Suchergebnisse

Regionally, Asia bears a high proportion of global burden of disease relating to human immunodeficiency virus (HIV), and men who have sex with men (MSM) are disproportionately affected. The research presented in this thesis focuses on MSM in Lao People's Democratic Republic (Laos). Whilst the prevalence of HIV among reproductive-aged adults in Laos is low (0.2%), HIV prevalence among MSM is considerably higher, estimated at 5.6% in Vientiane in 2007. MSM are a heterogeneous group of men with respect to identity, sexual practices and sexual attraction. Behaviourally bisexual men constitute a substantial proportion of MSM in Laos and more broadly in Asia. A systematic review of studies in Asia found that MSM with bisexual behaviour have similar prevalence of HIV and sexually transmitted infections (STIs) to MSM with homosexual behaviour, but are less likely to have received an HIV test. The involvement of behaviourally bisexual men in HIV interventions is essential to achieving HIV control and maintaining low HIV prevalence in Laos. This thesis describes a program of research designed to produce a better understanding of sexual risk and health needs of behaviourally bisexual men in Laos. The research informing this thesis was conducted in Vientiane, Laos in two phases using a mixed-methods approach. Firstly, quantitative data on sexual behaviour, alcohol and other drug use, and HIV knowledge was collected in 2010 using a behavioural survey with a social network design. Secondly, qualitative data collected in a follow-up study in 2013-14 enabled exploration of the motivations, influences, and moderators of behaviour and health-care seeking among behaviourally bisexual men in Vientiane. The research results demonstrate the complexity of sexual orientation in Laos. Young behaviourally bisexual men in Laos associate with different sexual identities and report varying sexual preferences, but most commonly identify as heterosexual. A high proportion of bisexual men reported multiple sex partners, concurrent male and female partners, inconsistent condom use, consuming alcohol before sex, and both buying and selling sex. Despite reporting high-risk sexual behaviours for HIV and STI, utilisation of healthcare services was low; uptake of HIV testing was poor, and use of STI services limited to symptomatic treatment. Common barriers to testing were low perception of risk, expectation of symptoms, fear of HIV, shyness, anticipation of stigma, confidentiality concerns, and waiting times. This research highlights the need for integrated HIV and STI services and improved health promotion targeting bisexual men in Laos. Strategies are needed to generate demand for both HIV and STI testing, improve the capacity of sexual healthcare providers, and promote available services. Heath promotion messages aimed at reaching bisexual men should emphasise the importance of consistent condom use with all sex partners, lubricant use and regular HIV and STI testing. Based on these findings, a range of recommendations for the content and delivery of interventions to reach behaviourally bisexual men are made. These include both mainstream and targeted channels, and the relevance of internet and mobile phone technologies is discussed. These findings have practical implications for the delivery of HIV prevention and sexual health promotion in Laos and have the potential to reduce HIV and STI transmission in this high-risk group.

AbstractIntroductionFemale sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre‐exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs.DiscussionFSWs have high unmet need for effective contraception and unintended pregnancy is common in low‐ and middle‐income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk‐taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single‐focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real‐life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two‐fold increase in condomless sex among FSWs on PrEP, which, given low use of non‐barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW‐focused community‐based HIV services is likely to be the most effective model for improving access to non‐barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.ConclusionsAs PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.