HIV Prevalence, Risks for HIV Infection, and Human
Rights among Men Who Have Sex with Men (MSM) in
Malawi, Namibia, and Botswana
Stefan Baral1,7*, Gift Trapence2, Felistus Motimedi3, Eric Umar4, Scholastika Iipinge5, Friedel Dausab6,
1Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America,
2Center for the Development of People, Blantyre, Malawi, 3Botswana Network on Ethics, Law, and HIV/AIDS, Gaborone, Botswana, 4Department of Community Health,
University of Malawi,-College of Medicine, Blantyre, Malawi, 5HIV/AIDS Coordinator, University of Namibia, Windhoek, Namibia, 6The Rainbow Project, Windhoek,
Namibia, 7Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
Background: In the generalized epidemics of HIV in southern Sub-Saharan Africa, men who have sex with men have been
largely excluded from HIV surveillance and research. Epidemiologic data for MSM in southern Africa are among the sparsest
globally, and HIV risk among these men has yet to be characterized in the majority of countries.
Methodology: A cross-sectional anonymous probe of 537 men recruited with non-probability sampling among men who
reported ever having had sex with another man in Malawi, Namibia, and Botswana using a structured survey instrument and
HIV screening with the OraQuick? rapid test kit.
Principal Findings: The HIV prevalence among those between the ages of 18 and 23 was 8.3% (20/241); 20.0% (42/210)
among those 24–29; and 35.7% (30/84) among those older than 30 for an overall prevalence of 17.4% (95% CI 14.4–20.8). In
multivariate logistic regressions, being older than 25 (aOR 4.0, 95% CI 2.0–8.0), and not always wearing condoms during sex
(aOR 2.6, 95% CI 1.3–4.9) were significantly associated with being HIV-positive. Sexual concurrency was common with 16.6%
having ongoing concurrent stable relationships with a man and a woman and 53.7% had both male and female sexual
partners in proceeding 6 months. Unprotected anal intercourse was common and the use of petroleum-based lubricants
was also common when using condoms. Human rights abuses, including blackmail and denial of housing and health care
was prevalent with 42.1% (222/527) reporting at least one abuse.
Conclusions: MSM are a high-risk group for HIV infection and human rights abuses in Malawi, Namibia, and Botswana.
Concurrency of sexual partnerships with partners of both genders may play important roles in HIV spread in these
populations. Further epidemiologic and evaluative research is needed to assess the contribution of MSM to southern
Africa’s HIV epidemics and how best to mitigate this. These countries should initiate and adequately fund evidence-based
and targeted HIV prevention programs for MSM.
Citation: Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, et al. (2009) HIV Prevalence, Risks for HIV Infection, and Human Rights among Men Who Have Sex
with Men (MSM) in Malawi, Namibia, and Botswana. PLoS ONE 4(3): e4997. doi:10.1371/journal.pone.0004997
Editor: Lisa F. P. Ng, Singapore Immunology Network, Singapore
Received December 21, 2008; Accepted March 4, 2009; Published March 26, 2009
Copyright: ? 2009 Baral et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by the Sexual Health and Rights Project (SHARP) of the Open Society Institute and the Open Society Initiative for Southern
Africa (OSISA). The decision to publish was made by the community partners and not the funders. Publication costs were offset by a grant from The Himmelfarb
Family Foundation to the Center for Public Health and Human Rights.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
While southern Sub-Saharan Africa has long been the most
HIV/AIDS affected region globally, it has been arguably the most
understudied for the risk of HIV associated with male to male
sexual contact [1–3] The crude characterization of these
epidemics as generalized and driven by heterosexual risks has
obscured the component of Southern Africa’s epidemics which
may be due to risks among men who have sex with men (MSM).
The marked homophobia, discrimination, and criminalization of
same-sex behavior in much of Africa have likely limited
investigation among these men. [4,5]. Data regarding the
prevalence of MSM in the region are among the sparsest globally,
but there is evidence that male to male sexual contact is a reality
on this continent as on all others . To date, there have been
published papers from only Senegal and Kenya describing HIV
risk and prevalence among MSM in Africa [6,7]. However, a
systematic review found studies from other African countries either
not presenting HIV prevalence data or studies that to-date have
only been presented as abstracts . These studies suggest that
African MSM are at substantial risk for HIV infection, and that
they have been markedly underserved and marginalized. Reported
HIV rates, where available, have been higher than among other
men of reproductive age in the same populations, yet these men
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HIV among Southern African MSM
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