Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations Republic of the Marshall Islands Patrick Rawstorne, Robyn Drysdale, Rachel Nicholls, Heather Worth, Michelle O’Connor, Scott McGill Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations – Republic of the Marshall Islands Acknowledgements The team would very much like to thank Women United Together Marshall Islands, particularly Kathryn Relang, for all their assistance and support with this project. Our thanks also to Youth to Youth in Health and the RMI Ministry of Health, Marie Maddison for translation of the behavioural surveys. We are also grateful to research assistants Adelma Louis and Loreena Maio and to Kristy for the recruitment of FSW. Special thanks also to the research assistants from the MSM/TG community who prefer not to be named. We thank as well all of the participants who gave their time and shared their stories. 2 Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations – Republic of the Marshall Islands Table of contents Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations .......................................................................................................... 1 Acknowledgements ................................................................................................................. 2 Table of contents ..................................................................................................................... 3 List of tables ............................................................................................................................. 5 Definitions ....................................................................................................................... 7 Executive summary ................................................................................................................. 8 1 Introduction ................................................................................................................... 12 2 Marshall Islands ............................................................................................................ 13 2.1 Men who have sex with men and transgender ................................................ 14 2.2 Female sex workers ............................................................................................ 15 3 Methodology ................................................................................................................. 16 3.1 Population size estimation ................................................................................ 16 3.2 Behavioural survey and interviews .................................................................. 17 3.2.1 Men who have sex with men and transgender ...................................... 17 3.2.2 Female sex workers .................................................................................. 17 3.3 Institutional capacity assessment .................................................................... 18 4 Results ........................................................................................................................... 19 4.1 Population size estimation ................................................................................ 19 4.2 Behavioural survey ............................................................................................. 20 4.2.1 Transgender and men who have sex with men ..................................... 20 4.2.1.1 Description of the sample ...................................................................... 20 4.2.1.2 Sexual history and practice ................................................................... 22 4.2.1.3 Sexually transmissible infections, including HIV ................................... 27 4.2.1.4 Stigmatising attitudes towards people living with HIV ........................... 29 4.2.1.5 Stigma and discrimination observed in the community ......................... 29 4.2.1.6 Emotional and physical well-being ........................................................ 30 4.2.1.7 Access to health services ...................................................................... 32 4.2.1.8 HIV testing.............................................................................................. 34 4.2.1.9 Alcohol and drug use ............................................................................. 35 4.2.2 Female sex workers .................................................................................. 36 4.2.2.1 Description of the sample ...................................................................... 36 4.2.2.2 Sexual history and practice ................................................................... 38 4.2.2.3 Alcohol and drug use ............................................................................. 45 4.2.2.4 Sexually transmissible infections, including HIV ................................... 46 4.2.2.5 Knowledge about HIV and AIDS ........................................................... 47 4.2.2.6 Stigmatising attitudes towards people living with HIV ........................... 48 4.2.2.7 Stigma and discrimination observed in the community ......................... 49 4.2.2.8 Access to health services ...................................................................... 50 4.2.2.9 HIV testing.............................................................................................. 51 4.3 In-depth Interviews ............................................................................................. 52 4.3.1 Transgender and men who have sex with men ..................................... 52 3 Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations – Republic of the Marshall Islands 4.3.1.1 Identity .................................................................................................... 52 4.3.1.2 Sexual behaviour ................................................................................... 53 4.3.1.3 Stigma and discrimination ..................................................................... 54 4.3.1.4 Condom use ........................................................................................... 55 4.3.1.5 Access to services ................................................................................. 56 4.3.2 Female sex workers .................................................................................. 57 4.3.2.1 Sexual behaviour ................................................................................... 58 4.3.2.2 Condom use ........................................................................................... 59 4.3.2.3 HIV and STI testing ................................................................................ 60 4.3.2.4 Stigma .................................................................................................... 61 4.4 Institutional capacity assessment: HIV organisations and services............ 62 4.4.1 Organisational mapping ........................................................................... 62 4.4.2 HIV and STI prevention activities in the Marshall Islands .................... 63 4.4.2.1 National oversight, coordination and funding ........................................ 63 4.4.2.2 HIV and STI testing, counselling and treatment .................................... 63 4.4.2.3 Condom distribution ............................................................................... 64 4.4.2.4 Peer education and outreach ................................................................ 64 4.4.2.5 Strategic health communication ............................................................ 64 4.4.2.6 Advocacy and legislation ....................................................................... 64 4.4.2.7 Other support services........................................................................... 64 4.4.3 Cross-cutting organisational strengths.................................................. 65 4.4.4 Cross-cutting organisational capacity-building needs......................... 65 4.4.5 Identified capacity-building resources ................................................... 65 References .............................................................................................................................. 66 Annex 1: UNAIDS GARP data needs .......................................................................... 68 4 Pacific Multi-Country Mapping and Behavioural Study: HIV and STI Risk Vulnerability among Key Populations – Republic of the Marshall Islands List of tables Table 1: Population size estimation ......................................................................................... 19 Table 2: Sexual identity ........................................................................................................... 20 Table 3: Highest level of education ......................................................................................... 20 Table 4: Relationship status .................................................................................................... 21 Table 5: Whom participants were living with (n=10)* .............................................................. 21 Table 6: Employment status .................................................................................................... 21 Table