Exploring risk and opportunity to improve the health of behaviourally bisexual men in Vientiane, Laos

Abstract

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.