A cross-sectional survey exploring HIV and HCV prevalence among men who purchase sex in Dnipro, Ukraine

The Dynamics study is a cross-sectional mixed methods study exploring the impact of conflict on HIV and HCV risk and prevalence among female sex workers and men who purchase sex in Dnipro city, Dnipropetrovsk oblast (study details have been described in detail in a previous publication [20]). Dnipro has a population of nearly 1 million people, with 45.2% of the population being male [21]. There are an estimated 86,600 sex workers working across Ukraine [18]. HIV cases in Dnipropetrovsk region are estimated at 765.0 per 100,000 population, compared to the national average of 355.1 per 100,000 population [5].

The Dynamics study is a partnership between the NGO “Ukrainian Institute for Social Research after Oleksandr Yaremenko” (UISR after Oleksandr Yaremenko) and the Institute for Global Public Health at the University of Manitoba, with collaboration from the Center for Public Health of the Ministry of Health in Ukraine and the Dnipro Oblast AIDS Center. Local data collection was undertaken by researchers from UISR after Oleksandr Yaremenko and DEF Group (a research organization-based in Dnipro).

Geographic mapping and population size estimation was conducted in “hotspots” that are associated with sex work (details on mapping are described in previous publications [22, 23]; details on hotspots are described in another publication [24]). Mapping and size estimation involved a two-stage approach. In the first stage, a list of potential hotspots was generated through interviewing key informants who are associated with, or aware of, workplaces for sex work. Key informants included sex workers, other individuals connected to sex work, and people working in NGOs. In the second stage, each identified hotspot was visited by the mapping team (consisting of a researcher and a social mobilizer, usually an outreach worker) to validate its existence and activity, and estimate population size. The mapping exercise captured hotspot types and estimates of the number of women working at each hotspot, and the number of men who were at the hotspot to purchase sex services. This list of 320 active hotspots formed the basis for the sampling frame for the bio-behavioural assessment. The mapping exercise estimated 1,395 female sex workers (range 1,155–1,635) and a mean of 9.2 men who intended on buying sex services (interquartile range [IQR] 5.0–11.0) per hotspot. Following mapping, we conducted a cross-sectional bio-behavioural survey between September 2017 and March 2018. Men were selected to participate following a two-stage study design, selecting hotspots in the first stage and participants in the second stage. The sample of hotspots were selected using a probability proportion to size of estimated men at the hotspot and then subsequently, men were selected randomly from the sampled hotspots. Study interviewers, with the help of social mobilizers, recruited participants. Inclusion criteria for men was purchasing sex at the validated hotspot and being ≥ 18 years. Following written informed consent for eligible participants, trained interviewers administered a structured questionnaire in the local language. Survey questions included standardized and locally validated questions on socio-demographics, risk behaviours, and structural factors based on Integrated Biological and Behavioural Survey Guidelines, and our prior work [25, 26]. Surveys took, on average, thirty minutes to complete and participants received an honorarium of 400 UAH (approximately $20 CDN) for their time.

For consenting participants, biological tests included a fingerprick sample to be used in rapid tests for HIV (SD Bioline HIV ½ 3.0) and HCV (Wantai Rapid test for HCV), as per national testing guidelines. Pre- and post-test counselling was provided, as well as linkage to treatment and care services for those who tested positive for HIV and HCV. A dried blood spot (DBS) sample was also collected for confirmatory HIV and HCV serological testing (Avioq HIV-1 Microelisa System and Ortho HCV v3.0 ELISA Test System respectively) and viral genotyping [27, 28] at the National HIV and Retrovirology Laboratories in Winnipeg, Canada. Prevalence results were calculated based on confirmatory serological testing.

Descriptive statistics and measures of central tendency were performed using Stata15.

Written informed consent was obtained for all participants. Ethical approval was obtained from the Human Research Ethics Board at the University of Manitoba [HS20653(H2017:097)], the Ethical Review Committee of the Sociological Association of Ukraine, and the Committee of Medical Ethics of the L. Gromashevsky Institute of Epidemiology and Infectious Diseases at the National Academy of Medical Sciences of Ukraine.

Participant characteristics are summarized in Table 1. The median age of study participants was 32 years (interquartile range [IQR] = 27–38 years). Over half of participants were single, widowed, divorced, or not living with an intimate partner. Approximately a third of participants (32.2%, n = 119) had completed graduate school and a third were entrepreneurs (33.2%, n = 123). Almost half of the men had enough money to buy necessities such as food, clothing and shoes, and other basic items, but had to save, borrow money, or take a loan to purchase expensive items (e.g., large household appliances—TV, refrigerator, computer, washing machine, etc.) (47.6%, n = 176).

The median age of first purchase of sexual services was 22 years (IQR = 19–27 years). Almost half of the men visited “offices”, a brothel-like venue, as their main place to purchase sex services (48.9%, n = 181); slightly more than half visited only one hotspot (55.1%, n = 204) and 44.1% (n = 163) visited more than one hotspot in the past 12 months. Two-thirds of men (66.2%, n = 245) reported seeing only one sex worker in the past 30 days. Condom use was high, with 95.9% (n = 347) of participants reporting using a condom 100% of the time with sex workers in the past 30 days, while 77.5% (n = 287) reported never paying extra for sex without a condom in the past 12 months. Most men had sex with other partners in the previous 30 days, including intimate, transactional, and/or casual sex partners (84.9%, n = 314). Of those who had sex with intimate partners, 39.7% (n = 106) did not use condoms.

Over a third of participants (38.1%, n = 141) had ever used illicit drugs; 14 (9.9%) of whom ever used injection drugs. Half of the participants “binge-drank” (defined as consumed 5 or more alcoholic drinks in a row) at least once a month (49.7%, n = 184) (Table 2).

Among participants, over half (56.2%, n = 208) reported ever testing for HIV in their lifetime, nearly all of whom (99.0%, n = 206) had received the result from their last HIV test. Two percent (n = 4) reported having tested positive for HIV. Three out of the four participants who had previously tested positive for HIV had started antiretroviral therapy (ART) and were on ART at the time of the survey. Among those who had ever tested, approximately a quarter (26.4%, n = 55) had tested within the past year. Forty percent (n = 148) of participants had ever tested for HCV; 95.9% (n = 142) had received results from their last HCV test, with two percent (2.1%, n = 3) having ever tested positive for HCV. Sixteen percent (15.7%, n = 58) of participants self-reported ever having a sexually transmitted infection (STI), such as chlamydia, gonorrhea, or syphilis. In the past 12 months, three (0.8%) participants reported being treated for an STI.

All participants (100%, n = 370) provided consent to receive a rapid test for HIV and HCV, and all but one (99.7%, n = 369) agreed to a DBS test for HIV and HCV testing. Nine participants (2.4%) tested positive for HIV in both the rapid and DBS test; 32 (8.7%) tested positive for HCV using the rapid test and 24 (6.5%) tested positive for HCV in the DBS. It is important to note that a positive HCV test result indicates having ever tested positive for HCV and is not necessarily indicative of an active infection.

Of the nine participants who tested positive for HIV, five did not self-report a previous positive HIV test result. Among the 24 participants who tested positive for HCV, 23 (95.8%) did not report a previous positive HCV test result. In sub-analyses, two of those testing positive for HIV and six of those testing positive for HCV reported ever using injection drugs.

These data are descriptive in nature and drawn from a cross-sectional bio-behavioural survey, therefore no causality can be inferred. Participant characteristics, sex and drug use practices, and previous STBBI testing and treatment are self-reported and subject to recall, social desirability, and misclassification biases. Since the list of hotspots identified in the mapping served as the sampling frame for this study, the men recruited from mapped hotspots and who agreed to participate in the study may not represent men who purchase sex outside of these hotspots or who chose not to participate. Further, these data were collected between 2017 and 2018 and do not reflect the current situation in Dnipro, Ukraine, which is undergoing a severe crisis due to full-scale, nation-wide war.