HIV testing, care and viral suppression among men who have sex with men and transgender individuals in Johannesburg, South Africa

Introduction Men who have sex with men and transgender individuals (MSM/TG) carry a disproportionately high burden of HIV, including in South Africa. However, there are few empirical population-representative estimates of viral suppression and the HIV care cascade including HIV testing among this population, nor of factors associated with these outcomes. Methods We conducted a respondent driven sampling (RDS) survey among 301 MSM/TG in Johannesburg in 2017. Participants gave blood samples for HIV testing and viral load. Participants self-completed a survey including sociodemographics, HIV testing history, and engagement in care. We calculated RDS-II weighted estimates of the percentage of HIV-negative MSM/TG reporting HIV testing in the previous 6 months, their testing experience and preferences. Among those HIV-positive, we estimated the percentage status-aware, on ART, and virally suppressed (<50 viral copies/ml plasma). We conducted RDS-weighted robust Poisson regression to obtain weighted prevalence ratios of factors associated with 1) HIV testing among those HIV-negative; and 2) viral suppression among those HIV-positive. Results There were 118/300 HIV-positive MSM/TG, (37.5%). Of the HIV-negative MSM/TG, 61.5% reported that they had tested for HIV in the previous 6 months, which was associated with selling sex to men (Prevalence Ratio = 1.67, 95% CI 1.36–2.05). There were 76/118 HIV-positive MSM/TG (56.5%) who reported having previously tested positive for HIV and 39/118 (30.0%) who reported current ART. There were 58/118 HIV-positive MSM/TG with viral loads <50 copies/ml plasma (46.9%). Viral suppression was associated with older age (adjusted PR = 1.03, 95% CI 1.00–1.06 for each year), neighbourhood, and having bought sex from men (adjusted PR = 1.53, 95% CI 1.12–2.08). Conclusions HIV prevalence was very high. Viral suppression among those HIV-positive was similar to the general male population in South Africa, but remains far short of national and international targets. A majority of HIV-negative MSM/TG had HIV tested in the previous 6 months, though there is room for improvement.


PRACTICE QUESTIONS
There are three main types of questions .. the most common has small ROUND buttons for the answers and you can click only one answer. Once you have clicked on an answer the question will disappear and the next one will be shown. If you have made a mistake, just click the left-facing arrow head ("BACK") button on the bottom left hand side of the screen. Try this one ...

How handsome are you?
Handsome Very handsome Incredibly handsome Other questions have small SQUARE buttons for the answers and you can click as many of the answers as you like. Once you have clicked on an answer the question will not dissappear -when you have finished you need to click the right-facing arrow head ("NEXT") button on the bottom right hand side. If you have made a mistake, just click the left-facing arrow head ("BACK") button on the bottom left hand side. Try this one ...

Which of the following sports do you watch on television?
Notice these questions often have an "OTHER" option -if you click this you need to type in your other answer. Click "OTHER" and write in "Boxing" (or any other sport you watch). Soccer Rugby Cricket Otherplease say which: (type in) A few questions ask you when you last did something and offer you a calender to pick the exact day, month and year. When this happens you can navigate the months and years using the left and right arrows on the calendar. When you have picked you date for your answer, click "Set" to record it. Once you have clicked on "Set" the question will disappear and the next one will be shown. Try this one ...

When did you last speak to one of your family members? Select date (day, month, year)
The next set of questions asks about how you meet and socialise with other men that have sex with men. I openly talk about it Not applicable D7. In the last 12 months, have you felt afraid to go to health care services because you worry someone may learn you have sex with men?

Yes No
D8. In the last 12 months, have you avoided going to health care services because you worry someone may learn you have sex with men?

Yes No
D9. In the last 12 months, have you felt that you were not treated well in a health centre because someone knew that you have sex with men?

Yes No
D10. In the last 12 months, have you heard health care providers gossiping or laughing about you because you have sex with men?

Yes No
D11. In the last 12 months, have you felt that the police refused to protect you because you have sex with men?

Yes No
D12. In the last 12 months, have you felt scared to be in public places because you have sex with men?

Yes No
D15. In the last 12 months, have you been blackmailed by someone because you have sex with men?

Yes No
D17. In the last 12 months, has someone ever physically hurt you (pushed, shoved, slapped, hit, kicked, choked or otherwise physically hurt you) due to the fact that you have sex with men? E14. In the last 12 months, have any women paid you in return for sex? By payment we mean she gave you money, gifts or favours in return for sex.

Yes No
E15. In the last 12 months, have you paid a woman in return for sex with her? By payment we mean you gave her money, gifts or favours in return for sex.

EX. SEXUAL BEHAVIOUR: PARTNERSHIP DYADS
We now want you to think about the last FOUR people you had sex with. We want to ask you a set of questions about each of these FOUR people. Choose a nickname or set of initials to help identify each one. These do not need to be real nicknames or initials, just something that will help keep track of who we are asking about.
Remember that by sex we mean any genital contact -including masturbation (wanking, fingering); oral sex (sucking/blowjobs, licking, rimming); vaginal or anal intercourse (fucking).

Partner #1:
Who was the last person you had sex with? (Write in a nickname, first name or initials)

[Enter initials]
Partner # 2: Before (Partner #1) who was the last person you had sex with? (Write in a nickname, first name or initials)

[Enter initials]
Partner #3: Before (Partner #2) who was the last person you had sex with? (Write in a nickname, first name or initials)

[Enter initials]
Partner #4: Before (Partner #3) who was the last person you had sex with? (Write in a nickname, first name or initials)

Partner #1
The following set of questions are about the first partner you mentioned.

Yes
There are three main routes through this section of the survey, depending on whether they are (1) a casual, one-off partner, (2) a regular sexual partner who they expect to have sex with again in the future, and (3) a partner who was regular but who they do not expect to have sex with again in the future. The online survey hosting system will automatically route people through the survey based on prior responses. For this Word version, all three routes are presented in turn. Revisions were necessary to this section following piloting. The questions remain largely the same as our previous submission, but have been re-ordered for clarity of completion and in anticipation of multiple partner types.

G. SEXUAL HEALTH & HIV
The next set of questions are about testing for HIV.

G1. What do you believe your current HIV status is today?
Negative (

G15. Where did you go the first time you visited a health care provider for this purpose?
A public hospital or clinic A private hospital or clinic A clinic just for men who have sex with men

ROUTINE HIV CARE
The next set of questions is about routine HIV care and support.

G16. When did you last see a health professional about your HIV care?
Within the last 6 months Between 6 to 12 months ago Between 1 to 2 years ago More than 2 years ago G17. Where did you go the last time you visited a health care provider for this purpose?
A public hospital or clinic A private hospital or clinic A clinic just for men who have sex with men G18. The last time you visited a health care provider for HIV care, were you satisfied with the privacy of the service?
Very satisfied Satisfied Dissatisfied Very dissatisfied I don't remember / I did not think about it G20. The last time you visited a health care provider for HIV care, were you satisfied with the respect staff showed you?
Very satisfied Satisfied Dissatisfied Very dissatisfied I don't remember / I did not think about it G22. Have you ever received a test to see how well your immune system is functioning. This is called a CD4 test?

G22a. [If G22 = yes] When did you last receive a CD4 count test result?
Within the last 6 months Between 6 to 12 months ago Between 1 to 2 years ago More than 2 years ago

G23. [If G22 = yes] What was your CD4 count the last time this was tested?
More than 500 Between 350-500 Under 350 I was told the result, but I do not remember I was told the result, but I did not understand it I was not told the result G24. Have you ever received a test to measure the amount of HIV infection in your blood? This is called a viral load test.
Yes No Not sure

G24a. [If G24 = yes] When did you last receive a viral load test result?
Within the last 6 months Between 6 to 12 months ago Between 1 to 2 years ago More than 2 years ago

G25. [If G24 = yes] What was the result of your viral load the last time it was tested?
Undetectable Detectable I was told the result, but I do not remember I was told the result, but I did not understand it I was not told the viral load test result

HIV TREATMENT (ART)
The next set of questions is about taking anti-HIV treatments (ART, HAART).

G26. Have you ever started taking antiretroviral therapy (sometimes called ART or HAART) for your HIV infection?
Yes

G29. What factors made you decide not to start antiretroviral treatment (ART)? [Tick all that apply]
Negative attitude of clinic staff toward MSM Negative attitude of clinic staff toward people living with HIV Fear of being noticed going to the clinic Long distance to get to the clinic High cost of the clinic/tests High cost of travel to the clinic High cost of medication Fear of medication side effects Fear that my medication will be noticed Did not believe the medication would work Did not believe I needed the medication Other reason [please specify_______________]

[JUMP TO SECTION G PART IV]
G30. Are you currently taking antiretroviral treatment (ART)?

[If G30 = no] When did you stop taking antiretroviral treatment (ART)?
Within the last 6 months Between 6 to 12 months ago Between 1 to 2 years ago More than 2 years ago

IF DISCREPENCY BETWEEN ANSWER TO A16 AND A17, OR IF TRANS IDENTIFYING IN A17
The next of questions is about access to -and use of -transgender services.

H. Post Exposure Prophylaxis (PEP)
The next set of questions is about Post Exposure Prophylaxis -which is also known as PEP.

H1. The following statement is true. Did you know this already?
Post exposure prophylaxis (PEP) is a one-month course of pills that may stop someone from becoming infected with HIV if they are exposed to the virus (such as by having sex without condoms). PEP needs to be started as soon as possible AFTER an HIV risk.

H. Pre Exposure Prophylaxis (PrEP)
The next set of questions is about Pre Exposure Prophylaxis -which is also known as PrEP.

H6. The following statement is true. Did you know this already?
Pre exposure prophylaxis (PrEP)

L. POPULATION ESTIMATORS
We now wish to ask whether or not you have used particular services recently. The answers to these questions will help us to estimate the number of MSM in the local area. No personal information will be passed on to or requested from any of these services to make this estimate.
[ If you feel you may have made any mistakes which you want to go back and correct, please mention this to the researcher who will help you.
If the survey has made you think of questions about your health or about this research study, please ask the researcher..

YOUR COUPON DISTRIBUTION (REFUSALS)
We want to ask you about the people who did NOT accept a coupon from you.

Q11
How many of the men you offered a coupon to, did not take one from you?

Q12 [For each of [Q11]
Thinking about the first man you offered a coupon too, that refused to take it, Why did that man not take a coupon from you? [tick all that apply] He said that he had already participated in the study He said that he had already received a coupon from someone else He said that he was not an MSM He said he was younger than 18 years old He said he was not from the same city as me He did not wish to participate in the study He said that there was not enough money for participating Other reasonsay what None of the above

YOUR COUPON DISTRIBUTION (ACCEPTED)
We now want to ask you about the people who did accept a coupon from you.

Q13 How many men did you offer a coupon to who accepted it?
[enter number 0-3]

IF Q13>0
Concerning the first person you gave a coupon to:

Q14i:
Thinking about the first man you offered a coupon too, that took it: Do you think this person would have given you a coupon if they had participated in the study before you?

Q14i:
Still thinking about the first man you offered a coupon too, that took it: Is this person over 30 years of age?

Yes No
Don't know