Data reveal high sexual risk among Asian MSMs
More intervention work is needed
Investigators have found a disturbing trend of increased levels of sexual risk behavior among a small, little-studied group: Asian/Pacific Islander (API) men who have sex with men (MSM).
Sexual risk behavior among this group has increased at a faster rate than with white MSM. This includes increases in unprotected anal intercourse with multiple partners, which rose from 12% in 1999 to 20% in 2002, compared with an increase from 19% to 20% in white MSM.1
At first glance, these findings may not be particularly alarming because the API MSM population has a very low rate of HIV infection, says Willi McFarland, MD, PhD, director of HIV/AIDS Statistics and Epidemiology at the San Francisco Department of Public Health.
But public health officials are concerned because this could be a sign that the window of opportunity is closing and HIV may soon begin to have a greater impact on this community, McFarland says.
"Now if sexually transmitted diseases (STDs) and risk behavior are equal to whites; who had experienced larger HIV transmission, then you could assume that HIV transmission will increase," McFarland says.
The key question is whether health officials will see a larger integration of the Asian community into the mainstream community, which would result in more sexual mixing, and a higher HIV prevalence pool might extend into the lower HIV prevalence pool, McFarland says.
At present, the HIV prevalence rate among API MSM is about 2.6%, and the incidence rate is 1.8%, says Kyung-Hee Choi, PhD, associate professor at the University of California, San Francisco.
"So that’s almost two out of 100 young Asian/Pacific Islander MSM are getting infected," Choi says. "Now, the incidence rate may go up, and that’s a concern."
One factor that may have prevented the HIV incidence rate from rising in the API community thus far is that it appears that when an API man has sex with a man who is white, Latino, or African-American, he is less likely to engage in risk behavior, Choi notes. "What’s happening within the API MSM community is that when a sexual partner is API they are more likely to engage in risk behavior. Since HIV prevalence within the API community is low and they don’t use condoms with other APIs, then HIV won’t spread."
The unknown factor is whether this pattern of ethnic serosorting will continue, Choi explains.
Also, the HIV testing rate is relatively low among API MSM, so they may assume an API partner is HIV negative when that’s not always the case, Choi says.
"There should be a continuing effort to stress that people need to be tested for themselves, but also to find out the status of their partners," Choi adds.
While there may not be many HIV prevention programs specifically designed for the API community, there is one in San Francisco that is culturally savvy. The Asian and Pacific Islander Wellness Center has individual and group HIV interventions, as well as outreach programs, says Maximilian Rocha, LCSW, director of health education at the center.
The center provides outreach services to sex clubs, bars, and to local businesses where APIs congregate, including restaurants and salons, he says. "Through outreach, we try to recruit for risk reduction counseling or some form of case management. We try to attract clients to come in for services by providing social groups and educational workshops."
Outreach workers also attend community events, street fairs, and health fairs to keep HIV services in the public eye for those who may be reluctant to take a brochure right then because of the stigma associated with HIV, Rocha notes. "We try to be integrated with our services and in collaboration with an internal HIV testing team."
One of the key priorities of the center’s HIV prevention work is to be culturally competent and linguistically capable, he says.
There are Chinese, Thai, and Filipino-language educators, and, previously, there was a Vietnamese health educator, Rocha says. In all, the center has access to people who speak 20 different API languages, he adds.
An example of an intervention directed to one portion of the API community is the DOWNETime support group for Filipino men who do not identify as MSM, but who are on the down low — that is, they are having sex with men, Rocha explains.
While some support groups and social groups are sponsored by the center, there also are community groups that are held wherever people wish to congregate, including private homes, he says.
Although the program’s anecdotal evidence suggests increased condom use after counseling and interventions, the outcomes have not yet been studied, and there’s still work to be done, Rocha notes. "Resistance still is there. Men struggle with [using condoms] because it doesn’t feel good, and sometimes, in our conversations with clients, we hear that this is not a top priority."
API men often are struggling with other issues, including housing, social needs, accessing peers, and having social relationships, Rocha adds.
In addition, the stigma of HIV and being gay poses a significant barrier to HIV prevention work.
For example, one health educator, who worked with the Vietnamese community, found that in Vietnam, the images associated with HIV are of women who are scantily dressed, who work as prostitutes, and who are on drugs and dying, he explains.
"So the stigma is that it’s not me and only those kinds of people will get HIV," Rocha says. "So upon arriving here, they find that it’s not true and that anybody can get HIV, and you may get it if you engage in these other risk activities."
1. Truong HM, McFarland W, Folger K, et al. Increases in rates of unprotected anal intercourse and sexually transmitted diseases in Asian MSM in San Francisco. Presented at the 11th Conference on Retroviruses and Opportunistic Abstract 844. Infections. San Francisco; February 2004.