Knowledge and associated factors of condom use among MSM; a cross sectional study in Global Fund peer led interventions in Sri Lanka

Introduction: Sri Lanka has a lower prevalence of HIV among MSM (0.9%) in the region. However, the HIV prevalence among MSM has been rising steadily 0.48% in 2009 and 0.9% in 2011. Prevention of HIV transmission through the introduction of “Prevention package” under GFATM round 09 HIV project is one of the main strategies to reduce new infections in the MSM community. Prevention package includes condom awareness and knowledge, condom demonstration and distribution. This project reaches 3203 MSM with the prevention package. Therefore, this study aims to assess the condom knowledge of MSM reached by the peer educators and the factors associated with level of knowledge. Methodology: Multistage probability sampling technique was used to select a sample of 325 MSM peers who have reached with basic HIV prevention service package were interviewed with a structured and semi structured interview schedule after receiving the oral informed-consent. Descriptive statistical analysis and non-parametric hypothesis testing were performed using the SPSS statistical software. Results: Sample has an average of 4.2 (SD=8.42) partner changes per month. One third of the sample had over 10 years of MSM behaviours. Around 70% of respondents knew at least five out of eight condom use steps. Partner exchange rate, composite knowledge on HIV and using a condom during the last sex were associated with respondents’ knowledge on correct use of condoms. Conclusions: Although the program has contributed significantly to increase the condom use among MSM population, effectiveness of the condom use is questionable. A comprehensive condom demonstration programme must be incorporated into the HIV prevention programs in more practical manner for effective condom programing.


Full Article Introduction
Globally, HIV pandemic remains one of the most serious infectious disease challenges to public health.The HIV prevalence in Sri Lanka is less than 0.1% according to the National STD/AIDS Control programme (8).Hence, Sri Lanka has been classified by UNAIDS as a country with a low-level HIV epidemic.HIV prevalence among high risk groups like Men who have Sex with Men (MSM), Female Sex Workers (FSWs), Drug Users (DUs), and Beach Boys (BBs) has not reached 5% and the general population prevalence is less than 0.1%.
The definition used in this survey for MSM is "Men who have had sex with another men in the past six months as a matter of preference or practice, regardless of their sexual identity or sexual orientation, and irrespective of whether they also have sex with women or not".

MSM are disproportionately affected in Sri
Lanka by HIV and other sexually transmitted infections including gonorrhoea, syphilis, chlamydia and hepatitis B and C. In several countries in the region, the incidence of these infections has increased among MSM, in some cases markedly, over the last decade.In the recent scattered epidemiological research has identified high HIV prevalence among MSM with varying degrees of study findings and conclusions across countries, India (4.4%), Thailand (7.1%),China (6.7%), Indonesia (8.5%) and Myanmar (8.9%) (2).In comparison, Sri Lanka has a lower prevalence of HIV among MSM (0.9%) in the region (3) .However, MSM population was included as a surveillance group beginning in the 2008 HIV Sentinel Sero-Surveillance Survey (HSS) and HIV prevalence among this group has been rising steadily at close to 0% in 2008, 0.48% in 2009 and 0.9% in 2011 (4).Overall, 11% of the total reported HIV infections are attributable to homosexual transmission in Sri Lanka (4).The current estimation of MSM in Sri Lanka is 7,551 (ranging from 6,547 to 8,554) across 1,438 hot spots (5).
Unprotected anal intercourse (UAI) is the main cause of HIV transmission between gay and bisexual men or MSM.The higher incidence of HIV observed among MSM as compared with heterosexual populations in similar settings is largely due to the higher transmissibility of HIV via anal intercourse (3).Prevention of HIV transmission through correct and consistence use of condoms is the most effective and important prevention strategy for MSM which demands more focus behavioral change interventions (6) (7) .The condom program of the project mainly focuses on comprehensive demonstration and distribution; an average distribution of 15 condoms per MSM per month.Condom demonstration is elaborated as "A trained peer educator meets one or more of his peers registered in the project, and provides information on importance of condom use and demonstrate following steps of correct use of male condoms.1. Inspect the condom and expiry date.2. Tear the condom free edge of package and take out the condom.Ensure that the nails do not cause a tear in the condom.3. To prevent the condom from bursting, squeeze the tip of the condom to take out the air.4. While holding onto the tip, unroll the condom down the shaft of the penis all the way to the base of penis. 5.After the sex, slide off the condom from the penis ensuring that the semen collected at the tip does not spill or leak out.6. Dispose-off the condom in a safe place where it cannot be handled by another person.7. Wash hands, if semen or vaginal secretions contact on the hand.8. Use a tissue or a paper to remove the condom to prevent potential contact of vaginal secretions in the hand.It is important but not mandatory to use a dildo to conduct a condom demonstration (8).
The objective of the study was to assess the knowledge of MSM reached by the program (peers) on correct use of condoms for prevention of HIV and associated factors.

Methods
Three hundred and twenty-five (325) MSM peers who have reached with basic HIV prevention service package were selected using a multi-stage probability sampling method.The sample size was calculated using McCallum Layton online sample size calculator (9).The main peer registration database of the GFATM project was used as the sampling frame.(10).The tool was pre-tested with 15 MSM with deferent demographic characteristics and revised accordingly before finalizing it.
The respondents were clearly briefed that the information collected will be treated with utmost confidentiality and will be only used for the research purposes, with anonymity.After taking the respondents oral consent the data was collected and recorded.The interviews were conducted by a team of Monitoring and Evaluation professionals who have field level experience in working with MSM at least three years.The selected peers were reached through their peer educators and field supervisors.The interviews were conducted at their hot-spots or places convenient to them.The enumerators were Papers __________________________________________________________________________________ conducted re-visits to their hot-spots maximum up to three times, if the selected peer is not available for the interviews at the time of the visit.However, this study was not subjected to an ethical review process, as the field survey was conducted among group of project beneficiaries who are well aware of the project and project activities.Data collected was cleaned and entered in to SPSS statistical software.Descriptive statistical analysis and non-parametric hypothesis tests were performed accordingly.

Sample Characteristics
Two hundred and eighty-one valid responses were received resulting 86 percent response rate.Response rate is somewhat lower than the standard for social surveys due to nature of the target population and difficulties in accessibility.The non-response rate was three times higher in urban areas of Colombo district in comparison to other locations.More than 50 percent of the respondents were recruited from Colombo and Galle districts align with the population coverage of the program.Around one third of the respondents represent rural communities of five selected districts.In the absence of clear demarcation of transgender communities in Sri Lanka, the self-identified "Nachchi" respondents can be considered as a proxy.Around 12 percent of respondents were selfidentified them as "Nachchi" which is somewhat lower than the figure reported in Colombo (28 percent), and Anuradhapura (26 percent) districts and higher than Galle (9 percent) in the IBBS survey (3).

Knowledge on condom use steps
In the event of 90 percent of respondents reported using condoms during the last anal sex, it is important to explore whether the use has been correct.Hence, as explained in the methodology, this study gathered information on respondents' awareness on the eight condom use steps (table 3)

Factors associated with knowledge on condom use steps
A scale of 1 to 8 was developed by taking number of steps correctly mentioned by each respondents.The lower scores represent weak knowledge on condom use steps and higher scores represent comprehensive knowledge.The scale shows an acceptable level of internal validity with 0.759 Cronbach's alpha (11).
We found that the number of sexual partners during the last month is positively associated with respondents' level of knowledge on condom wearing steps and safe practices (spearman r= 0.169, p=0.009).More specifically, the respondents who have higher number male sexual partners are likely to compose a better knowledge on condom wearing steps.This can be partially attributed to the effect of current and previous HIV programs which focuses on most at risk populations.
As anticipated, respondents' composite knowledge on HIV prevention is also positively associated with the knowledge on condom wearing steps and safe practices (r= 0.275, p=0.000).Similarly, those who are using condoms are likely to have better knowledge on condom wearing steps than non-users (Chi2 = 12.422, P=0.012).Respondents' age, years of formal education, marital status and number of years in MSM behavior are not significantly associated with knowledge on condom wearing steps and safe practices.Table 4 further demonstrate the factors associated with knowledge on condom wearing steps and safe practices.

Discussion
The project reached about 42 percent of estimated number of MSM in Sri Lanka (5).
Around 90 percent of responded reported a use of condoms during the last anal sex which is remarkably higher than the population estimates reported in recent IBBS (Colombo-64%, Galle-37% and Anuradhapura 55%) (3).However, only around 70% of respondents knew at least five out of eight condom use steps.Although the program has contributed significantly to increase the condom use among MSM population, effectiveness of the condom use is questionable.
Hence, these findings highlight that HIV education and distribution of condom among most at risk populations alone do not enough to handle the issue.A comprehensive condom demonstration programme must be incorporated in to the HIV prevention programs in more practical manner for effective condom programing.Currently, Sri Lanka does not have standard tools and guidelines for condom demonstrations and to measure effectiveness of knowledge transfer.Development and pilot testing of tools and national guidelines on condom demonstration and measuring effective use of condoms are priority areas for further development of condom programing in Sri Lanka.Further, the outreach workers must be trained adequately to conduct comprehensive condom demonstration programs giving equal importance and adequate time to discuss all the steps to promote correct use of condoms.

Conclusion
Although the program has contributed significantly to increase the condom use among MSM population up to 90 percent, effectiveness of the condom use is questionable.A comprehensive condom demonstration programme must be incorporated in to the HIV prevention programs in more practical manner for effective condom programing.Further, HIV prevention program should closely monitor effective use of condoms apart from condom distribution.