Alcohol consumption patterns among men who have sex with men in major cities of Myanmar: A cross-sectional study [version 1; peer review: awaiting peer review]

Background: Alcohol consumption patterns vary widely across the regions of the world. Although previous studies have focused on the sexual risk behaviours among men who have sex with men (MSM), studies regarding binge alcohol drinking among MSM in Myanmar are scarce. Methods: A cross-sectional study was conducted to identify the alcohol consumption patterns among MSM aged over 18 years in two major cities of Myanmar where the MSM population is higher than other regions. Purposive sampling was applied and sampling was made through Myanmar MSM network. Face-to-face interviews were conducted using a structured questionnaire. Patterns of alcohol consumption were described as frequency/percentage and mean/median as appropriate. Bivariate analysis was also done to find out the association between types of MSM and binge drinking. Results: A total of 256 MSM included in the study (mean age, 27.33±7.7 years). Of 256 participants, 225 MSM had the experience of alcohol consumption in their lifetime (225/256, 87.9%). Among ever drinkers, 152 MSM consumed alcohol within three months (152/225, 67.6%). Regarding beer consumption, the highest proportions of MSM from both groups (42.8%, 36.8%) consumed 1-3 times per week. Overall, 57.2% of young MSM and 41.2% of adult MSM consumed beer together with their friends. Nearly 34% of young MSM and nearly 38% of adult MMS consumed beer at gatherings of friends. At different time periods, higher proportions of Thange (partners of MSM) had experienced of binge drinking than apwint (open) and apone (hidden) (p<0.05). Conclusions: The current study identified the alcohol consumption patterns in terms of type, amount, frequency at different time periods among MSM in major cities of Myanmar. It is suggested to develop and implement alcohol control policy for MSM since the proportion of Open Peer Review Reviewer Status AWAITING PEER REVIEW Any reports and responses or comments on the article can be found at the end of the article. Page 1 of 9 F1000Research 2020, 9:1149 Last updated: 17 SEP 2020


Introduction
Globally, alcohol is widely consumed as a beverage and for recreation and socialization. Alcohol consumption patterns vary widely across the regions, ranging from daily heavy drinking to occasional hazardous drinking (Ennett et al., 2016;World_Health_Organization, 2018). Excessive alcohol use and chronic alcohol binging are associated with high morbidity and mortality (Stockings et al., 2016). About 40% of global population aged over 15 years had consumed alcohol while 2.3 billion of them are current drinkers. Worldwide, 44.8% of total recorded alcohol is consumed in the form of spirits. The second most consumed type of beverage is beer (34.3%) followed by wine (11.7%) (World_Health_Organization, 2018).
Previous studies have highlighted that hazardous alcohol drinking was common among men who have sex with men (MSM), ranging from incidences of 14% to 52%, and it was also associated with unsafe sexual behaviours (Davis et al., 2016;Herrera et al., 2016;Liu et al., 2016;Santos et al., 2018). Furthermore, a significant association was noted between hazardous alcohol drinking and sexually transmitted infections, including HIV. According to a study conducted in China, 14.4% of MSM reported hazardous drinking and 16.8% reported binge drinking. Hazardous or binge drinkers were associated with various risky sexual behaviours such as have multiple partnerships, pay for sex, and have condomless insertive anal intercourse (Liu et al., 2016). In a study in Peru, 45% of MSM and transgender women had an alcohol use disorder. Higher incidence of condomless anal intercourse was seen among participants with alcohol use disorder (AUD). However, AUD positivity was not associated with either condomless anal intercourse or recent STI/HIV infection (Herrera et al., 2016). Another study in US has documented the heavy alcohol use patterns and correlates in a diverse sample of MSM using respondentdriven sampling. It was found that prevalence of RDS adjusted weekly drinking was 24.9% and weekly binge drinking was 19.3%. Independent correlates of hazardous alcohol consumption were identified as being moderately or extremely interested in reducing alcohol use; ever receiving alcohol treatment; using ecstasy; reporting syphilis diagnosis; and having more than five male partners (Santos et al., 2018).
In Myanmar, HIV is concentrated among key affected populations like MSM, whereas HIV prevalence was over 10% among them (UNAIDS, 2015). Alcohol drinking was common among MSM, as it was with other men. Although previous studies have focused on risky sexual behaviours among MSM, few studies assessed hazardous alcohol drinking among MSM. Similarly, in Myanmar, we know of no studies to have reported on alcohol consumption among MSM. Therefore, current study was conducted to identify the alcohol consumption patterns and binge drinking at different time periods among men who have sex with men in Myanmar.

Methods
Study design, population and area A cross-sectional study was conducted among MSM those aged more than 18 years in Yangon and Mandalay, major cities of Myanmar where MSM population is higher than other regions during June and July 2020. Sampling and sample size Purposive sampling was applied and sampling of the MSMs was made through the Myanmar MSM network. Identification of the places for recruitment of the possible participants was made after discussion with the focal persons from the networks of MSM. There might be bias resulting from applying purposive sampling; however, attempts to reduce the bias were made by providing thorough explanations to the focal person to recruit different type of MSM from different sources, such as drop-in-centre and beauty parlours.
By considering the estimated proportion of MSM who are current drinkers as 20% (Oo et al., 2015), to achieve a 95% confidence level and an error of 5%, the minimum required sample size becomes 246 (Wayne, 1995).

Data collection
Firstly, a structured questionnaire was developed in English by reviewing the literature (see Extended data; Htut et al., 2020b). Then, translation was done into Myanmar language and back translation was carried out into English by a translator who was expert in both languages and had experience of translation regarding questionnaire used in MSM related research. Training of the interviewers was done at Department of Medical Research and pre-test was done at a non-study township in Yangon Region. After receiving ethical approval, at the venues where MSMs usually gather like drop-in-centers of International Non-governmental Organizations, beauty parlors, etc., eligible participants were contacted and invited to participate in the study. After getting the informed consent, data collection was done by face-to-face interview. Strict adherence to ethical principles were ensured throughout the data collection period in order to maintain the confidentiality of the information of the study participants.

Operational definitions
According to the local terminology in Myanmar, three groups of MSM were included in the study: Apwint or open type, Apone or hidden type and Tha Nge (National_AIDS_Program, 2019). Apwint or open MSM are defined as individuals born biological male but who openly express themselves femininely by dress and/or social interactions. Apone or hidden MSM are defined as individuals born biological males who may also want to express themselves femininely but may not disclose this behaviour to all segments of their social networks. Tha Nge are defined as having a masculine outward appearance but have sex with men".
Types of alcohol beverages consumed by MSM included Beer, Wine and Rum.

Data management and analysis
Data entry was carried out with EpiData version 3.1 and data analysis was done with SPSS version 21. Exploratory data analysis was done to check the errors, consistencies and missing values. The number of standard drinks was calculated by volume of container in liters multiplied by the percentage of alcohol volume multiplied by 0.789 (the specific gravity volume of ethyl alcohol). Binge drinking was defined as five or more standard drinks for men in a sitting or within two hours. Descriptive statistics were shown according to the data obtained from the assessment. Patterns of alcohol consumption were described as frequency/percentage and mean/median as appropriate. Bivariate analysis was also done to find out the association between types of MSM and binge drinking.

Ethical considerations
The proposal was submitted to Institutional Review Board, Department of Medical Research, Myanmar (Ethics/DMR/2020/036). Written informed consent was taken from the participants after thorough explanation about the objectives of the study.
Confidentiality and anonymity of the information were strictly ensured. All answer sheets and data reports were kept in locked cabinet.  (Htut et al., 2020a) Of the 256 participants, 225 had experience of alcohol consumption in their lifetime (225/256, 87.9%). Among ever drinkers, 152 had consumed alcohol within the past three months (152/225, 67.6%). The amount and frequency of different types of alcohol consumption within three months in terms of amount, frequency, with whom they drink together, time of consumption and reasons are shown in Table 2. Regarding beer consumption, the mean amount consumed was 4.1±2.5 standard drinks by young MSM and 4.5 ± 3.0 standard drinks by adult MSM (ethanol concentration of 41 and 45 grams, respectively), highest proportions of MSM from both groups (42.8%, 36.8%) consumed 1-3 times per week.

Discussion and recommendation
Worldwide, the prevalence of alcohol consumption was 43% in general population while about half has never consumed alcohol. Of all participants in present study, nearly 90% have ever consumed alcohol in their life time and over 50% were current drinkers within one month. Previous studies have documented the alcohol consumption among general population in Myanmar. They reported the prevalence of 50% lifetime drinkers and 20% current drinkers. The proportion of ever drinkers in current study was much higher than those from previous studies done in two different townships in Myanmar (Oo et al., 2015;Win & Areesantichai, 2014). These studies focused on the general adult population, which might differ from the MSM population. These differences in study population and time periods might contribute to the discrepancy. Regarding the types of alcoholic beverages, as reported in the report of World Health Organization, common types of alcoholic beverages consumed in Myanmar included spirits, beer and wine. Likewise, beer, whisky and wine were the common alcoholic beverages stated by MSM in current study.
Studies in China and other countries also highlighted alcohol consumption among MSM and general population but using different screening tools. Additionally, previous studies have documented the prevalence of alcohol consumption at different time periods (Liu et al., 2016;Lu et al., 2019). In present study, nearly 70% of MSM had consumed alcohol within the past 3 months and 36.2% of Apwint (open type), 35.3% of Apone (hidden type) and 62.8% of Thange (sexual partners of MSM) had experience of binge drinking. In a large-scale study in China, over 56% of 3,588 MSM had consumed alcohol in the past 3 months and 17% were binge drinkers (Liu et al., 2016). Though recent alcohol consumption within 3 months among MSM was similar between the studies, the proportion of binge drinkers was higher in present study.
In Peru, 45% of MSM had an alcohol use disorder and over 90% were hazardous drinkers (Herrera et al., 2016). Another study in China among a general adult population aged 18 to 34 years also identified the prevalence of alcohol consumption as about 45% (Lu et al., 2019). Similarly, another study in US among MSM documented that nearly 14% and 25% were monthly and weekly binge drinkers (Santos et al., 2018). Unlike other studies in China, Fan et al. (2016) documented that 23% of MSM had consumed a drink containing alcohol in the previous year while 7% were heavy alcohol drinkers.   The current study also identified the proportion of drinkers and binge drinkers in different time periods (one month, three months, six months, one year and lifetime). and over one third to nearly two third among different types of MSM reported binge drinking within three months. A higher proportion of participants drinking alcohol was noted in current study than in previous studies among MSM population. Differences in background sociocultural conditions may contribute to this discrepancy. (Liu et al., 2016;Lu et al., 2019).
There was a limitation in the present study that should be acknowledged. Alcohol consumption patterns were self-reported and their behaviours could not be validated with other methods, such as observation. However, we tried to overcome this limitation by carefully explaining the objectives of the study to allow participants to answer with accurate responses.
The development and implementation of an alcohol control policy for MSM should be considered, since over half of them were current drinkers (within one month). Between one-third and three-quarters of them had binge drinking at different time periods, which could lead to adverse health and social consequences.
This project contains the de-identified underlying data from each participant for the present study.
This project contains the questionnaire used in the present study.
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).