We describe the sexual practices and condom usage of men who have sex with men (MSM) at a community-based anonymous voluntary counseling and testing centre in Kuala Lumpur, Malaysia. This study is a first for Malaysia in this context. 433 MSM clients disclosed their sexual practices and condom use in the preceding 6 months using a self-reported questionnaire during pre-HIV test counseling at the centre. The mean age was 29.7 years, and 356 were homosexuals while 77 were bisexuals. Forty tested HIV positive (9.2%). 387 (94.9%) of 408 clients had anal sex, 395 (97.8%) of 404 clients had oral sex, while 43 (18.4%) of 233 clients had vaginal sex which revealed that even men who identified themselves as homosexuals do practice vaginal sex. Having multiple sexual partners is common (mean 11.6 partners per client). 259 (59.8%) had unprotected sex within the last 6 months. Consistent condom use rates during vaginal, anal, and oral sex were 20%, 23.5%, and 1.3%, respectively. The odds ratio of testing HIV positive with inconsistent condom use during anal sex was 3.7 (
Men who have sex with men (MSM) are male persons who engage in sexual activity with members of the same sex, regardless of how they identify themselves. The term was created in the 1990s by epidemiologists in order to study the spread of disease among men who have sex with men, regardless of identity. Many men who engaged in sex with other men often do not consider themselves to be either gay or bisexual [
While the HIV epidemic seems to have stabilized at low levels in the general population or even declined globally over the last few years, amongst the MSM community, there is evidence of resurgence of HIV infection in the Western world as well as countries in Asia, Africa, and Latin America [
Between 2002 and 2007, HIV infection in several Asian countries such as Hong Kong and Taiwan increased by more than 200% [
Until recently, little is known about condom use during sexual intercourse and sexual habits of MSM in Malaysia. A survey using venue-day-time sampling by Kanter et al. [
Data were collated from the pre-HIV testing questionnaires filled by all clients seeking VCT services at the community-based VCT centre from January 2008 until December 2008. Completion of the form was voluntary, and no data identifiable to the client were required. A total of 740 clients sought VCT services at the centre between January1, 2008, and December 31, 2008. There were 433 clients who disclosed their sexuality as either homosexual or bisexual men and they were collectively categorized as MSM in this study. Transgender people have been excluded from this study as they are increasingly viewed as a separate group with unique needs and concerns [
Clients were asked to disclose their sexual practices, number of sexual partners in the preceding 6 months, last unprotected sexual intercourse, and condom usage during sexual intercourse in the preceding 6 months. Condom use during sexual intercourse was categorized as “consistent condom use” (condom was used on every single sexual intercourse in the preceding 6 months) and “inconsistent condom use” (condom may or may not have been used on every single sexual intercourse in the preceding 6 months).
HIV rapid tests were performed using either SD Bioline HIV test (Standard Diagnostics Inc.) or ACON HIV test kits according to the manufacturer’s specification. Descriptive analysis including calculation of chi square and odds ratio was performed using SPSS for Windows v17.
Of 433 MSM, 356 (82.2%) identified themselves as homosexuals while 77 (17.8%) identified themselves as bisexuals. The mean age was 29.2 years old (median 28 years). The youngest was 18 years old, while the oldest was 61 years old. Most of the clients were of Chinese (
Sociodemographic profiles of MSM seeking VCT services.
Sociodemographic factors | Frequency | Percentage |
---|---|---|
Age groups in years ( |
||
<20 | 7 | 1.6 |
20–29 | 258 | 59.8 |
30–39 | 130 | 30.2 |
40–49 | 28 | 6.5 |
50–59 | 6 | 1.4 |
>60 | 2 | 0.5 |
Ethnic group ( |
||
Malay | 115 | 26.8 |
Chinese | 253 | 59.0 |
Indian | 21 | 4.9 |
Other | 40 | 9.3 |
Marital status ( |
||
Single | 310 | 97.5 |
Married | 8 | 2.5 |
Current relationship status ( |
||
Not in relationship | 340 | 80.8 |
Monogamous relationship | 55 | 13.1 |
Open relationship | 26 | 6.1 |
Sexuality ( |
||
Homosexual | 356 | 82.2 |
Bisexual | 77 | 17.8 |
*Number of clients who responded to this part of the pre-HIV testing questionnaire.
In the preceding 6 months, 387 clients reported having engaged in anal sex, 395 in oral sex, and 43 in vaginal sex (Table
Sexual practices engaged by MSM in the preceding 6 months.
Sexual practice | Number engaged in the sexual practice |
---|---|
Vaginal sex ( |
|
(i) Homosexuals ( |
15 (8.0%) |
(ii) Bisexuals ( |
28 (60.9%) |
Oral sex ( |
|
(i) Homosexuals ( |
328 (97.9%) |
(ii) Bisexuals ( |
67 (97.1%) |
Anal sex ( |
|
(i) Homosexuals ( |
322 (95.0%) |
(ii) Bisexuals ( |
65 (94.2%) |
*Number of clients who responded to this part of the pre-HIV testing questionnaire.
Combinations of sexual practices amongst MSM.
Sexual practice combinations | Homosexuals* (%) | Bisexuals* (%) |
---|---|---|
Vaginal only | 5 (1.4%) | 1 (1.4%) |
Anal only | 20 (5.7%) | 3 (4.1%) |
Oral only | 17 (4.8%) | 5 (6.8%) |
Vaginal and anal | 0 | 2 (2.7%) |
Vaginal and oral | 7 (2.0%) | 3 (4.1%) |
Anal and oral | 300 (85.2%) | 37 (50.7%) |
Vaginal, anal, and oral | 3 (0.9%) | 22 (30.1%) |
| ||
Total | 352 (100%) | 73 (100%) |
*Number of clients who responded to this part of the pre-HIV testing questionnaire.
With regards to number of sexual partners in the preceding 6 months (Table
Number of sexual partners in preceding last 6 months amongst MSM (
Number of sex partners in preceding 6 months |
|
HIV positive |
---|---|---|
<10 | 159 | 15 (9.4%) |
10–19 | 59 | 5 (8.5%) |
20–29 | 32 | 4 (12.5%) |
>30 | 27 | 1 (3.7%) |
| ||
Total | 277 | 25 (9.0%) |
*Number of clients who responded to this part of the pre-HIV testing questionnaire.
With regards to condom use during vaginal sex in the preceding 6 months, 32 (80.0%) out of 40 clients reported inconsistent condom (Table
Condom use during sexual intercourse amongst MSM and HIV test results.
Sexual practices |
|
HIV positive (%) |
---|---|---|
Vaginal sex ( |
||
(i) Consistent condom use | 8 (20%) | 0 |
(ii) Inconsistent condom use | 32 (80%) | 4 (12.5%) |
Oral sex ( |
||
(i) Consistent condom use | 3 (1.3%) | 0 |
(ii) Inconsistent condom use | 231 (98.7%) | 21 (9.1%) |
Anal sex ( |
||
(i) Consistent condom use | 87 (23.5%) | 3 (3.4%) |
(ii) Inconsistent condom use | 284 (76.5%) | 33 (11.6%) |
*Number of clients who responded to this part of the pre-HIV testing questionnaire.
Clients who used condoms inconsistently during anal sex were 3.7 times more likely to be HIV positive (
The HIV epidemic in Asia has traditionally been fueled and concentrated in high-risk populations, namely, the injecting drug users, sex workers and their clients, and MSM. From these 3 groups, HIV is steadily expanding into lower-risk populations through transmission to the sexual partners of those most at risk [
The prevalence of male-to-male sex in 2008 in Southeast Asia was estimated to be between 6% and 12% [
In a review of cross-sectional studies done in Asian countries, the HIV prevalence in MSM ranged 0.7–8.7% in Cambodia, 0−7.8% in Vietnam, 17.3–30.8% in Thailand, 5.6% in Lao PDR, 23.5% in Yangon (Myanmar), 35% in Mandalay (Myanmar), 8.5% in Taipei, 4.2% in Singapore, 4.1% in Hong Kong, and between 2% and 8.1% in the Indonesian cities of Bandung, Surabaya, and Jakarta, respectively [
In Malaysia, the actual prevalence of HIV or risk behaviors amongst MSM is unknown. A recent venue-based study in Kuala Lumpur amongst MSM by Kanter [
In our study cohort, the HIV prevalence was 9.2%. This figure is higher than what was reported by Kanter [
The majority of the clients in our study engaged in a combination of oral and anal sex while a number of them also engaged in vaginal sex although these men still identified themselves as homosexuals (Table
The majority of the clients in our study had multiple sexual partners. In the MSM community, having multiple sexual partners is well recognised. In the WHO SEARO [
In our study, the average number of sexual partners per client in the preceding 6 months was 11.6. Interestingly, there was no statistically significant difference in the prevalence of HIV between those who had less than 10 sexual partners and those who had more than 10 sexual partners (
Correct and consistent condom use during sexual intercourse remains the most effective method of preventing HIV transmission [
Unfortunately, the rate of condom use by MSM in Southeast Asia countries is generally very low. The United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) in its report for 2009 revealed that while >80% of MSM in Thailand and Cambodia used condoms, other Southeast Asian countries have much lower rate of condom use. For instance, only 24.2% of MSM in Lao PDR, 32% of MSM in the Philippines, and 39.3% of MSM in Indonesia used condoms [
Until now, the rate of condom use during amongst MSM in Malaysia is unknown. The high rates of inconsistent condom use disclosed by clients in this study are alarming with 80% not using a condom consistently during vaginal sex, 98.7% during oral sex, and 76.5% during anal sex, respectively (Table
None of those who reported using condom consistently during oral (
The low rate of consistent condom use during anal sex in our study cohort is a cause for grave concern. Unprotected anal sex has the highest risk of HIV transmission because the thin lining of the rectum and anus can easily be compromised during sex. In our study, the odds ratio of acquiring HIV infection for a person who engaged in anal sex with inconsistent condom use is 3.7 times higher compared to a person who consistently used condoms during anal sex. The possible reasons contributing to inconsistent condom use may be the relative inaccessibility of condoms at venues of sexual activities, ignorance or lack of knowledge in the spread of sexually transmitted infections, incorrect perception of one’s own likelihood of HIV acquisition, concurrent substance abuse, the false security in having a steady partner, lack of communication with partners regarding risk reduction practices, frequent rough intercourse, as well as attitudinal and behavioral issues. [
Our study showed that the sexual practices of MSM in our study cohort are not unlike their counterparts in other Asian countries. A significant number of clients in our study cohort also have female sex partners, potentially becoming a conduit for the spread of HIV to the non-MSM population as is happening in other parts of Asia. The low rate of consistent condom use during anal sex in our study cohort is also a cause for concern.
Our findings in this study were subjected to 3 potential biases. First, our findings would be biased if participants chose not to give accurate information regarding their sexual practices, condom use, or whether they had tested HIV positive previously in another testing facility. We did not use computer-based self-administered questionnaire which may be more effective in obtaining sensitive information [
Secondly, since our study was confined to MSM who attended a MSM-identified VCT centre, our findings may not be generalized to MSM who do not use VCT services. Thirdly, MSM requesting VCT services have high-risk sexual behaviors and are at risk of HIV acquisition. We observed a higher HIV prevalence amongst MSM in our study compared to a venue-based study conducted in the same city [
Nevertheless, our findings of high-risk sexual behaviors coupled with a high rate of inconsistent condom use are major concerns. Specific interventions that target sexual risk behaviors and condom use are necessary in this group.
The authors declare no conflict of interests in submitting this paper for publication. They further declare that this study received no funding from any organizations or persons.
K. C. Koh contributed to the study design, data collating and data entry, statistical analysis, literature search, and writing of the paper. A. Kamarulzaman helped with the Study design and reviewing of the paper. K. Kanagalingam and F. T. Tai contributed to the formulation of questionnaire and data gathering.