous studies on drug use in different settings, including Vietnam, have

focused on the behavioural aspects of health-related harms associated with drug use.

Studies rarely examine the influence of personal, environmental, community or

interpersonal, societal and cultural factors on drug use and associated harms (4).

Additionally, in HIV research and prevention, it has been argued that while the

pathological organism (i.e. HIV) and transmission routes of the virus are well understood,

the epidemic continues to affect both high-income countries and LMIC (83-85, 344),

meaning that interventions that primarily target individual behaviours (i.e. sexual or drug

use behaviours) do not appear to be sufficient to prevent the transmission of the virus. It

has been recommended that a comprehensive HIV prevention package which addresses

structural barriers, for example, homosexuality-related stigma and discrimination, is

essential to control the epidemic (193, 257). We have identified many factors which

influence HIV-related sexual and drug use behaviours, but changing these behaviours is

harder (345). It has also been argued that studies of drug use and sexual behaviour risk

3 This article is in the public domain and it may be reproduced without permission.

34

factors at the individual and personal levels have not been sufficient to reduce risk and

harms (343). A socio-ecological approach, therefore, is likely to be helpful in better

understanding ATS use and its associated harms in MSM, but it is likely to remain difficult

to change in practice. Nonetheless, the results of a multi-level analysis may be useful in

providing evidence for a holistic HIV prevention, care and treatment approach at not only

the individual level but also at the social and structural levels (193, 257).

In Vietnam, there has not been any reported study on ATS use and its associated health-

related harms among MSM. To specifically guide the assessment of ATS use and its

associated harms among MSM in Vietnam, I propose a social-ecological framework,

including various factors at different levels, that is based on the literature presented

above and summarised below (see Figure 4).

Figure 1.4. The proposed Socio-Ecological Framework for the study of ATS use and

associated harms in Vietnam

Individual, personal factors. Evidence from other settings has demonstrated that

demographic and other socio-economic characteristics can be associated with drug use

behaviour in different ways. Additionally, other literature has shown that personal traits,

such as sexual sensation seeking, can be associated with both drug use and risky sexual

behaviours (112, 113). Moreover, other comorbid conditions such as depression can be

associated with men’s propensity to engage in drug use and risky sexual behaviour (268,

35

269). In my study, individual factors include socio-demographic characteristics, sexual

sensation seeking and depression.

Community/interpersonal factors. Men’s engagement with the MSM community may

impact ATS use as well as sexual behaviours. Attachment to the gay community can

be associated with drug use and sexual behaviours among MSM in negative or positive

ways (134, 346). Interpersonal factors such as social support can also be associated

with sexual behaviour (342) and with beliefs about the effectiveness of different HIV

prevention strategies. Moreover, interpersonal interactions among men in gay social

networks might also shape their perception of how popular drug use is in the network

(134). There has been no evidence of the relationship between attachment to the gay

community, the level of social support and perceptions of ATS use and sexual

behaviours in MSM in Vietnam. This study is the first to assess these relationships.

Environmental factors. Previous evidence in both high-income and LMIC countries

has shown that utilisation of HIV prevention services, particularly HIV testing services,

can be associated with either increased or decreased probability to engage in risky

sexual behaviours (141, 174, 191) and HIV infection (200). Additionally, HIV testing is

generally regarded as an essential component in any HIV prevention package (257). In

my study, I assessed the use of HIV prevention services, including free condoms, HIV

testing, safe sex counselling and STI diagnosis and treatment.

Cultural, societal factors. Homosexuality-related stigma and discrimination can

create a hostile environment which is subsequently associated with psychological

distress including drug use and depression (50). Additionally, homosexuality-related

stigma and discrimination may also increase men’s propensity to engage in risky

sexual behaviour including CAI (140) and prevent men from accessing HIV prevention

services (257). Homosexuality-related stigma and discrimination is being regarded as a

structural barrier to HIV prevention (257). I therefore assessed homosexuality-related

stigma and discrimination, including enacted (experienced) stigma, perceived stigma

and internalised homophobia.

RESEARCH QUESTIONS AND STUDY OBJECTIVES

Research gaps in drug use, risky sexual behaviours and HIV infection in

MSM in literature

There are several gaps in the understanding of drug use behaviours, including ATS use,

and their relationship with risky sexual behaviour and HIV infection, particularly in MSM

in the current literature. Firstly, most of the current literature is from high-income

36

countries and literature about drug use, particularly ATS use among MSM in LMIC

countries, including Vietnam is limited (4, 7). Secondly, most of the current quantitative

studies on drug use, including ATS use in this population (68, 98, 146, 148, 160-162,

175), except for a few studies which measured specific types of drug use before or during

sex (149, 157, 158, 163-165), often combine all drugs together to make a composite

drug use index. As such, understanding the correlates of individual drug use is difficult

to achieve. Thirdly, most of the studies, particularly studies from LMIC countries, often

measure overall drug use with different recall periods and separately examine sexual

behaviours. More than 20 years ago, Leigh and Stall suggested stronger, more rigorous

measurements for drug use, including contextual, sex-related drug use (i.e. drug use

before or during sex) and event-level drug use (i.e. drug use in specific sexual events)

(347). Last but not least, in almost all of the current studies looking at drug use, including

ATS use, and its relations to HIV-related risky sexual behaviours, these behaviours have

not been assessed in a broader interpersonal, contextual, cultural and societal

perspective (334-337). To contribute to a much needed holistic understanding of drug

use, in particular ATS use among MSM in Vietnam, a multifaceted assessment from a

socio-ecological perspective has been undertaken.

Research gaps in drug use, risky sexual behaviours and HIV infection in

Vietnam

To date, knowledge of the correlations or risk factors of drug use, sexual behaviours and

HIV infection in MSM in Vietnam remains limited. While studies with MSM in Vietnam

have placed considerable emphasis on identifying risky sexual behaviours, there has

been little research on drug use behaviours among Vietnamese MSM, particularly the

recent emerging use of ATS. Knowledge of the popularity of drugs and correlations of

drug use, particularly ATS use, in MSM in Vietnam is limited. Additionally, studies have

often used simple indices of drug use, such as ‘any drug use’, but have not specifically

measured the use of individual drugs. Additionally, as elsewhere, studies undertaken in

Vietnam have often used composite indices of drug use, such as ‘any drug use’, but have

not specifically assessed the use of specific drugs. Furthermore, in the context of

increasing use of ATS and other stimulants in Vietnam, particularly among MSM,

knowledge of ATS use and its association with HIV-related sexual risk behaviours and

HIV infection, as well as its potential psychological harms, particularly depression, is

much needed. Currently it is unknown if ATS use among MSM in Vietnam has any

relationship with HIV-related sexual risk behaviours and HIV infection, and if ATS use is

associated with mental health problems in MSM, including depression. Previous

research seems to have mostly focused on mapping sexual risk behaviour among MSM

37

in Vietnam, in particular in Ho Chi Minh City and southern provinces of Vietnam; evidence

is lacking from the northern province cities, notably Hanoi. Furthermore, understanding

of the multilevel influences on sexual risk behaviours in MSM in Vietnam has remained

limited. Some experiential evidence is available from qualitative studies in small samples

of MSM, but quantitative, correlational data is lacking. The majority of studies on drug

use, sexual risk behaviours and HIV infection has focused on behavioural correlates and

has not addressed interpersonal, cultural, and societal factors.

Rationale for this study

The shortcomings and gaps in research into the drug use, particularly ATS use, sexual

risk behaviour, HIV infection and wellbeing among MSM in Vietnam create challenges

with respect to the development of targetted, effective HIV prevention interventions in

the context of emerging ATS use among MSM in Vietnam. Accordingly, I have conducted

this study to answer the following research questions:

▪ What is the magnitude of ATS use among MSM in Vietnam?

▪ What are the patterns and correlates of ATS use among MSM in Vietnam?

▪ Is ATS use associated with HIV-related risky sexual behaviours, particularly CAI,

among MSM in Vietnam?

▪ Is ATS use associated with HIV infection among MSM in Vietnam?

▪ Is there any relationship between ATS use and psychological distress, namely

depression, among MSM in Vietnam?

To answer my research questions, I conducted an integrated research project, including

a community-based, cross-sectional survey in major cities in Vietnam and a systematic

review and meta-analysis of the relationship between ATS use and HIV infection in MSM.

This research is the first to investigate ATS use in depth in the MSM population in

Vietnam. The findings of this study are designed to help understand associations

between ATS use and sexual behaviour, and HIV risk and associated psychological

disorders, particularly depression symptomology, among MSM in Vietnam. The findings

will assist with identifying appropriate, integrated interventions to reduce the harms

potentially associated with ATS use among MSM, especially harms that can lead to HIV

and other STIs. In such a way it will contribute to preventing the spread of HIV and other

harms among MSM – a marginalised and key population in Vietnam. Additionally, this

research suggests 1urther research priorities related to drug use, sexual behaviour, HIV

infection and mental health among MSM in Vietnam.

38

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69

CHAPTER 2

METHODOLOGY OF THE CROSS-SECTIONAL SURVEY IN VIETNAM

AND THE SYSTEMATIC REVIEW AND META-ANALYSIS

70

In this chapter, I describe the research protocol for the community-based survey in

Vietnam and the systematic review and meta-analysis that I conducted. Please note that

the study design and analytical strategy are also described in each of the published

manuscripts.

COMMUNITY-BASED, CROSS-SECTIONAL SURVEY OF MSM IN HANOI

AND HO CHI MINH CITY, VIETNAM

Study design. The cross-sectional, community-based study was conducted in

collaboration with Hanoi HIV/AIDS Prevention Centre (Hanoi PAC), the Centre for

Community Health Promotion (CHP) in Hanoi, and the Centre for Promotion of Quality

of Life (Life Centre) in Ho Chi Minh City, Vietnam, and community-based organisations

(CBO) of MSM in the two cities during September–December 2014. Supporting letters

from the local collaborating organisations can be found in Appendix 1. These

organisations have experience in working with MSM and delivering HIV prevention

though USAID and Global Fund supported projects. HIV prevention services, including

behavioural counselling, educational materials, and free condoms and lubricant are

delivered via peers from local CBOs. These CBOs provide social and emotional support,

HIV prevention education and referral to HIV treatment for MSM in their localities. Peer

outreach workers of these CBOs were engaged to reach a large number of MSM in the

two cities.

The collaborating organisations assisted with recruiting potential participants and

contributed in-kind resources, such as coordinating fieldwork activities, providing venues

for interviews and offering free HIV testing (for a subsample of participants in Hanoi).

Interview venues were arranged in different parts of the cities to facilitate easy access

by participants.

Sampling method. MSM remain a hidden, hard-to-reach population in Vietnam because

of social stigma and discrimination regarding homosexuality (1, 2). Accordingly,

developing a randomised sampling frame is impossible. A non-random, convenience

sampling method was used to recruit participants for the study. Recruitment was

continued until the expected sample size was reached. The study recruited participants

using several approaches:

▪ Staff and/or peer outreach workers of local collaborating organisations and CBOs

helped to recruit initial participants for the study via MSM groups. Initial potential

participants were referred to the research team for eligibility screening and

71

interviewing. Since each CBO targets different subgroups of MSM, it was

anticipated that initial participants in each of the two cities would come from

different socio-demographic backgrounds.

▪ Peer referral recruitment. Once interviews were completed, participants were

asked to invite other MSM they knew who might be interested in participating in

the study. They were provided with invitation letters (see Appendix 2A) which

they could give to other potential participants. Peer outreach workers of the local

collaborating organisations could also refer other MSM to the study during

fieldwork. The invitation letter contained brief information about the study,

including its purpose, ethical aspects and rights of the participants, the phone

number of the local study coordinator and the addresses of interview venues.

Interested potential participants were encouraged to contact the local study

coordinator to book a time for an interview.

This is entirely a convenience sample with men referred to the study by either: i) peer

educators of collaborating CBOs or ii) other men who already participated in the study.

We did not track the number of men referred by each of the sampling strategies,

however, the majority of men were referred to the study by CBO’s field staff.

Sample size: I used the findings regarding the prevalence of methamphetamine use,

the prevalence of ecstasy use and the prevalence of CAI with any male partner in the

last 3 months to calculate the expected sample size. The calculation of sample size was

based on the WHO formula for hypothesis testing with respect to a population proportion

with a power of 80% and two-tailed type-I error of 5% (i.e., two-tailed significance

p<0.05). Indicators used to calculate the sample size were taken from previous studies

by Bengtsson et al (3) and UNODC’s Vietnam report (4). From this calculation, it was

expected that 600 MSM would need to be recruited for the community study. With this

sample size, 95% of the CAI prevalence from the study was expected to lie in the range

of 30% to 40%; 95% of the methamphetamine use prevalence found in the study would

lie in the range of 24% to 36% and 95% of the ecstasy use prevalence was expected to

be found in the range from 34% to 46% with the power of the test at 80%.

Eligible criteria: men were eligible to participate in the study if they had Vietnamese

citizenship, were aged 18 or older, had good comprehension of Vietnamese; reported

sex with another man in the last 3 months and consented to participate. Due to the small

number of transgender women who participated in the study (less than 10), it was

decided to exclude this group and focus the primary analyses for the study on MSM,

participants who reported that they were assigned male gender at birth, who identified

72

as male at the time of the study and who identified as gay or bisexual orientation or were

sexually interested in men.

Data collection. The face to face interviews were administered by trained, experienced

interviewers from Hanoi Medical University. MSM connected to local CBOs who had

experience in conducting interviews in other studies were also invited to be interviewers

for this study. The interviews were organised at the venues arranged by the local

collaborating organisations. Each interview lasted between 35-50 minutes and interviews

were arranged from 8 am to 8pm and during weekends to accommodate men who

worked during the week.

The data collection process consisted of three steps, as illustrated in Figure 4 below:

1. Welcome: there was a host from the study team to receive study participants once

they arrived at the interview venue. The host explained the study purpose, interview

process and ethical considerations, including confidentiality, and access to

counselling and other services, if the participants needed them. Once men agreed to

participate, they were asked to sign the Participant Information and Consent form to

confirm their agreement. This form can be found in Appendix 2B. In this consent form,

men were informed that they can withdraw at any time during the interview. Men were

screened by the study host to ensure that they were eligible to participate. Men who

were not eligible were informed thereof, received compensation for their time and

were offered HIV educational materials and access to HIV-related services, if they

were requested. The study host provided eligible men with their study ID.

2. Interview: Research in different settings has shown that interview questions of a

sensitive nature, such as those related to sexual practices and drug use, may be

affected by over-reporting or under-reporting of behavior. Over-reporting may occur,

for example, when participants are incentivised (paid) to participate in research, while

under-reporting may occur if the behaviours in question are socially stigmatised.

Participants received a modest monetary compensation equivalent to US$5. The

value of this compensation was equal to that of similar studies in Vietnam. Also, as

drug use and same-sex behaviours are stigmatised in Vietnam, findings may be

affected by over-reporting as well as under-reporting biases. To minimize these

potential biases, we took several preventive measures. Firstly, all the interviewers,

including peer recruiters, participated in training on the questionnaire, and effective

techniques in asking sensitive questions about personal and confidential information,

including communicating with MSM in ways that were trustworthy, respectful and

designed to put participants at ease. Secondly, participants were given the

73

opportunity to select the interviewer they felt most comfortable talking to (e.g. a man

or a woman, a peer or a researcher). Thirdly, the questionnaire did not collect

personally identifying information, such as full name, date of birth or address. Lastly,

interviews were conducted in private (i.e. meeting rooms or offices) to ensure privacy

and confidentiality. Each interview lasted for 35-50 minutes.

3. Completion: After completing the interview, participants returned to reception and

met with the study host to receive compensation and invitation letters to circulate to

other potential participants. Each participant received compensation equal to US$5,

similar to the level used in other studies conducted with Vietnamese MSM. The

compensation was for transportation and the time taken to participate in an interview.

All participants were offered HIV prevention materials, including a list of all local HIV

service providers. Participants who expressed concern or interest in accessing any

HIV-related services were referred to appropriate service providers. Participants who

expressed mental health problems or distress were referred to appropriate mental

health support, counselling or treatment services (particularly those provided by local

partner organisations). Men could also be referred to relevant MSM groups for peer-

support and counselling.

Optional HIV testing: In Hanoi, men who wished to test for HIV were referred to an

on-site testing team provided by the Hanoi PAC. Trained staff explained the

procedure for testing, answered any questions and explained that the test result

could be linked to their questionnaire data for research purposes only, if participants

agreed. Participants could choose to test without their data being linked (consistent

with the principles of voluntary testing). Those who agreed to data linkage signed an

additional informed consent form to allow the research team to access their HIV test

results using their study ID (see Appendix 2D). Men who consented to test for HIV

and data linkage could later withdraw consent for the study team to access their HIV

test result. In this case, men were asked to sign a separate Revocation of consent

form (Appendix 2E). For consenting participants, blood samples were labelled with

the participant’s study ID. Once their blood was collected, participants were given a

letter indicating the time and location where they could obtain their test results. When

participants collected their results, they were referred to HIV care and support

services, as required, by the Hanoi PAC staff, particularly if they received an HIV

positive test result. The testing procedure follows the Vietnamese Ministry of Health

HIV testing protocol. Testing was carried out in a separate room at the collaborating

community organisation, to ensure privacy and infection control. Because of resource

constraints, optional HIV testing was delivered to the first 210 men participating in

Hanoi only.

74

Figure 2.1: Participant interview protocol

75

Once interviews were completed, questionnaires were given to a local supervisor for its

completeness, possible missing data and the accuracy of recording checking, and safe

storage. There was a brief reflection meeting at the end of each working day for

interviewers to discuss any difficulties or challenges they faced during the interview

process and to seek suggestions and advice from peers. The local supervisor identified

errors and inconsistencies in the questionnaires and discussed the correct way to record

information in the questionnaire in such situations.

Ethical considerations. Because homosexuality-related stigma and discrimination is

still common in Vietnam, we took several steps to protect the participants’ confidentiality.

Participants were not asked for their full name or address. During the fieldwork in

Vietnam, all study documents were securely stored in a locked cabinet at Hanoi Medical

University. Data entry was conducted on password-protected laptops owned by the study

team, and the data did not contain any personally identifying information of participants.

Once data entry was completed, the data was then transferred to UNSW Australia and

stored on a secure server of UNSW, only accessible by the study team. All the study

documents, including signed consent forms, are stored securely at the Centre for Social

Research in Health, UNSW Sydney. All study team members who accessed participants’

information signed a confidentiality agreement (see Appendix 2F). The survey received

ethical approval from the Human Research Ethical Committee of the University of New

South Wales, Sydney, Australia and Hanoi University of Public Health (see Appendix 3).

Questionnaire: A structured questionnaire was used to gather the following information,

based on the study’s socio-ecological framework. The questionnaire was developed in

English and translated into Vietnamese. Two separate consultation meetings were held,

one in Hanoi and one in Ho Chi Minh City, with a total of approximately 20

representatives from local MSM organisations, to seek input into the questionnaire and

colloquial terms for sexual orientation, drug use and sexual behaviours commonly used

by MSM.The representatives also commented on the user-friendliness and social and

cultural acceptability of the questionnaire. The questionnaire was pilot-tested with ten

MSM in Hanoi and revised as required. Pilot testing was used to make sure that all terms

used in the questionnaire were easily understood. Pilot testing indicated that men had

no difficulty understanding the terms used to describe specific drugs, including drugs

with which they had little or no personal experience. In addition, the training for

recruitment staff and interviewers included discussion of local street names used by

MSM for drugs, so that they could correctly capture the experience of MSM who

participated and, if necessary, translate the chemical names for drugs into street terms

76

and vice versa. The English version of the final questionnaire can be found in Appendix

4.

The questionnaire contained the following sections, each concerned with a range of

variables:

Section 1. Socio-demographic and other personal characteristics (questions Q101-

Q122), including age, highest level of education, occupation, marital status, income,

sexual orientation, age at first sexual debut with men and women, engagement in sex

work and self-reported HIV status.

Section 2. Homosexuality-related stigma and discrimination (questions Q201-Q226)

I adapted a previously tested scale to measure enacted (experienced) homosexuality-

related stigma (questions Q201-Q208), perceived (anticipated) homosexual stigma

(questions Q209-Q218), and self-stigma (internalised homophobia) (questions Q 219-

Q226) among MSM in Vietnam (5). Responses were given on 4-point scales, with

anchors depending on the questions. The adapted scale encompassed eight items

pertaining to enacted homosexuality-related stigma, for example “How often have you

lost a job or career opportunity due to your engagement in homosexual activities”

(1=never, 4= often); ten items measuring perceived homosexuality-related stigma, for

instance “Many people are unwilling to accept homosexual individuals” (1=completely

disagree, 4=completely agree); and eight items measuring internalised homophobia, for

example “Sometimes you wish you were not gay/bisexual/transgender” (1=totally

disagree, 4=totally agree). In this study, the scale had good internal consistency

(Cronbach’s ɑ=0.74). Mean scores were calculated for each sub-scale with higher scores

indicating higher levels of stigma.

Section 3. Drug use behaviours

The Alcohol, Smoking and Substances Involvement Screening Test (ASSIST) (6),

developed by the World Health Organization, was used to assess alcohol use,

methamphetamine, amphetamine and ecstasy use, substance use before or during sex

in the last three months and classifying the severity of drug use. ASSIST encompasses

eight questions for each substance, asking about 1) lifetime use; 2) frequency of use; 3)

frequency of strong desires or urges to use; 4) frequency of health, social, legal or

financial problems associated with use; 5) failure to fulfil daily activities because of use;

6) relatives and/or friends’ concerns over use; 7) attempts to cut down or quit; and 8)

drug injection. As suggested in the ASSIST manual, response cards were given to

77

participants to assist them with answering these questions. For each substance, a

summary score was calculated by adding scores on questions two to seven. Severity of

ATS use was classified using ASSIST guidelines, according to which scores from 0-3

were classified as low-risk use, scores from 4-26 were classified as moderate-risk use,

and scores of 27 and higher were classified as high-risk use. The ASSIST screening test

has demonstrated validity in assessing the severity of alcohol, tobacco and psychoactive

drug use (7). Participants were also asked about their age when they first used drugs

(question Q302), routes of administration for drugs (question Q303 and Q304), people

they had used drugs with (question Q305), lifetime use of drugs (question Q301), and

lifetime sex-related use of alcohol and the followings drugs: alcohol, heroin, cannabis,

ketamine, methamphetamine, amphetamine (‘speed’), ecstasy, poppers (amyl nitrite)

and EDM (question Q306). ATS use in the last three months was asked by question

Q307. The severity of ATS use was measured by questions from Q307 to Q 313.

Section 4. Sexual behaviours (question Q401a-Q462)

Participants were asked about sexual behaviours and sexual partners over their lifetime,

in the previous three months and with respect to the three most recent instances of anal

or vaginal sex with regular and casual male and female partners. Regular sexual partners

were defined as sexual partners with whom participants had had sex more than once.

Casual partners were sexual partners with whom participants had had sex only once.

For each recall period and sexual partner type, participants were asked about the

number of sexual partners, their knowledge of their partners’ HIV status, how they met

these partners, positions during sex (i.e., insertive/receptive) and the use of condoms.

Participants were also asked about participation in group sex with more than two people

in the last twelve months, the places where these sexual encounters occurred, the types

of sexual partners involved, including HIV status, sexual positions during the encounters

and the use of condoms.

Additionally, in this section, sexual sensation-seeking was assessed using a scale

developed by Kalichman et al. (8). Ten items assessed the propensity to seek out

exciting and novel sexual experiences, for instance “I like wild, uninhibited sexual

encounters”. Participants provided their answers on 5-point scales, ranging from 1 (not

at all like me) to 4 (very much like me). Internal consistency of the items was sufficient

(Cronbach’s ɑ = 0.72). Item scores were averaged, with higher scores indicating more

sexual sensation-seeking.

Section 5. Involvement with MSM (question Q501-Q515)

78

Participants were asked about their use of MSM websites, accessing internet-based

MSM social networks, frequenting MSM-specific venues, participating in activities with

MSM in their city, and being active in MSM groups in the city where they lived. Reponses

were given on four-point scales (1=never, to 4=often). We also asked participants how

many gay/MSM friends they had. All variables assessing involvement with other gay

men/MSM were treated as binary variables (1=any involvement, 0=no involvement). The

number of gay/MSM friends was categorised into a 3-level categorical variable based on

the distribution of responses.

In this section, we also asked participants to respond to two statements assessing

participants’ perception of the popularity of methamphetamine use and ecstasy use in

the context of sex in their MSM social network. Responses were given on 4-point

scales (1=totally disagree, 4=totally agree).

Section 6. Depression assessment (question Q601-Q609)

Depression was assessed with the Patient Health Questionnaire 9 item scale (PHQ-9),

which has been used with MSM in other studies (9, 10). The scale consists of nine

items, such as “In the last two weeks, how often have you had trouble falling or staying

asleep, or sleeping too much?” Participants provided their answers on a scale ranging

from 0 (not having the problem at all) to 3 (having the problem nearly every day). The

items had good internal consistency in this study (Cronbach’s ɑ= 0.80). Participants

were categorised as having major depressive disorder if they scored 10 or more (11).

Section 7. Accessibility and uptake of HIV prevention services (question Q701-Q712)

We asked participants if they had recently tested for HIV (i.e., testing for HIV at least

once in the last 12 months) and if they had recently received safe sex counselling (i.e.,

engaging with safe sex counselling in the last 12 months) and sexual transmitted

diseases (STI) assessment and treatment. Participants were also asked where they

accessed these HIV prevention services.

Section 8. Belief in HIV prevention strategies (question Q801-Q809)

Participants were asked how effective they thought different strategies were in

preventing HIV transmission: use of condoms, antiretroviral treatment of HIV, taking the

insertive (top) position during anal sex, and withdrawal before ejaculation. Response

options ranged from 1 (totally disagree) to 4 (totally agree). Belief in the efficacy of

79

each HIV prevention method was dichotomised into disagreement (scores 1 and 2)

versus agreement (scores 3 and 4).

HIV testing

All blood samples were screened for HIV by the Murex HIV Ag/Ab combination assay

(Diasorin S.p.A, Italia). Samples that were reactive during screening were tested again

using confirmatory tests (Serodia® HIV, Fujirebio, Japan; DetermineTM HIV1/2, Alere

Medical, US). The main outcome variable was HIV status as confirmed by testing (HIV-

negative or HIV-positive). We referred to participants’ self-reported HIV status (HIV-

negative, untested/unknown or HIV-positive) to identify participants who tested HIV-

positive but were unaware of their infection before the study.

SYSTEMATIC REVIEW AND META-ANALYSIS OF THE ASSOCIATION

BETWEEN ATS USE AND HIV INFECTION

Search strategies

Electronic databases. A systematic search was undertaken of MEDLINE, EMBASE,

GLOBAL HEALTH and PsycINFO to identify relevant English, peer-reviewed journal

articles reporting quantitative studies published between 1980 and 25 April 2013.

Extended citation search. Reference lists of identified studies were screened to identify

further relevant studies.

Search terms. The search used a combination of free terms and Medline subject

headings, including:

▪ MSM OR men who have sex with men OR homosexual men OR bisexual men

OR gay men OR male homosexual OR bisexual male OR homosexuality OR

bisexuality AND

▪ Risk factors OR determinants OR associations OR correlates OR correlations

OR predictors OR high risk behaviours OR predictor variables AND

▪ HIV prevalence OR HIV incidence OR HIV sero-conversion OR HIV status OR

human immunodeficiency virus OR human immunodeficiency virus

prevalence/infection.

Inclusion criteria. Articles were eligible for inclusion in the review if the study and report

satisfied all of the following criteria:

▪ Published in a peer-reviewed English language journal;

80

▪ MSM were the target population;

▪ Cross-sectional, case-control or longitudinal study design;

▪ Quantitative assessment of ATS use and HIV infection;

▪ Crude quantitative measures of association between ATS use and HIV infection

were provided, or data to calculate this; and

▪ Participants’ HIV status was confirmed by a standardised laboratory method.

Screening process. First, electronic databases were searched using the defined key

words and/or Medical Subject Heading terms. Articles identified in this step were

downloaded to Endnote and duplicates removed. The screening process for the

remaining article was as follows:

▪ Title screening: all studies with irrelevant titles (i.e. different from the review

question) were excluded and recorded.

▪ Abstract screening: abstracts of the remaining studies were screened to

exclude irrelevant studies.

▪ The full texts of remaining studies were reviewed for availability of estimates of

the association between ATS use and prevalence and/or incidence of HIV/STI

infection.

▪ Authors of articles in which estimates of association or data to calculate it were

not provided were contacted via email to see if data could be obtained. If no

reply was received after 4 weeks, then the articles were excluded from the

review list.

▪ Authors of articles for which the full text was not accessible were also contacted

via email to ask for the full text. After 4 weeks, if no reply was received, then the

articles were excluded. Full texts provided by the author were screened as

described above.

▪ Reference lists of articles included in review were screened to identify additional

relevant articles.

Quality assessment. Quality of the included studies and reports was assessed using

quality assessment criteria adapted from Boyle for cross-sectional studies (12), and

from Wells et al. for case-control and longitudinal studies (13). The checklists can be

found in Appendix 5. Studies and reports were assigned a summative score on a scale

from 0 to 9 for cross-sectional studies, 0-10 for case-control studies and 0-11 for

longitudinal studies. All scores were categorised as high and low quality, based on a

cut off of 50%.

81

Data extraction. Extracted information included: the primary author, year of

publication, country of research, sampling method(s), sample size, type of drug(s)

examined and recall periods, basic participant characteristics (e.g., age, sexual

identification) and either a crude measure of association with 95% confidence intervals

(CI) or data to calculate this.

If articles reported on more than one drug or assessed more than one recall period,

each measure of drug use was extracted as a separate record. Measures of

association reported without 95% CIs were not extracted. Extracted data from cross-

sectional and case-control studies were used to calculate prevalence rate ratios (PRR)

(14), and odds ratios (OR), respectively. For longitudinal studies, hazard ratios (HR) or

relative risk (RR) of ATS use and new HIV seroconversion with 95% CIs were taken

directly from articles. Data extraction was carried out by two people to avoid potential

extraction bias.

82

References

1. Horton P. 'I thought I was the only one': the misrecognition of LGBT youth in

contemporary Vietnam. Culture, health & sexuality. 2014;16(8):960-73.


stigma and sexual risk behaviors among men who have sex with men in Hanoi,

Vietnam. Archives of sexual behavior. 2015;44(2):349-56.



sexual network modelling. BMJ Open. 2014;4(1):e003526.

4. United Nations Office on Drugs and Crime (UNODC). Amphetamine-type

stimulants in Vietnam. Review of the availibility, use and implications for health and

security. UNODC: 2012; 2012.

5. Ha H, Ross MW, Risser JM, Nguyen HT. Measurement of Stigma in Men Who

Have Sex with Men in Hanoi, Vietnam: Assessment of a Homosexuality-Related

Stigma Scale. Journal of sexually transmitted diseases. 2013;2013:174506.

6. World Health Organization. The Alcohol, Smoking and Substance Involvement

Screening Test (ASSIST). Geneva, Switzerland2010.

7. Humeniuk R, Ali R, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, et al.

Validation of the Alcohol, Smoking And Substance Involvement Screening Test

(ASSIST). Addiction (Abingdon, England). 2008;103(6):1039-47.

8. Kalichman SC, Rompa D. Sexual sensation seeking and Sexual Compulsivity

Scales: reliability, validity, and predicting HIV risk behavior. Journal of personality

assessment. 1995;65(3):586-601.

9. Hirshfield S, Wolitski RJ, Chiasson MA, Remien RH, Humberstone M, Wong T.

Screening for depressive symptoms in an online sample of men who have sex with

men. AIDS care. 2008;20(8):904-10.

10. Mao L, Kidd MR, Rogers G, Andrews G, Newman CE, Booth A, et al. Social

factors associated with Major Depressive Disorder in homosexually active, gay men

attending general practices in urban Australia. Australian and New Zealand journal of

public health. 2009;33(1):83-6.

11. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression

severity measure. Journal of general internal medicine. 2001;16(9):606-13.

12. Boyle MH. Guidelines for evaluating prevalence studies. Evidence Based

Mental Health. 1998;1(2):37-9.

83

13. Wells G, Shea B, O’connell D, Peterson J, Welch V, Losos M, et al. The

Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in

meta-analyses. 2000.

14. Skov T, Deddens J, Petersen MR, Endahl L. Prevalence proportion ratios:

estimation and hypothesis testing. Int J Epidemiol. 1998;27(1):91-5.

84

CHAPTER 3

AMPHETAMINE-TYPE-STIMULANT USE AMONG MEN WHO HAVE

SEX WITH MEN (MSM) IN VIETNAM: RESULTS FROM A SOCIO-

ECOLOGICAL, COMMUNITY-BASED STUDY

Author Contributions

Nga Thi Thu VU1,2, Martin HOLT1, Huong Thi Thu PHAN3, Huong Thi LE2, Lan

Thi LA4, Gioi Minh TRAN5, Tung Thanh DOAN5, Trang Nhu Nguyen NGUYEN6

and John de Wit1

1: Center for Social Research in Health, University of New South Wales, Sydney,

New South Wales, Australia; 2: Institute of Preventive Medicine and Public Health,

Hanoi Medical University, Hanoi, Vietnam; 3: Vietnam Administration for

HIV/AIDS Prevention and Control, Hanoi, Vietnam; 4: Hanoi Center of HIV/AIDS

Prevention and Control, Hanoi, Vietnam; 5: Center for Community Health

Promotion, Hanoi, Vietnam; 6: Center for Promotion of Quality of Life, Ho Chi Minh

City, Vietnam.

Reference

Vu NT, Holt M, Phan HT, Le HT, La LT, Tran GM, et al. Amphetamine-type

stimulant use among men who have sex with men (MSM) in Vietnam: Results

from a socio-ecological, community-based study. Drug and alcohol dependence.

2016;158:110-7.

Declaration

I certify that this publication was a direct result of my research toward this PhD,

and that reproduction in this thesis does not breach copyright regulations.

Nga Thi Thu Vu June 2017

85

Copyright permission

The candidate is the first author of the present article, therefore, she retains the

right to include the article in a thesis or dissertation. This is an accepted

manuscript of an article published by Elsevier in journal Drug and Alcohol

Dependence on 10th November, 2015, available online:

http://doi.org/10.1016/j.drugalcdep.2015.11.016.

As this is a retained right, no written permission from Elsevier is necessary.

86

http://doi.org/10.1016/j.drugalcdep.2015.11.016

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Drug and Alcohol Dependence 158 (2016) 110–117

Contents lists available at ScienceDirect

Drug and Alcohol Dependence

j ourna l ho me pa g e: www.e l sev ier .com/ locate /druga l cdep

mphetamine-type stimulant use among men who have sex withen (MSM) in Vietnam: Results from a socio-ecological,

ommunity-based study

ga Thi Thu Vua,b,∗, Martin Holta, Huong Thi Thu Phanc, Huong Thi Leb, Lan Thi Lad,ioi Minh Trane, Tung Thanh Doane, Trang Nhu Nguyen Nguyenf, John de Wita,∗∗

Centre for Social Research in Health, UNSW Australia, Sydney 2032, NSW, AustraliaInstitute of Preventive Medicine and Public Health, Hanoi Medical University, No. 1 Ton That Tung Street, HaNoi, VietnamVietnam Administration for HIV/AIDS Prevention and Control, Ministry of Health, 135/3 Nui Truc Street, Hanoi, VietnamHanoi Centre of HIV/AIDS Prevention and Control, Khu Hanh Chinh Moi, Ha Dong, Hanoi, VietnamCenter for Community Health Promotion, Suite 117-120, Block B17, Kim Lien Diplomatic Compound, Dong Da, Hanoi, VietnamCentre for Promotion of Quality of Life, 140, Street No. 7, Trung Son Area, Binh Chanh District, Ho Chi Minh City, Vietnam

r t i c l e i n f o

rticle history:eceived 10 October 2015eceived in revised form0 November 2015ccepted 10 November 2015vailable online 22 November 2015

eywords:mphetamine-type stimulantsrevalenceorrelatesen who have sex with menietnamocio-ecological perspective

a b s t r a c t

Introduction: Amphetamine-type-stimulants (ATS) use is associated with HIV-related sexual riskbehaviours and is an emergent problem among men who have sex with men (MSM) in Vietnam. Thepurpose of this study is to describe ATS use patterns and understand the correlates of recent metham-phetamine use from a socio-ecological perspective.Methods: From September through December, 2014, 622 MSM were recruited in Hanoi and Ho Chi MinhCity, Vietnam. We collected information on demographic characteristics, HIV testing behaviours, useof ATS and other recreational drugs (ever and recently), sexual sensation seeking, depressive mood,experienced and internalized stigma related to homosexuality, social involvement with other MSM, andperceptions of ATS use in MSM networks. We performed descriptive statistics to describe ATS use patternsand multivariate logistic regression to establish independent correlates of recent methamphetamine use.Results: Nearly one-third (30.4%) had ever used ATS, including 23.6% who had used methamphetamine,4.3% who had used amphetamine (‘speed’) and 20.9% who had used ecstasy. 20.1% and 11.9% had everused methamphetamine and ecstasy, respectively, during sex. Eighteen percent of methamphetamineusers were classified as engaged in high-risk use. Recent methamphetamine use (in the last 3 months)
was associated with participants perceiving more methamphetamine use in their MSM network, recentsex work, and higher sexual sensation seeking scores.Conclusions: ATS use is relatively prevalent among MSM sampled in Vietnam’s main cities. Interventionsto address methamphetamine are warranted for MSM in Vietnam. Methamphetamine treatments areneeded for high-risk users.
. Introduction

Internationally, amphetamine type stimulants (ATS) are
he second most commonly used type of illicit drugs, afterannabis/marijuana (United Nations Office on Drugs and Crime,010, 2013b). In 2009, the United Nations Office on Drugs and
∗ Corresponding author at: Centre for Social Research in Health, UNSW Australia,ydney 2032, NSW, Australia. Tel.: +61 2 9385 6776.∗∗ Corresponding author. Tel.: +61 2 9385 6799.

E-mail addresses: [email protected] (N.T.T. Vu),[email protected] (J. de Wit).

ttp://dx.doi.org/10.1016/j.drugalcdep.2015.11.016376-8716/© 2015 Elsevier Ireland Ltd. All rights reserved.

© 2015 Elsevier Ireland Ltd. All rights reserved.

Crime (UNODC) estimated that worldwide there were 13.7 to 52.9million people aged 15–64 (equivalent to 0.3% to 1.2% of the totalworld population in those age groups) who had ever used any kindof ATS (United Nations Office on Drugs and Crime, 2010). ATS canbe classified into two groups: the amphetamine substance groupand the ecstasy substance group (United Nations Office on Drugsand Crime, 2010). The substances in both groups can be ingested,injected, inhaled, snorted or smoked and can have immediate accel-erated physiological and psychological effects which may last up
to ten to 12 h for amphetamines or three to 6 h for ecstasy (Colfaxand Guzman, 2006; Nordahl et al., 2003). While amphetamines areclassified as psychoactive stimulants, ecstasy can have both psy-choactive and hallucinogenic effects in high doses (World Health
87

dx.doi.org/10.1016/j.drugalcdep.2015.11.016

http://www.sciencedirect.com/science/journal/03768716

http://www.elsevier.com/locate/drugalcdep

http://crossmark.crossref.org/dialog/?doi=10.1016/j.drugalcdep.2015.11.016&domain=pdf

mailto:[email protected]



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rganization, 2004). Regular ATS use has been found to be asso-iated with long-term adverse health impacts such as depressionr psychosis (United Nations Office on Drugs and Crime, 2013a).he use of ATS, particularly methamphetamine, has been found toe associated with an increased prevalence of sexual behaviourshat may increase the risk of HIV or sexually transmitted infectionsSTIs) such as condomless sex (Beyrer et al., 2004; Celentano et al.,006; Colfax et al., 2010, 2004; Colfax et al., 2001; Klitzman et al.,002; Koblin et al., 2003, 2007; Mansergh et al., 2006; Rusch et al.,004), having more sexual partners (Molitor et al., 1998), havingex with anonymous partners (Parry et al., 2008), or participating inroup sex (Prestage et al., 2011). Injection of ATS can also facilitateIV or hepatitis infection if unsafe or unsterile injecting practicesre practiced (Colfax et al., 2010; Martin et al., 2010). A recenteta-analysis of 35 studies from nine countries found a statisti-

ally significant relationship between methamphetamine use andIV infection among men who have sex with men (MSM), mainly

n high income countries (Thu Vu et al., 2015).Studies undertaken in the last ten years report different trends

n ATS use among gay, bisexual and other men who have sex withen in different places in the world. A study using 2008–2011

rug use surveillance data of substance using MSM in Los Ange-es (Reback et al., 2013) reported a significant upward trend in

ethamphetamine use in the previous 30 days (23.7% in 2008 to7.4% in 2011). In contrast, a study drawing on annual behaviouralurveillance data of MSM in Sydney, Melbourne and Queenslandn Australia observed a downward trend in ATS use between 2004nd 2011. However, the self-reported rates of ATS use were high inhis study; ecstasy was the most commonly used ATS, reported by6.2% in 2004 and 25.7% in 2011; methamphetamine was the leastommonly used ATS, reported by 15.4% in 2004 and 10.0% in 2011Lea et al., 2013). A cross-sectional study undertaken in 2011 with54 MSM attending sexual health clinics in London, UK, found lowates of ATS use in the last previous 30 days; 5.5% reported usingcstasy, 0.8% reported using amphetamine, and 1.2% reported usingethamphetamine. However, rates of ever having used ATS were

ubstantially higher, with 40.8% reported ever using ecstasy, 29.8%ver using amphetamine and 16.9% ever using methamphetamineHunter et al., 2014).

Few studies have been conducted on ATS use and associatedarms among MSM in low income or middle income countries. Aecent published study from Mexico found that 16.9% of 191 MSMecruited by respondent driven sampling had ever used metham-hetamine in the previous month (Pitpitan et al., 2015). A studyonducted in 2011 among MSM in Shenyang province, China foundhat 4% had ever used methamphetamine (Xu et al., 2014a). Anothertudy conducted in 2012–2013 among 3830 MSM from six cities inhina also reported a low prevalence of recent ATS use in the last sixonths, with 2.8% having used ecstasy, 2.5% having used metham-

hetamine, and 0.7% having used amphetamine (Xu et al., 2014b).n Thailand, the rate of ever having used methamphetamine among

SM visiting a sexual health clinic during 2008–2009 was found toe 12.6% (Chariyalertsak et al., 2011). In Vietnam, no recent study ofTS use has been reported, but a study undertaken in 2004 reported

hat 4% of MSM in Ho Chi Minh City had ever used amphetaminesNguyen et al., 2008). Therefore, we conducted this study to explorehe rate of ATS use among MSM in the two main cities of Viet-am (i.e., Hanoi and Ho Chi Minh City), and examine correlates ofhe most common form of ATS use identified in our study from aocio-ecological perspective.

. Methods

This was a cross-sectional, community-based study, conducted in collaborationith Hanoi HIV/AIDS Prevention Center (Hanoi PAC), the Center for Communityealth Promotion (CHP) in Hanoi, and the Centre for Promotion of Quality of Life

Life Center) in Ho Chi Minh City, Vietnam during September–December, 2014. A

endence 158 (2016) 110–117 111

non-random, convenience sampling method was used to recruit participants asMSM remain a relatively hidden, hard-to-reach population in Vietnam because ofhomosexuality-related stigma and discrimination (Vu et al., 2008). Potential partic-ipants were referred to the study by outreach workers of CHP and the Life Center,via local community-based organizations/groups of MSM and through peer refer-ral of MSM who had participated in the study. Men were eligible if they were 18years or older at the time of the study, reported having anal sex with at least oneman in the previous three months, had good command of listening to and read-ing the Vietnamese language and consented to participate in the study. The studyreceived approval from the Human Research Ethics Committee of the University ofNew South Wales (UNSW) Australia (reference HC14130) and from the InstitutionalReview Board of the Hanoi School of Public Health (reference 014 262/DD-YTCC).

2.1. Data collection

We adapted the socio-ecological model proposed by DiClemente et al. (2005),which proposes that people’s behaviours are influenced by their psychologicalcharacteristics as well as socio-ecological factors that reflect the surrounding envi-ronment, ranging from the proximal community/peer level to the distal societallevel. Our adapted socio-ecological model includes three levels: the individual, com-munity/peer and society levels. At the individual level, we assessed participants’demographic characteristics, HIV testing, HIV status, use of alcohol and other drugs,level of sexual sensation-seeking, and depression. Community/peer-level variablesincluded participants’ social involvement with other MSM, and their perceptionof the popularity of ATS use in their MSM social network. Societal-level variablesencompassed enacted, perceived and internalized homosexuality-related stigmaand discrimination and sex work behaviours (although a recognized economic activ-ity, sex work is illegal and stigmatized in Vietnam).

Face-to-face, structured interviews using a questionnaire were administered bystaff from Hanoi Medical University and by MSM peers, all trained by the study team.To ensure confidentiality, interviews were conducted in private rooms at locationsconvenient for participants, arranged by Hanoi PAC and CHP/Life Center. Interviewswere conducted between 8 am and 8 pm on weekdays or during weekends to accom-modate MSM who could not participate during office hours. Potential participantsreceived information about the study, were briefed on ethical considerations andconsent, screened for eligibility and provided with a unique, anonymous study ID ifthey met the inclusion criteria and signed a written consent form. Interviews lastedfor approximately 35–50 min. We took several steps to protect the participants’ con-fidentiality. Participants were not asked for their full name or address. During thefieldwork in Vietnam, all study documents were kept securely in a locked cabinet atHanoi Medical University. Data entry was conducted on password-protected laptopsowned by the study team; the dataset does not contain any personally identifyinginformation about participants. Once data entry was completed, the dataset wasthen transferred to Australia and stored on a secure server of UNSW, only accessibleby the study team. All the study’s documents, including signed consent forms, arestored securely at the Centre for Social Research in Health, UNSW Australia. After theinterviews, men received a reimbursement of 100.000 Vietnam Dong (VND) (equiv-alent to US$5) for their time and expenses, were provided with HIV preventionmaterials and referred to voluntary HIV testing. Men were also referred to supportservices, if appropriate or requested.

2.2. Measurement

The questionnaire was developed in English and translated into Vietnamese.Two separate consultation meetings were held, one in Hanoi and one in Ho ChiMinh City, with a total of approximately 20 representatives from local MSM organi-zations and researchers, to seek input into the questionnaire and colloquial termsfor drug use, sexual orientation and sexual behaviours commonly used by MSM.The representatives also commented on the user-friendliness and acceptability ofthe questionnaire. The questionnaire was pilot-tested with ten MSM in Hanoi andrevised as required.

2.2.1. Demographic and behavioural characteristics. We collected the participants’age, education, occupation, monthly income, time living in their city of residence,sexual orientation, gender of sexual partners, age at first sex with men and women,engaging in sex work (ever and in the last 3 months), and self-reported HIV status.Participants were categorized as regular sex workers if they (i) reported ever sellingsex and (ii) currently worked in a MSM-specific sauna or massage parlour wheretransactional sex occurs.

2.2.2. HIV testing. We asked participants if they had recently tested for HIV (havingat least one HIV test in the last 12 months). Participants also self-reported their HIVstatus.

2.2.3. Alcohol and drug use. For ATS and other substances, participants were asked
about having ever used them, and, if they had, age at first use, routes of administra-tion, peoples they had used with, and use in the context of sex. Substances assessedincluded: alcohol, heroin, cannabis, ketamine, methamphetamine, amphetamine(‘speed’), ecstasy, poppers (amyl nitrite) and erectile dysfunction medications(EDM); participants also had the option of reporting use of any other substance.
88

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he Alcohol, Smoking and Substances Involvement Screening Test (ASSIST; Worldealth Organization, 2010), developed by the World Health Organization, was used

o measure recent alcohol use, methamphetamine, amphetamine and ecstasy usen the last three months and classify the severity of drug use. ASSIST has eight ques-ions for each substance, asking about (1) lifetime use; (2) frequency of use; (3)requency of strong desires or urges to use; (4) frequency of health, social, legalr financial problems associated with use; (5) frequency of failure to fulfil dailyctivities because of use; (6) relatives and/or friends’ concerns over use; (7) failedttempts to cut down or quit; and (8) drug injection. As suggested in the ASSISTanual, response cards were given to participants to assist them with answering

hese questions. For each substance, a summary score is calculated by adding scoresn questions two to seven. Severity of ATS use was classified using ASSIST guide-ines, according to which scores from 0–3 are classified as low-risk use, scores from

to 26 are classified as moderate-risk use, and scores of 27 and higher are classifieds high-risk use. The ASSIST screening test has demonstrated validity in assessingeverity of alcohol, tobacco and psychoactive drug use (Humeniuk et al., 2008).

.2.4. Sexual sensation-seeking. The questionnaire included an adaptation of theevised sexual sensation-seeking scale (Kalichman and Rompa, 1995). Ten itemsssessed the propensity to seek out exciting and novel sexual experiences, fornstance “I like wild, uninhibited sexual encounters”. Participants provided theirnswers on 5-point scales, ranging from 1 (not at all like me) to 4 (very much like me).nternal consistency of the items was sufficient (Cronbach’s ̨ = 0.72). Item scores

ere averaged, with higher scores indicating more sexual sensation-seeking.

.2.5. Depression. This was assessed with the short form of the Patient Health Ques-ionnaire previously used with MSM (Hirshfield et al., 2008; Mao et al., 2009), whichonsisted of nine items, such as “In the last two weeks, how often have you hadrouble falling or staying asleep, or sleeping too much?” Participants provided theirnswers on a scale ranging from 0 (not having the problem at all) to 3 (havinghe problem nearly every day). In this study, the scale had good internal consis-ency (Cronbach’s ̨ = 0.80), and participants were categorized as having a depressiveisorder if they had a score of 2 on at least four items.

.2.6. Involvement with other gay men/MSM. Using six items, we assessed whetherarticipants used MSM websites, accessed internet-based MSM social networks,requented MSM-specific venues, participated in activities with MSM in their city,r were active in MSM groups in the city where they lived. Reponses were givenn four-point scales (1 = never, to 4 = often). We also asked participants how manyay/MSM friends they had. All variables assessing involvement with other gayen/MSM were treated as binary variables (1 = any involvement, 0 = no involve-ent). The number of gay/MSM friends was categorized into a 3-level categorical

ariable based on the distribution of responses. Perceptions of ATS use among MSMetwork: We asked participants to respond to two statements assessing partici-ants’ perception of the popularity of methamphetamine use and ecstasy use in theontext of sex in their MSM social network. Responses were given on 4-point scales1 = totally disagree, 4 = totally agree).

.2.7. Stigma and discrimination related to homosexuality. We adapted Ha’s scale toeasure enacted (experienced) homosexuality-related stigma, perceived (antici-

ated) homosexual stigma, and self-stigma (internalized homophobia) (Ha et al.,013). Responses were given on 4-point scales, with anchors depending on theuestions. The adapted scale encompassed eight items pertaining to enactedomosexuality-related stigma, for example “How often have you lost a job or careerpportunity due to your engaging in homosexual activities” (1 = never, 4 = often);en items measuring perceived homosexuality-related stigma, for instance “Manyeople are unwilling to accept homosexual individuals” (1 = completely disagree,

= completely agree); and eight items measuring internalized homophobia, forxample “Sometimes you wish you were not gay/bisexual/transgender” (1 = totallyisagree, 4 = totally agree). In this study, the scale had good internal consistencyCronbach’s ̨ = 0.74). Means score were calculated for each sub-scale; higher scorendicate higher levels of stigma.

.3. Data analysis

To minimize data entry errors, questionnaire data was double entered using Epi-ata 3.1. The two versions of the dataset were compared to detect inconsistencies,hich were then checked and corrected. Descriptive and analytical statistics were

alculated using Stata version 13.0 (Stata Corp, College Station, TX, USA). We reportrequencies and percentages for categorical variables and means (standard deviationSD]) or medians (inter quartile range [IQR]) for continuous variables. We comparedhe distributions of categorical variables using Chi-square tests or Fisher’s exactests, and compared means using t-tests or Mann–Whitney tests, as appropriate.ogistic regression analysis was used to identify the correlates of methamphetaminese, after it was found to be the most commonly used ATS in the sample. First, we
erformed bivariate logistic regression analyses to assess relationships between therimary outcome variable, recent methamphetamine use (i.e., use in the last threeonths), and potential covariates, including demographic characteristics, selling
ex, recent HIV testing, use of alcohol and other drugs, sexual sensation seeking,epression, involvement with other gay men/MSM, perception of the popularity of

pendence 158 (2016) 110–117

methamphetamine use or ecstasy use for sexual arousal purpose in their MSM socialnetwork, and enacted, perceived and internalized homosexuality-related stigma.Variables related to methamphetamine use in the last three months at a bivariatelevel (p < 0.10) were included in a multivariate logistic regression model to iden-tify independent associations (significance level p < 0.05) (Hosmer et al., 2013). Wechecked the final model for model specification errors, goodness-of-fit and multi-collinearity.

3. Results

3.1. Sample characteristics

Approximately 5% of men referred to the study did not meetthe inclusion criteria, so were not interviewed (reported by recruit-ment staff). Two out of 643 men who were eligible and consented toparticipate did not complete the interview; therefore, the final sam-ple included 622 men. Demographic characteristics of participantsare presented in Table 1. Overall, participants had a median age of24.1 years (IQR: 18.1 to 49.7) with the majority in their twenties(63.2%). Most participants had completed university undergradu-ate education or higher (54.1%); a minority (17.4%) had completedonly secondary school education. One third of participants werelow-skilled, self-employed, freelance labourers, and nearly 15% ofparticipants worked in hospitality industry jobs such as in cafés,restaurants, bathhouses, or massage parlours; 23.5% of participantswere students. Participants’ median monthly income was five mil-lion VND (equivalent to approximately US$250), and 14.8% hada monthly income of less than three million VND (equivalent toUS$150). Over half of participants (51.6%) had migrated from otherprovinces to live in Hanoi or Ho Chi Minh City, and the median timethat participants had lived in either Hanoi or Ho Chi Minh City was18.5 years (IQR: 0.2–48.7 years).

The majority of men described themselves as “ –d `̂ong tính”(gay/homosexual) (74%), 18.7% self-reported as “song tính” (bisex-ual), and the remaining said they were “di. tính/trai th�̆ang”(heterosexual) or indicated another sexual orientation. Two-thirdsof men exclusively had sex with other men (71.7%), and the remain-der had sex with both men and women. Over a quarter of men hadever sold sex (29.1%), and nearly a quarter (23.4%) had sold sexin the last three months. A minority of participants (7.2%) reportedthat they were regular sex workers. In relation to HIV testing, 45.5%reported that they had recent tested for HIV in the last twelvemonths, and 39.2% did not know their HIV status.

In terms of social involvement with other MSM, the mediannumber of MSM friends was 30 (IQR: 2.0–900.0). The majority ofmen reported visiting MSM specific websites (81.5%), accessingMSM online social networks (74.6%), frequenting MSM-specificvenues (84.4%), participating in MSM community activities (68.8%),and participating in MSM groups (63.3%). Participants reported thatmethamphetamine use was moderately popular in their MSM net-work (mean 2.2, SD: 0.8), as was ecstasy use (mean 2.2, SD: 0.8)(Table 2).

Participants in Hanoi and in Ho Chi Minh City were similar withrespect to age, occupation, and age of first sex with either men orwomen. There were significant differences between the subsam-ples from the two cities in terms of education, income, length oftime living in the city, sexual orientation, gender of sexual partners,selling sex, having recent HIV testing, having depression signs andsexual sensation seeking score. More men in Ho Chi Minh City hadcompleted only secondary education or lower (23.2% vs. 11.3%),and fewer had an income of more than 5 million VND per month(50.2% vs. 59.7%). Additionally, fewer participants in Ho Chi Minh
City reported having sex with both men and women comparedto men in Hanoi (17.5% vs. 39.6%), and a larger proportion of HoChi Minh City participants reported ever or recently selling sex(38.2% vs. 19.5% and 31.0% vs. 14.9%, respectively). More men in
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N.T.T. Vu et al. / Drug and Alcohol Dependence 158 (2016) 110–117 113

Table 1Demographic and behavioural characteristics of the full sample and by study locations for men who have sex with men in Hanoi and Ho Chi Minh City Vietnam, 2014.

Total (N = 622) Hanoi (N = 303) Ho Chi Minh City (N = 319) p

Age (Median (IQR)) 24.1 (18.1–49.7) 24.2 (18.1–51.2) 24.1 (18.2–47.2) 0.386<20 years 89(14.3) 42 (13.9) 47 (14.7)≥20–30 years 393 (63.2) 201 (66.3) 192 (60.2)≥30–40 years 100 (16.1) 42 (13.9) 58 (18.2)≥40 years 40 (6.4) 18 (5.9) 32 (6.9)

Education (n (%)) 0.000Up to secondary school 108 (17.4) 34 (11.3) 74 (23.2)High school and some vocational training 177 (28.5) 87 (28.8) 90 (28.2)University undergraduate degree or higher 336 (54.1) 181 (59.9) 155 (48.6)

Occupation (n (%)) 0.365Student 146 (23.5) 77 (25.4) 69 (21.6)Office-based jobs 156 (25.1) 71 (23.4) 85 (26.7)Service jobs 92 (14.8) 41 (13.5) 51 (16.0)Self-employed/Casual employments 188 (30.2) 90 (29.7) 98 (30.7)Unemployed 40 (6.4) 24 (7.9) 16 (5.0)

Monthly income (n (%))* 0.049<3 million VND 92 (14.8) 42 (13.9) 50 (15.7)3–5 million VND 189 (30.4) 80 (26.4) 109 (34.2)>5 million VND 341 (54.8) 181 (59.7) 160 (50.2)

Time living in city (Median (IQR)) 18.5 (0.2–48.7) 10 (0.1–51.2) 20 (0.5–47.1) 0.004

Sexual orientation 0.000“ –d `̂ong tính” (gay/homosexual) 460 (74.0) 216 (71.3) 244 (76.5)“song tính” (bisexual) 116 (18.7) 77 (25.4) 39 (12.2)“di. tính/trai th�̆ang” (heterosexual/other) 46 (7.4) 10(3.3) 36 (11.2)

Gender of sexual partners (n (%)) 0.000Men only 446 (71.7) 183 (60.4) 263 (82.5)Men and women 176 (28.3) 120 (39.6) 56 (17.5)

Age at first sex (Median (IQR)) 0.635With men 19 (14–34) 19 (14–40) 18 (14–31)With women# 19 (13–30) 19 (13–30) 19 (14–28)

Selling sex (n (%))Ever sold sex 181 (29.1) 59 (19.5) 122 (38.2) 0.000Sold sex in the last 3 months 144 (23.2) 45 (14.9) 99 (31.0) 0.000Regular sex worker 45 (7.2) 21 (6.9) 24 (7.5) 0.775

Sexual sensation seeking score (Mean (SD)) (N = 620) 2.5 (0.4) 2.5 (0.4) 2.6 (0.4) 0.679

Recent HIV testing (n (%)) 0.001Yes 339 (54.5) 144 (47.5) 195 (61.1)No 283 (45.5) 159 (52.5) 124 (38.9)

Self-reported HIV status (n (%))HIV positive 11 (1.8) 3 (1.0) 8 (2.5)HIV negative 367 (59.0) 170 (56.1) 197 (61.8)Don’t know 244 (39.23) 130 (42.9) 114 (35.7)Enacted homosexuality-related stigma (Mean (SD)) 1.3 (0.4) 1.2 (0.3) 1.4 (0.5) 0.000Perceived homosexuality-related stigma (Median(IQR)) 3.5 (0.8) 3.7 (0.9) 3.3 (0.6) 0.000Internalized homosexuality-related stigma (Mean (SD)) 3.1 (0.8) 3.2 (0.8) 3.0 (0.7) 0.000Having depression disorders 41 (6.6) 17 (5.6) 24 (7.5) 0.337

Hilmi(

3

w2

* VND = Vietnamese dong.# Among 176 participants who reported sex with women.

o Chi Minh City had recently tested for HIV compared to menn Hanoi (61.1% vs. 47.5%). Lastly, while men in Hanoi reportedess enacted homosexuality-related stigma (mean 1.2, SD: 0.3 vs.

ean 1.4, SD: 0.5), they reported more perceived and internal-zed homosexuality-related stigma than men in Ho Chi Minh cityTable 1).

.2. Patterns of ATS use and use of other substances

Nearly one third (30.4%) of participants had ever used any ATS,ith methamphetamine use reported by 23.6%, ecstasy use by

0.9%, and amphetamine use by 4.3% (see Table 3). Among those

who had used any ATS, most reported first using ATS in theirearly twenties. The most common administration routes of ATSwere smoking (methamphetamine and amphetamine), inhaling(methamphetamine) and swallowing (ecstasy). Injecting drug usewas not reported by any men (data not shown). Relatively moderateproportions of men reported ever using ATS in the context of sex:20.1% had used methamphetamine in the context of sex, 2.9% hadused ecstasy in the context of sex and 11.7% had used amphetamine
in the context of sex. The use of other substances was relativelyuncommon: 4.8% had ever used heroin, 10.8% had used cannabis,6.6% had used ketamine, 9.7% had used poppers, and 8.5% had usederectile dysfunction medication.
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114 N.T.T. Vu et al. / Drug and Alcohol De

Table 2Socially involvement with other MSM and perception of the popularity of ATS sub-stance use among MSM network’s friends of the full sample and by study locationfor men who have sex with men in Hanoi and Ho Chi Minh city, Vietnam, 2014.

n (%) (N = 622)

Number of MSM friends (Median(IQR))

30.0 (2.0–900.0)

Having visited MSM websites 507 (81.5)Accessing MSM online social

networks464 (74.6)

Frequenting MSM specific venues 525 (84.4)Participating in MSM activities 428 (68.8)Participating in MSM groups 364 (63.3)Perception that methamphetamine

use is popular in MSM network(Mean (SD))

2.2 (0.8)

Perception that ecstasy use ispopular in MSM network (Mean(SD))

2.2 (0.8)

Table 3Patterns of amphetamine-type stimulants (ATS) and other substances among menwho have sex with men sampled in Ho Chi Minh City and Hanoi, Vietnam, 2014.

n (%) (N = 622)

Lifetime (ever) use of ATSAny ATS 189 (30.4)Methamphetamine 147 (23.6)Amphetamine 27 (4.3)Ecstasy 130 (20.9)

Age at first use* (Median (IQR))Methamphetamine 22.0 (14.0–40.0)Amphetamine 20.0 (16.0–28.0)Ecstasy 21.0 (16.0–35.0)

Recent ATS use (last three months)Any ATS 126 (20.3)Methamphetamine 105 (16.9)Amphetamine 9 (1.5)Ecstasy 61 (9.8)

Ever used ATS in the context of sexMethamphetamine 125 (20.1)Amphetamine 18 (2.9)Ecstasy 73 (11.7)

ATS use in the context of sex, in thelast three monthsMethamphetamine 89 (14.3)Amphetamine 9 (1.5)Ecstasy 35 (5.6)

Severity of ATS use among recentusers (ASSIST classification)Methamphetamine*

Low-risk use 10/105 (9.5)Moderate-risk use 76/105 (72.4)High-risk use 19/105 (18.1)

Ecstasy*

Low-risk use 10/61 (16.4)Moderate-risk use 49/61 (80.3)High-risk use 2/61 (3.3)

Ever consumed alcohol 552 (88.8)Recent alcohol use (last three

months)479 (77.0)

Alcohol use in the context of sex inthe last three months

270 (43.4)

Ever use of other substancesHeroin 30 (4.8)Cannabis 67 (10.8)Ketamine 41 (6.6)Popper 60 (9.7)Erectile dysfunction medication 53 (8.5)

* Among those who had used the substance.

pendence 158 (2016) 110–117

In the three months prior to interview, 20.3% of participantsreported using any ATS substances. Of these men, 16.9% reportedmethamphetamine use in the context of sex, and 9.8% had usedecstasy in the context of sex. Only 1.5% had used amphetaminein the last three months, and all of this use was in the context ofsex (see Table 3). Most participants (77.0%) reported alcohol con-sumption in the last three months, of whom 56.4% had consumedalcohol in the context of sex. As regards to severity of ATS use classi-fied using ASSIST scoring, 18.1% of recent methamphetamine userscould be classified as high-risk users. Few ecstasy users (3.3%) couldbe classified as high-risk users, and no amphetamine users wereclassified as high-risk users.

3.3. Covariates of recent methamphetamine use

Bivariate analyses identified a number of covariates of metham-phetamine use in the last three months (see Table 4), includingindividual-level factors (education, occupation, income, and sex-ual sensation seeking), community/peer-level factors (accessinginternet-based MSM social networks, and perception of the popu-larity of methamphetamine use for sex in participants’ MSM socialnetwork) and society-level factors (selling sex behaviours) withrecent methamphetamine use. In multivariate logistic regression(Table 3), recent methamphetamine use was independently asso-ciated with selling sex in the last three months (Adjusted OddsRatio (AOR: 2.50; 95% Confidence Interval (CI: 1.54–4.05), sexualsensation seeking (AOR: 2.69; 95% CI: 1.44–5.02), and perceivedpopularity of methamphetamine use for sex in participants’ MSMnetwork (AOR: 2.52; 95% CI: 1.92–3.30).

4. Discussion

This study of ATS use among MSM in Vietnam from a socio-ecological perspective identified a number of important findings.We found ATS use was relatively common among MSM recruitedfrom Hanoi and Ho Chi Minh City, Vietnam. Among all ATSsubstances, methamphetamine was the most commonly usedsubstance (16.9%). This suggests that interventions to reducedrug-related harm and related HIV risks should focus on metham-phetamine use. The lifetime rates of methamphetamine use foundin our study were higher than those found in studies conducted inother Asian countries (Chariyalertsak et al., 2011; Xu et al., 2014a,b) and higher than the rate reported in a 2004 study in Vietnam(Nguyen et al., 2008). Reporting bias may be the reason for the dif-ferences between reported rates among studies. Stigma associatedwith ATS use may vary over time and between locations. Alter-natively, different sampling methods between studies or actualdifferences in methamphetamine use between countries and overtime may account for the high rates of ATS use in our sample.Our findings indicate that public health interventions should beformulated to reduce harmful drug use among MSM in Vietnam,particularly for MSM who regularly use methamphetamine use.Our study found that the approximately one fifth of recent metham-phetamine users (3% of the whole sample) could be categorized ashigh-risk users. Therefore, accessible, effective and affordable treat-ment services should be made available for those who need it. Ourparticipants reported ATS use exclusively via non-injection routessuch as smoking, snorting or inhaling. It is possible that inject-ing methamphetamine and or other ATS substances is relativelyuncommon among Vietnamese MSM, or that we failed to recruitmen who injected, or that men who injected did not want to admit
to this practice in the survey interviews.
We found recent methamphetamine use among MSM inVietnam was associated with societal, community/peer andindividual-level factors. At societal level, recent methamphetamine

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N.T.T. Vu et al. / Drug and Alcohol Dependence 158 (2016) 110–117 115

Table 4Bivariate and multivariate regression analyses of covariates of recent methamphetamine use among men who have sex with men sampled in Ho Chi Minh City and Hanoi,Vietnam, 2014.

Bivariate analysis* (N = 622) Multivariate analysis (N = 620)

OR (95% CI) p (Chi2/Z) AOR (95% CI) p (Z)

Living in Ho Chi Minh city vs. living in Hanoi 1.39 (0.91–2.13) 0.12 (2.35)

Age 0.45 (2.62)<20 years 1≥20–30 years 1.25 (0.64–2.43) 0.51 (0.65)≥30–40 years 1.81 (0.84–3.91) 0.13 (1.51)≥40 years 1.36 (0.49–3.77) 0.55 (0.59)

Education <0.001 (21.98) 0.392 (1.87)Up to secondary school 1 1High school and some vocational training 0.68 (0.39–1.18) 0.17 (-1.38) 0.82 (0.43–1.56) 0.547 (−0.60)University undergraduate degree or higher 0.30 (0.17–0.51) 0.000 (-4.38) 0.58 (0.26–1.28) 0.176 (−1.35)

Occupation <0.001 (21.33) 0.110 (7.54)Student 1 1Office-based jobs 1.25 (0.59–2.68) 0.56 (0.58) 0.72 (0.29–1.84) 0.496 (-0.68)Service jobs 3.41 (1.63–7.15) 0.001 (3.25) 1.03 (0.41–2.59) 0.953 (0.06)Self-employed/Casual employment 3.03 (1.56–5.89) 0.001 (3.25) 1.56 (0.72–3.40) 0.263 (1.12)Unemployed 2.97 (1.17–7.57) 0.02 (2.28) 2.44 (0.83–7.22) 0.106 (1.62)

Monthly income 0.02 (8.36) 0.08 (4.94)<3 million VND 1 13–5 million VND 1.83 (0.80–4.18) 0.15 (1.42) 1.29 (0.52–3.18) 0.582 (0.55)>5 million VND 2.66 (1.23–5.76) 0.01 (2.49) 2.07 (0.90–4.77) 0.087 (1.71)Sexual orientation 0.19 (3.36)“ –d `̂ong tính” (gay/homosexual) 1“song tính” (bisexual) 1.30 (0.78–2.16) 0.20 (1.30)“di. tính/trai th�̆ang” (heterosexual/other) 0.47 (0.14–1.56) 0.09 (1.68)Having sex with both male and femalepartners vs. having sex with male partnersonly

1.81 (1.17–2.81) 0.009 (6.85) 1.64 (0.97–2.79) 0.067 (1.83)

Sexual sensation seeking 4.41 (2.52–7.71) <0.001 (29.50) 2.39 (1.27–4.51) 0.007 (2.70)

Involved in selling sex vs. not selling sex in thelast 3 months

3.69 (2.37–5.75) <0.001 (32.11) 2.43 (1.49–3.96) 0.000 (3.54)

Having recent HIV testing vs. not havingrecent HIV testing

0.68 (0.45–1.04) 0.08 (3.11)

Having depression signs vs. not havingdepression signs

1.90 (0.92–3.92) 0.10 (2.75)

Number of MSM friends 1.00 (0.99–1.00) 0.99 (0.00)Having used MSM websites vs. not havingused MSM websites

0.85 (0.55–1.33) 0.48 (0.50)

Accessing MSM online social networks vs. notaccessing MSM online social networks

0.65 (0.43–0.99) 0.05 (3.94) 1.79 (0.97–3.30) 0.063 (1.86)

Frequenting MSM specific venues vs. notfrequenting MSM specific venues

1.12 (0.73–1.73) 0.60 (0.27)

Participating in MSM activities vs. notparticipating in MSM activities

0.89 (0.58–1.36) 0.58 (0.31)

Participating in MSM groups vs. notparticipating in MSM groups

0.80 (0.51–1.25) 0.32 (1.01)

Perception that methamphetamine use for sexis popular in MSM network

2.86 (2.19–3.72) 0.0000 (72.15) 3.23 (2.35–4.43) 0.000 (7.23)

Perception that ecstasy use is popular for sexin MSM network

2.20 (1.72–2.80) 0.0000 (43.49)

Enacted homosexuality-related stigma 1.31 (0.83–2.07) 0.25 (1.3)Perceived homosexuality-related stigma 0.99 (0.75–1.31) 0.95 (0.00)Internalized homosexuality-related stigma 1.16 (0.88–1.51) 0.29 (1.13)

N

ua2r(ip

S: non-significant.* Sample size varies by each individual covariate.

se was associated with sex work. Men who sell sex may be vulner-ble to HIV and other sexually transmitted infections (Baral et al.,015). In Vietnam, a recent cross-sectional study reported a high
ate of drug use and STIs among male sex workers in three citiesClatts et al., 2015). Our findings suggest that methamphetaminenterventions should target male sex workers in Vietnam to bothrevent drug-related harms as well as HIV transmission. At the
community/peer level, we found that the perception of the pop-ularity of methamphetamine use in MSM networks was associatedwith recent methamphetamine use, suggesting that interventions
should acknowledge and address norms of drug use within MSMsocial networks.
At the individual level, we found that men who had higherlevels of sexual sensation-seeking were more likely to use

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16 N.T.T. Vu et al. / Drug and Alcoh

ethamphetamine. Previous research has found that sexualensation-seeking is associated with drug use for sex (Kalichmannd Rompa, 1995). Interventions to reduce harmful metham-hetamine use among Vietnamese MSM should, therefore, beesigned to be culturally acceptable to men who engage in ‘adven-urous’ sex and drug-based sex. In Australia, previous researchound that subgroups of gay men who engaged in sexually adven-urous activities (drug-related sex, group sex, condomless analntercourse and esoteric sex practices such as sadomasochismnd fisting) were at increased risk of HIV seroconversion (Kippaxt al., 1998). To conclude, our findings suggest that interventionsddressing ATS use, specifically methamphetamine use amongSM in Vietnam, should address individual, social and commu-

ity/peer factors in order to be culturally acceptable and effective.nterventions that address personal, community and societal levelsre more likely to be successful (Hong et al., 2015).

Our study had several limitations. First, though the study teamtrived to recruit a diversified sample of MSM in the two cities,ur sample was largely a peer-referred, convenience sample, andherefore unlikely to be representative of the Vietnamese MSMopulation. As such, generalization of our findings to the broaderopulation of MSM in Hanoi and in Ho Chi Minh City should bepproached with caution. Second, because of the stigma relatedo ATS use, homosexuality and HIV, MSM who participated in ourtudy might have under-reported their drug use behaviours andnsafe sexual practices. Lastly, to avoid the weaknesses of con-enience and peer-referred sampling methods, we recommendedore rigorous, random-based sampling recruitment methods such

s respondent driven sampling or time location sampling to be usedn future studies of MSM in Vietnam.

Our study confirms a moderate prevalence of ATS use amongSM recruited from the two main metropolitan areas of Viet-

am. We found a moderate proportion of MSM who recentlysed methamphetamine reported heavy or problematic use andhat recent methamphetamine use was associated with individual,ommunity/peer-level and societal-level factors. We recommendhat interventions addressing harmful ATS/methamphetamine usehould focus on these factors to provide culturally appropriate sup-ort for the minority of Vietnamese MSM who are in immediateeed.

ole of funding resources

Nga TT Vu has received the Australian Award Scholarship (AAS)or her PhD study at UNSW Australia. The study received financialupport from the Faculty of Arts and Social Sciences (FASS), UNSWustralia under FASS Postgraduate Essential Research Programunding scheme and FASS External Research Program Fundingcheme.

The Centre for Social Research in Health is supported by fundingrom the Australian Government Department of Health. Fundinggencies were not involved in the development of the researchrotocol, data collection, data analysis, interpretation or the dis-emination of research findings.

ontributors

Nga Thi Thu Vu contributed to the development of the researchrotocol, data collection, data analysis and the manuscript draftingnd finalization. John De Wit and Martin Holt provided oversightupervision and valuable inputs for the whole process and the
anuscript drafting and finalization. Huong Thi Thu Phan, Huong
hi Le, Lan Thi La, Gioi Minh Tran, Tung Thanh Doan and Tranghu Nguyen Nguyen provided inputs for the data collection andanuscript drafting and finalization.

pendence 158 (2016) 110–117

Conflict of interest statement

No conflict declared.

Acknowledgements

We acknowledge great support and inputs from staff of theInstitute of Preventive Medicine and Public Health, Hanoi Medi-cal University, Hanoi Centre of HIV/AIDS Prevention and Control,Center for Community Health Promotion, Center for Promotion ofQuality of Life and leaders and representatives of community-basedorganizations of MSM in Ho Chi Minh City during data collectionprocess in Hanoi and Ho Chi Minh City.

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CHAPTER 4

THE RELATIONSHIP BETWEEN METHAMPHETAMINE USE, SEXUAL

SENSATION SEEKING AND CONDOMLESS ANAL INTERCOURSE

AMONG MEN WHO HAVE SEX WITH MEN IN VIETNAM: RESULTS

FROM A COMMUNITY-BASED, CROSS-SECTIONAL STUDY

Author Contributions

Nga Thi Thu VU1,2, Martin HOLT1, Huong Thi Thu PHAN3, Lan Thi LA4, Gioi Minh

TRAN5, Tung Thanh DOAN5, Trang Nhu Nguyen NGUYEN6 and John de Wit1







City, Vietnam.

Reference

Vu NT, Holt M, Phan HT, La LT, Tran GM, Doan TT, et al. The Relationship

Between Methamphetamine Use, Sexual Sensation Seeking and Condomless

Anal Intercourse Among Men Who Have Sex With Men in Vietnam: Results of a

Community-Based, Cross-Sectional Study. AIDS and Behavior.

2017;21(4):1105-16.

Declaration




95


As the first author of the original article, the candidate has the right to include this

article in this thesis. This is an accepted manuscript of an article published by

Springer in journal AIDS and Behavior on 28th June, 2016, available online:

https://link.springer.com/article/10.1007%2Fs10461-016-1467-x

The candidate received permission from Springer to reuse this article in her

thesis. The license number is 4093960721033, issued in 21st April, 2017.

96

https://link.springer.com/article/10.1007%2Fs10461-016-1467-x

ORIGINAL PAPER

The Relationship Between Methamphetamine Use, SexualSensation Seeking and Condomless Anal Intercourse Among MenWho Have Sex With Men in Vietnam: Results of a Community-Based, Cross-Sectional Study

Nga Thi Thu Vu1,2• Martin Holt1

• Huong Thi Thu Phan3• Lan Thi La4

•

Gioi Minh Tran5• Tung Thanh Doan5

• Trang Nhu Nguyen Nguyen6•

John de Wit1,7

Published online: 28 June 2016

� Springer Science+Business Media New York 2016

Abstract This study assessed the relationship between

methamphetamine use and condomless anal intercourse

(CAI) among men who have sex with men (MSM) in Hanoi

and Ho Chi Minh City, Vietnam. Of 622 MSM partici-

pants, 75.7% reported any CAI in the last three months,

23.2% reported engaging in sex work in the last three

months, 21.1% reported group sex in the last twelve

months (21.1%) and 14.3% had used methamphetamine for

sex in the last three months. CAI was associated with living

in Ho Chi Minh City vs. Hanoi, being versatile during anal

sex, a greater degree of sexual sensation-seeking, and more

strongly agreeing that withdrawal before ejaculation is

effective in preventing HIV. Effect-modification analysis

showed that recent sex-related methamphetamine use was

related to a higher probability of CAI for men with low

sexual sensationseeking scores. Methamphetamine assess-

ment and/or interventions should be incorporated into HIV

prevention and research with Vietnam’s MSM population.

Keywords Sex-related methamphetamine use � Sexualsensation seeking � Condomless anal sex � Men who have

sex with men � Vietnam

Introduction

Men who have sex with men (MSM) are disproportionately

affected by HIV worldwide, and the size of HIV epidemics

is either stable or increasing among MSM in different

countries [1, 2]. Condomless anal intercourse (CAI) is the

primary risk factor for HIV transmission among MSM.

Studies in low- and middle-income countries (LMIC) have

found that 27–78 % of MSM report CAI during their recent

or last sexual encounter [3–7]. In Vietnam, recent online

studies have found that 45 % of MSM report CAI during

their last sexual encounter [8], and 36 % report at least one

instance of CAI in the previous 3 months [9]. A community-

based cross-sectional study of MSM in Southern Vietnam

found that 34 % of participants had CAI with more than two

male partners in the month before the study and the overall

rate of CAI in the last month was 74 % [10].

In previous studies conducted mostly in high-income

countries, CAI among MSM has been found to be associ-

ated with numerous factors. CAI among MSM was less

likely among MSM who were exposed to HIV prevention

[11], but was found to be more likely for men who had

higher numbers of sexual partners [12], identified as

& Nga Thi Thu Vu

[email protected]

& John de Wit

[email protected]

1 Centre for Social Research in Health, UNSW Australia,

Sydney, NSW 2032, Australia

2 Institute of Preventive Medicine and Public Health, Hanoi

Medical University, No 1 Ton That Tung Street, Hanoi,

Vietnam

3 Vietnam Administration for HIV/AIDS Prevention and

Control, Ministry of Health, 135/3 Nui Truc Street, Hanoi,

Vietnam

4 Hanoi Centre of HIV/AIDS Prevention and Control, Khu

Hanh Chinh Moi, Ha Dong, Hanoi, Vietnam

5 Center for Community Health Promotion, Suite 117-120,

Block B17, Kim Lien Diplomatic Compound, Dong Da,

Hanoi, Vietnam

6 Centre for Promotion of Quality of Life, 140, Street No. 7,

Trung Son Area, Binh Chanh District, Ho Chi Minh City,

Vietnam

7 Utrecht University, Heidelberglaan 1, 3584 CS Utrecht,

Netherland

123

AIDS Behav (2017) 21:1105–1116

DOI 10.1007/s10461-016-1467-x

97

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http://crossmark.crossref.org/dialog/?doi=10.1007/s10461-016-1467-x&domain=pdf

bisexual rather than gay [13], reported adverse psycho-

logical conditions (e.g., depression, psychological distress

and negative mood) [12, 14, 15], experienced internalized

homophobia [16], had financial difficulties [16], used club

drugs [12, 17], had sex with primary versus non-primary

partners [18], and were more sexual sensation seeking

[19, 20]. Drug use among MSM, particularly the use of

methamphetamine, and associations with CAI, is of par-

ticular interest to HIV research and prevention in many

settings.

Methamphetamine is a psychostimulant that can be

orally ingested, smoked, inhaled, snorted, injected or

shafted (inserted into the anus) [21]. Among MSM,

methamphetamine is a popular drug. In the US, the

prevalence of its use was found to be ten times greater

among MSM than in the general population [22].

Methamphetamine use can enhance stamina and sexual

pleasure [22, 23], promote sexual disinhibition and facili-

tate experimentation [24, 25], and heighten euphoria, sex-

ual pleasure and impulsiveness [23]. A recent case–control

study found that using methamphetamine decreased self-

control over sexual activities [26].

Studies in some high-income countries have found that

methamphetamine use by MSM is associated with con-

domless sex, high numbers of sexual partners and HIV

infection [22, 23, 27]. A systematic review and meta-

analysis of 35 published studies into the association

between amphetamine-type substances and HIV infection

among MSM showed that methamphetamine was signifi-

cantly associated with higher HIV prevalence or incidence

[28]. Recent studies have continued to find significant

associations between methamphetamine use and CAI

among MSM [26, 29, 30].

Findings are, however, mixed with respect to a relationship

between methamphetamine use and sexual risk behaviors

such as CAI. One US-based study found an association

between methamphetamine use and the frequency of con-

domless insertive and receptive anal intercourse among gay

and bisexual men, but could not confirm the temporal

sequence of drug use and sexual behaviours [31]. In Australia,

increasing methamphetamine use among MSM in Sydney

during 2002–2005 was not associated with an increase in

condomless sex [32]. Additionally, several published papers

included in a recent meta-analysis [28] did not find that

methamphetamine use was associated with increased risk of

HIV infection. Moreover, most previous studies assessed the

relationship between CAI and any use of methamphetamine

[28], regardless of whether drug use occurred in conjunction

with sex or not. A more stringent approach would be to

specifically examine the relationship between CAI and

methamphetamine use before or during sex.

While studies of methamphetamine use and its associ-

ation with HIV infection among MSM are relatively

common in high-income countries, to date few studies have

been conducted in LMIC, especially in East Asia and South

East Asia. A study in Thailand conducted in 2008–2009

found that 13.6 % of MSM attending a sexual health clinic

in Chiang Mai had ever used methamphetamine [33]. Two

studies of MSM in China conducted between 2011 and

2013 found that 3–4 % had ever used methamphetamine

[6, 34]. A study in Indonesia found that methamphetamine

use was associated with a higher likelihood of HIV infec-

tion in MSM [35], while a study conducted with gay,

bisexual and transgendered people in Thailand found no

relationship [33].

In Vietnam, there have been few studies of metham-

phetamine use by MSM and its association with sexual

behavior and risk of HIV. A study conducted in 2004

found that 4 % of MSM had ever used methamphetamine

[36]. Other studies on drug use by MSM in Vietnam used

composite measures of drug (any drug use vs. none)

[36–38], and cannot differentiate the specific effect of

methamphetamine use on sexual behavior or risk for HIV.

The use of methamphetamine by MSM may have

increased recently in major cities in Vietnam [39], and

there is concern that this has increased the likelihood of

CAI and risk of HIV infection. However, no previous

studies in MSM in Vietnam have reported this

association.

Recent studies among MSM in high-income countries

have found that sexual sensation-seeking may modify the

association between risky sexual behaviors and substance

use, in particular alcohol use [40, 41]. Notably, previous

research has found that among men with higher levels of

sexual sensation-seeking, men who drank alcohol were

more likely to engage in CAI compared to those who did

not drink alcohol [40]. In another study, high levels of

sexual sensation-seeking were found to strengthen the

positive association between alcohol or other drug use with

sex partners and the likelihood of CAI among young MSM

[41]. This study also found that drug use with sex partners

increased the likelihood of CAI among men who had low

sexual sensation-seeking, suggesting that in some circum-

stances drug use before or during sex is a stronger influence

on risk-taking than sexual sensation-seeking. Sexual sen-

sation-seeking might also modify the association between

methamphetamine use and CAI, but such an assessment

has not been reported.

We conducted the present study to examine the rela-

tionship between methamphetamine use and CAI and

among MSM in the two main cities of Vietnam—Hanoi

and Ho Chi Minh City (HCMC). Taking into account the

mixed findings of previous research, we assessed the

association between CAI and sex-related metham-

phetamine use, and examined the potential modification

effect of sexual sensation-seeking.

1106 AIDS Behav (2017) 21:1105–1116

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98

Methods

This was a cross-sectional, community-based study, con-

ducted in collaboration with Hanoi HIV/AIDS Prevention

Center (Hanoi PAC), the Center for Community Health

Promotion (CHP) in Hanoi, and the Centre for Promotion

of Quality of Life (Life Center) in HCMC, Vietnam, during

September-December 2014. CHP and Life Centre have

outreach networks of MSM who are students, white-collar

workers, male sex workers, or self-employed professionals

who can reach diverse subgroups of MSM. A detailed

description of the study design can be found elsewhere

[39]. In summary, a non-random, convenience sampling

method was used to recruit participants, as MSM remain a

relatively hidden, hard-to-reach population in Vietnam,

because of homosexuality-related stigma and discrimina-

tion [42]. Potential participants were referred by outreach

workers of CHP and the Life Center, via local community-

based organizations/groups of MSM, and through partici-

pant referral. Men were eligible if they were Vietnamese

citizens, 18 years or older at the time of the study, had anal

sex with at least one man in the previous 3 months, had

good comprehension of the Vietnamese language, and

consented to participate in the study. A total of 622 MSM

were recruited. Before the study, we estimated the sample

size based on expert opinion and previous research, which

suggested that the prevalence of recent CAI would be 36 %

among MSM in Vietnam [9]. Our sample size, based on

90 % power and a 95 % significant level, was sufficient to

detect a prevalence of CAI that was 6 % higher than the

previously found prevalence of CAI.

Data Collection

Face-to-face, structured interviews using a self-report

questionnaire were administered by experienced data col-

lectors from Hanoi Medical University and by trained MSM

peers. To ensure confidentiality, interviews were conducted

in private rooms at locations convenient for participants,

arranged by Hanoi PAC and CHP in Hanoi and Life Center

in HCMC. Interviews were conducted between 8 am and

8 pm on weekdays and weekends to accommodate MSM

who could not participate during office hours. Potential

participants received information about the study, were

briefed on ethical considerations and informed consent,

screened for eligibility, and provided with a unique,

anonymous study ID if they met the inclusion criteria and

consented to participate. Interviews lasted for approximately

35–50 min. Participation in the study was entirely voluntary

and study participants were informed that they could with-

draw from the study at any time, without giving a reason and

without prejudice. After the interview, men received a

reimbursement of 100,000 Vietnam Dong (VND; equivalent

to US$5) for their time and expenses, were provided with

HIV prevention materials, and were referred to voluntary

HIV testing. Men were also referred to support services, if

appropriate or requested.

Measures

The questionnaire was developed in English and translated

into Vietnamese, confirming the quality of the translation

with MSM peers and Vietnamese colleagues. Two separate

consultation meetings were held, one in Hanoi and one in

HCMC, with a total of approximately 20 representatives

from local MSM organizations and researchers, to seek

input into the appropriateness of the questions and collo-

quial terms for drug use, sexual orientation and sexual

behaviors commonly used by MSM. The representatives

also commented on the user-friendliness and acceptability

of the questionnaire. The questionnaire was pilot-tested

with ten MSM in Hanoi and subsequently refined.

Demographic Characteristics

We collected information regarding age, education, occu-

pation, monthly income, self-reported sexual orientation,

age of first sex with men and women, and self-reported

HIV status.

HIV Testing and Safe Sex Counseling

We asked participants if they had recently tested for HIV

(i.e., having tested for HIV at least once in the last

12 months) and if they had recent safe sex counseling (i.e.,

having received safe sex counseling at least once in the last

12 months).

Sexual Behaviors

Participants were asked about ever having engaged in sex

work and having engaging in sex work in the last 3 months,

their number of regular and casual male and female part-

ners in the last 3 and 12 months, their position during anal

sex with male partners, the use of condoms during sexual

intercourse with male or female partners in the last

3 months and the use of condom during group sex in the

last 12 months. Regular sexual partners were defined as

sexual partners with whom participants had had sex more

than once, while sexual partners with whom participants

had had sex once were considered casual partners. Because

numbers of different types of sexual partners were skewed,

we undertook logarithmic or square root transformations of

these variables, as appropriate. Receptive condomless anal

AIDS Behav (2017) 21:1105–1116 1107

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99

intercourse (RCAI) was defined as not or inconsistently

using a condom during anal sex with the participant in the

receptive (bottom) position; insertive condomless anal

intercourse (ICAI) was defined as not or inconsistently

using a condom during anal sex with the participant in the

insertive (top) position. Any recent CAI defined as

reporting either RCAI or ICAI in the past three months,

was the primary outcome of interest. CAI during group sex

in the last 12 months was defined as having had CAI (in the

insertive or receptive position) while engaging in sex with

two or more male partners at the same time.

Alcohol and Drug Use

Participants were asked questions about any use of

methamphetamine, amphetamine, ecstasy, alcohol and

other substance use (i.e., ketamine, erectile dysfunction

medications and amyl nitrite [‘poppers’]) before or during

sex in the last 3 months. Previously methamphetamine was

available in Vietnam mostly in the form of tablets. How-

ever, recently and commonly it is available in crystal form

[43]. We, therefore, asked about the use of crystal

methamphetamine. Answers to questions about substance

use were dichotomized (any use vs. none). Metham-

phetamine use before or during sex was considered as the

primary independent variable.

Depression

This was assessed with the Patient Health Questionnaire 9

scale, which has been used with MSM in other studies

[44, 45]. The scale consists of nine items, such as ‘‘In the

last 2 weeks, how often have you had trouble falling or

staying asleep, or sleeping too much?’’ Participants pro-

vided their answers on a scale ranging from 0 (not having

the problem at all) to 3 (having the problem nearly every

day). The items had good internal consistency (Cronbach’s

a = 0.80). Participants were categorized as having a

depressive disorder if they had a score equal or larger than

ten [46].

Sexual Sensation-Seeking

We adapted the revised sexual sensation-seeking scale by

Kalichman [47] for our study population and included ten

items assessing the propensity to seek exciting, novel and

stimulating sexual experiences, for instance ‘‘I like wild,

uninhibited sexual encounters’’. Participants provided their

answers on 4-point Likert-type scale ranging from 1 (not at

all like me) to 4 (very much like me). Internal consistency

of the items was adequate (Cronbach’s a = 0.72), and item

scores were averaged; a higher score indicated a higher

level of sexual sensation-seeking.

Belief in the Efficacy of HIV Risk Reduction Strategies

Participants were asked how effective they thought dif-

ferent strategies were in preventing HIV transmission:

antiretroviral treatment of HIV, taking the insertive (top)

position during anal sex, and withdrawal before ejacula-

tion. Answer options ranged from 1 (totally disagree) to 4

(totally agree). Belief in the efficacy of each HIV preven-

tion method was dichotomized into disagreement (scores 1

and 2) versus agreement (scores 3 and 4).

Data Analysis

To minimize data entry errors, questionnaire data was

double entered using EPIDATA 3.1. The two versions of

the dataset were compared to detect inconsistencies, which

were then checked and corrected. Descriptive and analyt-

ical statistics were calculated using STATA version 13.0

(Stata Corp, College Station, TX, USA). We reported fre-

quencies and percentages for categorical variables and

means and standard deviations (SD) or medians and inter

quartile ranges (IQR) for continuous variables. We com-

pared the distribution of demographic variables by

methamphetamine use. Categorical variables were com-

pared using Chi Square tests or Fisher’s exact tests, and

continuous variables were compared by t-tests or Mann–

Whitney tests, as appropriate. Previous studies on CAI

among MSM in Vietnam suggested that the prevalence of

CAI was relatively high, ranging from 36 to 74 % [8–10].

We therefore calculated Prevalence Ratios instead of

Prevalence Odds Ratios [48]. We first tested the bivariate

relationship between any CAI with male partners in the last

3 months and methamphetamine use before or during anal

sexual intercourse in the last 3 months. We subsequently

tested for associations between other potential covariates

and recent CAI with male partners, including demographic

characteristics, HIV testing and safe sex counseling, other

aspects of sexual behavior (i.e., number of sexual partners,

position during anal sex), other drug use during sex,

depression, sexual sensation-seeking, and belief in different

HIV prevention methods. Factors significantly (p\ .05)

associated with the outcome variable in bivariate analyses

were entered into a multivariate regression model. The

final model included only covariates significantly (p\ .05)

associated with CAI. Previous research has found that

sexual sensation-seeking may modify the association

between substance use and CAI [40, 41]. We therefore

tested if sexual sensation-seeking was an effect modifier of

the association between recent sex-related metham-

phetamine use and recent CAI as reflected in the signifi-

cance of the interaction term of sex-related

methamphetamine use and sexual sensation-seeking, con-

sistent with a previously suggested method [49]. For all

1108 AIDS Behav (2017) 21:1105–1116

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100

analyses of associations, we used generalized linear models

with modified Poisson regression and robust error vari-

ances [50].

Results

A description of sample characteristics can be found in

Table 1 and participants’ HIV-related sexual and drug use

behaviors are presented in Table 2. Bivariate and multi-

variate analysis of covariates of CAI are presented in

Table 3.

Factors significantly associated with any CAI with male

partners in the last 3 months in bivariate analyses included

living in HCMC versus Hanoi; college or University edu-

cation or higher vs. secondary education or less; working in

service jobs or being self-employed or a freelance worker

versus being a student (CPR: 1.24; CI 1.08–1.42 and CPR:

1.15; CI 1.01–1.31); being both insertive and receptive vs.

being exclusively insertive during anal sex (CPR: 1.71; CI

1.52–1.94); recently engaged in sex work (CPR: 1.21; CI

1.12–1.32); number of regular male sexual partners in the

last 3 months (CPR: 0.73; CI 0.62–0.86); number of casual

male partners in the last 3 months (CPR: 1.05; CI

1.01–1.10); recent sex-related methamphetamine use

(CPR: 1.19; CI 1.08–1.30); recent sex-related alcohol use

(CPR: 1.13; CI 1.04–1.24); recent sex-related poppers use

(CPR: 1.20; CI 1.06–1.36); sexual sensation-seeking (CPR:

1.27; CI 1.14–1.42); belief in the safety of withdrawal as

HIV prevention strategy (CPR: 1.22; CI 1.12–1.33); and

belief in the safety of being insertive during sex as a HIV

prevention strategy (CPR: 1.13; CI 1.04–1.23).

All variables that were significantly (p\ 0.05) associ-

ated to CAI in bivariate analyses were included in the

multivariate model (Table 3). That is, in this multivariate

analysis the potential association between CAI and recent

sex-related methamphetamine use was adjusted for other

variables significantly associated in bivariate analyses,

including city of residence, engaging in sex work in the last

3 months, recent use of alcohol before or during sex, recent

use of poppers before or during sex, sexual sensation-

seeking, belief in the safety of being insertive during anal

sex, and belief in the safety of withdrawal as HIV pre-

vention strategy(binary variables); educational level,

occupation, position during anal sex (categorical vari-

ables), number of regular male sexual partners in the last

3 months, and number of casual male partners in the last

3 months (continuous variables).

In the multivariate analysis, any CAI with male partners

in the last 3 months was independently associated with

living in HCMC versus Hanoi (APR: 1.13; CI 1.03–1.23),

practicing both receptive and insertive anal sex versus.

being exclusively insertive (APR: 1.63; CI 1.44–1.84),

higher number of regular male partners (APR: 0.83; CI

0.71–0.97), higher sexual sensation-seeking scores

(APR:1.19; CI 1.06–1.34), belief in the effectiveness of

withdrawal as a HIV prevention strategy (APR: 1.14; CI

1.05–1.24), recent sex-related methamphetamine use

(APR: 1.19; CI 1.15–3.23) and the interaction between sex-

related methamphetamine use and sexual sensation-seeking

(APR: 0.80; CI 0.67–0.96).

Table 1 Demographic characteristics of MSM recruited in Hanoi

and HCMC, Vietnam, 2014

Total

(N = 622)

n (%)

Age (Median (IQR)) 24.1

(18.1–49.7)

\20 years old 89 (14.3)

C20–30 393 (63.2)

C30–40 100 (16.1)

C40 40 (6.4)

Education

To secondary school 108 (17.4)

High school and some vocational training 177 (28.5)

College, University and higher 336 (54.1)

Occupation

Student 146 (23.5)

Office-based jobs 156 (25.1)

Service jobs 92 (14.8)

Self-employed/casual low-paid jobs 188 (30.2)

Unemployed 40 (6.4)

Monthly income (median (IQR) (N = 303) 5.0 (0.5–30.0)

\3 million VND (equivalent to 150 $US) 92 (14.8)

C3–5 million VND (equivalent to 150–250 $US) 189 (30.4)

[ 5 million VND (equivalent to 250 $US) 341 (54.8)

Sexual orientation

Homosexual 460 (74.0)

Bisexual 116 (18.7)

Heterosexual, other or no specified identity 46 (7.4)

Self-reported HIV status

HIV positive 11 (1.8)

HIV negative 367 (59.0)

Unknown 244 (39.2)

HIV testing in the last 12 months 339 (54.5)

Safe sex counselling in the last 12 months 363 (58.4)

Depression 70 (11.3)

Sexual sensation seeking score (mean (SD)) 2.5 (0.4)

Belief in the effectiveness of HIV

prevention strategies

Treatment as prevention 100 (16.1)

Being a top (insertive) during anal sex 242 (38.9)

Withdrawal 298 (47.9)

AIDS Behav (2017) 21:1105–1116 1109

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101

To illustrate the modification effect of sexual sensation-

seeking of the association between any recent CAI and

recent sex-related methamphetamine use, the association

between recent sex-related methamphetamine use and any

CAI in the last 3 months by participants’ sexual sensation-

seeking scores is shown in Fig. 1. After adjustment for

other independent covariates, including place of residence,

position during anal sexual intercourse, number of regular

male partners in the last 3 months, sexual sensation-seek-

ing and belief in the safety of withdrawal as HIV preven-

tion, differences in the probability of engaging in recent

CAI between recent methamphetamine use versus no

Table 2 Sexual and drug use behaviours among MSM in Hanoi and HCMC, Vietnam, 2014

Mean (SD)/median (IQR) n (%)

Type of sexual partners (N = 622)

Male sexual partners only 446 (71.7)

Both male and female sexual partners 176 (28.3)

Age of first sex with male partner (median (IQR)) (N = 622) 19 (14–34)

Age of first sex with female partner (mean (SD)) (N = 175) 19.5 (3.3)

Position in anal sexual intercourse with male partners (N = 621)

Receptive only 229 (36.9)

Insertive only 180 (29.0)

Both receptive and insertive (versatile) 212 (34.1)

Ever engaged in sex work (N = 622) 181 (29.1)

Engaged in sex work in the past 3 months (N = 622) 144 (23.2)

Group sex in the past 12 months (N = 622) 131 (21.1)

Sex with regular male partners

Number of regular male partners in the last 12 months (median (IQR)) (N = 579) 3 (1–55)

Number of regular male partners in the last 3 months (median (IQR)) (N = 558) 1 (1–25)

Perceived HIV status of regular male partners in the last 3 months (N = 558)



Unknown 418 (74.9)

Sex with casual male partners

Number of casual male partners in the last 12 months (median (IQR))(N = 474) 7 (1–300)

Number of casual male partners in the last 3 months (median (IQR)) (N = 416) 3 (1–90)

Perceived HIV status of casual male partners in the last 3 months (N = 417)



Unknown 298 (95.4)

Any CAI with any male partners in the last 3 months (N = 622) 471 (75.7)

Any RCAI with any male partners in the last 3 months (N = 622) 367 (59.0)

Any ICAI with any male partners in the last 3 months (N = 622) 252 (40.5)

Condomless group sex in the last 12 months (N = 131)

No 63 (48.1)

Yes 58 (44.3)

Don’t know/Don’t remember 10 (7.6)

Drug use before or during sex in the last 3 months (N = 622)

Methamphetamine 89 (14.3)

Amphetamine 9 (1.5)

Ecstasy 35 (5.6)

Alcohol 270 (43.4)

Ketamine 8 (1.3)

Erective Dysfunction drugs (EDM) 17 (2.7)

Popper 31 (5.0)

1110 AIDS Behav (2017) 21:1105–1116

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102

Table 3 Bivariate and multivariate analyses of any CAI with male partners in the last 3 months among MSM recruited in Hanoi and HCMC,

Vietnam, 2014 (N = 556)

CPR (95 % CI) P APR (95 % CI) P

Place of residence (HCMC vs. Hanoi) 1.13 (1.03–1.24) 0.008 1.13 (1.03–1.23) 0.002

Age 0.991

\20 years old 1

C20–30 1.13 (0.97–1.30)

C30–40 1.02

(0.85–1.23–1.32)

C40 1.08 (0.86–1.35)

Education 0.015

To secondary school 1 1

High school and some vocational training 0.92 (0.82–1.04) 1.05 (0.94–1.16) 0.399

College, University and higher 0.87 (0.78–0.97) 1.11 (0.97–1.26) 0.131

Occupation 0.019

Student 1 1

Office-based jobs 1.03 (0.89–1.19) 1.04 (0.91–1.18) 0.577

Service jobs 1.24 (1.08–1.42) 1.12 (0.99–1.27) 0.078

Self-employed/freelance jobs 1.15 (1.01–1.31) 1.09 (0.97–1.23) 0.142

Unemployed 1.08 (0.88–1.34) 0.99 (0.81–1.22) 0.957

Monthly income 0.414

\3 million VND (equivalent to US$150) 1

C3–5 million VND (equivalent to US$150–250) 1.13 (0.98–1.30)

[5 million VND(equivalent to US$250) 1.00 (0.87–1.15)

Sexual orientation 0.568

Gay/homosexual 1

Bisexual 0.97 (0.86–1.09)

Heterosexual/not specified/to be determined 1.09 (0.95–1.26)

Ever tested for HIV (Yes/No) 1.01 (0.92–1.12) 0.78

HIV testing versus no HIV testing in the last 12 months 1.05 (0.96-1.15) 0.324

Safe sex counselling versus no safe sex counselling in the last 12 months 0.98 (0.89–1.07) 0.583

Position during anal intercourse \0.001

Exclusive insertive 1 1

Exclusive receptive 1.15 (0.99–1.34) 0.069 1.14 (0.98–1.32) ‘0.084

Versatile (both insertive and receptive) 1.71 (1.52–1.94) \0.001 1.63 (1.44–1.84) \0.001

Sex with both male and female partners versus having sex with male partners

only

0.97 (0.87–1.07) 0.507

Engaged in sex work versus not engaged in sex work in the last 3 months 1.21 (1.12–1.32) \0.001 0.98 (0.89–1.09) 0.749

Number of regular male sexual partners in the last 3 monthsa 0.73 (0.62–0.86) \0.001 0.83 (0.71–0.97) 0.021

Number of casual male sexual partners in the last 3 monthsb 1.05 (1.01–1.10) 0.017 1.004

(0.96–1.05)

0.87

Methamphetamine use before or during sex versus no

methamphetamine use with sex in the last 3 months

1.19 (1.08–1.30) \0.001 1.93 (1.15–3.23) 0.013

Amphetamine use before or during sex versus no amphetamine

use with sex in the last 3 months

1.03 (0.72–1.46) 0.88

Ecstasy use before or during sex versus no ecstasy use

with sex in the last 3 months

1.14 (0.99–1.32) 0.071

Other drug use before or during sex versus no drug use

with sex in the last 3 months

Alcohol 1.1 3(1.04–1.24) 0.005 1.01 (0.93–1.11) 0.773

Ketamine 1.16 (0.89–1.51) 0.28

Ejaculation Dysfunction Medication (EDM) drugs 1.09 (0.87–1.37) 0.451

AIDS Behav (2017) 21:1105–1116 1111

123

103

methamphetamine use were significant in men who had

lower sexual sensation-seeking scores (i.e. mean of sexual

sensation-seeking less than 2.6), but not among men who

scored higher on sexual sensation-seeking.

We undertook exploratory sensitivity analyses to test

whether sex-related amphetamine use was associated with

a higher reported rate of RCAI or ICAI. After controlling

for other identified independent covariates of any CAI, and

including the interaction term between sexual sensation-

seeking, the association between sex-related metham-

phetamine use and RCAI was not significant (APR = 1.4;

CI 0.80–2.53, p = 0.23), while the association between

sex-related methamphetamine use and ICAI approached

statistical significance (APR = 2.82; CI 0.96–8.30),

p = 0.06) (data provided upon request). Of note, while the

sample size for the analysis of any CAI was 556, the

sample size was 405 for the analysis of RCAI and 349 for

the analysis of ICAI.

Discussion

To the best of our knowledge, this study is the first to report

on the relationship between sex-related methamphetamine

use and CAI among Vietnamese MSM, taking into account

a potential modification effect by sexual sensation seeking.

Data confirm that methamphetamine use before or during

sex was associated with any CAI and uniquely show that

this association was modified by sexual sensation-seeking.

Specifically, among men with lower sexual sensation-

seeking we found that those who recently used metham-

phetamine before or during sex were more likely to report

CAI than men who did not use methamphetamine for sex.

In contrast, among men who scored higher on sexual sen-

sation-seeking there was no difference in reporting CAI

between those who used methamphetamines before or

during sex and those who did not. Putting this another way,

while MSM with lower sexual sensation-seeking scores

tended to report CAI if they used methamphetamine before

or during sex, MSM with higher sexual sensation-seeking

scores were generally more likely to report CAI, regardless

of their use of methamphetamine for sex.

The nature of the observed effect modification differs

from previous studies reporting a modification effect of

sexual sensation-seeking on the association between alco-

hol use and CAI. These previous studies found that, among

men higher in sexual sensation-seeking, those who drank

alcohol in conjunction with sex were more likely to engage

in CAI compared to men who did not drink alcohol [40, 41].

The different modification effect of sexual sensation-seek-

ing observed in our study may reflect that in our sample

sexual sensation-seeking was independently associated with

the likelihood of CAI, such that a higher sexual sensation-

seeking score was independently associated with an

increased probability of reporting CAI by MSM, similar to

the findings found in other research [19, 20, 51]. In contrast,

previous studies of the modification effect of sexual sen-

sation seeking on the association between alcohol

Table 3 continued

CPR (95 % CI) P APR (95 % CI) P

Poppers 1.20 (1.06–1.36) 0.003 1.07 (0.93–1.22) 0.343

Depression 1.11 (0.99–1.25) 0.088

Sexual sensation seeking score 1.27 (1.14–1.42) \0.001 1.19 (1.06–1.34) 0.002

Belief in the safety of withdrawal as a HIV prevention strategy 1.22 (1.12–1.33) \0.001 1.14 (1.05–1.24) 0.002

Belief in the effectiveness of HIV treatment as an HIV prevention strategy 0.97 (0.86–1.10) 0.67

Belief in the safety of being insertive during sex as a HIV prevention strategy 1.13 (1.04–1.23) 0.006 1.07 (0.99–1.17) 0.089

Product term of sex-related methamphetamine use and sexual sensation seeking 0.80 (0.67–0.96) 0.019

CPR Crude Prevalence Ratio; APR Adjusted Prevalence Ratioa square root of number of regular male sexual partners in the last 3 monthsb logarithm transformation of casual male sexual partners in the last 3 months

-.4-.2

0.2

.4

Pro

babi

lity

(of i

nvol

ving

in re

cent

CA

I) di

ffere

nce

1.5 2 2.5 3 3.5

Sexual sensation seekingDifferences in probability of involving in CAI*

Upper and Lower 95% confidence limit

Sexually - related methamphetamine use - No methamphetamine use

Fig. 1 Differences in the probability of involving in CAI in the last

three months for sexually-related methamphetamine use versus no

methamphetamine use by sexual sensation seeking

1112 AIDS Behav (2017) 21:1105–1116

123

104

consumption and CAI have not found that sexual sensation-

seeking was independently associated with CAI [40, 41]. In

our sensitivity analysis we found a marginally significant

association of methamphetamine use before or during sex

with ICAI, but not with RCAI. These findings partly agree

with previous studies that methamphetamine use was

associated with ICAI and/or RCAI [26, 29–31, 52, 53].

There may be several reasons for inconsistencies in these

findings, including the reduced power of our sensitivity

analyses due to smaller sample sizes. Also, while several

prior studies measured overall methamphetamine use for

different recall periods [26, 31, 52], we measured

methamphetamine use before or during sex. Furthermore,

while we included an interaction term to assess the modi-

fication effect of sexual sensation-seeking, previous studies

did not include an interaction term.

The finding that methamphetamine use was associated

with CAI, particularly among men who have low sexual

sensation-seeking scores, has implications for HIV

research and interventions targeting MSM in Vietnam.

With respect to research, in light of our findings we suggest

incorporating the assessment of methamphetamine use and

its association with CAI into national, bio-behavioral

surveillance to better understanding methamphetamine’s

potential impact on HIV transmission in this population.

Future studies should also consider applying more detailed

assessments of methamphetamine and/or other substance

use, notably event-level measurement as previously sug-

gested [54], and using longitudinal designs to strengthen

confidence in the temporal association between metham-

phetamine use and sexual behaviors. Additionally, ana-

lyzing first person, narrative accounts of the role of

methamphetamine use in CAI among MSM in Vietnam

could be beneficial.

Regarding HIV prevention, our findings suggests that

interventions targeting MSM in Vietnam should consider

addressing methamphetamine use as a potential facilitator

of CAI and HIV transmission, and incorporate metham-

phetamine interventions into current sexual behavioral

change interventions. We recommend awareness raising

and capacity building for health professionals who work in

HIV prevention for MSM, including outreach workers,

regarding methamphetamine-associated harms, harm

reduction and methamphetamine treatment. Relatedly, we

recommend that HIV prevention workers providing ser-

vices to MSM incorporate routine assessment of metham-

phetamine use and its associated harms for timely linkage

to methamphetamine-related interventions, as required.

Additionally, since we found that sexual sensation-seeking

was related to CAI, we recommend that HIV prevention

interventions for MSM should consider specifically tar-

geting men who engage in more sexual sensation-seeking.

Our experience during the research process is that sexual

sensation-seeking can be assessed in only a few minutes

with easy to complete self-report items, suggesting that the

sexual sensation-seeking scale could be used at a com-

munity level to screen for men who engage in sexual

sensation-seeking and might benefit from participation in

targeted sexual behavior change interventions. This could

include, where available, the provision of pre-exposure

prophylaxis, which has been proven to be effective in

prevent HIV transmission among MSM population [55].

Our findings also indicate that sexual risk-taking

behaviors may also depend on other factors, such as the

position during sexual intercourse. We found that CAI was

more likely to be reported by men who reported being

versatile in their positioning during anal sex (i.e., being

both insertive and receptive with their anal sex partners),

compared to men who were exclusively insertive. This is

similar to a finding reported in a recent study among MSM

in China [56]. In contrast, a recent study in India found that

men who were exclusively insertive were more likely to

engage in CAI than other men [57]. While it is not clear

whether inconsistent findings regarding the relationship

between positioning during sex and CAI reflect differences

in men’s belief in and practice of strategic positioning as a

HIV prevention strategy, we did find that men who

believed that withdrawal was an effective HIV prevention

strategy reported a higher CAI rate. This suggests potential

misunderstandings regarding HIV transmission risk among

Vietnamese MSM, which need to be addressed in HIV

education and prevention interventions.

The level of recent CAI with male partners we observed

was high (75.7 %), higher than seen in various studies

conducted in Vietnam between 2009 and 2012 [9, 38, 39],

but similar to a 2009 study [10]. Different sampling and

recruitment methods may explain the level of recent CAI

we found or it may be that CAI has become more common

among Vietnamese MSM over time. In any case, the level

of condom use reported by MSM in our study was lower

than the target of achieving 50 % safe sex by MSM set out

in the 2015 Vietnam National Strategy for HIV/AIDS

Prevention and Control [58]. A report by the Vietnam

Ministry of Health shows that programs targeting MSM

accounted for just 1.4 % of total HIV prevention funding in

2011 and 2012, and condom accessibility among MSM still

remains low [59]. This may partially explain the low levels

of condom use reported by MSM in our study. Given that

MSM have been recognized as a key population at high

risk for HIV infection in Vietnam [60], our findings

underscore the urgent need to invest more to make HIV

interventions more accessible to MSM and to promote the

broader, effective use of condoms.

We found that nearly two fifths of participants did not

know their own HIV status, and the majority of partici-

pants did not know their male and female partners’ HIV

AIDS Behav (2017) 21:1105–1116 1113

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105

status. Informal conversations with participants suggest

that it remains unusual for MSM to disclose or ask about

the HIV status of their partner(s), because HIV remains

highly stigmatized in Vietnam. HIV status disclosure can

be an important factor in the prevention of HIV trans-

mission [61]. Our findings indicate a need for culturally

appropriate interventions to promote HIV testing and HIV

status disclosure among MSM as part of a comprehensive

approach to prevent HIV transmission among MSM in

Vietnam. Only half of our participants had tested for HIV

in the previous 12 months and nearly a third had never

been tested for HIV. In order to achieve the target of

80 % MSM tested for HIV in 2020 [58], our findings

underscore the importance of promoting HIV testing

among MSM.

Several limitations should be borne in mind when

interpreting the results of our study. Although we included

contextual, sex-related assessments of methamphetamine

use, our study had a cross-sectional survey design, so we

cannot confirm the temporal relationship between

methamphetamine use and CAI. We used a convenience,

peer referral sampling method which is unlikely to have

resulted in a sample representative of the larger population

of MSM in Vietnam. Additionally, since same-sex sexual

practices and drug use are stigmatized in Vietnam, our data

may underestimate the true level of HIV-related sexual

behaviors and drug use among MSM, although our findings

are comparable with previous studies. Our results may have

been affected by recall and reporting bias and hidden

confounders.

Conclusion

Our study found a high prevalence of CAI with male

partners among MSM in Hanoi and HCMC, Vietnam.

Importantly, CAI was associated with recent sex-related

methamphetamine use and this association was found to be

modified by sexual sensation-seeking. Notably, while men

higher in sexual sensation seeking were more likely to

report CAI than men lower in sexual sensation seeking,

sex-related methamphetamine use increased the risk of

CAI among men with low sexual sensation seeking scores.

HIV prevention interventions targeting MSM in Vietnam

should therefore consider incorporating interventions for

methamphetamine use.

Acknowledgments We acknowledge the great support and input

from staff of the Institute of Preventive Medicine and Public Health,

Hanoi Medical University, Hanoi Centre of HIV/AIDS Prevention

and Control, Center for Community Health Promotion, Center for

Promotion of Quality of Life and leaders and representatives of

community-based organizations of MSM in Ho Chi Minh City during

the data collection process.

Funding Nga Thi Thu Vu received Australian Award Scholarship for

her PhD study in UNSW Australia. The study received financial

support from the Faculty of Arts and Social Sciences (FASS), UNSW

Australia under its Postgraduate Essential Research Program Funding

scheme and External Research Program Funding schemes. The Centre

for Social Research in Health is supported by funding from the

Australian Government Department of Health. Funding agencies were

not involved in the development of the research protocol, data col-

lection, data analysis, interpretation or the dissemination of research

findings.

Author’s contribution Nga Thi Thu Vu contributed to the devel-

opment of the research protocol, data collection, data analysis and the

manuscript drafting and finalization. John De Wit and Martin Holt

provided supervision of the research process and provided advice

during data analysis and the drafting of manuscript. Huong Thi Thu

Phan, Lan Thi La, Gioi Minh Tran, Tung Thanh Doan and Trang Nhu

Nguyen Nguyen provided inputs for the development of the research

protocol and manuscript drafting and finalization.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of

interest.

Research involving Human Participants and/or Animals The

study received approval from the Human Research Ethics Committee

of UNSW Australia (reference HC14130), and from the Institutional

Review Board of the Hanoi School of Public Health (reference

014_262/DD-YTCC). All procedures performed in studies involving

human participants were in accordance with the ethical standards of

the institutional and/or national research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical

standards.

Informed consent Informed consent was obtained from all individ-

ual participants included in the study.

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CHAPTER 5

AMPHETAMINE-TYPE-STIMULANTS AND HIV INFECTION AMONG

MEN WHO HAVE SEX WITH MEN: IMPLICATIONS ON HIV

RESEARCH AND PREVENTION FROM A SYSTEMATIC REVIEW AND

META-ANALYSIS

Author Contributions Nga Thi Thu VU1,2, Lisa Maher and Iryna Zablotska

1: The Kirby Institute, The University of New South Wales Australia, Sydney, New

South Wales, Australia; 2: Center for Social Research in Health, The University

of New South Wales Australia, Sydney, New South Wales, Australia;

Reference

Vu NT, Maher L, Zablotska I. Amphetamine-type stimulants and HIV infection

among men who have sex with men: implications on HIV research and

prevention from a systematic review and meta-analysis. Journal of the

International AIDS Society. 2015;18:19273.

Declaration





This article was published in the Journal of the International AIDS Society

(JIAS), an open-access journal, available online:

http://www.jiasociety.org/index.php/jias/article/view/19273.

No copyright permission, therefore, is needed for reusing it in this thesis

dissertation.

109

http://www.jiasociety.org/index.php/jias/article/view/19273

Research article

Amphetamine-type stimulants and HIV infection among men who

have sex with men: implications on HIV research and prevention

from a systematic review and meta-analysis

Nga Thi Thu Vu§,1,2, Lisa Maher1 and Iryna Zablotska1

§Corresponding author: Nga Thi Thu Vu, The Kirby Institute, The University of NSW Australia, Sydney, NSW 2052, Australia. Tel: �61 431691214,

Fax: �61 2 9385 6455. ([email protected])

Abstract

Introduction: HIV infections and the use of amphetamine-type stimulants (ATS) among men who have sex with men (MSM) have

been increasing internationally, but the role of ATS use as a co-factor for HIV infection remains unclear. We aimed to summarize

the association between ATS use and HIV infection among MSM.

Methods: We conducted a systematic search of MEDLINE, EMBASE, GLOBAL HEALTH and PsycINFO for relevant English, peer-

reviewed articles of quantitative studies published between 1980 and 25 April 2013. Pooled estimates of the association �prevalence rate ratios (PRR, cross-sectional studies), odds ratio (OR, case-control studies) and hazard ratio (HR, longitudinal

studies), with 95% Confidence Intervals (CI) � were calculated using random-effects models stratified by study design and ATS

group (meth/amphetamines vs. ecstasy).We assessed the existence of publication bias in funnel plots and checked for sources of

heterogeneity using meta-regression and subgroup analysis.

Results: We identified 6710 article titles, screened 1716 abstracts and reviewed 267 full text articles. A total of 35 publications

were eligible for data abstraction and meta-analysis, resulting in 56 records of ATS use. Most studies (31/35) were conducted in

high-income countries. Published studies used different research designs, samples and measures of ATS use. The pooled

association between meth/amphetamine use and HIV infection was statistically significant in all three designs (PRR�1.86; 95%

CI: 1.57�2.17; OR�2.73; 95% CI: 2.16�3.46 and HR�3.43; 95% CI: 2.98�3.95, respectively, for cross-sectional, case-control andlongitudinal studies). Ecstasy use was not associated with HIV infection in cross-sectional studies (PRR�1.15; 95% CI: 0.88�1.49;OR�3.04; 95% CI: 1.29�7.18 and HR�2.48; 95% CI: 1.42�4.35, respectively, for cross-sectional, case-control and longitudinal

studies). Results in cross-sectional studies were highly heterogeneous due to issues with ATS measurement and different

sampling frames.

Conclusions: While meth/amphetamine use was significantly associated with HIV infection among MSM in high-income

countries in all study designs, evidence of the role of ecstasy in HIV infection was lacking in cross-sectional studies. Cross-

sectional study design, measurement approaches and source populations may also be important modifiers of the strength and

the direction of associations. Event-specific measure of individual drug is required to establish temporal relationship between

ATS use and HIV infection. HIV prevention programmes targeting MSM should consider including interventions designed to

address meth/amphetamine use.

Keywords: HIV; amphetamine-type stimulants; MSM; systematic review; meta-analysis; risk behaviour; meth/amphetamine;

ecstasy.

To access the supplementary material to this article please see Supplementary Files under ‘Article Tools’.

Received 12 May 2014; Revised 2 November 2014; Accepted 28 November 2014; Published 2 February 2015

Copyright: – 2015 Nga Thi Thu Vu et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

IntroductionAmphetamine-type stimulants (ATS) are the second most

popular group of illegal drugs globally and are increasingly

used in different populations and in different parts of the

world [1,2]. ATS can be classified into two main subgroups:

meth/amphetamines, which include amphetamine sulphate,

amphetamine hydrochloride, methamphetamine and meth-

cathinone, and ecstasy subgroup, which comprises MDMA

(3,4-methylenedioxy-N-methylamphetamine) and its analogue

(called meth/amphetamines and ecstasy hereafter) [1,3].

Both groups are synthetic neurotropic stimulants that can

be ingested orally, injected, inhaled, smoked or ‘‘shafted’’

(inserted in the anus) and have immediate accelerated

physical and psychological effects which last up to 10�12hours (meth/amphetamines) or 3�6 hours (ecstasy) [4,5].

Ecstasy is the most common street name for MDMA [6]. As to

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methamphetamine, its street slang names vary geographi-

cally, and some of them ‘‘crystal,’’ ‘‘speed,’’ ‘‘ice,’’ ‘‘crank,’’

‘‘batu,’’ ‘‘glass,’’ ‘‘chalk’’ and ‘‘go-fast’’ [7,8].

In relation to sex, meth/amphetamine and ecstasy have been

documented to have different effects. Meth/amphetamines

are often used to increase sexual desire, make intercourse

more pleasurable, facilitate sexual experimentation and

decrease sexual inhibition [9,10]. Meth/amphetamines may

increase sexual pleasure, help prolong sexual performance,

facilitate sexual marathons, make anal intercourse easier and

less painful, particularly during more forceful and traumatic

sexual penetration [11]. Such attributes have been valued in

more sexually adventurous gay community subcultures [12].

Meth/amphetamine use clearly affects both physiological

and psychological aspects of sexual behaviour and may

facilitate risky sexual practices, including unprotected sex,

thereby increasing the risk of HIV transmission.

While some studies suggest that ecstasy use may also

increase sexual satisfaction, prolong and enhance sexual

arousal [13�17], other studies found no effect on sexual

desire in penetrative sexual intercourse [18,19]. Ecstasy has

also been reported to increase feelings of sensuality and

emotional closeness [20,21]. Therefore, it may be used in the

context of less risky sex and its impact on HIV transmission is

less well defined.

In the past decade, ATS use has become increasingly

popular among men who have sex with men (MSM) in North

America, Asia, Western and South Western Europe [22�33].In high-income countries such as the United Kingdom and the

United States, the prevalence of recent (past 12 months)

amphetamine use among MSM was reported to be between

7.2 and 18.8% [22,23], recent meth/amphetamine use �between 2.8 and 18.0% [23�25] and recent ecstasy use �between 18.5 and 36.7% [23,34,35]. The prevalence of

lifetime use of these substances among MSM in seven US

cities was found to be much higher [26,32,33]. An online

study of drug use among MSM in 12 countries in Asia in 2010

reported an overall prevalence of recreational drug use over

a six-month period of 16.7%, with ecstasy the most com-

monly used drug (8.1%) [30]. Data from studies assessing

drug use during specific gay community events and venues in

Western countries, (e.g. circuit parties, dance clubs, bars and

bathhouses) have found the prevalence of both meth/

amphetamine and ecstasy use to be even higher [34,36].

A growing body of literature documents significant asso-

ciations between meth/amphetamine and ecstasy use and

unprotected anal intercourse (UAI), including receptive UAI �a practice which carries the highest risk of HIV infection

[11,22,28,32,37�43]. ATS use and UAI are co-occurring risk

behaviours with the potential to facilitate HIV transmission

among MSM. Since ATS can also be administered parenter-

ally, exposure to HIV can also occur via unsafe injecting

practices [44,45].

A number of studies have directly focused on the asso-

ciation between ATS use and HIV infection or included mea-

sures of ATS use in their analyses of associates/risk factors of

HIV infection among MSM [8,25,42,46�77]. However, the

results of these studies have been inconsistent as to the sig-

nificance of this association. Furthermore, the interpretation

of their findings may be complicated given the variety of

study designs, sampling frames and measures of ATS use. The

main objective of this systematic review and meta-analysis

was to evaluate and summarize the association between ATS

use and HIV infection among MSM in different study designs

and by ATS subgroup (meth/amphetamines and ecstasy).

MethodsThis paper followed the guidelines for reporting a meta-

analysis of observational studies (MOOSE) proposed by

Stroup et al. [78].

Search strategy

We conducted a systematic search in MEDLINE, EMBASE,

GLOBAL HEALTH and PsysINFO for relevant publications from

1980 until 25 April 2013. The search used a combination

of free terms and the Medline subject headings, including

(1) MSM OR homosexual men OR bisexual men OR gay men

OR male homosexual OR bisexual male OR homosexuality OR

bisexuality AND (2) risk factors OR determinants OR associa-

tions OR correlates OR correlations OR predictors OR high-risk

behaviours OR predictor variables AND (3) HIV prevalence OR

HIV incidence OR HIV seroconversion OR HIV status OR human

immunodeficiency virus OR human immunodeficiency virus

prevalence/infection. Some articles reported only a combined

drug use measure, did not specify the drug(s) used, did not

provide a quantitative effect measure with an associated 95%

confidence interval (95% CI) and did not include the original

data. In these instances, we contacted the corresponding

authors by email to obtain the effect measure or a descriptive

tabulation of ATS use and HIV infection. If no reply was

received within four weeks, the corresponding articles were

excluded from further review. The search was carried out by

Nga Thi Thu Vu and Julia Kennedy.

Inclusion and exclusion criteria

Articles were eligible for inclusion in the review if they

satisfied all of the following criteria: 1) cross-sectional, case-

control or longitudinal study design; 2) quantitative data

collection; 3) MSM as a target population; 4) the article

reported a crude quantitativemeasure of association between

ATS use and HIV infection or provided data to calculate it; 4)

HIV status of participants was confirmed by a standardized

laboratory method, and 5) the article was published in a peer-

reviewed English language journal. Studies were excluded if:

1) they applied only qualitative methods or mathematical

modelling; 2) specifically targeted only HIV positive MSM or

only ATS users; 3) quantitative data could not be extracted

and/or were not provided by the authors; 4) HIV status of

participants was self-reported; 5) the publication included

only conference proceedings; and 6) was published in a

language other than English. These inclusion and exclusion

criteria aimed to minimize any classification bias as to HIV

status and to exclude articles which did not provide a

quantitative measure of the association between ATS use

and HIV infection.

Quality assessment

The article quality was assessed using quality assessment

criteria adapted for cross-sectional studies from Boyle [79]



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and for case-control and longitudinal studies from Wells et al.

[80] (the checklist is provided in Supplementary 1). According

to these quality criteria, a score of 1 was assigned for each of

the items included and articles were assigned a summative

score on a scale of 0 to 9 for cross-sectional studies, 0�10for case-control studies and 0�11 for longitudinal studies.

All scores were categorized into high- and low-quality groups

based on the cut off of 50%.

Data extraction

Extracted information included the primary author, year of

publication, country of research, sampling method(s), sample

size, type of drug(s) examined and recall periods, basic

participant characteristics (e.g. age, sexual identification) and

either a crude measure of association with 95% CI or data to

calculate it. If articles reported more than one drug or used

more than one recall period, each measure of drug use

at each recall period was extracted as a separate record.

Measures of association reported without 95% CIs were not

extracted. Extracted data from cross-sectional and case-

control studies were used to calculate prevalence rate ratios

(PRR) [81] and odds ratios (OR), respectively. For longitudinal

studies, we directly extracted hazard ratios (HR) or relative

risk (RR) with 95% CI as a measure of association between

ATS use and HIV seroconversion. Data extraction was carried

out by Nga Thi Thu Vu and Julia Kennedy.

Statistical analysis

Meta-analysis was performed using STATA 13.0 (StataCorp,

College Station, TX, USA) and was stratified by study design

and ATS subgroup (meth/amphetamine vs. ecstasy). We

did not combine effect measures (i.e. PRR, OR and HR) of

all selected studies because of differences in the nature and

calculation methods for each of these measures. In the group

of longitudinal studies, all articles reported HR as a measure

of association, and only Burcham et al. [74] used RR. We

treated this RR as equivalent to HR. The pooled estimates

of the association and their 95% CI were estimated using

random-effects models, as suggested by DerSimonian and

Laird. Heterogeneity was defined by Q statistic when p�0.1

as Hardy et al. [82] had previously reported this method to

have low power. Based on the I2 classification suggested by

Higgins and Thompson [83], we used the cut-offs of 25, 50

and 75% to define low, medium and high levels of hetero-

geneity, respectively [84]. Sources of heterogeneity were

checked using subgroup analysis and meta-regression [85].

The variables for meta-regression included the study quality

score (high vs. low), ATS group (meth/amphetamines vs.

ecstasy) and study location (high vs. low- and middle-income

countries (LMIC), as according to World Bank income classi-

fication, sampling location (clinic based vs. other), drug use

recall period (recent use vs. lifetime use), injecting drug use

reporting (Yes vs. No) and other specific drug use measure-

ments, that is, nitrite inhalants, heroin, cocaine and EDM use

(Yes vs. No). Injecting drug use, specifically needle and

syringe sharing and these specific drug use behaviours were

assessed because they were found to be associated with

HIV infection and/ or unprotected risky sexual behaviours

[45,69,72,86,87], therefore, may be confounders of the

association between ATS use and sexually transmitted HIV

infection. Sensitivity analysis was performed by the Compre-

hensive Meta-Analysis software V2.0 (Biostat, Englewood,

New Jersey) to explore any possible influence of abnormal or

outlier data on pooled estimates. Publication bias and the

effects of small sample sizes were evaluated in a funnel plot

[88]. Asymmetry of the funnel plot was tested as recom-

mended by Egger et al. [89].

ResultsThe flow of the review process is shown in Figure 1. We

identified 6710 unique article titles, 262 of which progressed

to full text screening, resulting in 42 articles relevant for this

review (list of excluded articles is provided upon request).

The review yielded six additional articles: two from reference

lists [69,77] and four from corresponding authors of articles

reporting only composite measures of drug use [46,47,53,59].

We contacted by email 30 authors of manuscripts which re-

ported composite drug use measures and received seven

responses: four [46,47,53,59] responded with tabulations of

ATS use and HIV infection and three clarified that ATS had not

been measured in their study or was not analyzed [90�92].Seven articles provided a descriptive tabulation of ATS and

HIV without analysis of the association with HIV infection

[25,42,49,54,64,65,72]. Because some articles reported more

than one drug used and/or more than one recall period, 58

records were extracted from 36 articles [8,25,42,46�77]. Tworecords were excluded from analysis because of a 0 cell for a

2x2 table [49,93]. Finally, 56 records from 35 studies were

retained for meta-analysis. Records from Van Griensven et al.

[46], Menza et al. [54] and Chesney et al. [69] were taken

from the baseline data of their longitudinal studies; there-

fore, these records were treated as a cross-sectional design

such that PRR was calculated for these records. The HR

reported in Chesney [69] were not comparable with that

measurement in other studies; therefore, these HR were not

included in the analysis.

Description of the selected studies and their participants

Among 35 selected articles, only five were from low- and

middle-income countries (LMIC), while 30 were from the

United States and other high-income countries, specifically

The Netherlands, Australia and the United Kingdom. The

majority of studies (30/35) used convenience, non-random

sampling, and recruited participants using such approaches as

advertising, community outreach, referrals from gay commu-

nity and networks, clients of MSM-specific clinics or HIV

testing centres. Nine studies used purely clinic-based recruit-

ment, sixteen used community-based recruitment and ten

used both. Most of the articles (26/35) reported a global

measure of drug use with different recall periods, including

1, 3, 6, or 12 months and lifetime use; five articles

[8,51,55,58,63] reported a contextual measure of ATS use in

relation to sex, and the remaining articles did not specify the

recall period. Almost all of the study had a quality score larger

than 50%, only seven studies, among which one from the

LMIC countries, had a quality score lower than 50%.

Table 1 presents the characteristics of studies selected for

meta-analysis and their participants. Regarding ATS use, the

majority of articles reported the use of methamphetamine



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(n�19), amphetamine (n�14), ecstasy (n�14) and speed

(n�3). Almost all articles (n�34) also reported the use

of other drugs of which the most popular reported drugs

including cocaine (n�24), nitrites/poppers (n�23), mari-

juana (n�18) and alcohol (n�17) and heroin (n�13).

Among 29 cross-sectional studies, 25 reported high HIV

prevalence (9�34%) and only five reported HIV prevalence of

less than 9%. All longitudinal studies found an HIV incidence

between 1.90 and 2.55 per 100 person years.

Seventeen of 35 articles reported injecting drug use (eight

of 21 cross-sectional, three of seven case-control and six of

seven longitudinal studies) and just three measured needle

and syringe sharing. Prevalence of injecting drug use varied

markedly between 0 and 58%. Out of eight articles which

investigated the relationship between injecting drug use and

HIV infection, seven found a significant univariate associa-

tion. Only three articles confirmed a significant association

Elig

ibili

tyId

enti

fica

tio

nS

cree

nin

gIn

clu

sio

n

42 relevant articles

Embase3458 articles

Global Health3047 articles

Medline3395 articles

PsycINFO1022 articles

6710 articles for title screening

1716 articles for abstract screening

267 articles for full-text screening

48 articles for inclusion assessment

2 from reference lists

4 from authors of articles which reported composite measures of drug use

Article with wrong effect measurement: 1

35 eligible articles(56 extracted records of ATS use)

Amphetamine use 20 records, including:12 cross-sectional records2 case-control records6 longitudinal records

Including:6 cross-sectional records7 case-control records4 longitudinal records

Methamphetamine use 19 records, including:11 cross-sectional records5 case-control records

39 records of meth/amphetamines use 17 records of ecstasy use

4212 Duplication removed

1449 articles excluded by:Abstract was not retrieved: 45 Behavioural studies only: 251Description pattern of HIV epidemic only: 111 HIV Prevalence observation only: 226Other STI infections other than HIV: 29Qualitative, modelling studies: 76Review/editorial letters, commentary/Conference Abstracts: 292Other population of interest: 252Irrelevant topics: 167

225 articles excluded by:Full-text could not retrieved: 13Composite drug use measures/Drugs not specified: 44Not peer reviewed articles (editorial letter/commentary/conference abstract): 20 Other languages rather than English: 27 Without HIV risk (HR/RR/OR) analysis: 121

13 articles excluded by:Had only self-reported HIV status: 2Did not provide crudemeasures of association or data to calculate it: 8Article with duplication dataset: 1Article with 0 cell in 2x2 table of ATS and HIV infection: 1

4994 irrelevant articles excluded

Figure 1. Flow chart for selection of studies with number of articles.



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Table 1. Articles in the analysis (n �35): description of studies and their participants

Author, yeara Countryb

World

Bank

rankingb

Data

collection

period

Study

typecQuality

score

Sampling

(method,

sample size)

Age mean (SD)/

median (range)

Sexual

orientation (%)

Reporting

IDU (%)

Drug use measure

Recall period ATS use (%) Other drug use

Van Griensven

et al. 2013

[46]

Thailand 1 2006 1 77.8 CS: 1744 Baseline: Median:

26 (18�56)NR NR Sexual: P4M

drug: lifetime;

P4M

Lifetime: Ecs: 7.4

Meth: 11.2 P4M: Ecs:

3.3 Meth: 6.0

Alcohol; nitrite; EDM5

Pham et al.

2012 [47]

Vietnam 1 8�12/2009 1 55.6 CS: 381 Median: 20.4

(18�25.1)Gay: 39.6; trans:

20.0; Hetero: 40.4

Yes (16.5%) Sexual: P1M

drug use:

lifetime

Meth: 16.7 IDU

alcohol

Ackers et al.

2012 [48]

USA 2 6/1998�10/1999

3 72.7 CS: 4684 Baseline: median:

35 (18�62) 18�30:25.0%

NR Yes (baseline:

0.23%)

P6M Baseline: Amp: 9.0 IDU; crack; cocaine;

poppers; tranquilizers;

EDM5; hallucinogens;

alcohol

Oster et al.

2011 [49]

USA 2 2�4/2008 2 50.0 CS: 110 Mean: 21 Case/control: gay:

76.0/61.0; bisexual:

12.0/27.0; hetero &

other: 12.0/12.0

Yes (0.0%) P12M Case/control: Ecs:

4.0/79.0 Meth: 0.0/

7.0

IDU; other non-

injection drugs

Chariyalertsak

et al. 2011

[50]

Thailand 1 2008�2009 1 44.4 CS: 551 B30: 88.7% Gay: 56.1 bisexual:

18.5 trans: 25.4

NR Lifetime Meth: 12.7 Marijuana; heroin

Morineau et al.

2011 [51]

Indonesia 1 8�11/2007 1 55.6 TLS, RDS:

749

NR NR NR 1�3 months Meth: 14.6 NR

Truong et al.

2011 [52]

USA 2 1/2004�12/2006

1 77.8 CS: 6859 NR NR Yes (NR) P12M Amp (NRa) IDU

Forrest et al.

2010 [25]

USA 2 2004�2005 1 TLS: 946 NR NR Yes (3.0%) P12M Meth: 18.0 Ecs: 17.8 Viagra; IDU

Feng et al.

2010 [53]

China 1 3�7/2007 1 66.7 CS: 513 Median: 24

(16.8�44.5)Gay: 72.9; bisexual:

25.34; hetero: 7.02

NR Sexual: P6M

drug: NR

Amp: 13.3 IDU; ketamine;

alcohol; heroin

Menza et al.

2009 [54]

USA 2 10/2001�5/2008

1 77.8 CS: 1903 B40: 79.72% NR NR P6M Meth: 6.73 Nitrite; crack/cocaine

Carey et al.

2009 [55]

USA 2 2003�2005 2 60.0 CS: 444 530: 47.5 NR No Sexual:P6M drug

use: sex-related

drug use/P6M

Case/control: Meth:

28.8/11.4 Ecs: 6.3/

4.5

Alcohol; ketamine;

GHB; viagra; poppers;

marijuana; cocaine;

LSD; heroin

Drumright et al.

2009 [56]

USA 2 5/2002�2/2006

2 50.0 CS: 145 Median: 32 NR No Sexual: P12M

drug: P12M; sex-

related drug use;

P12M

Case/control: P6M:

Meth: 28.8/11.4 Ecs:

6.3/4.5 Sex-related/3

partners: Meth:

44.2/28.2 Ecs: 14.0/

8.5

Nitrite; marijuana;

GHB; Cocaine; EDM5

Rudy et al.

2009 [57]

USA 2 2006�2007 1 44.4 CS: 6435 18�24: 15.0%25�34: 37.0% ]35:

48.0%

NR NR Sexual: P3M

drug: P12M

Meth: 13.0 EDM; nitrite; Ecs;

ketamine

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Table 1 (Continued )


World

Bank

rankingb

Data

collection

period

Study

typecQuality

score

Sampling

(method,

sample size)

Age mean (SD)/

median (range)

Sexual

orientation (%)

Reporting

IDU (%)

Drug use measure


Thiede et al.

2009 [58]

USA 2 7/2002�5/2005

2 60.0 CS: 142 B30: case: 31.3%

control: 40.0%

Gay: case: 96.6

control: 76.4

Yes (10.6%) P6M Case/control: Meth:

43.4/12.7 Ecs: 18.8 /

0.9

IDU; popper; viagra;

ketamine; GHB;

cocaine; alcohol

Prestage et al.

2009 [59]

Australia 2 6/2001�12/2004

3 CS: 1427 Baseline: 37 (18�75) Homosexual: 95% No P6M Meth: 38.4; Ecs &

other ATS: 58.9

Cocaine; cannabis;

heroin; EDM;

barbiturates; amyl

nitrite; psychedelics

Raymond et al.

2008 [60]

USA 2 10/2003�12/2004

1 88.9 TLS: 794 18�30: 41% Gay: 83.0; Bisexual:

15.0; Hetero: 1.0;

Other: 1.0

NR Sexual: P6M

Drug: P12M

Ecs: 6.9 Speed: 14.1 Cocaine; Marijuana;

Crack; Poppers

Macdonald et al.

2008 [61]

UK 2 9/2002�10/2004

2 70.0 CS: 232 Mean: Case: 35.2

(20�58) Control:35.1 (20�66)

Gay: 77.0 Yes (Case: 8.0%,

Control: 3.0%)

P2Y Case/Control: Meth:

16.0/13.0, Ecs: 67.0/

44.0, speed: 25.0/

18.0

Alcohol; Nitrite;

Cocaine; Cannabis;

Ketamine; Viagra;

GHB; LSD; Valium

Schwarcz et al.

2007 [42]

USA 2 6/2002�1/2003

1 RS: 1976 Median: 42 (18�92) NR NR NR Meth: 16.8 Viagra; Nitrite; Nocaine;

other club drugs

(Ketamine, Ecstasy, GHB)

Plankey et al.

2007 [62]

USA 2 4/1984�9/1991 & 10/

1996�9/2004

3 63.6 CS: 4003 Baseline: Mean: 34.4

(SD: 8.6)

NR Yes (baseline: 17.0%) P6M Baseline: Meth: 23.0

Ecs: 12.0

Poppers; Cocaine

Koblin et al.

2006 [63]

USA 2 1/1999�2/2001

3 63.6 CS: 4295 Baseline: Mean: 34

525: 19.0%

NR Yes (baseline: 10.0%) P6M Baseline: Amp: 12.3 Alcohol; IDU; non-

injection drugs

Fuller et al.

2005 [64]

USA 2 8/2000�2/2004

1 55.6 CS: 95 Median: 28 (18�40) Gay/bisexual: 72.0;

Hetero: 28.0

Yes (25.0%) Sexual: P2M

Drug: life-time

Meth: 9.0 Ecs: 20.0 IDU; heroin; cocaine;

crack

Kral et al.

2005 [65]

USA 2 1998�2002 1 77.8 TS: 357 B30: 22.0% Gay: 34.0; bisexual:

44.0; hetero: 22.0

Yes (sharing needle:

84.0%)

P6M Amp: 79.0 IDU; heroin; cocaine;

crack

Buchbinder

et al.2005 [66]

USA 2 4/1995�5/1997

3 63.6 CS: 3257 Enrolment: 535:

34.6%

NR Yes (baseline: 1.5%) P6M % visit: Amp: 8.8 Nitrite; cocaine;

hallucinogens; IDU

Robertson et al.

2004 [67]

USA 2 4/1996�12/1997

1 66.7 RS: 475 B30: 65.0% Gay/bisexual: 75.5;

Hetero: 24.5

Yes (58.3%) Life-time Meth: 46.4 IDU, heroine, cocaine

Weber et al.

2003 [68]

Canada 2 1995�12/2000

3 45.5 CS: 673 Baseline: median: 25

(22�28)NR Yes (NR) P11M Meth (NR); Ecs (NR) Crack; cocaine; poppers;

marijuana; alcohol

Chesney et al.

1998 [69]

USA 2 1985 1 70.0 CS: 337 Mean 34.8�36 NR NR P6M Amp: 19.3 Alcohol; marijuana;

nitrite; cocaine;

barbiturate;

hallucinogens; heroin

Molitor et al.

1998 [8]

USA 2 7/1994�12/1995

1 66.7 CS: 32,321 Mean 28 Gay: 49.6; bisexual:

50.4

NR Sex-related drug

use

Meth: 3.5 NR

Ruiz et al.

1998 [70]

USA 2 2�11/1994 1 66.7 CS: 824 17�22: 50.6%22�25: 49.4%

NR Yes (sharing needle:

6.4%)

P6M Ecs: 22.6 Amp: 44.1 Poppers; crack; cocaine;

heroin; IDU


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Table 1 (Continued )


World

Bank

rankingb

Data

collection

period

Study

typecQuality

score

Sampling

(method,

sample size)

Age mean (SD)/

median (range)

Sexual

orientation (%)

Reporting

IDU (%)

Drug use measure


Page-Shafer

et al.1997 [71]

USA,

Australia,

Canada,

Holland

2 1982�1985 2 60.0 CS: 690 Mean: 35.3 (7.7) NR No P6M Case/control: Amp:

26.9/13.3

Cannabis; nitrite;

alcohol

Buchbinder

et al.1996 [72]

USA 2 1/1993�7/1994

3 77.8 CS: 1975 Baseline: median: 31 NR Yes (NR) P6M Baseline: Amp/

P12M: 15.7

IDU; cocaine; popper;

marijuana; barbiturate

Seage et al.

1992 [73]

USA 2 5/1985�12/1988

1 66.7 CS: 481 B30: 34.1 NR NR P5Y Amp: 28.5 Marijuana; nitrite;

cocaine; heroin; LSD;

PCP; barbiturate;

methaquolone; nitrous

oxide

Burcham et al.

1989 [74]

Australia 2 1/1984�7/1987

3 45.5 CS: 643 Enrolment: HIV

seroconverts: Mean

33 (17�65) HIVnegative: 34 (15�64)

NR No P6M Amp (NR) Ecs (NR) Cocaine; nitrite;

marijuana

Rietmeijer et al.

1989 [75]

USA 2 11/1982�12/1985

1 55.6 CS: 216 B30: 40% NR Yes (17.8%) Not specified Amp: 66.4 IDU; alcohol; marijuana;

nitrites; cocaine; LSD;

heroin; barbiturate;

alcohol

Van Griensven

et al. 1987

[76]

Holland 2 10/1984�05/1985

1 33.3 CS: 741 Mean: 35 Bisexual: 34.0; gay

34

NR Not specified Amp: 3.0 Marijuana; nitrite;

cocaine; LSD

Jeffries et al.

1985 [77]

Canada 2 11/1982�2/1984

2 50.0 CS: 448 Mean: 32 NR No P8M Case/control: Ecs:

65.0/44.0

LSD; cocaine; marijuana;

nitrite

aNumber in the reference list.bWorld Bank’s country name (USA: United States; UK: United Kingdom); World Bank ranking, 1: low- and middle-income country, 2: high-income country.c1: cross-sectional study; 2: case-control study; 3: longitudinal study.

NR: not reported; CS: convenience sampling; TS: targeted sampling; RS: random sampling; TLS: time location sampling; RDS: respondent driven sampling; IDU: injecting drug users; Trans: transgender;

hetero: heterosexual; P1M: past one month; P2M: past two months; P3M: past three months; P4M: past four months; P6M: past six months; P8M: past eight months; P11M: past 11 months; P12M: past

12 months; P2Y: past two years; P5Y: past five years; Meth: methamphetamine; Amp: amphetamine; Ecs: ecstasy; ATS: amphetamine-type stimulants; EDM: erectile dysfunction medications; GHB: gamma

hydroxybutyrate; LSD: lysergic acid diethylamide; PCP: phencyclidine.


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between ATS use and HIV infection when injecting drug use

was included in the model.

Association between ATS use and HIV

Association between ATS and HIV infection was significant in

all study designs (Figure 2). In cross-sectional studies, MSM

who reported ever using ATS were 1.70 times more likely to

be infected with HIV than non-users (PRR�1.70; 95% CI:

1.47�1.98). Results in cross-sectional studies were highly

heterogeneous (Q28�124.68, p�0.000 and I2�77.5%). In

case-control studies, the pooled OR was 2.90 (95% CI: 2.04�4.12), with high heterogeneity (Q13�39.89, p�0.000 and

I2�67.4%). In longitudinal studies, the pooled HR was 3.13

(95% CI: 2.65�3.70) with medium heterogeneity (Q12�20.92,

p�0.052 and I2�42.6%).

In the meth/amphetamine subgroup (Figure 3), the pooled

estimate was statistically significant in all study designs (PRR

for cross-sectional studies was 1.85; 95% CI: 1.57�2.17; OR for

case-control studies was 2.73; 95% CI: 2.16�3.46 and HR for

longitudinal studies was 3.43; 95% CI: 2.98�3.95). Hetero-geneity in longitudinal and case-control studies was low

(Q7�9.17, p�0.328, I2�12.7% and Q5�3.42, p�0.754,

I2�0.0%, respectively) while the results of cross-sectional

studies were highly heterogeneous (Q22�109.11, pB0.001

and I2�79.8%). However, in the ecstasy subgroup (Figure 3),

in cross-sectional studies, the pooled PR estimate was not

Figure 2. Summarized effect measure of the association between ATS use and HIV infection, by study design.



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Figure 3. Summarized effect measure of the association between ATS use and HIV infection, by study design and drug type. (a) Cross-sectional

study; (b) case-control studies; (c) longitudinal studies.



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statistically significant (PR�1.15; 95% CI: 0.88�1.49), withlow heterogeneity (Q5�5.92, p�0.314 and I2�15.5%). In

case-control studies, the pooled OR estimate was significant

(OR�3.04 (95% CI: 1.29�7.18), with high heterogeneity

(Q5�36.33, p�0.000 and I2�83.5%). Similarly, the pooled

HR estimate was statistically significant (HR�2.48; 95% CI:

1.42�4.35), with high heterogeneity (Q3�9.26, p�0.026

and I2�67.6%). Sources of heterogeneity among cross-

sectional studies were presented in Table 2. Due to the

limited number of selected case-control and longitudinal

articles and because of low power of Q statistic [82],

the test of heterogeneity in these study designs was not

conducted.

Sources of heterogeneity in cross-sectional studies

The results of subgroup analysis are presented in Table 2.

Sampling locations, ATS subgroup, recall period for drug use,

reporting EDM use and alcohol consumption were respon-

sible for a high heterogeneity of the results in cross-sectional

studies. The pooled estimates of the association between ATS

use and HIV were significantly higher in studies which re-

cruited participants in clinics rather than in other locations;

used measures of recent versus lifetime drug use; reported

EDM use (yes vs. no) or alcohol consumption (yes vs. no).

Finally, the pooled PRR is higher in studies that reported

meth/amphetamine use versus ecstasy use.

Sensitivity analysis

None of the individual study results noticeably affected the

pooled estimate for longitudinal and cross-sectional studies.

In relation to case-control studies, the pooled OR decreased

by 13.6% (from OR�2.9; 95% CI: 2.04�4.11 to OR�2.51;

95% CI: 2.02�3.12) when one high OR of a record of ecstasy

use reported by Macdonald et al. [61] was excluded from the

analysis. This record explained 50.4% of the heterogeneity of

the results.

When restricted to the ecstasy subgroup among case-

control studies, the pooled estimate of the association with

HIV infection was also noticeably affected by the same

record, which was responsible for 34.9% of the heterogeneity.

After excluding this record, the pooled OR decreased by

32.2% (from OR�3.04; 95% CI: 1.29�7.18 to OR�2.06; 95%

CI: 1.19�3.58).

Publication bias

The funnel plot of all selected studies (Supplementary 2)

indicates potential publication bias. However, the result of

the test for symmetry of the funnel plot was not statistically

significant, suggesting no small sample size effect.

DiscussionOur review andmeta-analysis of the published evidence found

a statistically significant relationship between ATS use and HIV

infection. The use of meth/amphetamines was significantly

associated with HIV infection in all study designs, while ecstasy

use was not associated with HIV in cross-sectional studies. The

pooled estimate from case-control studies had low hetero-

geneity and the significant pooled HR from longitudinal

studies was affected by studies with large samples and highly

significant results [62]. The pooled estimates of case-control

studies were affected by a record from study of Macdonald

et al. [61]; however, while the exclusion of this record in the

analysis resulted in decreasing the effect size; it did not change

the significance of the overall effect size.The pooled estimates

of cross-sectional studies were heterogeneous as a result of

sampling location approach, different drug use recall periods

and the diversity of different drug use measurement. Our

findings of the relationship between ATS and HIV infection are

consistent with results from a previous review by Drumright

et al. [45]; that review covered fewer studies. It found that

Table 2. Stratification analysis for cross-sectional studies

Study

characteristic

No. of

records

Meta-regression

(b, p-value)aPooled PR

(95% CI)b

Study location

LMIC countries 8 b�0.72, p�0.086 1.36 (1.12�1.65)

High-income

countries

21 1.85 (1.54�2.21)

Study quality

Low 3 b�1.34, p�0.289 2.10 (1.36�3.27)

High 26 1.66 (1.42�1.94)

Sampling

locations

Clinic-based

sample

6 b�1.66, p�0.005 2.53 (1.70�3.77)

Other venues 23 1.52 (1.32�1.76)

Drug use recall

period

Recent use 19 b�1.42, p�0.047 1.93 (1.57�2.37)

Lifetime use 9 1.38 (1.19�1.61)

Reported injecting

drugs

No 20 b�1.02, p�0.914 1.70 (1.46�1.97)

Yes 9 1.62 (1.09�2.42)

Type of ATS

Amphetamines 23 b�0.59, p�0.02 1.85 (1.57�2.17)

Ecstasy 6 1.15 (0.88�1.49)

Reported alcohol

use

No 21 b�0.69, p�0.039 1.90 (1.61�2.45)

Yes 8 1.30 (1.10�1.54)

Cocaine use

No 13 b�0.74, p�0.106 1.78 (1.40�2.25)

Yes 16 1.63 (1.34�1.98)

Heroin use

No 17 b�1.04, p�0.84 1.96 (1.63�2.36)

Yes 12 1.35 (1.12�1.64)

EDM use

No 21 b�0.60, p�0.003 1.67 (1.37�2.03)

Yes 8 1.77 (1.40�2.24)

aSignificant p-value indicates significant source of heterogeneity.

Results from meta-regression analysis.bResults from subgroup analysis.

LMIC: low- and middle-income countries.



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meth/amphetamine use was associatedwith HIV infection and

reported insufficient evidence of an association between

ecstasy and HIV infection. More recently, a meta-analysis of

the relationship between ecstasy use and risky sexual behavi-

our by Hittner et al. found ecstasy use to be significantly

associated with behaviours associated with HIV infection [20],

but that review combined different sexual outcomes and

did not specifically focus on MSM. Our finding of consis-

tently significant pooled estimates of the association between

meth/amphetamine use and HIV infection in all study designs

proves the robustness of this association and echoes the

finding of Vosburgh et al. [87] that methamphetamine

was associated with event-level measurement of sexual risk

behaviour among MSM.

Differences in the relationship between meth/amphetamine

and ecstasy with HIV infection can potentially be explained

by their different sexual behavioural effects. Previous re-

search has found that meth/amphetamines facilitate sexual

disinhibition and experimentation [9], increase sexual desire

and facilitate sexual marathons [11] in which men practice

prolonged sexual encounters with different sexual par-

tners for hours and days [94]. Prestage et al. found that

meth/amphetamines have often been combined with orally

administered erectile dysfunction medications to further

enhance sexual performance [59]. Unprotected sex is com-

mon in these contexts, as are lesions due to forceful sexual

penetration and increased likelihood of condom failure, all of

which can increase the risk of sexual transmission of HIV [94].

Furthermore, high dose of methamphetamine was found to

increase anal sensation for receptive partners, thus promoting

receptive positioning in anal sex which is the practice of

highest risk in sexual transmission of HIV among MSM [44]. In

relation to ecstasy, where reported effects include improved

sexual performance and satisfaction [13,14], participants

also reported enhanced sensuality rather than sexuality [17]

and increased feelings of intimacy and emotional closeness

[20,21]. Such effects may compensate for the negative effects

associated with condom use such as decreased sensuality and

sexual satisfaction. These effects may account for the lack of

consistency of findings in relation to ecstasy observed across

different studies included in our review. However, it is

important to acknowledge that the pooled estimate of

association between ecstasy and HIV infection was signifi-

cant in case-control and longitudinal studies which provided

stronger evidence than cross-sectional studies. This find-

ing may suggest that a more robust approach to study the

relationship between ecstasy and HIV infection should be

explored in future studies.

Our review highlights the methodological limitations of

current research. First, many studies used composite mea-

sures of drug use (e.g. any drug use) which ignore the different

effects of specific drugs on sexual behaviour and ultimately on

HIV transmission. Second, most studies used global measures

of ATS use (that is measures unrelated to sexual encounters)

with various recall periods from one month to lifetime use.

Only five articles [8,51,55,58,63] reported situational or

contextual drug use in which ATS were taken before or during

sexual intercourse, but not during a specific event. As early as

1993, Leigh and Stall [95] recommended the use of event-

specific measures of ATS use in relation to sexual encounters

to enable assessment of the causal relationship between ATS

use and HIV infection. Our review, conducted in 2013, was

unable to find any studies which used the recommended

measures. Third, a number of studies, including reviews,

explored the relationship between ATS use and HIV infection

[5,45,96] but not its nature or pathway; therefore, the

question about causality of this relationship remains largely

unanswered. Future research should take into account the

methodological limitations of current studies on ATS use.

Studies should adopt study designs, sampling methods and

ATS use measures which would allow investigating and better

understanding the temporal relationship between ATS use and

HIV infection among MSM. Our analysis found that most

studies were also based on opportunistic samples recruited

from different source populations. Our finding of a higher

pooled prevalence ratio in cross-sectional studies using

samples purely recruited from clinical settings, compared to

studies which relied on community-based and/or other

recruitment approaches may be explained by the higher

prevalence of ATS use and HIV infection among clinic patients.

Our review also identified an important gap in current

research. While ATS use and HIV infections among MSM are

increasing in many settings, there is little published research

from LMIC. We excluded 27 articles published in languages

other than English. Since 25 of them were from studies

conducted in LMIC countries, it is possible that research from

these countries is underrepresented in this analysis. We were

not able to assess whether these studies investigated the

association between ATS use and HIV infection. We found

only five studies published in English language conducted

in LMIC compared to 30 in high-income countries (all five

studies were cross-sectional in design). As such, general-

ization of the relationship between ATS use and HIV infection

to LMIC may not be appropriate. Further investigation is

warranted in regions where ATS use is highly prevalent, such

as South East Asia, and may be an important co-factor in

increasing HIV transmission among MSM [97].

Our study has limitations that should be born in mind in

interpreting the results. As with all meta-analyses, we were

restricted to data from reports written in English [88]. Our

meta-analysis cannot improve the quality of the results

reported by the original studies and depends on their validity.

The study diversity with respect to designs, sampling frames,

populations, ATS use measures and other drug use measure-

ment, and the heterogeneity of their results, particularly in

cross-sectional and longitudinal studies, may have implica-

tions for our pooled estimates of the association between ATS

use and HIV infection. We assessed heterogeneity of cross-

sectional studies but unfortunately we were not able to do

the same analysis for other study designs due to the small

number of published articles from the longitudinal and case-

control studies. They leave a potential for biased results and

limit their generalizability. An inherent limitation of meta-

analysis is that we could only analyze the role of ATS use in

explaining the variance in HIV infections, and could not

account for the possibility of various confounding factors

which could also explain the association between ATS use and

HIV infections (e.g. the concurrent injecting of drugs, specific



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sexual practices and characteristics of MSM and their net-

works which are the known risk factors for HIV infection). We

should also acknowledge that the cross-sectional or case-

control studies pooled together do not provide information

about the temporal sequence between ATS use and HIV

infection and, therefore, cannot attest to the causality of this

relationship.

ConclusionsThe findings from our meta-analysis confirmed the significant

association between meth/amphetamine use and HIV infec-

tion in all study designs, but there is lack of evidence

(particularly in cross-sectional studies) regarding the role of

ecstasy in HIV infection. Our review and meta-analysis also

revealed important methodological limitations as to the

currently used measures of drug use and their ability to

establish the causal relationship between ATS use and HIV

infection. Finally, our results have implications for policy and

practice. Because ATS are often used in the context of high-

risk unprotected sex, particularly among more adventurous

MSM [11], and a significant number of HIV infections happen

in these contexts [98], HIV prevention programmes targeting

MSM should take into account the role of ATS use, particularly

meth/amphetamines, in HIV transmission. They should also

consider including interventions designed to address meth/

amphetamine use in this population and adopt novel HIV

prevention approaches for MSM at high risk for HIV.

Authors’ affiliations1The Kirby Institute, The University of NSW Australia, Sydney, NSW, Australia;2Centre for Social Research in Health, The University of NSW Australia, Sydney,

NSW, Australia

Competing interests

No declared competing interests.

Authors’ contributions

Nga Thi Thu Vu contributed significant efforts in the development and conduct

of the review, performance of the statistical analysis and drafting of the

manuscript. Iryna Zablotska and Lisa Maher provided oversight in the design,

implementation and interpretation of findings and provided significant input

into the preparation of this manuscript. All authors have seen and approved

the final version of this paper.

Acknowledgements

We are grateful to Julia Kennedy for assistance with reviewing the abstracts,

Eric Chow for assistance with data extraction and Lei Zhang for advice on the

methods of meta-analysis.We thank the researchers who provided information

and further data on our request, including Frits van Griensven, Sarika

Pattanasin and Timothy H. Holtz (Thailand MOPH � US CDC Collaboration,

TUC); Ying Li and Michael W. Plankey (Department of Medicine, Division of

Infectious Diseases, Georgetown University); Quang Duy Pham (Pasteur

Institute, Ho Chi Minh city, Vietnam and Kirby Institute, University of New

South Wales, Australia); Garrett Prestage and Jeff Jin (Kirby Institute, University

of New South Wales); Yuji Feng (Department of Epidemiology, School of Public

Health, University of California, Los Angeles, CA, USA); Alexa Oster (Incidence

and Viral Resistance Team, Division of HIV/AIDS Prevention Centers for Disease

Control and Prevention, USA); Wolfgang Hladik (CGH/DGHA, Centers for

Disease Control and Prevention, USA) and Hillard Weinstock (Surveillance and

Special Studies Team, Epidemiology and Surveillance Branch, Division of STD

Prevention, Centers for Disease Control and Prevention, USA).

Funding

This study was carried out without funding.

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CHAPTER 6

THE PREVALENCE AND CORRELATES OF HIV AND UNDIAGNOSED

INFECTION AMONG MEN WHO HAVE SEX WITH MEN IN HANOI,

VIETNAM: FINDINGS FROM A CROSS-SECTIONAL, BIOBEHAVIORAL

STUDY.

Author Contributions Nga Thi Thu VU1,2, Martin HOLT1, Huong Thi Thu PHAN3, Lan Thi LA4, Gioi Minh

TRAN5, Tung Thanh DOAN5, Trang Nhu Nguyen NGUYEN6 and John de Wit1







City, Vietnam.

Reference

Vu NT, Holt M, Phan HT, La LT, Tran GM, Doan TT, et al. The Prevalence and

Correlates of HIV and Undiagnosed Infection among Men Who Have Sex with

Men in Hanoi, Vietnam: Findings from a Cross-sectional, Biobehavioral Study.

Frontiers in public health. 2016;4:275.

Declaration




124


This article was published in Frontiers in Public Health, an open-access journal,

available online:

http://journal.frontiersin.org/article/10.3389/fpubh.2016.00275/full.

No copyright permission, therefore, is needed for reusing it in this thesis

dissertation.

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http://journal.frontiersin.org/article/10.3389/fpubh.2016.00275/full

December 2016 | Volume 4 | Article 2751

Original researchpublished: 19 December 2016

doi: 10.3389/fpubh.2016.00275

Frontiers in Public Health | www.frontiersin.org

Edited by: Tak Fai Joseph Lau,

The Chinese University of Hong Kong, Hong Kong

Reviewed by: Gerjo Kok,

Maastricht University, Netherlands Zixin Wang,

The Chinese University of Hong Kong, Hong Kong

*Correspondence:Nga Thi Thu Vu

[email protected]; John de Wit

[email protected]

Specialty section: This article was submitted to

HIV and AIDS, a section of the journal

Frontiers in Public Health

Received: 02 August 2016Accepted: 02 December 2016Published: 19 December 2016

Citation: Vu NTT, Holt M, Phan HTT, La LT,

Tran GM, Doan TT and de Wit J (2016) The Prevalence and Correlates

of HIV and Undiagnosed Infection among Men Who Have Sex with Men

in Hanoi, Vietnam: Findings from a Cross-sectional, Biobehavioral Study.

Front. Public Health 4:275. doi: 10.3389/fpubh.2016.00275

The Prevalence and correlates of hiV and Undiagnosed infection among Men Who have sex with Men in hanoi, Vietnam: Findings from a cross-sectional, Biobehavioral studyNga Thi Thu Vu1,2*, Martin Holt1, Huong Thi Thu Phan3, Lan Thi La4, Gioi Minh Tran5, Tung Thanh Doan5 and John de Wit1,6*

1 Centre for Social Research in Health, UNSW Australia, Sydney, NSW, Australia, 2 Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam, 3 Vietnam Administration for HIV/AIDS Prevention and Control, Ministry of Health, Hanoi, Vietnam, 4 Hanoi Centre of HIV/AIDS Prevention and Control, Hanoi, Vietnam, 5 Center for Community Health Promotion, Hanoi, Vietnam, 6 Utrecht University, Utrecht, Netherlands

introduction: Men who have sex with men (MSM) are a key population for HIV infection in Vietnam, and the use of amphetamine type substances (ATS) is prevalent and possibly increasing in this population. The reported analysis examines the association between ATS use before or during sex and HIV infection among MSM in Hanoi, Vietnam.

Methods: This cross-sectional study of 210 MSM was conducted in Hanoi, Vietnam, in late 2014. Men tested for HIV and answered questions about demographic char-acteristics, sexual sensation seeking, depression, belief in HIV prevention strategies, homosexuality-related stigma and discrimination, recent accessing of HIV prevention services, sexual behaviors and ATS, and other drug use behaviors. We performed logis-tic regression to assess correlates of HIV infection.

results: HIV prevalence was 6.7% (14/210), and 85.7% (12/14) of HIV-positive men were not aware of their HIV status. Of the 210 participants, 10.5, 2.9, and 3.8% of men had used methamphetamine, amphetamine, and ecstasy before or during sex in the last 3 months. In multivariable analysis, HIV infection was associated with recent sex-related methamphetamine use [adjusted odds ratio (AOR): 5.03, 95% confidence interval (CI): 1.35–18.68], engaging in recent sex work (AOR: 3.55, 95% CI: 1.07–11.75), and homosexuality-related perceived stigma (AOR: 2.32, 95% CI: 0.98–5.47).

conclusion: Findings underscore the importance of integrating methamphetamine use interventions into HIV prevention services and scaling-up of gay-friendly, non-stigmatiz-ing HIV testing services for MSM in Hanoi. We recommend the routine assessment of ATS use and undiagnosed infection in this population.

Keywords: hiV prevalence, amphetamine type stimulants, men who have sex with men, undiagnosed hiV, hanoi—Vietnam

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Vu et al. Correlates of HIV Infection among MSM in Hanoi

Frontiers in Public Health | www.frontiersin.org December 2016 | Volume 4 | Article 275

inTrODUcTiOn

The HIV epidemic was first described in Vietnam in the early 1990s (1), and in the last 30 years, the epidemic has spread to dif-ferent parts of the country. Since 1999, HIV has been reported in all provinces and cities of Vietnam (2). Although men who have sex with men (MSM) have been recognized as a key population affected by HIV in different parts of the world (3), in Vietnam, they were only identified as a priority population for HIV preven-tion in the last decade (4), despite warning signs in the early 2000s that HIV was spreading in this population (5, 6).

A study conducted only in Ho Chi Minh City in 2004 reported an HIV prevalence of 8% in a sample of MSM recruited in MSM-specific venues (7). The first, national integrated biological behavioral surveillance (IBBS) conducted in 2006 reported that the HIV prevalence among MSM in Ho Chi Minh City and Hanoi was 5 and 9%, respectively (8). In the second IBBS conducted in 2009, HIV prevalence exceeded 10% in Hanoi (19.8%) and Ho Chi Minh City (14.3%), as well as in Haiphong (16.6%), the country’s third largest city (9), suggesting HIV prevalence had increased substantially among MSM in major cities across Vietnam. A more recent study found an HIV prevalence of 14.8% among MSM in Ho Chi Minh City (10). A better understanding of the individual, social, and structural factors that affect HIV risks is, therefore, needed to prevent further transmission of HIV in the MSM population in Vietnam.

Previous studies have found that HIV infection among MSM in Vietnam is associated with younger age, lower education and injecting drug use (7, 11), a higher number of recent sexual part-ners (5, 7), and sex work and inconsistent condom use (5). MSM in Vietnam have consistently reported low levels of condom use with casual and regular male partners (8, 9).

Amphetamine type stimulants (ATS) are commonly used drugs by MSM, and their use has been found to be associated with condomless anal intercourse (CAI) and HIV infection (12). A recent meta-analysis found a significant association between methamphetamine and amphetamine use and HIV infection across 35 studies (13). However, most previous studies have been conducted in high-income countries, and evidence regarding the association between ATS use and HIV infection among MSM is lacking in low- and middle-income countries (13), particularly Vietnam. It was reported that ATS use, particularly metham-phetamine use is prevalent among MSM in Vietnam (14). The relationship between ATS use and HIV infection among MSM in Vietnam, however, remains to be assessed.

In Vietnam, homosexuality remains socially stigmatized (15), despite recent activism to protect the rights of lesbian, gay, bisexual, and transgender people. Previous international research underscores that homosexuality-related stigma and discrimina-tion are associated with a higher risk of depression (16, 17). Depression has been found to be highly prevalent among MSM, particularly HIV-positive men (18, 19), and is considered a major health issue among MSM (20). Furthermore, homosexuality-related stigma, discrimination, and depression have been found to be associated with engaging in HIV-related risky behaviors such as CAI (21–23), drug use (24, 25), having sex while on drugs (26), less awareness and underutilization of HIV prevention services

(27–29), and experiencing less benefit from participating in HIV prevention interventions (27).

Previous studies of HIV infection among MSM in Vietnam have mainly focused on individual-level covariates rather than examining social and structural barriers to HIV prevention, such as homosexuality-related stigma and discrimination. Evidence from previous studies indicates that sexual sensation seeking is associated with an increased likelihood of CAI among MSM (30–33) and that sexual sensation seeking can modify or strengthen the association between alcohol or drug use and HIV-related sexual behaviors (34, 35). However, the effect of sexual sensation seeking on HIV risk among MSM in Vietnam has not been previously investigated.

Previous research in Vietnam has found relatively high rates of CAI between MSM (8, 9), and international research has found that MSM may use various strategies to reduce HIV transmission risk during CAI, such as serosorting (having sex with partners of the same perceived HIV status), strategic positioning (HIV-negative men being insertive during CAI), withdrawal before ejaculation, or limiting CAI to HIV-positive partners who are virally suppressed (36, 37). However, belief in the efficacy of these strategies has not been previously assessed among Vietnamese MSM.

To improve HIV prevention among MSM in Vietnam, we sought to assess the prevalence of HIV and undiagnosed infec-tion among MSM in Hanoi and examined factors associated with HIV infection, including homosexuality-related stigma and discrimination, depression, sexual sensation seeking, belief in the efficacy of risk reduction strategies, and drug use, particularly ATS use.

MaTerials anD MeThODs

Participants included in this analysis were part of a larger con-venience sample of 303 MSM recruited into a cross-sectional, community-based study in Hanoi, Vietnam, from September to October 2014. The study received approval from the Human Research Ethics Committee of the University of New South Wales, Australia, and from the Institutional Review Board of the Hanoi School of Public Health. A description of the study has been previously published (14). In short, the study was conducted in collaboration with the Hanoi Center for HIV/AIDS Prevention and Control (Hanoi PAC), the Center for Community Health Promotion (CHP), and MSM community-based organizations (CBOs). MSM are a relatively hidden population in Vietnam, and developing a randomized sam-pling frame is impossible. Convenience sampling was hence used to recruit participants. First, staff and outreach workers of collaborating organizations referred potential participants to the study. Additionally, peers of collaborating CBOs referred men from their social networks. Finally, participated men were asked to invite their peers who might be interested in the study.

Men were eligible to participate if they were 18 years or older at the time of the study, reported having anal sex with at least one man in the previous 3 months, had a good command of the Vietnamese language, and provided consent. Men were screened

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for eligibility and were interviewed after provided written consent. Upon interview completion, men were informed about optional HIV testing.

Men who chose to be tested were referred to an on-site test-ing team provided by Hanoi PAC. Separate written consent was obtained for HIV testing. Venous blood samples were collected by technicians from Hanoi PAC. Blood samples were assigned a unique, anonymous ID code enabling linkage to participants’ questionnaires (and for participants to get results). Due to resource constraints, we could only offer 210 free HIV tests to participants.

confidentiality and PrivacyBeing identified as a MSM or drug user in Vietnam may result in social stigma and discrimination (38). As such, MSM partici-pants, particularly those who use drugs, may underreport sexual and drug use behaviors. We took several steps to mitigate this potential bias. First, all interviewers were trained to be supportive and non-judgmental of MSM. Second, MSM participants were not asked to provide personal details that could reveal their identity. Third, all interviews were conducted in private rooms. Finally, all field staff signed a confidentiality agreement.

hiV Testing and statusBlood samples were tested for HIV at the Hanoi PAC labora-tory, following Vietnamese Ministry of Health guidelines. All blood samples were screened for HIV by the Murex HIV Ag/Ab combination assay (DiaSorin S.p.A., Italy). Samples that were reactive during screening were tested again using confirmatory tests (Serodia® HIV, Fujirebio, Japan; Determine™ HIV1/2, Alere Medical, USA). The main outcome variable was HIV status as confirmed by testing (HIV negative or HIV positive). We also referred to participants’ self-reported HIV status (HIV negative, untested/unknown, or HIV positive) to identify participants who tested HIV positive but were unaware of their infection. The self-report information collected through the questionnaire has previously been described (14) and contained the questions described below.

Demographic characteristicsWe asked participants about their self-reported HIV status, sexual orientation, age, place of birth, education, occupation, and monthly income.

sexual sensation seekingWe adapted a measure of sexual sensation seeking for a Vietnamese sample (39). Ten items assessed the propensity to seek out exciting and novel sexual experiences, for instance “I like wild, uninhibited sexual encounters.” Participants provided their answers on 5-point scales, ranging from 1 (not at all like me) to 4 (very much like me). Internal consistency of the items was sufficient (Cronbach’s α = 0.72). Item scores were averaged, with higher scores indicating more sexual sensation seeking.

DepressionThis was assessed with the Patient Health Questionnaire 9 scale, which has been used with MSM in other studies (40, 41). The

scale consists of nine items, such as “in the last two weeks, how often have you had trouble falling or staying asleep, or sleeping too much?” Participants provided their answers on a scale rang-ing from 0 (not having the problem at all) to 3 (having the prob-lem nearly every day). The items had good internal consistency (Cronbach’s α = 0.80). Participants were categorized as having a depressive disorder if they had a score equal or larger than 10, as previously described (42).

Belief in hiV Prevention strategiesParticipants were asked how effective they thought different strategies were in preventing HIV transmission: antiretroviral treatment of HIV, HIV-negative men taking the insertive (top) position during anal sex, and withdrawal before ejaculation. Answer options ranged from 1 (totally disagree) to 4 (totally agree). Belief in the efficacy of each HIV prevention method was dichotomized into disagreement (scores 1 and 2) versus agree-ment (scores 3 and 4).

Perceived stigma and DiscriminationWe adapted a scale to measure enacted (experienced) homosex-uality-related stigma, perceived (anticipated) homosexuality-related stigma, and self-stigma (internalized homophobia) (22). Responses were given on 4-point scales, with anchors depending on the questions. The adapted scale encompassed eight items pertaining to enacted homosexuality-related stigma, for example “how often have you lost a job or career opportunity due to your engaging in homosexual activities” (1 = never, 4 = often); 10 items measuring perceived homosexuality-related stigma, for instance “many people are unwilling to accept homosexual individuals” (1 = completely disagree, 4 = completely agree); and eight items measuring internalized homophobia, for example “sometimes you wish you were not gay/bisexual/transgender” (1 = totally disagree, 4 = totally agree). In this study, the scale had good internal consistency (Cronbach’s α = 0.74). Mean scores were calculated for each sub-scale; higher scores indicated higher levels of stigma.

recent accessing of hiV Prevention servicesWe asked participants if they had recently tested for HIV (i.e., at least once in the last 12 months) and if they had recently received safe sex counseling (i.e., at least once in the last 12 months).

sexual BehaviorsWe asked about the gender of sexual partners and age at first sex with men and women. Participants were asked about ever engaging in sex work (selling sex), recent sex work (in the last 3 months), their number of regular and casual male partners in the last 3 and 12 months, and the use of condoms during anal sexual intercourse with regular and casual male partners. Because numbers of different types of sexual partners were skewed, we undertook logarithmic or square root transformations of these variables, as appropriate. Any CAI was defined as not or incon-sistently using a condom during anal sex (assessed for regular and casual male partners in the previous 3 months).

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aTs and Other Drug UseParticipants were asked questions about ever having used ATS, alcohol, and other substances (i.e., ketamine, erectile dysfunction medications, and amyl nitrite “poppers”), any recent use of these substances (in the last 3 months) and any use of these substances before or during sex in the last 3 months. Answers to these ques-tions were dichotomized (any use versus none).

Data analysisDescriptive and correlational statistical analyses were performed using STATA version 13.1 (StataCorp, College Station, TX, USA). We report frequencies and percentages for categorical variables and medians with interquartile ranges (IQR) for continuous variables. We tested bivariate associations between laboratory-confirmed HIV status and potential covariates using logistic regression. Factors associated with the outcome variable at p < 0.25 were subsequently entered into a multivariate regression model to identify independent covariates. We used a stepwise procedure as previously suggested (43) to develop the final multivariate model with independent covariates, which retained statistical significance (p < 0.05).

resUlTs

A total of 222 men were referred to the study as potential partici-pants, among whom nine men did not meet selection criteria, two men chose not to complete an interview, and one man refused to be tested. As such, the following analysis includes 210 men who completed an interviewer-administered questionnaire and agreed to be tested for HIV and release their HIV test result. We compared the sociodemographic characteristics of men who did and did not undertake HIV testing (analysis not shown). Men who tested for HIV and consented to release their HIV test results were significantly younger, had lower incomes, and were more likely to be students or self-employed. Men who did and didn’t undertake HIV testing were similar in terms of place of birth, education level, sexual orientation, and perceived HIV status.

sample characteristicsTable 1 presents the demographic characteristics of the 210 MSM who participated. The majority of the sample reported being homosexual (73.3%), 22.4% bisexual, and the remainder (3.8%) heterosexual or other sexual orientation. The median age of the sample was 22.7 years (IQR: 20.6–25.5); 90.0% were younger than 30 years. The majority of men had a college or university educa-tion (57.9%), 30.1% had high school or vocational training, and only 12.0% had secondary or lower education. Approximately 30.0% of the sample was students, 9.0% were unemployed, and the remainder had office-based jobs, service jobs, or were in self-employed, casual, or freelance jobs. Participants had a median monthly income of 5 million Vietnamese Dong (approximately US$228) (IQR: 3.0–8.0 million). The median sexual sensation-seeking score was 2.5 (IQR: 1.4–3.5). A minority of men (14.3%) were categorized as having depression. In relation to belief in different HIV prevention strategies, 9.5% men believed in the effectiveness of HIV treatment as prevention, 28.6% believed in

the safety of being insertive during sex, and 38.6% men believed that withdrawal was effective. The median score regarding homosexuality-related enacted stigma was 1.1 (IQR: 1.0–2.4); scores for perceived stigma and internalized homophobia were 4.0 (IQR: 1.20–5.0) and 3.4 (IQR: 1.0–4.6), respectively.

sex and Drug Use BehaviorsTable 2 presents HIV-related sex and drug use behaviors. Approximately 63% men self-reported having sex with men only; the remainder reported having sex with both men and women. The median age of first homosexual sex was 19.0 (IQR: 18.0–21.0), and the median age of first heterosexual sex was 18.0 (12.0–30.0). Of the 210 participants, 73.8% reported any recent CAI with male partners (66.2% with regular part-ners and 32.4% with casual partners). The median number of regular male sexual partners in the last 3 months was 1 (IQR: 1.0–80.0), and the median number of casual male sexual part-ners in the last 3 months was 3.0 (IQR: 1.0–100.0). Of the 210 participants, 26.2% reported having ever engaged in sex work and 21.4% reported recent sex work. One in five participants (22.9%) reported ever having used methamphetamine, 14.8% reported recent use, and 10.5% reported recent sex-related use. The corresponding rates for amphetamine use were 7.6, 2.9, and 2.9%, respectively. Rates for ecstasy they were 20.0, 8.6, and 3.8%. Men reported higher levels of alcohol use: 90.0% had ever drunk alcohol, 76.2% had recently consumed alcohol, and 39.5% reported sex-related alcohol use in the last 3 months.

hiV Testing resultsFourteen men out of 210 [6.7%, 95% confidence interval (CI): 3.7–10.9] tested HIV-antibody positive (see Table 1) and 12 of these 14 HIV-positive men (85.7%) were not aware of their HIV status. Just over half (52.4%) of all participating men had ever tested for HIV, and just under half (46.6%) did not know their HIV status, including 29.5% who had ever tested for HIV but did not know their test result and 17.1% who had never tested for HIV. Out of the 210 men who were tested, approximately 10 men returned for their results, including one man who was previously undiagnosed with HIV.

correlates of hiV infectionThe results of bivariate and multivariate analyses of associa-tions between HIV infection and other covariates are presented in the Table 3. Potential independent covariates identified in bivariate analysis included occupation, sexual sensation seek-ing, belief in the safety of being insertive during sex as a HIV prevention strategy, homosexuality-related perceived stigma, engaging in recent sex work, number of regular male sexual partners, any recent CAI with casual male sexual partners, recent methamphetamine or amphetamine use before or dur-ing sex, and having a HIV test in the last 12 months. In the final multivariate logistic regression model, HIV infection was more likely among MSM who reported recent sex work or the use of methamphetamine before or during sex. Additionally, HIV infection was marginally associated with homosexuality-related perceived stigma.

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TaBle 1 | Participant characteristics.

Frequency Percent (95% ci)

hiV status confirmed by lab tests (N = 210) Negative 196 93.3 (89.1–96.3) Positive 14 6.7 (3.7–10.9)

Perceived hiV status (on enrollment) (N = 210) HIV positive 2 0.9 (0.1–3.4) HIV negative 110 52.4 (45.4–59.3) Tested but didn’t know the result 62 29.5 (23.4–36.2) Never previously tested 36 17.1 (12.3–22.9)

sexual identity (N = 210) Homosexual 154 73.3 (66.8–79.2) Bisexual 47 22.4 (16.9–28.6) Heterosexual and other 9 4.3 (2.0–8.0)

age [median and interquartile ranges (iQr)] (N = 210) 22.7 (20.6–25.5) <20 38 18.1 (13.1–24.0) 20–29 151 71.9 (65.3–77.9) 30–39 14 6.7 (3.7–10.9) ≥40 7 3.3 (1.4–6.7)

Place of birth (N = 210) Hanoi 86 41.0 (34.2–47.9) Other provinces 124 59.0 (52.1–65.8)

education (N = 209) Primary and lower school 25 12.0 (7.9–17.1) High school and vocational training 63 30.1 (24.0–36.9) College and university 121 57.9 (50.9–64.7)

Occupation (N = 210)

Student 66 31.4 (25.2–38.2) Office-based job 35 16.7 (11.9–22.4) Service job 38 18.1 (13.1–24.0) Self-employed/freelance 52 24.8 (19.1–31.2) Unemployed 19 9.0 (5.5–13.8)

Median monthly income (iQr) (N = 210) 5.0 (3.0–8.0) Income <3 million VND 37 17.6 (12.7–23.5) 3 million VND ≤ income <5 million VND 62 29.5 (23.4–36.2) Income ≥5 million VND 111 52.9 (45.9–59.8)

Median sexual sensation-seeking score (iQr) (N = 210) 2.5 (1.4–3.5)

Depression (N = 210) 30 14.3 (9.9–17.8)

Belief in hiV prevention strategies (N = 210) Treatment as prevention 20 9.5 (5.9–14.3) Being insertive during anal sex 60 28.6 (22.6–35.2) Withdrawal 81 38.6 (32.0–45.5)

Median score for homosexuality-related stigma and discrimination (iQr) (N = 210)

Enacted stigma 1.1 (1.0–2.4) Perceived stigma 4.0 (1.2–5.0) Internalized homophobia 3.4 (1.0–4.6)

any hiV test in the last 12 months (N = 210) 93 44.3 (37.5–51.3)

received any safe sex counseling in the last 12 months (n = 210) 110 52.4 (45.4–59.3)

5



DiscUssiOn

To the best of our knowledge, this is the first reported analysis of an association between a broad range of important structural, personal dispositions, and behavioral factors and HIV infec-tion among MSM in Vietnam. While we found that MSM who reported recently using amphetamine or ecstasy before or during sex were not more likely to have an HIV positive test result, MSM who self-reported the recent use of methamphetamine before or during sex had a fivefold increased likelihood of HIV infection, compared with MSM who did not use methamphetamine for

sex. These findings are similar to those of a recent meta-analysis (13), as well as recent empirical research, finding higher rates of methamphetamine and/or amphetamine use among diagnosed HIV-positive MSM compared to HIV-negative MSM (44–47). In our study, we also found that men who engaged in recent sex work were more likely to test positive for HIV. Together, our findings suggest that men who use ATS for sex and men who engage in sex work should be targeted as priority groups for HIV preven-tion in Hanoi, Vietnam. We also suggest that interventions for methamphetamine use are made available for MSM in Vietnam and be incorporated into current HIV prevention activities.

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TaBle 2 | sexual and drug use behaviors.

Frequency Percent (95% ci)

Type of sexual partners (N = 210) Male sexual partners only 132 62.9 (55.9–69.4) Both male and female sexual partners 78 37.1 (30.6–44.1)

Median age at first homosexual sex (N = 210) (iQr) 19.0 (18.0–21.0)

Median age at first heterosexual sex (N = 78) (iQr) 18.0 (12.0–30.0)

any condomless anal intercourse (cai) with male partners in the last 3 months (N = 210) 155 73.8 (67.3–79.6)

regular male sexual partners Median number of regular male sexual partners in the last 3 months (N = 196) (IQR) 1 (1–80) Any CAI with regular male sexual partners in the last 3 months (N = 210) 139 66.2 (59.4–72.6)

casual male sexual partners Median number of casual male sexual partners in the last 3 months (N = 128) (IQR) 3 (1–100) Any CAI with casual male sexual partners in the last 3 months (N = 210) 68 32.4 (26.1–39.1)

ever engaged in sex work (n = 210) 55 26.2 (20.4–32.7)

engaged in sex work in the last 3 months (n = 210) 45 21.4 (16.1–27.6)

lifetime use of alcohol and other drugs (N = 210) Alcohol 189 90.0 (85.1–93.7) Amphetamine (speed) 16 7.6 (4.4–12.1) Amyl nitrite (poppers) 11 5.2 (2.6–9.2) Cannabis 35 16.7 (11.9–22.4) Ecstasy 42 20.0 (14.8–26.1) Erectile dysfunction medication 15 7.1 (4.1–11.5) Heroin 12 5.7 (3.0–9.8) Ketamine 16 7.6 (4.4–12.1) Methamphetamine 48 22.9 (17.4–29.1) Sleeping pills 8 3.8 (1.7–7.4)

any alcohol and aTs use in the last 3 months (N = 210) Alcohol 160 76.2 (69.8–81.8) Amphetamine (speed) 6 2.9 (1.1–6.1) Ecstasy 18 8.6 (5.2–13.2) Methamphetamine 31 14.8 (10.3–20.3)

any alcohol and aTs use before or during sex in the last 3 months (N = 210) Alcohol 83 39.5 (32.9–46.4) Amphetamine (speed) 6 2.9 (1.1–6.1) Ecstasy 8 3.8 (1.7–7.4) Methamphetamine 22 10.5 (6.7–15.4)

CI, confidence interval; IQR, interquartile range.

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Furthermore, future periodic surveillance of HIV among MSM in Vietnam would benefit from the inclusion of measures of ATS use and its association with sexual risk behaviors. Such research would contribute to an increasing understanding of the complex relationships between drug use, sexual behaviors, and HIV infec-tion among Vietnamese MSM that can guide HIV prevention.

We found a relatively moderate prevalence of HIV (6.7%) among MSM recruited in Hanoi, lower than that found in previ-ous government-run surveillance studies (6, 8). Our convenience sample did not include any MSM who reported injecting drug use, so we may have under-recruited men who are at higher risk of HIV. As such, generalizing our findings to the broader com-munity of MSM in Hanoi should therefore be undertaken with caution. Strikingly, we found the majority of HIV-positive men (12 out of 14) indicated that they were HIV-negative or did not know their HIV status. To the best of our knowledge, no previ-ous studies have reported the level of undiagnosed HIV among MSM in Vietnam (7, 9, 11, 48), and our results suggest that many HIV-positive MSM in Hanoi may be unaware of their infection. Some of the HIV-positive men in our study may have chosen not

to reveal that they had already been diagnosed when interviewed, because of reticence or fear about disclosing their status. Previous studies in high-income countries, while reporting lower levels of undiagnosed HIV (49, 50), have found that men with undiag-nosed HIV report more risky sexual and drug use behaviors than HIV-negative men (49). We also found a borderline association between homosexuality-related perceived stigma and HIV infec-tion in our analysis. Therefore, promoting accessible HIV testing services, for example, MSM-run, community-based, HIV testing services, is recommended, because they could encourage HIV testing as well as returning for HIV test results (51). Additionally, as little is known about undiagnosed HIV among MSM in Vietnam, future research could assess the extent of undiagnosed HIV and its correlates in different parts of the country.

We did not find a significant association between HIV infec-tion and any form of CAI, despite previous research establishing CAI as a key risk factor for HIV infection in MSM (52). Since the sample size for this analysis was relatively small, power may have been insufficient to detect an association between CAI and HIV infection. Alternatively, the lack of variance between HIV status

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TaBle 3 | Bivariate and multivariate analysis of associations with hiV infection (N = 210).

cOr (95% ci) p aOr (95% ci) p

age group (in years) 0.415 <20 1 20–29 1.14 (0.24–5.51) 0.87 ≥30 3.0 (0.46–19.59) 0.251

education 0.01 0.843 Primary and lower school only 1 1 High school and above 5.61 (1.52–20.79) 1.20 (0.20–7.34)

Occupation 0.04 Student or office-based job 1 1 Service job 4.95 (1.12–21.85) 0.035 0.30 (0.01–8.65) 0.485 Self-employed/freelance 4.26 (1.02–17.80) 0.047 0.28 (0.01–6.82) 0.435 Unemployed 1 (omitted)a

Monthly income 0.307 <3 million VND (US$163.4) 1 3 million–4.9 million VND 0.28 (0.05–1.58) 0.148 ≥5 million VND 0.64 (0.18–2.26) 0.49

sexual orientation 0.857 Homosexual 1 Bisexual 0.89 (0.24–3.32) 0.858 Heterosexual and other 1 (omitted)a

had major depression in the last 2 weeks 2.56 (0.51–12.74) 0.252

sexual sensation seeking 4.59 (1.17–17.96) 0.023 2.27 (0.47–11.08) 0.31

Belief in the safety of withdrawal as a prevention strategy 0.88 (0.28–2.72) 0.82

Belief in the effectiveness of hiV treatment as a prevention strategy 1 (omitted)a

Belief in the safety of being insertive during sex as a prevention strategy 0.40 (0.09–1.83) 0.235 0.25 (0.05–1.32) 0.102

homosexuality-related enacted stigma 1.48 (0.24–9.20) 0.672

homosexuality-related perceived stigma 1.99 (0.92–4.31) 0.081 2.32 (0.98–5.47) 0.054

homosexuality-related homophobia 0.78 (0.43–1.42) 0.425

had male partners only versus both male and female partners 0.94 (0.30–2.90) 0.909

engaged in sex work (selling sex) in the last 3 months 4.16 (1.38–12.56) 0.012 3.55 (1.07–11.75) 0.038

number of regular male sexual partners 0.24 (0.04–1.63) 0.145 1.38 (0.08–23.31) 0.822

number of casual male sexual partners 1.34 (0.81–2.20) 0.255

any condomless anal intercourse (cai) with regular sexual partners in the last 3 months 1.95 (0.53–7.22) 0.319

any cai with casual sexual partners in the last 3 months 3.02 (1.00–9.09) 0.049 1.76 (0.29–10.58) 0.537

any cai in the last 3 months 1.32 (0.36–4.93) 0.676

Methamphetamine use before or during sex in the last 3 months 5.85 (1.76–19.44) 0.004 5.03 (1.35–18.68) 0.016

amphetamine use before or during sex in the last 3 months 8.0 (1.33–48.15) 0.023 1.73 (0.14–21.29) 0.668

ecstasy use before or during sex in the last 3 months 1 (omitted)a

Drinking alcohol before or during sex in the last 3 months 1.58 (0.53–4.68) 0.41

having at least one hiV test in the last 12 months 0.48 (0.15–1.59) 0.229 1.0 (0.21–4.68) 0.999

receiving any safe sex counseling in the last 12 months 0.66 (0.22–1.98) 0.463

COR, crude odds ratio; AOR, adjusted odds ratio.aOne of the cells contained a value of 0 and was excluded from the analysis.

7



groups may reflect a ceiling effect of high levels of CAI in both HIV-positive and non-HIV-positive MSM. Because CAI with male sexual partners was so common in the sample (73.8%) and the level of undiagnosed HIV was strikingly high, we recommend an intensified promotion of safe sex among MSM in Hanoi.

Previous studies have found that depression can be highly prevalent among MSM and is more likely higher among diag-nosed, HIV-positive MSM (41, 53). However, we did not find

an association between depression and HIV infection in our sample. This may be because we found a relatively low prevalence of depression in the sample, and the majority of men who had HIV were unaware of their infection. We also did not find an independent association between sexual sensation seeking and HIV infection. However, like other researchers, we have previ-ously found a positive relationship between sexual sensation seeking and CAI (30–33).

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Our study had several limitations. Since MSM are a hid-den population in Vietnam, we used a convenience sampling approach, as a result of which our findings may not be rep-resentative of the broader MSM population in Hanoi. Our sample is more likely to be representative of young MSM in urban settings in Vietnam who are students or self-employed and have lower incomes. As MSM are a hidden population in Vietnam, previous studies have also used a variety of non-random convenience sampling methods and, as in many high income countries, no randomized samples of MSM have been recruited in Vietnam (8, 9, 38, 54–56). Also, although we tried to eliminate reporting bias during the interview process, our findings might reflect underreporting of sexual and drug use behaviors and other socially sensitive issues. Additionally, men who engaged in transactional sex were disproportionately affected by HIV (57). As one fifth of the sample engaged in sex work, assessing sex practices with their sexual partners would have been useful but no such assessment was included in our study.

cOnclUsiOn

We found a moderate prevalence of HIV infection among MSM in Hanoi, Vietnam, and most of the men who tested HIV-positive seemed to be unaware of infection. HIV infection was associated with sex-related methamphetamine use and engagement in sex work. Our analytical and descriptive findings point to several recommendations. For HIV prevention, we recommend an integration of interventions for methamphetamine use into HIV prevention, an intensified promotion of safe sex, and implemen-tation of community-based, MSM-run, or MSM-friendly HIV testing services in Hanoi, Vietnam. In research, we recommend the routine assessment of ATS use in national HIV surveillance and research to enable analysis of trends in ATS use and associa-tions with sexual behaviors. We also recommend further study of

men’s beliefs and practices with respect to various harm reduction strategies. Finally, we urge examination of the extent of undiag-nosed HIV infection in MSM in different parts of Vietnam.

aUThOr cOnTriBUTiOns

NV led the development of the research protocol and data collec-tion tools, undertook data collection and data analysis, wrote the initial draft of the manuscript, and prepared the final manuscript. JW and MH guided and supervised the development of the research protocol, data collection and analysis, and contributed to the writing of the manuscript. HP, LL, GT, and TD provided advice and guidance on the research protocol and data collection and contributed to the manuscript.

acKnOWleDgMenTs

We acknowledge the great support and input from staff of the Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi Centre of HIV/AIDS Prevention and Control, Center for Community Health Promotion, Center for Promotion of Quality of Life and leaders and representatives of community-based organizations of MSM in Hanoi during the data collection process.

FUnDing

NV was supported by an Australia Awards Scholarship to study at UNSW Australia. The study received financial support from the Faculty of Arts and Social Sciences, UNSW Australia. The Centre for Social Research in Health is supported by the Australian Government Department of Health. Funding agencies were not involved in the development of the research protocol, data collection, data analysis, interpretation, or the dissemination of research findings.

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Conflict of Interest Statement: The authors declare that the research was con-ducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer ZW and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.

Copyright © 2016 Vu, Holt, Phan, La, Tran, Doan and de Wit. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/licenses/by/4.0/

CHAPTER 7

AMPHETAMINE-TYPE-STIMULANTS (ATS) USE AND

HOMOSEXUALITY-RELATED ENACTED STIGMA ARE ASSOCIATED

WITH DEPRESSION AMONG MEN WHO HAVE SEX WITH MEN

(MSM) IN TWO MAJOR CITIES IN VIETNAM IN 2014

Author Contributions Nga Thi Thu VU1,2, Martin HOLT1, Huong Thi Thu PHAN3, Lan Thi LA4, Gioi

Minh TRAN5, Tung Thanh DOAN5, Trang Nhu Nguyen NGUYEN6 and John de

Wit1

1: Center for Social Research in Health, University of New South Wales,

Sydney, New South Wales, Australia; 2: Institute of Preventive Medicine and

Public Health, Hanoi Medical University, Hanoi, Vietnam; 3: Vietnam

Administration for HIV/AIDS Prevention and Control, Hanoi, Vietnam; 4: Hanoi

Center of HIV/AIDS Prevention and Control, Hanoi, Vietnam; 5: Center for

Community Health Promotion, Hanoi, Vietnam; 6: Center for Promotion of

Quality of Life, Ho Chi Minh City, Vietnam.

Reference

Vu NTT, Holt M, Phan HTT, La LT, Tran GM, Doan TT, et al. Amphetamine-

Type-Stimulants (ATS) Use and Homosexuality-Related Enacted Stigma Are

Associated With Depression Among Men Who Have Sex With Men (MSM) in

Two Major Cities in Vietnam in 2014. Substance use & misuse. 2017:1-9.

Declaration




136


As the first author of the original article, the candidate has the right to include

this article in this thesis. This is an accepted manuscript of an article published

by Taylor and Francis in journal Substance Use and Misuse on 24th April, 2017,

available online

http://www.tandfonline.com/doi/full/10.1080/10826084.2017.1284233

137

SUBSTANCE USE & MISUSEhttp://dx.doi.org/./..

ORIGINAL ARTICLE

Amphetamine-Type-Stimulants (ATS) Use and Homosexuality-Related EnactedStigma Are Associated With Depression Among Men Who Have Sex With Men(MSM) in Two Major Cities in Vietnam in

Nga Thi Thu Vua,b, Martin Holta, Huong Thi Thu Phanc, Lan Thi Lad, Gioi Minh Trane, Tung Thanh Doane,Trang Nguyen Nhu Nguyenf, and John de Wit a

aCentre for Social Research in Health, University of New South Wales, Sydney, Australia; bInstitute of Preventive Medicine and Public Health,Hanoi Medical University, Hanoi, Vietnam; cVietnam Administration for HIV/AIDS Prevention and Control, Ministry of Health, Hanoi, Vietnam;dHanoi Centre of HIV/AIDS Prevention and Control, Hanoi, Vietnam; eCenter for Community Health Promotion, Hanoi, Vietnam; fCentre forPromotion of Quality of Life, Ho Chi Minh City, Vietnam

KEYWORDSMen who have sex with men;amphetamine-type-stimulants;homosexuality-relatedstigma and discrimination;depression; Vietnam

ABSTRACTBackground: Men who have sex with men (MSM) are disproportionately affected by mental healthconcerns, including depression. Amphetamine-type-stimulants (ATS) use and homosexuality-relatedstigma and discrimination have been found associated with depression among MSM. Objectives: Toassess the prevalence of depression and its associations with ATS use and homosexuality-relatedstigma and discrimination among MSM in Vietnam. Methods: 622 MSM were conveniently recruitedin Hanoi and Ho Chi Minh city, Vietnam, from September to December 2014. We collected informationon demographic characteristics, ATS, alcohol and other drug use, sexual behaviors, homosexuality-related and discrimination stigma, and sexual sensation-seeking. Depression and suicidal thoughtswere assessed by the Patient Health Questionnaire (PHQ-9). We assessed associations of depressionwith ATS use and homosexuality-related stigma and discrimination using logistic regression. Results:Of 622 sampled MSM, 11.3% were classified as having major depression, 9.8% reported any suicidalthoughts in the last two weeks, 30.4% ever had used any ATS, 88.8% ever ad drank alcohol and 21.5%had ever used any other drugs. In multivariate analysis, depression was significantly associated withATS use (Adjusted Odds Ratio [AOR: 2.20; (95% Confidence Interval (CI): 1.32–3.67], younger age ofsexual debut with another man (AOR: 0.09; 95% CI: 0.02–0.50), and greater enacted homosexuality-related stigma (AOR: 1.97; 95% CI: 1.19–3.26). Conclusions: We found a moderate prevalence of depres-sion among sampled MSM, which was associated with ATS use and enacted homosexuality-relatedstigma. We recommend integrating assessment and interventions regarding depression and metham-phetamine use into gay-friendly, culturally adapted holistic HIV prevention for MSM in Vietnam.

Men who have sex with men (MSM) have been foundto be disproportionately affected by psychological dis-orders, including depression and anxiety (Meyer, 2003;Safren, Blashill, & O’Cleirigh, 2011). Depression andrelated forms of psychological distress have been identi-fied as priority health issues among men who have sexwith men (Gee, 2006; Sullivan et al., 2009). In the UnitedSates, as well as other parts of the world, the prevalenceof depression among MSM is found to be higher thanamong heterosexual men (Frost & LeBlanc, 2014; Meyer,2003). In the United States and in European countriessuch as Belgium and Estonia, recent studies have reporteda prevalence of depression of approximately 30% amongMSM (De Santis, Colin, Provencio Vasquez, & McCain,2008; Parker, Lohmus, Valk, Mangine, & Ruutel, 2015;Wim, Christiana, & Marie, 2014). Recent studies from

CONTACT Nga Thi Thu Vu [email protected] Center for Social Research in Health, Level John Goodsell Building, UNSW Sydney, Kensington,Sydney , Australia.

Supplemental data for this article can be accessed at http://dx.doi.org/./...

the Asia-Pacific region report varying levels of depressionamong MSM: 11% in India (Tomori et al., 2016), 46% inChina (Yan et al., 2014) and 61% in Nepal (Deuba et al.,2013). In Vietnam, recent studies have found a high levelof depression among a subgroup of MSM, male sex work-ers, ranging from 47% to 58% (Biello, Colby, Closson, &Mimiaga, 2014; Goldsamt, Clatts, Giang, & Yu, 2015; Old-enburg et al., 2014). A recently published study reporteda prevalence of depression of 68% among young MSM inHanoi (Ha, Risser, Ross, Huynh, & Nguyen, 2015).

Previous studies in different country settings havefound that MSM experiencing depression are more likelyto use stimulant drugs, including methamphetamine(Carrico et al., 2012; Stall et al., 2001), possibly as a meansto reduce anxiety and other symptoms, or to escape oravoid negative psychological states (Carrico et al., 2012).

© Taylor & Francis Group, LLC

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2 N. T. T. VU ET AL.

Research also suggests that amphetamine-type-stimulant(ATS) use can result in psychological problems suchas depression (Darke, Kaye, McKetin, & Duflou, 2008;Folkman & Lazarus, 1988; Parrott, 2001). Use of stim-ulants, including methamphetamine or amphetamine, isalso associated with HIV infection (Thu Vu, Maher, &Zablotska, 2015). To achieve better outcomes in HIV pre-vention, it has been suggested to incorporate interven-tions for mental health problems alongside interventionsthat address the social and structural determinants ofrisky sexual behavior and HIV infection (Mayer et al.,2013; Safren, Reisner, Herrick, Mimiaga, & Stall, 2010).

In many parts of the world, despite efforts to promoteand protect the rights of sexual minority populations,social stigma and discrimination persist against MSM(Altman et al., 2012). Homosexuality-related stigma anddiscrimination can result in adverse psychological, phys-ical, and social outcomes (Mayer et al., 2013; Safrenet al., 2011). The Minority Stress Theory suggests thatsexual minorities tend to have higher levels of men-tal illness, including depression, because they experi-ence excess social and psychological stress (Meyer, 2003).Various studies have found that homosexuality-relatedsocial stigma does indeed increase the probability ofmental health problems in MSM in low, middle andhigh income countries, including anxiety, depression,and suicidal ideation (Choi, Steward, Miege, Hudes, &Gregorich, 2016; Gibbs & Rice, 2016; Mayer et al., 2013;Secor et al., 2015; Stahlman et al., 2015). MSM are alsodisproportionately affected by sexually transmitted infec-tions, including HIV (Beyrer et al., 2012; Gee, 2006).Previous studies have found direct and indirect associa-tions between homosexuality-related stigma, depressionand risky sexual behaviors among MSM, with depressionincreasing the risk of engaging in condomless anal inter-course (CAI) (Chakrapani, Newman, Shunmugam, Logie,& Samuel, 2017; Deuba et al., 2013; Mimiaga et al., 2013;Safren et al., 2011; Shiu et al., 2014; Tucker et al., 2014).

In Vietnam, a study conducted in 2011 foundthat a minority (21%) of MSM had ever experiencedhomosexuality-related stigma and discrimination (Haet al., 2015). Nevertheless, this study also found anassociation between homosexuality-related stigma anddiscrimination and risky sexual behavior, particularlyan increased number of sexual partners and engaging ininconsistent condom use (Ha et al., 2015). Recent studieshave found a relatively high level of CAI (Bengtsson, Lu,Liljeros, Thanh, & Thorson, 2014; Garcia et al., 2014;Pham et al., 2015), and a moderate level of ATS useamong MSM in Vietnam (Vu et al., 2016). Recent studiesin Vietnam have also found high a prevalence of depres-sion (68%) among MSM and male sex workers (58%)(Goldsamt et al., 2015; Ha et al., 2015). Recently, a study

on psychological disorders among male sex workers in HoChi Minh city reported that depression was significantlyassociated with sex work-related stigma, any recent druguse and experiencing sexual violence (Biello et al., 2014;Oldenburg et al., 2014). To date, however, no studies fromVietnam have assessed the correlates of depression in abroader sample of MSM. As part of a study assessing ATSuse, sexual risk behavior and HIV infection of MSM inHanoi and Ho Chi Minh City, the current analyses wereundertaken to assess the prevalence of depression and itsassociations with ATS use, homosexuality-related stigmaand discrimination and other correlates.

Methods

This was a cross-sectional, community-based study,conducted in collaboration with the Hanoi HIV/AIDSPrevention Center (Hanoi PAC), the Center for Commu-nity Health Promotion (CHP) in Hanoi, and the Cen-tre for Promotion of Quality of Life (Life Center) in HoChi Minh City (HCMC), Vietnam, during September-December 2014. CHP and Life Centre have outreach net-works that reach various subgroups of MSM. Because ofsocial stigma and discrimination towards homosexual-ity (Blanc, 2005; Ha et al., 2015), MSM are still a hid-den population in Vietnam and, as elsewhere, developinga sampling frame for a representative sample of MSM isnot possible. Therefore, a community-based, conveniencesampling method was used to recruit participants for thestudy. Study participants were recruited via several strate-gies at the same time. First, staff and peer outreach work-ers of the local collaborating organizations assisted withrecruiting participants via those organizations and groupsof MSM. Second, participants were asked to refer otherMSM to the study. Men were eligible to participate if theywere 18 years or older at the time of the study, reportedhaving anal sex with at least one man in the previous3 months, had a good command of the Vietnamese lan-guage and consented to participate. Men were screenedfor eligibility and interviewed after they had signed theParticipant Information and Consent Forms. A detaileddescription of the study design can be found elsewhere(Vu et al., 2016). The study received approval from theHuman Research Ethics Committee of UNSW Australia(reference HC14130), and from the Institutional ReviewBoard of the Hanoi School of Public Health (reference014_262/DD-YTCC).

Study locations

The study was conducted in the two biggest cities in Viet-nam: Hanoi in the Northern region and Ho Chi Minh City

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in the Southern part of Vietnam, where large communi-ties of MSM can be found. While homosexuality-relatedstigma and discrimination occur across Vietnam, Ho ChiMinh City is regarded as a more socially tolerant location,while Hanoi is considered a location where MSM canface more social stigma (Blanc, 2005).

Measures

Face-to-face, structured interviews using a self-reportquestionnaire were administered by experienced data col-lectors from Hanoi Medical University and by trainedMSM peers. The questionnaire was developed in Englishand translated into Vietnamese by the first author. Twomeetings with MSM informants were organized in Hanoiand Ho Chi Minh City to review the appropriateness ofthe language and acceptability of the questions. Men werealso asked to confirm colloquial terms used by MSM fordrug use, sexual orientation and sexual behavior in Viet-nam. The questionnaire was pilot-tested with ten MSM inHanoi and refined afterwards.

Dependent variableDepression was assessed with the Patient Health Ques-tionnaire 9 item scale (PHQ-9), which has been used withMSM in other studies (Hirshfield et al., 2008; Mao et al.,2009). The scale consists of nine items, such as “In thelast two weeks, how often have you had trouble falling orstaying asleep, or sleeping too much?” Participants pro-vided their answers on a scale ranging from 0 (not hav-ing the problem at all) to 3 (having the problem nearlyevery day). The items had good internal consistency inthis study (Cronbach’s ɑ = 0.80). Participants were cate-gorized as having major depressive disorder if they scored10 or more (Kroenke, Spitzer, & Williams, 2001).

Explanatory variablesDemographic characteristics. We collected informationregarding age, education, occupation, monthly income,self-reported sexual orientation, and self-reported HIVstatus. Men’s ages were calculated by subtracting date ofbirth from date of interview. The highest level of edu-cation men had completed was categorized as following:up to secondary school, high school, or vocational train-ing, and university or higher degree. Mens’ current occu-pation was grouped into five categories: student, office-based jobs, service jobs (working in restaurants, cafés,bars, discotheques, bathhouses or similar facilities), self-employed (or casually employed), and unemployed. Menwere asked to report their total monthly income from allsources and were classified into three groups: less than

3 million Vietnam Dong (VND) (equivalent to approxi-mately US$150 at the time of interviews), from 3 millionVND to 5 million VND and above 5 million VND.

HIV testing. Men were asked about their HIV testingbehaviors in the last 12 months. Men were categorized ashaving previously tested for HIV if they self-reported atleast one HIV test during the last 12 months.

ATS use, alcohol consumption and other drug use. Par-ticipants were asked questions about having used anymethamphetamine, amphetamine, ecstasy, alcohol orother substances (i.e., heroine, ketamine, marijuana, andamyl nitrite [‘poppers’]) during their lifetime (ever havingused ATS, alcohol or other drugs) and in the last threemonths (recently use). Men were also asked about theirrecent use of any ATS substance or alcohol before or dur-ing sex in the last three months (recently used ATS oralcohol before or during sex). Only measures of lifetime(ever) use were included in this analysis.

Sexual behaviors. Participants were asked about theirage at first sex with a man or a woman, ever havingengaged in sex work, having engaged in sex work in thelast 3 months, and the use of condoms during sexual inter-course with regular or casual male partners in the lastthree months.

Sexual sensation-seeking. We adapted the sexualsensation-seeking scale (Kalichman & Rompa, 1995)for our study population. The scale was reviewed andadapted for language appropriateness during our consul-tation meetings with MSM informants, and tested andrevised before interviews. One item from the originalscale was dropped and ten items assessing the propensityto seek exciting, novel and stimulating sexual expe-riences, for instance “I like wild, uninhibited sexualencounters”, were retained. The adapted scale can befound in the online supplemental material. Participantsprovided their answers on 4-point Likert-type scalesranging from 1 (not at all like me) to 4 (very much likeme). The items had good internal consistency in thisstudy (Cronbach’s ɑ = 0.72) and item scores were aver-aged; a higher score indicating a higher level of sexualsensation-seeking.

Stigma and discrimination related to homosexuality.We adapted an existing scale previously validated inan MSM population in Vietnam, to measure perceived(anticipated) homosexual stigma, enacted (experienced)homosexuality-related stigma and self-stigma (internal-ized homophobia) (Ha, Ross, Risser, & Nguyen, 2013).

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The scale was reviewed and adapted for language appro-priateness during our consultation meetings with infor-mant MSM. After consultation, one item from theenacted stigma subscale and one item from the perceivedstigma subscale were dropped. The adapted scale encom-passed ten items measuring perceived homosexuality-related stigma, for instance “Many people are unwilling toaccept homosexual individuals” (1 = completely disagree,4 = completely agree); eight items pertaining to enactedhomosexuality-related stigma, for example “How oftenhave you lost a job or career opportunity due to yourengaging in homosexual activities” (1 = never, 4 =often); and eight items measuring internalized homo-phobia, for example “Sometimes you wish you were notgay/bisexual” (1 = totally disagree, 4 = totally agree).Responses were given on 4-point scales, with anchorsdepending on the questions. The full scale had goodoverall internal consistency in this study (Cronbach’sɑ = 0.74) and internal consistency for the subscales was0.66 (enacted sigma), 0.74 (perceived stigma) and 0.74(internal homophobia). Mean scores were calculated foreach sub-scale and higher scores indicated higher levelsof stigma.

Data analysis

To minimize data entry errors, questionnaire data wasdouble entered using EPIDATA 3.1. The two versionsof the dataset were compared to detect inconsistencies,which were checked and corrected. Descriptive and ana-lytical statistics were calculated using STATA version 13.0(Stata Corp, College Station, TX, USA). We report fre-quencies and percentages for categorical variables andmeans and standard deviations (SD), or medians andinterquartile ranges (IQR), for continuous variables. Wetested potential correlates of depression using logisticregression modeling, including demographic character-istics (age, education, income and occupation), life-timeuse of any ATS substances, life-time alcohol consump-tion and other drug use, recent HIV-related risky sex-ual behaviors, homosexuality-related stigma and discrim-ination and sexual sensation-seeking. Factors associatedwith depression (p < .10) were entered into a multi-variable logistic regression model. A final model includ-ing only covariates significantly associated with depres-sion (p < .05) was built using the strategy suggested byHosmer (2013). First, a base model containing all signifi-cant covariates identified in bivariable analyses was devel-oped. The least significant variable was eliminated fromthe base model and the nested model was compared withthe base model with a likelihood ratio test as suggestedby Vittinghoff and colleagues (Vittinghoff, Glidden, &Shiboski, 2012). If the test was nonsignificant (i.e. the

eliminated variable did not significantly contribute to thebase model) the nested model was retained. This elimi-nation process was continued until the final model wasreached, including only significant (p < .05) covariates.

Results

The final sample of participants included 622 men, amongwhom 303 men were recruited in Hanoi and the rest fromHo Chi Minh City; 30 men were referred to the studyteam but did not meet inclusion criteria, and two othermen were eligible and consented to participate but didnot complete their interviews. The demographic char-acteristics of the study participants have been describedelsewhere (Vu et al., 2016). This was a sample of youngMSM with a median age of 24 years (interquartile range[IQR]: 18.1–49.7; 77.5% were younger than 30 years old).Men had relatively high education levels (82.6% hadcompleted high school or higher education). The major-ity of sampled MSM were students or office-based staff(48.6%), and 54.8% had an average monthly income ofover five million Vietnam Dong or higher (approximatelyUS$ 250 or more). The majority of men (74.0%) self-identified as gay/homosexual, 18.7% identified as bisexualand the remainder reported being heterosexual or hav-ing another (unspecified) sexual orientation. The medianage of men at sexual debut with another man or womanwas 19.0 years. In the last 12 months, 54.5% had at leastone HIV test; nearly two-fifths of men did not know theirHIV status, with the majority (59.0%) self-reporting thatthey were HIV-negative. Men had a median score of per-ceived homosexuality-related stigma of 3.6 (IQR: 1.5–5),of enacted homosexuality-related stigma of 1.1 (IQR: 1–3), and of internalized homosexuality-related stigma of3.1 (SD: 0.8) (see Table 1). Men had an average sexualsensation-seeking score of 2.5 (SD: 0.4). Over one in tenmen (11.3%) were classified as having major depression atthe time of the survey (PHQ-9 score � 10).

Sexual and drug use behaviors of the sample are pre-sented in Table 2. Of the 622 men, 30.4% had ever usedany ATS use, 88.8% had ever drunk alcohol, and 21.5%had ever used any other drugs (ketamine, cannabis, hero-ine or poppers). In the last three months, 20.3% of par-ticipants had used any ATS, 77.0% had drunk alcoholand 15.8% had used any other drugs. In relation to self-reported engagement in sex work, 29.1% of men had everengaged in sex work (i.e. selling sex), and 23.2% hadengaged in sex work in the last three months. In the lastthree months, men had a median of 1 casual male sexualpartner (IQR: 1–90), and a median of 3 regular male part-ners (IQR: 1–25). The majority of participants (75.7%)self-reported any CAI in the past three months (68.3%had CAI with regular male sexual partners and 38.7% had

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Table . Characteristics of MSM recruited in Hanoi and Ho Chi MinhCity, Vietnam, .

n Percent % CI

Depression in the last weeks . [.–.]Suicidal ideation in the last

weeks . [.–.]

Location of recruitmentHanoi . [.–.]Ho Chi Minh City . [.–.]

Age (Median, IQR) .(.–.)< years . [.–.]– years . [.–.]– years . [.–.]� years . [.–.]

EducationUp to secondary school . [.–.]High school and some

vocational training . [.–.]

University undergraduatedegree or higher

. [.–.]

OccupationStudent . [.–.]Office-based job . [.–.]Service job . [.–.]Self-employed/Casual

employment . [.–.]

Unemployed . [.–.]Monthly income

< million VND . [.–.]– million VND . [.–.]> million VND . [.–.]

Sexual orientationGay/homosexual . [.–.]Bisexual . [.–.]Heterosexual/other . [.–.]

Recent HIV testingYes . [.–.]No . [.–.]

Self-reported HIV statusHIV-positive . [.–.]HIV-negative . [.–.]Don’t know . [.–.]

Age at first sex (Median, IQR)With men (–)With women# (–)

Perceivedhomosexuality-relatedstigma (Median, IQR)

. (.–.)

Enacted homosexuality-relatedstigma (Median, IQR)

. (.–.)

Internalizedhomosexuality-relatedstigma (Mean, SD)

. (.)

Sexual sensation seeking score(Mean, SD)

. (.)

CI: Confidence Interval; VND: Vietnam Dong; IQR: Interquartile Range;#: among men who reported having sex with women.

CAI with casual male partners); 21.1% had engaged in anygroup sex in the past 3 months.

In bivariable logistic regression analyses, depressionwas significantly associated with age at sexual debut withanother man, involvement in life-time and recent sexwork, recent CAI with casual sexual male partners, higherenacted homosexuality-related stigma, and higher sexualsensation-seeking. Depression was also significantly asso-ciated with ever using ATS and ever using other recre-ational drugs. In multivariable analysis, depression was

Table . Sexual and drug use behaviors of MSM recruited in Hanoiand Ho Chi Minh City, Vietnam, .

n Percent % CI

Substance use behaviorsEver used ATS . [.–.]Ever alcohol use . [.–.]Ever used other drugs . [.–.]Recent ATS use . [.–.]Recent alcohol use . [.–.]Recent ATS use before or

during sex . [.–.]

Recent alcohol use before orduring sex

. [.–.]

Sexual behaviorsEver sold sex . [.–.]Sold sex in the last months . [.–.]No. of casual male partners in

the last months (IQR) (–.)

No. of regular male partnersin the last months (IQR)

(–)

Any recent CAI (last months) . [.–.]Recent CAI with regular male

sexual partners . [.–.]

Recent CAI with casual malesexual partners

. [.–.]

Any recent group sex . [.–.]

CI: Confidence Interval; IQR: Interquartile Range.

independently associated with ever having used any ATS(AOR: 2.20; 95% CI: 1.32–3.67, p < .01), younger ageat sexual debut with another man (AOR: 0.09; 95% CI:0.02–0.50; p < .01) and a greater experience of enactedhomosexuality-related stigma (AOR: 2.08; 95% CI: 1.28–3.36; p < .01) (see Table 3).

Discussion

To the best of our knowledge, this is the first reportedanalysis of major depression and its associations with ATSuse and homosexuality-related stigma and discriminationamong MSM in Vietnam. We found a moderate preva-lence of major depression among MSM from Hanoi andHo Chi Minh City, similar to that found in a recent studyof MSM in India (Tomori et al., 2016), but much lowerthan the prevalence found in recent studies of MSM inChina (41.1%) and Vietnam (67.6%) (Goldsamt et al.,2015; Yan et al., 2014). The primary difference betweenthese studies appears to be the use of different measuresof depression. While the study in India used the PHQ-9scale to measure depression (Tomori et al., 2016), as wedid in this study, the studies among MSM in China and theearlier study among MSM in Vietnam used the Center forEpidemiological Studies Depression Scale (Ha et al., 2015;Yan et al., 2014). Also, while most of participants in the Haet al. (2015) study were less than 22 years of age (87.0%),only 31.8% of our sample were younger than 22. Previousstudies have found that younger MSM are more likely toexperience depression than older MSM (Salomon et al.,2009).

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Table . Bivariable and multivariable analysis of correlates of depression among MSM recruited in Hanoi and Ho Chi Minh City, Vietnam,.

Bivariable analysis Multivariable analysis

COR % CI p AOR % CI p

City .Hanoi Ho Chi Minh City . [.–.]

Age . [.–.] .< years . . [.–.] .– years . [.–.] .– years . [.–.] .� years . [.–.] .

Education .Up to secondary school High school and some vocational training . [.–.] .University undergraduate degree or higher . [.–.] .

Occupation .Student Office-based jobs . [.–.] .Service jobs . [.–.] .Self-employed/Casual employment . [.–.] .Unemployed . [.–.] .

Monthly income .< million VND – million VND . [.–.] .> million VND . [.–.] .

Sexual orientation .Gay/homosexual Bisexual . [.–.] .Heterosexual/other . [.–.] .Recent HIV testing . [.–.] .

Substance use behaviorsEver used ATS . [.–.] <. . [.–.] <.Ever drank alcohol . [.–.] . . [.–.] .Ever used other drugs . [.–.] <. . [.–.] .Age at first sex with another man . [.–.] <. . [.–.] <.

Sexual behaviorsEver engaged in sex work, i.e. selling sex . [.–.] <. . [.–.] .Engaged in sex work, i.e. selling sex in the last months . [.–.] <. . [.–.] .No. of casual male partners in the last months . [.–.] .No. of regular male partners in the last months . [.–.] .Any recent CAI (last months) . [.–.] .Recent CAI with regular partners . [.–.] . . [.–.] .Recent CAI with casual partners . [.–.] <. . [.–.] .Any recent group sex . [.–.] . . [.–.] .Enacted homosexuality-related stigma . [.–.] <. . [.–.] <.Perceived homosexuality-related stigma . [.–.] .Internalized homosexuality-related stigma . [.–.] . . [.–.] .Sexual sensation seeking score . [.–.] <. . [.–.] .

COD: Crude Odds Ratio; AOD: Adjusted Odds Ratio; CI: Confidence Interval; VND: Vietnamese Dongs.

We found that men who had experienced higher levelsof homosexuality-related stigma were more likely toreport depression than other men. This is similar to thefindings of recent studies undertaken in other settings(Choi et al., 2016; Gibbs & Rice, 2016; Secor et al., 2015;Stahlman et al., 2015), and is in line with Minority StressTheory (Meyer, 2003), according to which MSM expe-rience excess stressors related to their sexual orientationthat may adversely affect their mental health outcomes.We also found that men who reported ever having usedATS were more likely to report depression compared tomen who had never used ATS. Previous research suggeststhat ATS use may be a problem-solving, coping or escapestrategy for people with depression (Carrico et al., 2012;

Folkman & Lazarus, 1988; Stall et al., 2001), but ATSuse can also increase the likelihood of depression amongMSM (World Health Organization, 2004). Because of thecross-sectional nature of our study we cannot determinethe causal direction of the association between ATS useand depression in this sample of MSM from Vietnam,which may well be bidirectional. Of importance, wedid not find independent associations between depres-sion and risky sexual behaviors, such as CAI with malepartners, number of male partners or having group sex,nor did we find associations with alcohol consumptionor other recreational drug use, as opposed to severalprevious studies (Chakrapani et al., 2017; Goldsamtet al., 2015; Wim et al., 2014). We also did not find any

143


association between depression and men’s age or demo-graphic characteristics, including education, income andoccupation. It is possible that depression is distributedsimilarly across different demographic strata of MSM inVietnam and that differences in antecedents and con-sequences reflect the specific social contexts of variousstudies. Future research may provide additional evi-dence and contribute to understanding these differencesfindings.

Several limitations should be born in mind when inter-preting our findings. Since we recruited a conveniencesample of participants, the sample may not be representa-tive of the broader communities of MSM in Hanoi or HoChi Minh City. Also, because of the cross-sectional natureof our study, no conclusions can be drawn regarding thetemporal or causal relationship between depression, ATSuse or and other correlates. As data were self-reported, thestudy could also be subject to reporting bias.

Our findings nevertheless have several implicationsfor HIV prevention research and interventions target-ing MSM in Vietnam. To better understand the tem-poral and causal relationship between ATS use, depres-sion and other correlates among MSM in Vietnam, futureresearch could make use of longitudinal or case-controldesigns. Previous analyses of the same dataset show thatmethamphetamine use before or during sex was associ-ated with CAI among MSM in Vietnam (Vu et al., 2017),and a sizeable subgroup of MSM in Vietnam are still con-fronted with homosexuality-related stigma and discrim-ination (Ha et al., 2015). Together these findings sug-gest that a comprehensive, gay-friendly, culturally adaptedHIV prevention package for MSM in Vietnam may beindicated. This could include psychological counselingand treatment for depression, interventions for metham-phetamine use, interventions addressing homosexuality-related stigma and discrimination, and behavior changeapproaches to reduce risky sexual behaviors and promoteHIV testing, as previously suggested (Mayer et al., 2013;Safren et al., 2010).

Acknowledgments

We acknowledge great support and inputs from staff of the Insti-tute of Preventive Medicine and Public Health, Hanoi MedicalUniversity, Hanoi Centre of HIV/AIDS Prevention and Con-trol, Center for Community Health Promotion, Center for Pro-motion of Quality of Life and leaders and representatives ofcommunity-based organizations of MSM in Ho Chi Minh Cityduring data collection process in Hanoi and Ho Chi Minh City.Nga Thi Thu Vu contributed to the development of the researchprotocol, data collection, data analysis and the manuscript draft-ing and finalization. John de Wit and Martin Holt providedoversight supervision and valuable inputs for the whole pro-cess and the manuscript drafting and finalization. Huong ThiThu Phan, Lan Thi La, Gioi Minh Tran, Tung Thanh Doan, and

Trang Nguyen Nhu Nguyen provided input for the data collec-tion and manuscript drafting and finalization.

Declaration of interest

The authors report no conflict of interest.

Funding

Nga Thi Thu Vu received Australian Award Scholarship for herPhD study in UNSW Australia. The study received financialsupport from the Faculty of Arts and Social Sciences (FASS),UNSW Australia under its Postgraduate Essential Research Pro-gram Funding scheme and External Research Program Fundingschemes. The Centre for Social Research in Health is supportedby funding from the Australian Government Department ofHealth. Funding agencies were not involved in the developmentof the research protocol, data collection, data analysis, interpre-tation or the dissemination of research findings.

ORCID

John de Wit http://orcid.org/0000-0002-5895-7935

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http://dx.doi.org/10.1007/s10461-008-9439-4

http://dx.doi.org/10.1097/qad.0000000000000846

http://dx.doi.org/10.1111/jsm.12638

http://dx.doi.org/10.1007/s10461-015-1094-y

http://dx.doi.org/10.1080/09652140120080723

http://dx.doi.org/10.1016/j.annepidem.2009.03.004

http://dx.doi.org/10.7448/ias.18.1.19273

http://dx.doi.org/10.1007/s10461-015-1201

http://dx.doi.org/10.1080/09540121.2013.859652

http://unsw.eblib.com/patron/FullRecord.aspx?p=973179

http://dx.doi.org/10.1007/s10461-016-1467-x

http://dx.doi.org/10.1016/j.drugalcdep.2015.11.016

http://dx.doi.org/10.1007/s10461-013-0516-y

http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf

http://dx.doi.org/10.1071/sh14017

CHAPTER 8

DISCUSSION AND CONCLUSION

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During the past several decades, the use of ATS has become more common among

MSM in different parts of the world (1-3). In high-income countries, particularly in settings

where HIV disproportionately affects MSM, the use of ATS, particularly

methamphetamine, has been found to be associated with a higher probability of

engagement in risky sexual behaviours (4-9) and HIV infection (10-19). Additionally,

there is evidence that the use of ATS, particular methamphetamine, can contribute to

mental health problems, such as depression and anxiety (20-25). Nevertheless, most of

the research on ATS, HIV and MSM is from high-income countries, and there is a lack

of knowledge about ATS use and its associated harms from LMIC (26), particularly

Southeast Asian countries such as Vietnam.

This PhD thesis is the first in-depth investigation of the magnitude and patterns of ATS

use and associated harms in MSM in Vietnam. The foundation of this thesis is a series

of five published manuscripts in English language, peer-reviewed journals. A cross-

sectional, community-based survey was conducted in Hanoi and Ho Chi Minh City,

Vietnam from September 2014 to December 2014 to investigate ATS use by MSM and

related harms, and a systematic review and a meta-analysis of the available literature on

the relationship between ATS use and HIV infection among MSM was conducted.

This chapter summarises the main findings of the PhD study, the implications of these

results for drug use interventions and HIV prevention, and recommendations for further

research. The chapter also discusses limitations in the study design and data analysis.

KEY FINDINGS

Chapter 3 presented an analysis of the magnitude, patterns and correlates of ATS use

among MSM from two major cities in Vietnam, using an adapted socio-ecological

approach. It showed that ATS use was relatively common by Vietnamese MSM, and

methamphetamine was the most popular substance, followed by ecstasy and

amphetamine. ATS were generally used by smoking, snorting and inhaling. Men reported

starting ATS use during their early 20s and a notable proportion of men had recently

consumed methamphetamine or ecstasy before or during sex. The majority of men who

used methamphetamine or ecstasy were classified as moderate to high rate users on

the WHO ASSIST scale. The patterns of ATS use among Vietnamese MSM appeared

similar to patterns of ATS use by MSM in high-income countries (26, 27). However, the

prevalence of ATS use, including methamphetamine use, was higher than that found in

neighbouring countries such as China and Thailand (28-30) and higher than that found

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in earlier studies conducted in Vietnam (31). The high rate of ATS use, particularly

methamphetamine use, may reflect the actual level of ATS use among Vietnamese MSM

or it could relate to differences in reporting due to stigma, other reporting biases or

sampling methods. Nevertheless, these findings indicate that an intervention for ATS

use, particularly methamphetamine use, might be needed for MSM in Vietnam.

Moreover, the finding that the majority of methamphetamine use could be classified as

moderate or high-risk suggests that treatment for methamphetamine abuse or

dependence should be available and accessible to people who need it.

I found that recent methamphetamine use in the sample was associated with a range of

factors, including sexual sensation-seeking, involvement in sex work and perceiving that

methamphetamine use was common in MSM networks. The study was the first to find

that higher sexual sensation-seeking was associated with higher levels of

methamphetamine use. Previous studies have found that sexual sensation-seeking is

associated with a higher rate of practicing risky sexual behaviours (32) and may modify

the relationship between alcohol consumption, drug use and CAI (33, 34). Assessment

of sexual sensation-seeking, therefore, could help in identifying subgroups of men who

are involved in riskier drug use and sexual behaviours for specific HIV prevention

interventions, such as PrEP. I also found that methamphetamine use was more prevalent

among MSM who had engaged in sex work. Previous studies in Vietnam have found that

up to 44% of MSM have engaged in sex work (31, 35-37). In other studies in Vietnam,

ATS use and risky sexual behaviours have been found to be commonly reported by

Vietnamese male sex workers (31, 35, 36, 38).

The last correlation with methamphetamine use that I found was the perception that

methamphetamine use was popular in MSM networks. This finding is similar to findings

of previous research which shows that perceiving a high level of alcohol use among

peers is associated with higher alcohol consumption (39-41). Sociological studies of drug

use suggest that when drug use becomes normalised (perceived as common and

accepted by the community), then there is a greater chance of substance use (42). My

study did not assess whether ATS use is accepted by MSM in Vietnam. The level of

lifetime use of ATS in our sample (at 30%) was high but still lower than the level regarded

as a sign of normalisation (40%) (43), suggesting that ATS use may not yet be

normalised among MSM in Vietnam. However, from our findings it is not clear the extent

of ATS use normalisation and what the motivations are for ATS use by MSM in Vietnam.

Further research is needed to understand these factors.

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To my knowledge, this is the first ever socio-ecological analysis of the correlations of

ATS use that has been conducted in Vietnam. The findings indicate the correlates of

ATS at multiple levels related to individuals, community norms and the social

environments of MSM. As such, our results imply that interventions addressing ATS use,

particularly methamphetamine use, among MSM in Vietnam could be more successful if

they address factors at different levels, including personal, community and social levels.

Chapter 4 presented an analysis of HIV-related sexual behaviours by MSM and

correlations with CAI. The analysis found a very high level of recent CAI (78%) by MSM

in Hanoi and Ho Chi Minh City. This level of CAI is higher than that found in other studies

conducted in Vietnam (44-47), although different study designs, sampling methods and

recall periods were used. Although the results may not be directly comparable,

collectively the studies underline that there are low levels of consistent condom use by

MSM in Vietnam. In 2012, Vietnam's National Strategy for HIV/AIDS prevention and

control set a target that 50% of MSM should consistently practice safe sex (48). However,

a recent government report indicates that the allocation for HIV prevention targetting

MSM only accounts for a small proportion (1.4%) of total national HIV funding and

condom accessibility remains poor (49). It is unlikely that the above target could be

achieved unless greater resources are allocated for HIV prevention with MSM, including

a more intense focus on safe sex counselling and easy access to condoms.

In the analysis of correlations of CAI, I found that methamphetamine use before or during

sex was significantly associated with CAI. This relationship was modified by sexual

sensation-seeking in that men with lower sexual sensation-seeking scores who used

methamphetamine for sex were significantly more likely to practise CAI than men who

did not use methamphetamine. For men with higher sexual sensation seeking scores,

there was no difference in the likelihood of CAI between men who used

methamphetamine or not. Men who had higher sexual sensation seeking scores tended

to report both risky sexual and drug use behaviours. Previous studies have found a

modification effect of sexual sensation seeking on the relationship between alcohol

consumption and CAI (32-34). Our finding that men who used methamphetamine use

before or during sex were more likely to have CAI is similar to findings of previous studies

conducted in high-income settings (9, 50-55). I also found that sexual sensation-seeking

and belief in withdrawal as an effective HIV prevention strategy were significantly

associated with higher levels of CAI. These findings again imply that assessing sexual

sensation-seeking could identify men who are involved in risky sexual behaviours, and

may have a higher risk of acquiring or transmitting HIV infection. Additionally, because

methamphetamine use is associated with higher CAI, HIV prevention for MSM in

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Vietnam could achieve greater outcomes if interventions for methamphetamine use were

developed and integrated into existing HIV prevention services.

The findings also showed that many men had never been tested for HIV (approximately

30%), and only half of the sample had tested for HIV in the last 12 months, despite high

levels of CAI. Other studies in Vietnam have also found that a high proportion of MSM

have not been tested for HIV (ever or recently) (37, 56).

This analysis has several strengths. It was the first to analyse sex-related drug use by

MSM in Vietnam and its relationship with CAI. This type of measurement is not as strong

as event-level measurement (57, 58), but it provides contextual measures for drug use

and sexual behaviour. This research also represents the first interaction modification

analysis of sexual sensation-seeking and the relationship between methamphetamine

use and CAI, having been inspired by previous research on sexual sensation-seeking

and alcohol consumption (33, 34).

Chapter 5 presented the findings of a systematic review and meta-analysis of the

relationship between ATS use and HIV infection in MSM. The meta-analysis included 35

publications using different study designs with various types of drug use measurement

and sampling. The pooled estimates from random-effect models demonstrate that

collectively, ATS use was associated with higher levels of HIV infection. While

methamphetamine use was associated with HIV infection in all study designs, ecstasy

use was only associated with HIV infection among MSM in case-control and longitudinal

studies. The analysis demonstrated that the meta-analysis was reliable and valid and

there was no evidence of publication bias.

The systematic review and meta-analysis of the relationship between ATS use and HIV

infection is the first published report of its kind. It covered all accessible, published

studies from the beginning of the HIV epidemic to the time of analysis. It pooled estimates

for each ATS subgroup and study design, enabling an assessment of each ATS

substance as a risk factor for HIV seroconversion (from longitudinal and case-control

studies) and as a correlation with HIV infection (in cross-sectional studies). Additionally,

several efforts were made during data extraction to include not only the association

estimates of ATS use and HIV infection but also descriptive data for manual calculation

of these estimates. I also separately extracted the use of each ATS from studies which

measured more than one ATS to maximise the number of studies in the analysis.

The systematic review and meta-analysis highlighted several limitations of current

research on ATS use and HIV in MSM. Firstly, throughout the HIV epidemic, the study

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of ATS use and HIV has predominantly been conducted in high-income countries. The

systematic review only found five studies from LMIC. Others have called for research on

ATS use and HIV infection in these settings (26, 27). Secondly, the majority of studies

measured global drug use with different recall periods, from lifetime use to monthly use,

and sexual behaviour was measured separately. Thirdly, studies used cumulative

measures of drug use, making it difficult to identify the effects of individual drugs. Lastly,

many studies recruited MSM from clinics or HIV testing sites. These men may have been

at higher HIV infection risk compared with men from community-based samples. Indeed,

the meta-regression analysis found significantly higher pooled estimates of ATS use and

HIV infection in studies with clinic-based samples.

Chapter 6 presented an analysis of HIV prevalence (confirmed by biological testing)

among MSM in Hanoi and an analysis of the correlates of HIV infection. The participants

had a moderate HIV prevalence of 6.7% but a strikingly high proportion of HIV-positive

men (85.7%) were unaware of or did not disclose their HIV status. The HIV prevalence

of 6.7% is lower than that found in previous IBBS surveys in 2006 and 2011 (59, 60) but

higher than in the more recent 2013 IBBS (47). It is not clear if HIV prevalence in MSM

in Hanoi has decreased from 2006 to 2013; however, there are several possible

explanations for the discrepant findings. Firstly, my sample used a peer-referred,

convenience sample while IBBS recruited participants by respondent- driven sampling

(RDS). Secondly, there were no MSM who injected drugs in my sample, while the IBBS

included a sizeable proportion of MSM who injected (47, 59, 60). RDS samples can vary

dramatically depending on where initial seeds are recruited from, i.e. MSM who inject or

MSW. Nevertheless, to date, because MSM are a hidden, hard-to-reach population in

Vietnam, almost all published studies have used non-random sampling methods, such

as peer referral, time-location sampling, RDS or online recruitment (31, 36, 46, 61-63).

There was a strikingly high proportion of undiagnosed HIV among HIV-positive MSM in

my study. This may have occurred for several reasons. A recent qualitative study

reported high levels of HIV-related stigma and discrimination as barriers to testing,

treatment uptake and retention among MSM in Hanoi (64). Previously diagnosed men

may have not wanted to disclose their HIV status to the study team during interviews.

Other research indicates a lack of MSM-specific HIV testing and counselling services in

Vietnam remains a barrier to HIV testing uptake (65), and therefore many of the men in

the sample may have avoided testing. HIV-positive MSM who are unaware of their

infection can unknowingly transmit the virus to others (66-68). Evidence from overseas

has shown that undiagnosed MSM may report riskier sexual and drug use behaviours

compared to HIV-negative men (68-70). This finding has important implications for HIV

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prevention in Vietnam. Promoting greater HIV testing uptake by MSM and subsequent

referrals to treatment could prevent further transmission of the virus in this population.

The analysis of the correlates of HIV infection identified a range of social and behavioural

factors associated with HIV, which are similar to findings of previous research in other

settings, including the use of methamphetamines before or during sex (9, 50, 53, 55,

71-73), recent sex work (74-77) and perceiving a higher level of homosexuality-related

stigma (76, 78). A previous study in MSM in Ho Chi Minh City also reported a positive

relationship between involvement in sex work and HIV infection (31). Additionally, the

analysis showed that many MSM reported recent CAI (74%), particularly with regular

sexual partners (66%).

A recent qualitative study in HIV-positive MSM in Hanoi revealed that after diagnosis with

HIV, men often engaged in less sex and CAI (64). However, most of the HIV-positive

men in my analysis were undiagnosed (and therefore could not be expected to have

altered their behaviour as a result of knowing their HIV status). My analysis did not find

a significant association between CAI and HIV infection. This lack of variance between

HIV-positive men (whether diagnosed or not) and HIV-negative men may reflect a ceiling

effect of high levels of CAI in both groups. The analysis didn’t find any significant

associations between other individual, community, interpersonal or environmental

factors and HIV. The lack of other significant associations, including CAI, may have

resulted from the relatively small sample size (n=210) for this analysis.

Chapter 7 presented an analysis of the prevalence of depression and its correlations

among men recruited from both Hanoi and Ho Chi Minh City. The prevalence of

depression found in my study is lower than that found in a 2010 study conducted with

young MSM in Hanoi (68%) (63), and lower than the prevalence found among MSW in

Hanoi and Ho Chi Minh City (79-81). Previous evidence suggests that younger MSM are

more likely to report depression (82). While Ha’s study recruited mostly young MSM

(87% younger than 22 years old), only 32% in my sample were aged less than 22.

Alternatively, while my study used the classification of major depression versus not

having major depression (83), Ha's study reported men who had any form of depression

(including moderate depression). Additionally, while the study with young MSM in Hanoi

used the Centre for Epidemiologic Studies Depression Scale with 20 items, I used the

Patient Health Questionnaire with nine items to identify depression. Therefore,

differences in sampling and measurement may account for the differences in the

prevalence of depression in these studies. My finding that a sizable proportion of MSM

in Hanoi and Ho Chi Minh City had major depression and that depression was related to

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ATS use suggests that mental health assessment and treatment should be incorporated

into HIV care and treatment services.

The analysis of correlates of depression found two factors associated with a higher

likelihood of depression: any ATS use and enacted homosexuality-related stigma.

Meanwhile, we found that men who reported earlier sex with another man were less likely

to have depression compared to men who had sex with another man at a later age. ATS

can be used to cope with isolation and loneliness, and deal with boredom, unpleasant

feelings and conflict (1, 84, 85). At the same time, use of ATS can result in mental health

problems, including depression (21). However, because of the cross-sectional nature of

my study, the analysis could not identify if depression or ATS use occurred first (or

whether another cause influenced both drug use and mental health).

I found that enacted (experienced) homosexuality-related stigma was associated with a

higher likelihood of depression. This result is similar to previous studies in settings

outside Vietnam (86-89). It accords with the minority stress theory which outlines how

sexual minority groups may experience social pressure based on their sexual identity or

orientation, leading to adverse events, including mental health problems (90). Though

there has been intensive activism for lesbian, gay, bisexual and transgender rights in

recent years (91), homosexuality-related stigma and discrimination are still common in

many parts of Vietnam, including major urban areas (63, 92). Other analyses in this study

found perceived homosexuality-related stigma is associated with recent

methamphetamine use (Chapter 2) and HIV prevalence (Chapter 5). Therefore,

addressing homosexuality-related stigma and discrimination could not only be beneficial

in reducing harmful drug use but could also improve the mental health of MSM in Vietnam

and contribute to the prevention of HIV transmission in this population.

LESSONS LEARNED, LIMITATIONS AND FUTURE DIRECTIONS

Lessons learned

My study was one of the first studies in Vietnam where academic researchers

collaborated with governmental agencies, non-governmental organisations and

community-based organisations of MSM. This collaboration had several benefits. Firstly,

while MSM remains a hidden, hard-to-reach population in Vietnam, the collaboration with

NGOs and CBOs facilitated my access to networks of MSM in Hanoi and Ho Chi Minh

City. Additionally, the collaboration allowed the full participation of key informants who

were MSM during the study. Key informants provided important suggestions about how

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the study should be conducted, such as the screening/eligibility process and using

appropriate language to reflect sexual orientation, sexual behaviour and the street

names of drugs. Moreover, this collaboration assisted with reaching subgroups of MSM

who are usually difficult to reach, such as highly educated, professionally employed

MSM. The sample included many subgroups of MSM who may have never been included

in previous research in Vietnam. The collaboration with government agencies allowed

us to leverage resources beyond those available in a PhD project, such as accessing

offices for interviews and providing free HIV testing in Hanoi. The other lesson learned

from the study was the need for extended interview hours and flexible interview locations.

Working hours were extended to evenings and weekends to facilitate interviews with

MSM who could not participate during office hours or weekdays. Additionally, a range of

interview locations was offered to facilitate accessibility, while still ensuring the privacy

and confidentiality of participants.

Limitations

My study had several limitations that should be acknowledged. These range from study

design to data analysis.

Firstly, the sample was a convenience, peer-referred sample and therefore may not

represent the broader population of MSM in Hanoi and Ho Chi Minh City. Nevertheless,

no other studies in Vietnam have achieved random samples of MSM (31, 36, 37, 45-47,

59, 60, 62) . Secondly, the survey data relied upon self-reporting of past events. As such,

the data could have been affected by recall bias. Additionally, because drug use and

homosexuality are socially stigmatised in Vietnam (93), the data could have been

affected by information bias or social desirability bias. Participants could have under-

reported some behaviours, and therefore the study estimates could have underestimated

ATS use and CAI by MSM. The cross-sectional study design could identify correlations,

but not identify risk factors that led to ATS use, CAI, depression or HIV. Thirdly, although

sex-related measures of ATS use were employed, these measures could not identify the

temporal relationship between ATS and CAI.

My study analysed correlations with ATS use using an adapted socio-ecological

framework which involved several levels of factors from the individual to the societal level

(94). It has been suggested that interactions within and between levels of the socio-

ecological framework should be conducted (95). However, I could only perform within-

level interaction analysis in my study. In the study, environmental influences were

indirectly measured by participants reporting engagement with HIV testing, safe sex

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counselling and STD services. The study could have better assessed the environmental

availability of HIV prevention services by directly measuring the number of services

available within each study location, or participants’ awareness of these services.

Future research directions

In the context of the increasing use of ATS by MSM in Vietnam, periodic HIV surveillance

is encouraged to integrate assessment of the magnitude and patterns of ATS use,

particularly methamphetamine use, and its associated harms to monitor change over

time. Additionally, since quantitative designs can rarely provide deep insights into the

contexts and social networks in which ATS are used, or the meanings attached to ATS

use by MSM, I recommend further qualitative or ethnographic work to explore the social,

environmental, interpersonal and personal dynamics of ATS use. This may be

particularly useful for understanding the role of peer norms in supporting or discouraging

methamphetamine use. Lastly, because of the high level of undiagnosed HIV among

HIV-positive men in my study, I recommend further studies to measure the prevalence

of undiagnosed HIV and its correlates in different parts of Vietnam.

MSM remain a hidden, hard-to-reach population in Vietnam and therefore achieving a

random, representative sample is unlikely to be possible. Evidence from other settings

has demonstrated that convenience sampling methods, including peer outreach,

informal referral through social networks, online and venue-based sampling, can yield

samples which significantly differ in socio-demographic characteristics, sexual behaviour

and HIV/STD prevalence (96). Other probability-based sampling methods have their own

limitations: time-location sampling can consume a large amount of resources and time

(97), while RDS tends to recruit men from lower socio-demographic backgrounds and

under-recruits men from higher education and income levels (98, 99). My

recommendation is that studies with MSM in Vietnam should consider several concurrent

recruitment methods, including time-location sampling, peer-referral and online

sampling, to reach men from diverse backgrounds (96). With peer-referral or snowball

sampling, a diverse group of initial seeds is needed to reach men from a range of

subgroups (97).

Regarding the correlation between drug use and risky sexual behaviours, establishing a

causal relationship is rare, outside of prospective studies (57, 58). However, a temporal

relationship between drug use and risky sexual behaviours may be identified in

longitudinal studies with event-level measurement of drug use. Recording other

contextual factors via diaries and sexual behaviour logs might also reduce the recall bias

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for past events (57, 100). Measurement should be designed so events with drug use can

be compared to events without drug use to facilitate and obtain within-person analyses

(57). Additionally, the use of specific drugs should be measured to differentiate each

drug's relationship to sexual behaviours. Moreover, since multiple drug use is popular in

MSM (93, 101-103), polydrug use or concurrent drug use should be measured.

Alternatively, as previously suggested, studies could consider implementing an

intervention for drug use, to see if a reduction in drug use is paralleled with a reduction

in risky sexual behaviours, suggesting an association between the two sets of behaviours

(58).

Lastly, research on the correlates of HIV prevalence should not only focus on the

individual risks of HIV infection but should include the assessment of homosexuality-

related stigma and discrimination and access to HIV prevention services (104). From my

study experience, I recommend that future research on drug use and risky sexual

behaviours should take into account not only individual factors, including the underlying

causes of health behaviours such as personality traits, but also a broader range of

factors, including community, environmental, social and cultural influences. As

previously suggested, any study of people’s health behaviours conducted in separation

from the study of wider cultural, social and environmental contexts is incomplete and

insufficient to comprehend the complex causes of diseases and health behaviours (105).

A holistic understanding of the range of influences over health can assist in designing

effective interventions.

RECOMMENDATIONS FOR HIV INTERVENTIONS IN VIETNAM

In this section, I discuss the implications and recommendations from the study’s findings

as well as current international practice.

Interventions for ATS use

The finding that ATS use, particularly methamphetamine use is relatively widespread

(Chapter 3) and that sex-related methamphetamine use is related to a higher prevalence

of CAI (Chapter 4) and HIV infection (Chapter 6) suggests that interventions for ATS use,

particularly methamphetamine use, should be developed and integrated with existing

HIV prevention, care and treatment services for MSM in Vietnam. Firstly, I recommend

that health care workers who work in HIV prevention services are sensitized about ATS

use and its potential to drive HIV transmission in MSM in Vietnam. Secondly, ATS use,

particularly methamphetamine use, and its associated risky sexual behaviours should be

assessed in both HIV prevention outreach programs and counselling at HIV testing and

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or sexually transmitted infections (STI) services to identify men who use it who may be

involved in riskier HIV-related sexual behaviours. Thirdly, I recommend the

dissemination of accurate knowledge of ATS use, indications of harm and ways to reduce

harm to encourage harm reduction strategies among MSM networks in Vietnam. A

previous study overseas has shown that gay men can develop a so-called "folk

pharmacology" to provide information and knowledge to each other about how to reduce

the harms of drug use (106). I hope that with proper knowledge of ATS, its potential

harms and harm reduction strategies, MSM in Vietnam could minimise the adverse

impacts of ATS use, particularly methamphetamine use, and develop their own

strategies for safer use.

Additionally, my finding that the majority of methamphetamine use could be classified as

moderate or high-risk use by WHO’s ASSIST scale suggests that treatment for

methamphetamine abuse or dependence should be available and accessible to MSM

who need it. Currently, there are no available effective pharmacotherapies for

methamphetamine dependence treatment (107-109). Public health managers in Vietnam

could consider psychological therapies, such as cognitive behavioural therapy or

contingency management, which have proven to be effective in addressing

methamphetamine use and dependence (110). In my survey, I found that

methamphetamine use before or during sex was more prevalent among HIV-positive

men. A previous study in the US found most methamphetamine use occurred after an

HIV positive diagnosis, possibly to deal with the emotional consequences related to

diagnosis (111). Human and animal studies have demonstrated that methamphetamine

use may lower HIV treatment adherence and exacerbate HIV disease progression, thus

altering the effectiveness of ARV treatment (112-114). Altogether, I recommend that the

assessment of methamphetamine use and associated harms should not only be routinely

conducted at the community outreach and prevention programs but should also be

integrated into existing HIV clinics, and treatment for methamphetamine use should be

available through these services. The assessment of ATS use, particularly

methamphetamine use, at HIV clinics could contribute to the prevention of risky sexual

behaviours among HIV-positive men but may also improve mental health and prevent

problems in HIV treatment.

Greater promotion of condom use and safe sex

My survey in Vietnam found a high prevalence of CAI among MSM (Chapter 4) after

more than 10 years of HIV prevention efforts with this population. I recommend a greater

promotion of condom use and behavioural change communication in community

158

outreach programs. HIV prevention programming in Vietnam should consider applying

successful interventions from overseas which have been found to be effective in reducing

HIV-related risky sexual behaviours, including group-based interventions and

community-based interventions (115), although these would need to be adapted to the

local context to be effective. Additionally, behavioural change communication strategies

for MSM in Vietnam might gain better results by using evidence-based community

models such as the popular opinion leader model (116). In this model, popular, well-

respected MSM are recruited from the local community and trained in HIV prevention,

sexual health and harm reduction. These leaders then outreach to MSM in their social

networks, correcting misunderstandings about HIV prevention and drug use, and

describing strategies for effective HIV prevention and harm reduction. This intervention

is designed to influence the community’s norms in regard to drug use, safe sex and harm

reduction. (116). However, to have the best chance of success, these overseas models

would need to be adapted for local use in Vietnam, with training, support, community

ownership and oversight (117, 118) .

Integration of mental health (particularly depression) assessment and treatment

My finding that a sizable proportion of MSM in Hanoi and Ho Chi Minh City were classified

as having major depression and that depression was related to ATS use (chapter 7)

suggests that mental health assessment and accessible treatment are needed for

Vietnamese MSM. International research has found that MSM have a higher probability

of developing mental health problems, including depression (90, 119, 120). Given ATS

use, particularly methamphetamine use, is associated with CAI and HIV infection

(Chapter 3 and 5), I recommend that assessment and treatment for depression and other

mental health problems should be incorporated into HIV care and treatment services,

along with evaluation and treatment for methamphetamine use. Internationally

recommendations suggest that a successful response to HIV should not only provide

HIV prevention and treatment, STI diagnosis and treatment and support for mental health

problems, but also needs to address the root causes of these health disparities (120).

Vietnam's public health managers should consider developing and piloting clinics where

an integrated, holistic package of clinical care for HIV, STD, depression, and

methamphetamine use is delivered to MSM, as has already been suggested elsewhere

(120).

Targetting men who engage in sex work

Male sex work may be associated with financial hardship, and younger male sex workers

(MSW) may experience power imbalances with older, male clients and offer sex in

159

exchange for food, gifts, drugs, shelter or economic support (121, 122). Previous studies

in Vietnam have found that up to 44% of MSM have engaged in sex work (31, 35-37). In

other studies, ATS use and risky sexual behaviours have been found to be common

among Vietnamese MSW (31, 35, 36, 38). A qualitative study exploring the needs of

MSW in Ho Chi Minh City highlighted the need for alcohol and drug use interventions

and alternative income generation opportunities (35). Globally, male sex workers are

generally found to be at high risk of HIV (121). From my study’s finding that men who

engaged in sex work were more likely to use methamphetamine (Chapter 3) and test

positive for HIV (Chapter 6), I recommend that this subgroup of MSM should be a priority

group for ATS use interventions and HIV prevention in Vietnam. I recommend that drug

use and HIV prevention interventions should be delivered with other complementary

supports, such as income generation opportunities.

Assessing personality traits and referral to Pre-exposure prophylaxis (PrEP)

My finding that sexual sensation-seeking was positively related to methamphetamine

use (Chapter 3), CAI (Chapter 4) and modified the relationship between

methamphetamine use and CAI underlines the importance of assessing personal traits

that may affect behavioural change strategies for safer drug use and sexual behaviour.

As noted above, I recommend the assessment of sexual sensation-seeking in outreach

activities and during counselling at HIV testing services. Screening for sexual sensation-

seeking could be considered by services to identify men who may be at high risk of HIV

infection, and to identify candidates for harm reduction interventions. Further

assessment of risky sexual and drug use behaviors as recommended by WHO, CDC

and/or national guidelines should be strictly followed, including taking sexual histories

and drug use histories in a sensitive and supportive manner that protects clients’

confidentiality. However, caution should be exercised to ensure that screening tools are

not misused to label and stigmatise MSM because of their behaviour or personal traits.

This would create an unwelcome and additional barrier to health-seeking behaviour.

MSM attending services should be provided with sufficient counselling and information

about available and affordable HIV prevention services so that they can make well-

informed decisions about the most appropriate and effective HIV prevention method(s)

that would suit them, supported by their health care provider. Men identified with higher

levels of sexual sensation-seeking and who engage in risky drug use and sexual

behaviour might be considered a priority group for alternative, evidence-based

interventions, such as PrEP. A recent study in Vietnam reported that the majority of MSM

were interested in and willing to use PrEP (123). PrEP has been proven to be effective

in preventing the transmission and infection of HIV in MSM (124).WHO recommends

160

making PrEP available to people at substantial risk of infection, and this subset of men

in Vietnam may be appropriate candidates (125).

Expand HIV testing accessibility and uptake

I found that a sizable proportion of MSM had never accessed HIV testing (Chapter 4)

and a striking proportion of men were unaware of having undiagnosed HIV (Chapter 6),

suggesting that an expansion of HIV testing and counselling services is needed. I

recommend piloting peer-controlled HIV testing services at a community level, as

suggested by WHO (126). Additionally, to empower and promote HIV testing for high-

risk people and people with undiagnosed HIV in the context of high levels of stigma and

discrimination, Vietnam’s public health managers should also consider piloting HIV self-

testing in the country, also suggested by WHO (127). Recent research in Vietnam shows

MSM's explicit needs for MSM-friendly HIV testing and counselling services and their

fears of confidentiality being breached (65). As such, to encourage men to access and

use HIV testing, government-run HIV testing services should be strengthened to be

MSM-friendly and culturally appropriate. This could be done by organising homosexuality

sensitization workshops for health care providers who work in HIV facilities to raise their

awareness about homosexuality and the importance of issues like confidentiality for

MSM. As such, I hope that HIV prevention, care, and treatment services can become

friendlier to and more supportive of MSM, increasing uptake and retention in care.

Strengthened, diversified and expanded HIV testing services for MSM may encourage

more men to seek testing. Health care managers should consider expanding HIV testing

options not only for MSM but also for other key populations at high risk of HIV in Vietnam

(e.g. female sex workers, people who inject drugs). This may assist Vietnam in reaching

the UNAIDS 90-90-90 diagnosis, treatment and viral suppression targets by 2020, to

which the Vietnamese government has already committed.

Tackling homosexuality-related stigma and discrimination

Homosexuality-related stigma and discrimination were associated with both depression

and HIV infection in the study (Chapter 5 and 6). Because of social stigma, MSM have a

higher probability of developing mental health problems, including depression (90, 119,

120). As such, it is suggested that a successful response to HIV should not only provide

HIV prevention and treatment, STI diagnosis and treatment and support for mental health

problems, but also needs to address the root causes of these health disparities, i.e.

homosexuality-related stigma and discrimination (120). As such, I want to recommend

NGOs and CBOs for MSM and other sexual minority groups continue their efforts to

protect and promote the rights of LGBT communities in Vietnamese society, as they have

161

been doing in recent years (91). Moreover, homosexuality sensitization workshops as

mentioned above should be organised for health care providers, particularly those who

work in HIV prevention, care and treatment facilities. Reports from different settings in

the world have shown that to be successful in engaging and retaining MSM in HIV

prevention, care and treatment, health care providers should be trained to provide

culturally appropriate counselling and care (120). Lastly, I believe that tackling

homosexuality-related stigma and discrimination will not only improve the overall health

and well-being of MSM but also contribute to the prevention of HIV transmission in

Vietnam.

Inclusion of MSM in HIV prevention, care and treatment interventions

HIV prevention practice in different settings demonstrates the benefits of the active

involvement of gay, bisexual and other MSM in the design and delivery of HIV prevention,

treatment and care programs (104). I recommend CBOs of MSM actively participate in

a number of different HIV prevention activities.

First of all, I recommend MSM’s active delivery of HIV prevention outreach programs to

promote condom use, encourage the accessibility and uptake of HIV testing and other

HIV prevention services (i.e. STI diagnosis and treatment). As there is a high prevalence

of ATS use, particularly methamphetamine use, in MSM, I encourage CBOs for MSM to

disseminate proper knowledge of ATS and its associated harms and potential harm

reduction strategies. I believe that MSM in Vietnam might be able to develop a “folk

pharmacology” to minimise harms associated with ATS use. Additionally, routine

assessment of ATS use, particularly methamphetamine, together with associated risky

sexual behaviours is encouraged in community outreach work to monitor changes in

patterns of ATS use and associated harms. Further, peer educators could also do rapid

assessments of sexual sensation-seeking to identify men with a higher tendency to

engage in risky drug use and sexual behaviours for advanced HIV prevention

interventions such as PrEP.

Secondly, I recommend the inclusion of CBOs of MSM in delivering HIV testing services,

PrEP interventions and other HIV care and treatment services. Particularly, with political

support and proper training, I believe CBOs of MSM could deliver trusted, MSM-friendly

peer-based HIV testing and self-testing, as recommended by WHO (126, 127). This

diversification of HIV testing, prevention and care and treatment services, together with

strengthened government-based HIV prevention services, would create more MSM-

friendly service provision and encourage men to access and use HIV prevention, care

and treatment services.

162

International literature suggests comprehensive HIV prevention should include the

following services: condom promotion, risk reduction counselling, access to lubricant,

linkage to HIV care and treatment, expansion of HIV testing and counselling, STD

diagnosis and treatment and strategies to decrease stigma and promote the social

integration of MSM (119). Loxley et al’s research on evidence-based interventions

related to drug use, indicates that a mixture of harm reduction interventions (including

prevention education and information about safer drug use) and investment in drug

treatment are effective in reducing drug-related harms for people in all age groups(128).

From international experience, and from the recommendations already discussed, I

present below a schematic of a comprehensive intervention package for ATS use and

HIV prevention for MSM in Vietnam.

Figure 8.1. Recommendation for a comprehensive HIV prevention package for MSM in

Vietnam

Note: No suggestion for STI diagnosis and treatment is drawn from the findings of this

thesis but it is included as a component of a comprehensive HIV prevention package as

previously recommended.

163

CONCLUSION

This thesis has contributed a range of novel research findings and suggested a number

of recommendations that would improve HIV prevention, care and harm reduction

practice and research for MSM in Vietnam. The thesis demonstrates an interplay among

sex-related methamphetamine use, risky sexual behaviour, HIV infection and depression

among MSM which requires an integrated, multilevel response. I recommend addressing

drug use at individual and community levels, promoting condom use, diversifying HIV

testing options and developing mental health services for MSM, particularly subgroups

of men with riskier drug use and sexual behaviours. My thesis recommends the inclusion

of MSM in the provision of HIV prevention, care and treatment services, particularly HIV

testing. The thesis also highlights that tackling social stigma and discrimination toward

MSM could yield beneficial outcomes not only for HIV prevention but also improving the

mental health and wellbeing of MSM in Vietnam. Lastly, I believe my thesis provides

valuable recommendations to strengthen future research on drug use, sexual behaviour

and HIV infection in MSM who use ATS, and who remain at risk of HIV.

164

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APPENDIX 1

LETTERS OF SUPPORT

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177

Human Research Ethics CommitteeThe University of NSWHigh StreetKensington NSW 2052

TO WHOM IT MAY CONCERN

Hanoi HIV/AIDS Prevention CenterAdd: Khu hinh chlnh m0i eu0n Hd D6ngHa Dong, Hanoi, VietnamTel: +84.433.512.746

Fax: +84.433.512.741

E-mail: [email protected]

I write in reference to ethics application for the research project entifled ,sex, Drug and Health of Men who have sex withmen in Vietnam'.

Hanoi Hlv/AIDS Prevention. Center (PAC) is the authorized lo-cal agency responsible for all Hlv+elated programs In theHanoi region. Hanoi PAC,,is the.managbment body.of .ail HtV teiiing'sitei-titV ctinics, .in.i rrrr,Lity_based HtVprevention programs and other H|V*elated services in the locality,

By this letter, I would like to confirm that Hanoi PAC is willing to carry out blood sampling procedures and Hlv and hepatitisc testing for participants of this study, who are interested inletting tested. rne pnc routinely conducts HIV testing and wehave a mobile testing service which. we are willing to provideiree oi cnirje to ttre stuly, as we are supportive of the study,saims and the data it will provide- Having revieried ihe protocol, I undirstand that Hlv/hepatitis C testing is a votuntaryservice that will be offered by PAC staff to men who have'sex *yt|',. *91 9191inrv't rrr been intervieweo torine main study.PAc will undertake this testing. following the vietnam Mli:try of Heaitn irr,roij rirrrt.rting protocot, *1'i.t .*pnrrises thattesting should be informed, voluntary and anonymous, if the'subject *.h.* t,i remain so]Rttid;i.i;;; il;larticipate inthe collection of blood samples are well kained and have exiensive .rpuii*.r in pre and post-test counselling andvenepuncture technlques. T.h: trTpl3 collection process willshictty follow'standard infbction ili;i G;tions to avoidharm to participants and PAC staff. To allow the linkage of test re'sufts witn questionnaire data collected in the research

study, I understand that participants.will sign a consentiorm ano provioe pnC lturi *itn , ,n(r. riro,, io ,, tiirt their testresults can be matched later on. No research staff will be invoived in conouc'ting Htv tests or ,iiiii#gi;rt resutts toparticipantd'once blood is collected, participants will be given a letter indicater ir,i tiru and location wndre tney can gettheir test.results'when participants collect their results, thiy will be linked to care ano support r."iru., u, ,rquired, by thePAC staff.

As part of my representative role for Hanoi PAC, I am supportive of the proposed study. The option of providing free l-uVtesting and counselling for participants of the above mentioned stuoy nas ttrJ irrr rrpport of the Hanoi pAC, subject to theindividual consent of the potential participants in the study.

Hanoi HIV/AIDS Prevention Centre

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179

CENTER FOR COMMUNITY HEALTH PROMOTION

____________________________________________________________________

TO WHOM IT MAY CONCERN

I write in reference to ethics application for the research project entitled ‘Behaviors and Health of Men who have sex with men in Vietnam (BHMV)’.

Center for Community Health Promotion (CHP) is a Vietnamese non-governmental organization (NGO) established in 2006. Since the establishment, HIV/AIDS prevention and care and support services have been a key focus area for CHP. Via its community-based projects funded by different international donors such as PEPPAR, GLOBAL FUND, CHP’s goal is to improve the quality of life of individuals living with and affected by HIV/AIDS, to decrease HIV infection rate among most at risk population (MARP) groups and community, to improve the quality of life for people living with HIV/AIDS and orphan and vulnerable children and build capacity and promote for positive living for people living with HIV/AIDS and vulnerable populations.

By this letter, I would like to confirm that CHP commits to support BHMV study team to conduct their study in Vietnam. CHP will provide inputs and contributions to BHMV study in kinds of reviewing and commenting for the development of the research protocol and data collection tools and subsequently published manuscripts, piloting the quantitative questionnaire and coordinating the data collection in Vietnam by contributing human for interviews and recruitment of study participants.

As part of my representative role for CHP, I am charged with ensuring that the conduct of this study is acceptable to CHP supported community-based groups of MSM. This project has the full support of the CHP, subject to the individual consent of the potential participants in the study.

Yours sincerely, Tran Minh Gioi

Director Center for Community Health Promotion

180

APPENDIX 2

PARTICIPANTS INFORMATION STATEMENT AND CONSENT FORMS

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1

Study title: SEX, DRUGS AND HEALTH OF MEN WHO HAVE SEX WITH MEN IN VIETNAM STUDY FLYER

We are researchers from The Centre for Social Research in Health (CSRH), University of New South

Wales, Australia and The Institute of Preventive Medicine and Public Health, Hanoi Medical University.

We are conducting a study about the behaviours and health of men who have sex with men (MSM) in

Vietnam. In particular, we are interested in understanding more about the use of amphetamine

(stimulant)-type drugs and how this may affect sexual behaviours. Our findings will help to facilitating

the formulation of appropriate drug education and HIV prevention programs for MSM in Vietnam.

Taking part involves being interviewed (for up to 45 minutes) about your sex life, drug use,

relationships with other MSM and general health. All men who have had sex with another man in the

past year and who are aged 18 or older are eligible to take part.

If you are interested in participating:

▪ You should contact our research assistant to make an appointment. We are interviewing

people between 8am and 8pm every day.

▪ You will be screened to see if you are eligible to participate in our study

▪ If you are eligible, you will be interviewed by an experienced, friendly interviewer for

about 30 to 45 minutes.

If you participate in our study, you will receive:

▪ $5 to compensate you for your travel costs and your time

▪ HIV prevention materials, including free condoms

▪ Access to HIV, STI and support facilities if you want them, including HIV testing

Our contact details and locations of interviews

Research assistant name: Contact number:

Location of interviews:

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Study “Sex, Drugs and Health of Men who have sex with men in Vietnam”

1

THE UNIVERSITY OF NEW SOUTH WALES

PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM


FACE-TO-FACE INTERVIEW

QUANTITATIVE STUDY

About the Study

We are researchers from The Centre for Social Research in Health (CSRH), University of New South

Wales, Australia and The Institute of Preventive Medicine and Public Health, Hanoi Medical

University. We are conducting a study about the behaviours and health of men who have sex with men

(MSM) in Vietnam. This study aims to understand amphetamine type stimulant (ATS) use among men

who have sex with men (MSM) in Vietnam. In this part of the study, we are particularly interested in

behaviours that could facilitate the transmission of viruses such as HIV. We will ask you questions

about your demographic background, your drug use and sexual behaviours, your beliefs about ATS use,

your mental health, your experience of sexuality-related stigma and discrimination and your access to

HIV prevention services where you live.

Who is Being Asked to Respond?

You have been selected as a potential participant in this study because you are male, reside in Vietnam,

are gay, bisexual or other MSM and are aged 18 or older.

What Would We Like You To Do?

If you decide to participate, before you are interviewed, you will be screened for eligibility. If you

eligible and consent to take part, you will be interviewed for between thirty to forty five minutes. The

interview involves a structured questionnaire which is administered by a trained and experienced

interviewer. You can select an interviewer of your preference among the on-site interviewers.

You will receive $5 to compensate for your travelling costs and your time.

Anonymity and Consent

Participation in the study is entirely voluntary. You can withdraw from the project at any time without

giving a reason and without prejudice. If you decide not to participate in this project, there will be no

consequences of not participating in our study.

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2


A number of measures will be put in place to ensure that you remain anonymous and cannot be

identified. The questionnaire does not include questions which could reveal your personal identity. The

questionnaire with your answers will be stored in a secure database on a password protected computer

and only the investigators will have access to it.

We will only publish aggregated (combined) data from this part of the study. If you give us your

permission by signing this document, we plan to present the results at scientific meetings and

conferences and to publish the findings in academic books and journals. In any publication, information

will be provided in such a way that you cannot be identified.

Risks

The risks to participants in this study are considered minimal. All participants are offered HIV

prevention materials, including the list of all HIV service providers in the locality. Participants who

express concern or interest in accessing any HIV-related services will be referred to the relevant service

providers. If you experience distress or require support we can refer you to a local relevant support

organisation.

Feedback

Direct benefits. All participants who report or express psychological distress during an interview or

questionnaire will be referred to a relevant local support service that can offer free, confidential and

culturally appropriate support and treatment. Men who are interested in peer support can also be

referred to relevant local MSM groups. Participants who expressed concerns or difficulties in

accessing HIV-related services will be provided with list of all relevant service providers in the

locality and referral as needed.

Indirect benefits. The study findings may indirectly help participants by facilitating the formulation of

appropriate drug use and HIV prevention interventions that may improve the health and well-being of

MSM in Vietnam.

Inquiries

Complaints may be directed to the Ethics Secretariat, The University of New South Wales, SYDNEY

2052 AUSTRALIA . Any complaint you make will be investigated promptly and you will be

informed out the outcome.

If you decide to participate, you are free to withdraw your consent and to discontinue participation at

any time without prejudice.

If you have any questions, please feel free to ask the study team. If you have any additional questions

later, Dr. Vu Thi Thu Nga will be happy to answer them.

You will be given a copy of this form to keep.

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3

You are making a decision whether or not to participate. Your signature indicates that, having

read the information provided above, you have decided to participate in this study.

…………………………………………………… .……………………………………………..

Signature of Research Participant Signature of Witness

…………………………………………………… .…………………………………………….

(Please PRINT name) (Please PRINT name)

…………………………………………………… .…………………………………………….

Date Nature of Witness

185

1

REVOCATION OF CONSENT


I hereby wish to WITHDRAW my consent to participate in the research titled “Sex, Drugs and Health of Men who have sex with men in Vietnam” and understand that such withdrawal WILL NOT jeopardise any services I receive or my relationship with University of New South Wales and Hanoi Medical University.

By signing into this form, I understand that the research team will keep my interview information confidentially and securely in the research office at Hanoi Medical University and my information will not be included in any forms of disseminations of the research’s findings, including abstracts to scientific conferences or meetings or publications to scientific journals or textbooks.

…………………………………………………… .……………………………………………… Signature Date

…………………………………………………… Please PRINT Name

The section for Revocation of Consent should be forwarded to:

Dr.Nga Thi Thu Vu Centre for Social Research in Health, UNSW Australia Institute of Preventive Medicine and Public Health, Hanoi Medical University Mobile: Email:

Or

Dr.Huong Thi Le Institute of Preventive Medicine and Public Health, Hanoi Medical University Mobile: Email:

186




1


PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM


OPTIONAL, VOLUNTEERING HIV AND HCV TEST

AND ACCESS TO TEST RESULTS

About the complementary, voluntary HIV testing

This HIV testing is a voluntary, optional component to the study “Sex, Drugs and Health of men who

have sex with men in Vietnam” offered free of charge by Hanoi HIV/AIDS Prevention Center. You

should discuss with the PAC staff whether you want or need an HIV test. This testing is anonymous

and Hanoi PAC staffs do not require any personally identifying information from you. If you do not

want to get HIV test, you are not obliged to do so and your relationship with the study or the study

partners is not affected.

All the testing procedures follow Vietnam Ministry of Health (MOH) testing procedures. All

technicians who participate in the collection of blood samples are from HIV testing clinics in Hanoi,

are well trained and have extensive experience in pre and post-test counselling and venepuncture

techniques. The sample collection process will strictly follow infection control precautions to avoid

harm to you or PAC staff. If you agree to be tested, your blood sample will be tested for HIV.

You can choose to be tested for HIV and collect your results independently of the study. However, if

you agree, we can link your HIV test results with your questionnaire data. Linking your test results with

the information we gather from the questionnaire will help us to better understanding the association

between drug use, sexual behaviors and HIV infection among MSM. To link your test results and

questionnaire data, you do not need to provide personally identifying information; we will use your

anonymous study ID.

Who is Being Asked to Respond?

You are offered this testing because you have already participated in the above mentioned study.

However, this testing component is not compulsory. If you do not want to have your blood tested for

HIV, you are not required to do so, nor are you required to link your test results with your questionnaire.

Please decide on the best option for you.

What Would We Like You To Do?

If you decide to get your blood tested for HIV, an experienced, trained technician from will take a small

blood sample from you. If you agree for your sample to be linked to your questionnaire, your blood

sample will be labelled with your study ID. You will be given a letter indicating the time and location

187


2

where you can get your test results and post-test counselling. You will not receive any compensation

for this testing but you do not have to pay for this testing (it is free).

Anonymity and Consent

Participation in the testing is entirely voluntary and anonymous. You can withdraw from this testing

component at any time without giving a reason and without prejudice. There is a revocation form for

you to sign if you want to withdraw from the testing. If you decide not to participate in this testing,

there will be no consequences to your participation in the overall study. You can choose to be tested for

HIV but not provide your test results to the study. In this case, there will be no consequences to you and

your relationship to the study partners will not be affected.

If you agree to allow us to use your test result, you should provide us two signatures: one is for

agreement to get your blood tested for HIV and the other is for allowing us to use your test results. If

you just want to have your blood tested, you will provide one signature for the testing only.

If you give us your permission to use your test results, we will connect it with your questionnaire data.

We plan to present the results of our study at scientific meetings and conferences and to publish the

findings in academic books and journals. In any publication, information will be provided in such a way

that you cannot be identified.

Risks

Measures are taken to minimize the risk of this testing component. Standard infection control

procedures are used to minimize the risk for you and for Hanoi PAC staff. If your HIV test result is

positive, this is likely to be a stressful experience. If you are not ready to receive a test result, we advise

that you consider testing at another time. Staffs who deliver the results at the PAC will provide you

advice and support, and you can be referred to an HIV treatment service near to you. Participants who

experience distress or require further information or support can be referred to relevant local support,

counselling or treatment services and/or community-based groups of people living with HIV/AIDS

(PLHIV) or MSM.

Feedback

Direct benefits. All participants who report or express psychological distress during an interview or

questionnaire will be referred to a relevant local support service that can offer free, confidential and

culturally appropriate support and treatment. Men who are interested in peer support can also be

referred to relevant local MSM groups. Participants who expressed concerns or difficulties in

accessing HIV-related services will be provided with list of all relevant service providers in the

locality and referral as needed.

Indirect benefits. The study findings may indirectly help participants by facilitating the formulation of

appropriate drug use and HIV prevention interventions that may improve the health and well-being of

MSM in Vietnam.

Inquiries

Complaints may be directed to the Ethics Secretariat, The University of New South Wales, SYDNEY

2052 AUSTRALIA (phone 9385 4234, fax 9385 6648, email [email protected]). Any

complaint you make will be investigated promptly and you will be informed out the outcome.

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3


If you decide to participate, you are free to withdraw your consent and to discontinue participation at

any time without prejudice.

If you have any questions, please feel free to ask the study team. If you have any additional questions

later, Dr. Vu Thi Thu Nga will be happy to answer them.

You will be given a copy of this form to keep.

Your signature below indicates that, having read the information provided above, you have

decided to participate in this HIV and HCV testing component.

…………………………………………………… .……………………………………………..


…………………………………………………… .…………………………………………….


…………………………………………………… .…………………………………………….


Your signature below indicates that, having read the information provided above, you have

decided to allow the study team to use your HIV testing results for our study purpose.

…………………………………………………… .……………………………………………..


…………………………………………………… .…………………………………………….


…………………………………………………… .…………………………………………….


189

1

REVOCATION OF CONSENT

Study “Sex, Drugs and Health of Men who have sex with men in Vietnam” HIV and HCV testing component

I hereby wish to WITHDRAW my consent to participate in the complement, voluntary testing component of the research titled “Sex, Drugs and Health of Men who have sex with men in Vietnam” and understand that such withdrawal WILL NOT jeopardise any treatment or my relationship with University of New South Wales Australia and Hanoi Medical University.

By signing into this form, I understand that the research team will keep my interview information confidentially and securely in the research office at Hanoi Medical University and my information will not be included in any forms of disseminations of the research’s findings, including abstracts to scientific conferences or meetings or publications to scientific journals or textbooks.

…………………………………………………… .……………………………………………… Signature Date

…………………………………………………… Please PRINT Name

The section for Revocation of Consent should be forwarded to:

Dr.Nga Thi Thu Vu Centre for Social Research in Health, UNSW Australia Institute of Preventive Medicine and Public Health, Hanoi Medical University Mobile: Email:

Or

Dr.Huong Thi Le Institute of Preventive Medicine and Public Health, Hanoi Medical University Mobile: Email:

190



1


CONFIDENTIALITY STATEMENT FOR PERSONS

ACCESSING RECORDS CONTAINING SENSITIVE INFORMATION


By signing this letter, I commit to:

* Keep confidential any personal information I have access to in taking part in the research project “Sex,

Drugs and Health of Men who have sex with men in Vietnam”; confidential information includes

interview records and personal information divulged by participants to me while working as: i) a research

assistant; ii) interviewer; or iii) transcriber;

* Not discuss or divulge any of that information to anyone outside the research team;

* Not use the information for any other purpose other than accurately recording the data for the research

project;

* Not access any other information from the records other than that required for the research project and

approved by the Human Research Ethics Committee;

* Ensure that I keep secure the records and information extracted from those records whilst in my

possession;

* Ensure that any waste paper I generate whilst accessing the records and recording the information

required will be destroyed in a manner which is permanent and which ensures the participants’

confidentiality, e.g. by shredding.

Name:……………………………………......................Signature:…………………………………….

Date:…………………………………………………….

191

APPENDIX 3

ETHICAL APPROVALS

192

HREC Ref: # HC14130

Sex, Drugs, and Health of Men Who Have Sex With Men In Vietnam

The Human Research Ethics Committee considered the above protocol at its meeting held on 24-Jun-

2014 and is pleased to advise it is satisfied that this protocol meets the requirements as set out in the

National Statement on Ethical Conduct in Human Research*. Having taken into account the advice of

the Committee, the Deputy Vice-Chancellor (Research) has approved the project to proceed.

Would you please note:-

• approval is valid from 24-Jun-2014 to 24-Jun-2019;

• you will be required to provide annual reports on the studys progress to the HREC, as

recommended by the National Statement;

• you are required to immediately report to the Ethics Secretariat anything which might warrant

review of ethical approval of the protocol (National Statement 3.3.22, 5.5.7:

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e72.pdf) including:

▪ serious or unexpected outcomes experienced by research participants (using the Serious

Adverse Event proforma on the University website at

http://research.unsw.edu.au/human-ethics-forms-and-proformas ;

▪ proposed changes in the protocol; and

▪ unforeseen events or new information (eg. from other studies) that might affect

continued ethical acceptability of the project or may indicate the need for amendments

to the protocol;

• any modifications to the project must have prior written approval and be ratified by any other

relevant Human Research Ethics Committee, as appropriate;

• if there are implantable devices, the researcher must establish a system for tracking the

participants with implantable devices for the lifetime of the device (with consent) and report

any device incidents to the TGA;

• if the research project is discontinued before the expected date of completion, the researcher is

required to inform the HREC and other relevant institutions (and where possible, research

participants), giving reasons. For multi-site research, or where there has been multiple ethical

review, the researcher must advise how this will be communicated before the research begins

(National Statement 3.3.22, 5.5.7:

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e72.pdf);

• consent forms are to be retained within the archives of the HIVSRC - National Centre in HIV

Social Research and made available to the Committee upon request.

Sincerely,

Professor Heather Worth

Presiding Member

Human Research Ethics Committee

* http://www.nhmrc.gov.au

193

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e72.pdf

http://research.unsw.edu.au/human-ethics-forms-and-proformas

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e72.pdf

http://www.nhmrc.gov.au/

194

APPENDIX 4

THE COMMUNITY-BASED, CROSS-SECTIONAL SURVEY’S

QUESTIONNAIRE

195

1

QUESTIONNAIRE

SEX, DRUGS AND HEALTH OF MEN WHO HAVE SEX WITH MEN IN

VIETNAM 2014

001 QUESTIONNAIRE IDENTIFICATION NUMBER: |___|___|___|___|___|

002 CITY OF INTERVIEW: 1 HANOI 2 HOCHIMINH CITY

003 NAME OF INTERVIEWER:…………………………………………SIGNATURE

004 DATE OF INTERVIEW: __/ ____ / ____

005 SUPERVISOR CHECK:

Supervisor name:……………………………………………Signature

Date of checking: __/ ____ / ____

DATA MANAGEMENT

Check and Clean

by

1st Data entry by 2nd Data entry by Checked by

Name

Date

196

2

SESSION 1. DEMOGRAPHIC AND OTHER PERSONAL INFORMATION

A. DEMOGRAPHIC INFORMATION

Q101.IN WHAT MONTH AND YEAR WERE YOU BORN?

Month [__|__] Don’t remember 99

Year [__|__|__|__] Don’t remember 99

Q102. IN WHAT PROVINCE/CITY WERE YOU BORN?

Q103. HOW LONG HAVE YOU BEEN LIVING IN THIS CITY?

Month [__|__] Year [__|__] Less than 1 month □ 99. Don’t remember

Q104. WHAT IS YOUR ETHNICITY? (cirlce the only one appropriate option”)

1. Kinh 2. Tày 3. Thái 4. Mường 5. Kh-me

6. Hoa 7. Nùng 8. Mông 9. Dao 10. Other

Q105 WHAT IS YOUR HIGHEST EDUCATION LEVEL? (circle the only one appropriate option”)

1. No schooling 2. Primary 3. Secondary 4. High school

5. Vocational training 6. College 7. Undergrad 8. Postgrad

9. Other

Q106. HAVE YOU EVER MARRIED OR CO-LIVING WITH A WOMAN?? 1.Yes 0. No

Q107. CURRENTLY, WHO DO YOU LIVE WITH? (do not read out the options, circle the only one

appropriate option)

1. Alone 2. Male partner 3. Male friend(s) who

is(are) gay

4. Male friend(s) who is

(are) not gay

5. Wife/Girld friend 6. Family

(mum/dad/siblings)

7. Homeless 8. Other (specify)

Q108. WHAT IS YOUR MAIN OCCUPATION WHICH YOU SPEND MOST OF YOUR TIME FOR? (do not

read out the options, circle the only one appropriate option)

1. Student 2. Gov. employee 3. Private company

employee

4. Foreign-investment

company employee

5. Self-employ 6. Army officer 7. Fine Art-related

occupations

8. Entertainment

venues’ employee

9. Freelance 10. Farmer 11. Unemployment 12. Other (specify)

Q109. WHAT IS YOUR AVERAGE MONTHLY INCOME FROM ALL SOURCES? (including monthly

allowance from parent if you are a student)? VNĐ

B. HEALTH AND SEXUAL LIFE

Q110. DO YOU THINK IF YOU ARE A GAY/HOMOSEXUAL MAN, BISEXUAL MAN,

HETEROSEXUAL MAN OR TRANSGENDER? (read out all options, circle the only one appropriate option)

1. Gay 2. Bisexual 3. Heterosexual 4. Transgender 5. Other

(specify)

Q111.WHO HAVE YOU BEEN HAVING SEX WITH? (read out all options, circle the only one appropriate

option) 1. Only with men 2. With both men

and women

3. Only with

women

4. Other (specify)

If answer: 1- ask Q112 2-ask Q112 and Q113 3- ask Q113

Q112 AT WHAT AGE DID YOU HAVE 1ST SEX WITH A MAN?..................age 99. Don’t

remember

Q113. AT WHAT AGE DID YOU HAVE 1ST SEX WITH A WOMAN?................age 99. Don’t remember

197

3

Q114. HAVE YOU EVER HAD SEX FOR MONEY? 0. No, I haven’t 1. Yes, I have

(If answer NO, move to Q118)

Q115. HAVE YOU HAD SEX FOR MONEY IN THE LAST 3 MONTHS? 0. No, I haven’t 1. Yes, I have

Q116. FOR HOW LONG HAVE YOU BEEN INVOLVED IN HAVING SEX FOR MONEY

(CUMULATIVELY)?....................year

Q117. WHAT IS THE AVERAGE AMOUNT OF MONEY YOU RECEIVE FROM A TRANSEXUAL SEX?

.........................VNĐ

Q118. WHAT IS YOUR HIV STATUS? (If HIV negative or don’t know, move to Q122) (circle the only one

appropriate option) 1. HIV positive 2. HIV negative

3. Never had HIV test before 99. Don’t know/Don’t remember/Don’t answer

Q119. WHEN DO YOU KNOW YOU ARE HIV POSITIVE?

Q120. ARE YOU ON HIV TREATMENT? 0. No, I don’t 1. Yes, I do

Q121. WHAT IS YOUR RECENT CD4 TEST RESULT?.............. cell/mm 99. Don’t know/Don’t remember

Q122. HAVE YOU PARTICIPATED IN ANY STUDY RELATED TO DRUG USE, SEXUAL BEHAVIOURS

AND/OR HIV INFECTION DURING THE LAST TWO YEARS?

0. No, I haven’t 1. Yes, I do

SESSION 2. HOMOSEXUALITY-RELATED STIGMA AND DISCRIMINATION

2A. EXPERIENCED HOMOSEXUALITY-RELATED STIGMA (Use prompt card # 1)

Question

Nev

er

Occ

atio

nal

ly

Som

etim

e

Usu

ally

Q201. Have you ever lost your job or job opportunity because you are found to

be homosexual or being engaging in homosexual activities? 1 2 3 4

Q202. Have you ever been rejected/isolated/disregarded by your family because

of your homosexuality/engaging in homosexual activities 1 2 3 4

Q203. Have you ever lost your friend(s) because they know about your

homosexuality or your engaging in homosexual activities? 1 2 3 4

Q204. Have you ever been hit/beaten because you are a homosexual or your

engaging in homosexual activities? 1 2 3 4

Q205. Have you ever changed your school or being kicked out of your school

because you are homosexual or your engaging in homosexual activities? 1 2 3 4

Q206. Have you ever changed your accommodation because you are a

homosexual or your engaging in homosexual activities? 1 2 3 4

Q207. Have you ever been refused health care services because of your

homosexual or your engaging in homosexual activities? 1 2 3 4

Q208. Have you ever felt ambarrassed or afraid of seeking health care services

because of your homosexuality or your engaging in homosexual activities? 1 2 3 4

2B. PERCEIVED HOMOSEXUALITY-RELATED STIGMA (Use prompt card # 2)

198

4

Question

Sto

rng

ly

dis

agre

e

Dis

agre

e

Ag

ree

Str

ong

ly a

gre

e

Q209. Many people unwilling to accept homosexual men/men engage in

homosexual activities 1 2 3 4

Q210. Homosexual men would lose their heterosexual girlfriend/wife if they

knew their homosexual status/activities 1 2 3 4

Q211. Many employers would underestimate homosexual men due to his

homosexuality/homosexual activities regardless of his appropriate qualifications

for the job

1 2 3 4

Q212. Many people curse or tease homosexual men 1 2 3 4

Q213. Many people have negative attitude toward homosexual men/men with


Q214. Many people don’t see homosexual men/men with homosexual activities

as a normal man 1 2 3 4

Q215. Many families are disappointed having a homosexual son/ a son with


Q216. Many people believe homosexual men/men with homosexual activities

are not normal people 1 2 3 4

Q217. Nhiều cán bộ y tế thường tỏ thái độ không thoải mái hoặc không tích cực

với người MSM (nam QHTD đồng giới) Many health care providers show

unpleasant or negative attitude toward homosexual men/men with homosexual

activities

1 2 3 4

Q218. Many people believe that homosexual activities are transmitted 1 2 3 4

2C. INTERNALIZED HOMOPHOBIA (Use prompt card # 2)

Items

Str

ongly

dis

agre

e

Dis

agre

e

Agre

e

Dis

agre

e Q219. Sometimes you wish you are not gay/a man with homosexual activities 1 2 3 4

Q220. Sometimes you think you would be happier if you were not gay/a man

with homosexual activities 1 2 3 4

Q221. Sometime to hide your homosexuality/homosexual activities you have to

conceal your interest/being attracted to other men in pubic places 1 2 3 4

Q222. Sometimes you wish you could be sexually attracted to a woman 1 2 3 4

Q223. Sometimes you think your homosexual preference is your weakness 1 2 3 4

Q224. Sometimes you feel ashame of your homosexual orientation 1 2 3 4

Q225. You ar afraid that your family and/or friends know about your sexual

preference 1 2 3 4

Q226. You try to look masculine in order to avoid other stigma/rejection 1 2 3 4

199

5

SESSION 3. DRUG USE BEHAVIOURS

Q301. IN YOUR LIFE, WHICH OF THE FOLLOWING SUBSTANCES HAVE YOU EVER USED FOR

NON-MEDICAL (i.e. NOT FOR HEADACHE/INSOMNIA) REASONS? (read out each substance, circle the

only ONE appropriate option)

SUBTANCE No Yes Don’t answer

1. Alcohol/Beer 0 1 99

2. Opioids (morphine, heroine, codeine, ect) 0 1 99

3. Cannabis (marijuana, pot, grass, hash, ect) 0 1 99

4. Sleeping pills (e.g. seduxen) or other sedatives 0 1 99

5. Inhalants (nitrous, glue, petrol, ect.) 0 1 99

6. Hallucinogens (e.g. ketamine) 0 1 99

7. Erectile dysfunction medication (e.g. Viagra) 0 1 99

8.Cocaine or crack 0 1 99

9. Methamphetamine (Ice) 0 1 99

10. Amphetamine 0 1 99

11. Ecstasy 0 1 99

12. Poppers 0 1 99

13. Other sexual stimulants 0 1 99

(If answer is NO for all substances, move to SESSION 4)

Q302. AT WHAT AGE DID YOU FIRST USE THE DRUGS YOU MENTIONED?

SUBSTANCE Age Don’t

answer/remember

1. Alcohol/Beer 99

2. Opioids (morphine, heroine, codeine, ect) 99

3. Cannabis (marijuana, pot, grass, hash, ect) 99

7. Sleeping pills (e.g. seduxen) or other sedatives 99

8. Inhalants (nitrous, glue, petrol, ect.) 99

9. Hallucinogens (e.g. ketamine) 99

7. Erectile dysfunction medication (e.g. Viagra) 99

8.Cocaine or crack 99

11. Methamphetamine ( Ice) 99

12. Amphetamine 99

11. Ecstasy 99

12. Poppers 99

13. Other sexual stimulants 99

Q303. HOW HAVE YOU USED SUBSTANCES YOU MENTIONED? (circle all appropriate cell for each

substance)

SUBSTANCE

Sm

ok

e

Nh

ai/n

uốt/

uố

ng

Hít

th

ẳng

ch

ất

đó

vào

mũi

Hít

kh

ói

Inje

ct

Oth

er

Do

n’t

an

wer

1. Alcohol/Beer 1 2 3 4 5 6 99

2. Opioids (morphine, heroine, codeine, ect) 1 2 3 4 5 6 99

3. Cannabis (marijuana, pot, grass, hash, ect) 1 2 3 4 5 6 99

10. Sleeping pills (e.g. seduxen) or other sedatives 1 2 3 4 5 6 99

11. Inhalants (nitrous, glue, petrol, ect.) 1 2 3 4 5 6 99

12. Hallucinogens (e.g. ketamine) 1 2 3 4 5 6 99

200

6

7. Erectile dysfunction medication (e.g. Viagra) 1 2 3 4 5 6 99

8.Cocaine or crack 1 2 3 4 5 6 99

13. Methamphetamine ( Ice) 1 2 3 4 5 6 99

14. Amphetamine 1 2 3 4 5 6 99

11. Ecstasy 1 2 3 4 5 6 99

12. Poppers 1 2 3 4 5 6 99

13. Other sexual stimulants 1 2 3 4 5 6 99

Q304. (Ask if answered practicing injection) HAVE YOU BEEN INVOLVED IN SHARING NEEDLE AND

SYRINGE?

Behaviour Yes No

I have shared needle and syringe, I am always the first person 1 0

I have shared, I am alaways not the first person 1 0

I have shared needle and syringe, I am both the first and the subsequent person 1 0

Q305. WITH WHOM YOU HAVE USED THE MENTIONED SUBSTANCE(S)?(cirle all appropriate cell for

each substance)

SUBSTANCE

Use

by

my

self

Wit

h r

egu

lar

mal

e

sex

ual

par

tner

s

Wit

h c

asu

al m

ale

par

tner

s

Wit

h m

ale

sex

wo

rker

Wit

h m

ale

clie

nts

Wit

h r

egu

lar

fem

ale

par

tner

s

Wit

h c

asu

al f

emal

e

par

tner

s

Wit

h f

emal

e se

x

wo

rker

s

Wit

h f

emal

e cl

ien

ts

Wit

h M

SM

fri

end

s

Wit

h c

oll

eag

es

Wh

ile

invo

lvin

g i

n

gro

up

sex

Oth

er(s

pec

ify

)

Do

n’t

an

swer

1. Alcohol/Beer 1 2 3 4 5 6 7 8 9 10 11 12 13 99

2. Opioids (morphine, heroine, codeine,

ect)

1 2 3 4 5 6 7 8 9 10 11 12 13 99

3. Cannabis (marijuana, pot, grass, hash,

ect)

1 2 3 4 5 6 7 8 9 10 11 12 13 99

13. Sleeping pills (e.g. seduxen) or other

sedatives

1 2 3 4 5 6 7 8 9 10 11 12 13 99

14. Inhalants (nitrous, glue, petrol, ect.) 1 2 3 4 5 6 7 8 9 10 11 12 13 99

15. Hallucinogens (e.g. ketamine) 1 2 3 4 5 6 7 8 9 10 11 12 13 99

7. Erectile dysfunction medication (e.g.

Viagra)

1 2 3 4 5 6 7 8 9 10 11 12 13 99

8.Cocaine or crack 1 2 3 4 5 6 7 8 9 10 11 12 13 99

15. Methamphetamine ( Ice) 1 2 3 4 5 6 7 8 9 10 11 12 13 99

16. Amphetamine 1 2 3 4 5 6 7 8 9 10 11 12 13 99

11. Ecstasy 1 2 3 4 5 6 7 8 9 10 11 12 13 99

12. Poppers 1 2 3 4 5 6 7 8 9 10 11 12 13 99

13. Other sexual stimulants 1 2 3 4 5 6 7 8 9 10 11 12 13 99

Q306. HAVE YOU EVER USED THE MENTIONED SUBSTANCE(S) BEFORE FOR DURING SEX FOR

SEXUAL PLEASUREMENT INHANCE PURPOSE?

SUBSTANCE No Yes Don’t answer









201

7

17. Methamphetamine ( Ice) 0 1 99


11. Ecstasy 0 1 99

12. Poppers 0 1 99


Q307. WHICH OF THE FOLLOWING SUBSTANCES HAVE YOU EVER USED FOR NON-

MEDICAL (i.e. NOT FOR HEADACHE/INSOMNIA) REASONS IN THE LAST 3 MONTHS? (read out

lound each substance) (If answer NO for all substances, move to SESSION 4)



2.Methamphetamine 0 1 99

3.Amphetamine 0 1 99

4. Ecstasy 0 1 99

Q308. IN THE LAST 3 MONTHS, HOW OFTEN YOU DID YOU USE THE DRUGS YOU MENTIONED?

SUBSTANCE

Nev

er

1-2

tim

es /

3

month

s

Sev

eral

tim

es a

month

Sev

eral

tim

es a

wee

k

Dai

ly

Don’t

answ

er

1. Alcohol/Beer 0 2 3 4 6 99

2.Methamphetamine 0 2 3 4 6 99

3.Amphetamine 0 2 3 4 6 99

4. Ecstasy 0 2 3 4 6 99

Q309. DURING THE LAST 3 MONTHS, HOW OFTEN YOU DID YOU HAVE A STRONG DESIRE OR

URGE TO USE THE DRUGS YOU MENTIONED

SUBSTANCE

Nev

er

Sev

eral

tim

es i

n

3 m

onth

s

Sev

eral

tim

es a

month

Sev

eral

tim

es a

wee

k

Dai

ly

Don’t

answ

er

1. Alcohol/Beer 0 3 4 5 6 99



4. Ecstasy 0 3 4 5 6 99

Q310. DURING THE LAST 3 MONTHS, HOW OFTEN HAVE YOU HAD HEALTH, SOCIAL, LEGAL OR

FINANCIAL PROBLEMS AS A RESULT OF THE DRUGS YOU MENTIONED? (i.e. health problems that

required medical care, being short of money, having problems with your friends or colleagues or getting into

trouble with the police))?

SUBSTANCE

Nev

er

Sev

eral

tim

es i

n

3 m

onth

s

Sev

eral

tim

es a

month

Sev

eral

tim

es a

wee

k

Dai

ly

Don’t

answ

er

202

8

1. Alcohol/Beer 0 4 5 6 7 99



4. Ecstasy 0 4 5 6 7 99

Q311. DURING THE LAST 3 MONTHS, HOW OFTEN HAVE YOU FAILED TO DO WHAT WAS

NORMALLY EXPECTED OF YOU BECAUSE OF YOUR USE OF the AFORE MENTIONED DRUGS (e.g.

you can’t not go to work or go to work late because of your drug use)?

SUBSTANCE

Nev

er

Sev

eral

tim

es i

n

3 m

onth

s

Sev

eral

tim

es a

mom

th

Sev

eral

tim

es a

wee

k

Dai

ly

Do

n’t

an

swer

1. Alcohol/Beer 0 5 6 7 8 99



4. Ecstasy 0 5 6 7 8 99

Q312. HAS ANYONE EVER BEEN CONCERNED ABOUT YOUR USE OF THE MENTIONED DRUGS?

SUBSTANCE

No,

nev

er

Yes

, in

wit

hin

the

last

3

month

s

Yes

, bef

ore

the

last

3 m

onth

s

Don’t

answ

er

1. Alcohol/Beer 0 6 3 99

2.Methamphetamine 0 6 3 99

3.Amphetamine 0 6 3 99

4. Ecstasy 0 6 3 99

Q313. HAVE YOU EVER TRIED TO CUT DOWN USING OR QUIT THE DRUGS YOU MENTIONED

BUT FAILED?

SUBSTANCE

No,

nev

er

Yes

, in

wit

hin

the

last

3

month

s

Yes

, bef

ore

the

last

3 m

onth

s

Don’t

answ

er

1. Alcohol/Beer 0 6 3 99

2.Methamphetamine 0 6 3 99

3.Amphetamine 0 6 3 99

4. Ecstasy 0 6 3 99

Q314. BY WHICH ROUTE HAVE YOU USED THE ABOVE-MENTIONED DRUGS IN THE LAST 3

MONTHS? (circle all appropriate cell for each substance)

203

9

SUBSTANCE

Sm

ok

e

Ch

ew/S

wal

low

Sn

ort

Inh

ale

Inje

ct

Oth

er (

spec

ify)

Do

n’t

an

swer

1. Alcohol/Beer 1 2 3 4 5 6 99

2.Methamphetamine 1 2 3 4 5 6 99

3.Amphetamine 1 2 3 4 5 6 99

4. Ecstasy 1 2 3 4 5 6 99

Q315. HAVE YOU EVER USED THE MENTIONED SUBSTANCE(S) BEFORE FOR DURING SEX FOR

SEXUAL PLEASUREMENT INHANCE PURPOSE?










19. Methamphetamine (Ice) 0 1 99


11. Ecstasy 0 1 99

12. Poppers 0 1 99


SESSION 4. SEXUAL BEHAVIOURS

A. SEXUAL BEHAVIOURS WITH INTIMATE/REGULAR MALE PARTNERS

Explain to participants: regular/intimate male partners are those you have sex for more than 2 times and you

regard them as your long-term sexual partners whom you have an intimate relationship with or those you

want to maintain long-term sexual relationship with

Q401a. HAVE YOU EVER HAD REGULAR/INTIMATE MALE SEXUAL PARTNER?

1. Yes 0. No

(If answer is NO, move to subsession B)

Q407. HAVE YOU EVER HAD SEX WITHOUT CONDOM WITH YOUR REGULAR MALE SEXUAL

PARTNERS?

1. Yes 0. No 99. Don’t answer/remember

Q401. IN THE LAST 12 MONTHS, HOW MANY REGULAR MALE SEXUAL PARTNERS HAVE YOU

GOT ANAL SEX (BOTH RECEPTIVE OR INSERTIVE) WITH?................people 99. Don’t remember

(If answer is 0 person, move to SESSION B)

Q401b. IN THE LAST 12 MONTHS, HAVE YOU EVER HAD SEX WITHOUT CONDOM WITH YOUR

REGULAR MALE SEXUAL PARTNERS?


Q402. IN THE LAST 3 MONTHS, HOW MANY REGULAR MALE SEXUAL PARTNERS HAVE YOU

GOT ANAL SEX (BOTH RECEPTIVE OR INSERTIVE) WITH?.............person 99. Don’t remember

Q403. HOW MANY OF THEM ARE MALE SEX WORKERS?............people 99. Don’t answer

204

10

Q404. HOW MANY OF THEM ARE YOUR MALE SEXUAL CLIENTS?............person 99. Don’t answer

(only ask this question if answered YES to transactional sex in Q115)

Q405. HOW MANY OF THEM ARE HIV POSTIIVE?..............person 99. Don’t know

Q406a. WHERE DO YOU USUALLY FIND YOUR REGULAR MALE SEXUAL PARTNERS?

1. They are my MSM

friends

2. At MSM-specific

bars/cafes

3. At sauna/massage 4. At discoque

5. From MSM-specific

page

6. From mobile phone,

social applications

7. At park/roads 8. At swimming pool

/cinema

9. Other (specify)

Q406. WHERE HAVE YOU HAD SEX WITH YOUR REGULAR MALE SEXUAL PARTNERS? (Cirle all

appropriate options)

1. Private house 2. Hotel/hostel 3. Bar/Discoque/Karao

ke

4. Massage/Sauna

5. Swimming

pool/Public toilets

6. Park/Lake

side/Roadside

7. Other (specify) 99. Don’t

remember/answer

Q408. WHICH POSITION DO YOU USUALLY PRACTICE WHILE YOU HAVE ANAL SEX WITH YOUR

REGULAR MALE SEXUAL PARTNERS IN THE LAST 3 MONTHS? (Cirlce the only ONE appropriate

option)

1. Only bottom 2. Only top 3. Both bottom

and top

99. Don’t

answer

If answer: 1 - ask Q409 2-ask Q410 3- ask Q409 and Q410

Q409. IN THE LAST 3 MONTHS, WHILE YOU ARE IN BOTTOM POSITION DURING ANAL SEX

WITH YOUR REGULAR MALE SEXUAL PARTNERS, HOW YOUR PARTNERS USE CONDOM?

(See interviewer’s Guide for detail instruction of asking question)

Condom use Never Sometime Usually

Don’t use condom and ejaculate outside your anus 1 2 3

Don’t use condom and ejaculate inside your anus 4 5 6

Don’t use condom throughout the sexual course 7 8 9

Always use condom throughtout the course with you 10 11 12

Q410. IN THE LAST 3 MONTHS, WHILE YOU ARE IN TOP POSITION DURING ANAL SEX WITH

YOUR REGULAR MALE SEXUAL PARTNERS, HOW YOU USE CONDOM? (See interviewer’s Guide

for detail instruction of asking question)


Don’t use condom and ejaculate outside his anus 1 2 3

Don’t use condom and ejaculate inside his anus 4 5 6


Always use condom throughtout the course with him 10 11 12

B. SEXUAL BEHAVIOURS WITH CASUAL MALE SEXUAL PARTNERS

Explain to participants: Casual male sexual partners are those you have sex for only 1 time or having sex

with him unexpectedly

Q411a HAVE YOU EVER HAD CASUAL MALE SEXUAL PARTNER?

1. Yes 0. No

(If answer NO, move to subsession C)

Q417. HAVE YOU EVER HAD SEX WITHOUT CONDOM WITH YOUR CASUAL MALE SEXUAL

PARTNERS?

10. Yes 0. No 99. Don’t remember/answer

Q411. IN THE LAST 12 MONTHS, HOW MANY CASUAL MALE SEXUAL PARTNERS HAVE YOU GOT

ANAL SEX (BOTH RECEPTIVE OR INSERTIVE) WITH?................people 99. Don’t remember

(If answer NO, move to subsession C)


205

11

CASUAL MALE SEXUAL PARTNERS?

3. Yes 11. No 99. Don’t remember/answer

Q412. IN THE LAST 3 MONTHS, HOW MANY CASUAL MALE SEXUAL PARTNERS HAVE YOU GOT

ANAL SEX (BOTH RECEPTIVE OR INSERTIVE) WITH?.............person 99. Don’t remember

Q413. HOW MANY OF THEM ARE MALE SEX WORKERS?............people 99. Don’t answer

Q414. HOW MANY OF THEM ARE YOUR MALE SEXUAL CLIENTS?............person 99. Don’t answer

(only ask this question if answered YES to transactional sex in Q115)

Q415. HOW MANY OF THEM ARE HIV POSTIIVE?..............person 99. Don’t know

Q416a. WHERE DO YOU USUALLY FIND YOUR CASUAL MALE SEXUAL PARTNERS? (Cirle all


12. They are my MSM

friends

13. At MSM-specific

bars/cafes

14. At sauna/massage 15. At discoque

16. From MSM-specific

website

17. From mobilephone

social applications

18. At park/roadside 19. At swimming

pool/cinema

20. Other (specify)

Q416. WHERE HAVE YOU HAD SEX WITH YOUR REGULAR MALE SEXUAL PARTNERS? (Cirle all



ke

4. Massage/Sauna

5. Swimming

pool/Public toilets

6. Park/Lake

side/Roadside


remember/answer

Q418. WHICH POSITION DO YOU USUALLY PRACTICE WHILE YOU HAVE ANAL SEX WITH YOUR

REGULAR MALE SEXUAL PARTNERS IN THE LAST 3 MONTHS? (Cirlce the only ONE appropriate

option)

4. Only bottom 5. Only top 6. Both bottom

and top

100. Don’t

answer

If answer: 1 – ask Q419 2-ask Q420 3- ask both Q419 and Q420

Q419. IN THE LAST 3 MONTHS, WHILE YOU ARE IN BOTTOM POSITION DURING ANAL SEX

WITH YOUR CASUAL MALE SEXUAL PARTNERS, HOW YOUR PARTNERS USE CONDOM? (See

interviewer’s Guide for detail instruction of asking question)


Don’t use condom and ejaculate outside your anus 1 2 3

Don’t use condom and ejaculate inside your anus 4 5 6


Always use condom throughtout the course with you 10 11 12

Q420. IN THE LAST 3 MONTHS, WHILE YOU ARE IN TOP POSITION DURING ANAL SEX WITH

YOUR CASUAL MALE SEXUAL PARTNERS, HOW YOU USE CONDOM? (See interviewer’s Guide

for detail instruction of asking question)


Don’t use condom and ejaculate outside his anus 1 2 3

Don’t use condom and ejaculate inside his anus 4 5 6


Always use condom throughtout the course with him 10 11 12

C. SEXUAL BEHAIVIOURS WITH INTIMATE/REGULAR FEMALE PARTNERS

Explain to participants: regular/intimate female partners are those you have sex for more than 2 times and

you regard them as your long-term sexual partners whom you have an intimate relationship with or those you

want to maintain long-term sexual relationship with

206

12

Q421a. HAVE YOU EVER HAD REGULAR/INTIMATE FEMALE SEXUAL PARTNER?

1. Yes 0. No

(If answer is NO, move to subsession D)

Q427. HAVE YOU EVER HAD SEX WITHOUT CONDOM WITH YOUR REGULAR FEMALE SEXUAL

PARTNERS?


Q421. IN THE LAST 12 MONTHS, HOW MANY CASUAL FEMALE SEXUAL PARTNERS HAVE YOU

GOT INSERTIVE SEX WITH?................people 99. Don’t remember

(If answer is NO, move to subsession D)


CASUAL FEMALE SEXUAL PARTNERS?

4. Yes 21. No 99.


GOT INSERTIVE SEX WITH?.............person 99. Don’t remember

Q423. HOW MANY OF THEM ARE HIV POSITIVE?.........person 99. Don’t know

Q424. HOW MANY OF THEM ARE FEMALE SEX WORKERS? ................ person 99. Don’t know

Q425. HOW MANY OF THEM ARE YOUR FEMALE CLIENTS?............. person 99. Don’t know

(Only ask this question If answer YES for participating in transactional sex in Q115)

Q426. WHERE HAVE YOU HAD SEX WITH YOUR REGULAR FEMALE SEXUAL PARTNERS? (Cirle

all appropriate options)


ke

4. Massage/Sauna

5. Swimming

pool/Public toilets

6. Park/Lake

side/Roadside


remember/answer

Q428. IN THE LAST 3 MONTHS, HOW YOU USE CONDOM WHILE YOU HAVE INSERTIVE SEX

WITH YOUR REGULAR/INTIMATE FEMALE SEXUAL PARTNERS? (See interviewer’s Guide for

detail instruction of asking question)


Don’t use condom and ejaculate outside her vagina 1 2 3

Don’t use condom and ejaculate inside her vagina 4 5 6


Always use condom throughtout the course with her 10 11 12

D. SEXUAL BEHAIVIOURS WITH CASUAL FEMALE PARTNERS

Explain to participants: Casual female sexual partners are those you have sex for only 1 time or having sex

with him unexpectedly

Q429a. HAVE YOU EVER HAD CASUAL FEMALE SEXUAL PARTNER?

1. Yes 0. No

(Nếu trả lời Chưa, chuyển sang phần E)

Q435. HAVE YOU EVER HAD SEX WITHOUT CONDOM WITH YOUR CASUAL FEMALE SEXUAL

PARTNERS?



GOT INSERTIVE SEX WITH?................people 99. Don’t remember

(If the answer is 0 people, move to subsession E)


CASUAL FEMALE SEXUAL PARTNERS?



GOT INSERTIVE SEX WITH?.............person 99. Don’t remember

207

13

Q431. HOW MANY OF THEM ARE HIV POSITIVE?.........person 99. Don’t know

Q432. HOW MANY OF THEM ARE FEMALE SEX WORK? ................person 99. Don’t know

Q433. HOW MANY OF THEM ARE YOUR FEMALE SEXUAL CLIENTS?.............person 99. Don’t

know/answer

(only ask this question if answered YES to transactional sex in Q115Q115)

Q434. WHERE HAVE YOU HAD SEX WITH YOUR CASUAL FEMALE SEXUAL PARTNERS? (Cirle all



ke

4. Massage/Sauna

5. Swimming

pool/Public toilets

6. Park/Lake

side/Roadside


remember/answer

Q436. IN THE LAST 3 MONTHS, HOW YOU USE CONDOM WHILE YOU HAVE INSERTIVE SEX

WITH YOUR CASUAL FEMALE SEXUAL PARTNERS? (See interviewer’s Guide for detail instruction

of asking question)


Don’t use condom and ejaculate outside her vagina 1 2 3

Don’t use condom and ejaculate inside her vagina 4 5 6


Always use condom throughtout the course with her 10 11 12

E. GROUP SEX

Q437. HAVE YOU EVER PARTICIPATED IN GROUP SEX WITH FROM 3 PEOPLE AND ABOVE IN

THE LAST 12 MONTHS?

0. No 1. Yes

(If no group sex participation, move to subsession F)

Q438. ON EVERAGE, HOW MANY PEOPLE PARTICIPATE IN ONE OF YOUR GROUP SEX

EPISODES?..................................person 99. Don’t answer/remember

Q439. WHICH TYPE OF SEXUAL PARTNERS HAD PARTICIPATED IN YOUR GROUP SEX

EPISODES? (Circle all appropriate options)

1. Regular male sexual

partners

2. Casual male sexual

partners

3. Male sex workers 4. Male clients

5. Regular female

sexual partners

6. Casual female sexual

partners

7. Female sex workers 8. Female sexual clients

9. Other (specify)

Q440. WHERE HAVE SUCH GROUP SEX EPISODE OCCURED? (Cirle all appropriate options)

1. Private house 2. Hotel/hostel 3. Bar/Discoque/Karaoke 4. Massage/Sauna

5. Swimming

pool/Public toilets

6. Park/Lake

side/Roadside


remember/answer

Q441. HOW YOU AND YOUR SEXUAL PARNTERS USE CONDOM IN THOSE GROUP SEX

EPISODES?

Condom use Yes No

All people in the top position use condom throughout the course 0 1

Don’t know/remember 99

Q442. HAD YOUR GROUP SEX EPISODE EVER INVOLVED HIV POSITIVE PARTNERS?

0. No 1. Yes 3. Don’t know

208

14

Q443. IN YOUR GROUP SEX EPISODES WHEN THERE WAS HIV POSITIVE PARTNERS

INVOLVED, HOW DID YOU AND YOUR SEXUAL PARTNERS USE CONDOM? (ask when answer

YES to Q442)

Condom use Yes No



F. SEXUAL BEHAVIOURS IN THE MOST RECENT 3 ANAL/VAGINAL SEXUAL EPISODES

F1. SEXUAL BEHAVIOURS IN THE FIRST RECENT SEXUAL EPISODE

Q. 444. DO YOU REMEMBER THE MOST RECENT SEXUAL EPISODE?

0. Yes 1. No

If answer NO, move to the second most recent sexual episode

Q445. WHERE DID THAT SEXUAL EPISODE HAPPEN? (Cirle the only one appropriate option)


5. Swimming

pool/Public

toilets

6. Park/Lake

side/Roadside

7. Other (specify)

Q446. IF THAT SEXUAL EPISODE A GROUP SEX WITH AT LEAST 3 PEOPLE PARTICIPATION?

0. No 1. Yes 99. Don’t remember/answer

Q447. WHO WAS/WERE YOUR SEXUAL PARTNER(S) AT THAT SEXUAL EPISODE? (Cirle all



partner(s)


partner(s)

3. Male sex worker(s) 4. Male client(s)

5. Regular female sexual

partner(s)


partner(s)

7. Female sex worker(s) 8. Female client(s)

9. Other (specify)

Q448. IF YOUR SEXUAL PARTNER(S) OF THAT SEXUAL EPISODE HIV POSITIVE?

1. HIV positive 2. HIV negative 3. Don’t know

Q449. WHAT WAS YOUR POSITION IN THAT SEXUAL EPISODE? (cirle all appropriate options)

1. Top, anal/vaginal sex 2. Bottom, anal sex 3. Both top and bottom 99. Don’t

remember/answer

If answer: 1-ask Q450 2- ask Q451 3- ask both Q450 and Q451

Q450. HOW DID YOU USE CONDOM IN THAT SEXUAL EPISODE WHEN YOU WERE IN TOP

POSITION? (cirle to only one appropriate option)

1. Used condom

throughout the

course

2. Didn’t use condom

throughout the

course

3. Didn’t use condom,

ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


remember/answer

Q451. HOW DID YOUR SEXUAL PARTNER(S) USE CONDOM IN THAT SEXUAL EPISODE WHEN

YOU WERE IN BOTTOM POSITION? ((cirle to only one appropriate option) 1. Used condom

throughout the

course


throughout the

course


ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


remember/answer

Q452. IF IT WAS A GROUP SEX EPISODE, HOW DID YOU AND YOUR SEXUAL PARTNERS USE

CONDOM (only ask this question if answer YES to Q446)

Condom use Yes No



Q453. DID YOU USE ANY OF THE FOLLOWING SUBSTANCES BEFORE OR DURING THAT SEXUAL

EPISODE? (read out lound each substance, circle to appropriate cell for each substance)

209

15

Substance 0. No 1. Yes

1. Alcohol/Beer 0 1

2. Opioids (morphine, heroine, codeine, ect) 0 1

3. Cannabis (marijuana, pot, grass, hash, ect) 0 1

22. Sleeping pills (e.g. seduxen) or other sedatives 0 1

23. Inhalants (nitrous, glue, petrol, ect.) 0 1

24. Hallucinogens (e.g. ketamine) 0 1

7. Erectile dysfunction medication (e.g. Viagra) 0 1

8.Cocaine or crack 0 1

21. Methamphetamine (Ice) 0 1

22. Amphetamine 0 1

11. Ecstasy 0 1

12. Poppers 0 1

13. Other sexual stimulants 0 1

F2. SEXUAL BEHAVIOURS IN THE SECOND MOST RECENT SEXUAL EPISODE

Q454. DO YOU REMEMBER THE MOST RECENT SEXUAL EPISODE?

0. Yes 1. No




5. Swimming

pool/Public

toilets

6. Park/Lake

side/Roadside

7. Other (specify)






partner(s)


partner(s)



partner(s)


partner(s)


9. Other (specify)





remember/answer



POSITION? (Cirle to only one appropriate option) 1. Used condom

throughout the

course


throughout the

course


ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


remember/answer


YOU WERE IN BOTTOM POSITION? (cirle to only one appropriate option) 6. Used condom

throughout the

course


throughout the

course


ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


remember/answer

210

16



Condom use Yes No




EPISODE? (read out loud each substance, cirle the appropriate cell for each substance)


1. Alcohol/Beer 0 1









24. Amphetamine 0 1

11. Ecstasy 0 1

12. Poppers 0 1


F3. SEXUAL BEHAVIOURS IN THE THIRD MOST RECENT SEXUAL EPISODE

Q454. DO YOU REMEMBER THE MOST RECENT SEXUAL EPISODE?

2. Yes 3. No




12. Swimming

pool/Public

toilets

13. Park/Lake

side/Roadside

14. Other (specify)






partner(s)


partner(s)



partner(s)


partner(s)


18. Other (specify)





remember/answer



POSITION? (Cirle to only one appropriate option) 6. Used condom

throughout the

course


throughout the

course


ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


211

17

remember/answer


YOU WERE IN BOTTOM POSITION? (cirle to only one appropriate option) 11. Used condom

throughout the

course


throughout the

course


ejaculate outside

anus/vagina


ejaculate inside

anus/vagina


remember/answer



Condom use Yes No




EPISODE? (read out loud each substance, cirle the appropriate cell for each substance)


1. Alcohol/Beer 0 1









26. Amphetamine 0 1

11. Ecstasy 0 1

12. Poppers 0 1


G. SEXUAL SENSATION SEEKING ASSESSMENT (Use prompt card # 5)

Questions

Co

mple

tely

dif

fere

nt

from

me

Dif

fere

nt

from

me

Sim

ilar

to m

e

Co

mple

tetl

y

like

me

Q474. I like wild unlimited sexual encounters without paying any attention to

possible consequences

1 2 3 4

Q475. To me, physical interaction is the most important thing when having

sexual encounter

1 2 3 4

Q476. I like the sexual sensation while having sex without condom 1 2 3 4

Q477. I can have sexual encounters with anyone who is physical attractive to me 1 2 3 4

Q478. I like to have sexual encounters with sexy sexual partners 1 2 3 4

Q479. I enjoy watching X-rated videos/movies 1 2 3 4

Q480. I could do anything to get a person to have sex with me 1 2 3 4

Q481. I like to explore my sexual ability 1 2 3 4

Q482. I like to demonstrate my sexual ability

Q483. I like new and exiting sexual experience and sensation 1 2 3 4

212

18

SESSION 5. ATTACHMENT TO LOCAL MSM COMMUNITY

Q501.HOW MANY GAY/HOMOSEXUAL/MSM FRIENDS DO YOU HAVE (including both close friends or

accquaintances)?...................person

A. ANSWER FOLLOWING QUESTIONS ASKING ABOUT YOUR INVOLVEMENT IN MSM

COMMUNITY ACTIVITIES IN YOUR LOCALITY (Use prompt card # 3)

Activities

Nev

er

Occ

atio

nal

ly

So

met

imes

Usu

ally

Q502. Log into gay/homosexual/MSM specific-websites 1 2 3 4

Q503. Go to MSM/gay-specific venues in my city 1 2 3 4

Q504. Pariticipate in social activities of gay/MSM community in my

city

1 2 3 4

Q505. Member of social networks (Facebook) or forum for MSM/gay 1 2 3 4

Q506. Member of MSM groups in my city 1 2 3 4

B. ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR FEELING AS A MEMBER OF MSM

COMMUNITY IN YOUR CITY OF LIVING (Use prompt card # 4)

Questions

Str

ongly

dis

agre

e

Dis

agre

e

Agre

e

Str

ongly

agre

e

Q507. I feel I am a member of gay/MSM community in my city 1 2 3 4

Q508. My thoughts are influenced/affected by my gay/MSM friends 1 2 3 4

Q509. My actions are influenced/affected by my gay/MSM friends 1 2 3 4

Q510. My gay/MSM friends help me when I have difficulties in my

life

1 2 3 4

Q511. Condom use in sexual encounters are popular among my

gay/MSM friends

1 2 3 4

Q512. Periodic HIV testing is popular among my gay/MSM friends 1 2 3 4

Q513. Checking HIV status of sexual partners before having sex is

popular among my gay/MSM friends

1 2 3 4

Q514. Ecstasy use to enhance sexual experience is popular among my

gay/MSM friends

1 2 3 4

Q515. Methamphetamine use to enhance sexual experience is popular

among my gay/MSM friends

1 2 3 4

\

213

19

SESSION 6. MENTAL HEALTH ASSESSMENT (Use frompt card # 6)

TRONG HAI TUẦN VỪA QUA, TẦN SUẤT BẠN BỊ CÁC VẤN ĐỀ SAU ĐÂY LÀ NHƯ THẾ NÀO?

Questions

No

t at

al

Sev

eral

day

s

Mo

re t

han

hal

f th

e d

ays

Nea

rly

ev

ery

day

Q601. You have little interest or pleasure in doing things 0 1 2 3

Q602. You are feeling down, depressed or hopeless 0 1 2 3

Q603. You have trouble falling/staying asleep or you sleep too much 0 1 2 3

Q604. You feel tired or having little energy 0 1 2 3

Q605. You have poor appetite or you are overeating 0 1 2 3

Q606. You are feeling bad about yourself, or that you are a failure or

have let yourself or your family down

0 1 2 3

Q607. You have trouble concentrating on things, such as reading the

newspaper or watching TV

0 1 2 3

Q608. You are moving or speaking so slowly that other people could

have noticed, or the opposite: you are being so fidgety or restless that

you have been moving around more than usual

0 1 2 3

Q609. You have thoughts that you would be better off dead or of

hurting yourself in some way

0 1 2 3

SESSION 7. ACCESSIBILITY TO AND UTILIZATION OF HIV PREVENTION

SERVICES A. HAVE YOU ACCSESSED TO AND UTILIZIED OF THE FOLLOWING HIV PREVENTION

SERVICES DURING THE LAST 12 MONTHS? (Use prompt card # 7)

Services

Nev

er

-2 t

imes

Quar

terl

y

Month

ly

Wee

kly

Oth

er (

spec

ify)

Don’t

answ

er

Q701. Receive information/brochure about HIV prevention 1 2 3 4 5 6 99

Q702. Receive HIV prevention information/materials for

gay/homosexual/MSM

1 2 3 4 5 6 99

Q703. Buy or receive free condom 1 2 3 4 5 6 99

Q704. Buy or receive free lubricant 1 2 3 4 5 6 99

Q705. Receive safe sex counselling 1 2 3 4 5 6 99

Q706. Receive harm reduction counselling for drug use behaviours 1 2 3 4 5 6 99

Q707. Receive STI counselling 1 2 3 4 5 6 99

Q708. Having HIV test 1 2 3 4 5 6 99

Q709. Having diagnosis and treatment for STI 1 2 3 4 5 6 99

Q710. Register at HIV clinic (ask if HIV positive) 1 2 3 4 5 6 99

Q711. Having methadone treatment (ask if using opioids) 1 2 3 4 5 6 99

WHERE YOU GOT SUCH SERVICES? (Ask for each column, multiple choice question for each column)

214

20

Sources

Q7

12

. H

IV p

rev

enti

on

mat

eria

ls

Q7

13

. C

oun

seli

ng

on

beh

avio

ura

l ch

ang

e

for

HIV

pre

ven

tion

Q7

14

. C

on

dom

Q7

15

. H

IV t

esti

ng

Q7

16

. S

TI

Dia

gn

sos

and

tre

atm

ent

1. Mass media 1 2 3 4 5

2. Online websites 1 2 3 4 5

3. Social networks such as facebook or forum or mobile

applications1 2 3 4 5

4. MSM specific websites 1 2 3 4 5

5. Communication events of MSM groups 1 2 3 4 5

6. HIV prevention program 1 2 3 4 5

7. Government health facilities 1 2 3 4 5

8. Private health facilities 1 2 3 4 5

9. Pharmacist 1 2 3 4 5

10. Hotel/hostel

11. Other 1 2 3 4 5

SESSION 8. BELIEF AND PRACTICE ANSWER FOLLOWING QUESTIONS ON YOUR BELIEF ON WAYS TO PREVENT HIV INFECTION

(Use prompt card # 8)

Questions

Str

ongly

dis

agre

e

Dis

agre

e

Agre

e

Tro

ngly

agre

e

Don’t

know

Q801. Use condom correctly in every sexual encounter with every

sexual partner will prevent HIV transmission

1 2 3 4 5

Q802. Sex without condom but with withdrawal will lower the risk

to get HIV infection

1 2 3 4 5

Q803. HIV infected people on ARV treatment will not transmit

HIV virus to other people

1 2 3 4 5

Q804. HIV negative people at top position will have lower risk to

get HIV infection

1 2 3 4 5

Q805. Sexual encounter between a man and another man 1 2 3 4 5

Q806. Can prevent HIV infection by PreP 1 2 3 4 5

Q807. Can prevent HIV infection by PEP 1 2 3 4 5

Q808. Circumstance can lower risk of HIV infection 1 2 3 4 5

Q809. HOW YOU PROTECT YOURSELF AND YOUR SEXUAL PARTNERS FROM HIV INFECTION?

(Read out lound each circumstance and circle the appropriate cell)

Behaviours Never Sometimes Usually

1. Always use condom correctly with every sexual partner when you are in

top position

1 2 3

2. When you are in bottom position, you always ask your sexual partners

use condom correctly

1 2 3

3. You only have sex with HIV negative people 1 2 3

4. You do not use condom but you withdraw if you are in top position 1 2 3

215

21

5. You ask your sexual partners to withdraw if you are in bot position and

your sexual partners do not use condom

1 2 3

6. You can have sex with a HIV positive but on ARV treatment 1 2 3

7. You only have sex in top position 1 2 3

8. You take PEP for HIV prevention 1 2 3

9. You take Prep for HIV prevention 1 2 3

10. You only wear dondom when you ejaculate 1 2 3

11. You only have sex with looking healthy, handsome, clean sexual

partner(s)

1 2 3

12. You check your sexual partners penis 1 2 3

13. Other (specify) 1 2 3

216

APPENDIX 5

QUALITY ASSESSMENT CHECKLIST FOR THE SYSTEMATIC REVIEW

AND META-ANALYSIS

217

Appendix 5: Quality Assessment Criteria (QAC)

1. QAC for cross-sectional studies

Ref.number:……………………………………… First author, year:

Q1 Was the population from which the sample was drawn clearly stated

Background inf provided: study location, recruitment location clearly defined 1

Background inf provided: study location, recruitment location is NOT clearly defined 0

Q2 Sampling Method Probability sampling (simple random, systematic, stratified, cluster, multi-stage, RDS, TLS) 1

Non probability sampling (convinient, snowball, purposive, quota…) 0

Q3 Sample represent the target population Includion criteria of study participants clearly defined 1

Includion criteria of study participants is NOT clearly defined 0

Q4 Response rate Response rate >80% 1

Not mention or <80% 0

Q5 Data collection method standardized Identical methods of assessment and data collection used for all participants 1

Identical methods of assessment and data collection were NOT used for all participants 0

Q6 Measure reliable

Survey instrument: tested-retested, piloted, adapted/adapted from other studies (with reference); HIV tests described (name of the test, procedure of testing) 1

Survey instrument was NOT/or MENTIONED tested-retested, piloted, adapted/adapted from other studies (with reference); HIV tests was NOT described 0

Q7 Measure is valid Study duration of behavioral variable was clearly defined 1

Study duration of behavioral variable was NOT clearly defined 0

Q8 Statistical method appropriate Yes, confident interval or SD/variance given for prevalence test 1

No, only prevalence was given 0

Q9 Confounder management Potential confounders not addressed in the design and analysis 1

Potential confounders addressed in the design and analysis 0

218

2. QAC for case-control studies







Q3 Sample represent the target population Case and control clearly defined and from a common base represent for the target pop 1

Case and control clearly defined and NOT from a common base represent for the target pop, Control did not have the outcome at the beginning 0





Q7 Measure reliable









219

3. QAC for longitudinal studies







Q3 Sample represent the target population Inclusion and exclusion criteria clearly defined, free of HIV at the beginning is clearly defined 1

Inclusion and exclusion criteria NOT clearly defined, free of HIV at the beginning is NOT clearly defined 0



Q5 Follow up rate Follow up rate mention, charateristic of lost to follow up is NOT DIFFERENT from those of follow up 1

Follow up rate not mention, charateristic of lost to follow up is DIFFERENT from those of follow up 0

Q5 Follow up time Follow up time is edequate for the outcome to be occurred

Follow up time is NOT edequate for the outcome to be occurred



Q7 Measure reliable








220


221

Documents

Sex, drugs and health of men who have sex with men in Vietnam