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HIV and syphilis risks highest among homosexual males: Local survey 

08 Feb 2022

  • Researchers note need for group to be targeted in intensive interventions 
BY Ruwan Laknath Jayakody  According to the findings of the sentinel surveillance survey (SSS) of 2019, men who have sex with men (MSMs) is the key population group, amongst MSMs, female sex workers (FSWs), clients of sex workers, transgender women (TGWs) and people who inject drugs (PWIDs), with the highest human immunodeficiency virus (HIV) prevalence (1.46%) and active syphilis prevalence (0.53%) and with a high overall syphilis prevalence (3.21%).  These findings were presented in a paper on “HIV SSS 2019/Prevalence and Characteristics of HIV Cases in Sri Lanka: Experience from Sentinel Site Surveillance 2019” which was authored by A.M.A.D.K. Alagiyawanna (Senior Registrar of the Sri Jayewardenepura University’s Medical Sciences Faculty), N.D.C.R.C. Gajaweera (Medical Officer at the National Sexually Transmitted Diseases [STDs] / Acquired Immunodeficiency Syndrome [AIDS] Control Programme [NSACP]) and A.P.S. Benaragama (Consultant Epidemiologist at the National STDs/AIDS Control Programme) and published in the Sri Lanka Journal of Sexual Health and HIV Medicine Volume Six in December 2020. Sri Lanka, according to A. Manathunge, J. Barbaric, T. Mestrovic, S. Beneragama and I. Bozicevic’s “HIV prevalence, sexual risk behaviours and HIV testing among FSWs in three cities in Sri Lanka: Findings from respondent driven sampling surveys” and A. Patil, J.P. Elwitigala, L. Rajapaksa, R. Gangakhedkar, D. Chaturbhuj, R. Pendse, D.I. Rajapaksha, B.B. Rewari, N. Malliawadu, K. Jayamanna and D. Dombawela’s “HIV-1 pol gene diversity and molecular dating of subtype ‘C’ from Sri Lanka”, remains a low prevalent country for HIV/AIDS. The national prevalence remains below 0.1%, according to the cases reported to the NSACP, remaining low even among high risk population groups.  Alagiyawanna et al. noted that per the estimates and reported cases of HIV, it appears that case detection needs to be strengthened as even though the number of new cases reported during a year is stagnating, the high risk groups out of which the new cases arise is changing, with the proportion of MSMs and bisexual men among people living with HIV (PLHIV) being on the rise since 2010, and the female dominant HIV epidemic in the early years being transformed into a male dominant one during the last few years. Also, the proportion of young people (15 to 24 years of age) contracting HIV has remained somewhat static, around 10%, since the last eight years. Most cases, per the NSACP’s Annual Report 2018, are concentrated in the Western Province.  In this backdrop, the NSACP is performing HIV sentinel surveillance as an ongoing activity. Sentinel groups include FSWs, STDs, clinic attendees, prisoners, blood donors, service personnel, pre-employment recruits, MSMs, drug users (DUs), intravenous drug users (IVDUs), and clients of FSWs. These surveys were supplemented by a series of Integrated Biological and Behavioural Surveillance (IBBS) Surveys.  The HIV SSS is carried out annually as repeated cross sectional sero surveys among selected population groups at selected geographical locations. These population groups are called sentinel groups while selected locations are known as sentinel sites (one sentinel site usually consists of several data collection centres). The decision on what groups are to be considered as sentinel groups is made by NSACP experts, based on the epidemiological characteristics of the cases reported during recent years. Alagiyawanna et al. explained that being a low prevalent country for HIV, it is of importance to continue HIV sentinel surveillance as it provides a reliable estimate of the disease prevalence among high risk subpopulation groups and the monitoring of trends of the HIV epidemic, and further, it provides an opportunity to screen for other common sexually transmitted infections (STIs), again having low prevalence in this setting. A cross sectional sero survey, as a part of the series of regular surveys, was conducted among selected population groups at selected geographical locations. STDs clinic attendees belonging to the defined risk categories comprised the study population. These population groups or sentinel groups were defined based on their risk behaviour as FSWs, clients of FSWs, PWIDs, MSMs and TGWs. Operational definitions were developed for each sentinel group. All nine provinces were identified as sentinel sites and one sentinel site usually consisted of several data collection centres which were sample collecting centres (STDs clinics). Those who were above the age of 18 years were included into the study but there was no age restriction for the TGWs group. Consecutive sampling of those individuals meeting the inclusion criteria were enrolled into the study. The data of selected participants were extracted to a data collection format from the clinic records, which included their age, sex and risk category. The results of blood tests were recorded when they were tested at the local or central STDs clinic.  A total of 3,554 individuals were enrolled from the five defined sentinel groups for the HIV SSS 2019.  The participants’ age was between 18 and 77 years. The MSMs had the lowest mean (average) age (29.9 years). The mean ages of clients of FSWs and PWIDs were 32.3 and 30.9 years, respectively. The mean age of FSWs and TGWs were over 36 years, respectively. A total of 15 HIV-positive cases were identified through the HIV SSS 2019, out of which 12 were MSMs while the other three were one each from FSWs, clients of FSWs and TGWs. The highest HIV prevalence was seen among MSMs which was 1.46%. FSWs and clients of FSWs have shown a low prevalence which was below 0.1%. The prevalence rate among TGWs has become 1.35%, as the denominator was made up of only 74 individuals. Out of the 15 reported HIV-positive cases in the HIV SSS 2019, 10 were from the Western Province (66.7%) out of which eight were MSMs while another three were from the North Western Province (NWP – 20%) and all of them were MSMs, and the Central and Southern Provinces reported one case each. In addition to HIV, patients presenting to the STDs clinics, including those who belong to the sentinel groups are routinely tested for Hepatitis B, Hepatitis C and syphilis if they have the risk factors, and while this procedure may vary depending on logistical issues, in most places however, this screening takes place. As many individuals remain asymptomatic in the initial stages of these diseases, Alagiyawanna et al. observed that screening them is important for the patients to get an early diagnosis and treatment, which may help to minimise potential complications. The prevalence of all forms of syphilis (both active and inactive) were tested among the 3,250 participants of the sentinel surveillance, and with regard to the numbers that were positive and the prevalence rate, the latter was the highest among TGWs (13.33%), followed by MSMs (3.21%) and PWIDs (2.86%). Active syphilis was seen only among MSMs (0.53%) and clients of FSWs (0.29%) in the sentinel surveillance. Only 1,466 FSWs, 1,097 clients of FSWs, 822 MSMs, 70 PWIDs and 74 TGWs were enrolled during the stipulated study period. It was observed that the expected sample sizes of most categories of sentinel groups were met only in the Western Province with the reason for not meeting the expected sample size being that there were no clinic attendees belonging to defined risk categories during the study period. Further, out of the 15 HIV-positive cases, 10 were from the Western Province whereas the other Provinces have a very small number or no cases of HIV over the years. An increasing trend of the prevalence of the HIV infection was observed among MSMs in the Western Province. Among FSWs in the Western Province, the trend seems to stagnate, and the numbers showed that in 2003, 2004, 2006, 2011 and 2019, one FSW each were positive out of those enrolled for the HIV SSS. According to 2019 HIV sentinel surveillance, MSMs had the highest HIV prevalence (1.46%). Alagiyawanna et al. pointed out that even though this is a low prevalence rate for a high risk population group according to the World Health Organisation’s definition, this is a high prevalence rate for the Sri Lankan setting. Out of the 15 reported HIV-positive cases in the survey, 12 (80%) were MSMs. As there were only 70 TGWs enrolled in the study and one person became positive, this made the prevalence rate look greater among TGWs. One each from TGWs, clients of FSWs and FSWs were HIV-positive. Unless the programme targets specific groups who are at higher risk, the interventions, Alagiyawanna et al. emphasised, tend to have a lower yield. Therefore, this, according to Alagiyawanna et al., emphasises the fact that MSMs need to be targeted more for intensive interventions, while maintaining the focus on other sentinel groups.  The constantly low prevalence of HIV among FSWs can be, per Alagiyawanna et al.’s view, attributed to the consistent and increased usage of condoms with commercial partners.  The highest number of cases was reported from the Western Province (10 – 66.7%). This is to be anticipated as the Western Province has the highest population density, and the central clinic has the highest number of clinic attendees. However, Alagiyawanna et al. noted that particularly when individuals want to visit a STDs clinic which has more stigma and discrimination, they may visit a clinic outside their resident area. Three MSMs in the North Western Province have become HIV-positive and this, per Alagiyawanna et al., is an important finding that warrants further investigations in order to find any epidemiological links among them, and for primary and secondary preventive activities to be initiated and commenced. Only 1,466 FSWs, 1,097 clients of FSWs, 822 MSMs, 70 PWIDs and 74 TGWs were enrolled during the stipulated study period. A majority of the sample constituted people from the Western Province. The reason for not meeting the prevalence was 1.35%. The small denominator expected sample size was because there were no clinic attendees belonging to the defined risk categories during the study period; therefore, considering the contribution of each sentinel site, Alagiyawanna et al. explained that it would be cost effective to limit the HIV SSS to sites with a higher yield.  If you or someone you know may require assistance regarding the above content, the following institutions may be of assistance to you:  National STD/AIDS Control Programme Sri Lanka: (011) 2 667 163  Family Planning Association of Sri Lanka: (011) 2 555 455  www.know4sure.lk


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