Since the identification of its first HIV case in 1992, Mongolia has had continued low prevalence of HIV. According to MOHS sources, as of May 2016, Mongolia had a cumulative number of 212 identified cases of HIV. Mongolian men who have sex with men and transgender people bear the brunt of these cases. The 2014 IBBS research found that 12% of MSM and TG in Ulaanbaatar were living with HIV, up from 7.5% during the first IBBS in 2011.
In 2015, a size-estimation exercise was done in Ulaanbaatar by the well-known expert Dr. Tobi Saidel. She estimated that there 1,745 MSM in Ulaanbaatar (range: 1,047-3,386). Since the 2014 IBBS had found that there was 12% HIV prevalence among the MSM and TG population, it could be deducted that there should be around 210 MSM living with HIV in Ulaanbaatar. According to sources at MOH, it was known in May 2015 that 65 MSM/TG were diagnosed already in Ulaanbaatar; most of them were already on antiretroviral treatment (ART). This would mean that 145 Ulaanbaatar-based MSM/TG remain undiagnosed.
This became the ‘mantra’ of the new outreach strategy of the three NGOs: To work towards finding these 145 undiagnosed MSM and help them access life-saving HIV treatment, whereas at the same time contributing to a reduced viral load in the MSM community, slowing down and ultimately halting HIV transmission.
Since the strategy was adopted in May 2015, hundreds of Mongolian MSM have been tested for HIV. However, only 5 new positive cases were found for a sero-positivity level between 1 and 2 percent. This is much lower than could be expected if the prevalence figure of 12% were true.
Two hypotheses are put forward to explain this. Some people are now saying that the ‘real’ prevalence is probably much lower than 12% – possibly between 6 and 8%. The 12% prevalence figure may be flawed. The IBBS 2014 study may have had some methodological flaws, leading to bias and an over-estimation of HIV prevalence. One peculiar finding which suggests bias, for example, was that around 35% of the sample in the study had male-to-male sex for the first time with a foreigner! This indicates that the participants in the IBBS survey may have been of a higher socioeconomic standard, and they may have been in contact with foreign (higher-risk and higher-prevalence) networks of risk.
The second hypothesis is that outreach workers are currently not reaching and not referring to testing those MSM that are at the highest risk for HIV. They may simply be unable to reach them, or be unable to convince/motivate those at highest risk to get tested. Whereas over 400 MSM have been tested in the past 18 months, more than 1000 who were reached by outreach workers have not tested. Who and where are they? There is a need to design more clever and innovative outreach strategies in order to reach more MSM who may be living with HIV without knowing it. If the Ministry finally approves community-based testing, this could help–although in some countries, like Cambodia, the number of new HIV cases found after the introduction of community-based testing has been rather disappointing.
As usual when there are two hypothesis pointing to totally different explanations, the truth is probably somewhere in the middle. This means that yes, the IBBS may have estimated the HIV prevalence too high, but perhaps only by a few percentage points. There is no way to know for sure except by doing a solid, high quality new IBBS — which I think it not in the planning. And concerning the second hypothesis: Yes, the outreach workers may need to move out of their comfort zone more, and access new networks of risk, via the internet and possibly at new locations in Ulaanbaatar.
The battle to end AIDS continues!
From: UNAIDS Regional Support Team in Bangkok and the Global Fund in Mongolia
Mr Jan W de Lind van Wijngaarden, PhD, MPH
Chiang Mai 5030, Thailand