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Risks for HIV and other sexually transmitted infections among Asian men who have sex with men in Vancouver,… Maung Maung, Thiha; Chen, Becky; Moore, David M; Chan, Keith; Kanters, Steve; Michelow, Warren; Hogg, Robert S; Nakamura, Nadine; Robert, Wayne; Gustafson, Reka; Gilbert, Mark Aug 16, 2013

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RESEARCH ARTICLE Open AccessRisks for HIV and other sexually transmittedinfections among Asian men who have sex withmen in Vancouver, British Columbia: across-sectional surveyThiha Maung Maung1, Becky Chen2, David M Moore2,3*, Keith Chan3, Steve Kanters3, Warren Michelow3,Robert S Hogg1,3, Nadine Nakamura1,7, Wayne Robert4, Reka Gustafson5, Mark Gilbert2,6 and The ManCount StudyTeamAbstractBackground: Individuals of Asian heritage represent the largest ethnic minority in Canada. Approximately 10% ofthe new HIV diagnoses in men in British Columbia occur among Asian-Canadians. However, the HIV risk patterns ofAsian men who have sex with men (MSM) have not been extensively studied.Methods: Participants aged ≥ 19 years were enrolled in a venue-based HIV serobehavioural survey of MSM inVancouver, Canada. We compared the demographic characteristics, risk behaviours, and prevalence of HIV andother sexual and blood borne infections between Asian and non-Asian MSM using bivariate analysis and logisticregression confounder modelling.Results: Amongst 1132 participants, 110 (9.7%) self-identified as Asian. Asian participants were younger than non-Asian participants (median age 29 vs. 32 years; p < 0.001), but otherwise did not differ from other study participants.HIV prevalence was lower among Asian MSM compared to Non-Asian MSM (3.7% vs 19.0%, p <0.001). Among menwho self-reported as HIV negative or unknown we found no differences in unprotected anal intercourse (UAI) witha discordant or unknown serostatus partner in the previous six months (11 vs. 13%; p = 0.503). However, Asian MSMwere less likely to report ever using injection drugs (10.8% vs. 19.2%; p = 0.043) or using alcohol before having sex(52% vs. 64.4%; p = 0.017).Conclusions: Asian MSM in our study reported similar rates of UAI as non-Asian MSM, but had a lower prevalenceof HIV infection. Other factors, such as the use of drugs and alcohol, in relation to sex, may partly explain thesedifferences. However this requires further investigation.Keywords: HIV, Homosexuality, Men who have sex with men, AsianBackgroundMen who have sex with men (MSM) in Canada continueto be heavily affected by HIV and sexually transmittedinfections (STI), accounting for 46.6% of the total newHIV infections in 2011 [1]. In the United States, ethnicminorities, predominantly black and Latino men, areoverly represented in the HIV epidemic among MSM[2]. However, relatively little has been written about eth-nicity for MSM outside of the United States. Individualswhose family origins are in Asia represent the largest ra-cial minority in Canada, making up 11% of the popula-tion [3]. However, 60% of new immigrants to Canadafrom 2001–2006 were from Asian countries. Further-more, in major metropolitan cities, such as Toronto andVancouver, individuals of Asian ancestry represent 30%and 40%, respectively, of the population [3].In British Columbia, Asian-Canadians accounted for11.9% of new HIV diagnoses in men in 2009, which is the* Correspondence: dmoore@cfenet.ubc.ca2Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada3British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, CanadaFull list of author information is available at the end of the article© 2013 Maung Maung et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Maung Maung et al. BMC Public Health 2013, 13:763http://www.biomedcentral.com/1471-2458/13/763largest number of any ethnic minority [4]. The majority ofthese infections are due to male-to-male transmission(M. Gilbert, personal communication). Despite the prom-inence and growth of the Asian-Canadian population, verylittle is known about HIV risk behaviours among Asian-Canadian MSM. Only a handful of studies have beenconducted on HIV risk among Asian-Canadians [5-9].In order to improve our understanding of Asian MSMand HIV risk behaviour we conducted a secondary ana-lysis of a cross-sectional serobehavioural survey of MSMin Vancouver. We sought to evaluate the differences indemographic characteristics, risk behaviours and HIVprevalence among Asian and non-Asian MSM, and evalu-ate testing patterns for HIV and other STIs and bloodborne infections among this population. In this analysisAsian MSM included participants who identified with anyAsian ethnic or cultural group whether from east, west,central or south Asia.MethodsWe used data from the ManCount Survey, the Vancouversite of M-Track, a behavioural and biological surveillanceprogram for HIV and other sexually transmitted andblood-borne infections among MSM coordinated by thePublic Health Agency of Canada. In Vancouver, the surveywas conducted between August 2008 and February 2009.ManCount applied a venue-based, time-space samplingmethodology [10] and recruited men 19 years of age andolder who self-identified as an MSM at a selection of 20community venues or events in Vancouver. Following in-formed consent, participants self-administered an Englishlanguage survey and provided a blood sample on filterpaper for a dried blood spot (DBS) specimen. The informedconsent process, questionnaire administration and bloodcollection all took place on-site in the recruitment venues.DBS specimens were tested for HIV and syphilis, at theNational HIV Retrovirology Laboratories in Ottawa. Thedetails of this testing is described elsewhere [11]. Ethics ap-proval for the ManCount survey was obtained from HealthCanada, Vancouver Coastal Health and the University ofBritish Columbia. Ethics approval was also obtained fromSimon Fraser University for this secondary data analysis.For this study, Asian ethnicity was defined based onanswers from two survey questions on ethnicity: “Whatare the ethnic or cultural origins of your ancestors?”(multiple responses permitted), and “Which single ethnicor cultural group do you most strongly identify with?”(single response permitted). Both questions provided alist of 26 examples of possible ethnicities followed by“etc.” to guide respondents. The list included Chinese,East Indian, Fillipino and Vietnamese as examples. Par-ticipants were identified as being of Asian ethnicity ifany of the following criteria were met: i) reported asAsian ethnicity in response to the first question; or ii)reported solely as Asian ethnicities in response to the sec-ond question; or iii) those reported only as Asian ethnici-ties and “Canadian” in the same question. All otherparticipants were classified as “non-Asian” for our ana-lysis. We classified reported ethnicities as Asian accordingto Statistics Canada’s Ethnic Origin Reference Guide, 2006Census [3].We performed bivariate analyses comparing Asian andnon-Asian participants with respect to demographic char-acteristics, HIV risk behaviour and HIV and other STItesting behaviour and results, using the Wilcoxon-Ranksum test and Fisher’s exact test. Unless otherwise stated,percentages are expressed from the total of respondentswho answered a particular question or set of questions.We did not weight the analyses based on the site of re-cruitment. Both recent testing (within the past two years)and lifetime testing behaviours were considered. To re-move, as best as possible, the effect of confounders on theobserved association between ethnicity (Asian/non-Asian)and HIV/ST testing over the last two years, we developedconfounder models using logistic regression analysis. Weused a backward stepwise approach based on the magni-tude of change in the coefficient of the explanatory vari-able of main interest. We stratified these models on thebasis of age, using 35 years of age as the cut-off, since pre-viously analyses from ManCount had found that testingbehaviours differ between younger and older men [11],We used SAS version 9.1.3 (Cary, NC, USA) for all statis-tical analysis.ResultsA total of 2805 individuals were approached for study par-ticipation, 1169 (41.7%) were enrolled and completed thesurvey and 1,132 (96%) provided a DBS sample suitablefor testing and answered the ethnicity questions. Of these,the median age was 34 years (Interquartile range [IQR]26–44 years), 87% (985/1129) resided in the metropolitanVancouver area and 80% (902/1128) had at least somepost-secondary education. A total of (935/1119) identifiedas being gay or queer, 10.8% (121) as being bisexual, 1.7%(19) as being straight and 2.9% (32) as being two-spiritedand 1.1% (12) as having another sexual identity.Of these, 9.7% (110/1132) of respondents self-identifiedas being of Asian ethnicity, 862 (76.2%) as having North-American or European ethnicity, 4.3% (49) as being Abori-ginal and 9.8% (111) as having other ethnic identities. Ofthe Asian MSM, 60% (66) reported that they spoke Eng-lish as a first language, while 40% (44) spoke the followinglanguages as their first language: Cantonese (36.3%), Man-darin (13.6%), Tagalog (11.4%), Japanese (9.1%), Vietnam-ese (6.8%), Thai (4.6%), Punjabi (2.3%), Sinhala (2.3%),Spanish (2.3%), Korean (2.3%), Filipino (2.3%), French(2.3%) and Indonesian (2.3%).Maung Maung et al. BMC Public Health 2013, 13:763 Page 2 of 8http://www.biomedcentral.com/1471-2458/13/763Asian MSM were younger than other study partici-pants (median age 29 years vs. 34 years; p < 0.001) andwere more likely to have completed or had some post-secondary education (88.2% vs. 79.1%; p = 0.023), but didnot differ in terms of income, sexual orientation or areaof residence (Table 1). In terms of sexual behavior, asmaller proportion of Asian MSM reported >5 anal sexpartners in their lifetime (43.6% vs. 58.5%; p = 0.006 fordichotomized variable) but we did not find any differ-ences in the number of reported sex partners in the pre-vious six months or having had any anal sex in the pastsix months (Table 2). We found that Asian MSM wereless likely to report attending gay bars or nightclubs(52% vs. 64.4%; p = 0.017), but were just as likely to lookfor sex partners in bars or on the internet. Asian MSMwere also less likely to report using alcohol before sex inthe past six months (67.3% vs. 78.3%; p = 0.015) andwere less likely to report ever having used injectiondrugs (10.8% vs. 19.2%; p = 0.043). However, we foundno differences in the reported use of stimulants or psy-chedelics before sex. There were also no differences inthe proportion of self-reported HIV negative participantswho reported unprotected anal intercourse with a knownHIV positive or unknown serostatus partner in theprevious six months (our definition of risky sex). This wasalso true of men who self-reported as HIV positive. AsianMSM also appeared to judge their likelihood of acquiringHIV in their lifetime similarly to non-Asian MSM, with39.8% reporting that it would be very unlikely (vs. 40.7%for non-Asian participants) and 40.9% reporting it unlikely(vs. 43.6% of non-Asians) that they would acquire HIV intheir lifetime (p = 0.436).Table 3 compares the HIV and STI testing behaviorsin Asian and non-Asian participants in our study. Asianparticipants were less likely to have ever been tested forHIV (75.0% vs. 86.8%; p = 0.004), but were similar tonon-Asian men in terms of testing for HIV in the pasttwo years (63.0% vs. 68.8%; p = 0.176). Asian MSM wereless likely to be HIV positive, both by self-report (2.8%vs. 18.1%; p < 0.001), as well as by the DBS result takenduring the survey (3.7% vs. 19.0%; p < 0.001). Of the 4Asian participants who tested positive for HIV, 3 (75.0%)were aware of their infection, in comparison to 88.1% ofHIV positive non-Asian participants. (p = 0.408) Thesedifferences in HIV prevalence were similar when theanalysis was restricted to only those aged <30 years ofage (1.8% vs. 7.2%) but did not reach statistical signifi-cance (p = 0.233). We also found lower proportions ofTable 1 Demographic characteristics among Asian and non-Asian study participants in the ManCount Survey,Vancouver, CanadaCharacteristics Non-Asian Asian p-valuen = 1022 (%) n = 110 (%)Median age (IQR) 34 (26–44) 29 (25–38) <0.001EducationLess than or completed high school 213/1018 (20.9) 13/110 (11.8) 0.023Some or completed post-secondary 805/1018 (79.1) 97/110 (88.2)IncomeUnder $30,000 388/998 (38.9) 50/108 (46.3) 0.30$30,000 - $59,999 372/998 (37.3) 37/108 (34.3)$60,000 or more 238/998 (23.8) 21/108 (19.4)Sexual orientationQueer or gay 838/1010 (82.9) 97/109 (88.9) 0.23Bisexual or two-spirit 142/1010 (14.1) 11/109 (10.1)Straight or other 30/1010 (2.9) 1/109 (0.9)Live in Metro VancouverYes 888/1019 (87.1) 97/110 (88.2) 0.88No 131/1019(12.9) 13/110 (11.8)Recruitment venueBar 557/1022 (54.5) 65/110 (59.1) 0.012Bathhouse 37/1022 (3.6) 10/110 (9.1)Event 260/1022 (25.4) 24/110 (21.8)Community association 48/1022 (4.7) 6/110 (5.5)Business 120/1022 (11.7) 5/110 (4.5)Maung Maung et al. BMC Public Health 2013, 13:763 Page 3 of 8http://www.biomedcentral.com/1471-2458/13/763Table 2 Bivariate comparison of HIV risk behaviours for Asian and non-Asian MSMCharacteristics Non-Asian Asian p-valuen/N (%) n/N (%)Anal sex in past 6 monthsNo 272/993 (27.4) 33/107 (30.8) 0.49Yes 721/993 (72.6) 74/107 (69.2)Sex partners (oral or anal) in past 6 monthsNone 83/994 (8.4) 7/108(6.5)Only one 229/994 (23) 29/108 (26.9) 0.892 to 5 349/994 (35.1) 36/108 (33.3)>5 333/994 (33.5) 36/108 (33.3)Lifetime number of anal sex partnersNone 64/906 (7.1) 9/101 (8.9)Only one 76/906 (8.4) 14/101 (13.9) 0.0062 to 5 236/906 (26.0) 34/101 (33.7)>5 530/906 (58.5) 44/101 (43.5)Risky sex* in past six months by HIV negative or unknownserostatus participants97/723 (13.4) 9/86 (10.5) 0.50Risky sex**** in pasts six months among self-reportedHIV + participants46/180 (25.6) 2/3 (66.7) 0.17Risky sex* in pasts six months in participants < 30 years of age 40/282(14.1) 4/42 (9.5) 0.41Attend gay bars (at least once per month) 600/931 (64.4) 53/102 (52.0) 0.017Attend bath houses (at least once per month) 103/924 (11.1) 13/101 (12.9) 0.619Attend Pride Parade or Pride Festival 826/989 (83.5) 87/107 (81.3) 0.58Search for sex partners on the internet 499/985 (50.7) 56/105 (53.3) 0.61Search for sex partners in gay bars 552/1003 (55.0) 54/105 (51.4) 0.54Received money, drugs, or goods/services in exchange for sex inpast 6 months131/963 (13.6) 13/104 (12.5) 0.88History of injection drug useNo 793/982 (80.8) 91/102 (89.2) 0.043Yes 189/982 (19.2) 11/102 (10.8)Use of alcohol within 2 hours before sex the past 6 monthsNo 215/989 (21.7) 35/107 (32.7) 0.015Yes 774/989 (78.3) 72/107 (67.3)Use of stimulants or psychedelics** within 2 hours before orduring sex in past 6 monthsNo 720/975 (73.8) 84/104 (80.8) 0.15Yes 255/975 (26.2) 20/104 (19.2)Perception of HIV infection in lifetime***Very unlikely 284/697 (40.7) 35/88 (39.8) 0.44Unlikely 304/697 (43.6) 36/88 (40.9)Somewhat likely 95/697 (13.6) 13/88 (14.8)Likely 7/697 (1) 3/88 (3.4)Very Likely 7/697 (1) 1/88 (1.1)*Unprotected anal sex with HIV positive or unknown sero-status male partners (HIV negative or unknown only).**ketamine, ecstasy, crystal meth, amphetamines, GHB or psychedelics.***among self-reported HIV negative or unknown only.****Unprotected anal sex with HIV negative or unknown sero-status male partners.Maung Maung et al. BMC Public Health 2013, 13:763 Page 4 of 8http://www.biomedcentral.com/1471-2458/13/763Table 3 Bivariate comparison of HIV sero-status and sexual and blood-borne infection testing experience for Asian andnon-Asian MSMCharacteristics Non-Asian Asian p-valuen/N (%) n/N (%)Ever been tested for HIVNo 112/998 (11.2) 23/108 (21.3) 0.004Yes 866/998 (86.8) 81/108 (75.0)Don’t know 20/998 (2.0) 4/108 (3.7)Tested for HIV in past 2 years*No 247/791 (31.2) 39/102 (38.2) 0.18Yes 544/791 (68.8) 63/102 (61.8)Self-reported HIV serostatusNegative 746/1002 (74.5) 89/109 (81.7) <0.001Positive 181/1002 (18.1) 3/109 (2.8)Don’t know 75/1002 (7.5) 17/109 (15.6)HIV test result from dried blood sampleNegative 807/996 (81.0) 104/108 (96.3) <0.001Positive 189/996 (19.0) 4/108 (3.7)HIV test result from dried blood sample in participants < 30 years of ageNegative 335/361 (92.8) 54/55 (98.2) 0.23Positive 26/361 (7.2) 1/55 (1.8)Disclosed male sex partners to a health care professionalNo 190/979 (19.4) 32/108 (29.6) 0.016Yes 789/979 (80.6) 76/108 (70.4)Ever tested for gonorrheaNo 213/978 (21.8) 39/108 (36.1) 0.001Yes 688/978 (70.3) 58/108 (53.7)Don’t know 77/978 (7.9) 11/108 (10.2)Tested for gonorrhea in past 2 yearsNo 448/954 (47) 59/105 (56.2) 0.080Yes 506/954 (53) 46/105 (43.8)Ever tested for syphilisNo 252/980 (25.7) 37/107 (34.6) 0.13Yes 646/980 (65.9) 61/107 (57.0)Don’t know 82/980 (8.4) 9/107 (8.4)Tested for syphilis in past 2 yearsNo 445/948 (46.9) 53/103 (51.5) 0.41Yes 503/948 (53.1) 50/103 (48.5)Ever tested for hepatitis CNo 203/977 (20.8) 38/108 (35.2) <0.001Yes 669/977 (68.5) 55/108 (50.9)Don’t know 105/977 (10.7) 15/108 (13.9)Tested for HCV in the past 2 yearsNo 441/902 (48.9) 63/103 (61.2) 0.022Yes 461/902 (51.1) 40/103 (38.8)*Asked only of self-reported HIV negative or unknown participants.Maung Maung et al. BMC Public Health 2013, 13:763 Page 5 of 8http://www.biomedcentral.com/1471-2458/13/763ever testing for gonorrhea (p = 0.001) and hepatitis C(p < 0.001) among Asian participants, but no difference inever testing for syphilis (p = 0.407). A lower proportion ofAsian MSM reported testing for hepatitis C in the pasttwo years (p = 0.22), but not for gonorrhea (p = 0.080) orsyphilis (p = 0.407). Asian MSM were also less likely tohave disclosed that they have male sex partners to a healthcare professional (70.4% vs. 80.6%; p = 0.016).Multivariate logistic regression revealed that Asianethnicity was independently associated with an increasedodds of not having tested for HIV in the past 2 years(adjusted odds ratio [AOR] = 2.04; 95% confidence inter-val [CI]) 1.08-3.86) and hepatitis C (AOR = 2.30; 95% CI1.27-4.19), but only for participants under the age of 35(Tables 4a and b). Both models included adjustments forfirst language, age, and disclosure of male sex partners.In addition, the HIV testing model was adjusted forcigarette smoking and history of injection drug use. Wedid not find any associations between Asian ethnicityand ever testing for syphilis (Table 4c) or gonorrhea(data not shown) in either age group in adjusted models.DiscussionWe found that approximately 10% of this sample of MSMfrom Vancouver self-identified as having Asian ancestry.While this represented the largest ethnic minority in oursample, this proportion is far below the estimated 40% ofthe population of Greater Vancouver who have Asian heri-tage [3]. This raises important questions regarding theunderlying structure of the MSM population in Vancouverand how well venue- and event-based time-location sam-pling can appropriately sample this population. Otherstudies from large cities in North America have generallyfound that individuals of Asian ethnicity are underrepre-sented in studies of MSM [12-14]. However, it is worthnoting that approximately 9.1% of the new positive HIVtests reported in men in BC over the 2003 – 2009 periodwere among men with Asian ethnicity [4], and this pro-portion appears to be increasing in recent years [15].We found that HIV risk behaviour did not differ sub-stantially between Asian and non-Asian MSM in oursample, except that Asian MSM were less likely to reportmore than five lifetime sexual partners, which may bepartly a result of the younger age of Asian participantsin this study. In particular, self-reported HIV negative orunknown sero-status Asian MSM reported unprotectedanal intercourse with a known HIV positive or unknownserostatus partner at the same frequency as non-AsianMSM. Despite this, Asian participants in our study wereless likely to have ever tested for both HIV and hepatitisC and this association remained for study participantsunder the age of 35 years, even after adjusting for otherimportant determinants of testing such as having told ahealth care provider that they have male sex partners.Table 4 Adjusted Confounder Model for not having tested for HIV, hepatitis C virus and syphilis in the past 2 years,stratified by ageVariable <35 p-value ≥35 p-valueAdjusted odds ratio (95% CI) Adjusted odds ratio (95% CI)a. Adjusted Confounder Model for not having tested for HIV in the past 2 years, stratified by ageAsian ethnicity 2.04 (1.08-3.86) 0.028 0.65 (0.28-1.51) 0.32English or French as first language 1.29 (0.69-2.43) 0.426 1.28 (0.62-2.66) 0.51Age (in years) of participate at study enrolment. 0.97 (0.92-1.02) 0.245 1.01 (0.98-1.03) 0.58IDU ever 0.81 (0.41-1.56) 0.522 0.42 (0.20-0.86) 0.017At the present time, do you smoke cigarettes? 1.31 (0.84-2.03) 0.234 1.15 (0.68-1.95) 0.60Not told doctor of male sex partners 5.83 (3.67-9.24) <0.001 3.47 (1.90-6.35) <0.001b. Adjusted Confounder Model for not having tested for Hepatitis C Virus in the past 2 years, stratified by ageAsian ethnicity 2.30 (1.27-4.19) 0.006 1.05 (0.51-2.15) 0.90English or French as first language 1.25 (0.71-2.22) 0.435 1.14 (0.61-2.13) 0.68Age (in years) of participate at study enrolment. 0.99 (0.95-1.04) 0.664 1.02 (1.00-1.04) 0.063Not told doctor of male sex partners 7.06 (4.30-11.60) <0.001 2.43 (1.41-4.18) 0.001c. Adjusted Confounder Model for not having tested for syphilis in the past 2 years, stratified by ageAsian ethnicity 0.85 (0.45-1.61) 0.625 0.67 (0.32-1.40) 0.29English or French as first language 1.19 (0.66-2.15) 0.563 0.81 (0.43-1.52) 0.51Age (in years) of participate at study enrolment. 0.96 (0.92-1.01) 0.124 0.99 (0.97-1.01) 0.48IDU ever 1.59 (0.86-2.93) 0.137 1.77 (1.08-2.90) 0.023At the present time, do you smoke cigarettes? 0.66 (0.44-1.00) 0.048 0.65 (0.43-0.98) 0.038Not told doctor of male sex partners 0.11 (0.07-0.18) <0.001 0.24 (0.14-0.42) <0.001Maung Maung et al. BMC Public Health 2013, 13:763 Page 6 of 8http://www.biomedcentral.com/1471-2458/13/763HIV prevalence, however, was found to be significantlylower among Asian MSM (3.7%) in our study comparedto non-Asian MSM (19.0%), and ancillary risk factors forHIV transmission such as use of alcohol prior to sex andever using injection drugs were reported at a lower fre-quency among Asian men in this sample. This mayimply that the HIV risk environment for Asian MSM isdifferent than for other MSM. It is also worth notingthat while Asian MSM reported being less likely to at-tend gay bars, they were just as likely to look for sexpartners in gay bars as non-Asian MSM.Lower HIV testing rates in our sample may be due to alack of awareness of local HIV testing services or guide-lines [16,17]. However, we found that testing for gonor-rhea or chlamydia was not significantly lower in AsianMSM, suggesting that perceptions around HIV risk maybe different from risk for other STIs in this population.Previous studies have indicated that Asian immigrantswere less likely to use health care services due to culturaland language barriers [17,18]. This is similar to studies inthe United States where lower HIV testing rates are foundamongst Asians and Pacific Islanders as a group [19,20].Lower testing rates may also be due to less knowledgeand less perceived risk for HIV and other STIs [17,21].This suggests that more sexual health promotion servicestargeting younger Asian MSM should be implemented. Inaddition, disclosure to health care professionals aboutmale sexual partners was independently and strongly asso-ciated with testing for HIV/STI. Therefore, any barrierswithin the healthcare setting which preclude a patient’scomfort in disclosing same sex sexual partners ought tobe addressed to ensure proper care and timely testing.Healthcare providers may require further training in sensi-tivity and cultural competence to foster improved patientrapport. Cultural barriers such as homophobia in Asiansocieties [17] may play a crucial role, making Asian MSMless inclined to disclose information about same-sex sex-ual partners.Our study revealed that nearly 40% of Asian MSMspoke a language other than English as their first lan-guage. This highlights the need to provide health careand prevention programs in languages other than Eng-lish, especially in large metropolitan areas.Readers should be cautious when interpreting our find-ings. The data presented here can be considered represen-tative of the population of Asian MSM who attended thecommunity venues sampled in the survey, and may notrepresent all Asian MSM in Vancouver. The venues wesampled may not have been ones that are most commonlyfrequented by Asian MSM. Furthermore, only those whowere comfortable disclosing personal information andproviding blood samples would have participated in thisresearch study, thereby potentially excluding participantswho may be even less likely to get tested. Because thissurvey was only administered in English, it may have lim-ited participation of those who do not feel comfortablereading in English. As well, the relatively small proportionof individuals who self-identified as having Asian heritagemay have limited our ability to demonstrate associationswith some of the outcomes we observed. Finally, self-reported behavioural data may be subject to social desir-ability bias.ConclusionsWe found a much smaller proportion of men who identi-fied as being of Asian ethnicity in our sample of MSM inVancouver than in the Vancouver population as a whole.We also found that the Asian MSM in this study had alower prevalence of HIV in comparison to men of otherethnicities, but that the likelihood of having been testedfor either hepatitis C or HIV was also lower for youngerAsian MSM. This highlights the need for HIV preventionprograms and further research which can more appropri-ately engage MSM of Asian and other ethnic minorities inVancouver and elsewhere in North America.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTMM and MG developed the concept for the paper and planned the initialanalysis. TMM wrote the first draft. BC and DMM revised the analysis planand the early drafts of the paper. KC and SK conducted the analyses. WM,RH, WR, NM and RG all provided input into writing the manuscript. Allauthors approved the final version.Authors’ informationMembers of the ManCount Study TeamPrincipal investigatorsMark Gilbert – BC Centre for Disease ControlRobert S. Hogg – BC Centre for Excellence in HIV/AIDSReka Gustafson – Vancouver Coastal HealthChris P. Archibald-Public Health Agency of CanadaTom Wong-Public Health Agency of CanadaCo-investigatorsCommunity Based Research CentreDr. Terry TrusslerDr. Rick MarchandHealth Initiative for MenPhillip BanksWayne RobertJim SheasgreenVancouver Coastal HealthMichael KwagMeaghan ThumathPublic health agency of CanadaMarissa McGuireSusanna Ogunnaike-CookeGayatri JayaramanMaureen PerrinStephanie TottenLiz VendittiBC Centre for excellence in HIV/AIDSDr. David MooreSteve KantersWarren MichelowArn SchilderUniversity of British ColumbiaDr. Paul GustafsonMaung Maung et al. BMC Public Health 2013, 13:763 Page 7 of 8http://www.biomedcentral.com/1471-2458/13/763AcknowledgementsThe authors would like to thank the venues who participated in the study,members of the community advisory board, volunteer interviewers, and theManCount Study participants. The M-Track/ManCount Survey was funded bythe Public Health Agency of Canada. DMM is supported by a NewInvestigator Award from the Canadian Institutes for Health Research.Author details1Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.2Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.3British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.4Health Initiative for Men, Vancouver, BC, Canada. 5Vancouver, Coastal Health,Vancouver, BC, Canada. 6Division of STI/HIV Prevention and Control, BritishColumbia Centre for Disease Control, Vancouver, BC, Canada. 7University ofLa Verne, La Verne, CA, USA.Received: 14 March 2013 Accepted: 12 August 2013Published: 16 August 2013References1. Public Health Agency of Canada: Summary: Estimates of HIV Prevalence andIncidence in Canada, 2011. Ottawa, Canada: Public Health Agency of Canada; 2012.2. Oster A, Johnson C, Le B, Finlayson T, Balaji C, Lansky A, et al: Trends in HIVprevalence and HIV testing among young MSM: five United States cities,1994–2008. Washington, D.C: International AIDS Conference; 2012.3. Statistics Canada: 2006 Community Profiles: Greater Vancouver (Regional district).Ottawa, ON: Statistics Canada; 2010.4. British Columbia Centre for Disease Control: STI/HIV Annual report.Vancouver, Canada: British Columbia Centre for Disease Control; 2010.5. Poon M, Ho P, Wong J: Developing a comprehensive AIDS preventionoutreach program: a needs assessment survey of MSM of East andSoutheast Asian descent who visit bars and/or bath houses in Toronto.Canadian Journal of Human Sexuality 2001, 10:25–39.6. Poon MK, Ho PT, Wong JP, Wong G, Lee R: Psychosocial experiences ofEast and Southeast Asian men who use gay internet chatrooms inToronto: an implication for HIV/AIDS prevention. Ethnicity & health 2005,10:145–167.7. Poon M, Ho PA: Qualitative analysis of cultural and social vulnerabilitiesto HIV infection among gay, lesbian, and bisexual asian youth. Journal ofGay & Lesbian Social Services 2002, 14(3):43–78.8. Ratti R, Bakeman R, Peterson JL: Correlates of high-risk sexual behaviouramong Canadian men of South Asian and European origin who havesex with men. AIDS Care 2000, 12:193–202.9. Singer SM, Willms DG, Adrien A, Baxter J, Brabazon C, Leaune V, et al: Manyvoices--sociocultural results of the ethnocultural communities facingAIDS study in Canada. Canadian journal of public health. Revue canadiennede sante publique 1996, 87(Suppl 1):S26–32. S28-35.10. Pollack LM, Osmond DH, Paul JP, Catania JA: Evaluation of the center fordisease control and prevention’s HIV behavioral surveillance of men whohave sex with men: sampling issues. Sex Transm Dis 2005, 32:581–589.11. Moore DM, Kanters S, Michelow W, Gustafson R, Hogg RS, Kwag M, et al:Implications for HIV prevention programs from a serobehavioural surveyof men who have sex with men in Vancouver. British Columbia: theManCount study. Canadian journal of public health. Revue canadienne desante publique 2012, 103:142–146.12. Grov C, Crow T: Attitudes about and HIV risk related to the “mostcommon place” MSM meet their sex partners: comparing men frombathhouses, bars/clubs, and Craigslist.org. AIDS education and prevention :official publication of the International Society for AIDS Education 2012,24:102–116.13. Traeger L, O’Cleirigh C, Skeer MR, Mayer KH, Safren SA: Risk factors formissed HIV primary care visits among men who have sex with men.J Behav Med 2012, 35:548–556.14. Schwarcz SK, Chen YH, Murphy JL, Paul JP, Skinta MD, Scheer S, et al:A randomized control trial of personalized cognitive counseling toreduce sexual risk among HIV-infected men who have sex with men.AIDS Care 2012, 25(1):1–10.15. British Columbia Centre for Disease Control: HIV Annual report. Vancouver,Canada: British Columbia Centre for Disease Control; 2011.16. Weston HJ: Public honour, private shame and HIV: issues affecting sexualhealth service delivery in London’s South Asian communities. Health &place 2003, 9:109–117.17. Wong FY, Campsmith ML, Nakamura GV, Crepaz N, Begley E: HIV testingand awareness of care-related services among a group of HIV-positiveAsian Americans and pacific islanders in the United States: findings froma supplemental HIV/AIDS surveillance project. AIDS education andprevention : official publication of the International Society for AIDS Education2004, 16:440–447.18. Bauer HM, Rodriguez MA, Quiroga SS, Flores-Ortiz YG: Barriers to healthcare for abused Latina and Asian immigrant women. J Health Care PoorUderserved 2000, 11:33–44.19. Zaidi IF, Crepaz N, Song R, Wan CK, Lin LS, Hu DJ, et al: Epidemiology ofHIV/AIDS among asians and pacific islanders in the United States. AIDSeducation and prevention : official publication of the International Society forAIDS Education 2005, 17:405–417.20. Kahle EM, Freedman MS, Buskin SE: HIV risks and testing behavior amongAsians and Pacific Islanders: results of the HIV Testing Survey, 2002–2003.J Natl Med Assoc 2005, 97:13S–18S.21. Do TD, Chen S, McFarland W, Secura GM, Behel SK, MacKellar DA, et al: HIVtesting patterns and unrecognized HIV infection among young Asianand Pacific Islander men who have sex with men in San Francisco. AIDSeducation and prevention : official publication of the International Society forAIDS Education 2005, 17:540–554.doi:10.1186/1471-2458-13-763Cite this article as: Maung Maung et al.: Risks for HIV and othersexually transmitted infections among Asian men who have sex withmen in Vancouver, British Columbia: a cross-sectional survey. BMCPublic Health 2013 13:763.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMaung Maung et al. 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