A descriptive study on risky sexual behaviors of men who have sex with men and the impact of counseling services on behavior change , in a sexually transmitted diseases clinic in Sri Lanka

Introduction: Sri Lanka is considered a low prevalence country for HIV since the first case was diagnosed in 1986. In the recent years, the country is experiencing an increasing incidence ofHIV among young men who have sex with men (MSM). A record based baseline study was first conducted to collect the demographic and behavioral data among the group. Based on these findings , a selfadministered questionnaire was then used at the first visit and 6 months later to assess the effectiveness of routine counseling provided in the sexually transmitted diseases clinic (STD clinic) on changing their behavior and attitudes.


Introduction
Sri Lanka remains as a low HIV prevalent country with an estimated sero-prevalence of less than 0.1 % in the general population 1 • The sero-prevalence among key populations (female sex workers (FSW), MSM, injecting drug users (IDU) and beach boys) is also< 0.1 % 1 • Among the most at-risk groups, MSM are an important group to address because of their pattern of risky sexual behavior.In the past few years, there has been increased concern about new, newly identified and resurging epidemics of HIV infection in MSM on a global level2• 3 .Over the past years, it is observed that the prevalence of sexually transmitted infections especially syphilis is increasing among MSMs all over the world.Research among MSM in low and middle income countries has been limited due to the result of criminalization and social stigmatization of these behaviors.
Change of risky sexual behavior is the key to reducing new infections among these populations.Behavior change communication is the mainstay of the behavior change process.At STD clinics in Sri Lanka, we offer standard counseling for HIV testing and a formal one-on-one interview with a trained health care worker to support people with risky sexual behaviors to change their behaviors.
The main objective of this study was to ascertain the effectiveness of counseling done at the STD clinic, Ragama on changing attitudes and sexual risk behaviors among MSM.Furthermore, the study specifically looked at the level of HIV risk behaviours, attitudes towards government STD clinic services and effectiveness of behavior change communication.
We observed a significant mcrease of MSMsattending the STD clinic at Teaching Hospital Ragama with STis and HIV during the recent years.The percentages of HIV diagnosis among MSMs who attended the Ragama Clinic was 1.75% (1/57), 3.22% (1131), 5.26% (1/19) and 3.09% ( 3/97) in years 2009,2010,2011 and 2012 respectively.The percentages of STI s reported among MSMs were also significant amounting to 61.4%, 58%, 68.4% and 44.3% in 2009,2010,2011and2012 respectively.As this was a new observation in comparison to the previous years, which may be indicative of a drastic change in the country's epidemic, we conducted a, baseline assessment of their sexual behavior.The findings were very significant with 42% having casual partners and 21 % having non-regular partners; their condom use at last exposure was only 13%.

Methodology
In 2012, a baseline assessment on the HIV risk behaviors among MSMs who attended the STD Clinic, Ragama was conducted 4 • Based on the alarming findings, we wanted to assess the impact of counseling services provided by the STD clinic Ragama.So a descriptive cross sectional study was carried out on the MSMs who attend the STD Clinic at Ragama from Ol5 1 January 2013 to 31 st May 2014.All the consecutive MSMs registered in the clinic during the specified period were recruited to the study.A questionnaire was introduced at the first visit to get the baseline data according to the objectives of the study.A separate questionnaire was given to the same subjects at 6 months to assess behavior change overtime and the change in the attitudes and perceived barriers to reach the services provided by the government STD clinics.
Even though 194 MS Ms were registered in the clinic during the study period, only 82 subjects attended the clinic for a follow up visit at six months.So, the results were analyzed only using the sample who responded after 6 months, by using the Statistical Package for the Social Sciences (SPSS) version 16.

Background characteristics
Only 82 (42.2%) attended the clinic after 6 months for a review at the clinic.Out of the number who attended after 6 months, majority (53.7%) was between 21-30 years of age, 8.6% belonged to the age group of 15-20 years while only a minority (2.4%) was above the age of 50.Sixty two (75.6%) of them The Sri Lanka Journal of Venereology Vol. 5, No. 1, December 2014 Paper were single while 16 (19.5%)were married.Majority (42.7 %) was educated up to OIL and 14.6% had only primary education.A small percentage (6.1 %) had a degree or a diploma.A major percentage (56.1 %) of them was employed with wages while 13.4% were unemployed.Nineteen percent of them were self-employed.
Half ( 50%) of the sample reported observing people was their method of finding partners while 35.4% reported friends as the way of finding partners.Out of the MSM studied, the majority (35.4%) were brought to the clinic by the escorts carried out by the peer led programme conducted in the district.Only a very small percentage (3.7%) attended the clinic voluntarily.While 19.5% of them attended the clinic with symptoms, 13.4% came to the clinic by a referral.It was interesting to note that more than half (53.7%) of them did have an STI on attendance.

Level of risk behaviour
A majority (79.3%) of them did know about the condom before coming to the clinic while 20.7% of them were unaware.Only 51.2% of them had knowledge on lubricants.Out of the total sample of 82, only 45 (54.8%) used a condom at their last sexual exposure.The majority (57.3%) of them were nonalcohol users.A significant number, 14 (17 .1 %) reported habitual use of alcohol.while 93.9% of them were non -recreational drug users.

Attitudes towards government STD services
More than half of them (63.4%) had a reluctance to attend the clinic for the first time while 24 (29.3%) reported that they did not have any reluctance .Majority (93.7% )of them said they were well accepted by both the minor and major staff including the doctors who worked as counselors and they did not have any concerns regarding the confidentiality while only 1.2% of them felt insecure with the STD clinic staff.Majority (92.7%) of them thought screening for STI's is important after the counseling session and 89% of them thought bringing the partners to the clinic for screening is important.Majority (79.3%) of them said that they realized attending the clinic again is very important and they will do that.Only 4.9% thought it is not important.Majority (96.3%) of them accepted that they gained knowledge on HIV and STis after the clinic visit.

Effectiveness of behavior change communicatio~
When we analyzed the sample after 6 months, the majority (89%) accepted that they changed their attitudes regarding attending STI services while only 11 % said that their attitudes were not changed.But a great majority (90.2%) of them wanted to change their risky behavior after routine counseling at STI services.9.8% of them did not want to change their behavior.Although 90.2% were willing to change their behavior, only 74.4% of them accepted that a behavior change has occurred.

Di.scussion
Behaviour change through counseling is the mainstay to reduce risky sexual behaviours and thereby reduce the transmission of HIV infection.The services provided in STD c1ill 1cs in Sri Lanka provide standard HIV test counseling as well as counseling on safer sexual practices for the clients .This study was conducted on the findings of baseline study done in 2012 and was focused to assess the level of risky sexual behaviours, attitudes among MSM towards government STD clinics and the effectiveness of behaviOTir change communication done in the STD clinic settings.

Socio-demographic factors
The survey showed that their literacy level is lower than the baseline survey showing the efficacy of the peer led programme to reach lower social strata as well.It is very important to reach this population as they are the most vulnerable and will not attend the services.The fact that a major percentage (56.1%) of them were employed with wages should be taken in to consideration for making the clinic opening hours friendly to them .. None from this group reported commercial sex as their method of livelihood while 4.1 % from the previous group reported commercial sex.

Level of risk behaviours
The rate of anal sex was significantly high and the condom use at last sex was 54.8%.This study showed an improved rate for condom use at last sex when compared with the baseline survey which was only 10%.UN GASS country progress reports in 2008 also showed similar results with 54% condom use at last sexual exposure 5 .This higher figure may be due to the peer led programme.None of them reported condom use with oral sex.Only 51.2% of them had some knowledge on lubricants.In contrast, a study done among Latina MSM in New York showed very high rate of knowledge and usage on lubricants 6 • The presence of STis in more than half of the sample was a significant factor increasing the acquisition of HIV.The use of alcohol and recreational drugs by them though the percentage is small, is contributory to increasing the risk of acquisition of HIV.A study done in a London sexual health clinic showed that although counselling reduces the immediate risk taking behaviour, it does not affect the rate of acquisition of new infections among high risk groups 7 • The analysis of reason for attendance showed us that both voluntary attendance and referrals were low.This factor should be taken in to consideration to improve knowledge of care providers on symptoms of STis and link between high risk groups and STis.A major percentage (93.9%) of them was( ffonrecreational drug users.A significant numl:\~ 14 (17 .1 % ) reported habitual alcohol use.A similar stiidy done in china revealed similar alcohol usage rate and higher illegal drug use 8 .HIV transmission and acquisition is high in the presence of an STI.It was interesting to note that more than half (53.7%) of them did have an STI on attendance.In the above study among Chinese MSM, only 20% were diagnosed to be having an STI 8 .

Attitude towards government STD services
Perceived stigma in clinical settings is the main factor discouraging high risk groups attending health care facilities.

Paper
In this study, more than half of them (63.4%) were reluctant to attend the clinic when interviewed in the first visit.But the majority (93.7%) of them said they were well accepted by both the minor and major staff.The well-structured training programmes including counselling for STD clinic staff should be done regularly.A similar study conducted in Nigeria showed poor attitude of staff towards them 9 .Compared to studies carried out in Belize 10 and Los Angeles 11 , the discrimination by the health care staff is minimal at the study setting.While the majority (92.7%) of them thought screening for STI's is important after the counseling session and the fact that most (89%) of them thought that bringing the partners to the clinic for screening is important should be studied in detail ideally by a qualitative survey as actual partner screening is very low at the Ragama Clinic as well as in all STI clinics in Sri Lanka.It was very satisfying and encouraging to notice that most (96.3%) of them said that they gained knowledge on HIV and STis after the clinic visit.

Effectiveness of behuviour change communication
A main objective of this study was to find out the change in risky behaviour after a period of time from the first presentation to the clinic.In this study only 42.2% attended the clinic for the second time which is lower than the expected.
A study done at an anonymous testing site in San Francisco, California on counselling interventions has given promising results in decreasing individual risk behaviour and thus limiting community-level HIV transmission 13 .A multi-center assessment on the effect of counselling on negative consequences can reduce HIV transmission behaviours significantly 14 .Although the majority (74.4%) verbally accepted a behaviour change, a low (54.8%)condom use at last sex was noted.The knowledge on lubricant use (51.2%) to protect the condom shows the efficiency of the peer led model to educate high risk groups.When we analysed the sample after 6 months, the majority (89%) accepted that they changed their attitudes regarding attending STI services.Only 9.8% of them did not want to change their behaviour.

• Paper
The investigators of this study wanted to assess the behaviour change of a major risk group in the country with regular counselling services done in the government STI services and to make necessary changes which will have an impact in changing the country epidemic.The study was done in only one clinic as the investigators were based at the study site.This result could be generalized as the medical officers and other staff working at STI clinics in Sri Lanka is given a standard training from the national programme on behaviour change counseling.

Conclusion
Although counseling is done aimed at reducing risky behavior and attitudes of MSMs on seeking regular health care including screening, the change is not up to the expected level of at least 80%.The attendance to clinics after the first visit is very low.Contact screening is also at a very low level.

Recommendations
Training of health care workers on counseling for change in sexual behavior of MSM should be a continuous process and the modules should be updated based on evidence.Measures should be taken to improve contact and default tracing.Health care providers should be given knowledge on STI, HIV, and high risk groups in order to improve refeITals.Qualitative research should be done in order to assess the factors for continuing risky behavior despite the knowledge.