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Sexual Partnership Patterns and HIV Risks among Male Migrant Market Workers from Central Asian countries in Kazakhstan
Gaukhar Mergenova2, Assel Terlikbayeva2, Louisa Gilbert1,2, Stacey A. Shaw3, Sholpan Primbetova2, Nabila El-Bassel1,2
1 – Columbia University School of Social Work, New York, NY, USA, 2 – Global Health Research Center of Central Asia, Almaty, Kazakhstan, 3- Brigham Young University, School of Social Work
Presented at the 22nd International AIDS Conference – Amsterdam, the Netherlands
INTRODUCTION Central Asia and Kazakhstan
Migration in Kazakhstan Estimates of labor migrant workforce is about: - 140 thousand to 1 million from Uzbekistan - 36-50 thousands from Tajikistan and - 120 thousands from Kyrgyzstan * - Rural-to-urban migration is driven by economic disparities between urban and
rural areas Migrant workers are vulnerable to HIV/STI due to multiple factors [1, 6-7]: • Separation from family • Unstable living conditions • Lack of access to health care services • Illegal migration or/and working status • Mobility and travel patterns (travel from high-endemic urban regions to low-
endemic rural regions) • Discrimination
METHODS Sample
Recruitment
Measures Sexual partnership patterns: 1) monogamous partnership (MP) - true monogamous partnership: mutually reporting one partner; 2) indirect multiple partnerships (IMP) - people who report one partner, although his/her partner has many sexual partners; 3) simple multiple partnership (SMP) - people reporting many sexual partners; in contrast, these later report only one sexual partner; 4) complex multiple partnerships (CMP) - people who reported many sexual partners who are themselves involved in many sexual relationships with other persons
CONCLUSIONS: - Non-monogamous sexual partnership patterns were observed
among one third of market workers in Kazakhstan (Central Asia). - Mobility is a factor that is associated with multiple partners not only
of men, but also of their primary female partners - Higher probability of unprotected sex, sex under influence of alcohol
and sex with SW among men in multiple partnerships may increase heterosexual HIV/STI transmission.
IMPLICATIONS:
#AIDS2018 | @AIDS_conference | www.aids2018.org
RESULTS We used log-binomial regression and logistic regression (adjusting for age, marital status, income, migration status) to examine the association between sexual partnership patterns, mobility for the last 90 days , HIV/STI sexual risk (unprotected sex , sex under influence of alcohol, sex with SW) and prevalence of sexually transmitted infections (STIs). Socio-demographic characteristics of the sample by migration status , N=830
• Barakholka Market is one of the biggest market in Central Asia is located in Almaty City;
• The conglomerate structure of Barakholka spans 4 km (2,5 miles) long and is 10 rows wide;
• Market consists of 28 independent submarkets, 5 of them were wholesale markets, with about 17,5 thousands of stalls, with total amount of workers about 30,000
Respondent Driven Sampling method was used. We identified 11 “seeds” with different socio-demographic characteristics. Group 1 (KZ non-migrant) – red Group 2 (KZ migrant) – green Group 3 (KG migrant) – purple Group 4 (TJ migrant) – blue Group 5 (UZ migrant) – yellow Missing - grey.
0
0,05
0,1
0,15
0,2
0,25
2005 2010 2016
Kazakhstan Kyrgyzstan Tajikistan
HIV incidence per 1000 population, (UNAIDS , 2017)
88,8 93,1
78,5 77,3 69 71,8 72
66,7 65,4 61
56
46,2 39,7
33,8 32,5 33 31 29,2
9,9 6,3
18,8 21 28 25
18 24,5
28,4 35
40,4
50 55,7
60,3 60,5 57,7 60,5 62
0,5 0 0,3 0,35 0,45 0,5 0,57 0,79 0,93 1,25 0,8 1,4 1,7 2,9 4 4,7
0
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parenteral heterosexual homosexual
Factors of HIV epidemics [1,2] • Closeness of the region to drug
trafficking routes • Increasing trend of injection drug
use • Limited harm reduction programs • Limited opioid substitution
therapy programs • Inadequate access to
antiretroviral therapy • Increase of heterosexual
transmission • Stigma toward HIV infected
HIV epidemics in Kazakhstan • Heterosexual transmission
makes up 62% of the detected cases in 2017;
• Injection drug use constituted 29.2% of HIV cases;
• Number of HIV cases in 2017 in Kazakhstan is 20,841
• Estimated number of PLWH is 26,000.
• HIV prevalence in key groups: PWID – 8.5% (2016), SW – 1.9%, MSM – 6.2% [3]
Kazakhstan is on 16th place among countries hosting the largest numbers of international migrants [4]. Officially, the country hosts from 500,000 to 1 million foreign workers, however, experts advance a more plausible figure of three million migrants. [5]
Eligibility • Aged 18-50 • Had a valid recruitment coupon • Citizens of Kazakhstan, Kyrgyzstan, Tajikistan or
Uzbekistan • Employed in the Barakholka market in the past
week • Fluent in Russian, Kazakh, or Tajik • Were able to provide informed consent
Central Asia includes five republic of the former Soviet Union: Kazakhstan (17.9 million), Kyrgyzstan (5.8 million), Tajikistan (8.0 million), Turkmenistan (5.2 million), Uzbekistan (30.2 million) and characterizes by the fast growing HIV epidemics.
We used baseline data from the Silk Road Health study among 1,342 male market workers conducted on Baraholka Market in Almaty, Kazakhstan. (NIMH, R01 NMH082684 to N. El-Bassel)
*P<0.05; **P<0.01; ***P<0.001
Sexual partnership and risky sexual behavior (last 90 days)
Travelled and spent one or
more nights outside Almaty
last 90 days, RR (CI 95%)
MP 0.70 (0.59, 0.83)***
IMP
0.47 (0.13, 1.73)
SMP
1.02 (0.83, 1.26)
CMP
1.68 (1.03, 2.72)*
Any STI, OR (95%
CI)#
Unprotected
vaginal/anal sex with
any female partner,
RR (95% CI)
Sex under influence of
alcohol with primary
partner, RR (CI 95%)
Sex with female sex
worker,
RR (CI 95%)
MP 1.59 (0.86, 2.93) 0.82 (0.71, 0.94)** 0.28 (0.18, 0.43)*** -
SMP
0.93 (0.52, 1.65) 1.13 (0.97, 1.32) 1.57 (1.12, 2.19)** 1.88 (1.32,2.69)***
CMP
0.65 (0.22, 1.92) 1.43 (1.17, 1.74)*** 2.19 (1.45, 3.29)*** 2.25 (1.46,3.45)***
Total, N(%) Non-migrants, N (%)
Internal migrants, N (%)
External migrants, N (%)
Age 27.0 (7.3) 26.5 (7.2)* 25.3 (6.6)* 28.7 (7.6)* Married/common law marriage 415 (50.0) 159 (42.1)*** 67 (39.6)*** 189 (66.8)***
Income below living wage 123 (14.8) 70 (18.5)** 27 (16.0)** 26 (9.2)**
Travelled and spent one or more nights outside Almaty last 90 days 344 (41.5) 152 (40.2) 79(46.8) 113 (39.3)
Less than high school 199 (25.1) 90(24.8)** 26 (16.3)** 83(30.6)**
*P<0.05; **P<0.01; ***P<0.001
Sexual Risks by migration status , N=830
Total, N(%) Non-migrants, N (%)
Internal migrants, N (%)
External migrants, N (%)
Any STI (missing=24) 47 (5.8) 25 (6.81)* 14 (8.5)* 266 (2.9)*
Commercial sex with female partner last 90 days 119 (14.3) 47(12.4) 28 (16.6) 44(15.6) Had sex under influence of alcohol 165 (19.9) 65(17.2) 38(22.5) 62(21.9)
Had unprotected sex with any female partner last 90 days 439 (52.9) 160 (42.3)*** 87 (51.5)*** 192 (67.8)***
*P<0.05; **P<0.01; ***P<0.001, # -logistic regression
Sexual Partnership Patterns by migration status, N=830
Total, N(%) Non-migrants, N (%) Internal migrants, N (%)
External migrants, N (%)
Monogamous partnership (MP) 373 (44.9) 142 (37.6)*** 66 (39.1)*** 165 (58.3)***
Indirect multiple partnerships (IMP) 10 (1.2) 7 (1.9)1* 2 (1.2)1* 1(0.4)1*
Simple multiple partnership (SMP) 216 (26.0) 116 (30.7)** 48(28.4)** 231 (18.4)**
Complex multiple partnerships (CMP) 59 (7.1) 35(9.3)* 12 (7.1)* 12 (4.2)*
*P<0.05; **P<0.01; ***P<0.001
*P<0.05; **P<0.01; ***P<0.001
Dependent variables: 1) Biologically confirmed cases of STI (gonorrhea, chlamydia, syphilis) 2) Sex under the influence of alcohol in the last 90 days 3) Condom use: any unprotected sex in the last 90 days 4) Sex with female sex worker in the last 90 days
Sexual partnerships and mobility
Key findings: • Of the sample, 44.9 % reported being in MP, 1.2% - IMP, 26 % - SMP,
7.11 % - CMP. • Mobility was associated with higher likelihood of being in CMP
(RR=1.68, 95%CI: 1.04, 2.72, p<0.05) and with lower probability of being in MP (RR=0.70, 95%CI: 0.59, 0.83, p<0.001).
• Being in CMP was associated with higher likelihood of having unprotected sex with a female partner (RR=1.43, 95%CI: 1.17, 1.74, p<0.001).
• Commercial sex was associated with higher likelihood of being in CMP (RR=2.25, 95%CI: 1.46, 3.45, p<0.001) and in SMP (RR=1.88, 95%CI: 1.32, 2.69, p<0.001).
• Likelihood of having sex under influence of alcohol was higher among men in CMP (RR=2.19, 95%CI: 1.45, 3.29, p<0.001) and in SMP (RR=1.88, 95%CI: 1.32, 2.69, p<0.001), whereas for men in MP, it was lower (RR=0.28, 95%CI: 0.18, 0.43, p<0.001).
References 1. Thorne, C., et al., Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infect Dis, 2010. 7(10): p.
479-88. Republican Center on Prevention and Control of AIDS. 2018. 2. UNAIDS data,2017 3. Nations, U. International migrant stock 2017. 2017; Available from:
http://www.un.org/en/development/desa/population/migration/data/estimates2/estimatesgraphs.shtml?3g3
4. IOM, Уязвимость мигрантов и постребности интеграции в Центральной Азии. Оценка постребностей мигрантов и общин и управление рисками. Краткий обзор. 2017: IOM.
5. UNAIDS, UNAIDS Report on the Global AIDS Epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS. 2010.
6. El-Bassel, N., et al., The Silk Road Health Project: How mobility and migration status influence HIV risks among male migrant workers in Central Asia. PLoS One, 2016. 11(3).
Hypothesis We hypothesized that sexual partnership patterns, including (1) monogamous partnership (MP), (2) indirect multiple partnerships (IMP), (3) simple multiple partnership (SMP), (4) complex multiple partnerships (CMP) would be associated with mobility and HIV/STI sexual risks (STIs, unprotected sex, sex under the influence of alcohol, sex with a female sex worker).
Structure fragment and waves of RDS
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1000
2000
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2005 2010 2016
New HIV infections , (UNAIDS,2017)
Sexual partnership characteristics of mobile populations must be studied and considered in HIV/STI prevention approaches for this target population in Central Asia.
The Bazaar in Samarkand, by Alexei Issupoff, Photo Courtesy of Sphinx Fine Art, London
WEPED376, Wednesday, 25 July 2018, 12:30-14:30, Poster exhibition area, Hall 1, Gaukhar Mergenova, [email protected], [email protected]
Acknowledgments: This study was funded by the National Institute of Health, NIMH R01 MH082684 to Dr. Nabila El-Bassel. We would like to thank research staff members who assisted with various stages of the project, including identifying participants, interviewing, translation, transcription, and data coding.
