HIV Integrated Behavioral and Biological Surveillance Surveys

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Biological and Behavioral Surveillance Survey on Armenian, Male, Seasonal Labor Migrants in Rural Communities in Armenia,

2016

ACKNOWLEDGEMENTS

The Biological and Behavioral Surveillance Surveys on Armenian, Male, Seasonal Labor Migrants in Rural Communities was implemented by the National Center for AIDS Prevention (NCAP), Yerevan, Armenia. Prof. Samvel Grigoryan, Director of NCAP, coordinated the survey. The survey implementing core team included Arshak Papoyan, Head of HIV Surveillance Department; Zhaneta Petrosyan, Head of Prevention Department; Marine Asryan, Head of Department of psychosocial counseling, Anahit Asatryan, Head of Laboratory Diagnostics Department; Trdat Grigoryan, Doctor-statistician; Vardan Arzakanyan, Doctor-epidemiologist; Eduard Hovhannisyan, Doctor- epidemiologist; Tigran Hovsepyan, Doctor-statistician; Lilit Hovhannisyan, Doctor-statistician; Seda Abgaryan, Monitoring and Evaluation specialist; Sofya Vardanyan, Assistant of Epidemiologist. The survey implementing team acknowledges the participation of all those involved in the surveys including those who gave their time to enroll and respond to the questionnaires. The team could not have efficiently carried out the surveys without the valuable support of the following people to whom we extend our gratitude:  Stepan Khachatryan, Head of the Department of Health and Social Welfare of the Ararat Regional Administration  Larisa Muradyan, Deputy Mayor of Armavir region  Anush Poghosyan, Head of the Department of Health and Social Welfare of the Gegharkunik Regional Administration  Samvel Lambaryan, Head of the Department of Health and Social Welfare  Lusine Vardanyan, Head of the Health Unit of the Lori Regional Administration  Vahagn Voskanyan Head of the Department of Health and Social Welfare of the Kotayk Regional Administration  Hovhannes Hovhannisyan, Head of the Department of Health and Social Welfare of the Shirak Regional Administration  Directors of the primary healthcare centers in each of the rural communities sampled. The team would like to give special thanks to Lisa G. Johnston, WHO Expert, for developing the survey protocol, providing consultancy support in the course of the survey implementation, analyzing the survey findings, and for preparing this report.

The survey was implemented with financial support of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

CONTENTS

ACKNOWLEDGEMENTS ...... 1

ABBREVIATIONS/ACRONYMS ...... 4

1. EXECUTIVE SUMMARY ...... 5

2. BACKGROUND ...... 7

3. OBJECTIVES ...... 9

4. SAMPLING METHODS ...... 10

4.1 MULTISTAGE CLUSTER SAMPLING ...... 10

4.2 SELECTION OF THE RURAL SURVEY COMMUNITIES ...... 10

4.3 SAMPLE SIZE CALCULATION ...... 12

4.4 ELIGIBILITY ...... 13

4.5 SELECTING PARTICIPANTS ...... 13

4.6 STAFFING ...... 14

4.7 DATA COLLECTION STEPS ...... 15

4.8 DATA MANAGEMENT AND ANALYSIS ...... 16

DATA TRANSFER ...... 16

DATA PROCESSING ...... 16

DATA ANALYSIS ...... 17

DATA SECURITY ...... 17

5. LABORATORY PROCEDURES ...... 18

5.1 BLOOD SAMPLES, TESTING AND HANDLING ...... 18

6. RESULTS ...... 19

6.1 SOCIO-DEMOGRAPHIC AND GENERAL WORKING CHARACTERISTICS ...... 21

6.2 GENERAL SEXUAL HISTORY ...... 22

6.3 SEXUAL BEHAVIORS WITH REGULAR PARTNERS ...... 23

6.4 SEXUAL BEHAVIORS WITH CASUAL PARTNERS ...... 25

6.5 SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS ...... 28

6.6 CONDOM USE WITH DIFFERENT PARTNER TYPES ...... 30

6.7 DRUG USE ...... 31

6.8 HIV AND STI TESTING AND RISK AND CONDOM ACCESS ...... 32

6.9 HIV KNOWLEDGE AND PERCEPTIONS ...... 34

6.10 HIV AND OTHER INFECTIONS PREVALENCE ...... 36

7. DISCUSSION OF FINDINGS ...... 37

8. LIMITATIONS AND INTERPRETING RESULTS ...... 38

9. KEY RECOMMENDATIONS ...... 40

10. CONCLUSION...... 41

A. ANNEX ...... 42

QUESTIONNAIRE...... 42

B. ANNEX ...... 52

ANALYSIS OF DATA BY EACH REGION...... 52

B.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS ...... 52

B.2 GENERAL SEXUAL HISTORY ...... 55

B.3 SEXUAL BEHAVIORS WITH REGULAR PARTNERS ...... 56

B.4 SEXUAL BEHAVIORS WITH CASUAL PARTNERS ...... 60

B.5 SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS ...... 64

B.6 DRUG USE...... 68

B.7 HIV AND STI TESTING AND RISK ...... 70

B.8 HIV KNOWLEDGE AND PERCEPTIONS ...... 73

B.9 HIV AND OTHER INFECTIONS PREVALENCE ...... 75

ABBREVIATIONS/ACRONYMS

ART Antiretroviral Therapy FSW Female sex workers GFATM Global Fund to fight AIDS, TB and Malaria HIV Human Immunodeficiency Virus HBV Hepatitis B virus HCV Hepatitis C virus BBS biological and behavioral surveillance MSM Men who have sex with men NCAP National Center for AIDS Prevention PWID People who inject drugs RDS Respondent Driven Sampling STI Sexually Transmitted Infection TWG Technical Working Group UNAIDS Joint United Nations Programme on HIV/AIDS HTC HIV testing and counseling

1. EXECUTIVE SUMMARY

This report presents findings of a Biological and Behavioral Surveillance Survey on Armenian, Male, Seasonal Labor Migrants in Rural Communities (henceforth, rural migrants) in Armenia conducted in 2016 using multistage cluster sampling. Data are presented for the entire population ages 18 to 76 years (n=1840) and for a subset of the population considered at higher risk for HIV and other infections, ages of 18 and 49 years (n=1381). The survey was conducted in rural areas of six regions of Armenia: Shirak (pop: 248,300), Lori (pop: 230,800), Armavir (pop: 267,200), Ararat (pop: 260,800), Gegharkunik (pop: 234,100), Kotayk (pop: 255,000). The primary objective of this survey was to provide information on the prevalence of HIV and associated risk behaviors among rural migrants to inform programmatic and policy responses.

Findings In January and February 2016, 1840 rural migrants Infections prevalence among the entire were sampled from 38 randomly selected villages population in Armenia. HIV sero-prevalence was just 0.2%, HIV 0.2% (95% CI: 0.1, 0.8) Hepatitis B virus (HBV) was 0.6%, Hepatitis C virus (HCV) was 2.1% and Syphilis was 0.3%. All Hepatitis B 0.6% (95% CI: 0.3, 1.1) HIV seropositive cases in this survey had been previously undetected. However, for those aged Hepatitis C 2.1% (95% CI: 1.4, 3.1) between 18 to 49 years, HIV prevalence was three Syphilis 0.3% (95% CI: 0.05, 1.3) times higher than the entire population. HBV and HCV was the same and syphilis was lower in the subset compared to the entire population. Infections prevalence among 18 to 49 For the entire sample, the majority of rural year olds migrants reported being 25 years or older, having a secondary education, being married and most HIV 0.6% (95% CI: 0.3, 1.2) often working in the Russian Federation. Of those Hepatitis B 0.6% (95% CI: 0.3, 1.1) married, few had their spouses traveling with them when they worked abroad. Of the 86.5%rural Hepatitis C 2.1% (95% CI: 1.4, 3.5) migrants who reported having regular partners (a Syphilis 0.07% (95% CI: 0.01, 0.3) sexual partner of at least 3 months), 25.6% reported having more than one regular partner in the past year. Thirty eight percent of rural migrants reported having sexual intercourse with casual partners (85% while abroad and 32% while in Armenia), 26% of which reported not using a condom during their last sexual intercourse and 73.2% having two or more casual partners in the past one year. Under 10% of rural migrants reported having sexual intercourse with a commercial partner (63% while abroad and 58% while in Armenia), of which 15% did not use a condom the last time they had sexual intercourse with a commercial partner and 62.1% reported having 2 or more commercial partners in the past one year.

A low percentage of rural migrants reported ever using drugs and only 0.3% reported ever injecting drugs. Eighty one percent of rural migrants did not feel themselves at risk for HIV. Only 31.2% knew where to go for an HIV test and only 20.2% had an HIV test and received their test results in 5

the past year. Only 6.3% reported having signs and symptoms of an STI and 3% had been diagnosed with and STI in the past year. Just over half reported relying on having ‘trusted partners’ to protect themselves from getting an STI. Only 33.8% had correct knowledge of HIV transmission based on a composite score of five questions.

Conclusions Despite the low prevalence of infections in both the entire sample and the sample of 18 to 49 year olds, and the majority of rural migrants reported being married, just over one quarter reported having multiple regular partners, more than one third reported having casual partners and one fifth reported having commercial partners in the past year. Furthermore, although the majority of rural migrants reported using condoms at last sexual contact with all partner types, condom use is nevertheless inconsistent. Furthermore, there is a high reliance on partner trust, low perception of having risk for HIV, low HIV transmission knowledge and a low percentage who know where to get tested and have been tested for HIV—all of which indicate increased risk for HIV and other infections. Programs are needed to strengthen the

2. BACKGROUND

According to UNAIDS Spectrum estimates, HIV prevalence among the general population in Armenia is 0.2% making it a low prevalence country. However, HIV is higher among most populations at higher risk for HIV exposure based on biological and behavioral surveillance surveys (BBSS) using respondent driven sampling conducted in 20141. In these surveys, HIV prevalence was found to be highest among people who inject drugs (PWID) at 4%, followed by men who have sex with men (MSM) at 0.4%. No HIV seropositive participants were found in the BBS of female sex workers (FSW).

Migration can place people in situations of increased vulnerability to HIV and other serious infections by limiting their access to health-care and, in some situations, legal services and protection, separating them from their family, spouses and local support networks and inducing additional social, political and economic stressors2. Social exclusion also leaves migrants highly vulnerable to HIV. Generally, Armenia is considered an emigration country with travel mostly to Russia (90%)3,4 and Ukraine where HIV prevalence is at least 1% in the general population (ages 15-49 years5). There is concern that labor migrants returning to Armenia may have been exposed to HIV while working and living in their receiving countries. According to some sources, it is estimated that at any one time there are approximately 80,000-100,000 returning labor migrants in Armenia6, 36.5% of whom live in rural communities. Other sources indicate that the majority of labor migrants were from urban areas (58.3% vs.53.7% rural labor migrants) in 20097. Almost all labor migrants returning to Armenia are males. In 2014, 1% of all HIV tests in Armenia (n=9278) were reported to be among returning labor migrants and out of 334 new cases identified in Armenia, 55% were returning labor migrants and 18% were partners of returning labor migrants8. In a BBSS survey conducted in 2014 using convenience sampling methods in six regions of Armenia HIV prevalence among returning labor migrants was found to be 0.4%9. However, given questions about the sampling reliability of the 2014 BBSS surveys, Armenia National Center for AIDS Prevention (NCAP) has conducted new surveys of returning labor migrants in 2016.

1 Ministry of Health, National Center for AIDS Prevention. (2015) Results from the HIV Biological and Behavioural Surveillance in the Republic of Armenia, 2014. Accessible at: ccmarmenia.am/images/uploads/bbc_report_2014_eng.pdf 2 UNAIDS/WHO. (2014) The Gap Report 2014: Migrants. Accessible at: http://www.unaids.org/sites/default/files/media_asset/04_Migrants.pdf 3European Training Foundation (2011). Migration Survey on the Relationship between Skills, Migration and Development in Armenia. Accessible at: http://www.crrc.am/hosting/file/_static_content/projects/Migration_and_skills_2011/Migration_and_skills_Armenia.pdf 4International Labour Organization. (2010). Migration and Development: Armenian Country Study, Yerevan. Accessible at: http://www.smsmta.am/upload/Migration%20and%20Development_Study_in_English.pdf. 5World Health Organization. Data and statistics. Accessed on September 12, 2015 at: http://www.euro.who.int/en/health- topics/communicable-diseases/hivaids/data-and-statistics. 6International Organization for Migration. (2013) Report on Household Survey on Migration in Armenia, Accessed at: http://publications.iom.int/bookstore/index.php?main_page=product_info&cPath=41_7&products_id=1400 7International Labour Organization. (2010). Migration and Development: Armenian Country Study, Yerevan. Accessible at: http://www.smsmta.am/upload/Migration%20and%20Development_Study_in_English.pdf. 8International Organization for Migration. (2013) Report on Household Survey on Migration in Armenia, Accessed at: http://publications.iom.int/bookstore/index.php?main_page=product_info&cPath=41_7&products_id=1400 9Ministry of Health, National Center for AIDS Prevention. (2015) Results from the HIV Biological and Behavioural Surveillance in the Republic of Armenia, 2014. Accessible at: ccmarmenia.am/images/uploads/bbc_report_2014_eng.pdf 7

This report presents findings from the Rural Migrant Study conducted in six regions in Armenia: Shirak, Lori, Armavir, Ararat, Gegharkunik, Kotayq. These surveys used a multistage cluster sampling method which randomly selects clusters of rural communities within rural regions and random sampling of rural migrants within each randomly selected cluster (rural community) to obtain representative findings. The Rural Migrant Study tested participants for HIV and other infections and collected data about migration characteristics, sexual risk, drug use, and HIV knowledge and testing.

3. OBJECTIVES

The proposed study objectives for the Rural Migrant Study was to measure HIV prevalence among Armenian male, seasonal labor migrants in select rural communities in six regions of Armenia. The other seven objectives were to measure: 1. Characteristics of migrants’ migration experiences; 2. Sociodemographic characteristics (age, marital status, etc.); 3. Sexual risk behaviors; 4. Injecting and non-injecting drug use; 5. knowledge of HIV transmission; 6. HIV testing; 7. Syphilis, Hepatitis B(HBV) and Hepatitis C (HCV) prevalence.

4. SAMPLING METHODS

4.1 MULTISTAGE CLUSTER SAMPLING

Returning male labor migrants were sampled using multistage cluster sampling. This method involved sampling a subset of individuals (Armenian, male, seasonal labor migrants) chosen from the larger population (all Armenian, male, seasonal labor migrants in a given area).

To conduct the multistage cluster sampling process, the population was randomly divided into groups or clusters comprising rural communities within six rural regions. The next step was to select eligible population members randomly and entirely by chance, such that each individual had the same probability of being chosen at any stage during the sampling process, and each subset of k individuals had the same probability of being chosen for the sample as any other subset of k individuals. Multistage cluster sampling is an unbiased sampling technique that results, after weighted analysis, in representative estimates of the population from which the sample was gathered.

In Armenia, generating sampling lists for selecting clusters through simple random sampling was only feasible in rural communities, rather than in urban communities, given that they have a centralized medical system which can provide accurate lists of returning labor migrants.

4.2 SELECTION OF THE RURAL SURVEY COMMUNITIES

To conduct the Rural Migrant Study, we selected the same regions sampled in the 2014 BBSS: Shirak (pop: 248,300), Lori (pop: 230,800), Armavir (pop: 267,200), Ararat (pop: 260,800), Gegharkunik (pop: 234,100), Kotayk (pop: 255,000). These regions were selected because they were determined to have the largest population of male, seasonal, labor migrants and the highest number of HIV cases. From these regions, we built a sampling frame of all rural communities comprising a general population size of 2000 or more people and organized alphabetically in the list.

From the sampling frame of six rural communities of a general population size of 2000 or more, the rural communities (clusters) were selected using the Stat Trek (http://stattrek.com/statistics/random-number-generator.aspx) random digit generation process assuming without replacement sampling (accounting for the small populations). Table 1 displays the randomly selected rural survey communities in each of the six regions.

TABLE 1. RANDOMLY SELECTED SURVEY COMMUNITIES (CLUSTERS) IN EACH OF THE SIX REGIONS

Rural region Randomly selected communities Population Shirak Akhuryan 9884 Arevshat 2124 Marmashen 2196 Pemzashen 3364 Sarnaghbyur 3510 Lori Arevashogh 2699 Akori 2687 Shahumyan 3019 Jrashen 3665 Sarchapet 2158 Armavir Aygeshat 2118 Dalarik 4345 Yeghegnut 2127 Hatsik 2887 Taronik 2265 Ararat Dalar 2542 NorKyanq 2921 Vostan 3052 Sisavan 2255 PokrVedi 3303 Gegharkunik Akunk 4362 Astghadzor 4324 Lichk 5161 Tsovasar 3031 Vardenik 8931 Kotayk Alapars 2336 Argel 3351 Goght 2055 Lernanist 2864 Qanaqeravan 3720

Each rural community had a number associated with it. If one community was not suitable (did not have a large enough population of male, seasonal labor migrants or there is no way to develop a complete list, the community in the list of communities directly after the originally randomly selected community was selected. If too many of the randomly selected rural communities in a

rural region were not suitable based on an initial review, then the random selection of rural communities would be conducted again and a sampling frame of male, seasonal labor migrants would be drawn up from the newly randomly selected communities.

FIGURE 1. REGIONAL MAP OF ARMENIA INCLUDINGTHE SIX REGIONS SAMPLED.

4.3 SAMPLE SIZE CALCULATION

We calculated the sample size with a 5% margin of error, 95% confidence, sample size of male returning migrants in each region and a response distribution using the condom use at last sex with a casual partner of 68% from the 2014 BBS of migrant survey. Using these inputs, the sample size n and margin of error E are given by: x = Z(c/100) 2r(100 - r) n = N x/((N - 1)E2 + x) E = Sqrt [(N - n)x/n(N -1)]

Where N is the population size r is the fraction of responses that you are interested in Z(c/100) is the critical value for the confidence level c. The final calculated sample sizes for each region is provided in the table 2:

TABLE 2. SAMPLE SIZES FOR EACH REGION.

Region Migrant population size Sample size Shirak 2,752 300 Lori 2,527 300 Amavir 4,823 315 Ararat 4,942 315 Gegharkunik 4,330 310 Kotayk 3,097 300 TOTAL 1840

4.4 ELIGIBILITY

The eligibility criteria were: . Males . 18 years of age and over . Abroad for 3 or more months for purposes of labor, but not more than one year, in the past year . Residing in the catchment area

In addition each eligible person had to have an assigned enrollment number and be able to give consent.

4.5 SELECTING PARTICIPANTS

Participants were those people who fulfilled eligibility who were in the community at the time the survey was being conducted (e.g., male, seasonal labor migrants who are overseas should not be included in this list). Within each of the randomly selected rural communities in one of the six selected regions, a sampling frame of migrants fitting the eligibility criteria was developed. The sampling frame was be generated through key informants from the community. In some cases, it took several iterations and follow up encounters with the community and key informants to ensure that the final sampling frame (list of eligible people) was as complete as possible (see challenges using simple random sampling, above).

The final sampling frame contained a list of names and corresponding addresses and/or phone numbers (some way to contact them) of eligible participants. In addition, each person on the list was assigned a number ranging from 1 to the total number of people on the list. Once the list was finalized, a random digit generator using the Stat Trek (http://stattrek.com/statistics/random- number-generator.aspx) random digit generation process assuming without replacement sampling (accounting for the small populations) identified a random list of numbers corresponding to the names and location information of eligible persons on the sampling frame list. The total number of migrants on the final random sampling list was equal to the calculated sample size.

4.6 STAFFING

All field staff were required to attend the NCAP training. The field staff consisted of the following titles and responsibilities: 1. Coordinator (NCAP)

Responsibilities: Generated the randomized numbers corresponding to sampling frame, supervised field staff, oversaw data collection, held weekly meetings with field staff, ensured adherence to the methodology, ensured adequate supply of all materials.

2. Regional assistants (1 person for each region=6), connected to the community and was able to encourage people to participate in the survey (Representative of the regional administration).

Responsibilities: Obtained and verified the sampling frame for each region, contacted persons to be interviewed based on the sampling frame, set up appointments for persons to participate in the study, kept detailed notes when someone refuses or when someone was not available (at least three attempts to contact someone was made), kept detailed notes when an alternate participant had to be selected (based on refusals and inability to contact someone), managed the list of randomly generated numbers corresponding to the name/address and assigned a corresponding unique number to be used on questionnaires and for testing, informed the contacted person of their unique number that must be presented when they enroll in the survey (and that the regional assistant was providing this so no one would know the name of the person associated with the questionnaire or testing), communicated with interviewers about appointments and provided the unique numbers associated with the person assigned to that appointment.

3. Interviewers/HIV testing and counseling pre and posttest counselor

(1 person for each region=6), who was NOT connected to the community (NCAP)

Responsibilities: Enrolled persons who presented with a unique number assigned by the regional assistant, verified eligibility, conducted informed consent (interviewer signed on behalf of participant-no personal identifying information was collected from participant), conducted interview (questionnaires were linked to the unique number assigned by regional assistant-no personal identifying information was collected from participant), conducted pretest counseling, escorted participant to lab technician, asked participant to wait until rapid test results were ready (tests were 14

linked to the unique number assigned by regional assistant-no personal identifying information was collected from participant), when test results were ready, provided posttest counseling and test results, provided referrals when necessary

4. Lab technician (1 person for each region=6) (NCAP)

Responsibilities: Collected blood specimen, labelled collected blood specimens, ensured appropriate storage, linked blood specimen to participant’s unique number, ran lab tests, provided test results to interviewer/HTC pre and posttest counselor

Other staff were responsible for managing and analyzing data and consisted of the following titles and responsibilities:

5. Data manager (NCAP)

Responsibilities: Inputted biological and behavioral data, discussed inconsistencies in data with the study coordinator

6. Data analyst (NCAP)

Responsibilities: Cleaned data sets, recoded data, analyzed data

4.7 DATA COLLECTION STEPS

Below are the study steps once the community clusters were selected and the sampling frames were created. 1. Initial contact with the participant Each regional assistant contacted each person on the random list of contacts in each randomly selected village to set up an appointment for that person to go to the survey site. Each regional assistant had a script of what to say to each participant but did not describe in detail the nature of the survey until the person arrived for their appointment and spoke with the interviewer or coordinator. Each regional assistant had the list of participants, including the corresponding participant number and a column to add the participants’ NEW and unique, non-identifying number (a series of numbers from 1 to the sample size). This ensured each participant’s anonymity and that no biological or behavioral results could be linked back to any specific person. An example of the table is displayed as Table 3.

TABLE 3. TABLE FOR EACH REGIONAL ASSISTANT TO USE TO ASSIGN UNIQUE, NON-IDENTIFYING NUMBERS.

Participant’sname and New, unique, non- Original number address, phone number identifyingnumber 012 Mr. Petrosyan, 10-861356 01 005 Mr. Arslanyan, 10-661224 02 622 Mr. Hovsepyan, 10-761353 03 321 Mr. Sarkisyan, 10-961399 04

During the call with each participant, the regional assistant gave the new, unique, non- identifying number to the participant which they used to identify themselves when arriving at the survey site for their interview. Once the interview date and time had been set, the regional assistance informed the interviewer and only provided the interviewer with the participant’s unique, non-identifying number (no identifying information was presented to the interviewer).

2. Enrollment in the survey, interview, pretest counseling When a participant presented at the survey site, the interviewer greeted him and ask for the unique, non-identifying number. The interviewer explain the nature of the survey and conducted informed consent, followed by the interview and pretest counseling. The participant was informed that they can remain in the survey site until the test results were ready in order to receive those results along with posttest counseling and any needed referrals for care and treatment. The interviewer then escorted the participant to the lab technician for biological testing.

3. Biological testing The participant met with the lab technician who collected blood from the participant’s finger for HIV, HCV, HBV and Syphilis testing. The participant was allowed to wait for the test results or leave the survey site after the testing.

4. Posttest counseling, test results and referrals The interviewer provided the test results and posttest counselling to those participants who waited for their test results. Any participants with positive results were referred to the appropriate services for care and treatment.

4.8 DATA MANAGEMENT AND ANALYSIS

DATA TRANSFER All questionnaire data and other management forms were verified and corrected on a daily basis by the coordinator. All data were linked by the participant’s unique non-identifying number and no personal data were collected or used to identify survey participants. Hard copy forms were stored securely in a locked cabinet with restricted access by the interviewer.

DATA PROCESSING The survey data manager developed the questionnaire database and supervised those responsible for double entering and reconciling all data entered into a database. Data were entered daily to ensure data quality. Data errors and missing data were also be verified from the hard copy study questionnaires. Interview questionnaire data and laboratory results data were linked by the unique participant number. Any unlinked data were verified with the study questionnaires.

DATA ANALYSIS The analysis plan was implemented by study team with technical support. All data were analyzed STATA. Datasets for rural regions were combined and analyzed as survey data (svy.) in STATA. Data were weighted by regional population sizes of males 18 years and older and clusters (Appendix C) to have one analysis representing the six regional areas. Univariate analysis (estimates and 95% confidence intervals) of all variables representing rural migrants of all ages (ages 18 to 76 years, n=1840) in Armenia are presented in the findings section of this report. In addition, a subset univariate analysis of key variables for rural migrants ages of 18 and 49 years (n=1381) are also presented in the findings. Additional analyses were conducted on each region separately, weighted by city population size and clusters and are presented in the Appendix B.

DATA SECURITY Access to data collected during interviews and laboratory data was limited to the coordinator, the interviewer and data manager. Data archives were password protected and locked in a cabinet with restricted access. At the end of the study, all electronic and hard copy data were stored in a locked cabinet in the office of the principal investigator in the Yerevan or in an office assigned for the study.

5. LABORATORY PROCEDURES

Blood samples from finger pricks were collected and tested in the survey sites by a trained laboratory technician. A linked anonymous code system was used for each participant and to ensure that the test results were given to the correct person. Repeated testing of positive samples were conducted to minimize the probability of false positive samples 10 . For testing quality assurance 10% of all samples tested negative were re-tested by ELISA method. The discordant results were tested for a third time, according to the Algorithm of HIV diagnostics specified in the Armenia National Protocol.

5.1 BLOOD SAMPLES, TESTING AND HANDLING

Rapid tests were used for the first HIV test and ELISA and Western Blot were used for consequent tests. Active syphilis screening was performed using a combination of two tests: 1) a non-treponemal test (Venereal Diseases Research Laboratory: VDRL); and, 2) a treponemal test (Treponema pallidum haemagglutination assay: TPHA). HCV was tested using Rapid Testing for Antibodies to HCV and HBV was tested using Rapid Testing for HBV Surface Antigen.

10HIV surveillance National Protocol and Operational Manual. 2010. National Center for AIDS Prevention, Ministry of Health of Armenia, Yerevan, 2011, 278 p. 18

6. RESULTS

Six regions and 38 randomly selected villages were sampled (table 4). Data in Ararat (n=315) were collected from eight villages representing a population of males 18 years and above of 8,613. In Armavir (n=315), data were collected from six villages representing a population 4, 301; in Kotayq (n=300), data were collected from ten villages representing a population of 15, 428 and in Lori (n=300), Shirak (n=300) and Gegharkunik (n=310) data were collected from five villages with populations of males 18 years and above of 4301, 4540, 4857 and 9944, respectively.

The total final sample size consisted of 1,840 rural migrants and a subset sample comprised of those ages 18 to 49 years created for additional analysis consisted of 1381 rural migrants.

TABLE 4. REGION, VILLAGES AND FINAL SAMPLE SIZE, RURAL MIGRANTS, ARMENIA, 2016.

Total No. Male ≥18 Regions Villages Sample size population years Dalar 2542 1033 50 Ararat Nor Kyanq 2921 1040 12 Vostan 3052 810 8 Sisavan 2255 765 71 PokrVedi 3303 1507 48

Dashtavan 2204 1300 46

Hovtashat 3673 1300 34

VerinDvin 2196 858 46 Total Ararat 22146 8613 315 Aygeshat 2118 701 34 Armavir Dalarik 4345 1524 111 Yegegnut 2127 400 26 Hatsik 2887 1015 114 Taronik 2265 661 30 Total Armavir 13742 4301 315 Lernanist 2864 964 21 Kotayq Meghradzor 2622 847 30 Argel 3351 1277 34 Zovuni 5641 1996 38 Garni 7494 3125 48

Mrgashen 2187 746 32

Arzakan 2752 1155 22

Geghashen 3998 1618 31

Jrvej 6408 1954 22

Proshyan 5594 1746 22 Total Kotayq 42911 15428 300

Total No. Male ≥18 Regions Villages Sample size population years Arevashogh 2699 896 66 Akori 2687 1016 13 Lori Shahumyan 3019 705 10 Jrashen 3665 1243 169 Sarchapet 2158 680 42 Total Lori 14228 4540 300 Akhuryan 9884 1285 4 Arevshat 2124 693 29 Marmashen 2196 758 33 Shirak Pemzashen 3364 870 74 Sarnaghbyur 3510 1251 160 Total Shirak 21078 4857 300 Akunq 4362 1665 16 Astghadzor 4324 1434 18 Gegharkunik Lichq 5161 2780 56 Tsovasar 3031 975 159 Vardenik 8931 3090 61 Total Gegharkunik 25809 9944 310 Total of all 139914 47683 1840

Of the total number of rural migrants approached (n=1962), 6.3% refused to participate in the survey (table 5). In addition, a total 316 rural migrants randomly selected from lists were absent from the area and known to be abroad and eight were absent from the area but known to be in another location in Armenia.

TABLE 5. NON-RESPONSE BY REGION, RURAL MIGRANTS, ARMENIA, 2016.

Table of participants and non-participants Number unavailable Number Number absent Total number absent from from rural area Regions of Number of Total rural area who who are known to participants refusals are known to be somewhere else be abroad in Armenia Ararat 315 90 65 0 25 Armavir 315 50 28 4 18 Gegharkunik 310 66 56 0 10 Kotayq 300 105 75 0 30 Lori 300 66 39 4 23 Shirak 300 69 53 0 16 TOTAL 1840 446 316 8 122

6.1 SOCIO-DEMOGRAPHIC AND GENERAL WORKING CHARACTERISTICS

Among the entire sample, the majority of rural migrants were 35 years and older; only 10% were between the ages of 18 and 24 years (table 6). The mean age was 40 years and median age was 38 years (range: 17 to 76). Most rural migrants had a secondary education (68%) and reported being married (80%). In terms of their working situation, rural migrants reported a mean number of eight and median of five years (range: 1 to 45) working abroad when worked for at least 3 months or more during a one year period. Most rural migrants reported working in the Russian Federation (97%), working and living in big cities (48% and 47%, respectively) or cities (48% for working and living) while abroad and working in construction (77%). Among those who are married, 90% reported that their spouse does not accompany them while they are abroad.

TABLE 6. SOCIO-DEMOGRAPHIC AND GENERAL WORKING CHARACTERISTICS OF RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) Age (four levels) 18-24 235 10.0 (8.4, 11.8) 25-34 653 32.7 (29.9, 35.8) 35-44 336 19.0 (16.5, 21.7) 45+ 616 38.3 (35.0, 41.6) Age group (two levels) ≤24 235 10 (8.4, 11.8) ≥25 1605 90 (88.0, 91.6) Education level Incomplete secondary 196 10.4 (8.6, 12.4) Secondary 1284 67.9 (64.7, 71.0) Secondary technical 131 8.7 (6.6, 11.4) Incomplete higher 44 1.8 (1.2, 2.7) Higher 185 11.0 (9.3, 13.3) Family status Single 411 19.5 (17.3, 22.0) Married 1413 79.6 (77.0, 81.9) Divorced 14 0.8 (0.5, 1.6) Civil Marriage 0 -- Widowed 1 0.01 (0.001, 0.09) Foreign countries worked most often in last three years (only those who worked for at least 3 months or more) Russian Federation 1804 97.1 (95.7, 98.0) Kazakhstan 15 1.3 (0.7, 2.2) Ukraine 10 1 (0.5, 2.2) Other 9 0.5 (0.02, 1.0)

N = 1840 n %, (95% CIs) Type of settlement worked the last time worked in past year (only those who worked for at least 3 months or more) Big city 936 47.8 (44.6, 51.1) City 841 48.3 (45.0,51.6) Village 55 3.4 (2.4, 4.8) Little-inhabited area 5 0.4 (0.1, 1.3) Type of settlement lived in the last time worked in past year (only those who worked for at least 3 months or more) Big city 921 47.3 (44.0, 50.5) City 833 48 (44.7, 51.3) Village 78 4.3 (3.2, 5.8) Little-inhabited area 4 0.3 (0.1, 1.3) Type of work performed in past one year (only those who worked for at least 3 months or more) Construction 1453 76.6 (73.8, 79.2) Agriculture 33 2.8 (1.8, 4.2) Trade 66 4.2 (3.1, 5.7) Services Sector 279 16.3 (14.1, 18.7) Other 0 -- Spouse accompanies while working abroad (only among married persons) Yes 124 10.3 (8.3, 12.8) No 1287 89.7 (87.2, 91.7)

6.2 GENERAL SEXUAL HISTORY

Almost all rural migrants (99%) reported ever having sexual intercourse and having sexual intercourse in the past 30 days (81%) (table7). The majority reported their sexual debut between the ages of 15 and 19 years, with a mean age of sexual debut at just under 19 years, median of 18 (range: 11 to 33). Among those who reported having sexual intercourse in the past 30 days, only 13% used a condom.

TABLE 7. GENERAL SEXUAL HISTORY OF RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) Ever had sexual intercourse Yes 1826 99.3 (98.6, 99.6) No 12 0.7 (0.36, 1.37 ) Age at first sexual intercourse ≤ 15 46 1.9 (1.3, 2.7) 15-19 1140 64.1 (61.4, 67.5) ≥ 20 608 33.6 (30.7, 36.7)

N = 1840 n %, (95% CIs) Sexual intercourse in past 30 days Yes 1446 80.9 (78.4, 83.2) No 380 19.1 (16.8, 21.6) Condom use at last sexual intercourse in past 30 days Yes 191 13.4 (9.2, 15.9) No 1255 86.6 (84.0, 88.8)

Among those in the age groups comprising 18 to 49 year olds, 78.4% (slightly lower than all rural migrants combined) of rural migrants reported sexual intercourse in the past 30 days, of which only 16.7% reported using a condom at last sex (table 7A).

TABLE 7A. GENERAL SEXUAL HISTORY OF RURAL MIGRANTS AGES 18 T0 49 YEARS, ARMENIA, 2016

N = 1367 n %, (95% CIs) Sexual intercourse in past 30 days Yes 1052 78.4 (75.3, 81.2) No 315 21.6 (18.8, 24.7) Condom use at last sexual intercourse in past 30 days Yes 173 16.7 (13.8, 20.0) No 879 83.3 (80.0, 86.2)

6.3 SEXUAL BEHAVIORS WITH REGULAR PARTNERS

Eighty six (86%) percent of rural migrants reported having sexual intercourse with a regular partner, described as partners who are wives (whether in a civil marriage or registered marriage) or “girlfriends” [or boyfriends] (someone with whom the participant has been having regular sex with for at least three months), in the past year (table 8). Most rural migrants reported having one regular partner in the past year (mean 1.3, median 1, range: 1 to 20). Twenty two percent of rural migrants had one regular partner while abroad, while 90% had 1 regular sexual partner while in Armenia. Among those having regular partners, a mean of 1.2 (median 1; range: 1 to 20) had these partners while abroad and a mean of 1.1 (median 1; range: 1 to 10) had regular sexual partners while in Armenia. The mean number of times on average having sex with one regular sexual partner in the past one year was 64 (median 50; range: 1 to 500) and the mean number of times using a condom during sex with all regular partners in the past one year was 44 (median 20; range: 1 to 900). Seventy five percent reported never using condoms with regular partners in the past year, 58% of whom reported “trusting their partner” and 48% reporting that it “reduces pleasure” as the reasons for not using condoms. Of those who reported having sexual intercourse with a regular partner in the past year, 94.5% reported doing so in Armenia and 26.2% reported doing so abroad. Of those, 90.1% in Armenia and 57.4% reported not using a condom during their last sexual intercourse with a regular partner.

TABLE 8. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH REGULAR PARTNERS AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1826 n %, (95% CIs) Sexual intercourse with a regular partner Yes 1548 86.5 (84.3, 88.4) No 278 13.5 (11.5, 15.7) Frequency of regular sexual partners 1 1159 74.1 (70.8, 77.1) 2-4 377 25.1 (22.1, 28.3) 5+ 12 0.6 (0.4, 1.9) Frequency of regular sexual partners while abroad 0 1137 74.9 (71.7, 77.9) 1 372 22.4 (19.5, 25.5) 2-4 32 2.0 (2.4, 3.1) 5+ 6 0.6 (0.2, 1.8) Frequency of regular sexual partners while in Armenia 0 87 4.4 (3.3, 5.9) 1 1391 90.4 (88.4, 92.2) 2-4 66 4.9 (3.8, 6.6) 5+ 4 0.2 (0.1, 0.5) Number of times on average having sex with one regular sexual partner (mean, median, range) 64.2, 50, (1-500) Number of times using condom during sex with regular partner 43.8, 20, (1-900) Used condom during last sex with regular partner Yes 192 11.5 (9.6, 13.7) No 1352 88.1 (85.8, 90) Not answered 3 0.4 (0.1, 1.2) Reasons why condom not used every time during sex with regular partner Too expensive 0 -- Ashamed to buy 4 0.2 (0.06, 0.4) Difficult to use 21 1.3 (0.8, 2.3) Not available 15 1.1 (0.6, 2.1) Reduces pleasure 630 48.0 (44.2, 51.7) Ashamed to ask sex partner to use 2 0.2 (0.1, 1.1) Trust partner 858 57.7 (54.0, 61.3) Don’t know about condom use efficacy 5 0.4 (0.1, 2.0) Want to get pregnant 68 4.5 (3.2, 6.1) Used condom the last time during sex with regular partner the last time in Armenia Yes 150 9.9 (8.1, 12.0) No 1313 90.1 (88.0, 91.9)

N = 1826 n %, (95% CIs) Used condom the last time during sex with regular partner the last time being abroad Yes 173 42.6 (3.8, 47.5) No 233 57.4 (52.6, 62.1)

Among rural migrants between the ages of 18 to 49 year olds, 83.3% reported having sexual intercourse with a regular partner in the past year, among which only 11.5% used a condom during sex with a regular partner (table 8A). A higher percentage of rural migrants in the age range of 18 to 49 years used condoms with regular partners the last time they were aboard (47.7%) compared to when they were in Armenia (12.2%).

TABLE 8A. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH REGULAR PARTNERS AMONG RURAL MIGRANTS AGES 18 T0 49 YEARS, ARMENIA, 2016

N = 1367 n %, (95% CIs) Sexual intercourse with a regular partner Yes 1115 83.3 (80.4, 85.8) No 252 16.7 (14.2, 19.6) Used condom during sex with regular partner Yes 192 11.5 (9.6, 13.7) No 1352 88.1 (85.8, 90) Not answered - - Used condom the last time during sex with regular partner the last time in Armenia Yes 131 12.2 (9.9, 15.0) No 901 87.8 (85.0, 90.2) Used condom the last time during sex with regular partner the last time being abroad Yes 152 47.7 (39.6, 55.9) No 172 52.3 (44.1, 60.3)

6.4 SEXUAL BEHAVIORS WITH CASUAL PARTNERS

Just under 40% of rural migrants reported having sexual intercourse in the past one year with a casual partner, defined as partners who are not a spouse (whether in a civil marriage or registered marriage) or a “girlfriend” (table 9). The majority of rural migrants (54%) reported having 2 to 4 casual partners (mean number of casual partners: 3.7; median 2; range: 1 to 25) of which 42% reported having 2 to 4 casual partners while abroad (among all those who reported having casual partners: mean 3.7; median 2; range: 1 to 40) and 16% reported having partners while in Armenia (mean 2.6; median 2; range: 1 to 20).

In the past year, the mean number of times rural migrants reported having sex with one casual sexual partner in the past one year was 6.5 (median 3; range: 1 to 130) and the mean number of

times using a condom during sex with all casual partners in the past one year was 18.1 (median 6.5; range: 1 to 400). Seventy four percent of rural migrants reported using a condom during sex with last casual partner in the past one year; of the 26% who reported not using a condom, the main reason for not doing so was that it “reduces pleasure” (67%) and that they “trust their partner” (38%). Of the rural migrants who reported having sexual intercourse with a casual partner in the past year, 31.8% reported doing so in Armenia and 85.8% reported doing so abroad. Among those, 25.5% in Armenia and 23.8% abroad reported not using a condom during their last sexual intercourse with a casual partner.

TABLE 9. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH CASUAL PARTNERS AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1826 n %, (95% CIs) Sexual intercourse with a casual partner Yes 754 38.2 (35.0, 41.4) No 1073 61.8 (58.5, 64.9) Frequency of casual sexual partners 1 201 26.7 (22.3, 32.0) 2-4 385 54.3 (48.9, 49.4) 5+ 168 18.9 (15.6, 22.7) Frequency of casual sexual partners while abroad 0 106 16.3 (12.9, 20.3) 1 206 27.9 (24.2, 33.2) 2-4 315 42.1 (36.9, 47.4) 5+ 127 13.7 (10.9, 17.0) Frequency of casual sexual partners while in Armenia 0 512 64.9 (59.9, 69.7) 1 98 15.0 (11.8, 18.9) 2-4 118 16.5 (13.1, 20.6) 5+ 26 3.6 (2.2., 5.6) Number of times on average having sex with one casual sexual partner (mean, median, range) 6.5, 3 (1-130) Number of times using condom during sex with casual partner (mean, median, range) 18.1, 6.5 (1-400) Used condom during sex with last casual partner Yes 546 73.9 (68.3, 78.8) No 208 26.0 (21.1, 31.6) Reasons why condom not used every time during sex with a casual partner Too expensive 0 -- Ashamed to buy 3 1.0 (0.3, 3.6) Difficult to use 7 1.7 (0.8, 3.8) Not available 7 1.9 (0.6, 5.5) Reduces pleasure 165 67.2 (54.8, 77.5)

N = 1826 n %, (95% CIs) Ashamed to ask sex partner to use 1 0.2 (0.03, 1.5) Trust partner 91 38.2 (27.5, 50.1) Don’t know about condom use efficacy 3 0.8 (0.2, 2.5) Want to get pregnant 2 0.8 (0.1, 3.7) Use a condom the last time during sex with a casual partner the last time in Armenia Yes 173 74.5 (50.4, 89.4) No 67 25.5(10.3, 49.5) No sex with casual partner in Armenia 514 65.1 (60.0, 69.8) Used condom the last time during sex with casual partner the last time being abroad Yes 485 76.2 (69.8, 81.6) No 162 23.8 (18.4, 30.1)

Among rural migrants between the ages of 18 to 49 year olds, 44.6% reported having sexual intercourse with a casual partner in the past year, among which 79% used a condom during sex with a casual partner (table 9A). A higher percentage of rural migrants in the age range of 18 to 49 years used condoms with casual partners the last time they were aboard (82.3%) compared to when they were in Armenia (76.6%).

TABLE 9A. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH CASUAL PARTNERS AMONG RURAL MIGRANTS AGES 18 T0 49 YEARS, ARMENIA, 2016

N = 1368 n %, (95% CIs) Sexual intercourse with casual partner Yes 661 44.6 (40.9, 48.3) No 707 55.4 (51.7, 59.1) Used condom during sex with last casual partner Yes 494 79.0 (74.7, 82.7) No 167 21.0 (17.3, 25.3) Use a condom the last time during sex with casual partner the last time in Armenia Yes 166 76.6 (68.7, 83.0) No 59 23.3 (17.0, 31.3) Used condom the last time during sex with casual partner the last time being abroad Yes 434 82.3 (78.1, 85.9) No 127 17.6 (14.1, 31.9)

6.5 SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS

Eight percent of rural migrants reported having sexual intercourse in the past one year with a commercial partner, defined as partners to whom the participant gave money in exchange for sex (table 10). Among those, 46% reported having 2 to 4 commercial partners (mean number of commercial partners: 3.7; median 2; range: 1 to 25) of which 26% reported having 2 to 4 commercial partners while abroad (among all those who reported having commercial partners: mean 1.9; median 1; range: 1 to 15 and 19% reported having 2 to 4 partners while in Armenia (mean 2.6; median 2; range: 1 to 10). In the past year, the mean number of times rural migrants reported having sex with one commercial sexual partner in the past one year was 3.6 (median 1; range: 1 to 50) and the mean number of times using a condom during sex with all commercial partners in the past one year was 13.8 (median 4; range: 1 to 520). Eighty five percent of rural migrants reported using a condom during sex with their last commercial partner in the past one year; of the 15% who reported not using a condom, the main reason for not doing so was that it “reduces pleasure” (95%). Of the rural migrants who reported having sexual intercourse with a commercial partner in the past year, 49.8% reported doing so in Armenia and 64.2% reported doing so abroad. Among those, 13.8% in Armenia and 16.5% abroad reported not using a condom during their last sexual intercourse with a commercial partner.

TABLE 10. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH COMMERCIAL PARTNERS AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1826 n %, (95% CIs) Sexual intercourse with commercial partner Yes 152 8.2 (6.6, 10.1) No 1675 91.8 (89.9, 93.4) Frequency of commercial sexual partners 1 50 37.8 (27.4, 49.5) 2-4 78 46.0 (35.4, 57.1) 5+ 24 16.1 (9.6, 25.6) Frequency of commercial sexual partners while abroad 0 65 36.4 (26.5, 47.5) 1 31 30.1 (20.4, 42.0) 2-4 44 26.8 (18.4, 37.3) 5+ 12 6.7 (3.2, 13.3) Frequency of commercial sexual partners while in Armenia 0 73 52.9 (41.9, 63.8) 1 33 18.8 (11.5, 29.3) 2-4 35 19.5 (10.9, 26.8) 5+ 11 10.7 (5.3, 20.4) Number of times on average having sex with one commercial sexual partner (mean, median, range) 3.6, 1 (1-50)

N = 1826 n %, (95% CIs) Number of times using a condom during sex with commercial partner (mean, median, range) 13.8, 4 (1-520) Used condom during last sex with commercial partner Yes 134 85.1 (74.6, 91.7) No 18 14.9 (8.3, 25.4) Reasons why condom not used every time during sex with commercial partner Too expensive 0 -- Ashamed to buy 1 3.4, (0.4, 24.9) Difficult to use 0 -- Not available 0 -- Reduces pleasure 18 95.4 (77.2, 99.2) Ashamed to ask sex partner to use 1 3.4 (0.4, 24.9) Trust partner 3 14.6 (3.7, 43.2) Don’t know about condom use efficacy 0 -- Want to get pregnant 0 -- Used condom the last time during sex with commercial partner the last time in Armenia Yes 71 83.5 (66.5, 92.8) No 9 16.5 (7.2, 33.5) Used condom the last time during sex with commercial partner the last time being abroad Yes 76 86.2 (72.1, 93.8) No 10 13.8 (6.2, 27.9)

Among rural migrants between the ages of 18 to 49 year olds, just 10.7% reported having sexual intercourse with a commercial partner in the past year, among which 83.8% used a condom during sex with a commercial partner (table 10A). A higher percentage of rural migrants in the age range of 18 to 49 years used condoms with commercial partners the last time they were aboard (91.9%) compared to when they were in Armenia (83.8%).

TABLE 10A. SEXUAL BEHAVIORS IN THE PAST ONE YEAR WITH COMMERCIAL PARTNERS AMONG RURAL MIGRANTS AGES 18 T0 49 YEARS, ARMENIA, 2016

N = 1368 n %, (95% CIs) Sexual intercourse with commercial partner Yes 146 10.7 (8.7, 13.3) No 1222 89.2 (86.7, 91.3) Used a condom during sex with commercial partner Yes 132 88.6 (79.0, 94.1) No 14 11.4 (5.9, 21.0) Used condom the last time during sex with commercial partner the last time in Armenia Yes 71 83.8 (66.8, 93.0) No 8 16.2 (7.0, 33.2)

N = 1368 n %, (95% CIs) Used condom the last time during sex with commercial partner the last time being abroad Yes 74 91.9 (80.9, 96.8) No 7 8.1 (3.1, 19.1)

6.6 CONDOM USE WITH DIFFERENT PARTNER TYPES

Condom use varied by partner type (figure 2). Seventy five percent of rural migrants reported never using a condom with regular partners whereas 19.4% never used them with casual partners and 11.9% never used them with commercial partners. Among those who reported having commercial partners, more than 80% reported always using condoms whereas 71% reported always using condoms with casual partner and only 7.9% reported always using them with regular partners.

FIGURE 2. PAST YEAR FREQUENCY OF CONDOM USE DURING SEXUAL INTERCOURSE WITH DIFFERENT PARTNER TYPES AMONG RURAL MIGRANTS, ARMENIA, 2016

90 84.8 80 71.1 70 65.2 60

30 19.4 20 16.9 11.9 7.9 9.4 10 3.8 0 Regular Casual Commercial

Always Sometimes Never

Condom use also differed by whether respondents were abroad or in Armenia for some partner types (figure 3). A higher percentage of rural migrants reported always using condoms with regular partners while abroad compared to while in Armenia. There was little difference in whether rural migrants were in Armenia or abroad for frequency of condom use with casual partners. A slightly higher percentage of rural migrants sometimes and never used condoms with commercial partners while in Armenia (13.7%) compared to while abroad (18%).

FIGURE 3. PAST YEAR FREQUENCY OF CONDOM USE DURING SEXUAL INTERCOURSE WITH DIFFERENT PARTNER TYPES WHILE ABROAD AND WHILE IN ARMENIA AMONG RURAL MIGRANTS, ARMENIA, 2016

6.7 DRUG USE

Few (8.5%) rural migrants reported ever using drugs (table 11). Among those, more than half (57%) reported first using drugs at 19 years or younger (mean age of 21; median 19; range 14 to 42). Among those ever using drugs, only 0.3% reported ever injecting drugs. Among those who ever reported injecting drugs, all reported using disposable syringes when injecting and not sharing injection paraphernalia or needles and syringes. Nor did they use injection drugs prepared by others or have any skin problems in the area of drug injection in past on month.

TABLE 11. DRUG USE AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) Ever used drugs Yes 179 8.5 (7.1, 10.2) No 1659 91.4 (89.8, 92.9) Age at first drug use ≤19 100 56.6 (48.2,64.6) ≥20 78 43.3 (35.3, 51.7) Ever injected drugs Yes 1 0.3 (0.04, 2.1) No 178 99.7 (97.9, 99.9)

N = 1840 n %, (95% CIs) Use disposable syringes when injecting drugs Yes 1 100 No 0 -- Shared injection paraphernalia (needles, syringes, cookers, drug containers, filters) in last one month Yes 0 -- No 1 100 Ever used injection drugs prepared by others Yes 0 -- No 1 100 Used non-sterile paraphernalia (needles, syringes, cookers, drug containers, filters) for injecting drug use in past one month Yes 0 -- No 1 100 Used sterile needle/syringe the last time injecting drug Yes 0 -- No 1 100 Sterilize needles/syringes before usage Yes, always 0 -- Occasionally 0 -- Never 0 -- Use only disposable needles and syringes 1 100 Have had any skin problems (skin reddening, pain, infection) in area of drug injection in past one month Yes 0 -- No 1 100

6.8 HIV AND STI TESTING, RISK AND CONDOM ACCESS

Almost all rural migrants have heard of HIV/AIDS (table 12). The majority reported their source of HIV/AIDS knowledge to be from mass media (89%) and/or peers and friends (25%). Eighty one percent of rural migrants perceived themselves to be at no risk for HIV. Thirty one percent of rural migrants know where to get an HIV test and 21% have had an HIV test in the past year (59.5% [unadjusted] of those who know where to get an HIV test have had an HIV test), of which 69% had their last test while abroad, 98% received their test results and 74% received counselling. Among all participants, only 20% had an HIV test in the last 12 months and received their test results. Six percent of migrants reported having genital/anal inflammation, unusual discharge, and/or warts and 3% were diagnosed with an STI in past 12 months. Almost no (1%) rural migrants received condoms during the past 12 months by outreach workers or at an NGO and 41% reported using condoms as a method for protecting themselves from getting a disease that is caused through sexual intercourse

TABLE 12. HIV AND STI TESTING AND RISK AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) Ever heard of HIV/AIDS Yes 1802 98.1 (97.1, 98.7) No 35 1.9 (1.3, 2.9) Known sources of HIV/AIDS knowledge family 48 2.8 (1.9, 4.1) friends/peers 478 25.0 (22.5, 27.8) mass media 1602 88.7 (86.5, 90.5) school 81 5.5 (4.1, 7.3) social/health care workers 138 9.8 (7.8, 12.1) counselling services 28 15.8 (1.1, 2.3) have not heard 0 -- no response 0 -- Self-assessed risk for becoming infected with HIV high 83 3.9 (2.9, 5.3) medium 255 15.3 (13.1,17.8) no risk 1457 80.7 (78.0,83.0) Knows where to go for HIV test Yes 585 31.2 (28.2, 34.4) No 1216 68.8 (65.6, 71.8) Had HIV test in past 12 months Yes 348 21.1 (18.5, 23.8) No 1452 78.9 (76.1, 81.5) Where HIV test was conducted in past 12 months Armenia 111 31.5 (25.4, 38.4) Abroad 237 68.5 (61.6, 74.6) Both locations 0 -- Received test results during last HIV test in past 12 months (among those tested in last 12 months) Yes 336 97.9 (95.3, 99.1) No 12 2.1 (0.9, 4.7) Had HIV test and received test results in past 12 months (among all participants) Yes 336 20.2 (17.7, 22.9) No 1504 79.8 (77.1, 82.3) Received counseling during last HIV test in past 12 months Yes 243 73.9 (67.6, 79.5) No 105 26 (20.5, 32.4) Had genital/anal inflammation, unusual discharge, and/or warts during past 12 months Yes 116 6.3 (4.9, 7.9) No 1719 93.7 (92.1, 95.0)

N = 1840 n %, (95% CIs) Diagnosed with an STI in past 12 months Yes 62 2.9 (2.1, 4.1) No 1771 97.1 (95.9, 97.9) Received condoms during past 12 months by outreach workers or at NGO Yes 22 1.1 (0.6, 2.1) No 1814 98.8 (97.9, 99.3) Methods for protecting self from getting a disease caused through sexual intercourse Use condom 797 41.2 (38.1, 44.4) Do not have sex 128 5.1 (4.1, 6.4) Have sex only with trusted partners 928 52.3 ()49.1, 55.6 Have only regular partners 236 16.7 (13.9, 19.8)

Similar to all rural migrants sampled, almost all of those between the ages of 18 and 49 had ever heard of HIV/AIDS (table 12A). Slightly higher percentages of rural migrants between the ages of 18 and 49 years assessed themselves to be at high risk of becoming infected with HIV (4.3%) compared to the entire sample. Twenty percent reported having had an HIV test and receiving the test results in the past 12 months.

TABLE 12A. HIV AND STI TESTING AND RISK AMONG RURAL MIGRANTS AGES 18 TO 49 YEARS, ARMENIA, 2016

N = 1381 n %, (95% CIs) Ever heard of HIV/AIDS Yes 1355 98.5 (97.5, 99.1) No 24 1.5 (0.9, 2.5) Self-assessed risk for becoming infected with HIV high 16 4.3 (3.0, 5.9) medium 212 16.8 (14.2,19.8) no risk 1079 78.9 (75.7,81.7) Had HIV test and received test results in past 12 months (among all participants) Yes 248 20.9 (18.0, 24.2) No 1133 79.1 (78.8, 80.0)

6.9 HIV KNOWLEDGE AND PERCEPTIONS

Rural migrants had inconsistent knowledge about HIV transmission: 16% did not think it was possible to reduce the risk of HIV infection by having sexual relations with one uninfected faithful sexual partner and 22% did not think it was possible to reduce the risk of HIV infection by using condoms (table 13). Rural migrants had some misperceptions about HIV transmission: 60% believed a person could get HIV from mosquito bites, 35% believed a healthy-looking person

cannot be HIV infected, 43% believed it is possible to get HIV by sharing a meal with a person infected with HIV, and 34% believed it is possible to become HIV infected by shaking hands with a person infected with HIV. Overall, 34% of rural migrants had correct knowledge and perceptions based on a composite score of knowledge and perception questions.

TABLE 13. HIV KNOWLEDGE AND PERCEPTIONS AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) It is possible to reduce HIV infection risk by having sexual relations with one uninfected faithful sexual partner Yes 1530 83.5 (80.8, 85.8) No 305 16.5 (14.1, 19.1) It is possible to reduce HIV infection risk by using condoms Yes 1477 78.0 (75.3, 80.5) No 355 21.9 (19.5, 24.7) A person get HIV from mosquito bites Yes 1132 60.4 (57.1, 63.5) No 702 39.6 (36.4, 42.9) A healthy-looking person can be HIV infected Yes 1175 65.3 (62.2, 68.4) No 660 34.6 (31.6, 37.8) It is possible to get HIV by sharing a meal with a person infected with HIV Yes 755 43.5 (40.2, 46.7) No 1080 56.5 (53.3, 59.7) It is possible to become HIV infected by shaking hands with a person infected with HIV Yes 599 33.5 (30.5, 36.7) No 1236 66.5 (63.3, 69.5) Correct HIV knowledge Yes 642 33.8 (30.7, 36.9) No 1198 66.2 (63.0, 39.3)

Thirty six percent of rural migrants between the ages of 18 and 49 years had correct knowledge and perceptions based on a composite score of knowledge and perception questions (table 13A).

TABLE 13A. HIV KNOWLEDGE AND PERCEPTIONS AMONG RURAL MIGRANTS AGES 18 TO 49 YEARS, ARMENIA, 2016

N = 1381 n %, (95% CIs) Correct HIV knowledge Yes 498 35.7 (32.1, 39.4) No 883 64.3 (60.5, 67.9)

6.10 HIV AND OTHER INFECTIONS PREVALENCE

Only 0.2% of rural migrants were HIV sero-positive, 0.6% had HBV, 2.1% for HCV and 0.3% for Syphilis (table 14). All HIV positives were previously undetected cases and were ages 44 and below. Of the few who were infected with HIV, 38.3% had sexual intercourse in the past 30 days, all of whom did not use a condom. Of those infected, 28% had sex with a regular partner among which none used a condom and 85% had sex in the past year with casual partners among which 92% used a condom. Also, among those found to be infected with HIV, 2 (17.1%) reported having an HIV test in the past year. Finally, among those found to be infected with HIV, 84.3% assessed themselves to be a no risk for HIV.

TABLE 14. HIV AND OTHER INFECTIONS PREVALENCE AMONG RURAL MIGRANTS, ARMENIA, 2016

N = 1840 n %, (95% CIs) HIV Yes 6 0.2 (0.07, 0.8) No 1834 99.7 (99.1, 99.9) Hepatitis B Yes 17 0.6 (0.3, 1.1) No 1823 99.4 (98.9, 99.6) Hepatitis C Yes 39 2.1 (1.4, 3.1) No 1801 97.9 (96.9, 98.6) Syphilis Yes 3 0.3 (0.05, 1.3) No 1837 99.7 (98.7, 99.9)

Among rural migrants between the ages of 18 to 49 years, HIV prevalence was slightly higher 0.6% than the entire population (table 14A). HBV and HCV was the same and syphilis was lower (0.07%) in the subset compared to the entire population.

TABLE 14A. HIV AND OTHER INFECTIONS PREVALENCE AMONG RURAL MIGRANTS AGES 18 TO 49 YEARS, ARMENIA, 2016

N = 1381 n %, (95% CIs) HIV Yes 6 0.6 (0.3, 1.2) No 1375 99.4 (98.8, 99.7) Hepatitis B Yes 13 0.6 (0.3, 1.1) No 1368 99.4 (98.8, 99.7) Hepatitis C Yes 28 2.1 (1.4, 3.5) No 1353 97.8 (96.5, 98.6) Syphilis Yes 2 0.07 (0.01, 0.3) No 1379 99.9 (99.7, 99.9)

7. DISCUSSION OF FINDINGS

LOW HIV PREVALENCE HIV sero-prevalence was just 0.2 among all rural migrants and three times higher (0.6%) among those ages 18 to 49 years. All HIV seropositive cases in this survey had been previously undetected and all cases were among those under the age of 45 years. Given that most rural migrants assess themselves as being at ‘no risk’ for HIV, many rely on trusting their partners as reasons for not using condoms and that there were low scores for HIV transmission knowledge, more education and outreach is needed to inform migrants of how HIV is transmitted and to encourage HIV testing.

LOW HEPATITIS AND SYPHILIS PREVALENCE Hepatitis B was 0.6%, Hepatitis C was 2.1% and Syphilis was 0.3%. No syphilis cases were infected with HIV and only 5.4% of HCV cases were infected with HIV. Twenty six percent of those who reported ever using drugs were infected with HCV and the one person who reported ever injecting drugs was infected with HCV. More research is needed to determine how migrants became infected with HCV. Hepatitis and syphilis prevalence was similar among rural migrants between the ages of 18 and 49 years.

INCONSISTENT CONDOM USE AND MULTIPLE PARTNER TYPES Rural migrants had multiple partnerships with different types of partners and inconsistent condom use. Of the few who were infected with HIV, 38.3% had sexual intercourse in the past 30 days, all of whom did not use a condom. Of those infected, 28% had sex with a regular partner among which none used a condom and 85% had sex in the past year with casual partners among which 92% used a condom. This indicates possible further sexual transmission of HIV among rural migrants and their partners.

MOST RURAL MIGRANTS ARE MARRIED BUT DO NOT TRAVEL ABROAD WITH THEIR SPOUSES The majority of rural migrants are married. However, few rural migrants have their spouse travel with them while they are abroad. Of those reporting being married, 24% reported having two or more regular sexual partners in the past year, 34% reported a casual partner and 6% reported having a commercial partner. Twenty nine percent of those with a casual partner and 18% of those with a commercial partner did not use a condom during their last sexual enounter with that partner. Migration causes men and women who are married to spend long periods of time separated, opening up opportunities for extramarial sexual relationships and more possibilities for increased transmission of HIV and other infections

LOW DRUG USE Drug use appears to be uncommon among rural migrants and, therefore, drug use services targetting this population may not be a priority. However, those who former migrants who used drugs may no longer be able to obtain placement in migrant jobs and therefore may not have fit the criteria for this survey. The upcoming BBS survey of people who inject drugs should include questions about past migration experience.

LOW HIV KNOWLEDGE AND LOW SELF-PERCEPTION OF HIV RISK Rural migrants had inconsistent knowledge about HIV transmission and low self-perception of HIV risk. Furthermore, among those found to be infected with HIV, 84.3% assessed themselves to be a no risk for HIV indicating that they are unaware of their high risk behaviors. Efforts are needed to improve HIV transmission knowledge and actual risk among rural migrants.

SIGNS AND SYMPTOMS AND DIAGNOSES OF STI. Although syphilis infection was found to be low in this survey, 6% of rural migrants reported having genital/anal inflammation, unusual discharge, and/or warts and 3% were diagnosed with an STI in past 12 months. This survey found no co-infection with HIV and syphilis. Migrants reporting multiple sexual partnerships during routine medical examinations should be tested for STIs, including HIV.

LOW HIV TESTING Thirty one percent of rural migrants know where to get an HIV test and only 20% had an HIV test in the last 12 months and received their test results. In our survey, 17% reported having an HIV test in the past year, most likely indicating recent infection. More effort is needed to inform rural migrants where to get HIV tests. Given that the majority of HIV tests were conducted while rural migrants were abroad could be an indication that they are either required to be tested as part of their employment or, if voluntary, that they may be uncomfortable getting tested at home. Assessments are needed to determine why so few rural migrants are voluntarily tested for HIV while they are in Armenia.

8. LIMITATIONS AND INTERPRETING RESULTS

The aim of the multistage cluster sample is to reduce the potential for human bias in the selection of clusters and cases to be included in the sample. We did not randomly select regions to sample but, instead, selected regions where rural migrants were mostly likely to be found. However, we did randomly select rural villages from the regions and developed sampling frames of rural migrants within rural villages. With the exception of Kotayk, which ended up having many small villages with few migrants in them, we randomly selected migrants from lists of all rural migrants in selected villages. In Kotayk we sampled all migrants on a list in each of the randomly selected villages. When a randomly selected village in the region had no migrants the next village on the sampling list was selected. When an individual on the sampling list was not available (due to not being in the region or refusing to participate), the next person on the list was selected for enrollment. Having high numbers of people in the sampling list not eligible to participate by not being in the country may result in biases. Although this survey had low refusal rates among those approached, there were high percentages of rural migrants who were not in the country during the survey. Although most seasonal migrants are known to be in Armenia in January and February, the nature of studying this population makes it difficult to predict that all migrants will be in Armenia during this time.

In this survey, all migrants who tested positive for HIV did not previously know about their HIV status. It may be that persons who knew their HIV positive status did not participate. If this is the case, we may have underrepresented the true HIV prevalence among rural migrants in the country. Every effort was made to describe the nature of the survey as a health survey, rather than as an HIV testing survey.

Another factor that may impact the findings is that the economic situation (including declines in the price of oil and a more than 200% decrease in the Ruble) in the Russian Federation, where the majority of Armenia seasonal migrants work, may have changed migration patterns and work opportunities.

9. KEY RECOMMENDATIONS

 Scale up HIV transmission education programs for both rural migrants and their spouses.  Evaluate HIV testing centers in Armenia to determine why rural migrants are not being tested.  Scale-up access to HIV testing for rural migrants.  Implement HIV prevention programmes among migrants focused on those aged 18-49.  Integrate HIV and STI prevention and screening among rural migrants at public health centers.  Educate health staff to improve prevention services targeting rural migrants.  Include migration questions to the BBS surveys of people who inject drugs;  Include questions about selling sex to migrants and condom use in the female sex worker BBS surveys.  Include questions for alcohol use and unprotected sex in future surveys of migrants.  Conduct a similar survey of urban migrants as these migrants may have different risk patterns than rural migrants.  Continue to scale up HIV prevention and education services.

10. CONCLUSION

To conclude, study findings clearly identify and confirm some risky sexual activities among rural migrants. Although HIV prevalence is low among this group, the sexual mixing patterns and the inconsistent condom use (especially among those found to be HIV sero-positive in this survey) indicate future possibilities for HIV and other infections transmission.

This was the first time a probability sampling method was used to provide important epidemiological data about rural migrants in Armenia. Future surveys, using the same sampling method should be conducted to monitor changes in prevalence and risk behaviors. In addition, to better understand HIV and infections prevalence and risk behaviors among Armenian, seasonal, labor migrants, surveys in the receiving countries (i.e., Russian Federation) and among migrants living in urban areas in Armenia are needed.

A. ANNEX

QUESTIONNAIRE

Section 1. Demographic characteristics

No. Question Answer Skip 101 Age ____

no response 99 102 Gender male 1 female 2 no response 99 103 Place of residence city/town 1 village 2 no response 99 104 Education incomplete secondary 1 secondary 2 secondary technical 3 incomplete higher 4 higher 5 no response 99 105 Family status Single 1 married 2 divorced 3 civil marriage 4 widowed 5 no response 99 106 For how many years in total have you ____ been working abroad where you worked for at least 3 months or more during a one no response 99 year period? 107 In the past 3 years in which foreign ____ country did you work most often where you worked for at least 3 months or more? no response 99 108 In the past one year, in what type of big city 1 settlement did you work the last time you city 2 worked for at least 3 months or more? village 3 little-inhabited 4 no response 99 109 In the past one year, in what type of big city 1 settlement did you live the last time you city 2 worked for at least 3 months or more? village 3 little-inhabited 4 no response 99

110 In the past one year, what work did you do Construction 1 the last time you worked for at least 3 Agriculture 2 months or more? Trade 3 Services sector 4 Other______97 No response 99 111 Does your spouse accompany you when yes 1 you go working abroad? no 2 not married 3 no response 99

Section 2. Questions related to sexual life and condom use

We would like to ask you some questions regarding your sexual behaviour. We understand how personal those questions are, but at the same time we would like to note once again that the study confidentiality is fully maintained, and the same questions are asked to all the study participants. When we speak about sexual relations we mean oral, vaginal and anal sex.

No. Question Answer Skip 201 Have you ever had sexual intercourse? yes 1 no 2 301 If “no”, go to Question 301 no response 99 202 At what age did you first have sexual ____ intercourse? no response 99 203 Have you had sexual intercourse in the yes 1 past 30 days? no 2 no response 99 204 Did you (or your sexual partner) use a yes 1 condom the last time you had sexual no 2 intercourse in the past 30 days? no response 99

Regular Partners: these are partners who are your husband or wife (whether in a civil marriage or registered marriage) or a boyfriend/girlfriend (someone with whom you have been having regular sex with for at least three months)

No. Question Answer Skip 205 Have you had sexual intercourse with a yes 1 regular partner in the past 1 year? no 2 218 If “no”, pass on to Question 218 no response 99 206 If “yes”, how many regular partners did ____ you have during the past year? no response 99 207 How many of those were while you were ______abroad?

No. Question Answer Skip 208 How many of those were while you were in ______Armenia? 209 How many sexual contacts on average did ____ you have with one regular partner during the past year? no response 99 210 How many times did you use a condom ____ when you had sex with a regular partner during the past year? no response 99 211 The last time you had sex with a regular yes 1 partner, did you or your partner use a no 2 condom? no response 99 212 With what frequency have you used a always 1 214 condom having sex with a regular partner sometimes 2 during the past year? never 3 if “always”, go to Question 214 no response 99 213 Why don’t you use condom every time very expensive 1 having sex with a regular partner (multiple ashamed to buy 2 answers are possible)? difficult to use 3 not so available 4 abates the pleasure 5 ashamed to ask the sexual partnerto use it 6 trust my partner 7 don’t know about the efficacy of condom use 8 use for pregnancy prevention 9 other ______10 no response 99 214 In the past one year, did you (or your yes 1 partner) use a condom the last time you no 2 had sex with a regular partner the last time Did not have sex with regular you were in Armenia? if “Did not have partner in Armenia 3 216 sex with regular partner in Armenia”, no response 99 go to Question 216 215 In the past one year, with what frequency always 1 did you use a condom having sex with a sometimes 2 regular partner the last time you were in never 3 Armenia? no response 99 216 In the past year, did you (or your partner) yes 1 use a condom the last time you had sex no 2 with a regular partner the last time you Did not have sex with a regular were abroad? partner abroad 3 218 if “Did not have sex with regular no response 99 partner abroad”, go to Question 218

No. Question Answer Skip 217 In the past year, With what frequency did always 1 you use condom having sex with a regular sometimes 2 partner the last time you were abroad? never 3 no response 99

Casual Partners: these are partners who are NOT your husband or wife (whether in a civil marriage or registered marriage) or a boyfriend/girlfriend

No. Question Answer Skip 218 Have you had sexual intercourse with a yes 1 casual partner in the past 1 year? no 2 231 if “no”, go to Question 231 no response 99 219 If “yes”, how many casual partners did you ____ have during the past year? no response 99 220 How many of those were while you were ______abroad? 221 How many of those were while you were ______in Armenia? 222 How many sexual contacts on average did ____ you have with one casual partner during the past year? no response 99 223 How many times did you use a condom ____ when you had sex with one casual partner during the past year? no response 99 224 The last time you had sex with a casual ____ partner, did you or your partner use a condom? no response 99 225 With what frequency have you used a always 1 227 condom having sex with a non-regular sometimes 2 partner during the past year? never 3 if “always”, go to Question 227 no response 99 226 Why don’t you use condom every time very expensive 1 having sex with a non-regular partner ashamed to buy 2 (multiple answers are possible)? difficult to use 3 not so available 4 abates the pleasure 5 ashamed to ask the sexual partnerto use it 6 trust my partner 7 don’t know about the efficacy of condom use 8 use for pregnancy prevention 9 other ______10 no response 99

No. Question Answer Skip 227 In the past one year, did you (or your yes 1 partner) use a condom the last time you no 2 had sex with a casual partner the last time Did not have sex with casual you were in Armenia? partner in Armenia 3 229 if “Did not have sex with casual no response 99 partner in Armenia”, go to Question 229 228 In the past one year, with what frequency always 1 did you use a condom having sex with a sometimes 2 casual partner the last time you were in never 3 Armenia? no response 99 229 In the past year, did you (or your partner) yes 1 use a condom the last time you had sex no 2 with a casual partner the last time you Did not have sex with a casual were abroad? partner abroad 3 231 if “Did not have sex with a casual no response 99 partner abroad”, go to Question 231 230 In the past year, with what frequency did always 1 you use condom having sex with a casual sometimes 2 partner the last time you were abroad? never 3 no response 99

Commercial Partners: these are partners to whom you gave money in exchange for sex.

No. Question Answer Skip 231 Have you had sexual intercourse with a yes 1 partner to whom you gave in exchange for no 2 224 sex in the past 1 year? no response 99 if “no”, go to Question 244 232 If “yes”, how many partners to whom you ____ gave in exchange for sex did you have during the past year? no response 99 233 How many of those were while you were ______abroad? 234 How many of those were while you were ______in Armenia? 235 How many sexual contacts on average did ____ you have with one partner to whom you gave in exchange for sex partner during no response 99 the past year? 236 How many times did you use a condom ____ when you had sex with one partner to whom you gave in exchange for sex no response 99 partner during the past year?

No. Question Answer Skip 237 The last time you had sex with a partner yes 1 to whom you gave in exchange for sex, no 2 did you or your partner use a condom? no response 99 238 With what frequency have you used a always 1 240 condom having sex with partner to whom sometimes 2 you gave in exchange for sex during the never 3 past year? if “always”, go to Question no response 99 240 239 Why don’t you use condom every time very expensive 1 having sex with a partner to whom you ashamed to buy 2 gave in exchange for sex (multiple difficult to use 3 answers are possible)? not so available 4 abates the pleasure 5 ashamed to ask the sexual partner to use it 6 trust my partner 7 don’t know about the efficacy of condom use 8 use for pregnancy prevention 9 other ______10 no response 99 240 In the past one year, did you (or your yes 1 partner) use a condom the last time you no 2 had sex with a partner to whom you gave Did not have sex with commercial in exchange for sex the last time you were partner in Armenia 3 242 in Armenia? if “Did not have sex with no response 99 commercial partner in Armenia”, go to Question 242 241 In the past one year, with what frequency always 1 did you use a condom having sex with a sometimes 2 partner to whom you gave in exchange for never 3 sex partner the last time you were in no response 99 Armenia? 242 In the past year, did you (or your partner) yes 1 use a condom the last time you had sex no 2 with a partner to whom you gave in Did not have sex with a exchange for sex the last time you were commercial partner abroad 3 24 4 abroad? no response 99 if “Did not have sex with a commercial partner abroad”, go to Question 244 243 In the past year, with what frequency did always 1 you use condom having sex with a partner sometimes 2 to whom you gave in exchange for sex the never 3 last time you were abroad? no response 99

No. Question Answer Skip 244 Have you ever had anal sex with a man? yes 1 no 2 301 if “no”, go to Question 301 no response 99 245 In the past one year, did you have anal yes 1 sex with a man the last time you worked no 2 abroad? no response 99 246 In the past one year, the last time you had yes 1 anal with a man, did you use a condom? no 2 no response 99

Section 3. Questions related to drug use

We would like to ask you some questions on drug use. We are assuring you that the study confidentiality is fully maintained. Do not forget that the same questions are asked to all the study participants.

No. Question Answer Skip 301 Have you ever used drugs? yes 1 no 2 401 If “no”, go to Question 401 no response 99 302 How old were you when you first used ____ drugs? no response 99 303 Have you ever injected drugs? yes 1 no 2 401 if “no”, go to Question 401 no response 99 304 Do you use disposable syringes when yes 1 injecting drugs? no 2 no response 99 305 Have you shared injection paraphernalia yes 1 (needles, syringes, cookers, drug no 2 containers, filters) in the last one month? no response 99 306 Have you ever used drugs prepared by yes 1 others? no 2 no response 99 307 Have you used non-sterile paraphernalia yes 1 (needles, syringes, cookers, drug no 2 containers, filters) for injecting drug use in no response 99 the past one month? 308 Did you use sterile needle and syringe the yes 1 last time you were injecting drug? no 2 no response 99

No. Question Answer Skip 309 Do you sterilize needles and syringes yes, always 1 before usage? occasionally 2 if “never or use only disposable never 3 311 needles and syringes”, pass on to use only disposable needles Question 311 and syringes 4 311 no response 99 310 If “yes” or “occasionally”, so in what way ______do you do that? 311 Have you had any skin problems (skin yes 1 reddening, pain, infection) in the area of no 2 drug injection in the past 1 month? no response 99

Section 4. Questions related to HIV/AIDS and STIs

No. Question Answer Skip 401 Have you heard of HIV/AIDS? yes 1 no 2 no response 99 402 Where from have you heard of HIV/AIDS family 1 (multiple answers are possible)? friends/peers 2 mass media 3 school 4 social/health care workers 5 counselling services 6 have not heard 7 no response 99 403 How would you estimate the probability for high 1 you to become infected with HIV? medium 2 no risk 3 no response 99 404 Do you know where you can undergo HIV yes 1 testing, if you wish to? no 2 no response 99 405 Have you been tested for HIV during the yes 1 past 12 months? no 2 409 if “no”, go to Question 409 no response 99 406 Where did you undergo you last HIV test  RA 1 in the last 12 month  Abroad 2  RA and abroad 3  no response 99 407 In the last year, the last time you were yes 1 tested, did you receive your test result? no 2 no response 99

No. Question Answer Skip 408 In the last year, the last time you were yes 1 tested did you receive counselling? no 2 do not know 3 no response 99 409 Have you had genital/anal inflammation, yes 1 unusual discharge, and/or warts during no 2 the past 1 year? no response 99 410 Have you been diagnosed with a sexually yes 1 transmitted disease in the past one year? no 2 no response 99 411 Have you been provided with condoms yes 1 during the past 12 months (for example by no 2 outreach workers or at an NGO)? no response 99 412 In what way do you try to protect yourself Use condom 1 from getting a disease that is caused Do not have sex 2 through sexual intercourse (multiple Have sex only with trusty partners3 answers are possible)? Have regular partners (the second family) 4 other ______5 no response 99

Section 5. Questions for assessing the level of knowledge on HIV prevention

No. Question Answer 501 Is it possible to reduce the risk of HIV yes 1 infection by having sexual relations with no 2 one uninfected faithful sexual partner? do not know 3 no response 99 502 Is it possible to reduce the risk of HIV yes 1 infection by using condoms? no 2 do not know 3 no response 99 503 Can a person get HIV from mosquito bites? yes 1 no 2 do not know 3 no response 99 504 A healthy-looking person be HIV infected yes 1 no 2 do not know 3 no response 99 505 It is possible to become HIV infected by yes 1 sharing a meal with a person infected with no 2 HIV do not know 3 no response 99

No. Question Answer 506 It is possible to become HIV infected by yes 1 shaking hands with a person infected with no 2 HIV do not know 3 no response 99

B. ANNEX

ANALYSIS OF DATA BY EACH REGION

Below are population weighted frequency tables and 95% confidence intervals of all variables for each of the six regions sampled in Armenia.

B.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS

TABLE B1A. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Age groups (four levels) 18-24 36 11.7 (7.8, 17.2) 48 14.7 (11.1, 19.3) 25 6.5 (4.2, 9.9) 25-34 81 25.7 (20.2, 32.2) 125 41.3 (35.7, 47.2) 84 26.3 (21.4, 31.8) 35-44 58 15.8 (11.8, 20.7) 43 13.5 (10.0, 18.0) 64 22.0 (17.4, 27.5) 45+ 140 46.8 (40.1, 53.6) 99 30.4 (25.3, 36.0) 127 45.1 (39.2, 51.2) Age groups (two levels) ≤24 36 11.7 (7.8, 17.2) 48 14.7 (11.1, 19.3) 25 6.5 (4.2, 9.9) ≥25 279 88.3 (82.8, 92.2) 267 85.3 (80.7, 88.9) 275 93.5 (90.1, 95.7) Age (mean, 42.0, 42 (20-75) 36.3, 33 (20-67) 42.9, 42 (17-76) median, range) Education level Incomplete 37 13.1 (8.8, 19.0) 36 11.2 (8.0, 15.5) 35 10.6 (1.4, 14.8) secondary Secondary 202 61.9 (55.0, 68.3) 209 67.9 (62.3, 73.1) 195 66 (60.1, 71.5) Secondary 40 13.1 (9.1, 18.5) 24 7.0 (4.6, 10.5) 17 4.9 (2.9, 8.1) technical Incomplete 8 2.2 (1.0, 4.6) 11 2.8 (1.5, 5.1) 7 1.8 (0.8, 4.1) higher Higher 28 9.7 (6.3, 14.6) 35 10.9 (7.8, 15.1) 46 16.6 (12.5, 21.7) Family status Single 60 18.8 (14.0, 24.6) 101 33.7 (28.4, 39.5) 47 13.0 (9.6, 17.3) Married 250 80.0 (74.0, 84.8) 213 65.7 (59.9, 71.1) 249 86.0 (81.6, 89.5) Divorced 5 1.2 (0.5, 3.1) 1 0.5 (0.07, 3.5) 3 1.0 (0.03, 0.3) Number of years working abroad (when worked for at least 3 months or more during one year period (mean, median, range) 7.5, 5 (1-40) 5.7, 4 (1-40) 6.2, 4 (1-30)

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Foreign countries worked most often in last three years (only those worked for at least 3 months or more) Russia 310 98.5 (96.5, 99.4) 313 99.2 (96.9, 99.8) 290 96.8 (93.5, 98.5) Kazakhstan 3 0.8 (0.2, 0.2) 0 -- 1 0.3 (0.05, 0.2) Ukraine 2 0.6 (0.2, 0.3) 2 0.8 (0.1, 3.4) 4 2.0 (0.7, 5.3) Other 0 -- 0 -- 3 0.8 (0.2, 2.7) Type of settlement worked last time worked in past year (only those worked for at least 3 months or more) Big city 194 63.2 (56.5, 69.4) 139 42.6 (37.0, 48.4) 151 46.6 (40.6, 52.6) City 117 35.6 (29.5, 42.3) 160 50.1 (44.3, 55.9) 140 50.6 (44.6, 56.6) Village 4 1.2 (0.4, 3.1) 15 6.8 (4.1, 11.0) 8 2.8 (1.4, 5.5) Little-inhabited 0 -- 1 0.5 (0.07, 3.5) 0 -- area Type of settlement lived in last time worked in past year (only those worked for at least 3 months or more) Big city 194 63.2 (56.5, 69.4) 136 41.5 (36.0, 47.4) 147 45.3 (39.4, 51.4) City 116 35.1 (29.0, 41.7) 158 49.3 (43.5, 55.1) 145 52.2 (46.1, 58.1) Village 5 1.4 (0.6, 3.4) 21 9.1 (6.0, 13.7) 7 2.5 (1.2, 5.3) Little-inhabited 0 -- 0 -- 0 -- area Type of work performed in past one year (only those worked for at least 3 months or more) Construction 227 71.4 (65.0, 77.0) 229 73.2 (67.7, 78.0) 196 64.4 (58.3, 70.0) Agriculture 7 3.0 (1.2, 7.4) 4 1.4 (0.5, 3.7) 14 5.5 (3.2, 9.2) Trade 16 5.3 (3.0, 9.0) 20 5.9 (3.7, 9.3) 18 6.9 (4.4, 10.9) Services Sector 63 20.3 (15.5, 26.0) 62 19.5 (15.3, 24.6) 68 23.2 (18.4, 28.8) Other 0 -- 0 -- 0 -- Spouse accompanies while working abroad (only among married persons) Yes 29 8.3 (5.5, 12.2) 22 9.6 (6.2, 14.5) 32 15.5 (11.1, 21.2) No 221 91.7 (87.8, 94.5) 191 90.4 (85.5, 93.8) 217 84.5 (78.7, 88.9)

TABLE B1B. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Age groups (four levels) 18-24 53 10.2 (7.5, 13.9) 30 7.4 (4.6, 11.6) 43 12.9 (8.9, 18.5) 25-34 121 43.7 (35.2, 52.6) 136 35.0 (25.4, 45.9) 106 39.0 (31.8, 46.8) 35-44 41 15.4 (9.9, 23.0 ) 61 20.2 (10.8, 34.6) 69 20.6 (15.3, 27.1) 45+ 85 30.7 (33.3, 39.2) 73 37.5 (23.6, 53.8) 92 27.4 (21.2, 34.6)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Age groups (two levels) ≤24 53 28.6 (9.6, 60.1) 30 7.4 (4.6, 11.6) 43 13.1 (8.8, 18.9) ≥25 247 71.4 (39.9, 90.4) 270 92.6 (88.4, 95.4) 267 86.9 (81.1, 91.2) Age (mean, median, 37.5, 33 (19-61) 40.0, 38 (19-67) 36.5, 34 (18-68) range) Education level Incomplete 46 21.3 (14.4, 30.4) 21 3.5 (2.1, 5.7) 21 5.8 (3.2, 10.3) secondary Secondary 202 66.3 (57.5, 74.0) 226 68.1 (52.3, 80.6) 250 76.7 (69.4, 82.6) Secondary 21 6.4 (3.6, 11.3) 15 17.2 (6.4, 38.6) 14 8.3 (4.7, 14.5) technical Incomplete 6 1.1 (0.5, 2.7) 6 1.2 (0.5, 2.8) 6 1.7 (0.6, 4.7) higher Higher 25 4.8 (3.1, 7.3) 32 10.0 (6.4, 15.5) 19 7.5 (4.2, 12.8) Family status Single 79 20.7 (14.7, 28.2) 55 13.4 (9.1, 19.3) 69 26.7 (20.4, 34.0) Married 220 79.0 (71.5, 85.0) 244 86.3 (80.4, 90.7) 137 72.1 (64.8, 78.5) Divorced 1 0.3 (0.0, 2.1) 1 0.2 (0.0, 1.7) 3 1.1 (0.3, 3.9) Number of years working abroad (when worked for at least 3 months or more during one year period (mean, median, range) 9.5, 7 (1-42) 8.2, 7 (1-37) 9.8, 8 (1-45) Foreign countries worked most often in last three years (only those worked for at least 3 months or more) Russia 298 99.5 (97.7, 99.9) 299 99.8 (98.8, 100) 294 92.9 (88.3, 95.8) Kazakhstan 0 0 0 -- 14 5.7 (3.2, 9.9) Ukraine 0 0 1 0.2 (0.0, 1.2) 2 1.3 (0.3, 5.2) Other 2 0.5 (0.1, 2.3) 0 -- 0 -- Type of settlement worked last time worked in past year (only those worked for at least 3 months or more) Big city 149 38.6 (31.2, 46.7) 126 28.2 (20.4, 37.5) 177 52.6 (44.9, 60.1) City 140 55.8 (47.3, 63.9) 163 70.0 (60.2, 78.2) 121 40.9 (33.7, 48.7) Village 8 1.8 (0.8 3.7) 9 1.8 (0.8, 3.9) 11 6.3 (3.1, 12.4) Little-inhabited 3 3.8 (1.1, 12.5) 0 -- 1 0.06 (0.008, 0.4) area Type of settlement lived in last time worked in past year (only those worked for at least 3 months or more) Big city 146 36.4 (29.3, 44.2) 125 28.4 (20.5, 37.9) 173 52.8 (45.1, 60.3) City 139 55.4 (46.9, 63.6) 151 66.7 (56.2, 75.8) 124 39.7 (32.5, 47.4) Village 12 4.3 (1.9, 9.4) 21 4.8 (2.9, 8.1) 12 7.4 (3.8, 13.8) Little-inhabited 3 3.8 (1.1, 12. 5) 0 -- 1 0.06 (0.008, 0.4) area

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Type of work performed in past one year (only those worked for at least 3 months or more) Construction 267 90.3 (84.4, 94.2) 271 92.9 (88.6, 95.6) 263 87.3 (81.8, 91.4) Agriculture 1 0.2 (0.0, 1.2) 3 0.9 (0.2, 3.2) 4 1.2 (0.2, 6.3) Trade 6 2.5 (0.7, 8.5) 5 1.8 (0.7, 4.7) 1 0.5 (0.07, 3.6) Services Sector 26 7.0 (4.1, 11.8) 18 4.4 (2.5, 7.7) 42 10.9 (7.3, 15.9) Other 0 -- 0 -- -- Spouse accompanies while working abroad (only among married persons) Yes 16 16.0 (8.9, 27.3) 20 5.4 (3.1, 9.3) 5 3.0 (0.9, 9.0) No 204 83.9 (72.7, 91.1) 222 94.6 (90.7, 96.9) 232 97.0 (90.9, 99.0)

B.2 GENERAL SEXUAL HISTORY

TABLE B2A. GENERAL SEXUAL HISTORY OF RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever had sexual intercourse Yes 313 99.3 (97.2, 99.8) 312 98.8 (96.4, 99.6) 298 99.7 (97.6, 99.9) No 2 0.6 (0.5, 2.8) 3 1.1 (0.3, 3.6) 1 0.3 (0.04, 2.4) Age at first sexual intercourse ≤15 8 2.1 (1.0, 4.5) 17 5.0 (3.0, 8.1) 6 2.1 (0.9, 4.8) 16-19 179 57.0 (50.0, 63.7) 212 68.8 (63.1, 74.0) 189 65.7 (59.7, 71.2) 20+ 120 40.8 (34.2, 47.8) 81 26.2 (21.3, 31.7) 98 32.1 (26.7, 38.0) Age at first sexual intercourse (mean, median, range) 18.9, 18 (12-33) 18.1, 18 (11-33) 18.6, 18 (12-31) Sexual intercourse in past 30 days Yes 252 81.1 (75.2, 85.5) 225 70.8 (65.1, 75.9) 249 84.8 (80.1, 88.6) No 61 18.9 (14.1, 24.8) 87 29.2 (24.1, 34.9) 49 15.1 (11.4, 19.8) Condom use at last sexual intercourse in past 30 days Yes 32 10.2 (7.1, 14.4) 39 17.3 (12.7, 23.2) 46 18.4 (13.8, 24.3) No 220 89.8 (85.5, 92.9) 186 82.7 (76.8, 87.3) 206 81.6 (75.7, 86.2)

TABLE B2B. GENERAL SEXUAL HISTORY OF RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever had sexual intercourse Yes 297 99.4 (97.9, 99.8) 299 100 307 98.5 (95.4, 99.5) No 3 0.6 (0.2, 2.0) 0 0 3 1.5 (0.5, 4.6) Age at first sexual intercourse ≤15 8 7.1 (0.7, 44.1) 5 1.1 (0.4, 3.2) 2 0.1 (0.0, 0.5) 16-19 199 71.4 (39.9, 90.4) 178 70.3 (60.4, 78.7) 183 65.7 (57.9, 72.7) 20+ 89 21.4 (5.9, 54.0) 111 28.5 (20.5, 38.2) 109 34.2 (27.2, 42.0) Age at first sexual intercourse (mean, median, range) 18.7, 18 (11-28) 18.4, 18 (12-28) 18.5, 18, (13-31) Sexual intercourse in past 30 days Yes 225 79.4 (71.9, 85.3) 251 87.4 (81.5, 91.5) 244 76.3 (69.2, 82.2) No 72 20.6 (14.6, 28.1) 48 12.6 (8.4, 18.5) 63 23.7 (17.8, 30.8) Condom use at last sexual intercourse in past 30 days Yes 28 13.1 (7.4, 22.0) 33 9.9 (6.1, 15.4) 16 8.1 (4.2, 15.3) No 197 86.9 (78.0, 92.6) 218 90.1 (84.5, 93.8) 228 91.8 (84.6, 95.8)

6.3 SEXUAL BEHAVIORS WITH REGULAR PARTNERS

TABLE B3A. SEXUAL BEHAVIORS WITH REGULAR PARTNERS IN THE PAST ONE YEAR AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with regular partner Yes 266 86.9 (82.3, 90.5) 255 81.2 (76.1, 85.4) 262 89.5 (85.3, 92.6) No 47 13.1 (9.5, 17.7) 57 18.8 (14.6, 23.9) 35 10.5 (7.4, 14.7) Frequency of regular sexual partners 1 210 78.1 (71.0, 83.8) 187 72.1 (65.7, 77.6) 204 79.0 (73.3, 83.7) 2-4 54 20.5 (15.0, 27.3) 61 24.2 (19.1, 30.2) 58 21.0 (16.2, 26.7) 5+ 2 1.4 (0.3, 7.0) 7 3.7 (1.7, 7.6) 0 -- Number of regular sexual partners (mean, median, range) 1.4, 1 (1-11) 1.6, 1 (1-20) 1.2, 1 (1-4) Frequency of regular sexual partners while abroad 0 213 78.9 (71.8, 84.7) 177 68.0 (61.6, 73.8) 221 86.4 (81.6, 90.2) 1 47 18.1 (12.8, 25.0) 68 27.4 (22.0, 33.6) 36 12.1 (8.6, 16.7) 2-4 5 1.7 (0.8, 4.4) 6 2.5 (1.1, 5.7) 5 1.5 (0.5, 4.0) 5+ 1 1.2 (0.2, 7.8) 4 2.0 (0.7, 5.4) 0 --

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Number of regular sexual partners while abroad (mean, median, range) 1.1, 1 (1-3) 1.3, 1 (1-8) 1.1, 1 (1-3) Frequency of regular sexual partners while in Armenia 0 11 4.4 (2.0, 9.1) 26 11.2 (7.6, 16.1) 4 0.9 (0.3, 24.3) 1 238 89.8 (84.4, 93.5) 208 79.1 (73.1, 84.1) 238 90.7 (86.2, 93.9) 2-4 16 5.5 (3.1, 9.7) 19 8.5 (5.3, 13.2) 20 8.4 (5.4, 12.9) 5+ 1 0.25 (0.25, 1.8) 2 1.2 (0.3, 4.7) 0 -- Number of regular sexual partners while in Armenia (mean, median, range) 1.1, 1 (1-5) 1.2, 1 (1-7) 1.1, 1 (1-3) Number of times on average having sex with one regular sexual partner (mean, median, range) 76.1, 60 (2-400) 56.5, 40 (2-275) 48.9, 40 (1-200) Number of times using condom during sex with regular partner 10.4, 0 (0-420) 14.3, 0 (0-350) 8.0, 0 (0-100) Used condom during sex with regular partner Yes 30 9.8 (6.4, 14.7) 53 21.4 (16.5, 27.3) 35 13.3 (9.5, 18.3) No 236 90.2 (85.3, 93.6) 202 75.6 (72.7, 83.5) 227 86.7 (81.7, 90.5) Frequency of condom use during sex with regular partner Always 23 7.8 (4.7, 12.5) 38 15.6 (11.4, 21.0) 21 8.8 (5.7, 13.3) Sometimes 35 14.2 (9.5, 20.9) 53 21.4 (16.5, 27.3) 49 17.3 (13.0, 22.6) Never 208 78.0 (70.9, 83.7) 164 62.7 (56.4, 69.0) 191 73.9 (67.9, 79.2) Reasons why condom not used every time during sex with regular partner Too 0 -- 0 -- 0 -- expensive Ashamed to 0 -- 1 0.7 (0.1, 5.2) 0 -- buy Difficult to 2 0.4 (0.1, 1.8) 7 3.8 (1.8, 7.9) 7 2.5 (1.2, 5.5) use Not available 6 1.6 (0.6, 3.9) 2 1.2 (0.3, 4.7) 4 1.8 (0.6, 5.1) Reduces 102 40.6 (33.2, 48.5) 80 39.1 (32.3, 46.3) 134 57.1 (50.3, 63.6) pleasure Ashamed to ask sex 0 -- 1 0.7 (0.1, 5.2) 0 -- partner to use trust my 136 58.1 (50.2, 65.6) 141 61.8 (54.6, 68.6) 110 44.7 (38.1, 51.5) partner Don’t know about 2 1.9 (0.4, 8.8) 0 -- 1 0.3 (0.04, 2.1) condom use efficacy Want to get 23 11.1 (6.7, 18.0) 9 2.9 (1.5, 5.6) 7 2.6 (1.1, 5.8) pregnant

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Used condom last time during sex with regular partner last time in Armenia Yes 22 6.4 (4.1, 9.8) 42 17.0 (12.5, 22.4) 32 12.8 (9.1, 17.8) No 234 89.6 (84.7, 93.1) 188 72.1 (65.9, 77.7) 226 86.3 (81.3, 90.1) No sex with regular part- 10 4.0 (1.8, 8.8) 25 10.9 (7.4, 15.9) 4 0.9 (0.3, 2.4) ner in Armenia Frequency of condom use during sex with regular partner last time in Armenia Always 16 4.7 (2.8, 7.7) 28 12.6 (8.6, 18.0) 20 8.7 (5.6, 13.3) Sometimes 27 9.6 (6.1, 14.7) 39 17.2 (12.6, 23.1) 30 10.9 (7.5, 15.5) Never 213 85.7 (80.3, 89.9) 163 70.1 (63.4. 76.0) 208 80.4 (74.7, 85.1) Use condom last time during sex with regular partner last time being abroad Yes 18 9.0 (5.0, 15.9) 34 13.9 (10.0, 19.1) 22 7.5 (4.8, 11.6) No 32 10.0, (6.7, 14.8) 44 18.4 (13.8, 24.1) 19 5.8 (3.6, 9.3) No sex with regular 216 80.9 (73.9, 86.3) 177 67.7 (61.3, 73.5) 221 86.7 (81.9, 90.3) partner while abroad Frequency of condom use during sex with regular partner last time being abroad Always 10 22.1 (10.2, 41.7) 21 27.6 (18.4, 39.3) 15 40.5 (24.8, 58.5) Sometimes 11 30.0 (14.5, 51.9) 23 28.5 (19.2, 40.1) 9 20.4 (9.9, 37.4) Never 29 47.9 (30.4, 65.8) 34 43.9 (32.6, 55.7) 16 39.1 (23.9, 56.7)

TABLE B3B. SEXUAL BEHAVIORS WITH REGULAR PARTNERS IN PAST ONE YEAR AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with regular partner Yes 244 83.9 (76.2, 89.5) 260 90.4 (85.6, 93.8) 261 83.0 (76.1, 88.2) No 53 16.1 (10.5, 23.8) 40 9.5 (6.2, 14.4) 46 17.0 (11.8, 23.8) Frequency of regular sexual partners 1 190 71.4 (39.9, 90.4) 201 75.0 (59.7, 85.9) 167 62.8 (49.2, 74.6) 2-4 53 21.4 (5.9, 54.0) 58 24.8 (14.0, 40.1) 93 37.2 (25.4, 50.8) 5+ 1 7.1 (0.7, 44.1) 1 0.2 (0.0, 1.3) 1 -- Number of regular sexual partners (mean, median, range) 1.3, 1 (1-6) 1.3, 1, (1-5) 1.5, 1, (1-8) Frequency of regular sexual partners while abroad 0 176 73.1 (64.0, 80.6) 200 75.2 (59.8, 86.0) 150 55.6 (47.2, 63.6) 1 62 23.8 (16.9, 32.5) 55 23.0 (12.5, 38.6) 104 40.5 (32.7, 48.8) 2-4 5 3.0 (0.7, 11.2) 5 1.8 (0.7, 4.8) 6 2.6 (1.0, 6.5) 5+ 0 -- 0 -- 1 1.3 (0.2, 8.6)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Number of regular sexual partners while abroad (mean, median, range) 1.1, 1 (1-4) 1.1, 1 (1-3) 1.3, 1, (1-8) Frequency of regular sexual partners while in Armenia 0 15 35.7 (13.7, 66.0) 9 2.5 (1.1, 5.4) 22 12.5 (6.4, 23.0) 1 226 57.1 (28.4, 81.7) 245 95.6 (91.8, 97.6) 236 87.0 (76.6, 93.2) 2-4 3 7.1 (0.7, 44.1) 5 1.7 (0.6, 4.6) 3 0.4 (0.1, 1.6) 5+ 0 -- 1 0.2 (0.0, 1.3) 0 -- Number of regular sexual partners while in Armenia (mean, median, range) 1.0, 1 (1-2) 1.0, 1, (1-5) 1.0, 1, (1-2) Number of times on average having sex with one regular sexual partner (mean, median, range) 73.1, 60 (6-300) 69.2, 50 (2-400) 76.2, 70, (0-500) Number of times using condom during sex with regular partner 9.6, 0 (0-300) 16.1, 0 (0-900) 11.9, 0, (0-240) Used condom during sex with regular partner Yes 25 6.5 (4.2, 9.9) 29 8.7 (5.4, 13.9) 20 9.9 (5.8, 16.3) No 219 93.5 (90.1, 95.8) 230 91.2 (86.1, 94.6) 241 90.1 (83.7, 94.2) Frequency of condom use during sex with regular partner Always 16 4.0 (2.3, 6.8) 15 4.0 (2.2, 7.2) 14 7.3 (3.8, 13.4) Sometimes 32 13.6 (8.2, 21.8) 45 14.2 (9.2, 21.1) 60 20.9 (15.1, 28.2) Never 196 82.4 (74.3, 88.3) 200 81.8 (73.9, 87.7) 187 71.8 (63.8, 78.6) Reasons why condom not used every time during sex with regular partner Too 0 -- 0 -- 0 -- expensive Ashamed to 2 0.8 (0.2, 3.3) 1 0.3 (0.0, 2.0) 0 -- buy Difficult to 3 0.9 (0.2, 3.1) 2 0.5 (0.1, 2.0) 0 -- use Not available 1 0.2 (0.0, 1.4) 1 0.6 (0.1, 4.0) 1 0.08 (0.001, 0.5) Reduces 92 34.0 (25.9, 43.2) 93 23.7 (16.3, 33.2) 129 63.4 (54.8, 71.1) pleasure Ashamed to ask sex 1 1.9 (0.3, 12.6) 0 -- 0 -- partner to use trust my 163 80.4 (73.6, 85.8) 162 78.9 (70.1, 85.7) 146 54.4 (45.8, 62.7) partner Don’t know about 2 0.7 (0.2, 3.0) 0 -- 0 -- condom use efficacy Want to get 7 3.8 (1.3, 10.7) 8 2.3 (1.0, 5.4) 14 3.5 (1.6, 7.4) pregnant

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Used condom last time during sex with regular partner last time in Armenia Yes 17 4.3 (2.5, 7.1) 27 8.3 (5.0, 13.3) 10 6.4 (3.1, 12.6) No 212 92.6 (89.1, 95.0) 224 89.2 (83.5, 93.2) 229 84.4 (77.0, 89.6) Did not have sex with regular 15 3.1 (1.8, 5.4) 9 2.5 (1.1, 5.4) 22 9.2 (5.4, 15.3) partner in Armenia Frequency of condom use during sex with regular partner last time in Armenia Always 11 2.9 (1.5, 5.4) 13 3.6 (1.9, 6.8) 7 6.2 (2.8, 13.0) Sometimes 20 8.6 (4.3, 16.4) 27 8.5 (5.1, 13.8) 26 5.7 (3.2, 10.1) Never 198 88.5 (81.0, 93.3) 211 87.9 (81.6, 92.2) 206 88.0 (81.1, 92.6) Use condom last time during sex with regular partner last time being abroad Yes 22 8.1 (4.6, 13.9) 29 8.8 (5.4, 14.0) 48 18.0 (12.4, 25.2) No 46 18.9 (12.4, 27.7) 30 15.9 (6.6, 33.6) 62 25.8 (19.3, 33.7) No sex with 176 73.0 (63.9, 80.5) 201 75.3 (60.0, 86.1) 151 56.2 (47.8, 64.2) regular partner while abroad Frequency of condom use during sex with regular partner last time being abroad Always 18 26.3 (14.0, 43.8) 23 26.2 (11.9, 48.1) 25 27.5 (17.5, 40.5) Sometimes 6 5.8 (2.3, 13.8) 11 17.4 (7.2, 36.5) 32 21.2 (13.2, 32.3) Never 44 67.9 (50.5, 81.4) 25 56.4 (29.1, 80.3) 53 51.2 (38.8, 63.5)

B.4 SEXUAL BEHAVIORS WITH CASUAL PARTNERS

TABLE B4A. SEXUAL BEHAVIORS WITH CASUAL PARTNERS IN PAST YEAR AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with casual partner Yes 110 35.6 (31.1, 44.5) 130 41.0 (35.4, 46.9) 106 32.2 (26.9, 38.0) No 203 62.4 (55.5, 68.8) 182 59.0 (53.1, 64.6) 192 67.8 (62.0, 73.0) Frequency of casual sexual partners 1 28 26.7 (17.6, 38.3) 31 22.2 (15.7, 30.4) 28 25.8 (17.8, 35.9) 2-4 58 53.4 (41.7, 64.6) 68 53.3 (4.1, 62.2) 55 55.8 (45.4, 27.1) 5+ 24 19.9 (12.7, 29.8) 31 24.5 (17.4, 33.2) 23 18.4 (12.0, 27.1)

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Number of casual sexual partners (mean, median, range) 3.7, 2 (1-25) 4.2, 3 (1-40) 3.9, 2 (1-50) Frequency of casual sexual partners while abroad 0 21 15.3 (9.6, 23.6) 22 17.0 (11.1, 25.0) 30 30.5 (21.7, 40.9) 1 29 29.0 (19.4, 41.1) 31 23.5 (17.0, 31.9) 28 26.4 (18.3, 36.5) 2-4 43 41.6 (30.5, 53.7) 56 43.0 (34.3, 52.2) 31 30.2 (21.6, 40.5) 5+ 17 14.0 (8.0, 23.4) 21 16.5 (10.7, 24.6) 17 12.7 (7.7, 20.7) Number of casual sexual partners while abroad (mean, median, range) 2.5, 2 (1-15) 3.1, 2 (1-25) 2.7, 2 (1-15) Frequency of casual sexual partners while in Armenia 0 69 64.4 (52.8, 74.5 26 63.1 (53.9, 71.4) 49 43.7 (33.9, 54.0) 1 15 12.8 (7.0, 22.1) 208 12.4 (7.7, 19.2) 27 27.4 (19.0, 37.7) 2-4 22 19.7 (12.0, 30.5) 19 19.3 (13.0, 27.7) 23 23.1 (15.3, 33.2) 5+ 4 3.1 (1.1, 8.3) 2 5.2 (2.2, 11.9) 7 5.8 (2.7, 12.2) Number of casual sexual partners while in Armenia (mean, median, range) 2.1, 2 (1-15) 2.4, 2 (1-8) 2.1, 1 (1-12) Number of times using condom during sex with casual partner 15.2, 4 (0-250) 14.8, 4 (0-400) 16.1, 6 (0-225) Used condom during sex with casual partner Yes 82 76.7 (66.4, 84.6) 87 67.2 (58.1, 75.1) 79 77.7 (68.1, 84.9) No 28 23.3 (15.4, 33.6) 43 32.8 (24.8, 41.9) 27 22.3 (15.0, 31.9) Frequency of condom use during sex with casual partner Always 80 75.1 (64.7, 83.2) 78 61.0 (51.8, 69.5) 78 77.2 (67.7, 84.5) Sometimes 7 5.2 (2.3, 11.4) 23 15.7 (10.3, 23.2) 8 5.6 (2.6, 11.6) Never 23 19.7 (12.4, 29.7) 29 23.3 (16.4, 32.0) 20 17.2 (1.8, 26.4) Reasons why condom not used every time during sex with casual partner Too expensive 0 -- 0 -- 0 -- Ashamed to 0 -- 0 -- 1 2.1 (.02, 15.1) buy Difficult to use 1 2.3 (0.3, 16.6) 4 7.6 (2.7, 19.4) 0 -- Not available 0 -- 3 3.9 (1.2, 12.0) 0 -- Reduces 18 67.2 (46.4, 82.8) 34 70.4 (56.0, 81.7) 22 75.5 (51.0, 90.1) pleasure Ashamed to ask sex 1 1.3 (0.2, 10.2) 0 -- 0 -- partner to use trust my 15 46.8 (27.3, 67.3) 15 24.2 (14.1, 38.3) 9 31.5 (15.0, 54.5) partner Don’t know about condom 0 -- 0 -- 0 -- use efficacy Want to get 1 3.9 (4.8, 25.5) 1 1.3 (0.1, 9.3) 0 -- pregnant

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Used condom during sex with casual partner the last time in Armenia Yes 26 22.9 (14.7, 33.8) 27 21.7 (15.0, 30.3) 47 47.7 (37.6, 58.0) No 14 12.1 (6.4, 21.4) 20 14.7 (9.4, 22.3) 10 8.6 (4.3, 16.3) No sex with casual partner 70 65.0 (53.4, 75.0) 83 63.6 (54.4, 71.9) 49 43.7 (33.9, 54.0) in Armenia Frequency of condom use during sex with casual partner the last time in Armenia Always 26 65.4 (45.6, 81.0) 21 47.6 (32.6, 63.0) 45 82.9 (70.1, 90.9) Sometimes 4 9.7 (3.2, 25.6) 16 30.7 (18.6, 46.2) 4 4.7 (1.6, 13.1) Never 10 24.9 (11.7, 45.4) 10 21.7 (11.5, 37.3) 8 12.4 (5.6, 24.9) Used condom during sex with casual partner last time being abroad Yes 68 65.9 (54.9, 75.4) 76 57.7 (48.5, 66.5) 58 55.2 (44.8, 65.1) No 20 18.5 (11.4, 28.5) 32 25.3 (18.1, 34.1) 18 14.3 (8.7, 22.7) No sex with casual 22 15.6 (9.9, 23.9) 22 17.0 (11.1, 25.0) 30 30.5 (21.7, 40.9) partner while abroad Frequency of condom use during sex with casual partner the last time being abroad Always 66 76.2 (64.4, 85.0) 69 63.8 (53.6, 72.8) 57 78.7 (67.4, 86.5) Sometimes 5 4.4 (1.7, 10.9) 14 11.3 (6.5, 18.8) 6 5.7 (2.3, 13.3) Never 17 16.4 (11.4, 31.0) 25 24.9 (17.1, 34.9) 13 15.6 (8.6, 26.4)

TABLE B4B. SEXUAL BEHAVIORS WITH CASUAL PARTNERS IN PAST YEAR AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with casual partner Yes 145 39.4 (31.6, 47.8) 125 42.2 (29.2, 56.4) 138 44.2 (36.8, 51.9) No 152 60.6 (52.2, 68.4) 175 57.7 (43.5, 70.8) 169 55.8 (48.1, 63.2) Frequency of casual sexual partners 1 47 21.4 (5.9, 54.0) 39 39.5 (19.6, 63.5) 28 22.8 (13.3, 18.6) 2-4 67 42.8 (18.3, 71.6) 64 48.0 (26.9, 69.9) 73 26.6 (16.4, 40.1) 5+ 31 35.7 (13.7, 66.0) 22 12.5 (6.6, 22.4) 37 51.3 (38.2, 64.2) Number of casual sexual partners (mean, median, range) 3.3, 2 (1-30) 2.5, 2 (1-20) 3.9, 2 (1-50) Frequency of casual sexual partners while abroad 0 12 5.5 (2.9, 9.9) 13 8.2 (3.8, 16.6) 8 5.2 (1.3, 18.6) 1 43 30.4 (20.3, 42.8) 41 38.7 (19.0, 62.9) 34 26.6 (16.4, 40.1) 2-4 65 50.3 (38.3, 62.2) 54 44.0 (23.5, 66.8) 66 51.3 (38.2, 64.2) 5+ 25 13.9 (8.9, 21.1) 17 9.1 (4.6, 17.2) 30 16.9 (9.6, 27.9)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Number of casual sexual partners while abroad (mean, median, range) 2.4, 2 (1-15) 2.1, 2 (1-15) 2.4, 2 (1-13) Frequency of casual sexual partners while in Armenia 0 114 81.2 (70.1, 88.9) 97 83.3 (71.4, 90.9) 101 62.6 (33.2, 84.9) 1 13 9.8 (3.9, 22.5) 11 7.8 (3.5, 16.1) 14 13.3 (2.8, 44.9) 2-4 16 7.6 (4.4, 12.9) 15 8.0 (3.8, 15.8) 18 15.7 (4.1, 45.1) 5+ 2 1.3 (0.3, 5.8) 2 0.9 (0.2, 4.2) 5 8.3 (1.4, 37.4) Number of casual sexual partners while in Armenia (mean, median, range) 2.1, 1 (1-15) 2.0, 2 (1-5) 2.1, 2 (1-5) Number of times using condom during sex with casual partner 15.5, 6 (0-270) 6.2, 2 (0-75) 19.1, 8 (0-225) Used condom during sex with casual partner Yes 88 69.0 (59.1, 77.4) 92 52.9 (29.8, 74.7) 118 82.4 (71.6, 89.7) No 57 31.0 (22.6, 40.9) 33 47.1 (25.2, 70.2) 20 17.5 (10.3, 28.3) Frequency of condom use during sex with casual partner Always 85 67.8 (57.7, 76.4) 84 48.5 (27.7, 69.8) 106 77.7 (66.8, 85.8) Sometimes 22 12.4 (7.7, 19.4) 18 9.1 (4.7, 17.2) 19 13.1 (7.2, 22.7) Never 38 19.8 (13.6, 27.9) 23 42.3 (20.1, 68.1) 13 9.2 (4.3, 18.4) Reasons why condom not used every time during sex with casual partner Too expensive 0 -- 0 -- 0 -- Ashamed to 0 -- 0 -- 1 0.6 (0.1, 5.1) buy Difficult to use 1 1.3 (0.2, 9.0) 1 1.1 (0.1, 9.5) 0 -- Not available 2 2.6 (0.6, 10.1) 0 -- 2 5.9 (0.9, 30.2) Reduces 36 60.2 (0.5, 0.7) 33 61.8 (18.9, 91.8) 22 65.3 (39.0, 84.8) pleasure Ashamed to ask sex part- 0 -- 0 -- 0 -- ner to use it trust my 32 0.5 (38.9, 66.0) 8 37.8 (8.0, 80.9) 12 40.5 (19.5, 65.7) partner Don’t know about condom 2 5.2 (1.3, 19.1) 1 1.1 (0.1, 9.5) 0 -- use efficacy Want to get 0 -- 0 -- 0 -- pregnant Used condom during sex with casual partner the last time in Armenia Yes 24 14.9 (7.9, 26.3) 18 11.9 (6.1, 22.1) 31 17.9 (11.0, 27.8) No 7 3.9 (1.7, 8.6) 10 4.7 (2.1, 10.4) 6 7.1 (2.9, 16.7) No sex with casual partner 114 81.2 (70.1, 88.9) 97 83.3 (71.4, 90.9) 101 74.9 (63.9, 83.4) in Armenia

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Frequency of condom use during sex with casual partner the last time in Armenia Always 23 77.1 (53.8, 90.7) 17 64.9 (42.6, 82.2) 29 70.3 (44.9, 87.3) Sometimes 2 7.0 (1.4, 28.9) 2 9.0 (1.7, 35.3) 3 10.7 (1.7, 44.6) Never 6 15.9 (5.8, 36.6) 9 26.1 (12.1, 47.6) 5 18.9 (7.0, 41.9) Used condom during sex with casual partner last time being abroad Yes 81 66.1 (55.9, 75.0) 86 48.3 (27.6, 69.5) 116 80.9 (69.6, 88.7) No 52 28.4 (20.5, 38.0) 26 43.5 (21.4, 68.6) 14 10.4 (5.1, 19.8) No sex with casual 12 5.5 (2.9, 10.0) 13 8.2 (3.8, 16.6) 8 8.7 (3.6, 19.5) partner while abroad Frequency of condom use during sex with casual partner the last time being abroad Always 76 67.7 (57.2, 76.7) 78 47.8 (25.9, 70.6) 104 83.4 (73.1, 90.3) Sometimes 21 12.2 (7.4, 19.3) 16 9.1 (4.4, 17.9) 16 9.2 (4.7, 17.3) Never 36 20.1 (13.6, 28.6) 18 43.0 (19.4, 70.3) 10 7.3 (2.9, 17.2)

B.5 SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS

TABLE B5A. SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS IN PAST ONE YEAR AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with commercial partner Yes 24 8.1 (5.0, 12.9) 31 11.2 (7.8, 15.7) 23 8.2 (5.3, 12.4) No 289 91.9 (87.1, 95.0) 281 88.8 (84.3, 92.2) 275 91.8 (87.5, 94.7) Frequency of commercial sexual partners 1 6 44.7 (20.7, 71.5) 11 33.7 (18.2, 53.8) 7 32.3 (14.3, 57.5) 2-4 15 46.7 (23.5, 71.3) 13 40.6 (23.7, 60.0) 10 41.4 (21.2, 64.9) 5+ 3 8.6 (2.2, 28.0) 7 25.7 (12.0, 46.5) 6 26.3 (10.8, 51.3) Number of commercial sexual partners (mean, median, range) 2.2, 2 (1-10) 4.3, 2 (1-20) 3.7, 2 (1-10) Frequency of commercial sexual partners while abroad 0 8 39.7 (17.9, 66.6) 12 33.6 (18.4, 53.1) 7 32.3 (14.5, 57.4) 1 4 26.2 (7.9, 59.3) 6 23.0 (10.2, 44.0) 8 38.6 (18.7, 63.1) 2-4 11 32.5 (15.2, 56.6) 7 22.1 (10.1, 41.7) 7 23.9 (10.1, 46.8) 5+ 1 1.6 (0.2, 12.3) 6 21.3 (9.2, 42.0) 1 5.2 (0.6, 3.2) Number of commercial sexual partners while abroad (mean, median, range) 1.7, 2 (1-3) 2.9, 2 (1-15) 1.9, 1 (1-5)

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Frequency of commercial sexual partners while in Armenia 0 15 57.3 (31.2, 79.9) 17 60.3 (40.9, 76.9) 13 51.0 (28.5, 73.1) 1 4 24.5 (7.6, 56.1) 8 19.8 (9.1, 37.8) 1 6.3 (0.8, 37.2) 2-4 3 11.1 (2.8, 34.9) 5 15.6 (6.1, 34.5) 3 16.4 (4.8, 43.1) 5+ 2 7.1 (1.5, 27.6) 1 4.3 (0.5, 37.3) 6 26.3 (10.8, 51.3) Number of commercial sexual partners while in Armenia (mean, median, range) 1.8, 1 (1-5) 1.7, 1 (1-4) 3.2, 2 (1-6) Number of times on average having sex with one commercial sexual partner (mean, median, range) 3.0, 1 (1-25) 5.1, 1 (1-26) 4.9, 1 (1-50) Number of times using condom during sex with commercial partner 4.1, 2 (0-36) 28.4, 3 (0-520) 29.0, 2 (0-500) Used condom during sex with commercial partner Yes 19 70.4 (39.1, 89.8) 29 92.4 (72.4, 98.3) 20 83.6 (56.9, 95.2) No 5 29.6 (10.2, 60.9) 2 7.6 (1.7, 27.6) 3 16.3 (4.8, 43.1) Frequency of condom use during sex with commercial partner Always 19 70.4 (39.1, 89.8) 27 86.3 (67.0, 95.1) 20 83.6 (56.9, 95.2) Sometimes 1 3.0 (0.3, 21.4) 2 6.1 (1.4, 23.1) 1 5.1 (0.6, 32.4) Never 4 26.6 (8.2, 59.6) 2 7.5 (1.7, 27.6) 2 11.2 (2.4, 39.1) Reasons why condom not used every time during sex with commercial partner Too expensive 0 -- 0 -- 0 -- Ashamed to 1 10.1 (2.9, 80.9) 0 -- 0 -- buy Difficult to use 0 -- 0 -- 0 -- Not available 0 -- 0 -- 0 -- Reduces 4 89.9 (19.1, 99.7) 4 100 3 100 pleasure Ashamed to ask sex partner 1 10.1 (2.9, 80.9) 0 -- 0 -- to use Trust partner 1 10.1 (2.9, 80.9) 0 -- 1 -- Don’t know about condom 0 -- 0 -- 0 -- use efficacy Want to get 0 -- 0 -- 0 -- pregnant Used condom last time having sex with commercial partner the last time in Armenia Yes 8 39.7 (19.6, 64.0) 14 39.7 (23.1, 59.1) 8 39.7 (19.6, 64.0) No 3 16.3 (4.8, 43.1) 0 -- 3 16.3 (4.8, 43.1) No sex with casual partner 12 44.0 (23.3, 67.0) 17 60.3 (40.9, 76.9) 12 44.0 (23.3, 67.0) in Armenia

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Frequency of condom use when having sex with commercial partner last time in Armenia Always 8 70.8 (32.1, 92.6) 12 84.6 (49.2, 96.9) 8 70.8 (32.1, 92.6) Sometimes 1 9.2 (0.8, 54.4) 2 15.4 (3.1, 50.8) 1 9.2 (0.8, 54.4) Never 2 20.0 (3.6, 62.4) 0 -- 2 20.0 (3.6, 62.4) Used condom last time having sex with commercial partner the last time being abroad Yes 14 55.4 (32.0, 76.7) 17 58.8 (39.4, 75.8) 14 55.4 (32.0, 76.7) No 1 5.2 (0.6, 32.4) 2 7.6 (1.7, 27.6) 1 5.2 (0.6, 32.4) No sex with casual partner 8 39.4 (19.3, 63.8) 12 33.6 (18.4, 51.3) 8 39.4 (19.3, 63.8) while abroad Frequency of condom use when having sex with commercial partner the last time being abroad Always 14 91.5 (51.5, 99.0) 17 88.6 (60.2, 97.5) 14 91.5 (51.5, 99.1) Sometimes 1 8.5 (0.9, 48.4) 0 -- 1 8.5 (0.9, 48.4) Never 0 -- 2 11.4 (2.4, 39.8) 0 --

TABLE B5B. SEXUAL BEHAVIORS WITH COMMERCIAL PARTNERS IN PAST YEAR AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Sexual intercourse with commercial partner Yes 35 8.0 (4.8, 13.0) 18 3.5 (2.0, 6.1) 21 9.3 (5.5, 15.1) No 262 92.0 (87.0, 95.2) 282 96.5 (93.9, 98.0) 286 90.7 (84.8, 94.5) Frequency of commercial sexual partners 1 12 42.8 (18.3, 71.6) 7 45.3 (21.2, 71.8) 7 41.2 (16.3, 71.6) 2-4 18 35.7 (13.7, 66.0) 11 54.7 (28.2, 78.8) 11 50.4 (22.6, 77.9) 5+ 5 21.4 (5.9, 54.0) 0 -- 3 8.3 (1.4, 37.4) Number of commercial sexual partners (mean, median, range) 2.6, 2 (1-10) 1.9, 2 (1-4) 2.0, 2 (1-5) Frequency of commercial sexual partners while abroad 0 19 41.2 (20.9, 64.9) 11 54.7 (28.2, 78.8) 8 35.6 (14.2, 64.8) 1 4 9.9 (3.1, 27.1) 3 24.8 (6.9, 59.4) 6 34.2 (13.3, 63.9) 2-4 9 40.4 (16.4, 70.0) 4 20.5 (6.7, 47.9) 6 24.6 (7.6, 56.5) 5+ 3 8.6 (2.2, 27.6) 0 -- 1 5.6 (0.6, 35.2) Number of commercial sexual partners while abroad (mean, median, range) 2.1, 2 (1-5) 1.7, 1 (1-4) 1.8, 1 (1-5) Frequency of commercial sexual partners while in Armenia 0 11 46.2 (21.8, 72.5) 7 45.3 (21.2, 71.8) 10 52.7 (26.0, 78.0) 1 11 24.9 (11.5, 45.8) 4 20.5 (6.7, 47.9) 5 28.7 (9.9, 59.7) 2-4 13 28.9 (13.9, 50.7) 7 34.2 (14.8, 60.8) 4 17.2 (5.1, 44.6) 5+ 0 -- 0 -- 2 1.3 (0.3, 6.5)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Number of commercial sexual partners while in Armenia (mean, median, range) 1.8, 2 (1-4) 2.0, 2 (1-4) 1.7, 1 (1-5) Number of times on average having sex with one commercial sexual partner (mean, median, range) 3.0, 1 (1-12) 4.1, 2 (1-20) 1.8, 1 (1-5) Number of times using condom during sex with commercial partner 5.2, 4 (0-30) 3.0, 3 (0-15) 4.9, 2 (0-25) Used condom during sex with commercial partner Yes 31 89.4 (70.7, 96.7) 15 75.2 (40.6, 93.1) 20 94.5 (65.2, 99.4) No 4 10.6 (3.3, 29.3) 3 24.8 (6.9, 59.4) 1 5.5 (0.6, 34.7) Frequency of condom use during sex with commercial partner Always 31 89.4 (70.7, 96.7) 15 75.2 (40.6, 93.1) 20 94.5 (65.2, 99.4) Sometimes 2 6.5 (1.3, 26.7) 1 4.5 (5.0, 31.0) 0 -- Never 2 4.1 (0.9, 16.8) 2 20.2 (4.4, 58.2) 1 5.5 (0.6, 34.7) Reasons why condom not used every time during sex with commercial partner Too 0 -- 0 -- 0 -- expensive Ashamed to 0 -- 0 -- 0 -- buy Difficult to use 0 -- 0 -- 0 -- Not available 0 -- 0 -- 0 -- Reduces 3 80.8 (5.2, 99.7) 3 100 1 100 pleasure Ashamed to ask sex 0 -- 3 100 0 -- partner to use Trust partner 0 -- 0 -- 0 -- Don’t know about condom 0 -- 0 -- 0 -- use efficacy Want to get 0 -- 0 -- 0 -- pregnant Used condom last time having sex with commercial partner the last time in Armenia Yes 21 45.2 (23.2, 69.3) 10 50.1 (25.1, 75.0) 10 41.8 (18.3, 69.7) No 3 8.6 (2.2, 27.6) 1 4.5 (0.5, 31.0) 1 5.5 (0.6, 34.7) No sex with casual partner 11 46.2 (21.8, 72.5) 7 45.3 (21.2, 71.8) 10 52.7 (26.0, 78.0) in Armenia Frequency of condom use when having sex with commercial partner last time in Armenia Always 21 84.1 (56.6, 95.5) 10 91.7 (48.6, 99.2) 10 88.4 (38.1, 99.0) Sometimes 1 8.3 (1.0, 44.1) 1 8.3 (0.8, 51.4) 0 -- Never 2 7.6 (1.7, 28.2) 0 -- 1 11.5 (1.0, 61.9)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Used condom last time having sex with commercial partner the last time being abroad Yes 15 56.8 (32.9, 77.9) 5 25.1 (9.3, 52.2) 13 64.4 (35.2, 85.8) No 1 2.0 (0.2, 14.9) 2 4.4 (58.2) 0 -- No sex with casual 19 41.2 (21.0, 64.9) 11 54.7 (28.2, 78.8) 8 35.6 (14.2, 64.8) partner while abroad Frequency of condom use when having sex with commercial partner the last time being abroad Always 15 96.5 (71.9, 99.7) 5 55.3 (11.0, 92.5) 13 100 Sometimes 1 3.5 (0.3, 28.1) 2 44.6 (7.5, 89.0) 0 -- Never 0 -- 0 -- 0 --

B.6 DRUG USE

TABLE B6A. DRUG USEAMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever used drugs Yes 38 11.7 (8.1, 16.5) 51 15.4 (11.6, 20.0) 37 10.3 (7.3, 14.2) No 277 88.3 (83.5, 91.9) 264 84.6 (80.0, 88.3) 261 89.7 (85.7, 92.7) Age at first drug use ≤19 17 52.4 (33.4, 70.7) 32 60.6 (45.0, 74.2) 19 49.3 (31.9, 66.8) 20+ 20 47.6 (29.3, 66.6) 19 39.4 (25.8, 54.9) 18 50.7 (33.2,68.1) Age at first drug use (mean, median, range) 20.3, 19 (14-32) 19.7, 19 (14-40) 22.3, 20 (14-42) Ever injected drugs Yes 0 0 0 0 0 0 No 38 100 51 100 37 100 Use disposable syringes when injecting drugs Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Shared injection paraphernalia (needles/syringes, cookers, drug containers, filters) in last one month Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 --

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever used injection drugs prepared by others Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Used non-sterile paraphernalia (needles/syringes, cookers, drug containers, filters) for injecting drug use in past one month Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Used sterile needle/syringe last time injecting drug Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Sterilize needles/syringes before usage Yes, always 0 -- 0 -- 0 -- Occasionally 0 -- 0 -- 0 -- Never 0 -- 0 -- 0 --

TABLE B6B. DRUG USE AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever used drugs Yes 22 3.8 (2.4, 6.0) 19 4.4 (2.5, 7.6) 12 4.3 (2.2, 8.1) No 278 96.2 (94.0, 97.6) 281 95.6 (92.3, 97.5) 298 95.7 (91.9, 97.8) Age at first drug use ≤19 11 49.3 (24.0, 75.0) 8 73.3 (33.0, 93.9) 20+ 8 50.7 (25.0, 76.0) 4 26.7 (6.1, 67.0) Age at first drug use (mean, median, range) 19.4, 18 (15-32) 20.3, 20 (16-26) 18.9, 19 (15-25) Ever injected drugs Yes 0 0 1 5.5 (0.6, 35.3) 0 0 No 22 100 18 94.5 (64.7, 99.4) 12 100 Use disposable syringes when injecting drugs Yes 0 -- 1 100 0 -- No 0 -- 0 -- 0 -- Shared injection paraphernalia (needles/syringes, cookers, drug containers, filters) in last one month Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Ever used injection drugs prepared by others Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 --

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Used non-sterile paraphernalia (needles/syringes, cookers, drug containers, filters) for injecting drug use in past one month Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Used sterile needle/syringe last time injecting drug Yes 0 -- 0 -- 0 -- No 0 -- 0 -- 0 -- Sterilize needles/syringes before usage Yes, always 0 -- 0 -- 0 -- Occasionally 0 -- 0 -- 0 -- Never 0 -- 0 -- 0 --

B.7 HIV AND STI TESTING AND RISK

TABLE B7A. HIV AND STI TESTING AND RISK AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever heard of HIV/AIDS Yes 305 97.6 (95.3, 98.8) 310 98.4 (96.2, 99.3) 288 97.3 (94.6, 98.7) No 10 2.4 (1.2, 4.7) 5 1.6 (0.7, 3.8) 9 2.6 (1.3, 5.4) HIV/AIDS knowledge sources family 6 1.7 (0.7, 3.8) 17 4.3 (2.6, 7.0) 14 5.9 (3.5, 9.7) friends/peers 72 24.4 (19.1, 30.7) 85 26.4 (21.6, 31.9) 73 25.8 (20.8, 31.6) mass media 277 90.3 (85.6, 93.6) 277 90.4 (86.5, 93.2) 253 87.3 (82.5, 90.9) school 10 8.2 (4.2, 15.2) 29 10.2 (7.0, 14.4) 13 3.9 (2.2, 6.9) social/health 24 7.5 (4.6, 11.8) 24 7.7 (5.1, 11.5) 20 6.1 (3.8, 9.5) care workers counselling 2 0.5 (0.1, 2.3) 5 1.6 (0.6, 4.0) 3 1.2 (0.3, 3.9) services have not 0 -- 0 -- 0 -- heard no response 0 -- 0 -- 0 -- Self-assessed risk for becoming infected with HIV high 8 2.3 (0.9, 6.2) 14 4.6 (2.6, 7.9) 22 7.4 (4.8, 11.3) medium 44 13.9 (9.8, 19.6) 53 17.1 (13.1, 22.0) 53 19.7 (15.1, 25.3) no risk 252 83.7 (77.8, 88.3) 241 78.2 (73.0, 82.7) 213 72.8 (66.9, 78.0)

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) Knows where to go for HIV test Yes 87 29.5 (23.6, 36.2) 107 35.1 (29.7, 40.9) 68 22.5 (17.8, 27.9) No 218 70.4 (63.8, 76.3) 203 64.9 (59.1, 70.3) 220 77.5 (72.1, 82.1) Had HIV test in past 12 months Yes 48 22.7 (16.6, 30.1) 52 18.6 (14.3, 23.8) 31 10.8 (7.5, 15.3) No 257 77.3 (69.9, 83.4) 258 81.4 (76.2, 85.7) 257 89.2 (84.7, 92.5) Where HIV test in past 12 months was conducted Armenia 19 50.3 (32.6, 68.0) 14 27.9 (16.8, 42.7) 11 33.1 (17.8, 53.0) Abroad 29 49.6 (32.0, 67.4) 38 72.1 (57.3, 83.2) 20 66.9 (46.9, 82.2) Both 0 -- 0 -- 0 -- locations Received test results during last HIV test in past 12 months (among those tested in last 12 months) Yes 48 100 48 93.6 (83.4, 97.7) 30 97.7 (83.5, 99.7) No 0 - 4 6.4 (2.3, 16.6) 1 2.3 (0.3, 16.5) Had HIV test in past 12 months and received test results (among all participants) Yes 48 22.1 (16.2, 29.4) 48 17.1 (13.0, 22.2) 30 10.2 (7.0, 14.5) No 267 77.9 (70.5, 83.8) 267 82.9 (77.8, 87.0) 270 89.8 (85.5, 93.0) Received counseling during last HIV test in past 12 months Yes 38 87.0 (75.5, 93.5) 29 59.9 (45.4, 72.9) 22 66.9 (45.9, 82.9) No 10 13.0 (6.5, 24.5) 23 40.1 (27.1, 54.6) 9 33.1 (17.1, 54.1) Had genital/anal inflammation, unusual discharge, and/or warts during past 12 months Yes 20 6.7 (3.9, 11.4) 28 98.4 (96.0, 99.4) 19 7.1 (4.5, 11.1) No 294 93.3 (88.6, 96.1) 287 1.6 (0.6, 4.0) 278 92.9 (88.9, 95.5) Diagnosed with STI in past 12 months Yes 11 3.4 (1.6, 7.4) 15 4.7 (2.7, 8.0) 7 2.6 (1.2, 5.6) No 303 96.5 (92.6, 98.4) 300 95.3 (92.0, 97.3) 288 97.4 (94.4, 98.8) Received condoms during past 12 months by outreach workers/NGO Yes 0 -- 4 1.5 (0.5, 4.1) 0 -- No 315 100 311 98.5 (95.9, 99.5) 297 100 Methods for protecting self from getting disease that is caused through sexual intercourse Use condom 114 37.1 (30.7, 44.0) 147 44.2 (38.5, 50.0) 122 41.4 (35.6, 47.5) No sex 22 6.3 (4.0, 9.6) 24 8.3 (5.6, 12.3) 16 3.9 (2.3, 6.6) Sex only with trusted 184 56.9 (50.1, 63.4) 144 44.6 (38.9, 50.4) 153 53.1 (47.0, 59.1) partners Have only regular 44 17.0 (12.7, 22.5) 26 7.6 (5.0, 11.3) 49 17.1 (12.9, 22.4) partners other ------

TABLE B7B. HIV AND STI TESTING AND RISK AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Ever heard of HIV/AIDS Yes 300 100 295 98.8 (96.7, 99.6) 304 98.3 (95.3, 99.4) No 0 -- 5 1.2 (0.4, 3.3) 6 1.7 (0.6, 4.6) HIV/AIDS knowledge sources family 3 0.5 (0.2, 1.5) 8 1.9 (0.9, 4.1) 0 -- friends/peers 86 31.5 (24.0, 40.2) 94 24.7 (17.6, 33.6) 68 20.9 (15.6, 27.5) mass media 263 89.1 (82.7, 93.3) 259 91.5 (87.2, 94.5) 273 87.1 (80.6, 91.7) school 9 4.7 (1.8, 12.0) 10 3.1 (1.5, 6.2) 10 5.0 (2.2, 10.7) social/health 29 20.6 (13.2, 30.6) 24 5.1 (3.1, 8.3) 17 11.5 (6.9, 18.7) care workers counselling 7 1.7 (0.8, 3.8) 8 2.9 (1.3, 6.1) 3 1.5 (0.5, 4.7) services have not heard 0 -- 0 ------no response 0 -- 0 ------Self-assessed risk for becoming infected with HIV high 6 1.2 (0.5, 2.8) 3 0.5 (0.1, 1.6) 30 2.8 (1.6, 4.9) medium 38 6.6 (4.6, 9.4) 23 6.5 (3.9, 10.7) 44 17.2 (12.1, 23.9) no risk 254 91.7 (88.6, 94.1) 268 93.0 (88.7, 95.7) 229 80.0 (73.3, 85.3) No response 2 0.5 (0.1, 2.0) ------Knows where to go for HIV test Yes 111 44.8 (36.2, 53.7) 115 44.6 (31.2, 58.8) 97 31.4 (24.7, 38.9) No 189 55.2 (46.3, 63.8) 179 55.4 (41.2, 68.8) 207 68.6 Had HIV test in past 12 months Yes 63 31.0 (22.9, 40.5) 74 21.2 (14.9, 29.4) 80 31.7 (25.0, 39.3) No 237 69.0 (59.5, 77.1) 219 78.7 (70.6, 85.1) 224 68.3 (60.7, 75.0) Where HIV test in past 12 months was conducted Armenia 15 11.7 (6.3, 20.9) 33 41.0 (29.2, 53.9) 19 26.0 (15.7, 39.9) Abroad 48 88.3 (79.1, 93.7) 41 46.1 (70.8) 61 74.0 (60.1, 84.3) Both locations ------Received test results during last HIV test in past 12 months (among those tested in last 12 months) Yes 60 93.9 (73.4, 98.9) 73 98.8 (91.8, 99.8) 77 99.4 (98.1, 99.8) No 3 6.0 (1.1, 26.6) 1 1.2 (0.1, 8.1) 3 0.6 (0.2, 1.9) Had HIV test in past 12 months and received test results (among all participants) Yes 60 29.1 (21.2, 38.5) 73 20.6 (14.5, 28.5) 77 31.0 (24.4, 38.5) No 240 70.8 (61.4, 78.8) 227 79.4 (71.5, 85.5) 233 69.0 (61.5, 75.6) Received counseling during last HIV test in past 12 months Yes 44 55.5 (36.6, 73.0) 56 68.5 (54.8, 79.6) 54 83.4 (72.4, 90.6) No 19 44.4 (27.0, 63.4) 18 31.4 (45.1) 26 16.6 (9.4, 27.6)

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) Had genital/anal inflammation, unusual discharge, and/or warts during past 12 months Yes 14 5.1 (2.4, 10.5) 19 4.3 (2.5, 7.3) 16 4.5 (2.4, 8.3) No 286 94.9 (89.4, 97.6) 280 95.7 (92.6, 97.5) 294 95.5 (91.7, 97.6) Diagnosed with STI in past 12 months Yes 7 1.8 (8.3, 4.1) 12 41.0 (29.2, 53.9) 10 2.8 (1.3, 6.1) No 293 98.1 (95.9, 99.2) 287 59.0 (46.1, 70.8) 300 97.2 (93.9, 98.7) Received condoms during past 12 months by outreach workers/NGO Yes 7 3.4 (1.2, 9.5) 6 1.4 (0.6, 3.3) 5 2.6 (0.9, 7.0) No 293 96.6 (90.5, 98.8) 293 98.5 (96.6, 99.4) 305 97.4 (93.0, 99.1) Methods for protecting self from getting disease that is caused through sexual intercourse Use condom 127 36.9 (29.2, 45.4) 123 33.3 (24.1, 44.0) 164 49.1 (41.5, 56.6) No sex 27 6.1 (4.0, 9.2) 21 3.4 (2.0, 5.6) 18 5.0 (2.6, 9.7) Have sex only with trusted 152 50.3 (41.7, 59.0) 161 55.5 (42.1, 68.2) 134 50.0 (42.4, 57.5) partners Have only re- 32 16.6 (10.5, 25.2) 17 25.2 (11.7, 46.1) 68 15.6 (11.1, 21.6) gular partners

B.8 HIV KNOWLEDGE AND PERCEPTIONS

TABLE B8A. HIV KNOWLEDGE AND PERCEPTIONS AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) It is possible to reduce risk of HIV infection by having sexual relations with one uninfected faithful sexual partner Yes 269 86.7 (81.8, 90.5) 248 78.9 (73.8, 83.3) 242 81.9 (76.8, 86.1) No 46 13.3 (9.5, 18.2) 67 21.1 (16.7, 26.2) 55 18.1 (13.9, 23.1) It is possible to reduce risk of HIV infection by using condoms Yes 247 78.5 (72.7, 83.4) 246 78.5 (73.4, 82.9) 22 73.2 (67.5 78.2) No 68 21.5 (16.6, 27.3) 69 21.5 (17.1, 26.6) 77 26.8 (21.8, 32.5) A person can get HIV from mosquito bites Yes 192 60.1 (53.3, 66.5) 199 65.4 (59.7, 70.7) 173 58.1 (52.0, 63.9) No 123 39.9 (33.4. 46.7) 116 34.6 (29.3, 40.3) 124 41.9 (36.0, 48.0) A healthy-looking person can be HIV infected Yes 210 71.1 (64.7, 76.7) 199 63.6 (57.9, 69.0) 192 60.1 (53.9, 66.0) No 105 28.9 (23.3, 35.3) 116 36.4 (31.0, 42.1) 105 39.9 (34.0, 46.1)

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) It is possible to get HIV by sharing meal with person infected with HIV Yes 137 45.1 (38.5, 51.9) 132 41.8 (36.2, 47.7) 130 42.5 (36.7, 48.6) No 178 54.9 (48.1, 61.5) 183 58.2 (52.3, 63.8) 167 57.5 (51.4, 63.3) It is possible to get HIV by shaking hands with person infected with HIV Yes 117 37.1 (30.9, 43.8) 107 32.6 (27.4, 38.2) 94 31.4 (26.1, 37.2) No 198 62.9 (56.2, 69.1) 208 67.4 (61.8, 72.6) 203 68.6 (62.7, 73.9) Correct HIV knowledge Yes 201 68.3 (61.7, 74.2) 218 69.7 (64.1, 74.8) 202 65.0 (59.0, 70.6) No 114 31.7 (25.8, 38.2) 97 30.3 (25.2, 35.9) 98 35.0 (29.4, 41.0)

TABLE B8B. HIV KNOWLEDGE AND PERCEPTIONS AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) It is possible to reduce risk of HIV infection by having sexual relations with one uninfected faithful sexual partner Yes 246 77.7 (68.7, 84.7) 256 83.6 (68.0, 92.5) 269 87.7 (81.6, 91.9) No 54 22.3 (15.3, 31.3) 42 16.3 (7.5, 32.0) 41 12.3 (8.1, 18.4) It is possible to reduce risk of HIV infection by using condoms Yes 254 77.1 (67.5, 84.5) 260 90.0 (85.0, 93.5) 250 79.4 (72.4, 85.0) No 43 22.9 (15.5, 32.5) 38 10.0 (6.5, 15.0) 60 20.6 (15.0, 27.6) A person can get HIV from mosquito bites Yes 201 67.0 (58.2, 74.8) 169 56.6 (42.5, 69.8) 198 60.9 (53.3, 67.9) No 98 33.0 (25.2, 41.8) 129 43.3 (30.2, 57.5) 112 39.1 (32.0, 46.7) A healthy-looking person can be HIV infected Yes 137 48.9 (40.2, 57.6) 192 68.4 (55.0, 79.2) 187 67.1 (59.8, 73.6) No 163 51.1 (42.4, 59.8) 106 31.6 (20.7, 45.0) 123 32.9 (26.4, 40.2) It is possible to get HIV by sharing meal with person infected with HIV Yes 127 29.2 (22.0, 37.5) 89 29.6 (18.9, 43.0) 140 51.3 (43.8, 58.8) No 173 48.6 (41.1, 56.2) 209 70.4 (56.9, 81.1) 170 48.6 (41.1, 56.2) It is possible to get HIV by shaking hands with person infected with HIV Yes 97 28.9 (22.0, 37.1) 67 24.1 (14.1, 38.0) 117 40.7 (33.4, 48.5) No 203 71.0 (62.9, 78.0) 231 75.9 (61.9, 85.9) 193 59.3 (51.5, 66.6) Correct HIV knowledge Yes 191 66.6 (58.2, 74.0) 182 57.0 (42.8, 70.1) 204 69.1 (62.0, 75.5) No 109 33.4 (26.0, 41.8) 118 43.0 (29.9, 57.2) 106 30.8 (24.5, 38.0)

B.9 HIV AND OTHER INFECTIONS PREVALENCE

TABLE B9A. INFECTIONS PREVALENCE AMONG RURAL MIGRANTS, ARARAT, ARMAVIR AND KOTAYQ, ARMENIA, 2016, ARMENIA, 2016

Ararat Armavir Kotayq N = 315 N = 315 N = 300 n % (95% CIs) n % (95% CIs) n % (95% CIs) HIV Yes 1 0.1 (0.0, 0.9) 0 -- 0 -- No 314 99.9 (99.1, 100.0) 315 100 300 100 Hepatitis B Yes 6 1.5 (0.6, 3.4) 3 1.0 (0.3, 3.4) 0 -- No 309 98.5 (96.6, 99.4) 312 99.0 (96.6, 99.7) 300 100 Hepatitis C Yes 4 1.2 (0.4, 3.1) 8 2.8 (1.4, 5.8) 13 3.9 (2.1, 6.9) No 311 98.8 (96.8, 99.6) 307 97.1 (94.1, 98.6) 287 96.1 (93.1, 97.8) Syphilis Yes 1 1.2 (0.2, 7.9) 1 0.3 (0.0, 2.5) 0 -- No 314 98.8 (92.1, 99.8) 314 99.6 (97.5, 99.9) 300 100

TABLE B9B. INFECTIONS PREVALENCE AMONG RURAL MIGRANTS, LORI, SHIRAQ AND GEGHARKUNIK, ARMENIA, 2016

Lori Shirak Gegharkunik N = 300 N = 300 N = 310 n % (95% CIs) n % (95% CIs) n % (95% CIs) HIV Yes 2 1.7 (0.3, 9.6) 2 0.4 (0.1, 1.7) 1 0.1 (0.0, 0.4) No 298 98.3 (90.4, 99.7) 298 99.6 (98.3, 99.9) 309 99.9 (99.5, 100) Hepatitis B Yes 2 0.3 (0.1, 1.3) 5 1.1 (0.4, 3.1) 1 0.5 (0.1, 3.5) No 298 99.7 (98.7, 99.9) 295 98.9 (96.9, 99.6) 309 99.5 (96.5, 99.9) Hepatitis C Yes 3 0.8 (0.2, 2.7) 10 2.6 (1.3, 5.3) 1 0.1 (0.0, 0.4) No 297 99.2 (97.3, 99.7) 290 97.4 (94.7, 98.7) 309 99.9 (99.5, 100) Syphilis Yes 0 -- 1 0.2 (0.0, 1.2) 0 -- No 300 100 299 99.8 (98.8, 100) 310 100