ArticlePDF Available

The epidemiology of HIV and prevention needs among men who have sex with men in Africa

Journal of the International AIDS Society

December 2013
16(4Suppl 3)

DOI:10.7448/IAS.16.4.18972

License
CC BY 3.0

Authors:

R. Cameron Wolf

Substance Abuse & Mental Health Services Administration

Laurent Kapesa

United States Agency for International Development (USAID)

While still an understudied area, there is a growing body of studies highlighting epidemiologic data on men who have sex with men (MSM) in sub-Saharan Africa (SSA) which challenge the attitudes of complacency and irrelevancy among donors and country governments that are uncomfortable in addressing key populations (KPs). While some of the past inaction may be explained by ignorance, new data document highly elevated and sustained HIV prevalence that is seemingly isolated from recent overall declines in prevalence. The articles in this series highlight new studies which focus on the stark epidemiologic burden in countries from concentrated, mixed and generalized epidemic settings. The issue includes research from West, Central, East and Southern Africa and explores the pervasive impact of stigma and discrimination as critical barriers to confronting the HIV epidemic among MSM and the intersecting stigma and marginalization found between living with HIV and sexual minority status. Interventions to remove barriers to service access, including those aimed at training providers and mobilizing communities even within stigmatized peri-urban settings, are featured in this issue, which further demonstrates the immediate need for comprehensive action to address HIV among MSM in all countries in the region, regardless of epidemic classification.While still an understudied area, there is a growing body of studies highlighting epidemiologic data on men who have sex with men (MSM) in sub-Saharan Africa (SSA) which challenge the attitudes of complacency and irrelevancy among donors and country governments that are uncomfortable in addressing key populations (KPs). While some of the past inaction may be explained by ignorance, new data document highly elevated and sustained HIV prevalence that is seemingly isolated from recent overall declines in prevalence. The articles in this series highlight new studies which focus on the stark epidemiologic burden in countries from concentrated, mixed and generalized epidemic settings. The issue includes research from West, Central, East and Southern Africa and explores the pervasive impact of stigma and discrimination as critical barriers to confronting the HIV epidemic among MSM and the intersecting stigma and marginalization found between living with HIV and sexual minority status. Interventions to remove barriers to service access, including those aimed at training providers and mobilizing communities even within stigmatized peri-urban settings, are featured in this issue, which further demonstrates the immediate need for comprehensive action to address HIV among MSM in all countries in the region, regardless of epidemic classification.

Map of West and Central Africa.

…

Baseline HS score and difference three months after training (71 participants).

…

. Participant baseline characteristics

…

RDS recruitment diagram from 338 MSM recruited in Blantyre, Malawi. Large nodes 0seeds; small nodes 0recruits; grey0HIV' according to Determine rapid HIV test; black 0HIV-on Determine rapid HIV test.

…

+10

. Sociodemographic characteristics of a sample of men who have sex with men in Swaziland in 2011

…

Figures - uploaded by R. Cameron Wolf

Content may be subject to copyright.

Content uploaded by R. Cameron Wolf

Content may be subject to copyright.

Available via license: CC BY 2.0

Content may be subject to copyright.

ONLINE

ONLINE ONLINE

ONLINE

OPEN ACCESS

OPEN

ACCESS

OPEN ACCESS

PEER-REVIEWD

PEER-REVIEWD PEER-REVIEWD

PEER-REVIEWD

HIV/AIDS JOURNAL

HIV/AIDS JOURNAL ONLINE

ONLINE

ONLINE OPEN ACCESS

OPEN ACCESS

OPEN

ACCESS OPEN ACCESS

OPEN ACCESS

OPEN

ACCESS OPEN A

CCESS

OPEN ACCESS

OPEN A

CCESS

OPEN ACCESS

PEER-REVIEWD

HIV/AIDS JOURNAL

PEER-REVIEWD

HIV/AIDS JOURNAL

Volume 16, Supplement 3

December 2013

The epidemiology of HIV and

prevention needs among men who

have sex with men in Africa

Guest Editors: R Cameron Wolf, Alison Surdo Cheng and Laurent Kapesa

MSM

DISCRIMINATION

SERVICES

BARRIERS

HEALTH

MEN WHO HAVE SEX WITH MEN

EPIDEMICS

HIV

BONE DENSITY

PREVALENCE

ACCESS

STIGMA

KEY AFFECTED POPULATIONS

Scan this QR code with

your mobile device to view

the special issue online

INTERVENTIONS

STIGMA

HIV

HEALTH

DISCRIMINATION

SERVICES

AFRICA

ACCESS

AFRICA

HEALTH

HIV

MSM

INTERVENTIONS

SERVICES

STIGMA

MSM

HIV

PREVALENCE

BARRIERS

DISCRIMINATION

ACCESS

MSM

AFRICA

EPIDEMICS

MSM

HIV

Support

This supplement was produced with support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the US

Agency for International Development (USAID) as well as the Foundation for AIDS Research (amfAR).

Paper from

responsible sources

FSC® C020438

MIX

Volume 16, Supplement 3

December 2013

The epidemiology of HIV and prevention

needs among men who have sex with

men in Africa

Guest Editors: R Cameron Wolf, Alison Surdo Cheng and Laurent Kapesa

Contents

Editorial: Building the evidence base for urgent action: HIV epidemiology and innovative programming for men

who have sex with men in sub-Saharan Africa

R Cameron Wolf, Alison Surdo Cheng, Laurent Kapesa and Delivette Castor

Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among

Kenyan healthcare providers in coastal Kenya

Elise M van der Elst, Adrian D Smith, Evanson Gichuru, Elizabeth Wahome, Helgar Musyoki, Nicolas Muraguri,

Greg Fegan, Zoe Duby, Linda-Gail Bekker, Bonnie Bender, Susan M Graham, Don Operario and Eduard J Sanders

A cross-sectional assessment of the burden of HIV and associated individual- and structural-level characteristics

among men who have sex with men in Swaziland

Stefan D Baral, Sosthenes Ketende, Zandile Mnisi, Xolile Mabuza, Ashley Grosso, Bhekie Sithole, Sibusiso Maziya,

Deanna L Kerrigan, Jessica L Green, Caitlin E Kennedy and Darrin Adams

Outcomes of a community-based HIV-prevention pilot programme for township men who have sex with men in

Cape Town, South Africa

Elizabeth Batist, Benjamin Brown, Andrew Scheibe, Stefan D Baral and Linda-Gail Bekker

A pilot cohort study to assess the feasibility of HIV prevention science research among men who have sex

with men in Dakar, Senegal

Fatou Maria Dramé, Emily E Crawford, Daouda Diouf, Chris Beyrer and Stefan D Baral

‘‘They are human beings, they are Swazi’’: intersecting stigmas and the positive health, dignity and prevention

needs of HIV-positive men who have sex with men in Swaziland

Caitlin E Kennedy, Stefan D Baral, Rebecca Fielding-Miller, Darrin Adams, Phumlile Dludlu, Bheki Sithole, Virginia A Fonner,

Zandile Mnisi and Deanna Kerrigan

Epidemiology of HIV among female sex workers, their clients, men who have sex with men and people

who inject drugs in West and Central Africa

Erin Papworth, Nuha Ceesay, Louis An, Marguerite Thiam-Niangoin, Odette Ky-Zerbo, Claire Holland,

Fatou Maria Dramé, Ashley Grosso, Daouda Diouf and Stefan D Baral

HIV prevalence and factors associated with HIV infection among men who have sex with men in Cameroon

Ju Nyeong Park, Erin Papworth, Sethson Kassegne, Laure Moukam, Serge Clotaire Billong, Issac Macauley, Yves Roger Yomb,

Nathalie Nkoume, Valentin Mondoleba, Jules Eloundou, Matthew LeBreton, Ubald Tamoufe, Ashley Grosso and Stefan D Baral

Experiences of Kenyan healthcare workers providing services to men who have sex with men: qualitative

ﬁndings from a sensitivity training programme

Elise M van der Elst, Evans Gichuru, Anisa Omar, Jennifer Kanungi, Zoe Duby, Miriam Midoun, Sylvia Shangani,

Susan M Graham, Adrian D Smith, Eduard J Sanders and Don Operario

HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to

inform HIV prevention

Andrea L Wirtz, Vincent Jumbe, Gift Trapence, Dunker Kamba, Eric Umar, Sosthenes Ketende, Mark Berry,

Susanne Strömdahl, Chris Beyrer and Stefan D Baral

http://www.jiasociety.org/index.php/jias/issue/view/1465

Editorial

Building the evidence base for urgent action: HIV epidemiology

and innovative programming for men who have sex with men

in sub-Saharan Africa

R Cameron Wolf

§,1

, Alison Surdo Cheng

, Laurent Kapesa

and Delivette Castor

Corresponding author: R Cameron Wolf, USAID Office of HIV/AIDS, Washington, DC, USA. (cwolf@usaid.gov)

Abstract

While still an understudied area, there is a growing body of studies highlighting epidemiologic data on men who have sex with

men (MSM) in sub-Saharan Africa (SSA) which challenge the attitudes of complacency and irrelevancy among donors and

country governments that are uncomfortable in addressing key populations (KPs). While some of the past inaction may be

explained by ignorance, new data document highly elevated and sustained HIV prevalence that is seemingly isolated from recent

overall declines in prevalence. The articles in this series highlight new studies which focus on the stark epidemiologic burden in

countries from concentrated, mixed and generalized epidemic settings. The issue includes research from West, Central, East and

Southern Africa and explores the pervasive impact of stigma and discrimination as critical barriers to confronting the HIV

epidemic among MSM and the intersecting stigma and marginalization found between living with HIV and sexual minority

status. Interventions to remove barriers to service access, including those aimed at training providers and mobilizing

communities even within stigmatized peri-urban settings, are featured in this issue, which further demonstrates the immediate

need for comprehensive action to address HIV among MSM in all countries in the region, regardless of epidemic classification.

Keywords: men who have sex with men; Sub-Saharan Africa; epidemiology; HIV programmes; stigma and discrimination.

Published 2 December 2013

Copyright: –2013 Wolf RC et al; licensee International AIDS Society.This is an Open Access article distributed under the terms of the Creative Commons Attribution

3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

The HIV epidemic in sub-Saharan Africa (SSA) is dynamic

with regional and temporal variation. The 2012 Report on

the Global AIDS Epidemic reports a decline in HIV incidence

among the general population (GP) by 25%, a decrease by

40% in HIV-related mortality, and that more than half of

people living with HIV (PLHIV) who are eligible for treatment

were on treatment in SSA [1]. The UN classifies countries

as low level when HIV prevalence in the GP, as measured by

HIV surveillance data, is under 1% and key population (KP)

prevalence does not exceed 5%, where KPs are defined as

female sex workers (FSWs), men who have sex with men

(MSM) and people who inject drugs (PWID); concentrated

epidemics are where HIV prevalence is under 1% in the GP,

but any KP (e.g., FSW) prevalence consistently exceeds 5%;

and generalized epidemics are where HIV prevalence exceeds

1% in the GP regardless of HIV status among KPs [1,2].

An epidemic appraisal proposed by Wilson and Halperin

and others that characterizes the typology of HIV transmission

within the country, rather than simply crude estimates of

incidence and prevalence at the national level, called for

reclassification of countries based on transmission dynamics

[3,4]. They posited that concentrated epidemics are driven by

KPs, and they added mixed epidemic settings, where both the

GP and KPs play a role in HIV transmission, and generalized

epidemics, in which they argued that contribution to new

infections from KPs is insignificant. But this is debatable.

UNAIDS estimates HIV prevalence to be 17.9% among MSM

in SSA. Yet there are limited epidemiological data for MSM or

KPs in general in this region. For programmes to be well

aligned, we need to better understand the epidemiologic and

behavioural burden and social drivers of HIV within KP groups

in all epidemic settings. The articles in this series focus on

building the literature on epidemiology, social drivers of

transmission and programmatic innovations for MSM in four

regions of SSA: West, Central, East and Southern Africa.

Respondent-driven sampling (RDS) methods were used to

engage networks of MSM in these pioneering studies, which

characterize the HIV epidemiology among MSM in Cameroon,

Senegal, Malawi and Swaziland as elevated and sustained

when compared to men in the GP. This supplement also

includes a meta-analysis of prevalence studies from KPs in

Central and West Africa, which helps to ground our under-

standing of MSM within the broader context of KPs.

The extraordinary burden of internalized and external

stigma and discrimination creates the paralyzing barriers to

MSM access for prevention, care and treatment services that

are notable across these studies. Key dynamics of intersect-

ing stigmas of HIV and sexual orientation among HIV-positive

MSM are also explored in Swaziland [5]. Structural interven-

tions to address the pervasive stigma in healthcare settings

have been called for by the public health community, and

this supplement also addresses this issue with findings from

Wolf RC et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18903

http://www.jiasociety.org/index.php/jias/article/view/18903 | http://dx.doi.org/10.7448/IAS.16.4.18903

sensitivity trainings in coastal Kenya, which can influence and

support clinical work with MSM who come to healthcare

settings for sexually transmitted infection (STI) and HIV-

related care and treatment. Additionally, innovative strate-

gies for community mobilization engaging peer leaders in

small-group safe spaces within stigmatized peri-urban town-

ships are addressed through the article from South Africa.

While the role of sex among men is increasingly de-

scribed in concentrated epidemic settings, studies from

Southern Africa within generalized epidemics, where KPs are

conventionally not thought to play a significant role (e.g.,

South Africa, Swaziland, Lesotho, Malawi, Namibia, Botswana

and Zimbabwe), have also shown MSM to have high preva-

lence of HIV, syphilis and hepatitis B virus, with disease

burdens equal to or greater than those of men in the GP. Still,

because of the conception of KPs as insignificant in these

generalized epidemic settings, any data collection or targeted

response is limited [6].

Swaziland has been documented to have the highest

HIV prevalence globally. The incidence of HIV appears to

have peaked in 19981999 at 4.6% according to UNAIDS

estimates, while in 2009 it was estimated to be 2.7%. Recent

data from the Swaziland HIV Incidence Measurement Survey

(SHIMS) estimated HIV incidence at 2.4% in the total popula-

tion: 3.1% among women and 1.7% among men [1,7,8]. The

2009 Swaziland Modes of Transmission (MOT) study char-

acterized major drivers of incident HIV infections to be

multiple concurrent partnerships before and during marriage

as well as low levels of male circumcision [9]. While these

drivers were validated through the SHIMS, it is critical to

note that like many MOT studies in generalized settings in

Africa, there was no known prevalence among FSWs or

MSM, so the MOT analysis assumed a low frequency of both

practices and therefore assigned them as minor drivers of the

epidemic.

In this issue, Baral and colleagues conducted the first

cross-sectional study to estimate HIV prevalence and its risk

factors among MSM in Swaziland [10]. The HIV prevalence in

the RDS sample of 324 MSM was 17.6%, and the odds of HIV

prevalence increased by 20% for each year of age. The vast

majority (70%) of the sample reported being unaware of

their HIV status, and consistent condom use with lubricants

with male partners was reported by 12.6% of respondents.

The authors note that within their MSM sample, HIV preva-

lence is consistent with that of an age-matched sample from

the GP until age 2426 years, when the prevalence of HIV

among MSM rises higher than that of other men in the

GP with HIV prevalence of 43.1% among MSM older than

27 years [10].

These data as well as other recent data showing alarming

rates (70.3%) among FSWs have called researchers to rethink

the prevention, care and treatment response in Swaziland

[11]. Similarly, in Malawi, a high-HIV-burden country in East

Africa, Wirtz et al. conducted the most comprehensive MSM

study to date in Malawi, where the HIV response has largely

focussed exclusively on heterosexual and vertical transmis-

sion of HIV and where an estimated 8% of GP men have HIV

[12,13]. A sample of 338 Malawi MSM had prevalence of

HIV and active syphilis of 12.5 and 4.4%, respectively, after

adjusting for RDS approaches. Ninety percent of HIV infec-

tions were previously undiagnosed, and about half reported

consistent condom use with casual male partners. Among

MSM 26 years and older, prevalence of HIV was 28.1%.

West and Central Africa, the most populous regions of

Africa, have a mixture of HIV epidemics, and KPs are better

understood to play an important role in the overall trans-

mission dynamics in Nigeria, Senegal and Burkina Faso, where

KPs consistently show elevated HIV prevalence in comparison

to the GP, as reported by Papworth et al. in a meta-analysis of

KPs from West and Central Africa [14]. In Cameroon, where

the GP HIV prevalence for men is 2.9%, Park and colleagues

sampled 511 MSM in Douala and Yaounde

´through RDS and

estimated the HIV prevalence to be 37% [15]. In Douala and

Yaounde

´, respectively, HIV prevalence was 25.5 and 44.4%

[16]. Like in the other studies, the sample was young, with

a median age of 24 years, and as age increased, HIV rates in-

creased at staggering levels. HIV among MSM aged 2429

years was 47%, and it was 49.4% for those over 30. About half

of respondents did not use condoms consistently with casual

partners (48.5%), and even more did not use them consis-

tently with regular partners (64.1%). Similarly striking in

Senegal, where GP prevalence among reproductive age men

is 0.5%, the article included by Drame et al. reports baseline

HIV prevalence among a sample of MSM at 36.0% (43/114)

with cumulative HIV prevalence after 15 months at 47.2% (51/

108) [17].

Due to the criminalized nature of male-to-male sex in all

countries where studies from this issue took place, with the

notable exception of South Africa (which still experiences

high stigma), MSM are often afraid to visit healthcare

services; and when they do go, they are reluctant to disclose

their sexual histories to healthcare providers for fear of

rejection, derision, or other negative reactions. Continued

work is needed to develop violence screening, reporting and

mitigation approaches within these settings [18]. The authors

in this issue demonstrate that access to and coverage of

quality HIV services for MSM are still marginal and not

sufficient to reverse the epidemic’s trend among MSM,

and this is aggravated by several factors, primarily stigma,

discrimination and limited domestic investment in pro-

grammes focussed on MSM [1921]. Lessons learned from

mature programmes targeting FSWs in the region show that

with limited coverage, poor dosage and an inadequate

combination of approaches, even proven interventions will

be ineffective [22].

Research focussing on MSM sexual risk behaviour in SSA is

scant, and even less is known about the stigmatization and

discrimination of HIV-positive MSM [23]. Kennedy et al.

conducted 40 in-depth interviews from 20 HIV-positive MSM,

16 interviews with key informants and three focus group

discussions with MSM community members. Internalized and

experienced stigma was high among the men living with HIV,

who report that they conceal their HIV status from others.

MSM living with HIV reported experiencing greater social

isolation and lack of support for care-seeking and medica-

tion adherence. Perceived and experienced stigma from

healthcare settings led to delayed care seeking and travel

to more distant clinics to retain anonymity at home.

Wolf RC et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18903

http://www.jiasociety.org/index.php/jias/article/view/18903 | http://dx.doi.org/10.7448/IAS.16.4.18903

The authors argue that mental health interventions, training

for healthcare providers and better protection against

discrimination are needed for Swazi MSM living with HIV,

which corroborates previous findings from South Africa [24].

The association between HIV prevalence and the existence

of community-based HIV interventions targeting MSM and

other KPs has been well described [25]. Tailored community-

based programmes that provide MSM with high-quality,

sensitive services that are socially and economically accept-

able and led by the beneficiaries themselves is a promising

approach. The current article by Batist et al. expands on this

association with the use of safe spaces to remove barriers to

service access, including those aimed at training providers and

mobilizing communities even within stigmatized peri-urban

settings, which led to greater feelings of connection, social

support and self-esteem among MSM community members

and also led to these spaces becoming distribution points for

condoms, lubricants and HIV education.

Also in this supplement, two articles look at a sensitivity

training for healthcare workers providing services to MSM

[21,26], highlighting the pre-existing attitudes that can

manifest during clinical encounters with MSM. Healthcare

workers in SSA generally do not receive specific training

in working with MSM or other KPs, and they may not be

aware of risk factors for HIV transmission or appropriate care

and treatment needs. Healthcare worker training has been

identified as a priority intervention to support a minimum

package of essential services for MSM [27]. In van der Elst

et al., the researchers implemented a novel approach to

sensitivity training for healthcare workers providing services

to MSM [21]. The training consisted of self-directed, publically

available online modules followed by group discussions

focussed on MSM sexual risks and healthcare needs. Knowl-

edge and homophobia were assessed prior to training,

immediately after training and three months post training.

There was a statistically significant decline in homophobia

sustained after three months post training, with greater

reductions for males and those in clinical roles (doctors and

nurses), who were also more likely to have higher homo-

phobia scores pre-training. However, it remains to be seen

whether these attitudes can be maintained over time without

ongoing support [21].

In a subsequent article in this supplement, van der Elst

et al. explored topics including the sexual identification of

subcategories of MSM, sexual practices and risks for HIV

and STI transmission, practices for sexual history taking and

sexual health examinations for MSM [26]. Stigma was also a

concern for healthcare workers, such as negative judgements

from peers or community members for being associated

with MSM, and was an ongoing challenge after the training.

After completing the programme, healthcare workers ex-

pressed greater acknowledgement of MSM patients in their

clinics, empowerment to address their needs, and a better

understanding of the biological, behavioural and social

influences that lead to HIV and STI risk for MSM.

The term ‘‘MSM’’ is meant to address all MSM, regardless

of their gender or sexual identities. Some MSM self-identify

as heterosexual rather than gay, homosexual, or bisexual,

especially if they also have sex with women, are married,

only take the penetrative role in anal sex, or have sex with

men for money or convenience [28]. They may not con-

sider their sexual encounters with other men in terms of

gender identity or sexual orientation, or they may more

aptly self-identify using local social terms which reference

sexual identities, masculinity and femininity, and behaviours.

One noteworthy finding within the articles presented in this

issue from Malawi and Swaziland was the disconnection

between gender identity and sexual orientation [10,12,20].

While nearly all the respondents of both surveys reported

that they were either gay or bisexual and had anal sex with

men as criteria for eligibility in the study, a sizeable number

reported that they were not male. In Malawi, 17.0% reported

they were female, and another 2.8% said they were trans-

gender. In Swaziland, 15.7% reported being female, and 1.8%

said they were both male and female. It is not clear whether

participants actually considered themselves to be women

or whether their sexual behaviour caused them to consider

themselves not to be men. There is a need for further study

to better understand how these terminologies translate into

risk and sexual identity profiles while not singling out these

individuals for further stigma.

As more data become available for MSM in SSA, including

in Southern African generalized settings, MSM needs should

be identified and addressed throughout the continuum of

HIV prevention, care and treatment. We continue to need

evidence-based interventions to identify, create and train

healthcare providers as well as community champions, includ-

ing lawyers, media owners, journalists and religious leaders

sensitive to MSM programming, and establish community-

driven programmes while expanding integration within the

health system as appropriate.

The articles in this series have shown that throughout SSA,

there is a significant and sustained epidemic among MSM,

fear of discrimination from healthcare settings, and provider-

based and self-stigma which impede prevention, care and

treatment [2931]. The findings highlight the need to focus

on MSM as a critical KP in ‘‘mainstream’’ approaches as well

as MSM-targeted models. Countries in Africa characterized as

having generalized epidemics, where KPs are not considered

relevant, must be re-conceptualized based on these findings.

All ‘‘generalized’’ epidemics are in reality mixed epidemics

with ongoing transmission among KPs, and this becomes

increasingly clear as GP prevalence rates decline while MSM

experience expanding epidemics.

While it is not clear what proportion of new HIV infections

are linked to MSM directly and via second-order transmission

among their partners, it is clear that without addressing this

underserved, stigmatized population, HIV transmission will

be impossible to abate. Therefore, the benefits of targeted

structural, behavioural and biomedical services for MSM go

beyond the individuals to benefit the larger public welfare

and security of all countries within SSA as well as globally.

After three decades of the fight against HIV, plans to end the

HIV epidemic through goals such as the AIDS-free generation

and the US President’s Emergency Plan for AIDS Relief’s

(PEPFAR) Blueprint seem possible. Substantial progress has

been made, and more will come through vigilance, courage,

tolerance and commitment.

Wolf RC et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18903

http://www.jiasociety.org/index.php/jias/article/view/18903 | http://dx.doi.org/10.7448/IAS.16.4.18903

Authors’ affiliations

United States Agency for International Development, Office of HIV/AIDS,

Washington, DC, USA;

United States Agency for International Development,

West Africa, Accra, Ghana

Competing interests

The authors have no other funding or conflicts of interest to disclose. The

findings and conclusions in this editorial are those of the authors and do not

necessarily represent the views of the United States Agency for International

Development (USAID).

Authors’ contributions

RCW, LK, AC and DC all contributed to the preparation of the first draft. All

authors approved the final manuscript.

Acknowledgements

The authors would like to acknowledge the significant contribution made

by the Center for Public Health and Human Rights at the Johns Hopkins

Bloomberg School of Hygiene and Public Health. The leadership that the Center

has shown on key populations, supported through multiple sources of funding

(including PEPFAR), has been transformational. In particular, the individual

leadership of Stefan D Baral catalysed these studies and therefore this

significant contribution to the field. Additionally, the authors are truly grateful

for the support of the JIAS editorial team, who gave expert guidance through

the entire review process.

References

1. UNAIDS. Report on the global AIDS epidemic; Geneva: UNAIDS; 2012.

2. UNAIDS. UNAIDS/WHO working group on global HIV/AIDS and STI

surveillance. Guidelines for second generation HIV surveillance. Geneva: World

Health Organization and Joint United Nations Programme on HIV/AIDS; 2000.

3. Mishra S, Sgaier SK, Thompson LH, Moses S, Ramesh BM, Alary M, et al. HIV

epidemic appraisals for assisting in the design of effective prevention

programmes: shifting the paradigm back to basics. PLoS One. 2012;7:e32324.

4. Wilson D, Halperin DT. ‘‘Know your epidemic, know your response’’: a useful

approach, if we get it right. Lancet. 2008;372:4236.

5. Mayer KH, Bekker LG, Stall R, Grulich AE, Colfax G, Lama JR. Comprehensive

clinical care for men who have sex with men: an integrated approach. Lancet.

2012;380:37887.

6. Beyrer C. LGBT Africa: a social justice movement emerges in the era of HIV.

SAHARA J. 2012;9:1779.

7. Reed JB, Justman J, Bicego G, Donnell D, Bock N, Ginindza H, et al.

Estimating national HIV incidence from directly observed seroconversions in

the Swaziland HIV Incidence Measurement Survey (SHIMS) longitudinal cohort

(FRLBX02). Washington, DC; 2012.

8. UNAIDS N, Ministry of Health, Swaziland. Monitoring the declaration of the

commitment on HIV and AIDS (UNGASS): Swaziland country report. Mbanane:

UNGASS; 2010.

9. HIV/AIDS. UWBSNERCo. Swaziland: HIV prevention, response and modes of

transmission analysis. Mbabane, Swaziland: World Bank; 2009.

10. Baral SD, Ketende S, Mnisi Z, Mabuza X, Grosso A, Sithole B, et al. A cross-

sectional assessment of the burden of HIV and associated individual- and

structural-level characteristics among men who have sex with men in

Swaziland. J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18768.

11. Baral L, Ketende S, Chen PA, Kennedy C, Mnisi Z, Adams D, et al.

Reconceptualizing HIV prevention needs in a generalized epidemic: the case of

female sex workers (FSW) in Swaziland. Kuala Lumpur, Malaysia: IAS; 2013.

12. Wirtz AL, Jumbe V, Trapence G, Kamba D, Umar E, Ketende S, et al. HIV

among men who have sex with men in Malawi: elucidating HIV prevalence

and correlates of infection to inform HIV prevention. J Int AIDS Soc. 2013;16(4).

doi: 10.7448/IAS.16.4.18742.

13. Government of Malawi. Global AIDS response progress report: Malawi

country report for 2010 and 2011. Lilongwe: Government of Malawi; 2012.

14. Papworth E, Ceesay N, An L, Thiam-Niangoin M, Ky-Zerbo O, Holland C,

et al. Epidemiology of HIV among female sex workers, their clients, men who

have sex with men, and people who inject drugs in West and Central Africa.

J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18751.

15. Statistics CNIo. 2011 Cameroon Demographic and Health Survey and

Multiple Indicators Cluster Survey (DHS-MICS): HIV prevalence. Calverton:

MEASURE DHS, ICF International; 2012.

16. Park JN, Papworth E, Kassegne S, Moukam L, Billong SC, Macauley I, et al.

HIV prevalence and factors associated with HIV infection among men who have

sex with men in Cameroon. J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.

18752.

17. Drame

´FM, Crawford EE, Diouf D, Beyrer C, Baral SD. A pilot cohort study

to assess the feasibility of HIV prevention science research among men who

have sex with men in Dakar, Senegal. J Int AIDS Soc. 2013;16(4). doi: 10.7448/

IAS.16.4.18753.

18. Betron M. Screening for violence against MSM and transgenders: report

on a pilot project in Mexico and Thailand. Washington, DC: Futures Group,

USAIDjHealth Policy Initiative, Task Order 1; 2009.

19. Batist E, Brown B, Scheibe A, Baral SD, Bekker L. Outcomes of a

community-based HIV-prevention pilot programme for township men who

have sex with men in Cape Town, South Africa. J Int AIDS Soc. 2013;16(4).

doi: 10.7448/IAS.16.4.18754.

20. Kennedy CE, Baral SD, Fielding-Miller R, Adams D, Dludlu P, Sithole B, et al.

‘‘They are human beings, they are Swazi’’: intersecting stigmas and the positive

health, dignity and prevention needs of HIV-positive men who have sex with

men in Swaziland. J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18749.

21. van der Elst EM, Smith AD, Gichuru E, Wahome E, Musyoki H, Muraguri N,

et al. Men who have sex with men sensitivity training reduces homoprejudice

and increases knowledge among Kenyan healthcare providers in coastal Kenya.

J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18748.

22. Semini I, Batona G, Lafrance C, Kessou L, Gbedji E, Anani H, et al.

Implementing for results: program analysis of the HIV/STI interventions for sex

workers in Benin. AIDS Care. 2013;25(Suppl 1):S309.

23. Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health

care settings: what works? J Int AIDS Soc. 2009;12:15.

24. Cloete A, Simbayi LC, Kalichman SC, Strebel A, Henda N. Stigma and

discrimination experiences of HIV-positive men who have sex with men in Cape

Town, South Africa. AIDS Care. 2008;20:110510.

25. Gurung A, Narayanan P, Prabhakar P, Das A, Ranebennur V, Tucker S, et al.

Large-scale STI services in Avahan improve utilization and treatment seeking

behaviour amongst high-risk groups in India: an analysis of clinical records from

six states. BMC Public Health. 2011;11(Suppl 6):S10.

26. van der Elst EM, Gichuru E, Omar A, Kanungi J, Duby Z, Midoun M, et al.

Experiences of Kenyan healthcare workers providing services to men who have

sex with men: qualitative findings from a sensitivity training programme. J Int

AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18741.

27. Beyrer C, Wirtz A, Walker D, Johns B, Sifakis F, Baral S. The global HIV

epidemics among men who have sex with men (MSM): Epidemiology,

prevention, access to care and human rights. Washington, DC: World Bank;

2011.

28. AMFAR. Ensuring universal access to comprehensive HIV services for MSM

in Asia and the Pacific: determining operations research priorities to improve

HIV prevention, treatment, care, and support among men who have sex with

men; New York: 2009.

29. Baral S, Adams D, Lebona J, Kaibe B, Letsie P, Tshehlo R, et al. A cross-

sectional assessment of population demographics, HIV risks and human rights

contexts among men who have sex with men in Lesotho. J Int AIDS Soc.

2011;14:36.

30. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in peri-urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

31. Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15:108897.

Wolf RC et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18903

http://www.jiasociety.org/index.php/jias/article/view/18903 | http://dx.doi.org/10.7448/IAS.16.4.18903

Research article

Men who have sex with men sensitivity training reduces

homoprejudice and increases knowledge among Kenyan

healthcare providers in coastal Kenya

Elise M van der Elst

, Adrian D Smith

, Evanson Gichuru

, Elizabeth Wahome

, Helgar Musyoki

, Nicolas Muraguri

2,3

Greg Fegan

1,2

, Zoe Duby

, Linda-Gail Bekker

, Bonnie Bender

, Susan M Graham

1,6

, Don Operario

and

Eduard J Sanders

§,1,2

Corresponding author: Eduard J Sanders, Kenya Medical Research Institute-Wellcome Trust Research Programme (KEMRI-WTRP), P.O. Box 230 Kilifi, Kenya.

Tel: 254 41 7522063, 254 41 7522535. (ESanders@kemri-wellcome.org)

Abstract

Introduction: Healthcare workers (HCWs) in Africa typically receive little or no training in the healthcare needs of men who have

sex with men (MSM), limiting the effectiveness and reach of population-based HIV control measures among this group. We

assessed the effect of a web-based, self-directed sensitivity training on MSM for HCWs (www.marps-africa.org), combined with

facilitated group discussions on knowledge and homophobic attitudes among HCWs in four districts of coastal Kenya.

Methods: We trained four district ‘‘AIDS coordinators’’ to provide a two-day training to local HCWs working at antiretroviral therapy-

providing facilities in coastal Kenya. Self-directed learning supported by group discussions focused on MSM sexual risk practices, HIV

prevention and healthcare needs. Knowledge was assessed prior to training, immediately after training and three months after

training. The Homophobia Scale assessed homophobic attitudes and was measured before and three months after training.

Results: Seventy-four HCWs (68% female; 74% clinical officers or nurses; 84% working in government facilities) from 49 health

facilities were trained, of whom 71 (96%) completed all measures. At baseline, few HCWs reported any prior training on MSM

anal sexual practices, and most HCWs had limited knowledge of MSM sexual health needs. Homophobic attitudes were most

pronounced among HCWs who were male, under 30 years of age, and working in clinical roles or government facilities. Three

months after training, more HCWs had adequate knowledge compared to baseline (49% vs. 13%, McNemar’s test pB0.001);

this was most pronounced in those with clinical or administrative roles and in those from governmental health providers.

Compared to baseline, homophobic attitudes had decreased significantly three months after training, particularly among HCWs

with high homophobia scores at baseline, and there was some evidence of correlation between improvements in knowledge and

reduction in homophobic sentiment.

Conclusions: Scaling up MSM sensitivity training for African HCWs is likely to be a timely, effective and practical means

to improve relevant sexual health knowledge and reduce personal homophobic sentiment among HCWs involved in HIV

prevention, testing and care in sub-Saharan Africa.

Keywords: sensitivity training; MSM behaviour; Homophobia Scale; homoprejudice; healthcare workers; Kenya.

Received 22 May 2013; Revised 6 September 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 van der Elst EM et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction

Sub-Saharan Africa has a very high burden of HIV-1 infection,

of which a substantial proportion occurs among populations

reporting high-risk sexual behaviour such as transactional

sex and anal intercourse [1]. Such populations suffer from

stigma and rejection, and they have been neglected by many

HIV prevention and care programmes [2]. As a result, most

African healthcare workers (HCWs) have not been informed

about the risk of HIV transmission with regard to heterosexual

or homosexual anal sex. In addition, African HCWs may lack

understanding of the many challenges that men who have sex

with men (MSM) and other key populations face in healthcare

facilities [3].

Societal discrimination on the grounds of sexual orienta-

tion has been reported frequently among African MSM,

taking the form of sexual, physical and verbal assault [47],

and a number of studies have demonstrated an association

between reported experience of discrimination and HIV risk

or risk behaviour [8]. Similarly, high levels of internalized

homophobia among MSM have been reported in Nigeria

[8], South Africa [9,10] and Uganda [11], known to be

associated with individual HIV risk-taking behaviour [12].

Overt stigmatization specifically from HCWs in the context

of HIV testing and care, such as denial of service [4,3,13]

and harassment in clinic spaces [14], has been reported

as a key element of perceived discrimination, presenting a

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

deterrent to service access [15] or accurate disclosure of

behavioural risk [14]. In the absence of resources targeted

to groups at high risk of HIV infection, the marginalization

of MSM from public HIV prevention and treatment re-

sources can only hamper the effectiveness of national HIV

control efforts [6].

Health worker training, social mobilization and community

engagement were prioritized as structural interventions in a

recent consultation on priority areas for MSM HIV prevention

research involving 69 participants from 17 African countries

[16]. HCWs have also been called to action to reduce stigma

and discrimination, provide integrated services for mental

health concerns and substance use, screen MSM routinely for

HIV and sexually transmitted infections (STIs) and ensure

training for all personnel in clinical settings [3]. As yet, African

HCWs lack any evidence-based, culturally adapted training

model that is sensitive to MSM needs. This problem likely

stems from cultural taboos about anal sex practices, even in

opposite-sex couples [17], and strong political, religious and

public prejudice against same-sex practices [18].

Since 2005, biomedical research has been ongoing with

both HIV-1 negative MSM and MSM living with HIV in coastal

Kenya [1,19]. To date, the only incidence data for African

MSM derive from our cohort and a related cohort in Nairobi

[19,20]. Overall HIV-1 incidence among young MSM in coastal

Kenya was as high as 8.6 (95% confidence interval [CI]:

6.711.0) per 100 person-years of observation [19]. The

majority of these MSM reported sex work, and large num-

bers of such men have been identified in coastal Kenya [21].

Similarly, our cohort study of MSM living with HIV showed

that 40% had less than 95% antiretroviral therapy (ART)

adherence, compared to 29% of heterosexual men and 12%

of women who were followed in the same research setting

[1]. These findings prompted us to brief health authorities

and develop materials to help improve care for MSM in

Kenya and elsewhere in Africa.

Internet-based learning (e-learning) as a cognitive tool has

increasingly been used in health professions in resource-

constrained low- and middle-income countries [22]. E-learning

technologies offer learners control over content, learning se-

quence, pace of learning, time and often media, allowing

learners to tailor their experiences to meet their personal

learning objectives [23]. The internet-based HCW MSM sensi-

tivity training described here represents our attempt to deploy

meaningful, clinically relevant material to meet this specific

learning need within Kenyan HIV services through adaptation of

an existing training curriculum to a web environment.

‘‘MSM: An introductory guide for health workers in

Africa’’ is a paper-based HCW sensitization training first de-

veloped in 2010. The content of training was validated and

revised through a programme of extensive classroom use in

South Africa, and following expert review [24]. The paper-

based training guide was electronically converted to a self-

directed electronic format and published online in July 2011,

a version of which was adapted for use in this study.

The objectives of this study were (1) to assess the fea-

sibility of facilitated self-directed learning of MSM health

issues in coastal Kenya and (2) to evaluate the effect of the

training intervention upon HCW knowledge and attitudes.

Methods

Study site and participants

Seventy-four HCWs involved in HIV prevention, treatment and

care services in coastal Kenya were recruited to participate in

the study. We mapped 54 ART-providing governmental and

nongovernmental health providers in four districts in coastal

Kenya (Kilindini, Mombasa, Kilifi and Malindi). An average of

two staff representatives from each health-providing facility

were invited to the training intervention, including clinicians

and counsellors as well as clinic administrators.

Four ‘‘district AIDS/STD coordinators’’ (DASCOs) working

within the study districts were trained to lead the MSM

sensitization training during a 2-day ‘‘training-of-trainers’’

course similar to the training proper. An additional day

was used to prepare focus-group topic guides and organiza-

tional matters. The study procedures were approved by the

ethical review board at the Kenya Medical Research Institute,

and all participants provided written informed consent for

impact evaluation. HCWs received Ksh2000 (approximately

US$24.00) to cover travel expenses and lodging.

The training intervention

The training consisted of two consecutive days and included

eight modules which were taken in four sessions (i.e., two

computer modules per session). Each session was followed

by a group discussion. Each group size comprised 1819

participants. DASCOs were supported by four members of the

research team (i.e., a community liaison officer, a research

counsellor, an MSM staff-fieldworker and a social scientist)

and two members of a local LGBTI (lesbian, gay, bisexual,

transgender and intersex) organization. HCWs were intro-

duced to the sensitivity training on MSM health issues and

learned that the training consisted of computer-assisted

learning (http://www.marps-africa.org) and group discus-

sions. The curriculum consisted of the following modules of

study: (1) MSM and HIV in sub-Saharan Africa; (2) Stigma; (3)

Identity, coming out and disclosure; (4) Anal sex and common

sexual practices; (5) HIV and sexually transmitted infections;

(6) Mental health, anxiety, depression and substance abuse;

(7) Condom and lubricant use; and (8) Risk reduction

counselling. Modules were designed to be self-completed in

12 hours each, including multiple-choice questions (median

12, range 916) at the end of each module. A score of 71%

correct was required to advance to the next module, and

upon successful completion of all eight modules, participants

were sent a link to download their course certificate. A post-

course evaluation asked for opinions and suggestions for

course improvements, using both closed and open-ended

questions.

Discussion topics included the identification of subcate-

gories of MSM and their characteristics, sexual practices of

MSM and risks for HIV and STI transmission, factors that make

MSM vulnerable to STIs and HIV, risk assessment in counsel-

ling MSM, best practice for sexual history taking and sexual

health examination with MSM, relevant information on safer

sex for MSM, personal values and attitudes towards MSM,

and addressed stigma and strategies to improve communica-

tion with clients who are MSM. At the end of the training,

HCWs discussed a work plan on how to strengthen clinical

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

care and uptake of HIV and STD testing for MSM in their day-

to-day practice. Study participants with a clinical role were

also requested to keep a journal for three months to

document and reflect upon their work practices and personal

attitudes towards MSM.

Data collection

Course participants completed an online registration, includ-

ing socio-demographic characteristics (age, gender and level

of education and training), details of working practice (role

within, type and location of healthcare organization) and

specific experience working with HIV prevention, treatment

and care with the most at-risk populations (MARPs) in Africa.

To assess baseline levels of knowledge, participants con-

ducted a pre-course 24-item multiple-choice assessment

covering key learning outcomes across the course material,

and they completed a 25-item Homophobia Scale (HS;

adapted from Wright et al. [25]). The same two measures

were repeated three months after course completion to

assess sustained changes in knowledge of and attitudes

towards MSM. Immediate post-course knowledge was as-

sessed using the same pre-knowledge questionnaire upon

completion of the eight modules. The results of pre-training

and post-training assessments were not communicated to

participating HCWs.

Measurement scales

Knowledge scores of course material were divided into the

following categories: Poor (B17 questions correctly answered),

Good (1722 questions correctly answered) and Excellent

(22 questions correctly answered). When 17 or more ques-

tions were correctly answered, the immediate post-training

knowledge was considered adequate.

The HS, which was developed and standardized among

college students in the United States by Wright et al. [25],

was adapted for use in Kenya. The HS aims to measure

thoughts, feelings and behaviours towards homosexuality

and MSM, and it consists of 25 statements to which res-

pondents indicate their level of agreement on a 5-point Likert

scale (Table 1). Questions were reviewed and adapted by

three Kenyan research staff and HCWs with professional and

personal experience working with local MSM. The adapted

HS is shown in Table 1 and reflects changes in terminology

(e.g., ‘‘gay’’ was replaced with ‘‘MSM’’ and ‘‘faggot’’ with

‘‘shoga’’ in question 9) to reflect local terminology in current

use. I have damaged property of gay persons, such as

‘‘keying’’ their cars, was replaced with Homosexuality should

be treated as an illness/Homosexuality can be cured (ques-

tion 17); I would feel comfortable with having a gay room-

mate was replaced with Homosexuality is un-African/is

something brought by foreigners (question 18); and I have

rocky relationships with people that I suspect are gay was

replaced with Gay men have the same rights to public/tax-

funded services as straight men (question 25). Responses to

items 1, 2, 4, 5, 6, 9, 12, 13, 14, 15, 17, 18, 19, 21, 23 and 24

were reverse coded (item scores 15, 24, 33 etc.). The

total HS score (HSS) was the sum of all item scores, with 25

subtracted from the total. The range is between 0 and 100,

with an HSS of 0 being the least homophobic and 100 being

the most homophobic.

Data analysis

Analysis was conducted using Stata 11.0 (StataCorp LP,

College Station, TX, USA). Binary and categorical character-

istics of study participants, established at baseline, were

compared using chi-square tests. Although both knowledge

and HS scores before and after training approximated to

Gaussian distributions, differences between paired measures

were non-normal, and thus unadjusted nonparametric meth-

ods were used for analysis. Median differences between pre-

and post-training knowledge and homophobia score are

reported with an interquartile range (IQR). A Wilcoxon signed

rank test for matched pairs was applied to test the statistical

significance of differences between pre- and post-training

scores. MannWhitney and exact McNemar’s tests were used

to test differences in scores and binary measures, respec-

tively, by HCW characteristics. Spearman’s rank was used to

assess correlation between pre- and post-training scores, and

knowledge and HS scores at both points. Multivariate linear

regression models of pre- and post-training score outcomes

were explored, but they yielded no additional insight beyond

bivariate analysis.

Results

Seventy-four HCWs were recruited to participate in the

training programme, and their characteristics are shown in

Table 2. The majority were female, and the mean age of

participants was 32 years (range: 23 to 53). Sixty-two

participants (84%) worked at a government health facility

(hospital or clinic), seven (9%) worked at a local nongovern-

mental organization (NGO) and three (4%) represented faith-

based organizations. Most (74%) were in a clinical role (nurse

or clinical officer). Irrespective of job role, 8% had received

any previous training on how to counsel MSM clients, and

a similarly low proportion (7%) had ever received training

on how to counsel on anal sex practices. HCWs who had

received training on anal sex practices were more likely to

have ever asked their male patients if they had sex with men

than HCWs who did not report previous training (86% (6/7)

versus 31% (21/67), x

pB0.01).

Training logistics

Most HCWs (73% (54/74)) required 1 hour or less to

complete each module, whilst 11% (8/74) required 2 hours

or more per module. While 68% (50/74) considered the

course duration to be ‘‘just right,’’ 23% (17/74) said that it

was too short, and 9% (7/74) that it was too long. Overall, by

the end of training, 60/74 (81%) HCWs reported feeling

empowered to discuss MSM behaviour and anal sex in their

professional work.

All participants said they would recommend the course to

others. Open-ended suggestions for course improvements

are presented in Table 3. Study participants recommended

that the training should be taken by all health stakeholders

dealing with MSM issues and be included in medical training.

There was an interest in similar training related to other key

populations (e.g., women who have sex with women and sex

workers).

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

Effect of training on MSM sexual health knowledge

among healthcare workers

Table 4 shows knowledge of MSM sexual health issues

among participants before the training course, and upon

reassessment three months after the course. Prior to the

training course, only 10/74 (14%) had an ‘‘adequate’’ level of

knowledge of MSM issues (threshold score: 17/24), reflecting

a median score of 54% (IQR 4963%). Levels of knowledge

were similar by socio-demographic and workplace character-

istics of HCWs, although it was somewhat lower for HCWs in

administrative roles compared to other roles (median 42 vs.

54, MannWhitney p0.293).

At the end of training, 70/74 (95%) HCWs had adequate

course knowledge (exact McNemar’s x

pB0.001 vs. pre-

training). At three months after the course, 35 (49%) of the

71 HCWs reassessed had retained ‘‘adequate’’ knowledge

compared to 9/71 (13%) at pre-training (exact McNemar’s

pB0.001). This represented a significant increase in

the median assessment score of 12% (IQR 421%) between

baseline and three-month knowledge assessments (Wilcoxon

signed test for matched pairs pB0.001). Significant sustained

improvements in knowledge were apparent for all HCW age

groups and genders, those with clinical or administrative

roles and those from governmental health providers.

Pre-training and three-month post-training scores were

negatively correlated (Spearman’s rho 0.51, pB0.001),

indicating that improvements in knowledge tended to be

highest among HCWs with lower pre-training knowledge.

There were no significant differences in the degree of

knowledge gain by the gender or age group of HCWs; however,

participants in counselling roles achieved significantly lower

gains in sustained knowledge than other HCWs (median

difference: 0% vs. 13%, MannWhitney p0.0163).

Effect of training on personal attitudes toward MSM

among healthcare workers

Table 5 shows HS scores among HCWs prior to training and

at reassessment three months later. Overall, the median HS

score prior to training was 68/100, representing extensive

agreement with homophobic statements and disagreement

Table 1. Homophobia Scale and MSM sensitivity training for healthcare workers (HCWs), coastal Kenya, 20112012

This questionnaire is designed to measure your thoughts, feelings and behaviours with regards to homosexuality. It is not a test, so there are

no right or wrong answers. Answer each item by circling the number after each question.

1Strongly agree

2Agree

3Neither agree nor disagree

4Disagree

5Strongly disagree

1 MSM make me nervous. 1 2 3 4 5

2 MSM deserve what they get. 1 2 3 4 5

3 Homosexuality is acceptable to me. 1 2 3 4 5

4 If I discovered a friend was an MSM, I would end the friendship. 1 2 3 4 5

5 I think homosexual people should not work with children. 1 2 3 4 5

6 I make derogatory remarks about MSM people. 1 2 3 4 5

7 I enjoy the company of MSM. 1 2 3 4 5

8 Marriage between homosexual individuals is acceptable. 1 2 3 4 5

9 I make derogatory remarks like ‘‘shoga’’ or ‘‘queer’’ to people who I suspect are MSM. 1 2 3 4 5

10 It does not matter to me whether my friends are MSM or straight. 1 2 3 4 5

11 It would upset me if I learned that a close friend was homosexual. 1 2 3 4 5

12 Homosexuality is immoral. 1 2 3 4 5

13 I tease and make jokes about MSM. 1 2 3 4 5

14 I feel that you cannot trust a person who is homosexual. 1 2 3 4 5

15 I fear homosexual persons will make sexual advances towards me. 1 2 3 4 5

16 Organizations which promote gay rights are not necessary. 1 2 3 4 5

17 Homosexuality should be treated as an illness/Homosexuality can be cured. 1 2 3 4 5

18 Homosexuality is un-African/is something brought by foreigners. 1 2 3 4 5

19 I would hit a homosexual for coming on to me. 1 2 3 4 5

20 Homosexual behaviour should not be against the law. 1 2 3 4 5

21 I avoid MSM individuals. 1 2 3 4 5

22 It bothers me to see two homosexual people together in public. 1 2 3 4 5

23 When I see an MSM, I think, ‘‘What a waste.’’ 1 2 3 4 5

24 When I meet someone, I try to find out if he or she is MSM. 1 2 3 4 5

25 Gay men have the same rights to public/tax-funded services as straight men. 1 2 3 4 5

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

with statements indicating tolerance of MSM (see Table 5).

Male HCWs had slightly higher HS scores at baseline than

female HCWs, while HS scores declined with increasing age

group but differences were not statistically significant. HCWs

in clinical roles (medical and nursing) had higher HS scores

than other staff (median 71 vs. 66 respectively, Mann

Whitney p0.116), and HCWs working in government

facilities had significantly higher HS scores than HCWs in

NGOs (Table 5, MannWhitney p0.037).

The majority of HCWs reported lower HS scores three

months post-training (80.3%, 57/71) compared to their

baseline HS score; in four (5.6%), HS scores were unchanged;

and in 14.1% (10/71), HS scores were higher after training

than before. Overall, the median decrease in individual

HS score after training was 8 points (IQR 215), which was

statistically significant. These findings did not change in a

sensitivity analysis omitting the three HS questions that were

culturally adapted (data not shown). Individual pre-training

and post-training HS scores were negatively correlated

(Spearman’s rho0.71, pB0.001), reflecting the ten-

dency for HCWs with high pre-training HS scores to exhibit

greater decreases in this measure as a result of training

(Figure 1).

Male HCWs and those working in clinical roles and in

governmental institutions recorded the most pronounced

reductions in HS score subsequent to training, although

differences in median reduction comparing HCWs’ gender,

age group, staff role and institution were not statistically

significant. More modest declines in HS score were apparent

for counsellors (median reduction after training: 4 points)

and staff of NGOs (median reduction after training: 0 points);

however, it is notable that these groups reported relatively

low HS scores prior to training. Collectively, there was some

evidence for correlation between scale of increase in

individual knowledge and scale of decline in HS score, and

this was of borderline statistical significance (Spearman’s

rho.21, p0.087).

Discussion

This formal evaluation of a training course aimed specifically

to improve knowledge and awareness of MSM sexual health

needs among healthcare staff involved in frontline HIV

prevention, treatment and care to adult populations in sub-

Saharan Africa. Specific and accurate knowledge relevant to

the management of behavioural and clinical risks for MSM

clients prior to training was poor.

Whilst this may not be surprising in the face of long-

standing neglect of Kenyan MSM within HIV policy and

resource allocation and a lack of attention to MSM within

medical, nursing and HIV counselling training in Kenya, it

draws focus to the challenge of maintaining and extending

the professional competence of the existing HIV workforce

to match the epidemiological realities of the Kenyan HIV

epidemic especially since the National AIDS & Sexually

Transmitted Diseases Control Programme (NASCOP) requires

Kenyan HCWs to document the number and category of

MSM using HIV services.

Whilst targeted services may well be necessary for sub-

populations of MSM, such as male sex workers, they are

unlikely to replace the need for MSM-specific clinical care

among general health services. MSM-specific programmes

have aroused considerable social antipathy in Kenya to date

[26] and may in any case not be perceived as accessible to

men who covertly engage in homosexual behaviour [27].

Furthermore, surveillance of key populations, including MSM,

and strategic information on service coverage to these

groups are now an international requirement [28].

The combination of self-directed, modular computer-based

learning supplemented by group discussions facilitated by

trainers identified from within the existing workforce may

offer a relatively sustainable and mobile model for episodic

health professional training in this context. The learning

content of this course is freely available as a web resource,

yet reliable access to internet services remains elusive and

expensive in most parts of the country. Even where it is

Table 2. Characteristics of 74 healthcare workers (HCWs)

Registration characteristics

HCWs selected for two-day

online training

N74

N(%)

Gender

Male 24 (32)

Female 50 (68)

Age (years)

1829 3 (4)

3039 44 (59)

40 27 (36)

Organization type

Government 62 (84)

NGO 7 (9)

Other 5 (7)

Education level

Up to secondary 6 (8)

Tertiary 68 (92)

Job type

Clinical 52 (70)

Counselling 12 (16)

Administrative 7 (9)

Other 3 (4)

Prior MSM training experience

Counselling clients who are MSM

No 68 (92)

Yes 6 (8)

Counselling on anal sex practices

No 67 (91)

Yes 7 (9)

Ever asked male clients about sexual

acts with other men

No 47 (64)

Yes 27 (36)

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

available, the narrative reflections by participants who

undertook this training emphasize the importance of the

sanction provided by facilitated group discussions to share

and explore personal and professional issues arising from

the training content that may well be lost in self-directed

learning [29].

Table 3. End-of-course suggestions for course improvements

Study participants (SP) (N74)

Selected from 45 (61%) responses

Theme: Expand training to all healthcare workers (HCWs) and other institutions

‘‘This online training should be streamed or provided to all institutions and politicians to sensitize them on the need to recognize MSM.’’

‘‘Should be introduced in medical training departments.’’

‘‘It should be done by all health stake holders dealing with MSM issues.’’

Theme: Advertisement and promotion website

‘‘Reach more people through media eg Radio and schools.’’

‘‘Make it available at facility by providing computer.’’

Theme: Connectivity, internet, computers and mobile phones

‘‘Improve internet speed.’’

‘‘No suggestion, it is that I am still learning how to use a computer.’’

Theme: Duration of course

‘‘It should also include field work.’’

‘‘The course is very interesting, it should be for at least five days, so we get time to discuss more.’’

(Nineteen additional participants asked for a longer course.)

Theme: Improve specific modules and further learning

‘‘Add women who have sex with women/prostitution.’’

‘‘Add more pictures on the STI module. Make the questions more relevant for some are contradictory. Have authoritative literature references.’’

‘‘The picture of the actual penetration on page 68 [cartoon of man penetrating a man while using a condom] is somehow too much to view.

Better picture can be used to demonstrate the same.’’

‘‘We need more testimony clips to narrate how many MSM got to fight stigma and be where they are now.’’

‘‘More research should be conducted on whether homosexuality could be reversed.’’

‘‘Perhaps translation in Kiswahili.’’

Table 4. Change in MSM sexual health knowledge from baseline to three months post-training

Healthcare

workers (HCWs)

Pre-training

(baseline)

Post-training

(three month)

Difference between pre-training and post-training

multiple-choice questions %

NMedian (%) Median (%)

Median

difference (%)

Interquartile

range

P-value

(Wilcoxon)

All 74 54 67 12 4 to 21 B0.001

Gender Male 24 56 71 16 5 to 21 B0.001

Female 50 54 65 11 1 to 21 B0.001

Under 30 23 54 71 16 0 to 21 0.001

Age group 30 to 39 34 58 63 9 0 to 21 0.002

40 or over 17 54 71 12 4 to 21 0.002

Clinical 52 54 71 13 8 to 21 B0.001

Counselling 12 58 56 0 9 to 13 0.813

Job type Admin 7 42 75 13 4 to 37 0.022

Other 3 54 73 19 9 to 29 0.190

Government 62 54 71 13 5 to 21 B0.001

Facility NGO 7 58 67 12 8 to 17 0.267

Other 5 54 58 45 to 25 0.414

Limited to 71 HCWs with paired observations.

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

The brief training programme described here resulted

in significant improvements in knowledge of MSM sexual

health issues pertinent to day-to-day prevention and clinical

practice, and it was sustained by most trainees until at least

three months after training. Increase in knowledge was

accompanied by a reduction in negative attitudes toward

MSM over the same period. Encouragingly, the positive

effect of training upon knowledge and personal attitudes

toward MSM was strongest among HCWs who had poor

levels of knowledge and/or more extreme negative atti-

tudes toward MSM prior to training. That positive changes

were most marked among HCWs in clinical roles within gov-

ernmental settings, which represent the backbone of Kenyan

HIV services, is cause for particular optimism. Studies to

date of perceived barriers to healthcare access identified by

MSM in Kenya [7,30] and elsewhere in sub-Saharan Africa

[31,32] have reported denial of service, lack of confidentiality,

ignorance and verbal abuse from governmental HIV services

as central challenges in accessing sexual and general health

services. The finding of this study, albeit preliminary, suggests

Table 5. Change in Homophobia Score (HS) from baseline to three months post-training

Healthcare

workers (HCWs)

Pre-training

(baseline)

Post-training

(three month)

Difference between pre-training and

post-training HS

Median HS

(0100)

Median HS

score (0100)

Median difference

(score)

Interquartile

range

P-value

(Wilcoxon)

All 74 68 60 82to15 B0.001

Gender Male 24 70 60 94to21 0.001

Female 50 68 60 71to13 B0.001

Under 30 23 71 62 93to14 B0.001

Age group 30 to 39 34 68 59 61to13 B0.001

40 or over 17 67 61 10 4to24 0.001

Clinical 52 71 61 10 3to20 B0.001

Job type Counselling 12 64 60 51to9 0.031

Administrative 7 68 55 11 6to19 0.022

Other 3 66 61 20to4 0.317

Government 62 71 60 92to15 B0.001

Facility Nongovernmental

organization

76256 01to13 0.444

Other 5 78 60 95to21 0.043

Limited to 71 HCWs with paired observations.

–40

–30

–20

–10

Change in HS score after training

40 50 60 70 80 90

HS score prior to trainin

Figure 1. Baseline HS score and difference three months after training (71 participants).

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

both that members of this workforce are willing to learn

about MSM sexual health and that their knowledge and

attitude toward MSM are responsive to this learning.

This study has a number of limitations. The HS, which was

originally developed and validated among college students

in the United States [25], required amendment to preserve

its face validity in a markedly different research context.

Whereas the modified scale was responsive to change with

training, and these changes were robust to sensitivity ana-

lysis excluding modified scale items, the objective meaning of

absolute scores and the convergent and divergent validity

of this scale in this population remain to be established.

Furthermore, although the assessment of training effects

upon knowledge and homophobic sentiment was assessed at

an endpoint long after the training itself, the longer term

effect of training cannot be assumed from this study. Finally,

this study lacked a control group which, ideally, would have

consisted of HCWs not receiving the intervention and HCWs

only participating in the self-directed learning.

We report qualitative narratives among HCWs returning

to their workplace after training but finding little support

for new perspectives amongst (untrained) colleagues [29].

In a recent qualitative assessment of counselling challenges

regarding MSM that are experienced by Kenyan counsellors

and clinicians in coastal Kenya, all felt that lack of training and

supervisory support impacted their ability to serve MSM [33].

These findings may suggest that either longer term support

of trained HCWs and/or more extensive facility-based train-

ing of all staff may be prerequisites to longer term changes in

institutional practice. While knowledge of same-sex practices

is a first step to improve services to MSM, serving MSM in

day-to-day practice will further improve services. Follow-up

of health workers trained in this study is planned and may

provide insights in current care services provided to MSM at

two years post-training. Additionally, although the training

itself was conducted by facilitators from governmental

services that were specially trained for the role, the study

was run by a team who was unusually experienced in work-

ing with Kenyan MSM, which may threaten generalizability to

other settings.

Finally, the ultimate goals of improving knowledge of MSM

sexual health needs and reducing prejudicial attitudes toward

MSM in healthcare settings are to enhance the accessibility

of population-based, public health services to MSM them-

selves. Although surely a prerequisite to accessible HIV pre-

vention, treatment and care for MSM, the extent to which

changes in the attitudes and practices of healthcare providers

are reflected in the perceived and practical accessibility and

acceptability of services to MSM themselves is unknown.

Further study will be required to establish the effect of this

brief intervention on long-term attitudes and professional

practices towards MSM, and what practical contribution such

strategies might make to addressing unmet HIV-related

needs among MSM.

Conclusions

In summary, we developed, implemented and evaluated a

brief training intervention addressing knowledge and atti-

tudes toward MSM and their sexual health needs in Kenya.

The training, which combined self-directed and facilitated

group learning, increased health worker knowledge and

reduced homophobic attitudes up to three months after

training. Scaling up such interventions offers a straightfor-

ward response to the immediate need to support HCWs in

offering accessible and informed services to address the

largely sexual health needs among MSM in Kenya.

Authors’ affiliations

Kenya Medical Research Institute-Wellcome Trust Research Programme,

Kilifi, Kenya;

Department of Public Health, University of Oxford, Oxford,

UK;

National AIDS and STI Control Programme, Nairobi, Kenya;

Desmond

Tutu HIV Foundation, Cape Town, South Africa;

International AIDS Vaccine

Initiative, Nairobi, Kenya;

Department of Global Health, University of

Washington, Seattle, WA, USA;

Department of Community Health, Brown

University, Providence, RI, USA

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Conceived and designed the study: EvdE, NM, AS, DO and EJS. Conducted

data analysis: EvdE, EW, GF, EJS and AS. Contributed to draft of the paper:

EvdE, AS, GF, SG and EJS. All authors contributed to and approved the final

manuscript.

Acknowledgements

We thank Jennifer Kanungi at the KEMRI-HIV Key Populations Studies Cluster,

KEMRI-Wellcome Trust Research Programme (KWTRP), in Kilifi for helping to

organize the training; the International AIDS Vaccine Initiative (IAVI) for finan-

cially supporting the establishment of www.marps-africa.org; and Mary-Anne

Barckhoff, an IAVI consultant, for designing and maintaining the website.

The KWTRP at the Centre for Geographical Medicine Research-Kilifi is sup-

ported by core funding from the Wellcome Trust (grant #077092). Support for

the in-person training and for 74 online participants was provided by a

Research to Practice grant from the United States Agency for International

Development (USAID). The contents are the responsibility of the study authors

and do not necessarily reflect the views of USAID or the US government.

We thank Stef Baral at Johns Hopkins School of Public Health, USA, for support

of our work with MSM in coastal Kenya. Special thanks go to Maria Mulwa,

Ibrahim Fauz, George Kissinger and Rahmah Hashim, district AIDS and STD

coordinators, Kenyan Ministry of Health. This report was published with

permission from KEMRI.

References

1. Graham SM, Mugo P, Gichuru E, Thiong’o A, Macharia M, Okuku HS, et al.

Adherence to antiretroviral therapy and clinical outcomes among young adults

reporting high-risk sexual behavior, including men who have sex with men, in

coastal Kenya. AIDS Behav. 2013;17(4):125565.

2. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe HW. Men who have sex with

men and HIV/AIDS in sub-Saharan Africa. Lancet. 2009;374(9687):41622.

3. Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G, et al. A call

to action for comprehensive HIV services for men who have sex with men.

Lancet. 2012;380(9839):42438.

4. Geibel S, Luchters S, King’Ola N, Esu-Williams E, Rinyiru A, Tun W. Factors

associated with self-reported unprotected anal sex among male sex workers in

Mombasa, Kenya. Sex Transm Dis. 2008;35(8):74652.

5. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV

prevalence, risks for HIV infection, and human rights among men who have

sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;

4(3):e4997.

6. Kajubi P, Kamya MR, Raymond HF, Chen S, Rutherford GW, Mandel JS, et al.

Gay and bisexual men in Kampala, Uganda. AIDS Behav. 2008;12(3):492504.

7. Onyango-Ouma W, Burungi H, Geibel S. Understanding the HIV/STI risks

and prevention needs of men who have sex with men in Nairobi, Kenya.

Washington: Population Council; 2005.

8. Adebajo SB, Eluwa GI, Allman D, Myers T, Ahonsi BA. Prevalence of

internalized homophobia and HIV associated risks among men who have sex

with men in Nigeria. Afr J Reprod Health. 2012;16(4):218.

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

9. Vu L, Tun W, Sheehy M, Nel D. Levels and correlates of internalized homo-

phobia among men who have sex with men in Pretoria, South Africa. AIDS

Behav. 2012;16(3):71723.

10. Knox J, Sandfort T, Yi H, Reddy V, Maimane S. Social vulnerability and HIV

testing among South African men who have sex with men. Int J STD AIDS.

2011;22(12):70913.

11. Ross MW, Kajubi P, Mandel JS, McFarland W, Raymond HF. Internalized

homonegativity/homophobia is associated with HIV-risk behaviours among

Ugandan gay and bisexual men. Int J STD AIDS. 2013;24(5):40913.

12. Ross MW, Berg RC, Schmidt AJ, Hospers HJ, Breveglieri M, Furegato M,

et al. Internalised homonegativity predicts HIV-associated risk behavior in

European men who have sex with men in a 38-country cross-sectional study:

some public health implications of homophobia. BMJ Open. 2013;3(2):

e001928.

13. Centre for the Right to Health. Assessing the HIV/AIDS burden among men

who have sex with men in Abuja, Nigeria. Lagos, Nigeria: CRH; 2008.

14. Lane T, Stuthers SH, Hamilton R, Gray G, McIntyre J. HIV risk behaviours

among black MSM in Johannesburg, South Africa. XV International Conference

on AIDS. Poster Exhibition - Abstract no. WePeD6267. Bangkok, Thailand; 2004.

15. Rispel L, Metcalf MC, Cloete A, Reddy V. You become afraid to tell them

you are gay: availability and utilisation of health services by men who have sex

with men (MSM) in the Johannesburg/Thekwini Men’s Study (JEMS). Journal of

Public Health Policy. 2011;32. doi: 10.1057/jphp.2011.29:S137-S151.

16. Baral S, Scheibe A, Sullivan P, Trapence G, Lambert A, Bekker LG, et al.

Assessing priorities for combination HIV prevention research for men who have

sex with men (MSM) in Africa. AIDS Behav. 2013;17(Suppl 1):S609. doi:

10.1007/S10461-012-0202-5.

17. Halperin DT. Heterosexual anal intercourse: prevalence, cultural factors,

and HIV infection and other health risks, Part I. AIDS Patient Care STDS. 1999;

13(12):71730.

18. Semugoma P, Nemande S, Baral SD. The irony of homophobia in Africa.

Lancet. 2012;380(9839):3124.

19. Sanders EJ, Okuku HS, Smith AD, Mwangome M, Wahome E, Fegan G, et al.

High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads

following seroconversion among MSM. AIDS. 2013;27(3):43746.

20. Price MA, Rida W, Mwangome M, Mutua G, Middelkoop K, Roux S, et al.

Identifying at-risk populations in Kenya and South Africa: HIV incidence in

cohorts of men who report sex with men, sex workers, and youth. J Acquir

Immune Defic Syndr. 2012;59(2):18593.

21. Geibel S, van der Elst EM, King’ola N, Luchters S, Davies A, Getambu EM,

et al. ‘‘Are you on the market?’’: a capture-recapture enumeration of men who

sell sex to men in and around Mombasa, Kenya. AIDS. 2007;21(10):1349 54.

22. Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al. E-

learning in medical education in resource constrained low- and middle-income

countries. Hum Resour Health. 2013;11(1):4.

23. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical

education. Acad Med. 2006;81(3):20712.

24. Brown B, Duby Z, Schiebe A, Sanders E, editors. Men who have sex with

men: an introducory guide for health care workers in Africa. Revised edition.

Cape Town, South Africa: Desmond Tutu HIV Foundation; 2011.

25. Wright LE, Adams HE, Bernat JA. Development and validation of the

homophonbia scale. J Psychopathol Behav Assess. 1999;21(4):33747.

26. BBC News. Gay pride and prejudice in Kenya [Internet]. 2010 [cited 2013

Mar 28]. Available from: http://www.bbc.co.uk/news/10320057

27. Smith AD. Men who have sex with men in sub-Saharan Africa: a case study

in Kenya. Nuffield Department of Population Health & St. Catherine’s College,

University of Oxford; 2013. Thesis submitted towards fulfillment of the degree

of Doctor of Philosophy.

28. National AIDS Control Council, Office of the President, Kenya, 2008.

UNGASS 2008 - Country Report for Kenya. NACC, Nairobi.

29. van der Elst EM, Gichuru E, Omar A, Kanungi J, Duby Z, Midoun M, et al.

Experiences of Kenyan health care workers providing services to men who have

sex with men: qualitative findings from a sensitivity training program. J Int

AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18741.

30. Sharma A, Bukusi E, Gorbach P, Cohen CR, Muga C, Kwena Z, et al. Sexual

identity and risk of HIV/STI among men who have sex with men in Nairobi.

Sex Transm Dis. 2008;35(4):3524.

31. Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. ‘‘They see you as

a different thing’’: the experiences of men who have sex with men with

healthcare workers in South African township communities. Sex Transm Infect.

2008;84(6):4303.

32. Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15(6):108897.

33. Taegtmeyer M, Davies A, Mwangome M, van der Elst EM, Graham SM,

Price MA, et al. Challenges in providing counselling to MSM in highly stig-

matized contexts: results of a qualitative study from Kenya. PLoS One. 2013;

8(6):e64527.

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18748

http://www.jiasociety.org/index.php/jias/article/view/18748 | http://dx.doi.org/10.7448/IAS.16.4.18748

Research article

A cross-sectional assessment of the burden of HIV and associated

individual- and structural-level characteristics among men who

have sex with men in Swaziland

Stefan D Baral

§,1

, Sosthenes Ketende

, Zandile Mnisi

, Xolile Mabuza

, Ashley Grosso

, Bhekie Sithole

Sibusiso Maziya

, Deanna L Kerrigan

, Jessica L Green

, Caitlin E Kennedy

and Darrin Adams

Corresponding author: Stefan D Baral, Key Populations Program, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of

Public Health, E7146, 615 N. Wolfe Street, Baltimore, MD, USA. Tel: 1 410 502 8975. Fax: 1 410 614 8371. (sbaral@jhsph.edu)

Abstract

Introduction: Similar to other Southern African countries, Swaziland has been severely affected by HIV, with over a quarter of its

reproductive-age adults estimated to be living with the virus, equating to an estimate of 170,000 people living with HIV. The last

several years have witnessed an increase in the understanding of the potential vulnerabilities among men who have sex with

men (MSM) in neighbouring countries with similarly widespread HIV epidemics. To date, there are no data characterizing the

burden of HIV and the HIV prevention, treatment and care needs of MSM in Swaziland.

Methods: In 2011, 324 men who reported sex with another man in the last 12 months were accrued using respondent-driven

sampling (RDS). Participants completed HIV testing using Swazi national guidelines as well as structured survey instruments

administered by trained staff, including modules on demographics, individual-level behavioural and biological risk factors, social

and structural characteristics and uptake of HIV services. Population and individual weights were computed separately for each

variable with a data-smoothing algorithm. The weights were used to estimate RDS-adjusted univariate estimates with 95%

bootstrapped confidence intervals (BCIs). Crude and RDS-adjusted bivariate and multivariate analyses were completed with HIV

as the dependent variable.

Results: Overall, HIV prevalence was 17.6% (n50/284), although it was strongly correlated with age in bivariate- [odds ratio

(OR) 1.2, 95% BCI 1.151.21] and multivariate-adjusted analyses (adjusted OR 1.24, 95% BCI 1.141.35) for each additional year

of age. Nearly, 70.8% (n34/48) were unaware of their status of living with HIV. Condom use with all sexual partners and

condom-compatible-lubricant use with men were reported by 1.3% (95% CI 0.09.7).

Conclusions: Although the epidemic in Swaziland is driven by high-risk heterosexual transmission, the burden of HIV and the HIV

prevention, treatment and care needs of MSM have been understudied. The data presented here suggest that these men have

specific HIV acquisition and transmission risks that differ from those of other reproductive-age adults. The scale-up in HIV

services over the past decade has likely had limited benefit for MSM, potentially resulting in a scenario where epidemics of HIV

among MSM expand in the context of slowing epidemics in the general population, a reality observed in most of the world.

Keywords: public health; men who have sex with men (MSM); Africa; HIV; Swaziland; epidemiology.

Received 8 June 2013; Revised 26 August 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 Baral SD et al; licensee International AIDS Society.This is an Open Access article distributed under the terms of the Creative Commons Attribution

3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Introduction

Swaziland is a small, land-locked, lower-middle-income coun-

try that is surrounded by South Africa and Mozambique;

it has a population of approximately 1.1 million people and

a life expectancy at birth of approximately 48 years [1].

Similar to other Southern African countries, Swaziland has

been severely affected by HIV, with over a quarter of its

reproductive-age adults (1549) estimated to be living with

the virus, equating to an estimate of 170,000 people living

with HIV [2]. Moreover, the incidence of HIV appears to have

peaked in 19981999 at 4.6% [95% confidence interval (CI)

4.274.95], according to estimates by the Joint United

Nations Programme on HIV/AIDS (UNAIDS), while in 2009 it

was estimated to be 2.7% (95% CI 2.23.1%) [36]. There

appear to have been further declines in incidence according

to 6054 person-years of follow-up data from 18,154 people

followed from December 2010 to June 2011 as part of the

Swaziland HIV Incidence Measurement Survey (SHIMS) long-

itudinal cohort. Overall incidence was approximately 2.4%

(95% CI 2.12.7%), with incidence estimated to be 3.1% (95%

CI 2.63.7) among women as compared to 1.7% (95% CI 1.3

2.1) among men [7]. Indeed, women and girls have been

more burdened with HIV than men throughout the history of

the HIV epidemic in Swaziland, with the HIV prevalence

among women 1524 in 2006 being estimated to be 22.6%

compared to 5.9% among age-matched men and boys [5].

The 2009 Swaziland Modes of Transmission study char-

acterized major drivers of incident HIV infections to be

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

multiple concurrent partnerships before and during marriage

as well as low levels of male circumcision [8]. These risk

factors were confirmed in the SHIMS study, with risk factors

for incident HIV infections among both men and women

including not being married or living alone, having higher

numbers of sex partners and having serodiscordant or

unknown HIV status partners [7]. There are no known HIV

prevalence estimates for key populations in Swaziland, in-

cluding female sex workers (FSW) or men who have sex with

men (MSM) [9,10]. The 2009 Swazi Modes of Transmission

Study indicates that both sex work and malemale sexual

practices are reportedly infrequent and assumed to be minor

drivers of HIV risks in the setting of a broadly generalized HIV

epidemic. However, the prevalence of these risk factors has

not been measured in the HIV surveillance systems that

are used to inform the Modes of Transmission Surveys [11].

The last several years have witnessed an increase in the

understanding of the potential vulnerabilities among these

same key populations through targeted studies including

MSM in neighbouring countries with similarly widespread

HIV epidemics [12,13].

The largest body of data is available from South Africa,

where the first study completed in 1983 of 250 MSM

demonstrated a high prevalence of HIV, syphilis and hepatitis

B virus [14]. More recently, a study of rural South African men

found that approximately 3.6% of men studied (n46)

reported a history of having sex with another man [15]. Among

these men, HIV prevalence was 3.6 times higher than among

men not reporting male partners (95% CI 1.013.0, p0.05)

[16]. There have also been several targeted studies of MSM

in urban centres across South Africa that consistently high-

light a population of men who have specific risk factors for

HIV acquisition and transmission and limited engagement in

the continuum of HIV care [17 19]. Relatively recent studies

from other countries, including Lesotho, Malawi, Namibia and

Botswana, have shown similar diverse populations of MSM

[16,20,21]. Diversity among populations of MSM across

Southern Africa manifests through diverse sexual orientations

and practices ranging from those who are gay identified, with

primarily male sexual partners, to those who are straight

identified, with both male and female sexual partners [22].

Diversity has also been measured in the range of HIV-

related risk practices among MSM, including understanding

of the HIV acquisition and transmission risks associated

with unprotected anal intercourse and of the levels of

use of condoms and condom-compatible lubricants (CCLs)

[23].

To better characterize vulnerabilities and HIV prevention,

treatment and care needs among MSM in Swaziland, a cross-

sectional assessment was completed to provide an unbiased

estimate of the prevalence of HIV and syphilis among adult

MSM in Swaziland. This study was completed in equal

collaboration with the Swaziland National AIDS Program

(SNAP) in the Ministry of Health. This study further sought to

describe the significant correlates of prevalent infections,

including individual behavioural characteristics, and describe

social and structural HIV-related factors and risks for HIV

infection among MSM.

Methods

Sampling

MSM in Swaziland were recruited via respondent-driven

sampling (RDS), a peer referral sampling method designed

for data collection among hard-to-reach populations [24].

Potential participants were required to be at least 18 years

of age, report anal sex with another man in the previous

12 months, be able to provide informed consent in either

English or siSwati, be willing to undergo HIV and syphilis

testing and possess a valid recruitment coupon.

Survey administration and HIV testing

All participants completed face-to-face surveys and received

HIV and syphilis tests on site. Surveys were administered by

trained members of the research staff and lasted approxi-

mately one hour. The study was completely anonymous and

did not collect any identifiable information; we used verbal

rather than signed consent to further ensure anonymity.

Questions on socio-demographics (e.g., age, marital status

and education), behavioural HIV-related risk factors (e.g., HIV-

related knowledge, attitudes and risk behaviours) and struc-

tural factors (e.g., stigma, discrimination and social cohesion)

were included [25]. HIV and syphilis tests were conducted by

trained phlebotomists or nurses, according to official Swazi

guidelines. Test results, counselling and any necessary treat-

ment (for syphilis) and/or referrals (for HIV) were provided on

site. Participant surveys and test results were linked using

reproducible, yet anonymous, 10-digit codes.

Analytical methods

Population and individual weights were computed separately

for each variable by the data-smoothing algorithm using

RDS for Stata [26]. The weights were used to estimate RDS-

adjusted univariate estimates with 95% bootstrapped con-

fidence intervals (BCIs). Crude bivariate regression analyses

were also conducted to assess the association of HIV status

with demographic variables as well as a selection of variables

either expected or shown to be associated with HIV status in

the literature. All demographic variables were then included

in the initial multivariate logistic regression model regardless

of the estimated strength of their crude bivariate association

with HIV status. Non-demographic variables were included

in the initial multivariate model if the chi-square pvalue

of association with HIV status was 50.25 in the bivariate

analyses. Most of the demographics variables, however,

dropped out of the final model after controlling for other

independent variables.

Because regression analyses of RDS data using sample

weights are complicated due to the fact that weights are

variable-specific [27], RDS-adjusted bivariate and multivariate

analyses were conducted using individualized weights that

were specific to the outcome variable (i.e., HIV status) [27].

The adjusted odds ratio (aOR) estimates were not statistically

different from the unadjusted estimates in the bivariate

analyses, although some slight differences were observed in

the multivariate analyses. Thus, only the unadjusted odds

ratios (ORs) are reported for bivariate analyses, while both

are presented in Table 1 for multivariate analyses. All data

processing and analyses were conducted using Stata 12.1 [28].

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

Missing data

Eleven out of the 324 participants were excluded from this

analysis due to missing data on key RDS-related variables.

There were 29 out of 313 participants with missing data on at

least one variable used in the multivariate analyses. Only two

variables had data missing for more than three participants:

age at first sex with another man (nmissing4) and knowl-

edge about the type of anal sex position that puts you most

at risk of HIV infection (nmissing6). Two of the 29 parti-

cipants with missing data were living with HIV; thus, the effec-

tive crude HIV prevalence used in the multivariate model

was 17.6% (50/284) versus 16.6% (52/313) without missing

data, and RDS-adjusted 13.4% (95% BCI: 7.919.7; homo-

phily: HIV0.0991, HIV0.134) versus 12.7% (BCI:

7.318.1; homophily: HIV0.0899, HIV0.1358)

Although the total number of cases with missing data is not

very small (9.3%: 29/313), the number missing by variable is

very small. Due to the small change in HIV prevalence in the

analysis sample compared to the complete sample as shown

in this article, no effort was made to impute missing data. The

29 cases were excluded in the multivariate regression models.

Sample size calculation

The sample size was calculated based on the ability to detect

significant differences in condom use among MSM living with

HIV and those not living with HIV. There were no known

estimates of condom use among MSM in Swaziland, but

previous studies of MSM from nearby countries estimated

that consistent condom use during anal sex with other

men among MSM is approximately 50% [19]. In addition,

Table 1. Sociodemographic characteristics of a sample of men who have sex with men in Swaziland in 2011

Variable Categories N

Crude

percentage

RDS-adjusted

percentage

95%

confidence

interval

Homophily

(1to1)

Age in years Under 21 94 30.0 36.3 27.4 45.2 0.199

2125 142 45.4 45.1 36.3 53.8 0.143

2630 56 17.9 12.0 7.2 16.7 0.148

31 and older 21 6.7 6.7 2.9 10.4 0.026

Education level Some secondary, high school

or lower

108 34.5 44.8 35.6 53.9 0.104

Completed secondary or high

school

133 42.5 40.4 32.4 48.4 0.119

Post-high-school vocational

training or higher

72 23.0 14.8 9.4 20.2 0.180

Employment status Unemployed 97 32.3 30.7 22.5 38.9 0.189

Employed 101 33.7 27.5 19.5 35.5 0.203

Student 102 34.0 41.8 32.6 51.0 0.001

Marital status with a

woman

Married or cohabitating 13 4.2 1.8 0.1 3.5 0.018

Single, never married 298 95.8 98.2 96.5 99.9 1.423

Current housing

tenure

Renting place 92 29.4 27.7 20.6 34.9 0.046

Own place 51 16.3 18.3 12.0 24.6 0.126

Staying with someone 101 32.3 34.8 27.1 42.5 0.119

Family 42 13.4 10.6 5.6 15.5 0.201

Other 27 8.6 8.6 4.5 12.8 0.095

Urban or rural origin Urban 192 61.5 61.0 52.6 69.5 0.101

Rural 120 38.5 39.0 30.5 47.4 0.172

Number of children Zero 274 87.8 89.5 84.7 94.2 0.174

One or more 38 12.2 10.5 5.8 15.3 0.115

Gender Identification Man 225 72.6 82.5 76.9 88.1 0.29

Woman 79 25.5 15.7 10.4 20.9 0.17

Both 6 1.9 1.8 0.0 3.9 0.018

Sexual orientation

identification

Gay or homosexual 198 63.5 56.3 48.0 64.6 0.242

Bisexual 109 34.9 40.5 32.3 48.6 0.062

Heterosexual or straight 5 1.6 3.2 0.0 7.4 0.096

Age at first sex with a

man

Under 21 years 238 77.0 77.6 70.7 84.6 0.110

21 and above 71 23.0 22.4 15.4 29.3 0.083

Ever been to jail or

prison?

No 276 88.2 86.8 81.4 92.1 0.216

Yes 37 11.8 13.2 7.9 18.6 0.157

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

a systematic review and meta-analysis of the literature on be-

havioural interventions targeting MSM have demonstrated

that behavioural interventions can increase reported condom

use by approximately 16.5% in all risk categories of MSM

[29,30]. Thus, this study was powered on the assumption that

those who have received information about preventing HIV

infection from other men would have a 16.5% increase in

reported consistent condom use. A power analysis demon-

strated that with 80% power, we would require 160 partici-

pants. Estimates of appropriate design effects for RDS have

varied in the literature, and we used a design effect of 2, plan-

ning for the accrual of 324 MSM [31]. This sample size faci-

litates the detection of significant differences in HIV-related

protective practices, such as consistent condom use, and tar-

geted HIV-prevention measures, and is sufficient for key social

factors such as experiences with stigma and discrimination.

Ethics

The study received approval for research on human partici-

pants from both the National Ethics Committee of Swaziland

as well as the Institutional Review Board of the Johns

Hopkins Bloomberg School of Public Health.

Results

Three hundred and twenty-four men were accrued from six

seeds over a range of between 1 and 14 waves of accrual,

with the largest recruitment chain including 123 participants.

As shown in Table 2, the majority of men sampled were

under 30 years of age, with a mean age of 23.1 and a mode

of 22. The crude sample was relatively educated, although

highly educated men were oversampled in this study when

comparing the crude results to RDS-adjusted results (un-

adjusted 23.0% and adjusted 14.8%). Most of the study

participants had never been married (98.2%, 95% CI 96.5

99.9), with only 13 men reporting either cohabitating with a

woman or being married to a woman. Similarly, only about

one in 10 men reported having children (10.5%, 95% CI 5.8

15.3). Notably, the majority of the sample of participants did

not self-identify as straight or heterosexual, with approxi-

mately two-thirds reporting being gay and one-third report-

ing being bisexual. When asked about gender identification,

nearly a quarter of the sample reported identifying as a

woman, although the adjusted proportion was 15.7% (95% CI

10.420.9). More than one-tenth of men reported having

been to jail or prison (13.2%, 95% CI 7.918.6). Among 71

men aged 1819, the HIV prevalence was 0%, compared to

8.8% (n6/68) among participants aged 2021, 15% (n9/

60) among participants aged 2223, 21.4% (n12/56)

among participants aged 2426, and finally 43.1% (n25/

58) among participants aged 2743 (data not shown). In

total, 29.2% (n14/48) of participants living with HIV

reported previously being told that they had HIV, although

four participants not found to be living with HIV reported

being given this diagnosis.

The majority of men had multiple male sexual partners

over the past 12 months (57.9%, 95% CI 49.866.0). More-

over, most study participants had multiple main sexual

partners, or boyfriends, over the past 12 months (82.9%,

95% CI 76.489.3) (Table 3). About one-third of participants

reported having had both male and female sexual partners in

the previous 12 months (35.7%, 95% CI 27.743.6). Approxi-

mately one-half of the participants reported always using

condoms during sex, although significant numbers of men

reported both unprotected insertive and receptive anal inter-

course in the past 12 months. Condom use was not sig-

nificantly different between main and casual male or female

partners. Overall, safe sex with other men, defined as always

using condoms and water-based lubricants over the last

12 months, was not common, with 12.6% (95% CI 7.612.6)

measured to report this behaviour. Safe sex, defined as

condom use with all sexual partners over the last 12 months,

was significantly higher with female partners (at 40.0% in the

crude assessment) than with male partners (pB0.05). Over-

all, safe sex with all sexual partners was uncommon and was

reported by 4.3% (RDS-adjusted 1.3%, 95% CI 0.09.7).

Knowledge of basic questions related to safe sex for MSM,

including sexual positioning, type of sexual act and lubricant

use, was low, with 11.2% (RDS-adjusted 9.1%, 95% CI 5.2

13.0) of participants providing correct answers.

Table 4 demonstrates levels of service uptake, with evi-

dence of statistically significantly lower levels of access to

targeted services focused on preventing HIV transmission via

sex between men as compared to sex between men and

women (pB0.05 for both). Notably, only about half of the

sample was somewhat or very worried about HIV. Just under

half of the men who had symptoms of a sexually transmitted

infection (STI) were tested in the previous 12 months, with

7.8% (95% CI 3.911.7) diagnosed in this same time frame.

About half of the sample had been tested for HIV in the

previous 12 months (50.7%, 95% CI 43.259.2), including

some who were tested more than one time. Reports of any

experienced rights violations related to sexual practices, in-

cluding denial of care, police-mediated violence and physical

or verbal harassment, were reported by about half of the

sample, although perceived rights violations related to sexual

orientation (fear of seeking healthcare and fear of walking

in the community) were more common, with 79.6% (95% CI

73.785.5) calculated to report this. Disclosure of sexual

practices to healthcare workers was reported by one-quarter

of the sample (25.0%, 95% CI 19.031.0), whereas about half

of the participants (44.0%, 95% CI 36.451.7) had reported

disclosure of sexual practices to a family member.

HIV prevalence was strongly correlated with age in both

bivariate analyses (OR 1.23, 95% BCI 1.151.21) for each year

of age and multivariate-adjusted analyses (aOR 1.24, 95% BCI

1.141.35) (Table 1). Other statistically significant associations

with HIV in adjusted analyses included identifying as the

female gender, having ever been to jail or prison, having lower

numbers of casual partners, being diagnosed with an STI in

the last 12 months and having easier access to condoms.

Discussion

In the country with the highest HIV prevalence in the world,

this study describes the burden of HIV and associated

characteristics among MSM who were accrued using RDS.

Interpreting the prevalence of HIV among MSM and its

relationship with the widespread and generalized female-

predominant epidemic in Swaziland is challenging on a

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

Table 2. HIV-related sexual and drug risk factors among MSM in Swaziland

Variable Categories N

Crude

percentage

RDS-adjusted

percentage 95% CI

Number of male sexual partners

in the past 12 months

1 103 33.0 42.1 34.0 50.2

2 68 21.8 20.3 14.7 26.0

3 70 22.4 20.3 14.2 26.5

471 22.8 17.2 11.7 22.7

Number of main male partners

in the past 12 months

1 37 11.8 17.1 10.7 23.6

2 183 58.5 57.2 49.7 64.7

3 61 19.5 18.5 13.0 24.1

432 10.2 7.1 3.9 10.4

Number of male casual sexual partners

in the past 12 months

None 132 42.4 46.6 39.0 54.2

12 127 40.8 41.1 33.8 48.5

352 16.7 12.3 7.7 16.8

Number of female sexual partners

in the past 12 months

None 198 64.3 53.6 44.9 62.4

1 52 16.9 19.5 12.5 26.5

2 29 9.4 15.1 8.7 21.6

329 9.4 11.8 6.2 17.4

Number of both male and female sex partners

in the past 12 months

Only male 221 70.6 64.3 56.4 72.3

Male and female 92 29.4 35.7 27.7 43.6

In general, how often have you used a condom

in the past six months?

Never or almost never 30 9.7 11.5 6.0 17.0

Sometimes 79 25.6 27.0 19.7 34.4

Almost always 58 18.8 18.9 12.9 24.9

Always 141 45.8 42.5 34.7 50.3

Had unprotected insertive anal sex

in the past 12 months

No 190 60.9 55.5 46.8 64.2

Yes 122 39.1 44.5 35.8 53.2

Had unprotected receptive anal sex

in the past 12 months

No 211 68.7 69.8 62.7 76.8

Yes 96 31.3 30.2 23.2 37.3

Condom use with main male partners

in the past 12 months

Not always 137 47.2 51.9 41.8 62.0

Always 153 52.8 48.1 38.0 58.2

Condom use with casual male partners

in the past 12 months

Not always 54 17.3 16.6 10.2 23.0

Always 150 47.9 46.1 38.6 53.6

No casual partner 109 34.8 37.3 29.8 44.9

Condom use with regular female partners

in the past 12 months

Not always 47 49.5 61.8 41.3 82.3

Always 48 50.5 38.2 17.7 58.7

Condom use with casual female partners

in the past 12 months

Not always 31 45.6 55.6 25.2 86.0

Always 37 54.4 44.4 14.0 74.8

Used water-based lubricant (WBL)

in the past 12 months

No 203 64.9 76.3 69.8 82.8

Uses WBL 110 35.1 23.7 17.2 30.2

Safe sex with men (condoms and water-based

lubricant) in the past 12 months

Does not 257 82.1 87.4 82.4 92.4

Does 56 17.9 12.6 7.6 17.6

Safe sex with women (condoms) in the

past 12 months

Does not 66 60.0 75.3 60.5 90.0

Does 44 40.0 24.7 10.0 39.5

Safe sex with both men and women

in the past 12 months

Does not 104 95.7 98.7 90.3 100.0

Does 6 4.3 1.3 0.0 9.7

Injected illicit drugs in the past

12 months

No 304 97.1 97.7 96.1 99.3

Yes 9 2.9 2.3 0.7 3.9

Used non-injection illicit drugs in the

past 12 months

No 203 65.1 66.4 58.5 74.3

Yes 109 34.9 33.6 25.7 41.5

Used alcohol in the last month None 121 39.0 36.1 28.7 43.5

At least one day 189 61.0 63.9 56.5 71.3

Which is the safest lubricant to

use during anal sex?

Non-WBL 128 49.8 63.5 53.6 73.4

WBL 129 50.2 36.5 26.6 46.4

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

number of levels. The significant association between HIV and

age suggests that the expanding epidemic among MSM in

Swaziland is not new and represents cumulative HIV acquisi-

tion risk exposures. The burden of HIV among all men aged

1519 is approximately 2% in Swaziland, increasing to 12.4%

among those aged 2024 and up to 44.9% among those aged

3539. While the participants in our study were relatively

young, the HIV prevalence was consistent with that of

general reproductive-age men until age 2426, when the

prevalence of HIV among age-matched MSM appears to be

higher than that of other men sampled as part of the Swazi

DHS study (Figure 1) [2]. Given that relatively few men

in our sample reported female sexual partners, their HIV

acquisition and transmission risks are likely different from

those of other men in Swaziland and potentially more related

to anal intercourse. Conversely, Swaziland may be among a

small number of countries where even the low acquisition

risks associated with insertive penile-vaginal intercourse is

counterbalanced by the significantly higher HIV prevalence

among women, resulting in significant acquisition risks as-

sociated with sex with women. However, the idea that

acquisition risk for MSM primarily related to sex with other

men is reinforced by the results that condom use was lower

with male sexual partners than with female sexual partners.

Condoms being used more frequently during sex with

women as compared to sex with other men have been ob-

served in other studies of MSM across Sub-Saharan Africa

and provide an argument against MSM being a population

that bridges the HIV epidemic from within their sexual

networks to lower risk heterosexual networks [19,20,32,33].

However, to answer this question, phylogenetic studies and

the characterization of sexual networks are needed to better

describe patterns of HIV transmission.

Participants were far more likely to have received infor-

mation about preventing HIV infection during sex with

women as compared to sex with other men. This lack of

access to or uptake of information, education and commu-

nication services has resulted in participants in this study

having a limited knowledge base of the sexual risks asso-

ciated with same-sex practices. Primarily, participants incor-

rectly believed that unprotected penile-vaginal intercourse

was associated with the highest risk of HIV transmission,

consistent with earlier studies of MSM across Sub-Saharan

Africa. Numerous studies have shown the opposite: HIV is

far more efficiently transmitted during anal intercourse as

compared to vaginal intercourse [13,34]. There was also

limited knowledge related to the importance of water-based

lubricants being CCLs, which is especially important during

anal intercourse given the absence of physiological lubrica-

tion in the anal canal. The importance of CCL was under-

scored as ultimately being the determining factor in just six

study participants reporting safe sex with all partners in this

study. Thus, while there is significant provision of general

HIV-prevention messaging across Swaziland, there has been

limited information focused on educating MSM on how to

prevent HIV acquisition and transmission during sex with

other men. Data suggest that starting with simple and proven

approaches, including peer education programmes, is neces-

sary to educate these men about their risks and protec-

tive behavioural strategies [35]. However, these approaches

will likely not be sufficient to change the trajectory of HIV

epidemics given the high risk of infection associated with

unprotected anal intercourse with non-virally suppressed

HIV serodiscordant partners. Thus, moving forward necessi-

tates assessing the feasibility of combination approaches

that integrate advances such as antiretroviral-mediated pre-

exposure prophylaxis and universal access to antiretroviral

therapy for people living with HIV [13]. However, the success

or failure in achieving coverage with these HIV prevention,

treatment and care approaches among MSM will, in part, be

determined by the level of stigma affecting MSM.

It is now broadly accepted that addressing the needs of

people living with HIV is vital to protect their own health as

well as prevent onward transmission of HIV [36]. In addition,

mean and total viral loads in a population have been linked to

population-level transmission rates of HIV [37]. Only a quarter

of the men living with HIV in this study were aware of

their diagnosis, demonstrating the need to increase HIV

testing, linkage to CD4 testing, and antiretroviral treatment

and adherence support for those who are eligible. A recent

Table 2 (Continued )

Variable Categories N

Crude

percentage

RDS-adjusted

percentage 95% CI

Can you get HIV from sharing a needle

to inject illegal drugs?

No 3 1.0 1.0 0.2 2.2

Yes 303 99.0 99.0 97.8 100.2

What type of sex puts you most at risk

for HIV infection?

Vaginal 110 35.1 43.7 36.1 51.2

Anal 75 24.0 18.2 12.4 24.0

Oral 25 8.0 8.6 3.8 13.5

Which type of anal sex position puts

you most at risk for HIV infection?

Insertive (top) 63 20.5 24.0 17.1 30.9

Receptive (bottom) 95 30.9 31.1 23.8 38.4

Insertive and

receptive anal sex

carry equal risk

149 48.5 44.9 36.6 53.2

Answered all of the above correctly No 278 88.8 90.9 87.0 94.8

Yes 35 11.2 9.1 5.2 13.0

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

systematic review and meta-analysis of self-testing for HIV in

both low- and high-risk populations demonstrated that self-

testing was both appropriate and associated with increased

uptake of HIV tests [38]. This may be especially relevant in

the Swazi context, where fear of seeking healthcare was

prevalent, suggesting the need to study new strategies to

overcome barriers to HIV testing among MSM in Swaziland,

including leveraging community networks and potentially

self-testing [39]. In this study, being a person living with HIV

was associated with lower numbers of casual male partners in

the last 12 months. This relationship appeared to be stronger

among those who were aware of their status, although it was

not statistically significant because of limited numbers. In

addition, these data are consistent with earlier research

findings that simply being made aware of one’s status of living

with HIV can change one’s sexual practices to decrease

onward transmission [40]. This further argues for implemen-

tation science research focused on optimal strategies to scale-

up HIV testing for MSM in Swaziland [41].

Over one-quarter of participants in this study self-identified

as women, and this was independently associated with living

with HIV. There is nearly a complete dearth of information

related to HIV among transgender people across Sub-Saharan

Africa [42,43]. However, where transgender people have been

studied, they have been found to be the most vulnerable to

HIV acquisition because of increased structural barriers to HIV

prevention, treatment and care services and because of

increased sexual risks, including unprotected receptive anal

intercourse [43]. Given the limited information available

about transgender people, transgender was assessed in this

Table 3. Service uptake and structural HIV risks among MSM in Swaziland

Variable Categories N

Crude

percentage

RDS-adjusted

percentage 95% CI

Participated in any meetings related to HIV/AIDS

in the past 12 months

No 175 55.9 58.5 51.1 65.8

Yes 138 44.1 41.5 34.2 48.9

Participated in any meetings related to HIV/AIDS

in the past 12 months related to MSM

No 243 78.4 83.5 78.1 88.8

Yes 67 21.6 16.5 11.2 21.9

Received information about preventing HIV

from sex with women in last 12 months

No 60 19.4 20.9 14.5 27.2

Yes 250 80.6 79.1 72.8 85.5

Received information about preventing HIV

from sex with other men in last 12 months

No 226 72.4 78.5 72.9 84.1

Yes 86 27.6 21.5 15.9 27.1

Level of concern related to HIV in the

last 12 months

Not worried 86 27.6 31.8 24.9 38.8

Not very worried 61 19.6 18.2 12.1 24.2

Somewhat worried 52 16.7 16.8 10.0 23.6

Very worried 113 36.2 33.2 26.0 40.3

Access to condoms: do you have them

when you need them?

No access 3 1.0 1.0 -0.4 2.3

Difficult or little access 58 18.6 16.8 11.2 22.4

Some access 36 11.6 12.6 7.2 18.0

Very easy access 214 68.8 69.6 61.9 77.4

Symptoms of sexually transmitted infection (STI)

in the past 12 months

No 247 79.2 78.5 72.4 84.6

Yes 65 20.8 21.5 15.4 27.6

Tested for STI in the past 12 months No 266 87.2 86.1 80.5 91.7

Yes 39 12.8 13.9 8.3 19.5

Diagnosis of STI in the past 12 months No 287 92.6 92.2 88.3 96.1

Yes 23 7.4 7.8 3.9 11.7

Been tested for HIV in the past 12 months No 144 46.0 49.3 41.8 56.8

Yes, once 94 30.0 31.2 24.2 38.2

Yes, 1 75 24.0 19.5 13.5 25.4

Ever been told that you have HIV? No 284 94.0 95.7 92.5 98.9

Yes 18 6.0 4.3 1.1 7.5

Perceived human rights violations No 63 20.1 20.4 14.5 26.3

Yes 250 79.9 79.6 73.7 85.5

Experienced human rights violations No 152 48.6 48.9 40.5 57.2

Yes 161 51.4 51.1 42.8 59.5

Disclosure to healthcare workers No 218 69.6 75.0 69.0 81.0

Yes 95 30.4 25.0 19.0 31.0

Disclosure to family No 146 46.6 56.0 48.3 63.6

Yes 167 53.4 44.0 36.4 51.7

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

study as both a sexual orientation and a gender identity.

There was a significant disconnect between these two as no

participants self-identified as being transgender. Ultimately,

further ethnographic research is needed to better understand

the HIV-prevention needs of transgender people in Swaziland.

Having been to jail was also independently associated with

living with HIV among MSM in this study. Globally, incarcera-

tion has been shown to be an important risk factor for HIV,

given the limited access to HIV-prevention services such as

condoms and CCLs, the interruption of HIV treatment as well

as exposure to higher risk sexual partners [4447]. While

further research is needed on same-sex practices within jails,

there is likely a need to provide HIV-prevention services for

men in Swazi prison settings [47].

The methods employed in this study have several limita-

tions. While RDS is an effective approach to characterize

asymptotically unbiased estimates intended to approximate

population-based estimates of characteristics in the absence

Table 4. Bivariate and multivariate associations with HIV status among men who have sex with men (MSM) in Swaziland

Bivariate Multivariate crude Multivariate RDS weighted

Variable Categories Estimate [95% CI] Estimate [95% CI]

Weighted

estimate

Weighted

estimate 95% CI

Current age Years 1.23 [1.151.31] 1.24*** [1.141.35] 1.28*** [1.151.43]

Gender Man 1 1 1

Woman 2.14 [0.905.05] 3.96** [1.669.43] 3.23* [1.07 9.71]

Both  

Education level Some secondary, high

school or lower

11 1

Completed secondary or

high school

1.06 [0.442.56] 1.32 [0.54 3.18] 1.51 [0.465.00]

Post-high-school

vocational training or

higher

1.34 [0.473.77] 0.56 [0.20 1.57] 0.62 [0.182.16]

Age at first sex with another

man

Under 21 years 1 1 1

21 and above 2.38 [0.99 5.72] 1.24 [0.493.14] 0.71 [0.18 2.75]

Urban or rural origin Urban 1 1 1

Rural 1.99 [0.914.35] 0.79 [0.341.79] 1.33 [0.453.93]

Ever been to jail or prison? No 1 1 1

Yes 2.75* [1.087.00] 3.00* [1.018.85] 4.37* [1.3813.84]

Diagnosis with an STI other

than HIV in last 12 months

No 1 1 1

Yes 1.57 [0.495.07] 6.26** [1.68 23.39] 4.30* [1.0417.72]

Number of casual male

partners in the last 12

months

None 1 1 1

12 0.51 [0.201.26] 0.33* [0.130.85] 0.26* [0.080.85]

31.12 [0.422.98] 1.04 [0.37 2.95] 0.50 [0.131.97]

Which type of anal sex

position puts you most at

risk for HIV infection?

Insertive (top) 1 1 1

Receptive (bottom) 0.91 [0.332.54] 0.49 [0.171.42] 0.53 [0.142.08]

Insertive and receptive

anal sex carry equal risk

0.96 [0.372.54] 0.39 [0.14 1.06] 1.43 [0.326.41]

In the past 12 months, have

you used any non-

injectable drug that was

not prescribed?

No 1 1 1

Yes 0.84 [0.3751.865] 0.356* [0.1360.935] 0.366 [0.121.11]

What kind of access to

condoms do you have

when you need them?

No access 1 1 1

Difficult or little access 0.13 [0.0072.380] 0.008** [0.0000.224] 0.031 [0.0011.23]

Some access 0.36 [0.021 6.115] 0.043 [0.0021.022] 0.170 [0.015.35]

Very easy access 0.49 [0.0347.054] 0.043* [0.0020.893] 0.264 [0.00710.020]

In the past 30 days, how

many days did you drink at

least one drink of alcohol?

Zero 1 1 1

At least one day 1.30 [0.553.07] 1.81 [0.744.41] 2.19 [0.607.96]

Analysis sample 284 284

Exponentiated coefficients; 95% CI 95% confidence intervals; *pB0.05, **pB0.01, ***pB0.001.

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

of a meaningful sampling frame, there are still several

uncertainties in the most appropriate tools for interpretation

of these data [48]. Moreover, the sample of men accrued here

was relatively young, consistent with recruitment challenges

observed in other studies of MSM across sub-Saharan Africa.

While we conducted significant engagement with older MSM,

fear associated with inadvertent disclosure limited their

participation in the study. Only with improved social environ-

ments will more information about the needs of older MSM

become available in difficult contexts [49]. In addition, while

RDS was used to accrue a diverse sample, all of the seeds were

connected with Rock of Hope, a newly registered organization

serving the needs of lesbian, gay, bisexual and transgender

populations in Swaziland. We thus may have overestimated

actual service uptake among MSM in Swaziland.

Conclusions

The implementation of the research project was guided by

recent guidelines to inform HIV-related research with MSM in

rights-constrained environments [50]. While these men had

not been previously engaged in research on HIV prevention,

treatment and care, the success of this study highlights

the fact that accrual of this population is both feasible and

informative for the HIV response in Swaziland. Moreover,

the interconnected social and sexual networks leveraged

for accrual can likely serve to disseminate HIV-prevention

approaches via MSM throughout the country. While the

epidemic in Swaziland is one driven by heterosexual trans-

mission, the burden of HIV and the HIV prevention, treatment

and care needs of MSM have been understudied, and these

men have been underserved in the context of large-scale

programmes [51]. The data presented here suggest that these

men have specific HIV acquisition and transmission risks that

differ from those of other reproductive-age adults. Encoura-

gingly, Swaziland has seen declines in the rate of new HIV

infections over the last seven years, and these declines are

related to HIV testing and treatment scale-up [5]. However,

the increase in HIV services likely has had limited benefit for

MSM, which may result in a scenario where epidemics of MSM

expand in the context of slowing epidemics in the general

population a reality observed in most of the world [13].

Authors’ affiliations

Key Populations Program, Department of Epidemiology, Center for Public

Health and Human Rights, Johns Hopkins Bloomberg School of Public Health,

Baltimore, MD, USA;

Swaziland National AIDS Program (SNAP), Ministry of

Health and Social Welfare, Mbabane, Swaziland;

Rock of Hope, Manzini,

Swaziland;

Department of Health Sciences, University of Stellenbosch,

Stellenbosch, South Africa;

Department of Health, Behavior and Society, Johns

Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;

Population

Services International, Swaziland;

Department of International Health, Johns

Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

SDB, ZM, JLG, CEK, DLK and DA conceptualized and designed the study.

Implementation was led by ZM, DA and XM, with significant support by SM

and BS. SDB, AG, JLG, SK and CEK developed the analytic strategy and

completed data analysis. SDB, CEK and DA drafted the manuscript, with all

authors providing critical inputs for the interpretation of the results. All

authors have read and approved the final manuscript.

Acknowledgements

Primarily, we would like to acknowledge the study participants, who completed

this study with little personal benefit and risk of inadvertent disclosure of sexual

orientation. We want to especially acknowledge the team from PSI Swaziland,

including Babazile Dlamini and Edward Okoth. In addition, the Swaziland Most-

at-Risk Populations (MARPS) technical working group provided significant

technical support, as did multiple agencies within the Swazi government. We

want to thank all members of the Rock of Hope organization, who provided

significant community support for this study that made it possible. From USAID

Swaziland, Jennifer Albertini and Natalie Kruse-Levy are acknowledged for

consistent support throughout the project; and from USAID Washington, Alison

Cheng and Cameron Wolf provided technical support. We would like to

acknowledge Andrea Vazzano for careful review of the manuscript.

Funding

This work was supported by USAIDjProject SEARCH, Task Order No. 2, funded

by the US Agency for International Development under Contract No. GHH-I-00-

07-00032-00, beginning 30 September 2008, and supported by the President’s

Emergency Plan for AIDS Relief.

References

1. World B. Gross national income per capita 2008, Atlas method and PPP.

Geneva: World Bank; 2009.

2. Macro I, Swaziland Central Statistics Office. Swaziland: demographic and

health survey 20062007. Mbabane, Swaziland: USAID; 2008.

3. UNAIDS. AIDS epidemic update 2009. Geneva: UNAIDS; 2009.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60+

HIV Prevalence

Age in years

DHS–Sampled Men MSM

Figure 1. Prevalence of HIV by age among Swazi men who have sex with men, 2011.

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

4. UNAIDS. Report on the global AIDS epidemic. Geneva: United Nations;

2012.

5. UNAIDS, NERCHA, Ministry of Health S, UNICED. Monitoring the declaration

of the commitment on HIV and AIDS (UNGASS): Swaziland country report.

Mbabane, Swaziland: UNGASS; 2010.

6. Ghys PD, Saidel T, Vu HT, Savtchenko I, Erasilova I, Mashologu YS, et al.

Growing in silence: selected regions and countries with expanding HIV/AIDS

epidemics. AIDS. 2003;17(Suppl 4):S4550.

7. Reed JB, Justman J, Bicego G, Donnell D, Bock N, Ginindza H, et al.,

editors. Estimating national HIV incidence from directly observed serocon-

versions in the Swaziland HIV Incidence Measurement Survey (SHIMS)

longitudinal cohort (FRLBX02). XIX International AIDS Conference, 2012 July

24; Washington, DC: International AIDS Society; 2012.

8. Swaziland National Emergency Response Council on HIV, AID. Swaziland:

HIV prevention response and modes of transmission analysis. Mbabane,

Swaziland: World Bank; 2009.

9. UNFPA, UNAIDS, Swaziland M, Swaziland National Emergency Response

Council on HIV, AIDS. Situation analysis on commercial sex work in Swaziland.

NovemberDecember 2007. Mbabane, Swaziland: UNFPA; 2007.

10. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection

among men who have sex with men in low- and middle-income countries

20002006: a systematic review. PLoS Med. 2007;4(12):e339.

11. Baral S, Phaswana-Mafuya N. Rewriting the narrative of the epidemiology

of HIV in sub-Saharan Africa. Sahara J. 2012;9(3):127 30.

12. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden

of HIV among female sex workers in low-income and middle-income countries:

a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(7):

53849.

13. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet. 2012;380(9839):36777.

14. Sher R. HIV infection in South Africa, 1982 1988 a review. S Afr Med J.

1989;76(7):3148.

15. Jewkes R, Dunkle K, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Factors

associated with HIV sero-positivity in young, rural South African men. Int J

Epidemiol. 2006;35(6):145560.

16. Baral S, Adams D, Lebona J, Kaibe B, Letsie P, Tshehlo R, et al. A cross-

sectional assessment of population demographics, HIV risks and human

rights contexts among men who have sex with men in Lesotho. J Int AIDS

Soc. 2011;14:36.

17. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in peri-urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

18. Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W,

et al. High HIV prevalence among men who have sex with men in Soweto,

South Africa: results from the Soweto Men’s study. AIDS Behav. 2011;15:

62634.

19. Rispel LC, Metcalf CA. Breaking the silence: South African HIV policies and

the needs of men who have sex with men. Reprod Health Matters.

2009;17(33):13342.

20. Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al.

Bisexual concurrency, bisexual partnerships, and HIV among Southern

African men who have sex with men. Sex Transm Infect. 2010;86(4):

3237.

21. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV

prevalence, risks for HIV infection, and human rights among men who have

sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;

4(3):e4997.

22. Reddy V, Sandfort T, Rispel L. From social silence to social science: same-

sex sexuality, HIV & AIDS and gender in South Africa. Johannesburg, South

Africa: HSRC Press; 2009.

23. Baral S, Scheibe A, Sullivan P, Trapence G, Lambert A, Bekker LG, et al.

Assessing priorities for combination HIV prevention research for men who have

sex with men (MSM) in Africa. AIDS Behav. 2013;17:S609.

24. Heckathorn DD. Respondent-driven sampling: a new approach to the study

of hidden populations. Soc Probl. 1997;44(2):17499.

25. Baral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological

model: a tool to guide the assessment of the risks and risk contexts of HIV

epidemics. BMC Public Health. 2013;13(1):482.

26. Schonlau M, Liebau E. Respondent-driven sampling. Stata J. 2012;12(1):21.

27. Johnston L, O’Bra H, Chopra M, Mathews C, Townsend L, Sabin K, et al.The

associations of voluntary counseling and testing acceptance and the perceived

likelihood of being HIV-infected among men with multiple sex partners in a

South African township. AIDS Behav. 2010;14(4):92231.

28. StataCorp. Stata statistical software: release 11.1. College Station, TX:

StataCorp LP; 2010.

29. Beyrer C, Wirtz A, Walker D, Johns B, Sifakis F, Baral S. The global HIV

epidemics among men who have sex with men (MSM): epidemiology, pre-

vention, access to care, costs, and human rights. Bank W, editor. Washington,

DC: World Bank; 2011.

30. Johnson WD, Diaz RM, Flanders WD, Goodman M, Hill AN, Holtgrave D,

et al. Behavioral interventions to reduce risk for sexual transmission of HIV

among men who have sex with men, Cochrane Database Syst Rev. 2008;3:

CD001230.

31. Salganik MJ. Variance estimation, design effects, and sample size calcula-

tions for respondent-driven sampling. J Urban Health. 2006;83(6 Suppl):

98112.

32. Onyango-Ouma W, Birungi H, Geibel S. Understanding the HIV/STI risks

and prevention needs of men who have sex with men in Nairobi, Kenya.

Nairobi: Population Council; 2005.

33. Onyango-Ouma W, Birungi H, Geibel S. Engaging men who have sex with

men in operations research in Kenya. Cult Health Sex. 2009;11:82739.

34. Baggaley RF, White RG, Boily MC. HIV transmission risk through anal inter-

course: systematic review, meta-analysis and implications for HIV prevention.

Int J Epidemiol. 2010;39:104863.

35. Sullivan PS, Carballo-Dieguez A, Coates T, Goodreau SM, McGowan I,

Sanders EJ, et al. Successes and challenges of HIV prevention in men who have

sex with men. Lancet. 2012;380(9839):38899.

36. Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum

of engagement in HIV care and its relevance to test-and-treat strategies for

prevention of HIV infection. Clin Infect Dis. 2011;52(6):793800.

37. Das M, Chu PL, Santos GM, Scheer S, Vittinghoff E, McFarland W, et al.

Decreases in community viral load are accompanied by reductions in new HIV

infections in San Francisco. PLoS One. 2010;5(6):e11068.

38. Pant Pai N, Sharma J, Shivkumar S, Pillay S, Vadnais C, Joseph L, et al.

Supervised and unsupervised self-testing for HIV in high- and low-risk

populations: a systematic review. PLoS Med. 2013;10(4):e1001414.

39. Trapence G, Collins C, Avrett S, Carr R, Sanchez H, Ayala G, et al. From

personal survival to public health: community leadership by men who have sex

with men in the response to HIV. Lancet. 2012;380(9839):40010.

40. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk

sexual behavior in persons aware and unaware they are infected with HIV in

the United States: implications for HIV prevention programs. J Acquir Immune

Defic Syndr. 2005;39(4):44653.

41. Padian NS, Holmes CB, McCoy SI, Lyerla R, Bouey PD, Goosby EP.

Implementation science for the US President’s Emergency Plan for AIDS Relief

(PEPFAR). J Acquir Immune Defic Syndr. 2011;56(3):199203.

42. Jobson G. Transgender in Africa: invisible, inaccessible, or ignored?

SAHARA J. 2012;9(3):1603.

43. Baral SD, Poteat T, Stromdahl S, Wirtz AL, Guadamuz TE, Beyrer C.

Worldwide burden of HIV in transgender women: a systematic review and

meta-analysis. Lancet Infect Dis. 2012;13(3):21422.

44. Wolfe MI, Xu F, Patel P, O’Cain M, Schillinger JA, St Louis ME, et al.

An outbreak of syphilis in Alabama prisons: correctional health policy and

communicable disease control. Am J Public Health. 2001;91(8):1220 5.

45. Beyrer C, Jittiwutikarn J, Teokul W, Razak MH, Suriyanon V, Srirak N, et al.

Drug use, increasing incarceration rates, and prison-associated HIV risks in

Thailand. AIDS Behav. 2003;7(2):15361.

46. Harris RM, Sharps PW, Allen K, Anderson EH, Soeken K, Rohatas A. The

interrelationship between violence, HIV/AIDS, and drug use in incarcerated

women. J Assoc Nurses AIDS Care. 2003;14(1):2740.

47. Kyomya M, Todyrs KW, Amon JJ. Laws against sodomy and the HIV

epidemic in African prisons. Lancet. 2012;380(9839):3102.

48. Salganik MJ. Commentary: respondent-driven sampling in the real world.

Epidemiology. 2012;23(1):14850.

49. Semugoma P, Nemande S, Baral SD. The irony of homophobia in Africa.

Lancet. 2012;380(9839):3124.

50. AMFAR, Center for Public Health and Human Rights JHSoPH. Respect,

protect, fulfill: best practices guidance in conducting HIV research with gay,

bisexual, and other men who have sex with men (MSM) in rights-constrained

environments. New York: IAVI; 2011.

51. AMFAR, Center for Public Health and Human Rights, JHSPH. Achieving an

AIDS-free generation for gay men and other MSM in Southern Africa.

Washington, DC: AMFAR; 2013.

Baral SD et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18768

http://www.jiasociety.org/index.php/jias/article/view/18768 | http://dx.doi.org/10.7448/IAS.16.4.18768

Research article

Outcomes of a community-based HIV-prevention pilot programme

for township men who have sex with men in Cape Town,

South Africa

Elizabeth Batist*

,§,1

, Benjamin Brown*

, Andrew Scheibe

, Stefan D Baral

and Linda-Gail Bekker

Corresponding author: Elizabeth Batist, Anzio Road Observatory, 7925 Cape Town, South Africa. Tel: 27 21 650 6969. (Elizabeth.batist@hiv-research.org.za)

*These authors contributed equally to the work.

Abstract

Introduction: Men who have sex with men (MSM) in Cape Town’s townships remain in need of targeted HIV-prevention services.

In 2012, a pilot community-based HIV-prevention programme was implemented that aimed to reach MSM in five Cape Town

townships, disseminate HIV-prevention information and supplies, and promote the use of condoms and HIV services.

Methods: Convenience sampling was used to recruit self-identified MSM who were 18 years old or older in five Cape Town

townships. The six-month pilot programme trained five community leaders who, along with staff, provided HIV-prevention

information and supplies to MSM through small-group meetings, community-based social activities and inter-community events.

After the completion of the pilot programme, in-depth interviews and focus group discussions (FGDs) were conducted with a

subset of conveniently sampled participants and with each of the community leaders. Qualitative data were then analyzed

thematically.

Results: Overall, 98 mostly gay-identified black MSM consented to participate, 57 community-based activities were facilitated

and 9 inter-community events were conducted. Following their enrolment, 60% (59/98) of participants attended at least one

pilot activity. Of those participants, 47% (28/59) attended at least half of the scheduled activities. A total of 36 participants took

part in FGDs, and five in-depth interviews were completed with community leaders. Participants reported gaining access

to MSM-specific HIV-prevention information, condoms and water-based lubricant through the small-group meetings. Some

participants described how their feelings of loneliness, social isolation, self-esteem and self-efficacy were improved after taking

part.

Conclusions: The social activities and group meetings were viable strategies for disseminating HIV-prevention information,

condoms and water-based lubricant to MSM in this setting. Many MSM were also able to receive social support, reduce social

isolation and improve their self-esteem. Further research is needed to explore factors affecting attendance and the sustainability

of these activities. Perspectives of MSM who did not attend pilot activities regularly were not equally represented in the final

qualitative interviews, which could bias the findings. The use of community-based activities and small-group meetings should be

explored further as components to ongoing HIV-prevention interventions for MSM in this setting.

Keywords: community-based; self-esteem; stigma; African men who have sex with men (MSM); social network; outreach.

Received 22 May 2013; Revised 17 September 2013; Accepted 2 October 2013; Published 2 December 2013

Copyright: –2013 Batist E et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution

3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Introduction

Men who have sex with men (MSM) remain significantly

affected by HIV in South Africa, with a reported HIV preva-

lence between 10 and 50% [16]. MSM risk is affected by

many individual and structural factors, including unprotected

anal intercourse (UAI), substance use and discriminatory

healthcare [213]. Although MSM-competent HIV-prevention

services are expanding across the country, there are still

several gaps [1,1417]. Reaching MSM with these services

is critical for their well-being and is considered essential

in addressing the broader HIV epidemic in South Africa

[1,6,10,18].

Community-based approaches have been used to reach

MSM and other marginalized populations with HIV-prevention

services in many settings [1821]. These programmes utilize

peer education and the facilitation of safe social spaces to

provide HIV education, address stigma, address behavioural

risks and link individuals into HIV testing or care [1825].

Similar strategies have been used to reach Southern African

MSM with HIV research, HIV-prevention information, and HIV

counselling and testing [2632].

In South Africa, MSM-specific service providers and non-

governmental organizations (NGOs), including the Desmond

Tutu HIV Foundation (DTHF), engage MSM through both peer

education and the use of safe spaces within township com-

munities [13,16,30,33,34]. In 2008, the DTHF used several of

these strategies to recruit MSM in Cape Town for the Global

iPrEX study, a biomedical HIV-prevention clinical trial [29,35].

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

MSM social networks in Cape Town’s townships have been

described as including key individuals who establish spaces

where other MSM are able to socialize safely [36]. As a result

of the iPrEX study, links with these individuals and multiple

MSM social networks were formed. This led the DTHF to

design and conduct a pilot community-based HIV-prevention

programme with MSM in these networks.

This pilot programme aimed to reach MSM in various

townships through the use of community-based social acti-

vities and meeting groups. The programme was designed to

disseminate HIV-prevention information and supplies, and

promote the use of condoms and HIV service uptake. This

article presents an overview of the project methods, a

description of the participants and results from follow-up

interviews and focus group discussions (FGDs) conducted

with a subset of participants.

Methods

The pilot HIV prevention programme was implemented with

MSM in five predominantly black African townships in greater

Cape Town. Three structured components were included:

(i) group meetings were held regularly with small gatherings

of MSM to facilitate knowledge exchange and disseminate

prevention supplies, (ii) community-based activities were

facilitated to provide opportunities for MSM group bonding

and (iii) inter-community activities were conducted to pro-

mote integration and diversity. All pilot activities took place

over a six-month period between May and October 2012.

Community leader selection and participant recruitment

Townships were selected based on high HIV prevalence,

which was identified through previous HIV surveillance data,

and on the presence of MSM social networks identified

through recruitment for the Global iPrEX study.

From each township, one MSM community leader was

identified from previous research [30]. Community leaders

participated in the planning and facilitation of all activi-

ties, disseminated HIV-prevention information and provided

healthcare referrals to MSM in their community. They were

at least 18 years old; had demonstrated leadership qualities;

were respected, trusted and socially prominent among their

MSM peers; and lived in a township where pilot activi-

ties were planned. The initial community leader team was

selected and trained between January and April 2012.

Self-identified MSM were then recruited to take part in the

pilot programme using convenience sampling through peer out-

reach workers and venue-based contact. All participants were

18 years old or older, were born male, were reported to have

sex with men and lived in a township where the pilot was

taking place. Each participant completed a self-administered

paper questionnaire that collected baseline data on their

demographic characteristics, sexual practices, health-seeking

behaviour and access to services. Participants were offered

voluntary HIV counselling and testing by trained staff and

were provided with information about MSM-competent

healthcare facilities. Participants who tested HIV positive

were provided counselling and referrals. Participant recruit-

ment was completed in 57 days between May and July 2012.

Implementation of the pilot programme

Community leaders received initial two-day training and

completed follow-up trainings throughout the pilot. Trainings

included education on sexually transmitted infections and

HIV but primarily focused on developing leadership skills

such as effective communication, managing complicated

social situations, strategic planning and goal setting, and

encouraging healthy social norms.

Group meetings took place every 12 weeks and were

held in private and safe venues in each township. Meetings

were semi-structured and included both social and educa-

tional components such as debates about current events,

training on condoms and water-based lubricant, and discus-

sions on HIV-prevention strategies. Meetings were facilitated

by a community leader and staff member but guided mostly

by the participants, who were encouraged to take owner-

ship and direction of each meeting. Condoms, water-based

lubricant and HIV-prevention information were disseminated

during these meetings.

Community-based activities were designed based on parti-

cipant feedback and used to supplement group meetings in

each township. Community-based activities included sports

(hiking, netball and soccer), dance competitions, drag pag-

eants and debates. Similar to group meetings, HIV-prevention

discussions were integrated into each of the activities. Light

refreshments were provided to participants at all meetings

and activities.

Finally, inter-community activities, which brought together

at least two different MSM groups, were conducted at least

once a month. These activities were similar in scope to the

community-based activities but were organized to promote

knowledge sharing and socializing between MSM from

different townships. MSM participants were provided with

transport to attend inter-community activities.

Data collection and analysis

Quantitative methods

Quantitative data from the baseline questionnaires were

analyzed using STATA version 11.0 (StataCorp LP, College

Station, TX). Numerical variables were explored using mea-

sures of central tendency and distribution [medians and

interquartile ranges (IQRs)], and categorical variables were

explored using proportions and frequency tables.

Participants were requested to sign an attendance register

at each activity. Registers were entered into a secure Excel

spreadsheet and linked to the participant’s ID. Attendance

was measured for each participant and defined as the total

number of events attended by the total offered to that

participant.

Qualitative methods

After completion of the pilot activities, IDIs with each of the

community leaders and FGDs with a subset of participants

were conducted in December 2012. A purposive sampling

strategy was initially used to equally represent MSM who

attended regularly and those who did not. However, many

participants who did not attend regularly were unable to be

contacted, resulting in the remaining FGD slots being filled by

participants who attended more frequently.

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

All FGDs and one IDI were conducted in private facilities

within each community, and four IDIs were conducted at the

research offices of the DTHF. All FGDs and IDIs were conducted

by one of the two trained facilitators and supported by a

research assistant who took notes. The FGDs and IDIs were

conducted predominantly in English, but participants were

also encouraged to use the language they felt most comfor-

table speaking. A semi-structured interview guide was used

to explore participants’ perceptions and experiences with

community life, project activities, stigma, healthcare services

and HIV.

Audio recordings from each FGD and IDI were transcribed,

and all participant-identifying information was removed.

Qualitative data were analyzed using the framework ap-

proach. Predetermined themes based on the interview guide

questions were used to structure the initial framework, and a

coding scheme was developed to identify emerging themes.

Two analysts reviewed transcripts from one FGD and IDI

together to establish consistency in coding. After this, the

analysts each reviewed the remainder of the transcripts

individually. Comparisons and discussion between analysts

were used to reach consensus on final themes.

Ethical consideration

Written informed consent was obtained from all participants,

who were reminded that they would be able to take part

in any community-based activities regardless of their decision

to participate in this pilot study. Participants taking part

in the follow-up FGDs and IDIs were informed that their

responses would remain anonymous and would not affect

their involvement in future initiatives from the DTHF or other

organizations. They received R50 (approximately US$5.00)

as reimbursement for their time and transport. Community

leaders were provided with a monthly stipend of R800

(approximately US$90.00) as compensation for transport

costs and their time spent in project activity planning and

implementation. Ethical approval for this project was ob-

tained from the University of Cape Town’s Faculty of Health

Sciences Human Research Ethics Committee.

Results

Participant baseline characteristics

In total, 98 MSM consented to participate and completed a

baseline questionnaire. The majority of participants were

black African (95%, 93/98) and gay identified (82.3%, 79/96).

The median age of participants was 24.5 with an IQR of

2129. Over half of the participants had received secondary

education (64.3%, 63/98), and less than one-third (28.6%, 28/

98) reported current employment. High-risk sexual beha-

viours including UAI and transactional sex were reported by

MSM in each community. In total, 26% (25/98) of partici-

pants reported having had at least one female sexual partner

in the last six months. A summary of participant baseline

characteristics is presented in Table 1.

Community activities

MSM community groups were established in 5 townships,

and 57 community-based activities including group meet-

ings and 9 inter-community activities were conducted be-

tween May and October 2012. Participant enrolment varied

between communities, with 33 participants enrolled from

Community A, 24 from Community C, 17 from Community D,

14 from Community B and 10 from Community E. Less

than half of the participants (44%, 43/98) had previously

engaged in other MSM-focused activities or research prior to

the pilot.

Attendance registers were not collected from 7 of the 57

community meetings and from one of the inter-community

events due to an administrative error. A median of eight

(IQR 69) MSM attended the 50 community meetings with

attendance registers, and the eight inter-community activities

were attended by a median of 20 (IQR 19.2521.5) MSM.

Condoms and lubricants were distributed during 23 activities

and were available on request throughout the duration of the

project. Following their enrolment, 60% (59/98) of partici-

pants attended at least one pilot activity. Of those partici-

pants, 47% (28/59) attended at least one-half of the

scheduled activities. A summary of attendance is shown in

Table 2.

Follow-up interviews and focus group discussions

Of the 100 MSM who took part in the pilot activities,

36 also participated in follow-up FGDs, and each of the five

community leaders completed an IDI. Efforts were made to

include participants with varying degrees of attendance;

however, there was substantial loss to follow-up of the

participants who had lower attendance. Overall, more than

half of the participants from the FGDs attended 50% or more

of the scheduled activities.

HIV knowledge, testing and services

Many participants described the benefits of receiving MSM-

specific HIV-prevention knowledge through the meeting

groups, while others reported having already received this

information elsewhere:

I didn’t know everything about preventing HIV or

AIDS but once I joined the group I’ve got more

information and then that information I used it ....

I was worried at first you know until I joined the

group and then it influenced me in a kinda way to

be strong don’t have to be worried since you know

that mhm theres so many things which can protect

you from getting HIV. (FGD1)

Participant attitudes towards HIV testing at local health

clinics remained consistently negative because of the insensi-

tive or discriminatory care many had previously received.

Despite reactions to local healthcare clinics, participants were

aware and made use of MSM-competent healthcare services

throughout the duration of the pilot project.

Use of water-based lubricants

Prior to the pilot, participants reported limited access to free

water-based lubricant and described using petroleum-based

lubricant during anal sex. Many participants described that

their use of condoms remained inconsistent, particularly with

regular sexual partners. Other participants continually re-

ferred to an improved knowledge and use of water-based

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

lubricant as a result of taking part in the pilot activities,

specifically the group meetings:

But we came to the group and they taught us that

you have to use specific lube ... before we can have

sex. (FGD 2)

Social support and personal development

Participants explained how their feelings of loneliness and

social isolation were improved after taking part in the pilot

because it created opportunities to socialize with other MSM.

This seemed particularly true in communities with little

existing MSM activities.

... You are able to, you know, be yourself and the

sense of getting to be yourself and also giving the

feeling that you are not alone .... (FGD 1)

... It’s nice when we had events, especially in our

communities, because there’s nothing happening so

Table 1. Participant baseline characteristics

Variable Community A Community B Community C Community D Community E Total

Total enrolled 33 14 24 17 10 98

Age median (IQR) 22 (1925) 23 (2027) 29.5 (24.536) 26 (2428) 25 (2131) 24.5 (21 29)

Race

Black 97% (32/33) 100% (14/14) 83% (20/22) 100% (17/17) 80% (8/10) 95% (93/98)

Coloured 3% (1/33) 0% 17% (4/22) 0% 10% (1/10) 6% (6/98)

White 0% 0% 0% 0% 10% (1/10) 1% (1/98)

Sexual orientation

Gay 78.8% (26/33) 100% (14/14) 77% (17/22) 77% (13/17) 90% (9/10) 82.3% (79/96)

Bisexual 3.0% (1/33) 0% 22% (5/22) 17.6% (3/17) 10% (1/10) 10.4% (10/96)

Straight 18.2% (6/33) 0% 0% 5.8% (1/17) 0% 7.3% (7/96)

Currently employed 24.2% (8/33) 28.6% (4/14) 20.8% (5/24) 35.2% (6/17) 50% (5/10) 28.6% (28/98)

Education

Primary 3% (1/33) 0% 4% (1/24) 0% 10% (1/10) 3% (3/98)

Secondary 60.6% (20/33) 50% (7/14) 79% (19/24) 53% (9/17) 80% (8/10) 64.3% (63/98)

Tertiary 36.4% (12/33) 50% (7/14) 17% (4/24) 47% (8/17) 10% (1/10) 33% (32/98)

Number of male partners in last year,

median (IQR)

9(215) 5.5 (36) 6 (2.515) 3 (25) 1 (1 3) 5 (210)

Number of female partners in last six

months, median (IQR)

2(12) 1 (11) 2.5 (2 13) 1.5 (13.5) 4.5 (2 7) 2 (1 3)

Number of male partners had UAI with

in the last six months, median (IQR)

2.5 (16) 1 (12) 2 (1 6) 1 (1 2) 1.5 (1 2) 2 (14)

Ever-reported STI 18.8% (6/32) 61.5% (8/13) 37.5% (9/25) 35.3% (6/17) 20% (2/10) 32.3% (31/96)

Transactional sex

Paid for 24.2% (8/33) 0% 20.8% (5/24) 23.5% (4/17) 20% (2/10) 19% (19/98)

Received 24.2% (8/33) 15.4% (2/13) 33% (8/24) 19% (3/16) 20% (2/10) 24% (23/98)

Age of sexual debut, median (IQR) 15 (1416) 17 (1418) 17 (1519) 17.5 (16 20) 18 (1619) 16 (1519)

Ever tested for HIV 90.9% (30/33) 92.8% (13/14) 100% (23/23) 94.4% (16/17) 90.0% (9/10) 93.8% (91/97)

Months since last HIV test, median (IQR) 5 (212) 3 (16) 6 (2 12) 2 (0.886) 7 (710) 4 (212)

Months since last visit to local clinic,

median (IQR)

3(26.5) 2 (13) 2 (1 4) 2 (0.755.5) 4 (.2512) 2 (16)

Disclosed orientation to a healthcare

worker

45.5% (15/33) 84.6% (11/13) 65.2% (15/23) 70.6% (12/17) 60% (6/10) 61.5% (59/96)

Ever visited an MSM-friendly clinic 21.2% (7/33) 100% (14/14) 70.8% (17/24) 47.1% (8/17) 30% (3/10) 50% (49/98)

Communication

Owns a cell phone 93.9% (31/33) 92.9% (13/14) 83.3% (20/24) 100% (17/17) 90% (9/10) 91.8% (90/98)

Regular access to the internet 69.7% (23/33) 85.7% (12/14) 41.7% (10/24) 82.4% (14/17) 80% (8/10) 68.4% (67/98)

Sexual partner contact

Via a cell phone chat programme 63.6% (21/33) 57.1% (8/14) 68% (17/25) 72.2% (13/18) 70% (7/10) 66% (66/98)

Via the internet 57.9% (19/33) 64.3% (9/14) 58.3% (14/24) 64.7% (11/17) 40% (4/10) 58% (57/98)

IQR: interquartile range; UAI: unprotected anal intercourse; STI: sexually transmitted infection; MSM: men who have sex with men.

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

much in our community. Especially for gay people

[...] So the moment there is an event some people

think that’s where they come out to explore, ‘‘okay,

I’m not the only one who’s gay’’ .... (FGD 4)

Participants detailed how they gained meaningful social

support from their peers during group meetings in each

township.

When you are having this, such groups, we en-

courage each other, we talk to each other, we giving

each other advice. So it’s quite good. Whatever

problem you experience in life, if you share with

someone, it does help. (FGD 4)

So sometime getting together as township gay

moffies, it builds us ... sometimes you need to

share your story with someone. That is, who will

understand who you are, you understand? Because

sometimes you talk to a person who’s, who’s a

stranger in LGBTI. It doesn’t work. There’s no use of

that because that person will look at you as you are

out of your mind. (FGD 4)

Many participants shared how their self-esteem and

self-efficacy improved during the meeting groups and

community-based activities. For example, participants in

multiple townships noted that they were able to explore

and understand their sexuality, some for the first time:

I have also grown and became quite content with

who I am. Cause at first, before I joined the group,

I was one of those people who were in the closet as

many of us would know. And [...] as the time went

by, I began [to be] interested in to finding out more

about who I am, and why am I gay. (FGD 3)

It really did help, like for me or like, for me my

family. They’re religious people and they hated the

fact that am gay but then I’ve started coming to the

meetings and then I ... I had the guts to tell them

that now am gay .... (FGD 1)

Stigma

Overall, participant opinions about the role that the pilot

programme played in addressing stigma were mixed, but

some participants felt that the pilot activities allowed MSM

to gain greater visibility in their communities.

There were outdoor events. So everybody who was

even passing when we doing these kinds of activities

[outdoor sporting event] were like ‘‘oh my god,

this is quite interesting.’’ Guys playing netball, you

know? [...] we are trying to show the community

that we are there. (FGD 3)

Participants also described how group meetings helped them

to better prepare for and mitigate the effects of stigma and

prejudice.

...People would like to ask question ‘‘why I’m gay?’’

and ‘‘why I’m doing this?’’ ... So I’m sure this

meeting helped me a lot, I mean, to get through -

those kind of answers, you know what I mean?

(FGD2)

If you tell your story, you talk to people then ...

[exhales] ... it’s a burden that you take off your

shoulders .... (FGD 2)

Suggestions to improve HIV programme implementation

Participants offered suggestions for improving the imple-

mentation of the pilot activities. Specifically, they felt that

staff changes should be kept minimal since it was challenging

to develop relationships with new outreach staff. Some

participants also expressed the need for improved efficiency

with inter-community activities, specifically highlighting the

transport and timeliness of other MSM as key barriers.

Overall, participants also shared a willingness to engage their

broader community to address stigma and expressed a need

for activities to do so by targeting other community members

beyond MSM.

Discussion

This article presents the outcomes of a pilot community-

based HIV-prevention programme for township MSM. It is

important to note that while participants described changes

in their behaviour as a result of the pilot, its aim was not

to measure behaviour change. Many factors, including

concurrent programmes, may have influenced participants’

behaviour [14,15]. Taking this into consideration, participant

responses do suggest that this pilot was successful in

achieving some of its primary objectives.

First, the pilot programme successfully engaged MSM from

high-risk networks in five Cape Town townships. Attendance

data suggest that social activities and group meetings were

a feasible method for reaching certain MSM in this pilot;

however, overall attendance varied greatly and included a

large percentage of participants who attended no activities.

This variability may suggest that the pilot activities did not

Table 2. Event attendance per community

Percentage of events

attended

Community 1

participants

Community 2

participants

Community 3

participants

Community 4

participants

Community 5

participants Total

0 16495539

125 5 4 5 4 0 28

2650 4 2 5 2 0 13

5175 3 1 4 2 5 15

76100 5 3 1 4 0 13

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

cater to the interests or needs of all participants, particularly

the unique needs of MSM [37]. Other factors that may

influence attendance have been described and should be

explored further in this context, including feelings of mistrust

and community stigma [33,38].

Second, HIV-prevention information and supplies were

successfully disseminated to MSM during this pilot. Other

studies have described how facilitated social spaces can

result in knowledge gain by encouraging the exchange and

processing of information between peers [39]. Similarly,

MSM in this pilot felt that group meetings created safe

environments to learn about HIV prevention with their peers.

In addition to improving knowledge, increasing access to

water-based lubricants and condoms is also essential for

MSM, particularly in communities where limited or incorrect

lubricant use has been reported [2]. These findings support

previous suggestions to explore the use of small community-

based spaces for lubricant dissemination [40]. Small meeting

groups and social activities should be further explored as

strategies to supplement current lubricant dissemination

strategies for MSM in this setting.

Third, participants reported other meaningful benefits to

this pilot, including improvements in their self-efficacy, self-

esteem and social isolation. Social isolation, poor self-efficacy

and limited social support may play important roles in the

individual risk of MSM, specifically condom negotiation and

lubricant use [10,33,41,42]. Since this study did not aim to

address social isolation or self-efficacy directly, it remains to

be seen if any risk reduction occurred through this pilot as a

result of diminished social isolation or improvements in self-

efficacy. However, these results do support previous recom-

mendations to further explore self-efficacy with township

MSM in HIV-prevention programmes, and they suggest that

community-based group meetings and social activities war-

rant further investigation as feasible methods to do so [41].

Additional research is needed to explore community-based

approaches for condom use and HIV testing in this setting.

HIV testing and condom use are complex behaviours affected

by a multitude of factors, including stigma [10,43]. MSM

in this pilot were supportive of broader community inter-

ventions to reduce stigma, lending further support to

current recommendations for future community-based HIV-

prevention interventions to explore methods that empower

MSM to safely and appropriately address stigma within their

communities [40].

There are limitations to this pilot study. This pilot targeted

black African townships; therefore, these findings cannot be

extrapolated to other groups. MSM who did not attend pilot

activities were not equally represented in the final qualitative

interviews. Their reasons for non-participation may not be

adequately included in these findings. Even though parti-

cipants openly shared suggestions for improving the pro-

gramme, their responses may have been biased towards

discussing positive benefits of the programme in general.

The timeframe of this pilot was brief and cannot address the

sustainability of these activities in the long term.

Taking these limitations into consideration, this community-

based HIV-prevention pilot programme provides useful in-

sights for MSM-specific HIV-prevention programming that

warrant further research. Specifically, small meeting groups

and social activities promoted an enabling environment,

within the context of larger stigmatizing communities, where

MSM were able to receive social support, improve their self-

esteem and gain access to relevant HIV-prevention informa-

tion and supplies.

Conclusions

Results from this pilot programme describe how township-

based MSM can benefit from facilitated social activities and

meeting groups. Results from this pilot programme suggest

that these strategies are a viable method for disseminating

HIV-prevention information, condoms and water-based lubri-

cant. Furthermore, these groups create a supportive environ-

ment in which MSM can learn from each other, explore their

sexual identities and overcome potential barriers to HIV

prevention such as social isolation and low self-esteem. The

use of community-based social activities and facilitated small-

group meetings should be furthered explored as components

to ongoing HIV-prevention interventions for MSM in this

setting.

Authors’ affiliations

Desmond Tutu HIV Foundation, Cape Town, South Africa;

Department of

Epidemiology, Johns Hopkins School of Public Health Baltimore, MD, USA

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

EB, BB and AS were the implementers of this work under supervision of SB and

L-GB. EB and BB led the analysis. The manuscript was written collaboratively

between EB and BB, with input from SB, AS and L-GB. SB and L-GB provided

ongoing support throughout the process of the entire project.

Acknowledgements

The authors extend their sincere thanks to all the study participants who

openly and willingly shared their experiences and insights. They also acknowl-

edge and thank Brian Kanyemba and the community leader team for

supporting data collection and study implementation, Alanna Costelloe-Kuehn

for assisting with data management, and Kate Snyder, Ashley Grosso and

Andrea Vazzano for their additional input and review.

References

1. Council SANA. National strategic plan on HIV, STIs and TB 2012 2016.

Pretoria, South Africa: South African National AIDS Council; 2012.

2. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in peri-urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

3. Burrell E, Mark D, Grant R, Wood R, Bekker L-G. Sexual risk behaviours and

HIV-1 prevalence among urban men who have sex with men in Cape Town,

South Africa. Sex Health. 2010;7(2):14953.

4. Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al.

High HIV prevalence among men who have sex with men in Soweto, South

Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):62634.

5. Rispel LC. HIV prevalence and risk practices among men who have sex with

men in two South African cities. J Acquir Immune Defic Syndr. 2011;57:6976.

6. Sandfort TG, Nel J, Rich E, Reddy V, Yi H. HIV testing and self-reported

HIV status in South African men who have sex with men: results from a

community-based survey. Sex Transm Infect. 2008;84(6):4259.

7. Lane T, Shade SB, McIntyre J, Morin SF. Alcohol and sexual risk behavior

among men who have sex with men in South African township communities.

AIDS Behav. 2008;12(Suppl 4):S7885.

8. Rispel LC, Metcalf CA, Cloete A, Reddy V, Lombard C. HIV prevalence and

risk practices among men who have sex with men in two South African cities. J

Acquir Immune Defic Syndr. 2011;57(1):6976.

9. Dunkle KL, Jewkes RK, Murdock DW, Sikweyiya Y, Morrell R. Prevalence of

consensual male-male sex and sexual violence, and associations with HIV in

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

South Africa: a population-based cross-sectional study. PLoS Med. 2013;10(6):

e1001472.

10. Jobson G, de Swardt G, Rebe K, Struthers H, McIntyre J. HIV risk and

prevention among men who have sex with men (MSM) in peri-urban

townships in Cape Town, South Africa. AIDS Behav. 2013;17(Suppl 1):S1222.

11. Knox J, Sandfort T, Yi H, Reddy V, Maimane S. Social vulnerability and HIV

testing among South African men who have sex with men. Int J STD AIDS.

2011;22(12):70913.

12. Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. ‘‘They see you as a

different thing’’: the experiences of men who have sex with men with

healthcare workers in South African township communities. Sex Transm Infect.

2008;84(6):4303.

13. Scheibe A, Brown B, Duby Z, Bekker LG. Key populations, key solutions: a

gap analysis for key populations and HIV in South Africa, and recommendations

for the National Strategic Plan for HIV/AIDS, STIs and TB (20122016).

Desmond Tutu HIV Foundation, Joint UN Team on HIV and AIDS. 2011.

14. McIntyre JA, Struthers H. HIV and men who have sex with men in South

Africa. AIDS Behav. 2013;17(Suppl 1):S13.

15. Rebe K, Swardt GD, Struthers H, McIntyre J. Towards ‘men who have sex

with men- appropriate’ health services in South Africa. Southern African

Journal of HIV Medicine. 2012;14:527.

16. Africa IS. Rapid situational assessment report: HIV prevention services

for men who have sex with men and capacity building assistance for high

risk, underserved populations in South Africa: The Eastern Cape, Free State,

Kwazulu-Natal, Limpopo & Northern Cape Provinces. Pretoria, South Africa:

Columbia University, International Centre for AIDS care and treatment

Programs (ICAP); 2012.

17. Technical Working group. Operational guidelines for HIV, STI, and TB

programmes for key populations in South Africa. Pretoria, South Africa:

South African National Department of Health; 2012.

18. Trapence G, Collins C, Avrett S, Carr R, Sanchez H, Ayala G, et al. From

personal survival to public health: community leadership by men who have sex

with men in the response to HIV. Lancet. 2012;380(9839):40010.

19. Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-

level HIV prevention intervention for young gay men. Am J Public Health. 1996;

86(8):112936.

20. Jana S, Basu I, Rotheram-Borus MJ, Newman PA. The Sonagachi Project:

a sustainable community intervention program. AIDS Educ Prev. 2004;16(5):

40514.

21. Campbell C, Scott K, Nhamo M, Nyamukapa C, Madanhire C, Skovdal M,

et al. Social capital and HIV competent communities: the role of community

groups in managing HIV/AIDS in rural Zimbabwe. AIDS Care. 2013;25(Suppl 1):

S11422.

22. Beyrer C. Global prevention of HIV infection for neglected populations:

men who have sex with men. Clin Infect Dis. 2010;50(Suppl 3):S108 13.

23. amfAR M. Lessons from the front lines: effective community-led responses

to HIV and AIDS among MSM and transgender populations. New York, NY:

American Foundation for AIDS Research; 2010.

24. Campbell C, Nhamo M, Scott K, Madanhire C, Nyamukapa C, Skovdal M,

et al. The role of community conversations in facilitating local HIV competence:

case study from rural Zimbabwe. BMC Public Health. 2013;13:354.

25. Cornish F, Campbell C. The social conditions for successful peer education:

a comparison of two HIV prevention programs run by sex workers in India and

South Africa. Am J Community Psychol. 2009;44(12):123 35.

26. Beyrer C, Wirtz A, Walker D, Johns B, Sifakis F, Baral S. The global HIV

epidemics among men who have sex with men. Washington, DC: World Bank;

2011.

27. Henry E, Marcellin F, Yomb Y, Fugon L, Nemande S, Gueboguo C, et al.

Factors associated with unprotected anal intercourse among men who have

sex with men in Douala, Cameroon. Sex Transm Infect. 2010;86(2):136 40.

28. Sanders EJ, Graham S, Okuku H, van der Elst E, Muhaari A, Davies A, et al.

HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya.

AIDS. 2008;21(18):251320.

29. Brown B, Burrell E, Scheibe A, Wood R, Bekker LG. Recruitment methods

for enrolling high-risk men who have sex with men into an HIV prevention

clinical trial. 18th International AIDS conference; 2010 July 21; Vienna.

30. Batist E, Brown B, Baral S, Bekker LG. Community engagement program-

ming and HIV prevention: perspectives from men who have sex with men

(MSM) in Cape Town’s township communities. 19th International AIDS

conference; 23 July 2012; Washington, DC.

31. Moreau A, Tapsoba P, Ly A, Niang C, Diop A. Implementing STI/HIV

prevention and care interventions for men who have sex with men in Dakar,

Senegal. Horizons research summary. Washington, DC: Population Council;

2007.

32. Johnson CA, Cameron E. Off the map: how HIV/AIDS programming is failing

same-sex practicing people in Africa. New York: International Gay and Lesbian

Human Rights Commission; 2007.

33. Tucker A, de Swardt G, Struthers H, McIntyre J. Understanding the needs of

township men who have sex with men (MSM) health outreach workers:

exploring the interplay between volunteer training, social capital and critical

consciousness. AIDS Behavior. 2013;17(Suppl 1):S3342.

34. SANAC. LGBT sector report. Pretoria, South Africa: South African National

AIDS Council; 2011.

35. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al.

Preexposure chemoprophylaxis for HIV prevention in men who have sex with

men. N Engl J Med. 2010;363(27):258799.

36. Tucker A. Queer visibilities: space, identity and interaction in Cape Town.

Chichester: Wiley-Blackwell; 2009.

37. Eaton LA, Pitpitan EV, Kalichman SC, Sikkema KJ, Skinner D, Watt MH, et al.

Men who report recent male and female sex partners in Cape Town, South

Africa: an understudied and underserved population. South Africa: an under-

studied and underserved population. 2008;42(7):1299308.

38. Campbell C, Gibbs A, Maimane S, Nair Y. Hearing community voices:

grassroots perceptions of an intervention to support health volunteers in

South Africa. SAHARA J. 2008;5(4):16277.

39. Campbell C, Nair Y, Maimane S. Building contexts that support effec-

tive community responses to HIV/AIDS: a South African case study. Am J

Community Psychol. 2007;39(34):347 63.

40. Jobson G. HIV Prevention for MSM in Cape Town, South Africa: context,

dynamics, and recommendations. Johannesburg, South Africa: ANOVA Health

Institute; 2010.

41. Tucker A, Liht J, de Swardt G, Jobson G, Rebe K, McIntyre J, et al. An

exploration into the role of depression and self-efficacy on township men who

have sex with men’s ability to engage in safer sexual practices. AIDS Care.

2013;25(10):122735.

42. Sandfort T, Yi H, Knox J, Reddy V. Sexual partnership types as determinant

of HIV risk in South African MSM: an event-level cluster analysis. AIDS Behav.

2013;17(Suppl 1):S2332.

43. Kaighobadi F, Konx J, Reddy V, Sandfort T. Age and sexual risk among black

men who have sex with men in South Africa: the mediating role of attitudes

towards condoms. J Health Psychol. 2013.

Batist E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18754

http://www.jiasociety.org/index.php/jias/article/view/18754 | http://dx.doi.org/10.7448/IAS.16.4.18754

Research article

A pilot cohort study to assess the feasibility of HIV prevention

science research among men who have sex with men in

Dakar, Senegal

Fatou Maria Drame

´*

, Emily E Crawford*

, Daouda Diouf

, Chris Beyrer

and Stefan D Baral

§,2

Corresponding author: Stefan D Baral, 615 N. Wolfe Street, Suite E7146, Baltimore, MD 21205, USA. (sbaral@jhsph.edu)

*These authors contributed equally to the work.

Abstract

Introduction: Men who have sex with men (MSM) are disproportionately burdened by HIV in Senegal, across sub-Saharan Africa

and throughout the world. This is driven in part by stigma, and limits health achievements and social capital among these

populations. To date, there is a limited understanding of the feasibility of prospective HIV prevention studies among MSM in

Senegal, including HIV incidence and cohort retention rates.

Methods: One hundred and nineteen men who reported having anal sex with another man in the past 12 months were

randomly selected from a sampling frame of 450 unique members of community groups serving MSM in Dakar. These men were

enrolled in a 15-month pilot cohort study implemented by a community-based partner. The study included a structured survey

instrument and biological testing for HIV, syphilis and hepatitis B virus at two time points.

Results: Baseline HIV prevalence was 36.0% (43/114), with cumulative HIV prevalence at study end being 47.2% (51/108).

The annualized incidence rate was 16% (8/40 at risk for seroconversion over 15 months of follow-up, 95% confidence interval

4.627.4%). Thirty-seven men were lost to follow up, including at least four deaths. Men who were able to confide in someone

about health, emotional distress and sex were less likely to be HIV positive (OR 0.36, pB0.05, 95% CI 0.13, 0.97).

Conclusions: High HIV prevalence and incidence, as well as mortality in this young population of Senegalese MSM indicate a

public health emergency. Moreover, given the high burden of HIV and rate of incident HIV infections, this population appears to

be appropriate for the evaluation of novel HIV prevention, treatment and care approaches. Using a study implemented by

community-based organizations, there appears to be feasibility in implementing interventions addressing the multiple levels of

HIV risk among MSM in this setting. However, low retention across arms of this pilot intervention, and in the cohort, will need to

be addressed for larger-scale efficacy trials to be feasible.

Keywords: HIV; socio-economic status; men who have sex with men; Africa; prevention.

Received 22 May 2013; Revised 30 September 2013; Accepted 9 October 2013; Published 2 December 2013

´FM et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction

The HIV epidemic in Senegal has followed a pattern distinct

from the epidemics observed in Southern and Eastern African

countries such as Kenya and Malawi, with a far more con-

centrated epidemic among key populations such as men who

have sex with men (MSM) and female sex workers [1]. The

Senegalese government launched an early and comprehen-

sive effort to prevent HIV infection in the general population

[2]. This campaign was deemed a success by many and is,

in part, likely responsible for the limited HIV epidemic in the

country, which reports an HIV prevalence of 0.8% among

reproductive age women and 0.5% among men ages 1549

[3,4]. More recently, there has been increased study of social

factors such as unregulated sex work, stigma and discri-

mination targeting those at high risk of HIV acquisition and

transmission, as well as HIV transmission related to same-sex

practices among men [511].

MSM have multiple, intersecting drivers of risk and

have had a consistently higher risk of HIV acquisition and

transmission since the first cases of HIV were discovered

[1,12]. This disproportionate burden of HIV in MSM has also

been observed in Senegal. Studies dating back nearly ten years

have highlighted this disproportionate burden with HIV

prevalence among MSM reported to be 22.4% in 2004 and

21.8% in 2007 [11]. Based on these and other data, Drame

reported that HIV prevalence among MSM is approximately 50

times higher than the prevalence observed among reproduc-

tive age adults in Senegal according to the most recent

demographic and health survey [13]. Finally, the attributable

fraction of HIV infections among MSM in Senegal is high; Van

Griensven et al. estimated that nearly a fifth of prevalent HIV

infections among men in Senegal are among MSM. Collec-

tively, these data reinforce the need to address the HIV

prevention, treatment and care needs of MSM in Senegal [14].

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

The definition for social capital is ‘‘institutions, relation-

ships, attitudes and values that govern interactions among

people and contribute to economic and social development’’

[15]. The importance of social capital has been increasingly

recognized as a major social determinant of health because

of its association with health outcomes including chronic

disease-related morbidity and mortality and, more recently,

sexually transmitted infections [1626]. Specifically, limited

social capital has been associated with higher rates of ex-

change, survival and commercial sex, and associated with a

higher burden of HIV among MSM in Africa [27 30]. HIV

infection has also been associated with low social capital; this

may be particularly relevant for stigmatized groups such as

MSM [3133]. Development of social capital among MSM

has been shown to be limited by enacted stigma [3436].

And discrimination and stigma affecting MSM are well-

documented, not only in Senegal, but throughout sub-

Saharan Africa and more broadly around the world [6,7].

Niang et al. describe the effect that stigma and discrimina-

tion can have on health care-seeking behaviours among MSM

in Senegal [6]. When men perceive or experience stigma and

discrimination in a health care setting, they are less likely to

access health services for STI, resulting in higher rates of

untreated STI within sexual networks, thereby mediating HIV

transmission [37,38].

MSM face additional challenges in countries where sex

between men is criminalized [3]. In Senegal, in 2008, several

health promoters working in HIV prevention were arrested

under suspicion of being homosexual. These arrests, and the

fear of further arrests, had wide-ranging effects on HIV in the

community of MSM in Senegal [39]. In response, many non-

governmental organizations who had been working in the

area of HIV prevention among MSM went into hiding for

their own safety. Those who continued distributing preven-

tion materials such as condoms and water-based lubricants

saw a marked decrease in the number of men accessing their

services. The decreased numbers of men accessing services

aimed at the community of MSM also resulted in a lesser

availability of social support among MSM. Furthermore, and

importantly, health care providers began to fear providing

services to MSM following the arrests. This had grave im-

plications for many HIV-positive MSM, who were no longer

able to access treatment, either because their provider

would no longer see them, or because they feared arrest if

they left their home. Some have said that these arrests set

HIV prevention efforts back ten years [39].

Stigma and discrimination affect HIV risk and social capital

not only by affecting how MSM access prevention and

treatment, but also by curbing the presence of research and

prevention projects targeting this group in Senegal. A small

number of research projects in West Africa has resulted in a

limited understanding of what interventions work in com-

munities of MSM in this region [37]. Interventions are

difficult to implement, particularly given the constrained

legal environment [39]. Community-based organizations of

MSM are those with the closest ties to the community and

the greatest ability to facilitate interventions [40]. However,

these organizations are often not legally registered [13].

Despite these significant challenges, HIV prevention inter-

ventions have been effectively implemented for MSM in

Senegal [11].

For a population where so much information is left

unknown, a cohort study can provide relevant data including

prospectively measured HIV incidence [41]. This research

project had two primary foci. The first was to assess the

feasibility of implementing and retaining participants in

a community-driven HIV prevention study in Senegal. The

second focus was to describe the study participants in terms

of HIV and STI prevalence and incidence, risk behaviours and

indicators of social capital at baseline.

Methods

A prospective cohort study of MSM was conducted from June

2011 to October 2012 in Dakar, Senegal, by members of

a community-based organization. Researchers worked with

MSM Community Organizations to develop a sampling frame

composed of 450 unique individual members of all known

MSM organizations in Dakar. Men eligible for the study were

at least 18 years of age, members of one of the known MSM

organizations in Dakar, had lived in Dakar for at least six

months and reported having anal sex with another man in

the past 12 months.

Ultimately, 119 men were enrolled in the feasibility cohort

study. At baseline, all participants completed an informed

consent process, a structured survey instrument and a

medical examination conducted by an infectious disease

physician. The medical examination included a physical exam

and syndromic diagnosis and treatment of STI, or a referral

for treatment and follow-up if necessary or preferred by

the participants. Participants also provided 10 ml of plasma

for testing for HIV, hepatitis B and syphilis, according to

the Senegalese national testing algorithm [42]. A subset of

the participants also received an exploratory intervention.

Because of the small sample size and high loss to follow

up, the outcomes of this intervention are not statistically

relevant and will not be discussed in this paper.

Follow up

Thirty-seven participants were lost to follow up between T1

(baseline) and T2 (15 months); 14 of these were HIV positive.

At the end of the planned implementation period, the

remaining participants (n82) again underwent a process

of informed consent and completed the same structured

survey instrument. At this time period, T2, 60 participants

presented for a second session of biological testing for HIV,

hepatitis B and syphilis. Whereas at T1, a partner organiza-

tion was able to perform biological testing on-site immedi-

ately following participant surveys, this coordination was

not possible at T2. Participants were required to make an

additional visit to a clinic for collection of biological samples;

22 participants were unable or unwilling to conduct this

additional visit because of inability to pay transportation

costs or other competing issues. Retention support was

provided by Enda Sante

´staff through regular visits or phone

calls throughout the follow up period, depending on the

wishes of the individual.

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

Ethics

All human subjects’ research conducted in accordance

with this study has been reviewed and approved by the

Senegalese National Ethics Committee for Health Research.

Analytic approaches

The collected data were linked using anonymous codes.

Survey data were entered into SPSS, and monitoring data

were collected utilizing Microsoft Excel. All data collected

were cleaned and merged into a single database. Incon-

sistencies found during the data cleaning were reconciled to

the original questionnaires or laboratory forms.

These data were analyzed using STATA Version 12 (College

Station, Texas). Preliminary analysis was conducted using chi

square analysis to determine potential associations of social

capital at baseline. HIV incidence was calculated by dividing

the number of people who seroconverted between T1 and

T2 by the number of participants at risk of HIV acquisition

(tested negative at T1 and returned for testing at T2), and

multiplying this number by person-time. Because of the small

sample size and high rate of loss to follow-up, multivariate

regression models were not used.

Results

The cohort consisted of 119 male participants who reported

having anal sex with another man in the past 12 months,

with ages ranging from 18 to 42 years. The mean age for all

participants was 28 years, with half of the participants

between the ages of 23 and 32 years. Those who were

found to be HIV-infected were older than those who tested

HIV negative (p0.05), with an average age of 28.8

(interquartile range: 25, 32), compared to HIV-uninfected

MSM who had an average age of 26.5 (interquartile range:

22, 29). All had had some contact with community groups of

MSM in Dakar, Senegal. One-third of the participants had

a primary school education or less (n43, 36.4%), one-

third had attended secondary school (n39, 33.1%), 15.3%

(n18) had attended university and an equal percentage

(n18, 15.3%) had attended Islamic or Arab schools. A large

majority of participants were single (n104, 88.1%), and

77.3% reported living with their family (n92). Table 1

summarizes the demographic, behavioural, social and finan-

cial characteristics of the cohort.

Retention results

Thirty-seven of 119 participants were lost to follow-up

(31.1%), meaning they were unable or unwilling to partici-

pate in the study at T2. Fourteen of those lost to follow up

were known to be HIV positive. HIV-positive participants

were not lost at a significantly different rate than HIV-

negative participants (p0.43). No statistically significant

differences were found between those lost to follow-up and

those retained to Time 2 comparing any of the variables

listed in Table 1.

Reasons for loss to follow up include participant death,

participants being unreachable via contact information and

social networks, or participants having moved outside of

Dakar. Of the participants lost to follow up, four are known to

have died (4/119, 0.03). Cause of death was not recorded in

this study.

Table 1. Baseline demographics and other cohort characteristics

N119 

Demographic variables

Ethnicity

Wolof 61 48.7

Other 58 48.7

Education

Primary or less 43 36.4

Secondary 39 33.1

University 18 15.3

Islamic/Arab School 18 15.3

Marital status

Single 104 88.1

Married (one wife) 9 7.6

Divorced/ separated 5 4.2

Lives with family 92 77.3

Risk variables

Always uses condom 102 87.1

Always uses condom and water-based lubricant 75 65.2

Has concurrent partnerships with women 91 76.5

Has ever paid for sex 33 27.7

Has had sex for money 60 50.0

Health variables

Previously tested HIV-positive 20 17.1

Received STI diagnosis at T1 59 49.2

Ever consulted for an STI 54 46.2

Ever tested for HIV 103 88.0

Ever tested for HIV and received results 91 76.5

Social variables

Relationship with family

Excellent 51 42.9

Good 41 34.5

OK 20 16.8

Bad 4 3.4

Very bad 3 2.5

Involved in family decisions 92 78.0

Age of first sex with another man

12 or younger 35 29.4

1316 26 21.9

1719 33 27.7

20 or older 25 21.0

Has a confidant 70 60.8

Financial variables

Can meet all expenses 28 27.2

Has previously received financial support from

HIV project

18 15.1

HIV project

Has professional qualification 57 71.3

Currently has a job 55 68.8

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

Social capital results

Analysis of social capital was completed using baseline data.

Participants reported having contact with a median of two

family members. On average, study participants reported

being able to meet about half of their living expenses.

Seventy participants (60.8%) reported having a confidant,

someone to confide in about matters concerning health,

emotional distress and sex.

Men who reported having a confidant were less likely to

be HIV positive (OR 0.36, pB0.05, 95% confidence interval

[CI] 0.13, 0.97). These men were also less likely to report

alcohol use (OR 0.22, pB0.01, 95% CI 0.078, 0.64). Men

who reported having a confidant and men who are able to

meet their expenses were more likely to report using a

condom and water-based lubricant at each anal sex act (for

confidant: OR 2.50, pB0.05, 95% CI 1.13, 5.51; for expenses:

OR 5.11, pB0.05, 95% CI 1.419.2). Further results are

reported in Table 2.

Biological results

At the baseline medical examination, 49.2% (n59) of

participants were diagnosed with an STI. In the biological

testing, three cases of syphilis were diagnosed at baseline

(prevalence 2.6%), and two cases were diagnosed at

follow-up (prevalence 3.3%). Forty-one participants tested

HIV-positive at baseline (36.0%). All participants returning for

biological testing at T2 were tested for HIV, regardless of

prior test results. Sixty-one participants were tested for at

T2, 40 of whom had tested negative at baseline. Eight new

infections were observed at T2 (15 months follow up),

equating to an annualized incidence of 16 cases per 100

person-years (95% CI 4.627.4%) (Table 3).

Discussion

This study attempted to use a community based approach to

accrue and retain MSM in Senegal for 15 months while

implementing a pilot intervention. Although this study was

focused on assessing the feasibility of HIV prevention studies,

these data also highlight HIV among MSM as an ongoing

public health emergency in Senegal. The high incidence of

HIV suggests that this is an ideal population in which to

assess novel approaches to prevent HIV acquisition. More-

over, the high prevalence of HIV indicates that this is also an

ideal population in which to assess the effectiveness of

approaches that address the needs of people living with HIV.

These approaches would aim to reduce viral load as a means

of improving the health of PLHIV, as well as decreasing the

risk of onward HIV transmission.

Loss to follow up in this study was significant, which poses

a challenge to the success of future HIV prevention research

among MSM in Senegal. Reasons for the loss to follow up

were likely multifactorial, including the fact that limited

resources were appropriated for enhanced retention ap-

proaches in this study. In addition, there was a surprisingly

high mortality among this group of men that, with a mean

age of 28, was relatively young. Although cause of death

was not recorded, anecdotal discussions with community

members suggested that these deaths were HIV-related.

This pilot cohort study leveraged community groups to

implement the study rather than academic teams with

significant experience in managing cohorts. Thus, the study

demonstrates that cohorts are possible using this approach,

but that participant retention strategies should be more

thoroughly incorporated into the research protocol. Further

research, including qualitative research, is needed to better

understand characteristics associated with being retained

in the study, and there is a need to explore appropriate

retention strategies, for example, using linked peer naviga-

tors or SMS-based appointment reminder systems.

Traditional HIV prevention interventions, including condom

promotion and HIV testing are necessary. But data on the

high force of HIV acquisition and transmission among MSM,

as well as the high incidence presented here, suggest that

these interventions alone are not enough [43]. Addressing

the needs of people at high risk for HIV acquisition could

be achieved by assessing the feasibility of antiviral-driven

measures such as topical or oral chemoprophylaxis. There are

currently Phase II rectal microbicide studies for MSM which

include a site in South Africa, and these may eventually

represent an important strategy [44]. Separately, oral pre-

exposure prophylaxis has been shown to be effective among

MSM and may represent a relevant strategy for particularly

high-risk men with limited condom usage despite exposure to

condom promotion programmes [45]. The proportion of par-

ticipants in this cohort who had previously been tested for HIV

was high, 88%, though many had not received their results.

This suggests the need to optimize the continuum of HIV care

in this population; this should include ensuring that people

are first aware of their HIV status, then assessed for treatment

Table 2. Odds of reporting consistent use of condom and water-based lubricant by social capital indicator

Condom lubricant use

Social capital indicator OR 95% CI p

Three or more sex partners each month 0.44 (0.20, 0.98) 0.04

Believes in MSM collective efficacy 0.42 (0.19, 0.91) 0.03

Current job satisfies needs 7.40 (2.69, 20.37) 0.00

Can meet all expenses (compared with those who can meet no expenses) 5.11 (1.36, 19.16) 0.02

Above median ability to meet expenses 2.83 (1.28, 6.24) 0.01

Ever consulted medical care for an STI 0.32 (0.14, 0.75) 0.01

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

eligibility, actively linked to treatment services and provided

with adherence support to achieve viral suppression [46].

Given the high prevalence and incidence of HIV, these data

suggest the need to evaluate active linkage to care interven-

tions for MSM in Senegal [47]. A recent systematic review of

linkage and utilization of HIV medical care among PLHIV in

the United States reported several approaches for linkage to

care may be efficacious, including counseling, education and

health system navigators [48]. This study was comprised

of a highly selected and relatively small sample of MSM

already linked into community based organizations in Dakar.

However, these men are subject to multiple levels of stigma

and discrimination, including exclusion from social activities,

isolation from broader social networks and a society that has

criminalized their behaviour. Thus, effective HIV intervention

packages should address the individual biological and beha-

vioural facilitators of HIV acquisition and transmission, but

also address the broader structural determinants of HIV

affecting these men.

The baseline data suggests a relationship between social

capital and HIV risk including sexual practices and, poten-

tially, prevalent HIV infections. Men who had less financial

need were significantly more likely to report use of condoms

and water-based lubricant. These results are consistent with

earlier data from Senegal noting the importance of finan-

cial stability integration of social services as part of health

services in the country [49]. These data link social capital to

HIV-related risks and suggest that addressing sexual risk

practices without addressing the social contexts in which

they are taking place may have limited benefit [43]. Docu-

mentation and anecdotal reports from the past two decades

have suggested that the implementation of interventions

that address social capital among MSM can potentially

effectively decrease marginalization, stigma and the risk for

HIV infection [16,17,5053]. Although the relationship be-

tween social capital and HIV risk is complex, increasing trust

and community involvement among this vulnerable popula-

tion may lead to positive changes in social norms and self-

efficacy, and can ultimately lead to lower HIV acquisition and

transmission risks [16,17,22,23,26,54,55].

The generalizability of this study to the general population

of MSM in Senegal is limited for several reasons. Because of

the difficulty of contacting MSM, recruitment was conducted

using existing community networks allowing for a represen-

tative sample of MSM who are members of community

organizations in Dakar. However, this approach potentially

excluded those who are the most isolated or those who feel

the least desire to become involved in the community of

MSM. Thus, using a sampling frame derived from members

of community based organizations serving MSM potentially

selects for a population with higher social capital than

average MSM in Senegal. As earlier mentioned, retention

in the study was limited, which did not allow for a statistically

powered assessment of the benefit of the intervention.

Future studies will need to put a heavy focus on participant

retention to facilitate evaluation of the tested packages of

interventions.

Conclusions

Moving forward, cohorts of MSM will be needed to char-

acterize the effectiveness of combination HIV prevention

approaches in the West African context. The experience of

conducting this feasibility cohort study with a pilot finan-

cial intervention illustrates the potential feasibility of such

studies among MSM in a region where they are known to be

at among the highest risk for the acquisition and transmis-

sion of HIV.

Authors’ affiliations

Universite

´Gaston Berger/Enda Sante

´, Dakar, Senegal;

Department of

Epidemiology, Center for Public Health and Human Rights, John Hopkins

Bloomberg School of Public Health, Baltimore, MD, United States;

Enda Sante

´,

Dakar, Senegal

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

SB, FM, DD MN conceptualized the study. EC conducted the data analysis and

led the writing of the manuscript. FD and DD provided management of the

research implementation and field teams and supported writing sections of the

manuscript. SB and CB provided technical oversight for the implementation,

data analysis and manuscript development.

All authors have read and approved the final manuscript.

Acknowledgements

We would like to thank the study participants who partook in this study as well

as the broader community of MSM in Senegal. Participants embraced this

research with limited benefit and even potential risk of inadvertent disclosure

of sexual practices. Further acknowledgement to Enda Sante

´and its partners

for their support to this operational research. These partners include the

Community-Based Organizations Adama, Aides, Espoir and Prudence, as well as

the Universite

´Gaston Berger, Centre Hyacinthe Thiandoum and Centre de

Traitement Ambulatoire. The enthusiasm and commitment of Murielle

Gue

`ye, Nde

`ye Mare

`me Ndaw, Dr Samba Mbaye, Djiadji Diouf, Ibrahima

Diagne, Mbacke

´Se

`ne, Djamil Bangoura, Pr Abdou Ka

ˆDiongue, Ndeye Camara,

Table 3. Observed prevalence and incidence of HIV and STI

HIV Syphilis Hepatitis B

Time NFrequency % NFrequency % NFrequency %

Prevalence

T1 114 41 36.0 115 3 2.6 115 16 13.9

T2 61 28 45.9 61 2 3.3 61 11 18.0

Cumulative 108 51 47.2 115 5 4.4 115 18 15.7

Incidence (per person-year)

40 8 0.16 61 2 0.03

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

Dr Wahab Cisse

´, Penda Dieng, Dr Lalah Fall Dieng, Dr Gilbert Batista, Dr Daniel

Sarr, Dr Nde

`ye Fatou Ngom, Dr Reinaldo Mendes, Abdoulaye Kanoute

´, Cheikh

Mabcke

´Se

`ne, Harouna Wassongma and Paul Sagna led the success of the

project.

Funding

The USAIDjProject SEARCH, Task Order No.2, is funded by the U.S. Agency for

International Development under Contract No. GHH-I-00-07-00032-00, begin-

ning 30 September 2008, and supported by the President’s Emergency Plan for

AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns

Hopkins Center for Global Health and managed by the Johns Hopkins

Bloomberg School of Public Health Center for Communication Programs.

References

1. Chris Beyrer ALW, Walker D, Johns B, Sifakis F, Baral SD. The global HIV

epidemics among men who have sex with men. Washington, DC: World Bank;

2011.

2. Pisani E, Carae

¨l M. Acting early to prevent AIDS: the case of Senegal, in

UNAIDS best practice collection. Geneva: UNAIDS; 1999.

3. UNAIDS. Report on the global AIDS epidemic. Geneva: UNAIDS; 2012.

4. Measure DHS. Senegal: standard demographic and health survey, 2010 11.

Dakar, Senegal: Statistique et de la De

´mographie (ANSD); 2011. Available from

http://www.measuredhs.com/what-we-do/survey/survey-display-365.cfm

5. Foley EE, Nguer R. Courting success in HIV/AIDS prevention: the challenges

of addressing a concentrated epidemic in Senegal. Afr J AIDS Res. 2010;9(4):

32536.

6. Niang CI, Tapsoba P, Weiss E, Diagne M, Niang Y, Moreau AM, et al. ‘It’s

raining stones’: stigma, violence and HIV vulnerability among men who have

sex with men in Dakar, Senegal. Cult Health Sex. 2003;5(6):499512.

7. Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15(6):108897.

8. Ansari DA, Gaestel A. Senegalese religious leaders’ perceptions of HIV/AIDS

and implications for challenging stigma and discrimination. Cult Health Sex.

2010;12(6):63348.

9. Preston DB, D’Augelli AR, Cain RE, Kassab CD, Schulze FW, Starks MT. The

influence of stigma on the sexual risk behavior of rural men who have sex with

men. AIDS Educ Prev. 2004;16(4):291303.

10. Wang C, Hawes SE, Gaye A, Sow PS, Ndoye I, Manhart LE, et al. HIV

prevalence, previous HIV testing, and condom use with clients and regular

partners among Senegalese commercial sex workers. Sex Transm Infect.

2007;83(7):53440.

11. Wade AS, Larmarange J, Diop AK, Diop O, Gueye K, Marra A, et al.

Reduction in risk-taking behaviors among MSM in Senegal between 2004 and

2007 and prevalence of HIV and other STIs. ELIHoS Project, ANRS 12139. AIDS

Care. 2010;22(4):40914.

12. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in Peri-Urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

13. Drame

´FM, Peitzmeier S, Lopes M, Ndaw M, Sow A, Diouf D, et al. Gay

men and other men who have sex with men in West Africa: evidence from the

field. Cult Health Sex. 2012;115.

14. Griensven Fv. Men who have sex with men and their HIV epidemics in

Africa. AIDS. 2007;21:13612.

15. Krishna AS, Shrader E. Social capital assessment tool. Conference on Social

Capital and Poverty Reduction. Washington, DC: World Bank; 1999.

16. Bhattacharya G. Social capital and HIV risks among acculturating Asian

Indian men in New York City. AIDS Educ Prev. 2005;17(6):55567.

17. Campbell C, Williams B, Gilgen D. Is social capital a useful conceptual tool

for exploring community level influences on HIV infection? An exploratory case

study from South Africa. AIDS Care. 2002;14(1):4154.

18. Friedman SR, Mateu-Gelabert P, Curtis R, Maslow C, Bolyard M, Sandoval

M, et al. Social capital or networks, negotiations, and norms? A neighborhood

case study. Am J Prev Med. 2007;32(Suppl 6):S16070.

19. Lindstrom M, Axen E. Social capital, the miniaturization of community and

assessment of patient satisfaction in primary healthcare: a population-based

study. Scand J Public Health. 2004;32(4):2439.

20. Lovell AM. Risking risk: the influence of types of capital and social

networks on the injection practices of drug users. Soc Sci Med. 2002;55(5):

80321.

21. Reid E. Incorporating social capital into development practice: the HIV

epidemic. Dev Bull. 2000;52:213.

22. Sivaram S, Zelaya C, Srikrishnan AK, Latkin C, Go VF, Solomon S, et al.

Associations between social capital and HIV stigma in Chennai, India:

considerations for prevention intervention design. AIDS Educ Prev. 2009;

21(3):23350.

23. Smith RA, Rimal R. The impact of social capital on HIV related actions as

mediated by personal and proxy efficacies in Namibia. AIDS Behav. 2009;13(1):

13344.

24. Sundquist K, Yang M. Linking social capital and self-rated health: a

multilevel analysis of 11,175 men and women in Sweden. Health Place. 2007;

13(2):32434.

25. Takahashi LM, Magalong MG. Disruptive social capital: (un)healthy socio-

spatial interactions among Filipino men living with HIV/AIDS. Health Place.

2008;14(2):18297.

26. Wouters E, Meulemans H, van Rensburg HCJ. Slow to share: social capital

and its role in public HIV disclosure among public sector ART patients in the

Free State province of South Africa. AIDS Care. 2009;21(4):41121.

27. Sanders EJ, Graham SM, Okuku HS, van der Elst EM, Muhaari A, Davies A,

et al. HIV-1 infection in high risk men who have sex with men in Mombasa,

Kenya. AIDS. 2007;21(18):251320.

28. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV

prevalence, risks for HIV infection, and human rights among men who have sex

with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;4(3):

e4997.

29. Kelly JA, Amirkhanian YA, McAuliffe TL, Dyatlov RV, Granskaya J, Borodkina

OI, et al. HIV risk behavior and risk-related characteristics of young Russian

men who exchange sex for money or valuables from other men. AIDS Educ

Prev. 2001;13(2):17588.

30. Baral S, Kizub D, Masenior NF, Peryskina A, Stachowiak J, Stibich M, et al.

Male sex workers in Moscow, Russia: a pilot study of demographics, substance

use patterns, and prevalence of HIV-1 and sexually transmitted infections. AIDS

Care. 2009;22:1128.

31. Pronyk PM, Harpham T, Morison LA, Hargreaves JR, Kim JC, Phetla G, et al.

Is social capital associated with HIV risk in rural South Africa? Soc Sci Med.

2008;66(9):19992010.

32. Cene

´CW, Akers AY, Lloyd SW, Albritton T, Hammond WP. Understanding

social capital and HIV risk in rural African American communities. J Gen Intern

Med. 2011;26(7):73744.

33. David AC, Li CA. Exploring the links between HIV/AIDS, social capital and

development. J Int Dev. 2010;22(7):94161.

34. Safren SA, Traeger L, Skeer MR, O’Cleirigh C, Meade CS, Covahey C, et al.

Testing a social-cognitive model of HIV transmission risk behaviors in HIV-

infected MSM with and without depression. Health Psychol. 2010;29(2):

21521.

35. Mimiaga MJ, Noonan E, Donnell D, Safren SA, Koenen KC, Gortmaker S,

et al. Childhood sexual abuse is highly associated with HIV risk-taking behavior

and infection among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr.

2009;51(3):3408.

36. Safren SA, Reisner SL, Herrick A, Mimiaga MJ, Stall R. Mental health and

HIV risk in men who have sex with men. J Acquir Immune Defic Syndr.

2010;55(Suppl 2):S747.

37. Johnson CA. Off the map how HIV/AIDS programming is failing same-sex

practicing people in Africa. New York: International Gay and Lesbian Human

Rights Commission; 2007.

38. Moreau A. Implementing STI/HIV prevention and care interventions for

men who have sex with men in Dakar, Senegal. Washington, DC: Population

Council/Horizons; 2007.

39. Poteat T, Diouf D, Drame FM, Ndaw M, Traore C, Dhaliwal M, et al. HIV risk

among MSM in Senegal: a qualitative rapid assessment of the impact of

enforcing laws that criminalize same sex practices. PLoS One. 2011;6(12):

e28760.

40. Trapence G, Collins C, Avrett S, Carr R, Sanchez H, Ayala G, et al. From

personal survival to public health: community leadership by men who have sex

with men in the response to HIV. Lancet. 2012;380(9839):40010.

41. Gordis L. Epidemiology. 4th ed. Philadelphia: Elsevier/Saunders. xv; 2009.

375 p.

42. CNLS. Surveillance sentinelle du VIH et de la syphilis aupre

`s des femmes

enceintes au Se

´ne

´gal. Bulletin e

´pide

´miologique. 2009;14:40.

43. Sullivan PS, Carballo-Die

´guez A, Coates T, Goodreau SM, McGowan I,

Sanders EJ, et al. Successes and challenges of HIV prevention in men who have

sex with men. Lancet. 2012;380(9839):38899.

44. McGowan I. Rectal microbicides: can we make them and will people use

them? AIDS Behav. 2011;15(Suppl 1):S6671.

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

45. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al.

Preexposure chemoprophylaxis for HIV prevention in men who have sex with

men. N Engl J Med. 2010;363(27):258799.

46. Gardner EM, McLees MP, Steiner JF, del Rio C, Burman WJ. The spectrum of

engagement in HIV care and its relevance to test-and-treat strategies for

prevention of HIV infection. Clin Infect Dis. 2011;52(6):793800.

47. Christopoulos KA, Das M, Colfax GN. Linkage and retention in HIV care

among men who have sex with men in the United States. Clin Infect Dis.

2011;52(suppl 2):S21422.

48. Liau A, Crepaz N, Lyles CM, Higa DH, Mullins MM, DeLuca J, et al.

Interventions to promote linkage to and utilization of HIV medical care among

HIV-diagnosed persons: a qualitative systematic review, 19962011. AIDS

Behav. 2013;17:194162.

49. Enel C, Larmarange J, Desgre

´es du LA, Wade AS. A

`propos des partenaires

´minines des hommes ayant des pratiques homosexuelles au Se

´ne

´gal

[Regarding feminine partners of Men having homosexuals practices in

Senegal]. Autrepart. 2009;49(1):10316.

50. Swendeman D, Basu I, Das S, Jana S, Rotheram-Borus MJ. Empowering sex

workers in India to reduce vulnerability to HIV and sexually transmitted

diseases. Soc Sci Med. 2009;69(8):115766.

51. Pinto RM, Melendez RM, Spector AY. Male-to-female transgender

individuals building social support and capital from within a gender-focused

network. J Gay Lesbian Soc Serv. 2008;20(3):20320.

52. Macinko J, Starfield B. The utility of social capital in research on health

determinants. Milbank Q. 2001;79(3):387427, IV.

53. Amirkhanian YA, Kelly JA, Kabakchieva E, Kirsanova AV, Vassileva S, Takacs

J, et al. A randomized social network HIV prevention trial with young men who

have sex with men in Russia and Bulgaria. AIDS. 2005;19(16):1897 905.

54. Campbell C, Mzaidume Z. Grassroots participation, peer education, and

HIV prevention by sex workers in South Africa. Am J Public Health. 2001;

91(12):197886.

55. Chiu J, Grobbelaar J, Sikkema K, Vandormoel A, Bomela N, Kershaw T.

HIV-related stigma and social capital in South Africa. AIDS Educ Prev.

2008;20(6):51930.

Drame

´FM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18753

http://www.jiasociety.org/index.php/jias/article/view/18753 | http://dx.doi.org/10.7448/IAS.16.4.18753

Research article

‘‘They are human beings, they are Swazi’’: intersecting stigmas

and the positive health, dignity and prevention needs of

HIV-positive men who have sex with men in Swaziland

Caitlin E Kennedy

§,1

, Stefan D Baral

, Rebecca Fielding-Miller

, Darrin Adams

1,4

, Phumlile Dludlu

, Bheki Sithole

Virginia A Fonner

, Zandile Mnisi

and Deanna Kerrigan

Corresponding author: Caitlin E Kennedy, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD

21205, USA. Tel: 1 443 287 8794. (ckennedy@jhsph.edu)

Abstract

Introduction: Despite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across

settings, there has been little investigation of the experiences of MSM who are living with HIV in sub-Saharan Africa. Using the

framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment

needs of MSM who are living with HIV in Swaziland.

Methods: We conducted 40 in-depth interviews with 20 HIV-positive MSM, 16 interviews with key informants and three focus

groups with MSM community members. Qualitative analysis was iterative and included debriefing sessions with a study staff,

a stakeholders’ workshop and coding for key themes using Atlas.ti.

Results: The predominant theme was the significant and multiple forms of stigma and discrimination faced by MSM living with

HIV in this setting due to both their sexual identity and HIV status. Dual stigma led to selective disclosure or lack of disclosure of

both identities, and consequently a lack of social support for care-seeking and medication adherence. Perceived and experienced

stigma from healthcare settings, particularly around sexual identity, also led to delayed care-seeking, travel to more distant

clinics and missed opportunities for appropriate services. Participants described experiences of violence and lack of police

protection as well as mental health challenges. Key informants, however, reflected on their duty to provide non-discriminatory

services to all Swazis regardless of personal beliefs.

Conclusions: Intersectionality provides a framework for understanding the experiences of dual stigma and discrimination faced

by MSM living with HIV in Swaziland and highlights how programmes and policies should consider the specific needs of this

population when designing HIV prevention, care and treatment services. In Swaziland, the health sector should consider

providing specialized training for healthcare providers, distributing condoms and lubricants and engaging MSM as peer outreach

workers or expert clients. Interventions to reduce stigma, discrimination and violence against MSM and people living with HIV

are also needed for both healthcare workers and the general population. Finally, research on experiences and needs of MSM

living with HIV globally can help inform comprehensive HIV services for this population.

Keywords: men who have sex with men; positive health dignity and prevention; people living with HIV; qualitative research;

Swaziland.

Received 22 May 2013; Revised 3 September 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 Kennedy CE et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction

Globally, men who have sex with men (MSM) have substan-

tially higher levels of HIV infection than men in the general

population [1]. This is true even in the generalized HIV

epidemics of sub-Saharan Africa, where MSM have more

than three times the HIV prevalence of general population

adult males on average [1]. Despite the knowledge that

MSM are more likely to be infected with HIV across settings,

there has been little investigation of the experiences of

MSM who are living with HIV in sub-Saharan Africa.

Positive health, dignity and prevention is a framework

used to highlight health and social justice issues for people

living with HIV (PLHIV) [2,3]. The primary goals of positive

health, dignity and prevention are ‘‘to improve the dignity,

quality, and length of life of people living with HIV; which,

if achieved will, in turn, have a beneficial impact on their

partners, families, and communities, including reducing the

likelihood of new infections’’ [2]. This framework builds upon

earlier concepts of ‘‘positive prevention’’ and ‘‘prevention

with positives,’’ which highlighted the importance of ensuring

the health of PLHIV and engaging PLHIV in HIV-prevention

efforts [46]. However, positive health, dignity and preven-

tion situates living with HIV within a human rights frame-

work and focuses on the importance of understanding and

addressing structural constraints. It also considers the role

of stigma and discrimination, which Parker and Aggleton [7]

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

describe as social processes related to social inequality,

power and oppression through which some groups are struc-

turally excluded in society. Stigma has often been defined

based on the classic work of Goffman as the social de-

valuation of a person based on a ‘‘significantly discrediting’’

attribute [8], while discrimination has been defined as

behaviour resulting from prejudice [9]. Both stigma and

discrimination are common in relation to both HIV and

same-sex relationships.

In Swaziland, HIV prevalence in reproductive-age adults

is among the highest in the world at 26.1% [10]. UNAIDS

classifies Swaziland as a generalized HIV epidemic and, to

date, the response to HIV in Swaziland has largely focused

on the general population. Recently, the first surveillance of

HIV prevalence and associated risk factors among MSM in

Swaziland was conducted and showed a high burden of HIV

among Swazi MSM, comparable to that of men in the general

population [11]. However, same-sex behaviour is criminal-

ized in Swaziland, and little attention has focused on the

experiences of MSM who are living with HIV in this setting.

Indeed, we identified just one peer-reviewed article focusing

on HIV-positive MSM in sub-Saharan Africa. Cloete et al. [12]

conducted a survey on HIV-related stigma and discrimina-

tion among a convenience sample of both HIV-positive MSM

and men who have sex with women in Cape Town, South

Africa. The survey found that internalized HIV-related stigma

was high among all participants. Overall, MSM reported

slightly greater social isolation and discrimination due to

their HIV status, but these differences generally did not reach

statistical significance.

In this study, we sought to explore the positive health,

dignity and prevention needs of MSM who are living with HIV

in Swaziland to inform HIV prevention, care and treatment

services for this population. To our knowledge, this is one of

the first qualitative studies to examine these issues among

HIV-positive MSM in sub-Saharan Africa. As such, findings

could inform the design and implementation of programmes

for MSM living with HIV in Swaziland and similar settings.

Methods

A qualitative approach was used to address the study aims.

Methods included key informant interviews, in-depth inter-

views with HIV-positive MSM, and focus groups with MSM

community members.

Key informants were selected if they had experience with

MSM and lesbian, gay, bisexual and transgender (LGBT)

populations or with HIV-related services in Swaziland. Sixteen

key informants were interviewed, including HIV programme

planners, policy makers, clinicians and LGBT community

leaders. Interviews were semi-structured and employed a

field guide to direct the conversation and stimulate probing.

Participants were asked to describe the situation of MSM in

their communities, their knowledge of existing services for

MSM and PLHIV and their suggestions for how services could

better meet the needs of MSM.

In-depth interviews were conducted with 20 MSM living

with HIV interviewed twice each for a total of 40 interviews.

Recruitment was conducted through a variety of settings and

organizations, including HIV clinics; PLHIV networks; LGBT and

MSM community organizations; and HIV prevention, care

and treatment services. Participants were asked about the

experiences of MSM generally in their communities; MSM

social networks; personal and community experiences with

HIV prevention, care and treatment services; experiences

with stigma and discrimination; and suggestions for how

services, interventions and messages could be better tailored

for MSM.

Focus groups were conducted with MSM to gather a

broader community perspective on the study topics; HIV

status was not asked for reasons of confidentiality. Three focus

groups were conducted with 26 MSM (4, 9 and 13 participants

in each group). Topics covered were similar to interviews.

All interviews and focus groups were conducted in a pri-

vate setting in either English or SiSwati and lasted approxi-

mately one to two hours. MSM were interviewed by a Swazi

familiar with the local LGBT community who received training

in qualitative research, while key informants were inter-

viewed by an American masters-level research assistant with

qualitative training living in Swaziland.

Qualitative data analysis

Analysis of qualitative data was conducted through identifi-

cation of recurrent patterns and themes following Crabtree

and Miller’s five steps in qualitative data analysis, or the

‘‘interpretive process’’ [13]. These steps are: (i) describing, (ii)

organizing, (iii) connecting, (iv) corroborating and (v) repre-

senting. These steps form part of an iterative process

which starts by re-examining the goals of the research and

considering questions of reflexivity, then moves towards

ways of highlighting, arranging and reducing texts to make

connections through the identification of recurrent patterns

and themes.

All interviews and focus groups were recorded, transcribed

and translated into English. Debriefing notes immediately

following each interview captured the interview context,

theoretical issues, methodological issues and follow-up topics.

Weekly meetings were held with all interviewers to discuss

emerging themes and identify topics for further exploration

to ensure an iterative process. After all data were collected,

a full-day data analysis workshop was attended by represen-

tatives from LGBT groups, Ministry of Health (MOH) and

National Emergency Response Council on HIV and AIDS

(NERCHA) representatives, interviewers, clinicians and other

stakeholders. This workshop devoted individual time to read

de-identified transcripts to identify themes, then group time

to categorize and discuss emerging themes and implications.

Following the workshop, a codebook was developed by four

study team members working together until agreement

was reached. Codes were selected based on a priori topics

of interest (research questions), themes identified during the

data analysis workshop and emergent themes from tran-

scripts. Codes were then applied using the computer software

package Atlas.ti (version 5.2, Scientific Software Development

GmbH, Eden Prairie, MN). The coded text was read to identify

further themes or patterns and memos were created for key

themes, which were developed into the findings presented

here.

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

Ethical considerations

All participants provided oral informed consent prior to

participation, and referrals to clinical and counselling services

were provided as needed. Study staff members were trained

on sensitivity issues around HIV and MSM. A study advisory

board, including representation from the LGBT community,

implementing partners and government, reviewed the study

protocol and interview guides and provided ongoing advice

to the management and execution of the study. Ethical

review and approval for this study was received from the

Scientific and Ethics Committee of the Swaziland MOH and

the Johns Hopkins Bloomberg School of Public Health in the

United States.

Results

Dual stigma and disclosure of sexual identity and HIV status

The predominant theme across interviews was the significant

and multiple forms of stigma and discrimination faced by

MSM living with HIV in Swaziland. MSM reported experien-

cing stigma and discrimination related to both their HIV

status as well as their sexual identity.

Same-sex behaviour is both criminalized and heavily

stigmatized in Swaziland. MSM reported experiencing sig-

nificant stigma, discrimination and rejection as a result of

their sexual identity. One man, when asked if he had ever

experienced stigma or discrimination as a result of being gay,

responded, ‘‘A lot, several times, too many times.’’

As a result of these experiences, and fear of similar stigma

and rejection, many participants said they had not disclosed

their sexual identity to anyone except other MSM. ‘‘That is

my secret and I’m not planning to tell anyone in my family,’’

explained one. Participants worried about negative reactions,

rejection and abuse if they disclosed. One man, when asked

what would happen if he disclosed his sexuality to his friends

or family, responded, ‘‘I would not even dare. It would be

like being in a devil’s den.’’ Others worried more about

disappointing their loved ones by not conforming to social

norms. One MSM asked,

Do you know this SiSwati saying that goes, ‘you have

to have a heart for the other person’? ... We always

put the next person before [ourselves] ... So we

hardly want to disappoint the next person with

being me, being myself and being comfortable with

myself and insisting that I should be accepted, you

know. We want to always conform [to] what society

expects.

However, some participants had disclosed their sexual iden-

tity to family members or friends and had found acceptance,

often after some initial difficulty.

Men also described stigma related to their HIV status.

One participant described ‘‘the abuse we are subjected to’’

as ‘‘stigma, you see, that once you are HIV-positive, people

think that you have AIDS. And also, that people have not

accepted and they still do not know what HIV is.’’ Experiences

or fear of HIV-related stigma prevented many MSM from

disclosing their HIV status to family, friends and sexual

partners. Lack of disclosure led to challenges with antire-

troviral drug (ARV) adherence, hiding medications and a lack

of social support for care-seeking and adherence to care and

ARVs.

Participants selectively disclosed either their HIV status

or their sexual identity to different individuals based on their

anticipated reaction. For example, participants said they

might disclose their HIV status to family members as they

anticipated receiving some material or emotional support as

a result, but they might not disclose their sexual identity

to those same family members due to fear of rejection or a

negative reaction.

Violence and lack of police protection

Violence was also a common experience for MSM. MSM

reported violence from a range of individuals. One man noted

that some MSM ‘‘are killed for being gay, others are assaulted

and others are chased away from home and disowned.’’

Due to the criminalized nature of same-sex behaviour in

Swaziland, many MSM felt they had no recourse to bring

incidents of discrimination or violence to the authorities.

Furthermore, many had experienced a lack of police protec-

tion as a result of their sexuality. One participant described

such an incident:

Participant (P): I was actually with a friend of mine in

Manzini and we went to the butchery for a braai

[barbecue], and when we got there, umm, there

were these people who were, like, sitting outside at

the car park. They were just rude and they started

insulting us and we didn’t try to defend ourselves,

try to explain anything, and they went on, like, we

are gay, we have to be beaten up, the gayness

should be beaten out of us. We just ignored them

and they attacked one of my friends we were with,

they started beating him and he was bleeding.

Interviewer (I): Really.

P: Like for real, he bled to the point where we had to

go to the hospital and we obviously went to lay a

charge. And the police were kind of ‘occupied’, they

didn’t have the time to go and find these people

that have beaten my friend.

I: Why did the police act in that way? Did you

narrate to them what happened?

P: We sure did, but I think it’s because we told them

how the whole thing started they called us names

because they say we are gay. And I think also the

police could tell that we are [gay], so they thought

there was no case there.

Stigma from healthcare settings

The stigma associated with being an MSM was the pre-

dominant barrier to accessing healthcare services for MSM

living with HIV. Both perceived and experienced stigma in

healthcare settings led to a lack of care-seeking behaviour.

As one participant described it,

When they say ‘bring your partner’, and then you

bring the same sex partner, they are like, ‘yah, this

is why you are having this [HIV], this is why’, and

they will be throwing words at you ... so then you

get embarrassed, sometimes you’ll decide to leave

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

without being treated, and where are you taking

that sickness to?

Another participant, when asked how the needs of MSM

differed from PLHIV in general, explained that the main

difference was how forthright MSM could be about issues

related to their sexuality:

I think they are different in the sense that for those

who are straight they are open and they commu-

nicate easily about sex issues. As for us gays, it’s

difficult unless you have someone you can talk

to and give you advice as to what you can do when

you have some health issues. As for people in

general, with them it’s easy for them to go to

hospital, but with us it’s difficult. You can’t say it’s

painful in your anus what will you say the cause

for that is?

This participant continued by noting that this influenced

care-seeking behaviour, as he would delay care-seeking or

self-medicate to avoid disclosure:

I: What happens, so you end up not going there

[to the hospital]?

P: I just stay at home and you find that this thing

becomes complicated. When this thing becomes

complicated, you find that maybe you go to the

pharmacy and they tell you that this thing is at an

advanced stage.

Other men said they travelled long distances to seek HIV care

at clinics where they either were not known personally or

where they did not experience stigma and discrimination.

P: Even at the hospital, they interviewed me, then

there were changes and I could tell that they wanted

me to reveal what type of person I am. Since then

I stopped fetching my drugs there. I now go to

another clinic which is far away from home. I drive

all the way to fetch my tablets instead of taking

them locally.

I: Really, why is it so?

P: Because I thought there is problem at the local

clinic since I am gay. So I decided to change ...They

treat us like small devils, as if we are the one who

are spreading the HIV virus.

However in a few cases, MSM did disclose their sexual

identity to healthcare providers and reported positive and

supportive reactions, particularly from non-governmental

HIV testing and counselling sites.

Fear of stigma also shaped the type and nature of

counselling that MSM received in healthcare settings,

particularly regarding offering services to sexual partners.

MSM, as well as key informants, noted that in clinical services

such as HIV testing and treatment, providers’ questions about

HIV prevention generally assume heterosexuality. Providers

would ask MSM to bring their wives into the clinic to be

tested for HIV. Due to fear of stigma, MSM would often

simply state that they did not have a wife, but would not

mention their male sexual partners.

Finally, participants reported mistreatment by staff and

lack of confidentiality at clinics due to being HIV-positive.

These negative experiences were particularly experienced

when picking up ARVs, leading one MSM to say that ‘‘the

ARVs end up being an inconvenience [rather] than helping

you.’’ Some men felt that PLHIV in general were treated

poorly by healthcare workers. ‘‘You really feel that you are

different from other people,’’ explained one. However, others

felt that at least some healthcare workers provided high-

quality care to PLHIV, and that MSM were not necessarily

treated any differently from other PLHIV.

Mental health challenges

Many MSM said that living with a stigmatized sexual identity

and a challenging, stigmatized disease led to feelings of

depression as well as self-stigma or shame. ‘‘To be like this to

me seems like I was created for nothing on earth,’’ said one,

‘‘because there is nobody who is happy about me at home

and at school.’’

The initial receipt of an HIV-positive diagnosis was

emotionally devastating for many participants. Participants

described feelings of depression and anger. They also said

that others had even more difficult coping. ‘‘Some of them

they commit suicide because they can’t accept their status,’’

said one MSM, ‘‘because no one can accept them as they

are gay and positive.’’ Some participants said feelings of self-

stigma led them to drink alcohol as a coping mechanism.

[After testing HIV-positive], I was very much hurt so

much that I decided to devote myself to drinking

alcohol. I was drinking every day, and there was not

a day that went by without me drinking.

However, over time, many participants said they came to

accept their HIV status and learn to cope with the disease.

MSM also reported that they had difficulty accepting their

sexuality. Some described shame related to having sexual

feelings for other men.

Participants reported receiving emotional support from a

variety of sources. One MSM said he went to his pastor for

support, while another derived comfort from religion but

had not disclosed or discussed his life with his church.

Only one participant mentioned going to formal counselling

services, saying he and his partner saw a private counsellor

who knew they were gay. However, most received support

from partners, friends or family to whom they had disclosed

either their HIV status or their sexual identity.

Preventing HIV transmission to sexual partners and the

context of MSM relationships

MSM in this study were very aware of the need to prevent

onward HIV transmission to sexual partners. Many discussed

how they had changed their behaviour after being diagnosed

with HIV in order to reduce transmission risk to others

by using condoms and reducing the number of partners.

However, others reported continued risk behaviour, often

linked to alcohol use. As one participant put it, ‘‘most of the

time we have sex without a condom it is when we are

drunk.’’

Poverty and lack of economic opportunities also shaped

risk behaviours. Participants reported that some members of

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

the MSM community were not necessarily gay, but engaged

in transactional sex with men to support themselves finan-

cially. However, the majority of our participants identified as

gay, and many said they were in long-term, monogamous

partnerships with other men.

Some MSM felt that the clandestine nature of MSM

relationships in Swaziland may lead to greater numbers of

and more casual types of partnerships. MSM described many

of their partners as bisexual or having female girlfriends and

wives, possibly to fulfil cultural expectations. Furthermore,

MSM said that their relationships are often kept secret

and therefore families do not play a role in relationship

counselling and peacekeeping as they might for heterosexual

couples.

Usually in our community we have short-term rela-

tionships. These relationships are caused by the

fact that there is nothing bonding those people. And

maybe the community, the parents or relatives are

not involved in our relationships. And then if I have

got a problem with my boyfriend, if I say it’s over,

it’s over ... you are not able to go tell your parents

or relatives ... if people are informed either way

about such people [MSM] in the community, if there

is a relationship going on with his parent, the parent

will be able to intervene either way, and those

relationships will sustain.

Improving positive health, dignity and prevention

services for MSM

MSM said that societal acceptance and stigma reduction

would be the most important way to improve services for

MSM living with HIV. As one man stated, ‘‘If we can be

recognized and they can know that there are people who are

living this kind of life and they can know how they can

reach us in terms of programmes and services.’’ Participants

knew that same-sex relationships were more accepted in

neighbouring South Africa and hoped that social norms

in Swaziland might shift in a similar direction. They also

discussed the organizations working openly for LGBT health

and rights in South Africa and noted that the lack of such

formal organization in Swaziland limited the ability to develop

an effective and appropriate response to HIV for MSM.

Participants held a variety of opinions on how best to tailor

existing interventions and services for MSM. Some partici-

pants suggested developing special clinics or services for HIV-

positive MSM. Others worried that targeted services would

reinforce stigma. One potential consideration was including

MSM living with HIV as ‘‘expert clients’’ to help navigate HIV

treatment services. Participants said less about mental health

services; just a handful of interviewees said that increasing

access to counsellors would be helpful, as existing HIV care

and treatment providers were overworked and did not have

time to provide in-depth counselling for PLHIV.

Currently, as there are essentially no HIV-prevention

services for MSM in Swaziland, participants suggested a

‘‘training of trainers’’ model, whereby trusted MSM commu-

nity members could be trained in HIV-prevention messages

particularly relevant for MSM and could then share those

messages with others in their community. MSM also suggested

continued or expanded distribution of condoms and particu-

larly lubricant to prevent condom breakage.

Several participants, both MSM and key informants, said

that healthcare workers should be trained on issues related

to MSM. As one key informant explained, ‘‘Even their pro-

cedures manuals should have information on how to handle

MARPS [most at-risk populations, including MSM].’’ Impor-

tantly, key informants in this study consistently said that

regardless of personal belief, they had an ethical responsi-

bility to provide services to everyone, equally.‘‘As a [member

of the] health sector, my belief is non-discriminatory services

to all the members of the population, and issues of legality

and everything rest with the Ministry of Justice,’’ said one.

Another stated,

Even though I don’t approve of what they are doing

... as a public health officer, I have to make sure

that they have access to health services. I don’t have

to judge them. I don’t have to give my views on

what they are doing. But my duty is to make sure

that they have access to services ... whatever their

sexual orientation is, they are human beings, they

are Swazi.

Discussion

This study is among the first studies to examine the positive

health, dignity and prevention needs of HIV-positive MSM in

sub-Saharan Africa. We found that a social and structural

context characterized by significant and multiple stigmas was

key to understanding these needs. Dual stigma related to

both sexual identity and HIV status led to selective disclosure

or lack of disclosure of both identities, and consequently

a lack of social support for care-seeking and medication

adherence. Perceived and experienced stigma from health-

care settings, particularly around sexual identity, also led

to delayed care-seeking, travel to more distant clinics and

missed opportunities for appropriate services. These findings

support and extend findings from other sub-Saharan African

settings that discrimination reduces the willingness of MSM

to access services [1416]. The lack of support from friends,

relatives and society for same-sex relationships was de-

scribed as weakening these relationships, leading to greater

numbers of sexual partners as well as relationships with

women to ‘‘hide’’ same-sex behaviours, potentially further

increasing HIV risk. This finding similarly echoes research

from the United States suggesting that psychosocial health

problems may increase HIV risk among MSM, leading to

a ‘‘syndemic’’ [17]; such findings highlight the need to

approach HIV prevention within the context of overlapping

health problems [18].

Intersectionality is a theoretical framework that examines

the relationship or ‘‘intersection’’ between multiple forms of

oppression and discrimination due to social categorizations

such as race, class or gender [19]. MSM living with HIV

experience the dual stigma of being a sexual minority and

having a stigmatizing illness. Intersectionality posits that

these multiple stigmas are not experienced independently,

but that they interact in complex ways to create disparity

and social inequality in health outcomes [19]. We found

that MSM living with HIV described dual stigma as an

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

overwhelming burden in their lives which influenced multiple

aspects of their health and relationships. Considering the

needs of MSM living with HIV in this intersectionality

framework provides the deepest understanding of their

experience.

Intersectionality also highlights the ways in which indivi-

dual experiences with stigma reflect larger social structures

that create and sustain inequality. Participants in our study

experienced outright discrimination, stigma and violence

against MSM and PLHIV. However, because sexual identity

can be concealed, they often encountered situations in

which they were assumed to be heterosexual assumptions

which they did not correct due to fear of discrimination.

For example, in healthcare settings, many providers assumed

their clients were heterosexual and provided services accor-

dingly. For our participants, these assumptions led to missed

opportunities for appropriate counselling services tailored

to their individual needs and risks, as well as missed

opportunities for offering important services, such as HIV

testing and counselling, to their sexual partners. Although the

World Health Organization couples HIV testing and counsel-

ling guidelines support offering these services to same-sex

couples [20], in practice, most couples HIV testing and coun-

selling services in sub-Saharan Africa focus exclusively on

steady, heterosexual partnerships and fail to consider same-

sex relationships. Although individual providers may offer

supportive services for same-sex partners, a more compre-

hensive approach is needed to incorporate training on same-

sex relationships into couples HIV testing and counselling

programmes.

Currently, services for MSM living with HIV in Swaziland

are essentially non-existent. This is unsurprising, given the

lack of data on MSM and HIV risk in Swaziland until very

recently and the criminalization of same-sex behaviour in

Swaziland. Research has documented a strong correlation

between criminalization of same-sex behaviour and lack

of investment in services for MSM globally [21]. However,

MSM have unique healthcare needs [22], and even in rights-

constrained settings, comprehensive HIV services for MSM

can and should be provided [23]. Our findings suggest the

beginnings of political will among healthcare workers, key

stakeholders at the government and local levels and the

MSM community to provide these services. Key informants

in particular reflected on their duty to provide services to

all Swazis in a non-discriminatory manner. These beliefs can

provide a foundation for establishing comprehensive HIV

services, including both prevention and care and treatment

services, for MSM. In fact, this research helped, in part, to

catalyze the official registration of an NGO, Rock of Hope,

dedicated to key population rights in Swaziland, including

LGBT rights, which has been invited to engage with the

country’s key population policy technical working group

addressing HIV among MSM and other key populations.

The technical working group is under the auspices of the

Swaziland National AIDS Programme (SNAP), a programmatic

body under the MOH. Other implementing partner organiza-

tions providing HIV-related services have indicated they

would be open to developing services for MSM. In this

changing political and institutional context, there appears to

be a genuine possibility of government, NGO and civil society

collaboration to develop an effective and comprehensive

response to the HIV epidemic among MSM in Swaziland.

This study provides unique information about the needs of

MSM living with HIV in a sub-Saharan African context with

high HIV disease burden. Conducting multiple interviews with

MSM living with HIV and working closely with local LGBT

groups increased the comfort level of our participants and

their willingness to participate in this study. However, MSM

participants were still discussing very sensitive, stigmatized

and illegal behaviours, and they may not have fully opened

up to interviewers. Data were collected largely from MSM in

urban centres due to reliance on existing networks; this may

limit transferability of the findings to rural MSM or those

without strong MSM social networks.

Conclusions

The intersecting stigmas of sexual identity and HIV status

shaped multiple facets of the lives of MSM living with HIV in

Swaziland. Intersectionality provides a framework for under-

standing these experiences and highlights how programmes

and policies should consider the specific needs of this

population when designing HIV prevention, care and treat-

ment services. In Swaziland, programmes should consider

tailored multi-level interventions that address these unique

needs at the policy, societal and healthcare delivery levels.

At the policy level, the health sector in Swaziland is already

initiating important research to examine the epidemio-

logy and service delivery needs of MSM; findings from

this research should be incorporated into the national HIV

response. For Swazi society in general as well as healthcare

providers, interventions to reduce stigma, discrimination and

violence against MSM and PLHIV are needed. The health

sector should also consider distributing condoms and lubri-

cant for MSM, training healthcare providers in the specific

health needs of MSM and engaging MSM as peer outreach

workers or expert clients in both prevention activities and

clinical services. Finally, further research examining the

experiences and needs of MSM living with HIV globally is

required to improve comprehensive HIV services for this

population.

Authors’ affiliations

Department of International Health, Johns Hopkins Bloomberg School of

Public Health, Baltimore, MD, USA;

Department of Epidemiology, Johns

Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;

Department

of Health Behavior, Emory University School of Public Health, Atlanta, GA,

USA;

Futures Group, Washington, DC, USA;

Mbabane, Swaziland;

University

of Stellenbosch, Stellenbosch, South Africa;

Ministry of Health and Social

Welfare, Mbabane, Swaziland;

Department of Health, Behavior and Society,

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

CEK, DK, ZM and SDB conceptualized and designed the study. All authors were

involved in study implementation. PD and BS assisted with participant recruit-

ment and community sensitization. RF-M and PD conducted interviews. CEK

led data analysis and RF-M, DA and VAF assisted with coding transcripts.

CEK drafted the article. All authors provided insight into key themes and

interpretations, and all authors read and approved the final article.

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

Acknowledgements

The authors thank all the study participants who so graciously shared their

time and stories with us. They thank the study team members including

Babazile Dlamini, Edward Okoth and Jessica Greene from PSI Swaziland; study

staff Sanelisiwe Zondo, Nonhlanhla Dlamini and Samkelo Sikhosana; and

community liaisons Xolile Mabuza, Sibusiso Maziya and the Rock of Hope

organization. From USAID, Jennifer Albertini, Natalie Kruse-Levy, Alison Cheng,

Sarah Sandison, Clancy Broxton and Ugo Amanyeiwe provided important

technical input and support for this study. From the Research to Prevention

(R2P) team at Johns Hopkins, they thank Jessica Spielman, Emily Hurley,

Andrea Vazzano and Brandon Howard. They also thank the members of the

Swaziland Most-at-Risk Populations (MARPS) technical working group, the

Swaziland Ministry of Health, and other Swazi government agencies that

provided valuable guidance and helped ensure the success of this study. They

appreciate the support and contributions from all the many individuals who

contributed in a wide variety of ways to this study.

Funding

This work was supported by USAIDjProject SEARCH, Task Order No. 2, funded

by the US Agency for International Development under Contract No. GHH-I-00-

07-00032-00, beginning 30 September 2008, and supported by the President’s

Emergency Plan for AIDS Relief.

References

1. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet. 2012;380(9839):36777.

2. GNP, UNAIDS. Positive health, dignity and prevention: a policy frame-

work. Amsterdam: GNP; 2011.

3. GNP, UNAIDS. Positive health, dignity and prevention. Technical consulta-

tion report. Amsterdam: GNP ; 2009.

4. Kennedy CE, Medley AM, Sweat MD, O’Reilly KR. Behavioural interventions

for HIV positive prevention in developing countries: a systematic review and

meta-analysis. Bull World Health Organ. 2010;88(8):61523.

5. Auerbach JD. Principles of positive prevention. J Acquir Immune Defic Syndr.

2004;37(Suppl 2):S1225.

6. Kalichman SC. Positive prevention: reducing HIV transmission among people

living with HIV/AIDS. New York: Springer; 2004.

7. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a

conceptual framework and implications for action. Soc Sci Med. 2003;57:

1324.

8. Goffman E. Stigma: notes on the management of a spoiled identity.

New York: Simon & Schuster; 1963.

9. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV

stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13(6):

116077.

10. World Bank. Swaziland HIV prevention response and modes of transmis-

sion analysis. Mbabane, Swaziland: National Emergency Response Council on

HIV and AIDS (NERCHA); 2009.

11. Baral S, Grosso A, Mnisi Z, Adams D, Fielding-Miller R, Mabuza X, et al.

Examining prevalence of HIV infection and risk factors among female sex

workers (FSW) and men who have sex with men (MSM) in Swaziland.

Baltimore, MD: Research to Prevention; 2013.

12. Cloete A, Simbayi LC, Kalichman SC, Strebel A, Henda N. Stigma and

discrimination experiences of HIV-positive men who have sex with men in Cape

Town, South Africa. AIDS Care. 2008;20(9):110510.

13. Crabtree BF, Miller WL. Doing qualitative research. 2nd ed. Thousand Oaks,

CA: Sage; 1999.

14. Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Lipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15(6):108897.

15. Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. ‘They see you as

a different thing’: the experiences of men who have sex with men with

healthcare workers in South African township communities. Sex Transm Infect.

2008;84(6):4303.

16. Rispel LC, Metcalf CA, Cloete A, Moorman J, Reddy V.You become afraid to

tell them that you are gay: health service utilization by men who have sex with

men in South African cities. J Public Health Policy. 2011;32(Suppl 1):S13751.

17. Parsons JT, Grov C, Golub S. Sexual compulsivity, co-occurring psychosocial

health problems, and HIV risk among gay and bisexual men: further evidence

of a syndemic. Am J Public Health. 2012;102(1):156 62.

18. Halkitis PN, Woliski RJ, Millett GA. A holistic approach to addressing HIV

infection disparities in gay, bisexual, and other men who have sex with men.

Am Psychol. 2013;68(4):26173.

19. Bowleg L. The problem with the phrase women and minorities: inter-

sectionality an important theoretical framework for public health. Am J

Public Health. 2012;102(7):126773.

20. World Health Organization. Guidance on couples HIV testing and counsel-

ling including antiretroviral therapy for treatment and prevention in serodis-

cordant couples: recommendations for a public health approach. Geneva,

Switzerland: World Health Organization; 2012.

21. AMFAR, JHSPH. Achieving an AIDS-free generation for gay men and other

MSM: financing and implementation of HIV programs targeting MSM.

Washington, DC: AMFAR, JHSPH; 2012.

22. Mayer KH, Bekker LG, Stall R, Grulich AE, Colfax G, Lama JR. Comprehen-

sive clinical care for men who have sex with men: an integrated approach.

Lancet. 2012;380(9839):37887.

23. Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G, et al. A

call to action for comprehensive HIV services for men who have sex with men.

Lancet. 2012;380(9839):42438.

Kennedy CE et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18749

http://www.jiasociety.org/index.php/jias/article/view/18749 | http://dx.doi.org/10.7448/IAS.16.4.18749

Review article

Epidemiology of HIV among female sex workers, their clients,

men who have sex with men and people who inject drugs in

West and Central Africa

Erin Papworth

§,1

, Nuha Ceesay

, Louis An

, Marguerite Thiam-Niangoin

, Odette Ky-Zerbo

, Claire Holland

Fatou Maria Drame

, Ashley Grosso

, Daouda Diouf

and Stefan D Baral

Corresponding author: Erin Papworth, Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health,

615 N. Wolfe Street, E 7146, Baltimore, MD 21205, USA. Tel: 237 99504671. (epapwort@jhuccp.org)

Abstract

Introduction: The West and Central Africa (WCA) sub-region is the most populous region of sub-Saharan Africa (SSA), with an

estimated population of 356 million living in 24 countries. The HIV epidemic in WCA appears to have distinct dynamics compared

to the rest of SSA, being more concentrated among key populations such as female sex workers (FSWs), men who have sex with

men (MSM), people who inject drugs (PWID) and clients of FSWs. To explore the epidemiology of HIV in the region, a systematic

review of HIV literature among key populations in WCA was conducted since the onset of the HIV epidemic.

Methods: We searched the databases PubMed, CINAHL and others for peer-reviewed articles regarding FSWs, MSM and PWID in

24 countries with no date restriction. Inclusion criteria were sensitive and focused on inclusion of any HIV prevalence data

among key populations. HIV prevalence was pooled, and in each country key themes were extracted from the literature.

Results: The search generated 885 titles, 214 abstracts and 122 full articles, of which 76 met inclusion and exclusion criteria

providing HIV prevalence data. There were 60 articles characterizing the burden of disease among FSWs, eight for their clients,

one for both, six for MSM and one for PWID. The pooled HIV prevalence among FSWs was 34.9% (n14,388/41,270), among

their clients was 7.3% (n435/5986), among MSM was 17.7% (n656/3714) and among PWID from one study in Nigeria was

3.8% (n56/1459).

Conclusions: The disproportionate burden of HIV among FSWs appears to be consistent from the beginning of the HIV epidemic in

WCA. While there are less data for other key populations such as clients of FSWs and MSM, the prevalence of HIV is higher among

these men compared to other men in the region. There have been sporadic reports among PWID, but limited research on the

burden of HIV among these men and women. These data affirm that the HIV epidemic in WCA appears to be far more concentrated

among key populations than the epidemics in Southern and Eastern Africa. Evidence-based HIV prevention, treatment and care

programmes in WCA should focus on engaging populations with the greatest burden of disease in the continuum of HIV care.

Keywords: men who have sex with men; sex work; people who inject drugs; HIV epidemiology; West Africa; Central Africa;

prevalence; risk factors.

To access the supplementary material to this article please see Supplementary Files under Article Tools online.

Received 23 May 2013; Revised 26 August 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 Papworth E et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction

The sub-region of West and Central Africa (WCA) is the most

populous of sub-Saharan Africa (SSA), with a combined

population of roughly 356 million [1]. The region possesses a

distinct cultural, economic and historical diversity. The major-

ity of countries purport French as their national language,

while English is the state language for four countries, and

Spanish and Portuguese are both spoken within the region.

Fifteen of the countries in WCA are classified by the World

Bank Atlas method as low income (US$1025), including

Benin, Burkina Faso, Cape Verde, Central African Republic,

Chad, the Democratic Republic of Congo (DRC), the Gambia,

Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Sierra

Leone and Togo [2]. Co

ˆte d’Ivoire, Cameroon, Ghana, Nigeria,

the Republic of Congo, Senegal and Sa

˜o Tome

´and Prı

´ncipe are

categorized as low-middle income (US$1026 to US$4035) [2].

One country in the region is upper-middle income (Gabon),

and one is ranked as a high-income country (Equatorial

Guinea), mainly due to newly found oil reserves and a

population under 1 million [2].

Historically and economically multifarious, the region has

not been immune to the HIV epidemic. The first reported cases

of HIV emerged in the mid-1980s, and national surveillance

bodies such as National AIDS Committees (NACs) were

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

established over the subsequent decade [3]. Early phyloge-

netic subtyping revealed unique regional dynamics, with both

HIV-1 and HIV-2 circulating, and the majority of global cases

of HIV-2 found in West Africa. Concurrently, the origins and

greatest subtype diversity of HIV-1 were reported in Central

Africa [4] (Figure 1).

Nevertheless, regional epidemiological reporting has

traditionally been immersed in the overall context of SSA.

Trends in the HIV epidemic show that SSA possesses the

highest burden of HIV, and 69% of the global population of

people living with HIV reside within its borders [23.5 million

(22.124.8 million)] [5,6]. While these statistics show an

important burden of disease on the continent, they mask

disparities in HIV epidemics regionally [7]. Countries in East

and South Africa report consistently generalized epidemics

among reproductive-age adults (ages 1549), which is defined

through the Joint United Nations Programme on HIV/AIDS

(UNAIDS) criteria as HIV prevalence consistently higher than

1% in antenatal clinics [8,9]. Nine out of the 15 Southern

African Development Community (SADC) members report

national prevalence over 10% [5,6,10]. Reproductive-age adult

estimates are as high as 25.9% in Swaziland and 24.8% in

Botswana [11]. Comparatively, national prevalence in WCA

has remained low or moderate since HIV surveillance report-

ing began, with current general-population estimates ranging

from 0.02 to 4.5% [5,6,12]. Twelve countries in the sub-region

report national prevalence under 2% [5]. Consequently, the

majority of these countries’ HIV epidemics are classified as

mixed, concentrated or borderline generalized [6,12].

The international community has recently noted that

classifications of the HIV epidemic based on prevalence

data often limit understanding of the complexity of transmis-

sion and appropriate prevention strategies. However, con-

centrated epidemics have historically been defined as

occurring in countries where HIV prevalence is consistently

higher than 5% in at least one subgroup within the

population, but less than 1% in antenatal clinics [7,9]. These

subgroups are generally considered to be female sex workers

(FSWs), men who have sex with men (MSM) and people who

inject drugs (PWID) [7,13]. There is less clarity around mixed

epidemics, although these are generally agreed to be low-

level generalized epidemics ranging from 2 to 5% HIV

prevalence in the general population, and high transmission

rates in subgroups of the population [7]. Based on this, the

HIV epidemics in countries in WCA are predominantly mixed

or concentrated.

Researchers have suggested that the complexity of the

regional dynamics in WCA has not been dissected adequately

[12,1416]. Underlying drivers such as migration patterns,

subtype diversity, significant regional variations of the disease

and at-risk populations are understudied [11,12,1619]. In an

era where the global spread of HIV is on the decline, data are

progressively emerging to show sustained or expanding trans-

mission in populations at high-risk for HIV [15,2022]. How-

ever, national surveillance systems, particularly in low and

middle-income countries, remain constructed on population-

level studies such as the Demographic and Health Survey

and antenatal care surveillance data [6,13]. These methods

provide a global overview of basic risk factors associated with

transmission, but they do not capture data characterizing sex

work and other transactional or compensated sex, same-sex

practices and drug use outside of alcohol consumption, all of

which are demonstrated high-risk factors and contributors to

the acquisition and transmission of HIV [11,21,23].

Globally, surveillance shows that groups such as FSWs, their

clients, MSM and PWID sustain a higher burden of disease

in concentrated epidemics and substantially contribute to

new infections annually [4,7,18,22,24]. In settings such as

Southeast Asia and Latin America, general-population HIV

prevalence remains similar to that of WCA, and a higher

burden of disease is observed among key populations. For

example, Pakistan and Indonesia report 25% and 35%

prevalence among PWID, respectively [25]. Vietnam and Chile

report an HIV prevalence rate of 15% and 20% among MSM,

respectively [25,26]. Myanmar (Burma) reports a prevalence

of 10% among FSWs, and Brazil reports 4.9% [25,26]. All of

these reported levels are roughly five to thirty times higher

than general-population prevalence in the specific countries

listed [25,26]. National-level responses on these continents

have included programmes for key populations, and note-

worthy advances in the reduction of new infections have been

reported over time [27,28]. In contrast, WCA reports partial or

sporadic data for key populations and limited government-

level policies defining key population treatment and preven-

tion needs [5]. National surveillance and programming in

WCA subsequently remain rooted in broad HIV prevention

messaging and approaches similar to those seen across East

and South Africa such as prevention of mother-to-child

transmission (PMTCT) and non-targeted community-based

behaviour change programmes [5,7].

Lessons learned from other contexts such as Southeast Asia

and Latin America, where limited prevalence of HIV among

average-risk reproductive-age adults also exists, require us to

examine the epidemiology of the HIV epidemic in WCA [11,29].

This systematic review aims to complete a historic, situational

and epidemiological analysis of the burden of disease among

key populations in 24 countries located in WCA.

Methods

The US National Library of Medicine’s MEDLINE database,

one of the most comprehensive sources of healthcare

Figure 1. Map of West and Central Africa.

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

information in the world, was searched using the PubMED

interface to obtain biomedical markers for any of the three

key populations: FSWs, MSM or PWID. The study objectives

specified the need for epidemiologic studies that report

biological endpoints (HIV prevalence) with defined methods;

thus, it was decided a priori that MEDLINE would be

sufficient. However, a sensitivity assessment was employed

using the same search strategy to explore EBSCOhost CINAHL

Plus, PsycINFO, Ovid, SocioFile and Popline, and no additional

data points were obtained which met the defined inclusion

and exclusion criteria. Google and Google Scholar were

searched for contextual information and non-peer-reviewed

literature. The Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRIMSA) guidelines were refer-

enced for the development of the search protocol and study

reporting structure [30,31].

The medical subject headings (MeSH terms) for HIV and

AIDS and key terms relating to ‘‘sex work,’’ ‘‘men who have sex

with men’’ and ‘‘intravenous drug use’’ were cross-referenced

with terms associated with 16 West African countries: the 15

countries of the Economic Community of West African States

(ECOWAS: Benin, Burkina Faso, Cape Verde, Gambia, Ghana,

Guinea (Conakry), Guinea-Bissau, Cote d’Ivoire, Liberia, Mali,

Niger, Nigeria, Senegal, Sierra Leone and Togo) plus Maur-

itania. Eight Central African countries were included in the

search: those in the Economic Community of Central African

States (CEMAC: Cameroon, Chad, Equatorial Guinea, Central

African Republic, Republic of Congo and Gabon), the Demo-

cratic Republic of Congo (DRC) and Sa

˜o Tome

´and Prı

´ncipe. The

search protocol was developed based on the objectives of this

study and can be accessed as a Supplementary file with this

manuscript.

The inclusion criteria for this study included reported HIV

prevalence data for any of the three key populations, as well

as clients of FSWs, in any of the 24 countries defined for this

review. Publications were included if prevalence was listed in

the article with sample size and sampling and HIV-testing

methods described, regardless of the overall aim or topic of

the study. Date of publication was not used as an inclusion

criterion. Exclusion criteria included manuscripts not pub-

lished in French, English or Spanish. Articles were down-

loaded and organized using Endnote (version X5), and data

collection was finalized in April 2013.

Screening and data abstraction

A title and abstract search protocol was utilized based on

previously validated methods for systematic reviews [32]. At

each step in the search protocol, the titles, abstracts and

available data were appraised by two independent reviewers

(LA and EP), and compiled and synthesized using standar-

dized forms. During the title and abstract reviews, if either of

the two reviewers considered the article relevant, it was

included. Articles classified as relevant at the title review

stage were downloaded for abstract and full-text evaluation.

Data were independently extracted by two reviewers (LA and

EP), then compared and consolidated for analysis.

Data, including sampling methods, HIV-1, HIV-2 and dual

HIV-1 and -2 (HIV-1/2) infections with sample size and

number of participants living with HIV, were detailed and

coded by the two independent reviewers (LA and EP).

Information was categorized by key population studied,

sampling techniques, country or countries, sample size,

number of study participants living with HIV and notes.

Discrepancies in abstracted data from the two reviewers

were assessed by a third reviewer independently evaluating

the article (SB), as was the final consolidated database (CH).

Results

Our search generated 995 citations, including 885 unique

titles with dates of publication from 1987 to 2013 (Figure 2).

Based on the inclusion criteria, 122 full articles were

reviewed for data extraction, and 76 of these contained

relevant data for at least one of the key populations defined.

HIV prevalence data for at least one key population existed in

13 of the 24 countries included in the search (54.2%). Eleven

of these countries were located in West Africa, and two

countries were in Central Africa (DRC and Cameroon).

The majority of publications were assessments regarding

FSWs (78.9%, 60/76), and another 10.5% (8/76) provided HIV

prevalence data for their clients. One publication provided

prevalence data for FSWs and well as clients of FSWs in Togo

[33]. Thus, 90.8% (69/76) of the publications included in this

study were related to FSWs, representing 41,270 FSWs across

13 countries and 5,986 clients of FSWs across 6 countries.

Two countries (Senegal and Nigeria) had published HIV

prevalence data among MSM, and one seroprevalence study

was conducted among male sex workers (MSWs) in Co

ˆte

d’Ivoire, which was included in the MSM pooled data for

analysis [34]. A total of six publications combined for the

three countries were found for MSM (7.9%, 6/76), and one

publication was available with HIV prevalence data for PWID,

995 titles found

781 titles excluded

110 duplicates

671 not related to PWID,

MSM, FSWs, or countries

92 titles excluded

92 did not have quantitative

data or prevalence data on

PWID, MSM or FSWs

122 full articles reviewed

214 abstracts reviewed

Article division: FSWs (89), clients

of FSWs (6), PWID (4), MSM (13),

MSW/FSWs (1), No data (9)

46 excluded due to lack of

information on sampling approach,

secondary analysis of previously

reported data, or not meeting

inclusion criteria

76 full articles with prevalence data included

Figure 2. Flow chart of search findings and included studies.

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

Table 1. Pooled prevalence data for female sex workers (FSWs), clients of FSWs, MSM and PWID per country

Country Year of publication(s)

Key

population

Pooled HIV prevalence

% (95% confidence

interval)

Pooled HIV

prevalence

(sample size N)

HIV-1 prevalence

% (sample size

N)*

HIV-2 prevalence %

(sample size N)

HIV 1 and 2

prevalence %

(Sample size N)

HIV prevalence %

Among adults

1549** Reference

Benin 1992, 1997, 2001, 2002,

2007, 2009, 2012

FSWs 45.8 (44.247.4) 3,885 41.8 (N498) 3.2 (N498) 11.2 (N498) 1.1 [35 41]

2000, 2007 Clients 6.7 (5.67.8) 1,996 [42,43]

Burkina Faso 1998, 2002 FSWs 45.8 (42.549.1) 873 1.0 [44,45]

Cameroon 1991, 1995, 1998, 1998,

2001, 2009

FSWs 23.6 (22.424. 8) 4,679 22.9 (N2260) 0.04 (N2260) 4.5 [41,4650]

Cote d’Ivoire 1987, 1988, 1992, 1995,

1995, 1997, 1998, 2000,

2002, 2012

FSWs 57.3 (56.158.5) 7,014 40.0 (N5204) 2.7 (N5204) 21.1 (N5204) 3.2 [17,29,6673]

2003 Clients 13.5 (10.216.8) 423 [74]

2012 Male sex

workers

50.0 (40.060.0) 96 [34]

DRC 1988, 1988, 1991, 1998, 2007 FSWs 26.3 (24.628.0) 2,518 1.1 [5155]

Gambia 1991, 1991, 1993 FSWs 28.5 (25.032.0) 627 1.3 (N627) 25.2 (N627) 2.1 (N627) 1.3 [5658]

1992 Clients 6.1 (4.18.1) 558 [59]

Ghana 2000, 2001, 2012 FSWs 60.4 (58.362.6) 1,982 46.7 (N1348) 2.2 (N1348) 6.7 (N1348) 1.4 [40,60,61]

2004 Clients 12.3 (9.415.2) 497 [62]

Guinea 2010, 2010, 2011 FSWs 36.9 (34.539.3) 1,577 1.7 [6365]

Mali 1988, 1998 FSWs 42.1 (37.346.9) 406 35.8 (N176) 3.9 (N176) 6.2 (N176) 0.9 [75, 76]

Niger 1994, 1998, 2006, 2006 FSWs 31.2 (28.434.1) 1,017 29.2 (N767) 0.9 (N529) 2.0 (N767) 0.5 [7780]

Nigeria 1989, 1993, 1993, 1993,

1998, 2002, 2008, 2011,

2012, 2012, 2013

FSWs 24.3 (23.525.1) 10,769 13.5 (N2291) 1.9 (N2041) 1.8 (N610) 3.2 [81 91]

2013 PWID 3.8 (2.84.8) 1,459 [92]

2011, 2012, 2013 MSM 15.1 (13.716.5) 2,676 [9395]

Senegal 1992, 1996, 1997, 2003,

2007, 2009

FSWs 19.0 (17.920.1) 4,612 7.6 (N4008) 10.1 (N4008) 1.1 (N4008) 0.5 [96 101]

1997, 2003 Clients 4.6 (3.65.7) 1,515 [102,103]

2005, 2009, 2010 MSM 21.7 (19.124.3) 942 18.1 (N442) 0.5 (N442) 2.9 (N442) [104,105]

Togo 2009 FSWs 36.2 (33.638.8) 1,311 2.9 [18]

2009 Clients 7.9 (6.29.6) 997 [18]

*Where available, the distribution of HIV1, HIV2 and dual HIV1/2 infections in the available study or pooled per country is listed.

**UNAIDS country prevalence data 2012 (6).

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

totalling 3,714 MSM from three countries and 1,459 PWID

represented in the region.

Results presented in Table 1 show a pooled HIV prevalence

for the relevant key population(s) in each country, the 95%

confidence interval (CI), and the date(s) of the publications

retrieved per country. We include both HIV-1 and HIV-2

infections in the pooled prevalence data for the country,

and, when possible, we display the division of HIV-1, HIV-2

and HIV-1/2 infections. The far-left data column in Table 1

displays the overall HIV prevalence among reproductive-age

adults (1549) per country as reported by UNAIDS’ most

recent country-level surveillance data [6].

Female sex workers and their clients

Behavioural and seroprevalence studies in FSWs were con-

ducted consistently over time; however, there was a sig-

nificant lull in published data between 2002 and 2007. When

pooled, the overall HIV prevalence for FSWs in WCA was

34.9% (95% CI 34.435.4) (Table 2). In the five countries with

six or more publications, pooled HIV prevalence was high:

57.3% (N7,014) in Co

ˆte d’Ivoire, 24.3% (N10,769) in

Nigeria, 45.8% (N3,885) in Benin, 23.6% (N4,679) in

Cameroon and 19.0% (N4,612) in Senegal. The pooled

prevalence found among clients of FSWs was 7.3% (95% CI

6.68.0) (Table 2). Six countries had at minimum of one study

reporting prevalence data for this demographic, with pub-

lications as early as 1992 and as late as 2009 (Table 1).

Men who have sex with men

While this review revealed a paucity of data for MSM, the

pooled HIV prevalence in this review was 17.7% (95% CI

16.518.9) for MSM in WCA (Table 2). No studies included

were published earlier than 2005, and all but one were

published after 2010. Three relevant Nigerian studies showed

a pooled prevalence of 15.1% compared to 3.2% in adults of

reproductive age [6,9395,106]. Senegal’s pooled prevalence

was 21.7% compared to 0.5% in the adults of reproductive

age [6,104,105,107]. The study conducted in Co

ˆte d’Ivoire

among MSWs reported 50.0% prevalence among a sample of

96 men in Abidjan [34]. Snowball, convenience, purposive

and respondent-driven sampling were the primary recruit-

ment methods used to obtain these data.

People who inject drugs

One study included directly sampled PWID. The study found

a slightly higher prevalence of HIV at 3.8% (95% CI 2.84.8),

compared to 3.2% in the general population in Nigeria [6,92].

The sample was recruited through respondent-driven sam-

pling and mainly compromised of men ( 90%) [6,92].

Limitations

This study was conducted as a systematic review to understand

the prevalence of key populations in WCA and compare

historical HIV prevalence to general-population statistics.

Data were obtained from peer-reviewed literature, and while

this ensures some quality control, we acknowledge that some

relevant data that exist in grey literature and other program-

matic data may have been overlooked. Programmatic data

were not included in this review as it was not possible to

implement a standardized assessment of the quality of the

methods used and to ascertain an overview of research

sampling and testing methods. However, the grey literature

obtained through this review played a key role in the

contextual analysis and discussion section of this study. Certain

limitations also include the use of only English, French and

Spanish, as other publications in other languages may have

relevant data not captured in these inclusion criteria.The study

among MSWs from Co

ˆte d’Ivoire was included in the overall

analysis; however, the sampling method directly recruited

these individuals from an established sex worker clinic, and

thus HIV prevalence may be overestimated in this subpopula-

tion. Also, while the authors noted that the majority of MSWs

in the Abidjan area were MSM, they did not collect data on

types of partner [34]. The contextual description from the

authors is supported by evidence from other contexts where

partners of MSWs are male [108,109]. Concurrently, systema-

tic review methods were applied; however, sensitivity analysis

and meta-analyses were not utilized. While odds ratios or

aggregated comparison data were not generated, the overall

analysis provides an overview of HIV prevalence among key

populations and details of the epidemiology of key populations

since the debut of HIV research in this region.

Discussion

Epidemiologic literature over the past 30 years has demon-

strated a consistent and disproportionate burden of HIV

among key populations in WCA. From the first published

study in 1987 to the most recent in 2013, elevated levels of

HIV among FSWs and their clients were consistently reported.

In recent years, studies emerged to display an elevated

burden of HIV among MSM within the region, although the

number of studies in this subpopulation remains limited.

Concurrently, there is nascent but growing evidence of the

existence of PWID and, consequently, HIV infections in this

subpopulation [92].

HIV prevalence

The elevated HIV prevalence among MSM, FSWs and clients

of FSWs is important based on the determinants of the HIV

epidemic in WCA and even more broadly across SSA.

Table 2. Pooled HIV prevalence data for female sex workers, clients of FSWs, MSM and PWID in West and Central Africa

Key population Pooled HIV prevalence (%) 95% Confidence interval (%) Pooled sample size, NnLiving with HIV

Female sex workers (FSWs) 34.9 34.435.4 41,270 14,388

Men who have sex with men (MSM) 17.7 16.518.9 3,714 656

People who inject drugs (PWID) 3.8 2.84.8 1,459 56

Clients of FSWs 7.3 6.68.0 5,986 435

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

Surveillance has shown that women carry the highest burden

of HIV on the continent, with national-level statistics con-

stantly reporting that women have a higher HIV prevalence

and incidence than men [13,110]. While programmes are

designed to address the various risks associated with female

HIV acquisition, the results of this study demonstrate that HIV

risks are significantly higher among FSWs than women who

do not sell sex in WCA. These results are substantiated by

a systematic review of FSWs in low and middle-income

countries, which showed that FSWs in SSA have a pooled

prevalence of 36.9% (95% CI 36.237.5) with a background

prevalence on the continent of 7.42% in females [15].

Globally, FSWs were 13.5 (95% CI 10.018.1) times more

likely to be living with HIV than women of reproductive age

[15]. Thus, the results of this review and the epidemiology of

HIV among FSWs worldwide suggest that inclusion of and

significant focus on these women and their clients are of

importance to address these populations’ high HIV acquisition

and transmission risks in WCA [11,72,81,84,96].

On a continent where women are disproportionately

burdened with HIV, prevalence of 17.7% (95% CI 16.518.9)

among MSM demonstrates a potentially concentrated epi-

demic in this key population. A prevalence of 7.3% (95% CI

6.68.0) in clients of FSWs is also elevated compared to the

general male population of the region and calls into question

prevention programmes targeting this population. For clients

of FSWs, male acquisition is linked to behavioural risks

associated with multiple sexual partners, limited condom

use and concomitant infection of an STI, amongst other

determinants that are specific to men who engage in

transactional sex [16,74,111]. For MSM, recent research has

emerged that displays the increased transmission of HIV

during anal sex, as well as sexual role versatility during same-

sex practices that increases individual HIV risks and drives

transmission within sexual networks of MSM [21]. Thus, the

acknowledgement of a heightened burden of disease in these

populations is important for the design and implementation

of specialized HIV prevention, treatment and care pro-

grammes regionally [16,26].

The heightened HIV prevalence in the MSM community

found in these results is not unexpected, although the lack of

data in WCA is noteworthy. The high prevalence reported in

this review is comparable to other continents, with research

indicating that MSM around the world are 19 times more

likely to be infected with HIV than their adult male counter-

parts [18]. Interestingly, same-sex practices in WCA were

reported as early as 1996 in a published population-based

review [112]. The authors noted that the cumulative number

of positive cases had exponentially increased from 1985 to

1995, and the primary modes of transmission were hetero-

sexual practices (73.0%), homosexual practices (0.8%) and

mother-to-child transmission (6.0%) [112]. More recent

behavioural studies equally noted homosexual behaviour in

different demographic studies. In Nigeria, 11.4% of sexually

active secondary school students reported same-sex prac-

tices, and 12.4% reported anal sex [113]. In two Ghanaian

studies in 2006 and 2008, prison inmates reported same-sex

practices or identified as homosexual at 30.8% and 29.5%,

respectively [114,115]. While sporadic reports of same-sex

practices and elevated HIV prevalence have been reported in

the region, there is limited targeted programme activity for

these men [5,116,117]. What does exist is limited in scale,

based on community-driven initiatives, and functioning in

highly stigmatized settings [33,117,118].

While HIV prevalence in PWID was found to be relatively

low, the Nigerian study provides two important details for

programming in WCA. Firstly, while it has generally been

assumed that PWID constitute a minimal presence in WCA,

the study’s ability to generate a sample size of 1459 through

respondent-driven sampling indicates that this population

does exist. Secondly, while HIV prevalence appears low, we

know from other contexts that once HIV is introduced into

this specific subpopulation, the possibilities of rapid spread

and sustained transmission are great [119,120]. Contextually,

policy makers are becoming aware of an increase of drug

trafficking in the region, with large quantities of drugs

confiscated in the past few years, and the recent conflict in

Mali ascribed mainly to this trade [121]. Further supporting

evidence of this regional trade was found in behavioural data

in prisoners. In the same Ghanaian study in 2006, 41% of

inmates reported imprisonment for narcotics; 7.3% had used

cocaine, 5.2% heroin and 4.2% phencyclidine [114]. In the

2008 Ghanaian prison study, 35% of 1336 prisoners reported

ever injecting drugs [115]. As was seen in Afghanistan as well

as Thailand, Cambodia and other Southeast Asian countries,

migration, trafficking, drug use and the HIV epidemic are

intrinsically linked [119,120,122]. Thus, this is an important

population to identify and appropriately engage in WCA in

the coming decade of HIV prevention and control.

Historical perspective

This review also indicates that knowledge of HIV prevalence

among key populations and the proportion of HIV infections

attributable to key populations in WCA are not representative

of new or changing dynamics of HIV transmission. In 1995,

Djomand et al. noted that the male:female ratio of HIV

infection in Co

ˆte d’Ivoire had declined over time and the

gender ratio had shown females to be 4.8 times more likely to

be infected than men in 1988, compared to 1.9 times more

likely in 1991 [20]. The authors asserted that this decline

displayed that the HIV epidemic was initially concentrated in a

core group of FSWs and their male partners, and was

potentially expanding in broader populations with less

identifiable risk factors, similar to dynamics observed in other

regions outside of SSA [20,122124]. In 2004, Co

ˆte

´et al.

conducted a study of adult males (15 59) in Accra, Ghana,

and attributed 84% of existing cases of HIV to sex work and

other transactional sex [125]. A study in 2008 based on

Demographic and Health Surveys across four countries in SSA,

including Ghana, showed that men who ever paid for sex were

more likely to have HIV than men who had not (odds ratio

1.89, 95% CI 1.572.28) [126].

In the capital city of Lome

´, Togo, researchers estimated the

attributable fraction of current HIV cases to sex work and

other transactional sex was 32%, in contrast to only 2% of

cases outside of Lome

´[18]. Finally, recently in Nigeria, a

modes of transmission study asserted that 23% of HIV

infection was attributable to key populations, including 10%

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

of new infections amongst MSM [93]. Despite high HIV

prevalence among key populations and a high number of

HIV in 2009, cases attributable to behaviours such as sex

between men and sex work, systematic prevention and

treatment programmes for key populations have not been

implemented regionally [5]. While prevention programmes for

FSWs and their clients have been noted in countries including

Ghana, Co

ˆte d’Ivoire, Nigeria and Cameroon, the appropriate

scale of these programmes and collected surveillance data are

limited, and HIV prevention, treatment and care programming

for key populations has failed to become a standard of best

practices in the region [5].

Economic and regional migration

Underlying dynamics of the epidemic indicate external,

economic and urban-centred disparities have contributed to

the complexity of the HIV epidemic in WCA over time.

Domestic and international migration patterns were repeat-

edly reported and significantly mirrored economic crises and

fluctuations in specific countries. For example, a study in Co

ˆte

d’Ivoire documenting the FSW population that accessed

health clinics between 1991 and 1998 noted a major shift in

country of origin over time, with Nigerian women surveyed

increasing from 2 to 56% between 1992 and 1998, and

Ghanaian women decreasing from 82 to 9% in the same time

period [29]. Other studies reported the migration of Ghanaian

FSWs to other countries in the 1990s and asserted that the

significant economic and political crises in the country at that

time contributed to this migration [3,35]. The proportion of

Liberian FSWs included in the same Ivorian study was shown

to have increased from 0% in 1992 to 15% in 1995, and then

to have declined to 2% in 1998 [94]. This evolution reflects the

first internal conflict experienced in Liberia in the 1990s

(19891996) [127,128]. In a study reviewing the spread of HIV

among FSWs in four cities across SSA, researchers noted that

Cameroonian FSWs were more likely to have migrated

internally to urban centres, while in Benin 86% of the FSWs

sampled were from another country [41]. The only MSM

study to discuss countries of origin was the MSW study

in Co

ˆte d’Ivoire. Of the 96 MSWs sampled in Abidjan, 7.3%

(7/96) reported a different country of origin [34].

The importance of these findings is revealed in the HIV

prevalence among immigrants in the various studies. Nigerian

and Ghanaian FSWs in the 2002 Co

ˆte d’Ivoire study were 1.03

(0.472.23) and 3.69 (2.285.97) times more likely to be

infected than their counterparts from Co

ˆte d’Ivoire, Liberia

and other West African countries [106]. In Lome

´, two-thirds of

FSWs were immigrants, and Ghanaian FSWs were 1.68 (1.06

2.66) times more likely to be living with HIV [126]. Addressing

the needs of migrating populations at risk for or living with

HIV is crucial, as these populations have less access to health

services, are less likely to understand their human rights, and

are more likely to contract a disease [129]. These populations

are also more likely to be mobile; thus, successful prevention

services for immigrant or mobile FSWs could potentially have

an important impact in the overall reduction of HIV transmis-

sion and acquisition in the region [129].

Concurrently, disparity of HIV prevalence per locality was

repeatedly reported in the various studies reviewed. In the

same study that cited higher HIV levels among Ghanaian FSWs

in Lome

´, the prevalence among Lome

´FSWs in 2005 was

reported at 45.4% compared to 17.7% in the rest of Togo [18].

In two studies in Benin, there was significant spatial variation

in the burden of HIV. For example, a study conducted in six

cities in 2005 showed prevalence for HIV as high as 48.2%

in Parakou, compared to 16.4% in Abomey/Bohicon [36]. A

similar study found HIV prevalence in Cotonou, Benin, among

FSWs to be 38.5%, compared to a pooled prevalence in three

other large cities of the country of 58.9% [35]. Therefore, from

an HIV prevention perspective, cross-border initiatives, effec-

tive community-based networking and standardized pro-

grammes across urban and regional landscapes for key

populations are relevant for the WCA region.

Ways forward

Our review makes clear that there is a significant gap in the

literature and subsequent HIV programmes for key popula-

tions in WCA. This may be ascribed to the application of the

HIV response model of SSA to WCA epidemiological and

prevention approaches. However, as reports of high HIV

prevalence among key populations have existed in the

literature since 1987, it also calls into question the structural

barriers to healthcare for populations that engage in these

defined sexual behaviours in this region. As in other contexts,

sex work and other transactional sex, same-sex practice and

drug use are either criminalized or highly stigmatized in this

region, and public policies have ignored or generally declined

to address the specific health needs of key populations

[5,130,131]. Research has shown that macro-level policies

that impede or deter health service delivery for key popula-

tions ultimately increase vulnerability to disease acquisition

[23,130,132].

Data presented here provide a useful framework for HIV

programming in the region. The inclusion of relevant sexual

history and behavioural questions in large-scale surveillance

surveys, such as DHS, may also be of benefit in obtaining

a better overview of the epidemiology of key populations,

both in WCA and worldwide. While the delivery of sensitive

questions such as engagement in sex work, transactional sex,

same-sex practices and drug use must be carefully adminis-

tered (ideally not within the household setting), standardized

national data collection would go far to inform country and

regional policy development in WCA.

Subsequently, emerging data have shown that addressing

the epidemic in key populations requires combined beha-

vioural, biomedical and structural approaches [23,133]. Lim-

ited condom use with regular sexual partners, unawareness of

HIV status and co-infections with genital ulcerative diseases

are contributing factors to heightened prevalence [10,21,

116]. High prevalence among key populations concurrently

has implications for prioritized biomedical interventions

[21,134].

While the knowledge that these populations have a higher

risk for transmission and acquisition of HIV and other STIs is

acknowledged, the method in which prevention and treat-

ment programmes address these risks has yet to be firmly

cemented in HIV prevention programming [13]. Researchers

in the United States and elsewhere have demonstrated the

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

importance of engaging populations in the continuum of HIV

care from undiagnosed cases to testing and diagnosis,

followed by linkage to ongoing care and treatment [135].

The continuum of HIV care significantly reduces the viral load

among people living with HIV and ultimately reduces

transmission [135,136]. In two recent studies in the United

States, researchers found that due to advances in antiretro-

viral regimes, with 7080% adherence to antiretroviral

therapy (ART) by participants, durable viral suppression

occurred in most individuals, lowering the possibility for

onward HIV transmission [136,137]. The findings indicate that

the key to community viral suppression is early diagnosis

of the disease, well-developed referral systems to clinical

services, and care and support programmes that encourage

adherence and access to treatment [136]. This approach has

been shown to be effective in contexts with both high and low

prevalence, and recent research from South Africa affirms

that adequate ART coverage at the community level reduces

incidence over time [138]. Thus, prevention programmes are

beginning to show that distribution of prevention commod-

ities and messages should be in concert with interventions

that address the virology and biomedical aspects of care and

treatment [135]. This is even more relevant for key popula-

tions who carry a significant burden of disease and ultimately

are people living with HIV.

Structural factors acting at the macro- and meso-levels

should not be ignored in WCA and are essential when building

combination biomedical programmes [23,139]. Criminalization

and public policy neglect substantially inhibit key populations’

ability to access appropriate, life-sustaining and prevention-

oriented health services. Policy-level gaps and community-

level stigma must be addressed if programmes are to adequately

confront the needs of these populations [140,141]. Studies

from other countries on the continent indicate the stigma

experienced within their communities and at health services,

significantly deters the uptake at clinical services for key

populations [130,142]. Public policies that adequately address

the intricate health needs, reduce stigma and discrimination,

and facilitate community and provider level HIV care and

treatment delivery will highly benefit the overall control and

prevention of HIV among key populations in WCA [23].

Conclusions

This systematic review suggests that the concentrated HIV

epidemic in WCA more closely resembles the epidemics in

Southeast Asia and Latin America than those in the rest of

SSA. This not only calls into question the response to the

HIV epidemic in WCA but indicates that the region has an

opportunity to adapt and develop region-specific preven-

tion and treatment strategies. Targeted, cost-effective pro-

grammes that address not only behavioural but also biological

and structural risk factors associated with HIV acquisition and

transmission key populations should be engaged to reduce the

onward spread of HIV. Prevention programmes should model

strategies on appropriate programmes that reduce commu-

nity viral loads, increase uptake of treatment among key

populations and address the barriers to healthcare that exist in

highly stigmatized settings. Ensuring that programmes rooted

in community-based approaches address the continuum of

HIV care, from diagnosis to viral suppression, will be a

challenge but also a possible victory for HIV prevention and

control in WCA.

Authors’ affiliations

Department of Epidemiology, Johns Hopkins Bloomberg School of Public

Health Baltimore, MD, USA;

Joint United Nations Programme on HIV/AIDS,

Banjul, Gambia;

Programme de Lutte Contre le SIDA Chez Les Populations

Hautement Vulne

´rables (PLS-PHV) Ministe

`re de la Sante et de la lutte contre le

SIDA, Abidjan, Co

ˆte d’Ivoire;

Programme d’Appui au Monde Associatif et

Communautaire (PAMAC), Ouagadougou Burkina Faso;

Enda Sante

´, Dakar,

Senegal

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

EP and SB developed the conceptual framework and conducted the overall

analysis of the study. SB provided guidance on research methods and sampling

approach and EP led the execution of these methods. EP and LA reviewed and

extracted data from all studies obtained. EP led the writing of the manuscript.

CH, LA and EP consolidated the databases and tables and CH and EP reviewed

the final databases versions. SB, AG, OK-Z, MT-N, NC, DD and FD all provided

expert review and contextual analysis for the region of WCA and were

instrumental in the interpretations of the results.

Acknowledgements

The authors acknowledge all participants involved in the studies included in

this systematic review. Their participation in research assists us in developing

wide-range and appropriate evidence-based public health programmes. We are

also grateful to the researchers of these studies for their dedication and efforts

to ensure that their findings are in the public sphere.

Funding

The authors thank and acknowledge The USAIDjProject SEARCH Task Order

No.2, funded by the US Agency for International Development under Contract

No. GHH-I-00-07-00032-00, for continued staff support and encouragement in

the development of this review. The Foundation for AIDS Research (amfAR) has

equally been a strong supporter of the Key Population Program under the

Center for Public Health and Human Rights at Johns Hopkins University, and we

continue to be thankful for their collaboration.

References

1. Bank TW. Population estimates 20082012. GPE Open Data Project 2012.

Washington, DC: World Bank; 2012.

2. Bank TW. Economic assessment of lending groups, world atlas method.

GPE Open Data Project. Washington, DC: World Bank; 2013.

3. Agyei-Mensah S. Twelve years of HIV/AIDS in Ghana: puzzles of interpreta-

tion. Can J Afr Stud. 2001;35(3):44172.

4. Gisselquist D. Emergence of the HIV type 1 epidemic in the twentieth

century: comparing hypotheses to evidence. AIDS Res Hum Retroviruses.

2003;19(12):10718.

5. UNAIDS. West and Central Africa: towards universal access to prevention,

care and treatment. Dakar, Senegal: UNAIDS/0829E/JC1585E; 2008.

6. UNAIDS. Report on the global AIDS epidemic. Geneva: United Nations;

2013.

7. Wilson D, Halperin DT. ‘‘Know your epidemic, know your response’’: a useful

approach, if we get it right. Lancet. 2008;372(9637):4236.

8. UNAIDS. Practical guidelines for intensifying HIV prevention: towards

universal access [Internet]. [cited 2013 May 1]. Available from: http://

dataunaidsorg/pub/Manual/2007/20070306_2007.;Prevention_Guidelines_

Towards_Universal_Access_en.pdf

9. Unaids W. Guidelines for second generation HIV surveillance. Geneva: WHO;

2000.

10. Espirito Santo ME, Etheredge GD. How to reach clients of female sex

workers: a survey by surprise in brothels in Dakar, Senegal. Bull World Health

Organ. 2002;80(9):70913.

11. Unaids. Sub-Saharan Africa: AIDS epidemic update regional summary.

Geneva: UNAIDS; 2008.

12. Lowndes CM, Alary M, Belleau M, Kofi Bosu W, Federic Kintin D, Asonye

Nnorom, et al. West Africa HIV/AIDS epidemiology and response synthesis:

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

characterisation of the HIV epidemic and reponse in West Africa: implications

for prevention. Washington, DC: World Bank; 2008.

13. Baral S, Phaswana-Mafuya N. Rewriting the narrative of the epidemiology

of HIV in sub-Saharan Africa. SAHARA J. 2012;9(3):12730.

14. Drame FM, Peitzmeier S, Lopes M, Ndaw M, Sow A, Diouf D, et al. Gay

men and other men who have sex with men in West Africa: evidence from the

field. Cult Health Sex. 2013;15(Suppl):721.

15. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden

of HIV among female sex workers in low-income and middle-income countries:

a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(7):538 49.

16. Lowndes CM, Alary M, Meda H, Gnintoungbe CA, Mukenge-Tshibaka L,

Adjovi C, et al. Role of core and bridging groups in the transmission dynamics

of HIV and STIs in Cotonou, Benin, West Africa. Sex Transm Infect.

2002;78(Suppl 1):i6977.

17. Djomand G, Greenberg AE, Sassan-Morokro M, Tossou O, Diallo MO,

Ekpini E, et al. The epidemic of HIV/AIDS in Abidjan, Cote d’Ivoire: a review of

data collected by Projet RETRO-CI from 1987 to 1993. J Acquir Immune Defic

Syndr Hum Retrovirol. 1995;10(3):35865.

18. Sobela F, Pepin J, Gbeleou S, Banla AK, Pitche VP, Adom W, et al. A tale of

two countries: HIV among core groups in Togo. J Acquir Immune Defic Syndr.

2009;51(2):21623.

19. Scott Kellerman M, Holtz S, Dutta A, Aliou S, Diallo I, Redding S, et al. The

epidemiology of HIV epidemics in the 21-country West and Central Africa

region: the impact of most at risk populations (MARPs). USAID AWARE II

project. Washington, DC: World Bank; 2012.

20. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection

among men who have sex with men in low- and middle-income countries

20002006: a systematic review. PLoS Med. 2007;4(12):e339.

21. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet. 2012;380(9839):36777.

22. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick R. HIV

prevention, treatment and care for people who inject drugs: a systematic

review of global, regional and country level coverage. Lancet. 2010;385(9719):

101428.

23. Baral S, Logie CH, Grosso A, Wirtz A, Beyrer C. Modified social ecological

model: a tool to guide the assessment of the risks and risk contexts of HIV

epidemics. BMC Public Health. 2013;13:482.

24. Nelson KE, Celentano DD, Eiumtrakol S, Hoover DR, Beyrer C, Suprasert S,

et al. Changes in sexual behavior and a decline in HIV infection among young

men in Thailand. N Engl J Med. 1996;335(5):297303.

25. UNAIDS. Regional response fact sheet: Asia and the Pacific. Geneva: Joint

United Nations Programme on HIV/AIDS; 2012.

26. UNAIDS. Regional fact sheet: Latin America and the Caribbean. Geneva:

Joint United Nations Programme on HIV/AIDS; 2012.

27. UNAIDS. Report on the global AIDS epidemic 2010. Geneva: United

Nations; 2010.

28. Hammett TM, Kling R, Johnston P, Liu W, Ngu D, Friedmann P, et al.

Patterns of HIV prevalence and HIV risk behaviors among injection drug

users prior to and 24 months following implementation of cross-border HIV

prevention interventions in northern Vietnam and southern China. AIDS Educ

Prev. 2006;18(2):97115.

29. Ghys PD, Diallo MO, Ettiegne-Traore V, Kale K, Tawil O, Carael M, et al.

Increase in condom use and decline in HIV and sexually transmitted diseases

among female sex workers in Abidjan, Cote d’Ivoire, 19911998. AIDS.

2002;16(2):2518.

30. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA,

et al. The PRISMA statement for reporting systematic reviews and meta-

analyses of studies that evaluate health care interventions: explanation and

elaboration. J Clin Epidemiol. 2009;62(10):e1e34.

31. Lipsey MW, Wilson DB. Practical meta-analysis. Applied Social Research

Methods Series, Volume 49, Sages Publications, Thousand Oaks: California;

2001.

32. Mateen FJ, Oh J, Tergas AI, Bhayani NH, Kamdar BB. Titles versus titles and

abstracts for initial screening of articles for systematic reviews. Clin Epidemiol.

2013;6:8995.

33. Beyrer C. Lesbian, gay, bisexual, and transgender populations in Africa:

a social justice movement emerges in the era of HIV. SAHARA J. 2012;9(3):

1779.

34. Vuylsteke B, Semde G, Sika L, Crucitti T, Ettiegne Traore V, Buve A, et al.

High prevalence of HIV and sexually transmitted infections among male sex

workers in Abidjan, Cote d’Ivoire: need for services tailored to their needs. Sex

Transm Infect. 2012;88(4):28893.

35. Ahoyo AB, Alary M, Meda H, Ndour M, Batona G, Bitera R, et al. Female

sex workers in Benin, 2002. Behavioural survey and HIV and other STI

screening. Sante. 2007;17(3):14351.

36. Ahoyo AB, Alary M, Ndour M, Labbe AC, Ahoussinou C. HIV and sexually

transmitted disease among female sex workers in Benin. Med Trop.

2009;69(5):45762.

37. Alary M, Mukenge-Tshibaka L, Bernier F, Geraldo N, Lowndes CM, Meda H,

et al. Decline in the prevalence of HIV and sexually transmitted diseases among

female sex workers in Cotonou, Benin, 19931999. AIDS. 2002;16(3):463 70.

38. Baganizi E, Alary M, Guedeme A, Padonou F, Davo N, Adjovi C, et al. HIV

infection in female prostitutes from Benin: association with symptomatic but

not asymptomatic gonococcal or chlamydial infections. AIDS. 1997;11(5):

6856.

39. Bigot A, Bodeus M, Burtonboy G, Ahouignan G, Zohoun I. Prevalence of

HIV infection among prostitutes in Benin (West Africa). J Acquir Immune Defic

Syndr. 1992;5(3):3179.

40. Labbe AC, Pepin J, Khonde N, Dzokoto A, Meda H, Asamoah-Adu C, et al.

Periodical antibiotic treatment for the control of gonococcal and chlamydial

infections among sex workers in Benin and Ghana: a cluster-randomized

placebo-controlled trial. Sex Transm Dis. 2012;39(4):2539.

41. Morison L, Weiss HA, Buve A, Carael M, Abega SC, Kaona F, et al.

Commercial sex and the spread of HIV in four cities in sub-Saharan Africa. AIDS.

2001;15(Suppl 4):S61S9.

42. Lowndes CM, Alary M, Gnintoungbe CA, Bedard E, Mukenge L, Geraldo N,

et al. Management of sexually transmitted diseases and HIV prevention in men

at high risk: targeting clients and non-paying sexual partners of female sex

workers in Benin. AIDS. 2000;14(16):252334.

43. Lowndes CM, Alary M, Labbe AC, Gnintoungbe C, Belleau M, Mukenge L,

et al. Interventions among male clients of female sex workers in Benin,

West Africa: an essential component of targeted HIV preventive interventions.

Sex Transm Infect. 2007;83(7):57781.

44. Lankoande S, Meda N, Sangare L, Compaore IP, Catraye J, Sanou PT, et al.

Prevalence and risk of HIV infection among female sex workers in Burkina Faso.

Int J STD AIDS. 1998;9(3):14650.

45. Nagot N, Ouangre A, Ouedraogo A, Cartoux M, Huygens P, Defer MC, et al.

Spectrum of commercial sex activity in Burkina Faso: classification model and

risk of exposure to HIV. J Acquir Immune Defic Syndr. 2002;29(5):51721.

46. Kaptue L, Zekeng L, Djoumessi S, Monny-Lobe M, Nichols D, Debuysscher

R. HIV and chlamydia infections among prostitutes in Yaounde, Cameroon.

Genitourin Med. 1991;67(2):1435.

47. Mauclere P, Mahieux R, Garcia-Calleja JM, Salla R, Tekaia F, Millan J, et al.

A new HTLV type II subtype A isolate in an HIV type 1-infected prostitute from

Cameroon, Central Africa. AIDS Res Hum Retroviruses. 1995;11(8):98993.

48. Ryan KA, Roddy RE, Zekeng L, Weir SS, Tamoufe U. Characteristics

associated with prevalent HIV infection among a cohort of sex workers in

Cameroon. Sex Transm Infect. 1998;74(2):1315.

49. Bestetti G, Renon G, Mauclere P, Ruffie A, Mbopi Keou FX, Eme D, et al.

High seroprevalence of human herpesvirus-8 in pregnant women and

prostitutes from Cameroon. AIDS. 1998;12(5):5413.

50. Mosoko JJ, Macauley IB, Zoungkanyi AC, Bella A, Koulla-Shiro S. Human

immunodeficiency virus infection and associated factors among specific

population subgroups in Cameroon. AIDS Behav. 2009;13(2):27787.

51. Mann JM, Nzilambi N, Piot P, Bosenge N, Kalala M, Francis H, et al. HIV

infection and associated risk factors in female prostitutes in Kinshasa, Zaire.

AIDS. 1988;2(4):24954.

52. Mulanga-Kabeya C, Nzilambi N, Edidi B, Minlangu M, Tshimpaka T,

Kambembo L, et al. Evidence of stable HIV seroprevalences in selected popula-

tions in the Democratic Republic of the Congo. AIDS. 1998;12(8):90510.

53. Nzila N, Laga M, Thiam MA, Mayimona K, Edidi B, Van Dyck E, et al. HIV and

other sexually transmitted diseases among female prostitutes in Kinshasa.

AIDS. 1991;5(6):71521.

54. Nzilambi N, De Cock KM, Forthal DN, Francis H, Ryder RW, Malebe I, et al.

The prevalence of infection with human immunodeficiency virus over a 10-year

period in rural Zaire. N Engl J Med. 1988;318(5):276 9.

55. Vandepitte JM, Malele F, Kivuvu DM, Edidi S, Muwonga J, Lepira F, et al.

HIV and other sexually transmitted infections among female sex workers in

Kinshasa, Democratic Republic of Congo, in 2002. Sex Transm Dis. 2007;34(4):

2038.

56. Pepin J, Morgan G, Dunn D, Gevao S, Mendy M, Gaye I, et al.

HIV-2-induced immunosuppression among asymptomatic West African

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

prostitutes: evidence that HIV-2 is pathogenic, but less so than HIV-1. AIDS.

1991;5(10):116572.

57. Pepin J, Dunn D, Gaye I, Alonso P, Egboga A,Tedder R, et al. HIV-2 infection

among prostitutes working in The Gambia: association with serological

evidence of genital ulcer diseases and with generalized lymphadenopathy.

AIDS. 1991;5(1):6975.

58. Pickering H, Quigley M, Pepin J, Todd J, Wilkins A. The effects of post-test

counselling on condom use among prostitutes in The Gambia. AIDS.

1993;7(2):2713.

59. Pickering H, Todd J, Dunn D, Pepin J, Wilkins A. Prostitutes and their clients:

a Gambian survey. Soc Sci Med. 1992;34(1):7588.

60. Asamoah-Adu C, Khonde N, Avorkliah M, Bekoe V, Alary M, Mondor M,

et al. HIV infection among sex workers in Accra: need to target new recruits

entering the trade. J Acquir Immune Defic Syndr. 2001;28(4):35866.

61. Deceuninck G, Asamoah-Adu C, Khonde N, Pepin J, Frost EH, Deslandes S,

et al. Improvement of clinical algorithms for the diagnosis of Neisseria

gonorrhoeae and Chlamydia trachomatis by the use of Gram-stained smears

among female sex workers in Accra, Ghana. Sex Transm Dis. 2000;27(7):

40110.

62. Co

ˆte

´AM, Sobela F, Dzokoto A, Nzambi K, Asamoah-Adu C, Labbe AC, et al.

Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana.

AIDS. 2004;18(6):91725.

63. Aho J, Koushik A, Diakite SL, Loua KM, Nguyen VK, Rashed S. Biological

validation of self-reported condom use among sex workers in Guinea. AIDS

Behav. 2010;14(6):128793.

64. Aho J, Nguyen VK, Diakite S, Sow A, Koushik A, Rashed S. High acceptability

of HIV voluntary counselling and testing among female sex workers: impact of

individual and social factors. HIV Med. 2012;13(3):15665.

65. Diallo BL, Alary M, Rashed S, Barry A. HIV prevalence, associated risk

factors and evolution among truck drivers from 2001 to 2007 in Guinea. Med

Trop. 2011;71(2):1426.

66. Denis F, Barin F, Gershy-Damet G, Rey JL, Lhuillier M, Mounier M, et al.

Prevalence of human T-lymphotropic retroviruses type III (HIV) and type IV in

Ivory Coast. Lancet. 1987;1(8530):40811.

67. Ettiegne-Traore V, Ghys PD, Maurice C, Hoyi-Adonsou YM, Soroh D,

Adom ML, et al. Evaluation of an HIV saliva test for the detection of HIV-1 and

HIV-2 antibodies in high-risk populations in Abidjan, Cote d’Ivoire. Int J STD

AIDS. 1998;9(3):1734.

68. Ghys PD, Diallo MO, Ettiegne-Traore V, Yeboue KM, Gnaore E, Lorougnon F,

et al. Dual seroreactivity to HIV-1 and HIV-2 in female sex workers in Abidjan,

Cote d’Ivoire. AIDS. 1995;9(8):9558.

69. Ghys PD, Fransen K, Diallo MO, Ettiegne-Traore V, Coulibaly IM, Yeboue

KM, et al. The associations between cervicovaginal HIV shedding, sexually

transmitted diseases and immunosuppression in female sex workers in

Abidjan, Cote d’Ivoire. AIDS. 1997;11(12):F8593.

70. Koffi K, Gershy-Damet GM, Peeters M, Soro B, Rey JL, Delaporte E. Rapid

spread of HIV infections in Abidjan, Ivory Coast, 1987 1990. Eur J Clin

Microbiol Infect Dis. 1992;11(3):2713.

71. Nkengasong JN, Kestens L, Ghys PD, Koblavi-Deme S, Otten RA, Bile C, et al.

Dual infection with human immunodeficiency virus type 1 and type 2: impact

on HIV type 1 viral load and immune activation markers in HIV-seropositive

female sex workers in Abidjan, Ivory Coast. AIDS Res Hum Retroviruses.

2000;16(14):13718.

72. Vuylsteke B, Semde G, Sika L, Crucitti T, Ettiegne Traore V, Buve A, et al. HIV

and STI prevalence among female sex workers in Cote d’Ivoire: why targeted

prevention programs should be continued and strengthened. PLoS One.

2012;7(3):e32627.

73. Ouattara SA, Diallo D, Meite M, Aron Y, Akran V, Gody M, et al.

Epidemiology of infections caused by human immunodeficiency viruses HIV-1

and HIV-2 in the Ivory Coast. Med Trop. 1988;48(4):3759.

74. Vuylsteke BL, Ghys PD, Traore M, Konan Y, Mah-Bi G, Maurice C, et al. HIV

prevalence and risk behavior among clients of female sex workers in Abidjan,

Cote d’Ivoire. AIDS. 2003;17(11):16914.

75. Peeters M, Koumare B, Mulanga C, Brengues C, Mounirou B, Bougoudogo

F, et al. Genetic subtypes of HIV type 1 and HIV type 2 strains in commercial

sex workers from Bamako, Mali. AIDS Res Hum Retroviruses. 1998;14(1):518.

76. Pichard E, Guindo A, Grossetete G, Fofana Y, Maiga YI, Koumare B, et al.

Human immunodeficiency virus (HIV) infection in Mali. Med Trop.

1988;48(4):3459.

77. Gragnic G, Julvez J, Abari A, Alexandre Y. HIV-1 and HIV-2 seropositivity

among female sex workers in the Tenere Desert, Niger. Trans R Soc Trop Med

Hyg. 1998;92(1):29.

78. Mamadou S, Laouel Kader A, Rabiou S, Aboubacar A, Soumana O, Garba A,

et al. Prevalence of the HIV infection and five other sexually-transmitted

infections among sex workers in Niamey, Niger. Bull Soc Pathol Exot. 2006;

99(1):1922.

79. Develoux M, Meynard D, Dupont A, Delaporte E. Hepatitis C virus

antibodies in prostitutes in Niger. Trans R Soc Trop Med Hyg. 1994;88(5):536.

80. Tohon Z, Garba A, Amadou Hamidou A, Sidikou F, Ibrahim ML,

Elhadj Mahamane A, et al. Behaviour and HIV seroprevalence investigation

in sex workers of Dirkou, Niger, 2002. Bull Soc Pathol Exot. 2006;99(1):4951.

81. Ahmed S, Delaney K, Villalba-Diebold P, Aliyu G, Constantine N,

Ememabelem M, et al. HIV counseling and testing and access-to-care needs

of populations most-at-risk for HIV in Nigeria. AIDS Care. 2013;25(1):8594.

82. Dada AJ, Ajayi AO, Diamondstone L, Quinn TC, Blattner WA, Biggar RJ.

A serosurvey of Haemophilus ducreyi, syphilis, and herpes simplex virus type 2

and their association with human immunodeficiency virus among female sex

workers in Lagos, Nigeria. Sex Transm Dis. 1998;25(5):23742.

83. Dada AJ, Oyewole F, Onofowokan R, Nasidi A, Harris B, Levin A, et al.

Demographic characteristics of retroviral infections (HIV-1, HIV-2, and HTLV-I)

among female professional sex workers in Lagos, Nigeria. J Acquir Immune

Defic Syndr. 1993;6(12):135863.

84. Eluwa GI, Strathdee SA, Adebajo SB, Ahonsi B, Azeez A, Anyanti J. Sexual

risk behaviors and HIV among female sex workers in Nigeria. J Acquir Immune

Defic Syndr. 2012;61(4):50714.

85. Imade G, Sagay A, Egah D, Onwuliri V, Grigg M, Egbodo C, et al. Prevalence

of HIV and other sexually transmissible infections in relation to lemon or lime

juice douching among female sex workers in Jos, Nigeria. Sex Health.

2008;5(1):5560.

86. Lawan UM, Abubakar S, Ahmed A. Risk perceptions, prevention and

treatment seeking for sexually transmitted infections and HIV/AIDS among

female sex workers in Kano, Nigeria. Afr J Reprod Health. 2012;16(1):617.

87. Obi CL, Ogbonna BA, Igumbor EO, Ndip RN, Ajayi AO. HIV seropositivity

among female prostitutes and nonprostitutes: obstetric and perinatal implica-

tions. Viral Immunol. 1993;6(3):1714.

88. Olaleye OD, Bernstein L, Ekweozor CC, Sheng Z, Omilabu SA, Li XY, et al.

Prevalence of human immunodeficiency virus types 1 and 2 infections in

Nigeria. J Infect Dis. 1993;167(3):7104.

89. Bakare RA, Oni AA, Umar US, Adewole IF, Shokunbi WA, Fayemiwo SA,

et al. Pattern of sexually transmitted diseases among commercial sex workers

(CSWs) in Ibadan, Nigeria. Afr J Med Sci. 2002;31(3):2437.

90. Chikwem JO, Mohammed I, Ola T. Human immunodeficiency virus type 1

(HIV-1) infection among female prostitutes in Borno State of Nigeria: one year

follow-up. East Afr Med J. 1989;66(11):7526.

91. Fayemiwo SA, Odaibo GN, Oni AA, Ajayi AA, Bakare RA, Olaleye DO. Genital

ulcer diseases among HIV-infected female commercial sex workers in Ibadan,

Nigeria. Afr J Med Sci. 2011;40(1):3946.

92. Eluwa GI, Strathdee SA, Adebayo SB, Ahonsi B, Adebajo SB. A profile on

HIV prevalence and risk behaviors among injecting drug users in Nigeria:

should we be alarmed? Drug Alcohol Depend. 2013;127(13):65 71.

93. Adebajo SB, Eluwa GI, Allman D, Myers T, Ahonsi BA. Prevalence of

internalized homophobia and HIV associated risks among men who have sex

with men in Nigeria. Afr J Reprod Health. 2012;16(4):218.

94. Merrigan M, Azeez A, Afolabi B, Chabikuli ON, Onyekwena O, Eluwa G,

et al. HIV prevalence and risk behaviours among men having sex with men in

Nigeria. Sex Transm Infect. 2011;87(1):6570.

95. Vu L, Adebajo S, Tun W, Sheehy M, Karlyn A, Njab J, et al. High HIV

prevalence among men who have sex with men in Nigeria: implications for

combination prevention. J Acquir Immune Defic Syndr. 2013;63(2):2217.

96. Kane CT, Diawara S, Ndiaye HD, Diallo PA, Wade AS, Diallo AG, et al.

Concentrated and linked epidemics of both HSV-2 and HIV-1/HIV-2 infections

in Senegal: public health impacts of the spread of HIV. Int J STD AIDS.

2009;20(11):7936.

97. Kanki P, M’Boup S, Marlink R, Travers K, Hsieh CC, Gueye A, et al.

Prevalence and risk determinants of human immunodeficiency virus type 2

(HIV-2) and human immunodeficiency virus type 1 (HIV-1) in west African

female prostitutes. Am J Epidemiol. 1992;136(7):895907.

98. Langley CL, Benga-De E, Critchlow CW, Ndoye I, Mbengue-Ly MD, Kuypers

J, et al. HIV-1, HIV-2, human papillomavirus infection and cervical neoplasia in

high-risk African women. AIDS. 1996;10(4):4137.

99. Laurent C, Seck K, Coumba N, Kane T, Samb N, Wade A, et al. Prevalence of

HIV and other sexually transmitted infections, and risk behaviours in

unregistered sex workers in Dakar, Senegal. AIDS. 2003;17(12):18116.

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

100. Ndiaye CF, Critchlow CW, Leggott PJ, Kiviat NB, Ndoye I, Robertson PB,

et al. Periodontal status of HIV-1 and HIV-2 seropositive and HIV seronegative

female commercial sex workers in Senegal. J Periodontol. 1997;68(9):82731.

101. Wang C, Hawes SE, Gaye A, Sow PS, Ndoye I, Manhart LE, et al. HIV

prevalence, previous HIV testing, and condom use with clients and regular

partners among Senegalese commercial sex workers. Sex Transm Infect.

2007;83(7):53440.

102. Thior I, Diouf G, Diaw IK, Sarr AD, Hsieh CC, Ndoye I, et al. Sexually

transmitted diseases and risk of HIV infection in men attending a sexually

transmitted diseases clinic in Dakar, Senegal. Afr J Reprod Health. 1997;1(2):

2635.

103. do Espirito Santo ME, Etheredge GD. HIV prevalence and sexual

behaviour of male clients of brothels’ prostitutes in Dakar, Senegal. AIDS Care.

2003;15(1):5362.

104. Wade AS, Larmarange J, Diop AK, Diop O, Gueye K, Marra A, et al.

Reduction in risk-taking behaviors among MSM in Senegal between 2004 and

2007 and prevalence of HIV and other STIs. ELIHoS Project, ANRS 12139. AIDS

Care. 2010;22(4):40914.

105. Wade AS, Kane CT, Diallo PA, Diop AK, Gueye K, Mboup S, et al. HIV

infection and sexually transmitted infections among men who have sex with

men in Senegal. AIDS. 2005;19(18):213340.

106. Stromdahl S, Onigbanjo Williams A, Eziefule B, Emmanuel G, Iwuagwu S,

Anene O, et al. Associations of consistent condom use among men who have

sex with men in Abuja, Nigeria. AIDS Res Hum Retroviruses. 2012;28(12):

175662.

107. Ndiaye HD, Toure-Kane C, Vidal N, Niama FR, Niang-Diallo PA, Dieye T,

et al. Surprisingly high prevalence of subtype C and specific HIV-1 subtype/CRF

distribution in men having sex with men in Senegal. J Acquir Immune Defic

Syndr. 2009;52(2):24952.

108. Baral S, Kizub D, Masenior NF, Peryskina A, Stachowiak J, Stibich M, et al.

Male sex workers in Moscow, Russia: a pilot study of demographics, substance

use patterns, and prevalence of HIV-1 and sexually transmitted infections. AIDS

Care. 2010;22(1):1128.

109. Infante C, Sosa-Rubi SG, Cuadra SM. Sex work in Mexico: vulnerability of

male, travesti, transgender and transsexual sex workers. Cult Health Sex.

2009;11(2):12537.

110. Ngugi E. Female sex workers in Africa: epidemiology overview, data gaps,

ways forward. SAHARA J. 2012;9(3):14853.

111. Lawoyin TO. Condom use with sex workers and abstinence behaviour

among men in Nigeria. J R Soc Promot Health. 2004;124(5):2303.

112. Fourn L, Ducic S. Epidemiological portrait of acquired immunodeficiency

syndrome and its implications in Benin. Sante (Montrouge France). 1996;6(6):

3716.

113. Bamidele JO, Abodunrin OL, Adebimpe WO. Sexual behavior and risk of

HIV/AIDS among adolescents in public secondary schools in Osogbo, Osun

State, Nigeria. Int J Adolesc Med Health. 2009;21(3):387 94.

114. Adjei AA, Armah HB, Gbagbo F, Ampofo WK, Quaye IK, Hesse IF, et al.

Prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C

virus and syphilis among prison inmates and officers at Nsawam and Accra,

Ghana. J Med Microbiol. 2006;55(Pt 5):5937.

115. Adjei AA, Armah HB, Gbagbo F, Ampofo WK, Boamah I, Adu-Gyamfi C,

et al. Correlates of HIV, HBV, HCV and syphilis infections among prison inmates

and officers in Ghana: a national multicenter study. BMC Infect Dis. 2008;8:33.

116. Alary M, Lowndes CM, Mukenge-Tshibaka L, Gnintoungbe CA, Bedard E,

Geraldo N, et al. Sexually transmitted infections in male clients of female sex

workers in Benin: risk factors and reassessment of the leucocyte esterase

dipstick for screening of urethral infections. Sex Transm Infect. 2003;79(5):

38892.

117. Henry E, Marcellin F, Yomb Y, Fugon L, Nemande S, Gueboguo C, et al.

Factors associated with unprotected anal intercourse among men who have

sex with men in Douala, Cameroon. Sex Transm Infect. 2010;86(2):136 40.

118. Kalamar M, Maharaj P, Gresh A. HIV-prevention interventions targeting

men having sex with men in Africa: field experiences from Cameroon. Cult

Health Sex. 2011;13(10):113549.

119. Beyrer C, Jittiwutikarn J, Teokul W, Razak MH, Suriyanon V, Srirak N, et al.

Drug use, increasing incarceration rates, and prison-associated HIV risks in

Thailand. AIDS Behav. 2003;7(2):15361.

120. Beyrer C, Mehta SH, Baral SD. The international drug epidemic. In: Pizer

H, Mayer K, editors. Social ecology of infectious disease. London: Elsevier;

2006. p. 77112.

121. Perry A. The cocaine crisis: how the drug trade is ruining West Africa.

Time Magazine. Oct. 22, 2012.

122. Beyrer C. War in the blood. Sex, politics and HIV/AIDS in SouthEast Asia.

London, UK: Zed Books; 1998.

123. Beyrer C. Fearful symmetry: heroin trafficking and HIV spread. Bull Narc.

2002;LIV(1):103.

124. Mathers BM, Degenhardt L, Adam P, Toskin I, Nashkhoev M, Lyerla R,

et al. Estimating the level of HIV prevention coverage, knowledge and

protective behavior among injecting drug users: what does the 2008 UNGASS

reporting round tell us? J Acquir Immune Defic Syndr. 2009;52(Suppl 2):

S132S42.

125. Cote AM, Sobela F, Dzokoto A, Nzambi K, samoah-Adu C, Labbe AC, et al.

Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana.

AIDS. 2004;18(6):91725.

126. Leclerc PM, Garenne M. Commercial sex and HIV transmission in mature

epidemics: a study of five African countries. Int J STD AIDS. 2008;19(10):660 4.

127. Decosas J, Kane F, Anarfi JK, Sodji KD, Wagner HU. Migration and AIDS.

Lancet. 1995;346(8978):8268.

128. Meredith M. The state of Africa: a history of fifty years of independence.

London: The Free Press; 2006.

129. Beyrer C, Baral S, Zenilman J. STDs, HIV/AIDS and migrant populations.

In: Holmes KK, Sparling PF, Mardh PA, Lemon SM, Stamm WE, Piot P, et al.,

editors. Sexually transmitted diseases. Seattle: McGraw-Hill Professional; 2006.

p. 25768.

130. Poteat TD, Diouf D, Baral S, Ndaw M, Drame F, Traore C, Wirtz A, et al.,

editors. The impact of criminalization of same sex practices on HIV risk among

men who have sex with men (MSM) in Senegal: results of a qualitative rapid

assessment (TUPE0709). International AIDS Conference; July 1823, 2010;

Vienna: IAS.

131. Munoz J, Adedimeji A, Alawode O. ‘They bring AIDS to us and say we give

it to them’: socio-structural context of female sex workers’ vulnerability to HIV

infection in Ibadan, Nigeria. SAHARA J. 2010;7(2):5261.

132. Millett GA, Flores SA, Peterson JL, Bakeman R. Explaining disparities in

HIV infection among black and white men who have sex with men: a meta-

analysis of HIV risk behaviors. AIDS. 2007;21(15):208391.

133. Baral SD, Wirtz A, Sifakis F, Johns B, Walker D, Beyrer C. The highest

attainable standard of evidence (HASTE) for HIV/AIDS interventions: toward a

public health approach to defining evidence. Public Health Rep. 2012;127(6):

57284.

134. Dreazen Y. Mali: Welcome to Cocainebougou Foreign Policy Magazine, FP

Group, Washington, DC, Published online March 27, 2013.

135. Beyrer C, Baral S, Kerrigan D, El-Bassel N, Bekker LG, Celentano DD.

Expanding the space: inclusion of most-at-risk populations in HIV prevention,

treatment, and care services. J Acquir Immune Defic Syndr. 2011;57(Suppl 2):

S969.

136. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum

of engagement in HIV care and its relevance to test-and-treat strategies for

prevention of HIV infection. Clin Infect Dis. 2011;52(6):793800.

137. Gross R, Yip B, Lo Re V, 3rd, Wood E, Alexander CS, Harrigan PR, et al.

A simple, dynamic measure of antiretroviral therapy adherence predicts failure

to maintain HIV-1 suppression. J Infect Dis. 2006;194(8):110814.

138. Tanser F, Barnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of

ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal,

South Africa. Science. 2013;339(6122):96671.

139. Auerbach JD, Parkhurst JO, Ca

´ceres CF. Addressing social drivers of HIV/

AIDS for the long-term response: conceptual and methodological considera-

tions. Glob Public Health. 2011;6(Suppl 3):S293309.

140. Logie C. The case for the World Health Organization’s Commission on the

Social Determinants of Health to address sexual orientation. Am J Public

Health. 2012;102(7):12436.

141. Chakrapani V, Newman PA, Shunmugam M, Kurian AK, Dubrow R. Barriers

to free antiretroviral treatment access for female sex workers in Chennai, India.

AIDS Patient Care and STDs. 2009;23(11):97380.

142. Baral S, Semugoma P, Diouf D, Trapence G, Poteat T, Ndaw M, Drame F,

et al., editors. Criminalization of same sex practices as a structural driver of HIV

risk among men who have sex with men (MSM): the cases of Senegal, Malawi,

and Uganda (MOPE0951). International AIDS Conference; July 1823, 2010;

Vienna: IAS.

Papworth E et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18751

http://www.jiasociety.org/index.php/jias/article/view/18751 | http://dx.doi.org/10.7448/IAS.16.4.18751

Research article

HIV prevalence and factors associated with HIV infection among

men who have sex with men in Cameroon

Ju Nyeong Park

, Erin Papworth

, Sethson Kassegne

, Laure Moukam

, Serge Clotaire Billong

, Issac Macauley

Yves Roger Yomb

, Nathalie Nkoume

, Valentin Mondoleba

, Jules Eloundou

, Matthew LeBreton

, Ubald Tamoufe

Ashley Grosso

and Stefan D Baral

§,1

Corresponding author: Stefan D Baral, Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health,

615 N. Wolfe Street, E 7146, Baltimore, MD 21205, USA. Tel: 1 410 502 8975. Fax: 1 410 614 8371. (sbaral@jhsph.edu)

Abstract

Introduction: Despite men who have sex with men (MSM) being a key population for HIV programming globally, HIV

epidemiologic data on MSM in Central Africa are sparse. We measured HIV and syphilis prevalence and the factors associated

with HIV infection among MSM in Cameroon.

Methods: Two hundred and seventy-two and 239 MSM aged ]18 from Douala and Yaounde

´, respectively, were recruited using

respondent-driven sampling (RDS) for this cross-sectional surveillance study in 2011. Participants completed a structured

questionnaire and HIV and syphilis testing. Statistical analyses, including RDS-weighted proportions, bootstrapped confidence

intervals and logistic regressions, were used.

Results: Crude and RDS-weighted HIV prevalence were 28.6% (73/255) and 25.5% (95% CI 19.131.9) in Douala, and 47.3%

(98/207) and 44.4% (95% CI 35.753.2) in Yaounde

´. Active syphilis prevalence in total was 0.4% (2/511). Overall, median age was

24 years, 62% (317/511) of MSM identified as bisexual and 28.6% (144/511) identified as gay. Inconsistent condom use with

regular male partners (64.1%; 273/426) and casual male and female partners (48.5%; 195/402) was common, as was the

inconsistent use of condom-compatible lubricants (CCLs) (26.3%; 124/472). In Douala, preferring a receptive sexual role was

associated with prevalent HIV infection [adjusted odds ratio (aOR) 2.33, 95% CI 1.025.32]. Compared to MSM without HIV

infection, MSM living with HIV were more likely to have ever accessed a health service targeting MSM in Douala (aOR 4.88, 95%

CI 1.6314.63). In Yaounde

´, MSM living with HIV were more likely to use CCLs (aOR 2.44, 95% CI 1.194.97).

Conclusions: High HIV prevalence were observed and condoms and CCLs were used inconsistently indicating that MSM are a

priority population for HIV prevention, treatment and care services in Douala and Yaounde

´. Building the capacity of MSM

community organizations and improving the delivery and scale-up of multimodal interventions for MSM that are sensitive to

concerns about confidentiality and the complex individual, social, community-level and policy challenges are needed to

successfully engage young MSM in the continuum of HIV care. In addition to scaling up condom and CCL access, evaluating the

feasibility of novel biomedical interventions, including antiretroviral pre-exposure prophylaxis and early antiretroviral therapy for

MSM living with HIV in Cameroon, is also warranted.

Keywords: Men who have sex with men (MSM); HIV/AIDS; epidemiology; Africa; prevalence; respondent-driven sampling (RDS);

homosexuality; prevention; risk factors; sexual behaviour.

Received 22 May 2013; Revised 26 August 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 Park JN et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution

3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Introduction

Globally, it has been observed that HIV prevalence among

men who have sex with men (MSM) significantly exceeds HIV

prevalence in the general population, even in the context

of generalized epidemics [13]. Across sub-Saharan Africa,

HIV prevalence is estimated to be approximately 5% in the

general population and 17.9% among MSM [1]. The few

published studies from West Africa consistently report

higher HIV prevalence among MSM than in the general

population, with HIV prevalence estimates of 13.5% among

MSM in Nigeria, 16.3% in Burkina Faso and 21.8% in Senegal

[1,2,46]. Individual-, network-, community-level and policy-

level factors noted to contribute to the higher risk of acqui-

sition and transmission of HIV and other sexually transmitted

infections (STIs) among MSM have been found to be pre-

valent in Central and West Africa [5,7,8].

With over 550,000 people living with HIV in Cameroon,

the prevalence of HIV among reproductive-age adults in

A preliminary analysis of data reported here was presented at the 7th International AIDS Society Conference, which was held from 30 June to 3 July 2013 in Kuala

Lumpur, Malaysia.The abstract was entitled ‘‘Optimizing multicomponent interventions for men who have sex with men (MSM) in Cameroon: Factors associated with

HIV testing.’’

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

Cameroon is estimated to be 4.3%, which represents a

mature and widespread generalized epidemic [9,10]. In

Douala and Yaounde

´, the two largest cities of the country,

HIV prevalence among reproductive-age adults is estimated

to be 4.6% and 6.3%, respectively [10].

MSM were recently listed as a priority group in the

Cameroon government’s ‘‘National Strategic Plan for HIV, AIDS,

and STIs: 20112015,’’ along with goals including strengthen-

ing HIV-prevention programmes and building capacity for HIV

health services that serve MSM [11]. The higher biological

risks of HIV acquisition and transmission associated with

unprotected anal intercourse (UAI) compared to other forms

of sexual intercourse make MSM an important target popu-

lation for HIV-prevention efforts [12]. However, only one HIV

prevalence estimate from programmatic data in Douala is

available to date for MSM; in this 2007 study, which used

convenience sampling, HIV prevalence was estimated to be

18.4% [13].

Established individual-level risks for HIV acquisition and

transmission among MSM in the region that are modifiable

include UAI, inconsistent use of condom-compatible lubricants

(CCLs), a high number of male partners, drug use and syphilis

co-infection [1]. In a recent study, UAI in the past 6 months was

frequent among MSM in Douala, as was having one or more

female sexual partners [7]. Bisexual concurrency and bisexual

partnerships among MSM have been observed in studies in

Nigeria, Senegal and southern Africa [5,14,15]. Inconsistent

condom use with male and female partners was common

among MSM in one Togo study, and in a study conducted in

Nigeria, it was associated with prevalent HIV infection, as was

having been the receptive partner in anal intercourse in the

past 6 months [5,16]. Other factors associated with prevalent

HIV infection among MSM in Nigeria and Senegal were older

age and having a symptomatic STI [5,15].

Network-level factors that may impact HIV-transmission

risk include sexual network size, STI prevalence, levels of peer

education, knowledge of HIV status within the population

and network tendencies for drug use or transactional sex [1].

Community-level factors that may contribute to HIV risk

include high community viral load and suboptimal coverage

or uptake of healthcare services [1]. Additionally, the social

stigma surrounding HIV, sexual identities and homosexuality

in Cameroon may deter MSM from seeking voluntary HIV

counselling and testing (VCT) or other health services [17 

20]. Perceived stigma, including fear of seeking healthcare

and refraining from disclosing same-sex practices to a health

professional, and enacted discrimination, including denial of

healthcare access based on sexuality, were frequently re-

ported by MSM in Senegal and southern Africa, and were

associated with increased sexual risk practices and prevalent

HIV infection [2126]. Similar to most countries in sub-

Saharan Africa, sexual relationships between men are both

criminalized and highly stigmatized in Cameroon, and prose-

cution can result in up to 5 years of imprisonment [8]; physical

violence from law enforcement is also a reality for some

MSM, posing challenges to HIV programming [8,27 29].

In light of the unique needs of MSM within generalized

epidemics, and the limited data available on this vulnerable

population in Cameroon, we aimed to describe the socio-

demographic and behavioural characteristics of MSM in

Douala and Yaounde

´, determine the age-stratified HIV and

syphilis prevalence in both cities, and investigate the

individual-, network- and community-level factors associated

with HIV infection among this population.

Methods

Study population

This cross-sectional study was conducted in AugustSeptember

2011 at two community-based organizations (CBOs) that

provide targeted services to MSM: Alternatives-Cameroun

in Douala and the Cameroon National Association for Family

Welfare (CAMNAFAW) in Yaounde

´. The interviewers were

MSM community volunteers from Alternatives-Cameroun,

Humanity First and CAMNAFAW. The MSM sensitivity trainings

for interviewers were conducted at the Association Camer-

ounaise pour le Marketing Social (ACMS) conference rooms

in Douala and Yaounde

´. Men aged 18 years or older who

reported engaging in penileanal or oral intercourse with

another man in the past 12 months were eligible for the study.

Participants were recruited using respondent-driven sampling

(RDS) [30], a sampling technique that enables estimation of

proportions and regression modelling while controlling for

non-random social network structures that bias peer-based

recruitment. Seven seeds heterogeneous in sexual identity

and sexual role preference were selected through existing

community contacts to begin the recruitment process in each

city. Upon enrolment in the study, all individuals were given

three uniquely coded coupons to refer other MSM to the

study. The CBOs worked with the research team to identify

the initial seeds, screen study participants for eligibility and

interview participants after receiving informed consent.

Sample-size calculations were based on the ability to

detect a 15% change in the prevalence of condom use at last

anal intercourse over time from 60% at baseline, with a

design effect of 2, a significance level of 0.05 and a power of

80%, yielding 241 men for each city.

All participants provided written informed consent. The

study was approved by the Cameroon National Ethics Com-

mittee, and the secondary analysis of the study data was

approved by the Johns Hopkins Bloomberg School of Public

Health.

Data collection

Participants completed an interviewer-administered structured

questionnaire containing questions on: socio-demographics;

network size; sexual behaviours, including condom and lubri-

cant use (always vs. often, sometimes or never); experiences

of STI symptoms; access to CBO-run MSM centres (which

included outreach services); access to free condoms; VCT

experiences; knowledge of HIV transmission, prevention and

treatment (a composite score from 13 questions); and per-

ceived social support for condom use (a composite score

from eight questions, including support from partners, family

and peers). Interviews were conducted in French or English,

and they were recorded in French.

After participants received pre-test counselling, approxi-

mately 4 ml blood specimen was collected from them by a

Global Viral Cameroon phlebotomist and tested to confirm

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

HIV and syphilis serostatus, followed by post-test counselling

on the same day. Men who screened positive for HIV or

syphilis were referred to appropriate health services. All par-

ticipants were reimbursed 1000 CFA franc (US$2) for com-

pleting the questionnaire and an additional 1000 CFA franc

(US$2) for each peer referred into the study. All participants

received free VCT, condoms and CCLs. Participants were also

given access to peer education, support groups and linkage

to HIV care.

Laboratory testing

Specimen processing and testing were conducted by staff

from Global Viral Cameroon at the field sites. The national

HIV surveillance algorithm for second-generation surveil-

lance of HIV, adopted by the Ministry of Public Health of

Cameroon, was used to measure current HIV status, including

Determine†HIV-1/2 (Inverness Medical, Chiba, Japan) and

Human HEXAGON HIV 1 2 (Human GmBh, Wiesbaden,

Germany). All indeterminate and positive samples and 15%

of the negative samples were transferred to the Global Viral

Cameroon Yaounde

´laboratory for fourth-generation HIV

enzyme-linked immunosorbent assay (ELISA), which detects

antibodies to HIV-1/2 and the p24 antigen (whose presence

indicates a possible seroconversion). Screening for syphilis was

performed according to the national algorithm in Cameroon

using Rapid Protein Reagin (RPR; SGM Italia, Roma, Italy) and

Treponema pallidum haemagglutination assay (TPHA; Fortress

Diagnostics Limited, Antrim, UK). Global Viral Cameroon was

responsible for blood specimen collection, laboratory testing

and serology data management.

Statistical analysis

ACMS and CARE International-Cameroon managed study

data. Questionnaire data were double entered into the

CSPro (version 4.0) software, exported into SPSS for data

cleaning by ACMS and then exported to Stata/SE (version

11.2) for data analysis.

To minimize biases associated with chain referral sampling,

weights were created in Stata/SE version 11.2 using the RDSII

estimator to account for the effect of differences in the social

network sizes of participants. Weights were based on the

transition matrix for the dependent variable, current HIV

status. Network size was assessed using the response from

the latter of two questions: ‘‘How many men who have had

oral or anal sex with men in the last 12 months do you know,

who also know you and live in this city?’’ and ‘‘among

these men that you know personally, how many of them are

18 years and older?’’ Homophily (range: 1to1) was

assessed to evaluate the preferences of individuals to recruit

MSM with the same HIV status [31].

Bivariate logistic regression models were used to esti-

mate the unadjusted association between HIV infection and

covariates selected based on our knowledge and the pub-

lished literature. RDS-weighted prevalence and bootstrapped

confidence intervals were calculated for all variables ex-

plored in regression modelling. Multivariate logistic regres-

sion models were built to estimate the adjusted association

between current HIV status and covariates, with age forced

into all models regardless of statistical significance. The

Akaike information criterion (AIC) was used to favour the

most parsimonious models. Bivariate and multivariate logistic

regression models were also built with RDS weighting.

p-values B0.05 were used to indicate statistical significance.

We further compared the associations between binary

covariates using the Pearson chi-square test.

Results

A total of 295 men were screened in Douala, of whom 272

participated. In Yaounde

´, a total of 246 individuals were

screened, resulting in 239 participants. The median number of

descendants per seed was 32 (range 699) in Douala and 31

(range 288) in Yaounde

´. In Douala, the median number of

waves per seed was 6 (range 18); homophily for HIV status

was 0.04 among the HIV-negative group and 0.06 in the

group living with HIV. In Yaounde

´, the median number of

waves per seed was five (range 19); homophily for HIV status

was 0.004 for the HIV-negative group and 0.06 for the group

living with HIV. In both samples, RDS network homophily was

close to 0, which may indicate a close approximation to

random recruitment. The majority (77.9%; 398/511) reported

that they would have given a coupon to their recruiter (an

indicator of the reciprocal ties assumption [32]).

Overall, the median age was 24 years (range 1851,

interquartile range (IQR) 2128). In both cities, the majority

had completed secondary education and were single. Sixty-

two percent of MSM in the overall sample identified as

bisexual, compared with 28.6% who identified as gay or

homosexual and 9.8% as MSM or other. Ninety-eight percent

of all participants reported having penile-anal intercourse

in the past 12 months. Median age of sexual debut with

another man was 19 (IQR 1722) (Table 1).

Responses to questions on health service uptake, HIV

knowledge, social support and sexual practices are presented

in Table 2. Men in Yaounde

´were much less likely to access CBO

services targeting MSM than men in Douala (33.7% vs. 66.1%,

(1), pB0.001). No difference was observed in ever receiving

free condoms (74.2% vs. 68.8%, x

(1), p0.2). In both cities, a

large proportion of men reported sex with males and females

(46.2%) and experienced STI symptoms in the previous

year (34.6%). Inconsistent use of condoms with regular male

partners (64.1%; 273/426) and casual male and female

partners (48.5%; 195/402) was common, as were condom

slippage and breakage (43.7%; 216/494). Ninety percent of

MSM who used condoms also reported using lubricant. Of

these men, 26.3% (124/472) reported using lotion, saliva,

Vaseline or other condom-incompatible lubricants.

As presented in Table 3, crude and RDS-weighted HIV

prevalence were 28.6% (73/255) and 25.5% (95% CI 19.1

31.9) in Douala and 47.3% (98/207) and 44.4% (95% CI 35.7

53.2) in Yaounde

´. Age-stratified prevalence is presented in

Figure 1. In Douala, only 17 (6.3%) MSM refused to be tested;

in Yaounde

´, this number was higher (13.4%, n32). An

association between having a history of VCT and refusing

testing in the study was observed in Yaounde

´, although it did

not reach statistical significance (15.2% vs. 4.9%, p0.08).

Refusal was not correlated with age, education level, age of

sexual debut, condom use, receptive sexual role preference,

number of male sexual partners in the past 12 months or

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

perceived social support for condom use (all p0.10). Active

syphilis infection was detected in only one participant per city.

Factors associated with HIV infection

Douala

Bivariate and multivariate analyses of the individual-, network-

and community-level factors associated with HIV infection in

Douala are presented in Table 4. The adjusted RDS-weighted

odds of having HIV increased for every year rise in age for

MSM aged 1829 (aOR 1.13 per year, 95% CI 1.011.27), then

plateaued for MSM aged 30 and older (aOR 0.89 per year, 95%

CI 0.721.09). Preference for the receptive sexual role (aOR

2.33, 95% CI 1.025.32) was associated with increased odds

of having HIV in both RDS-naı

¨ve and RDS-weighted multi-

variate analyses. Individuals living with HIV were more likely

to have ever accessed a CBO service for MSM compared

to individuals without HIV (aOR 4.88, 95% CI 1.6314.63).

Individuals who had sex with women (OR 0.50, 95% CI 0.26

0.96) or used condoms inconsistently with casual partners

(OR 0.40, 95% CI 0.180.89) in the past 12 months were less

likely to be living with HIV in bivariate analysis.

Yaounde

In multivariate analysis of the Yaounde

´sample (Table 5),

factors independently associated with having HIV infection

were age (aOR 1.14, 95% CI 1.021.26 if aged 1829; aOR

0.84, 95% CI 0.651.07 if aged ]30) and general use of CCLs

with condoms (aOR 2.44, 95% CI 1.194.97). Men living with

HIV were more likely to have four or more partners in the

past 12 months, although this did not reach statistical

significance (aOR: 1.88, 95% CI: 0.953.71).

Discussion

The high HIV prevalence and inconsistent use of condoms

and CCLs observed in this study highlight that MSM are a

Table 1. Characteristics of MSM recruited from Douala (n272) and Yaounde

´(n239) in Cameroon, 2011

All

Douala Yaounde

n(%) n(%) RDS-weighted % (95% CI) n(%) RDS-weighted % (95% CI)

Total 511 (100) 272 (100) 239 (100) 

Age, median (IQR) (years) 24 (21 28) 23 (2127) 25 (2128) 

1823 238 (46.6) 142 (52.2) 57.6 (50.664.6) 96 (40.2) 42.1 (34.050.3)

2429 185 (36.2) 85 (31.3) 29.5 (23.135.9) 100 (41.8) 42.5 (34.750.3)

30 88 (17.2) 45 (16.5) 12.9 (8.217.6) 43 (18.0) 15.3 (8.9 21.8)

Education

Primary or less 26 (5.1) 20 (7.4) 7.6 (4.011.2) 6 (2.5) 2.7 (0.15.2)

Secondary 341 (66.7) 183 (67.3) 70.1 (64.176.1) 158 (66.1) 69.8 (63.576.2)

Higher than secondary 144 (28.2) 69 (25.8) 22.3 (16.528.0) 75 (31.5) 27.5 (21.5 33.6)

Occupational status

Student or apprentice 204 (39.9) 116 (42.7) 46.5 (40.053.0) 88 (36.8) 36.9 (29.344.5)

Employed 248 (48.5) 126 (46.3) 45.0 (38.151.8) 122 (51.1) 48.8 (41.056.6)

Unemployed 59 (11.6) 30 (11.0) 9.1 (5.312.9) 29 (12.1) 14.3 (7.720.9)

Christian religion 456 (89.2) 231 (86.2) 87.9 (83.292.6) 220 (92.4) 91.6 (87.196.1)

Network size, median (IQR) 12 (6 25) 13 (5 25) 12 (624.5) 

Sexual identity

Bisexual 317 (62.0) 171 (62.9) 65.9 (59.3 72.5) 146 (61.1) 62.1 (54.170.1)

Gay or homosexual 144 (28.6) 70 (26.3) 22.7 (16.828.6) 73 (31.3) 28.7 (21.136.4)

MSM 41 (8.0) 26 (9.6) 9.4 (5.613.2) 15 (6.3) 8.4 (3.5 13.3)

Other 9 (1.8) 4 (1.5) 5 (2.1) 

Relationship status

Single 425 (84.2) 230 (84.6) 85.6 (80.590.6) 194 (83.3) 87.3 (82.2 92.4)

In a relationship or married 77 (15.2) 39 (14.3) 14.4 (9.419.5) 38 (15.9) 12.7 (7.617.8)

Separated, widowed or other 3 (0.6) 2 (0.8) 1 (0.5) 

Sexual role preference

Insertive 223 (45.0) 118 (43.9) 45.4 (37.4 53.5) 110 (46.2) 46.8 (38.754.9)

Receptive 160 (31.6) 85 (31.6) 29.8 (23.636.0) 75 (31.5) 32.2 (24.7 39.8)

Versatile 119 (23.5) 66 (24.5) 24.7 (17.9 31.6) 53 (22.3) 21.0 (15.026.9)

Age of sexual debut with another

man, median (IQR) (years)

19 (1722) 19 (17 22) 19 (1721) 

CI, confidence interval; IQR, interquartile range; MSM, men who have sex with men; RDS, respondent-driven sampling.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

Table 2. Health service uptake, HIV knowledge, social support and sexual practices among MSM recruited from Douala (n272)

and Yaounde

´(n239) in Cameroon, 2011

Douala Yaounde

All

n(%) n(%)

RDS-weighted %

(95% CI) n(%)

RDS-weighted %

(95% CI)

Ever accessed CBO service targeting MSM 302 (59.1) 199 (74.3) 66.1 (57.6 74.6) 100 (42.0) 33.7 (26.640.8)

Ever received free condoms 355 (71.7) 196 (74.2) 71.6 (64.378.9) 159 (68.8) 62.2 (54.170.4)

HIV knowledge composite, median score %

correct (IQR)

85 (7792) 85 (7792) 85 (77 92) 

Social support on condom use, median

score % (IQR)

63 (3888) 63 (3888) 75 (50 88) 

Ever had sexual intercourse after drinking alcohol 338 (66.1) 156 (57.4) 57.5 (49.664.8) 182 (76.2) 73.2 (65.980.4)

Ever had sexual intercourse after taking a drug 43 (8.4) 18 (6.6) 5.0 (1.78.2) 25 (10.5) 9.7 (5.813.5)

In the past 12 months

Had male and female sexual partners 236 (46.2) 125 (46.1) 48.3 (41.2 55.5) 111 (46.4) 49.6 (42.356.9)

Experienced STI symptom(s) 175 (34.5) 80 (29.9) 30.5 (23.6 37.4) 95 (39.9) 38.9 (31.546.4)

Number of male partners, median (IQR) 3 (2 5) 3 (25) 3(25) 

13 304 (59.5) 171 (62.9) 68.1 (61.374.8) 133 (55.7) 62.9 (55.570.3)

4207 (40.5) 101 (37.1) 31.9 (25.238.7) 106 (44.3) 37.1 (29.844.5)

Inconsistent condom use with regular male

partner(s)*

273 (64.1) 123 (56.9) 58.4 (49.167.8) 100 (42.2) 42.9 (36.349.4)

Inconsistent condom use with casual partner(s)

195 (48.5) 98 (46.9) 36.2 (29.443.1) 96 (50.3) 44.4 (33.655.2)

Condom torn or removed involuntarily during sex 216 (43.7) 118 (44.9) 46.3 (39.2 53.5) 98 (42.4) 41.6 (34.448.7)

Generally use lubricant with condom 460 (90.0) 235 (89.4) 88.5 (83.893.2) 219 (92.4) 93.8 (90.697.0)

CCLs 348 (73.7) 186 (75.6) 72.2 (65.379.0) 162 (71.7) 66.8 (57.9 75.7)

Lotion, saliva, Vaseline or other 124 (26.3) 60 (24.4) 27.8 (20.9 34.8) 64 (28.3) 33.2 (24.3 42.1)

Gave a woman money or objects in exchange for

sexual intercourse

25 (4.9) 14 (5.2) 5.7 (1.89.7) 11 (4.6) 4.3 (0.87.8)

Gave a man money or objects in exchange

for sexual intercourse

30 (5.9) 15 (5.5) 4.2 (1.66.8) 15 (6.3) 4.4 (1.86.9)

*In Douala, n52 (19.4%) did not have a regular partner. In Yaounde

´,n32 (13.4%) did not have a regular partner.

**In Douala, n59 (22.0%) did not have a casual partner; in Yaounde

´,n48 (20.1%) did not have a casual partner.

CBO, community-based organization; CCLs, condom-compatible lubricant; CI, confidence interval; IQR, interquartile range; MSM, men who have

sex with men; RDS, respondent-driven sampling; STI, sexually transmitted infection.

Table 3. HIV and syphilis prevalence among MSM in Douala (n272) and Yaounde

´(n239) in Cameroon, 2011

All

Douala Yaounde

n(%) n(%) RDS-weighted % (95% CI) n(%) RDS-weighted % (95% CI)

HIV prevalence*

All ages 171 (37.0) 73 (28.6) 25.5 (19.1 31.9) 98 (47.3) 44.4 (35.7 53.2)

Age 1823 54 (24.9) 27 (20.6) 14.6 (6.722.6) 27 (31.4) 20.8 (8.5 33.1)

Age 2429 79 (47.0) 27 (33.3) 30.0 (16.943.1) 52 (60.0) 59.7 (48.870.6)

Age 3038 (49.4) 19 (44.2) 43.8 (27.959.7) 19 (55.9) 55.9 (29.782.1)

Refused HIV testing 49 (9.6) 17 (6.3) 4.2 (1.86.6) 32 (13.4) 12.7 (7.318.2)

Active syphilis infection** 2 (0.4) 1 (0.5) 1 (0.4) 

*HIV status determined by two rapid tests, and confirmation by enzyme-linked immunosorbent assay (ELISA) test.

**Positive in both Rapid Protein Reagin (RPR) and Treponema pallidum hemagglutination assay (TPHA) tests.

CI, confidence interval; MSM, men who have sex with men; RDS, respondent-driven sampling.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

priority population for HIV prevention, treatment and care

services in Douala and Yaounde

´. Furthermore, these data

suggest that HIV risks are not evenly distributed given the

significant differences in HIV prevalence between cities and

between MSM sub-populations [1].

The individual-level factors found to be associated with HIV

infection indicate that future HIV programming and interven-

tions in Cameroon should address both behavioural and

structural hurdles relevant to MSM. Consistent with data from

other countries of sub-Saharan Africa [15,16,24], condom

breakage and slippage and inconsistent condom use were

common among this sample. CCLs, which decrease the risk of

condom breakage, were also used inconsistently [33], sug-

gesting that increased access to quality condoms and CCLs is

essential [34,35]. While maximizing the use of condoms and

CCLs is necessary in decreasing HIV risks among MSM, likely

it will not be sufficient to change the trajectory of the epi-

demic given the high transmission probability of HIV infection

associated with UAI, as observed in other settings [1,34]. The

prevalence of active syphilis was low, as observed in other

countries in the region [4,5]; however, a high proportion of

participants reported experiencing STI symptoms, highlighting

another network-level risk factor potentiating HIV transmis-

sion within the sexual network. Increasing the capacity for

routine STI diagnosis, particularly for genitourinary infections,

and linkage to treatment tailored towards MSM should be

incorporated to support HIV-prevention programmes [15,36].

MSM in Douala who reported a preference of being the

receptive partner during anal intercourse were more likely to

identify as gay and be living with HIV. This not only affirms

existing data demonstrating the increased HIV acquisition risk

associated with unprotected receptive anal intercourse [37]

but also echoes previous studies conducted in African settings

in which self-reporting as gay was associated with higher odds

of living with HIV compared to other MSM in the African

setting [24,38]. Given that antiretroviral pre-exposure pro-

phylaxis (PrEP) and rectal microbicides have been identified

as research priorities for African MSM [39], and that rectal

microbicides are currently in Phase II trials that are enrolling

MSM from the African continent [34], evaluating the feasi-

bility of novel biomedical interventions for sub-populations of

MSM in Cameroon with significant HIV acquisition risks may

be appropriate [34,40,41]. However, the cost-effectiveness

of implementationing such biomedical interventions requires

further research [42]. In addition, exploring increased anti-

retroviral therapy (ART) for MSM living with HIV likely

represents an important strategy for preventing the trans-

mission of HIV to sexual partners. However, the limited

availability of ART for people living with HIV who are cur-

rently eligible for treatment, which has been documented

in Cameroon, also needs to be addressed in order for ART-

based strategies for people at risk for the acquisition or

transmission of HIV to be effective [43].

A significant proportion of the MSM in our sample were

living with HIV by the age of 1823, indicating a high risk for

HIV acquisition for men under 18 in these settings [24,44];

however, men under 18 have traditionally been excluded from

HIV surveillance and prevention programmes [1]. Confidential

youth sexuality counselling hotlines, web-based education

and social marketing campaigns may be useful in reaching

younger MSM with HIV programmes [36,37].

While our study did not include a detailed assessment

of social stigma, other studies have demonstrated that

stigma limits the provision and uptake of HIV prevention,

treatment and care for MSM in the region [18,19,27]. Up-

take of services delivered by targeted CBO providers such

as Alternatives-Cameroun in Douala was high in our study,

suggesting that community-based approaches can spread

information-leveraging networks of MSM despite the con-

textual barriers. There was limited uptake of services in

Yaounde

´and higher refusal of HIV testing in the study; to

the best of our knowledge, MSM-tailored HIV programmes

were new and in development at the time of this surveillance

project. The historically limited services may partially explain

the higher HIV prevalence observed among MSM in Yaounde

as compared to Douala, although these participants also

tended to be older and report more male partners, drug and

alcohol use, and STI symptoms.

Data on the proportion of MSM living with HIV who were

eligible for treatment, or who were actually on treatment,

were not collected in this study. However, consistent data

highlight the importance of addressing the needs of people

living with HIV, including linkage to care, to optimize their

own health and prevent onward transmission to other men

and to women [45]. In Cameroon, only half of all patients

eligible for treatment are estimated to be receiving ART,

and ART stock outages at health facilities are frequent [43].

Given the significant stigma and discrimination that have

been documented as affecting MSM in Cameroon, MSM

living with HIV may be at higher risk of being unaware of

their diagnosis or not achieving viral suppression [8,20,46].

MSM community groups have long been known to play

essential roles in the HIV response, and the data collected

here suggest that community-driven approaches should be

scaled up to increase uptake of VCT and support linkage to

HIV care, treatment and adherence support for those eligible

[47,48].

The cross-sectional design of this study does not allow us

to assume causality of the associations present in the data.

There are several limitations to the generalizability of the

100

HIV-prevalence (%)

018–23 24–29 30+

Age category

Douala Yaoundé

Figure 1. Unadjusted HIV prevalence stratified by age category

among MSM from Douala (n255) and Yaounde

´(n207) in

Cameroon, 2011.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

Table 4. Bivariate and multivariate models of the individual-, network- and community-level factors associated with HIV infection among MSM in Douala (n255) in Cameroon, 2011

Living

with HIV

(n73)

HIV-

negative

(n182) OR (95% CI)

RDS-weighted OR

(95% CI) aOR (95% CI) p

RDS-weighted aOR

(95% CI) p

Age

Per-year increase for MSM aged 1829 54 (74.0) 158 (86.8) 1.13 (1.04



1.23) 1.14 (1.04



1.25) 1.15 (1.04



1.27) 0.005 1.13 (1.01



1.27) 0.03

Per-year increase for MSM aged 30 19 (26.0) 24 (13.2) 0.86 (0.731.01) 0.86 (0.72 1.03) 0.86 (0.711.04) 0.1 0.89 (0.72 1.09) 0.3

Education: higher than secondary 20 (27.4) 44 (24.2) 1.18 (0.642.19) 1.05 (0.52 2.14) 

Occupational status

Student or apprentice 17 (23.3) 92 (50.6) Ref Ref 

Employed 47 (64.4) 74 (40.7) 3.44 (1.82



6.48) 3.66 (1.90



7.04) 

Unemployed 9 (12.3) 16 (8.8) 3.04 (1.16



8.00) 2.09 (0.726.10) 

Christian religion 64 (87.7) 160 (87.9) 0.98 (0.432.24) 1.05 (0.402.72) 

Sexual identity: gay 29 (39.7) 39 (21.4) 2.42 (1.34



4.35) 2.53 (1.27



5.03)

Relationship status: single 54 (75.0) 160 (87.9) 0.41 (0.21



0.83) 0.48 (0.211.08) 

Sexual role preference: receptive 33 (45.2) 48 (26.4) 2.30 (1.31



4.06) 2.23 (1.15



4.31) 2.96 (1.50



5.82) 0.002 2.33 (1.02



5.32) 0.045

Age of sexual debut

517 28 (38.4) 62 (34.1) Ref Ref 

18 45 (61.6) 120 (65.9) 0.83 (0.471.46) 0.66 (0.351.26) 

Ever accessed CBO service targeting MSM 65 (89.0) 125 (68.7) 3.71 (1.67



8.23) 4.33 (1.75



10.75) 3.22 (1.17



8.89) 0.048 4.88 (1.63



14.63) 0.005

Ever received free condoms 60 (84.5) 124 (70.1) 2.33 (1.14



4.78) 2.82 (1.22



6.53) 

Generally use CCLs with condoms 59 (81.9) 113 (62.8) 2.69 (1.37



5.27) 2.89 (1.17



7.16) 2.32 (1.01



5.34) 0.049 2.29 (0.955.53) 0.07

HIV knowledge composite score, per 20% increase 85 (8) 85 (23) 0.85 (0.561.29) 0.81 (0.491.33) 

Social support composite score, per 20% increase 75 (50) 63 (50) 1.06 (0.881.29) 1.11 (0.881.40) 

In the past 12 months

Had male and female sexual partners 26 (35.6) 89 (48.9) 0.58 (0.33 1.01) 0.50 (0.26



0.96) 

Any STI symptom 26 (36.1) 49 (27.4) 1.50 (0.842.68) 1.38 (0.70 2.74) 

Number of male partners

13 46 (63.0) 116 (63.7) Ref Ref 

427 (37.0) 66 (36.3) 1.03 (0.59 1.81) 1.40 (0.722.70) 

Inconsistent condom use: regular male partner(s) 36 (60.0) 79 (54.9) 1.23 (0.672.28) 1.30 (0.642.66) 

Inconsistent condom use: casual partner(s) 15 (28.9) 76 (52.4) 0.37 (0.18



0.73) 0.40 (0.18



0.89) 

Condom slippage or breakage 77 (44.0) 34 (47.2) 1.14 (0.661.97) 1.28 (0.68 2.44) 

Bold indicates p-valueB0.05.

aOR, adjusted odds ratio; CBO, community-based organization; CCL, condom-compatible lubricant; CI, confidence interval; IQR, interquartile range; MSM, men who have sex with men; OR, odds ratio; RDS,

respondent-driven sampling; STI, sexually transmitted infection.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

Table 5. Bivariate and multivariate models of the individual-, network- and community-level factors associated with HIV infection among MSM in Yaounde

´(n207) in Cameroon, 2011

Living

with HIV

(n98)

HIV-

negative

(n109) OR (95% CI)

RDS-weighted OR

(95% CI) aOR (95% CI) p

RDS-weighted

aOR (95% CI) p

Age

Per-year increase for MSM aged 1829 79 (80.6) 94 (86.2) 1.15 (1.05



1.25) 1.17 (1.06



1.30) 1.11 (1.02



1.22) 0.02 1.14 (1.021.26) 0.02

Per-year increase for MSM aged 30 19 (19.4) 15 (13.8) 0.80 (0.65



0.98) 0.79 (0.62



1.00) 0.84 (0.671.04) 0.1 0.84 (0.65 1.07) 0.2

Education: higher than secondary 30 (30.6) 35 (32.1) 0.93 (0.521.68) 0.93 (0.481.83)   

Occupational status

Student or apprentice 28 (28.6) 46 (42.2) Ref Ref   

Employed 53 (54.1) 51 (46.8) 1.71 (0.933.13) 1.68 (0.833.38)   

Unemployed 17 (17.4) 12 (11.0) 2.33 (0.975.59) 1.88 (0.695.11)   

Christian religion 92 (93.9) 98 (89.9) 1.72 (0.614.84) 1.23 (0.383.97)   

Sexual identity: gay 38 (38.8) 27 (24.8) 1.92 (1.06



3.49) 2.36 (1.19



4.68)   

Relationship status: single 83 (85.6) 92 (87.6) 0.84 (0.371.89) 1.36 (0.543.46)   

Sexual role preference: receptive 35 (35.7) 32 (29.4) 1.34 (0.752.40) 1.35 (0.692.62)   

Age of sexual debut

517 34 (34.7) 31 (28.4) Ref Ref   

18 64 (65.3) 78 (71.6) 0.75 (0.421.35) 0.67 (0.341.31)   

Ever accessed CBO service targeting MSM 43 (43.9) 44 (40.4) 1.15 (0.662.01) 0.95 (0.511.78)   

Ever received free condoms 70 (72.2) 68 (66.7) 1.30 (0.712.38) 1.25 (0.622.49)   

Generally use CCLs with condoms 74 (76.3) 59 (54.6) 2.67 (1.46



4.88) 2.42 (1.19



4.91) 1.97 (1.04



3.72) 0.04 2.44 (1.19



4.97) 0.02

HIV knowledge composite score, per 20% increase 85 (15) 85 (15) 0.90 (0.58 1.40) 1.00 (0.601.69)   

Social support composite score, per 20% increase 75 (38) 63 (38) 1.14 (0.911.43) 1.18 (0.911.53)   

In the past 12 months   

Had male and female sexual partners 41 (41.8) 52 (47.1) 0.79 (0.451.37) 0.63 (0.341.18)

Any STI symptom 48 (49.0) 43 (39.8) 1.45 (0.842.52) 1.81 (0.963.42)   

Number of male partners

13 46 (46.9) 71 (65.1) Ref Ref Ref Ref 

452 (53.1) 38 (34.9) 2.11 (1.21



3.69) 2.25 (1.19



4.28) 1.81 (0.993.28) 0.05 1.88 (0.953.71) 0.07

Inconsistent condom use: regular male partner(s) 59 (67.8) 71 (75.5) 0.68 (0.361.31) 0.76 (0.361.59)   

Inconsistent condom use: casual partner(s) 43 (56.6) 43 (49.4) 1.33 (0.722.47) 1.55 (0.763.15)   

Condom slippage or breakage 46 (45.1) 41 (42.3) 0.89 (0.511.56) 0.69 (0.361.32)   

Bold indicates p-valueB0.05.

aOR, adjusted odds ratio; CCL, condom-compatible lubricant; CI, confidence interval; MSM, men who have sex with men; OR, odds ratio; RDS, respondent-driven sampling; STI, sexually transmitted

infection.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

HIV prevalence estimates reported in this study, which in-

cluded individuals who reported receptive or insertive anal

intercourse in the past 12 months. The generalizability of

the results for MSM living in smaller urban centres and

rural settings is unknown given that recruitment occurred in

two large cities. Similarly, as our sample was predominantly

young and educated, the results may not pertain to older

MSM or individuals with lower educational status. Future

studies to address these gaps could be conducted. The

modest sample size may have reduced our statistical ability

to detect other associations [49]. Due to the high refusal of

HIV testing during the study in Yaounde

´(13.4%), we were

unable to assess the potential for bias in the HIV prevalence

estimate from this city. However, RDS network homophily

was close to 0, which may indicate minimal recruitment bias

based on HIV status. Data on self-reported HIV status and the

percentage of undiagnosed men were not available, which

limit our interpretation of the association between knowl-

edge of one’s own HIV status and behavioural factors such as

inconsistent use of condoms and CCLs. This requires further

investigation in future studies. Although non-significant, the

positive association between having been tested and refusing

testing may suggest that individuals who are already aware

of their HIV status may be underrepresented in our study.

Conclusions

These data provide results that can be integrated into HIV

programmes for MSM in Cameroon and highlight the im-

portance of targeted HIV prevention, treatment and care

services that address all levels of HIV risk. Coordinating

behavioural, biomedical and structural interventions, and

supporting the work of local CBOs, will be keys to ensuring

that HIV-negative MSM receive regular VCT and appropriate

prevention services, and that MSM living with HIV are

effectively engaged in the continuum of HIV care. Success

in the continuum of HIV care necessitates addressing the

barriers to the uptake of care, such as concerns about con-

fidentiality and healthcare-related enacted and perceived

stigmas [8,20,36]. Protecting the dignity and rights of MSM

in healthcare settings and beyond allows for a safe environ-

ment for individuals to receive optimal care to protect

themselves and their partners [27,29]. Monitoring the success

of the next generation of HIV-prevention approaches will

require innovative implementation science exploring changes

not only in individual-level risks, community viral load and HIV

incidence, but also in social and policy-level factors including

stigma, discrimination, violence and criminalization.

Authors’ affiliations

Center for Public Health and Human Rights, Department of Epidemiology,

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA;

West

and Central Africa Region, Population Services International, Cotonou,

Benin;

Association Camerounaise pour le Marketing Social (ACMS), Yaounde

´,

Cameroon;

Comite

´national de lutte contre le sida (CNLS), Ministe

`re

de la Sante Publique (MINSANTE), Yaounde

´, Cameroon;

CARE International-

Cameroon, Yaounde

´, Cameroon;

Alternatives-Cameroun, Douala, Cameroon;

CAMNAFAW, Yaounde

´, Cameroon;

Humanity First, Yaounde

´, Cameroon;

Global Viral Cameroon, Yaounde

´, Cameroon

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

SK, LM, IM and SCB conceived and designed the study with input from YRY, NN,

JE, VM and UT. LM, SK, IM, YRY, NN and JE led the implementation. ML and UT

supervised sample collection and immunoassays. JNP and SB developed the

analytic plan. JNP performed the statistical analysis and wrote the first draft

of the article. All authors collaborated in writing sections of the manuscript,

gave critical input and assisted with data analysis. All authors have seen and

approved the final version of this article.

Acknowledgements

The authors gratefully acknowledge the study participants and the study staff.

We thank Chris Beyrer and Shruti Mehta of Johns Hopkins Bloomberg School

of Public Health for their input on the preliminary analysis. This study was

implemented through the United States Agency for International Development

(USAID) funded National HIV/AIDS Prevention Programme (HAPP), a collabora-

tive initiative involving the Association Camerounaise pour le Marketing Social

(ACMS), CARE International-Cameroon, the Cameroon Ministry of Public Health,

Global Viral Cameroon and three community-based organizations that provide

HIV prevention and health services to MSM: Alternatives-Cameroun, Humanity

First and the Cameroon National Association for Family Welfare (CAMNAFAW).

Funding

This study was supported by a grant from the United States Agency for

International Development (USAID).

References

1. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet. 2012;380(9839):36777.

2. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among

men who have sex with men in low- and middle-income countries 20002006:

a systematic review. PLoS Med. 2007;4(12):e339.

3. van Griensven F, de Lind van Wijngaarden JW, Baral S, Grulich A. The global

epidemic of HIV infection among men who have sex with men. Curr Opin HIV

AIDS. 2009;4(4):3007.

4. Wade AS, Larmarange J, Diop AK, Diop O, Gueye K, Marra A, et al. Reduction

in risk-taking behaviors among MSM in Senegal between 2004 and 2007 and

prevalence of HIV and other STIs. ELIHoS Project, ANRS 12139. AIDS Care.

2010;22(4):40914.

5. Merrigan M, Azeez A, Afolabi B, Chabikuli ON, Onyekwena O, Eluwa G, et al.

HIV prevalence and risk behaviours among men having sex with men in

Nigeria. Sex Transm Infect. 2011;87(1):6570.

6. National AIDS Control Commitee. UNGASS country progress report: HIV/

AIDS Report for Burkina Faso, 2012. Ouagadougou: Joint United Nations

Programme on HIV/AIDS; 2012.

7. Henry E, Marcellin F, Yomb Y, Fugon L, Nemande S, Gueboguo C, et al.

Factors associated with unprotected anal intercourse among men who have

sex with men in Douala, Cameroon. Sex Transm Infect. 2010;86(2):136 40.

8. Human Rights Watch. Criminalizing identities: rights abuses in Cameroon

based on sexual orientation and gender identity. New York; 2010. Retrieved

February 9, 2013, from: http://www.hrw.org/reports/2010/11/04/criminalizing-

identities-0.

9. UNAIDS. HIV and AIDS Estimates. Geneva; 2011. Retrieved April 19, 2013,

from: http://www.unaids.org/en/regionscountries/countries/cameroon/.

10. Cameroon National Institute of Statistics. 2011 Cameroon Demographic

and Health Survey and Multiple Indicators Cluster Survey (DHS-MICS): HIV

prevalence. Calverton: MEASURE DHS, ICF International, 2012.

11. National AIDS Control Committee. National strategic plan against HIV,

AIDS, and STIs: 20112015. Yaounde

´: National AIDS Control Committee; 2011.

12. Grulich AE, Zablotska I. Commentary: probability of HIV transmission

through anal intercourse. Int J Epidemiol. 2010;39(4):10645.

13. Alternatives-Cameroun. Biannual Activities Report, July December 2007,

Douala: Alternatives-Cameroun; 2007.

14. Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al.

Bisexual concurrency, bisexual partnerships, and HIV among Southern African

men who have sex with men. Sex Transm Infect. 2010;86(4):3237.

15. Wade AS, Kane CT, Diallo PA, Diop AK, Gueye K, Mboup S, et al. HIV

infection and sexually transmitted infections among men who have sex with

men in Senegal. AIDS. 2005 2;19(18):213340.

16. Koumagnanou K, Kassegne S, Dodzro KC. HIV prevention among marginal

groups: the case of homosexuals in Togo. Glob Health Promot. 2011;18(1):

1025.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

17. Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR, Ortiz DJ, et al.

Stigma in the HIV/AIDS epidemic: a review of the literature and recommenda-

tions for the way forward. AIDS. 2008;22(Suppl 2):S6779.

18. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and

voluntary HIV counselling and testing in a black township in Cape Town,

South Africa. Sex Transm Infect. 2003;79(6):4427.

19. Rankin WW, Brennan S, Schell E, Laviwa J, Rankin SH. The stigma of being

HIV-positive in Africa. PLoS Med. 2005;2(8):e247.

20. Kalamar M, Maharaj P, Gresh A. HIV-prevention interventions targeting

men having sex with men in Africa: field experiences from Cameroon. Cult

Health Sex. 2011;13(10):113549.

21. Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15(6):108897.

22. Preston DB, D’Augelli AR, Kassab CD, Cain RE, Schulze FW, Starks MT. The

influence of stigma on the sexual risk behavior of rural men who have sex with

men. AIDS Educ Prev. 2004;16(4):291303.

23. Poteat T, Diouf D, Drame FM, Ndaw M, Traore C, Dhaliwal M, et al. HIV

risk among MSM in Senegal: a qualitative rapid assessment of the impact of

enforcing laws that criminalize same sex practices. PLoS One. 2011;6(12):

e28760.

24. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV

prevalence, risks for HIV infection, and human rights among men who have sex

with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;4(3):

e4997.

25. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in peri-urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

26. Hladik W, Barker J, Ssenkusu JM, Opio A, Tappero JW, Hakim A, et al. HIV

infection among men who have sex with men in Kampala, Uganda a

respondent driven sampling survey. PLoS One. 2012;7(5):e38143.

27. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men

who have sex with men: stigma and discrimination. Lancet. 2012 28;380(9839):

43945.

28. International Lesbian GB, Trans and Intersex Association. State sponsored

homophobia report 2011: a world survey of laws criminalising same-sex sexual

acts between consenting adults. Belgium; 2012. Retrieved April 22, 2013, from:

http://old.ilga.org/Statehomophobia/ILGA_State_Sponsored_Homophobia_2012.

pdf.

29. Betron M, Gonzalez-Figueroa E. Gender identity, violence, and HIV among

MSM and TG: a literature review and a call for screening. Washington, DC:

Futures Group International, USAID. Health Policy Initiative, Task Order 1.2009.

30. Heckathorn DD. Respondent-driven sampling: a new approach to the study

of hidden populations. Soc Probl. 1997;44(2):17499.

31. Schonlau M, Liebau E. Respondent driven sampling. Stata J. 2012;12(1):

7293.

32. Heckathorn DD. Extensions of respondent-driven sampling: analyzing

continuous variables and controlling for differential recruitment. Socio Meth.

2007;37:151208.

33. Stone E, Heagerty P, Vittinghoff E, Douglas JM Jr., Koblin BA, Mayer KH,

et al. Correlates of condom failure in a sexually active cohort of men who have

sex with men. J Acquir Immune Defic Syndr Hum Retrovirol. 1999;20(5):

495501.

34. Sullivan PS, Carballo-Dieguez A, Coates T, Goodreau SM, McGowan I,

Sanders EJ, et al. Successes and challenges of HIV prevention in men who have

sex with men. Lancet. 2012;380(9839):38899.

35. Charania MR, Crepaz N, Guenther-Gray C, Henny K, Liau A, Willis LA, et al.

Efficacy of structural-level condom distribution interventions: a meta-analysis

of U.S. and international studies, 19982007. AIDS Behav. 2011;15(7):

128397.

36. World Health Organization. Prevention and treatment of HIV and other

sexually transmitted infections among men who have sex with men and

transgender people: recommendations for the public health approach 2011.

Geneva: WHO; 2011.

37. Beyrer C, Wirtz AL, Walker D, Johns B, Sifakis F, Baral SD. Scenario 3 country

studies: Kenya, Malawi, and Senegal. The global HIV epidemics among men

who have sex with men. Washington, DC: World Bank; 2011. p. 81110.

38. Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al.

High HIV prevalence among men who have sex with men in Soweto, South

Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):62634.

39. Baral S, Scheibe A, Sullivan P, Trapence G, Lambert A, Bekker LG, et al.

Assessing priorities for combination HIV prevention research for men who have

sex with men (MSM) in Africa. AIDS Behav. 2013;17(Suppl 1):609.

40. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al.

Preexposure chemoprophylaxis for HIV prevention in men who have sex with

men. N Engl J Med. 2010;363(27):258799.

41. World Health Organization. Guidance on pre-exposure oral prophylaxis

(PrEP) for serodiscordant couples, men and transgender women who have

sex with men at high risk of HIV: recommendations for use in the context of

demonstration projects. Geneva: WHO; 2012.

42. Gomez GB, Borquez A, Case KK, Wheelock A, Vassall A, Hankins C. The cost

and impact of scaling up pre-exposure prophylaxis for HIV prevention: a

systematic review of cost-effectiveness modelling studies. PLoS Med. 2013;

10(3):e1001401.

43. National AIDS Control Commitee. UNGASS country progress report:

National Monitoring Report on Political Declarations regarding HIV/AIDS in

Cameroon. Yaounde

´: Joint United Nations Programme on HIV/AIDS; 2012.

44. Sanders EJ, Graham SM, Okuku HS, van der Elst EM, Muhaari A, Davies A,

et al. HIV-1 infection in high risk men who have sex with men in Mombasa,

Kenya. AIDS. 2007;21(18):251320.

45. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC,

Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral

therapy. N Engl J Med. 2011;365(6):493505.

46. Henry E, Awondo P, Fugon L, Yomb Y, Spire B. Coming out of the Nkuta:

disclosure of sexual orientation associated with reduced risk behavior among

MSM in Cameroon. Arch Sex Behav. 2012;41(3):5257.

47. Trapence G, Collins C, Avrett S, Carr R, Sanchez H, Ayala G, et al. From

personal survival to public health: community leadership by men who have sex

with men in the response to HIV. Lancet. 2012;380(9839):40010.

48. Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G, et al. A

call to action for comprehensive HIV services for men who have sex with men.

Lancet. 2012;380(9839):42438.

49. Johnston LG, Chen YH, Silva-Santisteban A, Raymond HF. An empirical

examination of respondent driven sampling design effects among HIV risk

groups from studies conducted around the world. AIDS Behav. 2013;

17(6):220210.

Park JN et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18752

http://www.jiasociety.org/index.php/jias/article/view/18752 | http://dx.doi.org/10.7448/IAS.16.4.18752

Research article

Experiences of Kenyan healthcare workers providing services

to men who have sex with men: qualitative findings from

a sensitivity training programme

Elise M van der Elst

§,1

, Evans Gichuru

, Anisa Omar

, Jennifer Kanungi

, Zoe Duby

, Miriam Midoun

Sylvia Shangani

, Susan M Graham

1,5

, Adrian D Smith

, Eduard J Sanders

1,6

and Don Operario

Corresponding author: Elise M van der Elst, Centre for Geographic Medicine Research (Coast) (KEMRI CGMRC), Kenya Medical Research Institute, P.O. Box 230, Kilifi,

Kenya. Tel: 254 41 7522063, 254 41 7522535. (Evanderelst@kemri-wellcome.org)

Abstract

Introduction: Men who have sex with men (MSM) in Kenya are at high risk for HIV and may experience prejudiced treatment in

health settings due to stigma. An on-line computer-facilitated MSM sensitivity programme was conducted to educate healthcare

workers (HCWs) about the health issues and needs of MSM patients.

Methods: Seventy-four HCWs from 49 ART-providing health facilities in the Kenyan Coast were recruited through purposive

sampling to undergo a two-day MSM sensitivity training. We conducted eight focus group discussions (FGDs) with programme

participants prior to and three months after completing the training programme. Discussions aimed to characterize HCWs’

challenges in serving MSM patients and impacts of programme participation on HCWs’ personal attitudes and professional

capacities.

Results: Before participating in the training programme, HCWs described secondary stigma, lack of professional education about

MSM, and personal and social prejudices as barriers to serving MSM clients. After completing the programme, HCWs expressed

greater acknowledgement of MSM patients in their clinics, endorsed the need to treat MSM patients with high professional

standards and demonstrated sophisticated awareness of the social and behavioural risks for HIV among MSM.

Conclusions: Findings provide support for this approach to improving health services for MSM patients. Further efforts are

needed to broaden the reach of this training in other areas, address identified barriers to HCW participation and evaluate

programme effects on patient and HCW outcomes using rigorous methodology.

Keywords: on-line computer facilitated MSM sensitivity programme; healthcare worker; stigma; MSM; Kenya; HIV.

Received 21 May 2013; Revised 6 September 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 van der Elst EM et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons

Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction

Men who have sex with men (MSM) in sub-Saharan Africa

experience a high burden of HIV infection [13]. Strong

epidemiological evidence comes from studies in Kenya [47],

where an estimated 18.9% of MSM are HIV-positive [1].

Kenya’s National AIDS Control Council has prioritized HIV

programming for MSM in their National HIV Strategic Plan

[8], with the aim to support more inclusive health services for

MSM [9]. Implementation of Kenya’s AIDS policies requires

the ability of healthcare workers (HCWs) to deliver appro-

priate and sensitive services to MSM patients. Effective HCWs

must have accurate knowledge of the sexual health issues of

MSM, non-prejudicial attitudes and behavioural skills to treat

MSM patients [10]. However, HCWs in Kenya, as elsewhere in

sub-Saharan Africa, rarely receive specialized training on how

to provide care for MSM [11].

To address this gap in training service providers, Kenya’s

National AIDS and STI Control Programme (NASCOP) devel-

oped an education training programme to strengthen HCWs’

skills and capacity to provide non-judgemental counselling

and HIV healthcare services for MSM. The training pro-

gramme incorporated two learning modalities: a computer-

facilitated training programme covering eight modules [MSM

and HIV in sub-Saharan Africa; stigma; identity, coming

out and disclosure; anal sex and common sexual practices;

HIV and sexually transmitted infections; mental health,

anxiety, depression and substance use; condom and lubri-

cant use; risk-reduction counselling] in addition to facilitated

group discussions among programme trainees about the

programme content and relevant clinical experiences working

with MSM. Both learning modalities offer complementary

approaches to educational training. Computer-facilitated

training modules can offer a standardized and disseminable

approach to improve HCWs’ knowledge and health service

delivery skills for MSM patients [12], especially in settings

such as Kenya where access to formal medical education is

constrained. Supplementing the computer-facilitated training

with opportunities for peer discussion and support among

HCWs can potentially enhance the transfer of standardized

learning to the workplace [13].

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

We conducted a preliminary pre-post-evaluation of HCWs

who participated in the programme [14]. Quantitative

findings showed improvements in MSM-related knowledge

and reductions in discriminatory attitudes towards MSM.

Effects were most pronounced among HCWs who had low

levels of knowledge and/or more extreme negative attitudes

towards MSM at baseline, and among HCW in clinical roles

within governmental settings.

This article reports data from qualitative focus groups with

participating HCWs, conducted prior to and three months

after completion of the programme. The objectives of this

analysis are to explore: (i) how HCWs characterized their

professional challenges in serving MSM patients prior to

the programme, (ii) how HCWs described the impacts of

programme participation on their personal attitudes and

professional capacities and (iii) how the computer-facilitated

educational training programme can be improved.

Methods

Participants and intervention procedures

The study was conducted between October 2011 and March

2012 in four districts in coastal Kenya: Kilifi, Kilindini, Malindi

and Mombasa. To recruit trainee participants, NASCOP issued

announcements to 49 health facilities providing antiretroviral

treatment in the four targeted districts. Announcements

described the study as a two-day residential programme

involving computer-facilitated training and group discussions

on HIV and MSM. Volunteer participants completed informed

consent procedures, and those who enrolled received 2000

Kenya shilling (approximately US $24) for travel and lodging

adjacent to the training facility in Kilifi.

Participants were 74 HCWs from the four target districts.

Fifty were females and 24 males, including 22 clinicians,

43 nurses and counsellors, and nine were administrators/

managers. The average age was 34. All participants identified

as Kenyan, 84% as Christian and 15% as Muslim. Eighty-six

percent had no previous training about MSM or anal sexual

practices. Three participants (two females and one male)

were transferred to health facilities outside the study area

after the initial training and could not participate in the

follow-up focus groups.

A total of four groups were convened to participate in the

two-day residential training (one group per district), with

1819 participants per group. During Day 1, participants

received a general overview of the programme, and each

participant then independently self-administered the first

four modules of the standardized, computer-facilitated

training. Modules were designed to take up to two hours

to complete. At the end of each module, participants

answered a series of multiple-choice questions (up to 16

questions); to advance to the next module, participants were

required to achieve a minimum score of 71% correct. After

every two modules, participants engaged in a group discus-

sion to reflect on the information and identify barriers and

facilitators to improve on HIV prevention and other services

for MSM in Coastal Kenya. A member of the research team

facilitated group discussions. During Day 2, participants

completed the final four modules and group discussions.

At the end of Day 2, participants were asked to discuss work

strategies for improving the quality of clinical care and HIV/

STD testing for MSM patients in their districts. Research team

members included an MSM counsellor, a community liaison

officer, a senior research counsellor and a social scientist;

teams were supported by two MSM members from a local

non-governmental organization. Research team members

received a comprehensive three-day training on the inter-

vention objectives and procedures, including didactics and

role-play opportunities for discussion and problem solving.

Focus group discussions

Eight focus group discussions (FGDs) (each comprising 910

participants; two focus groups per training) were conducted

with participating HCWs prior to the training and were

repeated three months following completion of the training.

Focus groups were semi-structured and facilitated by a

member of the research team, with a co-facilitator present

to observe and take notes. Discussion topics included:

identification of subcategories of MSM and their character-

istics; sexual practices of MSM and risks for HIV and STI

transmission; practices for sexual history taking and sexual

health examination with MSM; risk-reduction counselling for

MSM; personal values and attitudes towards MSM; strategies

to improve communication between HCWs and MSM

patients. Most discussions were conducted in English,

although participants were also encouraged to speak in

Kiswahili depending on their preference and language skills.

All discussions were audiotaped, transcribed and entered into

NVivo. FGDs conducted in Kiswahili were translated into

English.

Analyses of qualitative data followed the ‘‘framework

approach’’ described by Ritchie and Spencer [15], which

involves systematic coding to identify and define concepts

emerging from the data, mapping the concepts, creating

typologies, finding associations between concepts and seek-

ing explanations from the data. Data were coded by two

independent research team members to ensure that inter-

pretations of quotes were consistent and that data analysis

was rigorous and transparent. The main concepts emerging

from the data included: secondary stigma, professional

training and service barriers to MSM patients; types of and

justifications for social discrimination towards MSM in

Kenyan culture; invisibility and silence about homosexuality

in Kenyan culture; and subjective theories about the origins

and nature of homosexuality. Differences among coders were

resolved by group discussion involving other members of the

research team.

The study procedures were approved by the ethical

review board at the Kenya Medical Research Institute. All

participants provided written informed consent for the FGD.

Results

Discussion of MSM-related attitudes, beliefs and

behaviours before training

Secondary stigma

For most participants, secondary stigma was a dominant

concern. Secondary stigma refers here to negative judgements

from peers and community members for being associated

with MSM. Participants cautioned that professional trainings

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

focused on MSM would deter many health professionals from

participation:

To me, the term MSM is stigmatizing because

naturally, a man is not supposed to have sex with

another man. As for this training ... The [invitation]

letter was written, ‘MSM training’. When we in-

formed them, people were like, ‘An MSM training,

what is MSM?’ ... Some individuals declined to go

for the training, ‘I can’t go for such training’.

Several participants feared that colleagues would question

their willingness to serve MSM patients, and perhaps suspect

the HCWs of being MSM themselves:

You know MSM, as he had mentioned, are regarded

as outcasts. Therefore, if you offer to treat them in

your clinic, the community will perceive it as ... the

clinicians are also MSM.

Owing to this fear, many HCWs described minimizing the

amount of time with MSM patients. For example, one

participant described having a basic willingness to serve

MSM patients, but would allocate the shortest time possible:

The fear of being associated, that’s what is making us

spend as little time with MSM clients when they come

to our facilities. You will hurriedly clear him out.

However, fear of secondary stigma was not consistently

expressed by all members of the discussion. A small subset of

participants who had previous education and sensitization on

MSM prior to the training reported comfort in attending to

MSM patients. Consequently, these HCWs had become MSM

patient advocates and educators in their clinics prior to

engagement in this research study:

I was trained ... on issues to do with MSM. Last

week, I met an MSM client who was HIV positive. It

was in one of our departments and the nurse was

like, ‘... you are the person who deals with these

kind of clients’. I told her to refer the client in my

office ...Actually, I had to take [my colleague] for an

MSM training. Her attitude has really changed and

she is a now a different person.

Inadequate professional training and resources

Participants acknowledged having little or no education

about MSM health. Indeed, prior to the training programme,

many HCWs expressed a sense of denial about the existence

of MSM. For example, one reported that:

I tend to reason differently when it comes to MSM. I

sometimes tell myself, no, this doesn’t exist; this is

not possible.

Across multiple discussions, others questioned whether MSM

are present in their local communities:

Some of us are really green, we just hear stories on

internet that some men are having sex with other

men but we have never had an interaction with the

MSM.

MSM are unheard of in the place I come from.

HCWs who acknowledged the presence of MSM patients in

their clinics described feeling inadequately prepared to

provide services. Those with prior experience consulting

MSM patients described specific challenges in diagnosing

and treating rectal STIs, and argued for more appropriate

guidelines:

Of late, it’s only a few individuals who have been

trained in our facility. We don’t have a guideline, yet

we see them daily. We have no idea on how to

manage infections affecting men who have sex with

other men ...

Most of the medical personnel are not sensitized on

issues to do with anal STIs and they are also not

indicated in the STI charts. They only specify about

urethral discharge, cervicitis, urethritis in men, PID

[pelvic inflammatory disease] etc. It doesn’t mention

the anus.

Lacking the knowledge, skills and treatment guidelines for

rectal STIs, HCWs often relied on guesswork and assump-

tions. Participants recognized the likelihood of under-

diagnosing or misdiagnosing rectal infections transmitted

through anal sex.

And when we are counselling or probing them about

sex, we only ask them, ‘Do you usually have sex?’

When they say yes, we don’t probe further to know

the type of sex i.e., we just assume it is heterosexual.

The medics are also not trained and if an individual

comes with an anal complaint, they assume that it is

haemorrhoids and refer them for surgery.

HCWs described how limitations in assessment forms

reinforce the invisibility of MSM in their clinics. By not

collecting information about same-sex behaviour or anal sex

practices, these topics are reinforced as taboo issues that

warrant silence and discomfort.

Most of the tools and the working conditions are

not accommodative for this line of sexual orienta-

tion. I have never seen a tool in the CCC [compre-

hensive care centre] or the TB clinic asking for the

clients’ sexual orientation. So it’s like, ‘I don’t need

to know of what you do’ ... Therefore, the tools

should be designed to capture the sexual orientation

of a person so that the health workers can have a

feel that it is a part of the health issues and not a

gossip.

Additional resource limitations for treating MSM were

discussed. HCWs reported on the inconsistent supply of

lubricants for use during anal sex, and also described how

the physical structure of the health facility hinders their

ability to provide privacy and confidentiality for sexual health

consultations.

The MSM usually come to the clinics and ask for

the lubricants or condoms but you will find that the

lubricants are not available; it’s only the condoms.

I think there is no confidentiality because of the

way our health facilities have been structured,

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

i.e., someone can bump in while you are attending

to a client. You could be talking of sensitive issues

but other staffs won’t bother. They will sit on the

other side and do their stuff. So the client might not

be free to open up.

Personal and social homophobia

Many HCWs acknowledged holding prejudiced views towards

MSM. A number of participants commented on how negative

judgements towards MSM may influence the provision of

services.

We perceive them negatively and feel that they

don’t deserve our services.

Some health workers don’t like to examine them.

They claim that such infections are self-inflicted.

HCWs reflected on the influences of culture and religion on

their treatment of MSM patients. When reminded of their

professional obligation to provide effective services to all

patients, they described internalized barriers that must be

overcome.

I find it abnormal for a man to have sex with another

man. It is both culturally and religiously unaccep-

table ... Voices from religion or the community tell

me that it is wrong. Professionally, I will have to

handle that shock and look at possible ways of

helping this person.

Participants reported a tendency to exhibit subtle forms of

stigma and discrimination towards MSM patients, such as by

maintaining body distance. Other times, HCWs explicitly

showed disparaging treatment:

When they seek medical assistance in our facilities,

the same providers will shout, ‘Look at him, he is

telling me that he is having an anal STI; can you

leave my room’. Instead of treating them with

respect, they end up drawing their colleagues’

attention.

However, some HCWs challenged those who expressed

personal prejudice towards MSM. Participants who had

prior exposure to MSM sensitization argued that HCWs

have a professional duty and societal obligation to provide

non-prejudicial services to MSM.

We as health workers feel that MSM issues need not

to be discussed, they are regarded as outcasts. How

then would we come up with a constructive

discussion about people whom we feel should not

be in the society at first place? In my opinion, I think

this is the biggest obstacle. If we accept these

people and treat them as our clients, then it will be

of great help to the society.

Post-training discussion of HCWs’ attitudes, beliefs and

behaviours

Recognition of MSM in Kenya

A pervasive theme in post-training focus groups was the

explicit recognition of MSM in Kenya. Many reflected on how

their prior denial of MSM behaviour, and their previous belief

that anal sex among men was negligible in Kenya, had

inhibited their capacity to provide services. Participants felt

‘‘empowered’’ by the training to address HIV and other

health needs of MSM, as one stated:

I didn’t ever believe that MSM were in existence but

the training empowered me with a lot of knowledge

and information on how to probe about issues of

anal sex.

Participants described how the training enhanced their

understanding of the complex interplay between homopho-

bia, community denial of MSM and HIV transmission. Some

advocated to local colleagues for the acceptance of MSM and

educated them about the biological and behavioural circum-

stances that place MSM at heightened risk for HIV infection.

One participant described:

I went and gave the feedback to my colleagues

immediately after the training and some were as if

they have never heard such a ... They used to hear

about it but they were not sure whether it was a

real, whether such people exist. Therefore, I had to

make them understand that the practice is in

existence and that’s nature.

Professional responsibilities as a health provider

During follow-up focus groups, participants described their

professional responsibility to treat all patients with equity

and respect. They endorsed a basic value of professionalism

and treating MSM patients to the best of their ability. For

many, this required a suspension of personal judgement in

order to provide effective care:

As a professional, I am not supposed to segregate

them, whether I support homosexuality or have a

different perception or judgment. As a clinician, my

duty is to treat without imposing my values on the

patient. That’s the positive thing I got from [the

training program] and it’s what I’m doing now.

Some described witnessing discriminatory actions towards

MSM in their facilities or observing breaches in patients’

confidentiality. They reflected on how these experiences

could foster distrust of HCWs and discourage MSM patients

from seeking care when needed, thus perpetuating a cycle of

HIV transmission. There was widespread consensus among

group members that a concerted effort must be made to

establish trusting rapport with MSM patients, and take extra

care to employ discretion at all times. As one participant

articulated:

I think the problem is that, the individuals we have

attended to still want to see if they can trust us, if

we can respect their privacy ... As for now, it will

take time because they are trying to internalize on

our missions towards them and they will come out

once they are convinced that you don’t have an ill

motive towards them.

During the follow-up focus groups, HCWs were asked to

reflect upon and share their experiences, that is, work

practices and attitudes towards MSM in their respective

health facilities, and to reflect on strategies to change

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

discriminatory actions towards MSM in their health facilities.

Many participants stressed the importance of separating

personal and religious values from professional ethics for the

sake of HIV prevention in Kenya. While some felt the training

had helped to normalize same-sex relations, others ada-

mantly affirmed their aversion to MSM practices, but felt

that they could compartmentalize their values to achieve the

greater national public health goal.

The key message is almost the same. We are

concentrating in breaking the transmission cycle

among special groups, neglected groups. The bot-

tom line is: we are not promoting but trying to help.

Sophisticated knowledge of risk in MSM

During the follow-up FGDs, participants exhibited a multi-

faceted understanding of the biological, behavioural and

social influences that place MSM at risk for HIV. They

described a better understanding of the processes through

which unprotected anal sex contributes to HIV and STI

transmission in both men and women, and the ways in

which condoms and lubricants help to reduce risk. Moreover,

many participants identified quality health education and

counselling for MSM patients as integral to HIV prevention

efforts in Kenya.

Participants generally recognized the societal pressures on

MSM to conceal their sexual orientation, which MSM often

mitigated by engaging in heterosexual relationships. They

discussed the ways in which discrimination and lack of

counselling and support services have hampered access to

vital health services for MSM. The stigma endured by MSM

in Kenya was consistently identified as an impediment to

treatment, and many participants emphasized the need for

HCWs to be thorough when examining MSM patients, who

might not readily disclose their sexual practices:

I think it is good to do an examination as far as STI is

concerned. A client might tell you that he is having a

problem in his private parts. Such a client will openly

tell you the exact location of the problem when you

take the initiative to examine him.

Even if they go, they tend to be reluctant to disclose

to clinicians that they are having anal infections.

They end up getting the wrong medication and

suffer in silence.

Ongoing challenges

Participants reflected on the challenges they will continue to

face in affording appropriate health services to MSM. Many

HCWs noted that time constraints and heavy workloads

hinder their ability to deliver sensitive health services that

MSM patients might require. Despite their desire to provide

comprehensive health services to their MSM patients, some

of the participants felt this was not always possible in

practice:

Sometimes, as much as you would like to give all the

attention to the client, there is a workload issue as

other patients will be waiting. You may want to give

the best, but the patients and the workload are too

much.

Secondary stigma was considered an ongoing challenge, and

HCWs tasked themselves to confront discrimination and

stigma towards MSM expressed by their professional peers.

Education, institutional support and other monitoring me-

chanisms were mentioned as powerful means for mitigating

the effects of secondary stigma on service delivery to MSM

patients, but all HCWs concurred with the fact that ‘‘it begins

with openness, respect and understanding.’’

HCWs emphasized the social challenges in targeting MSM

for HIV preventative care. The marginalization of MSM, the

belief that homosexuality runs contrary to cultural values and

the fear of secondary stigma and resistance from fellow

health professionals were regarded as impediments to the

provision of care for MSM. As one participated stated:

Personally, I can say that my values have changed,

though not 100%. I am not sure of the exact

percentage, but I have positively changed. As much

as I would like to live and exercise my changed

values, there are still so many challenges in the

society. I would like to give comprehensive care to

MSM, but the society is too negative about them.

This is a very big blow, given the fact that I am the

only changed person.

In light of this, many participants noted the need for

duplication opportunities for HCWs not yet trained on

MSM sensitivity issues. They unanimously remarked that

the on-line sensitivity course is very beneficial for skill

development and in combination with follow-up group

discussions allows for interpreting learning and connecting

it to daily practice.

All participating HCWs advocated for community-wide

sensitization campaigns to reduce stigma and encourage

awareness of HIV risk in MSM, expressing the need for the

community at large to engage in ongoing and productive

dialogue in the struggle against HIV in Kenya.

Discussion

This analysis provides qualitative insight into HCWs’ attitudes

and experiences with MSM prior to and following a

computer-facilitated MSM sensitization training programme

[15] that will assist in amending the health workers’

e-learning sensitization course in future. Primary concerns

expressed at baseline included fear of secondary stigma, lack

of professional education about MSM, and negative influ-

ences of personal and social prejudice towards MSM. The

nature of discussions changed following the programme, in

which participants acknowledged the presence of MSM in

their clinics, endorsed the need to treat MSM patients with

high professional standards, and demonstrated sophisticated

awareness of the social and behavioural risks for HIV among

MSM. HCWs advocated for continuing the training and

inviting more health professionals to participate, but cau-

tioned that exclusively targeting MSM in the programme title

could deter participation. HCWs also commented on the

need for ongoing community dialogue about MSM, but

recognized that community-level change will take time.

The attitudes and beliefs expressed by participants before

versus after the training reveal many of the challenges to

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

service provision for MSM patients. In general, participants’

personal beliefs about MSM and their endorsement of

stigmatizing attitudes appear to have transformed following

the programme. However, participants expressed ongoing

concerns about secondary stigma and the influence of their

professional peers’ negative judgements towards MSM

patient and, by association, towards themselves. Professional

peers’ negative and stigmatizing attitudes can potentially

dilute the effects of the training on HCWs. Efforts to train

larger cohorts of HCWs, establish networks of trained HCWs

across different health clinics and change of institutional

norms towards MSM patients may be necessary to counter

the effects of secondary stigma and achieve sustainable

improvements.

Limitations to this research must be acknowledged. First,

due to the nature of qualitative methodology, participants’

responses might be influenced by social desirability and peer

influences. Second, the findings reported here do not permit

temporal, causal, or quantitative inferences, but indeed

correspond with programme evaluation data reported in a

related paper [14]. Third, due to the voluntary nature of

participation, attitudes expressed by HCWs in this sample

might not be representative of their peers and colleagues.

Fourth, due to the active role of Kenyan health adminis-

trators in supporting this programme, the findings might not

be replicable in areas where such support is lacking.

Conclusions

This is the first known qualitative evaluation study of an

MSM sensitivity training in Africa, which suggests that an on-

line MSM sensitization training combined with group discus-

sions can be a promising approach to improving health

providers’ awareness, attitudes and beliefs about the health

needs of MSM patients. Quantitative evaluation results,

which show similar findings, are reported in a companion

paper [14]. Further research is needed to evaluate the

programme in a controlled study, and examine the imple-

mentation processes associated with successful programme

delivery. Perspectives and service delivery outcomes from

MSM patients would enhance understanding of the impact of

this training on patient interaction. A particular strength of

the intervention was the incorporation of two complemen-

tary training modalities computer-facilitated training and

group discussions to provide didactic content as well as

opportunities for group reflection, feedback and support. In

general, participants noted a transformation in their personal

attitudes and endorsement of stigma towards MSM following

the training. However, their comments revealed the con-

tinued challenges to providing services to MSM in the

context of broader societal homophobia and secondary

stigma among their peers; their comments also highlighted

challenges in recruiting larger groups of HCWs into the

training due to anxiety around secondary stigma. Findings

reported here can inform further adaptations of the training,

particularly those domains that might influence HCWs’

willingness to participate and respond to the training (e.g.,

by emphasizing professional responsibilities of all health

providers) and that diminish the effects of secondary stigma

(e.g., by providing opportunities for ongoing support among

trained HCWs). Findings underscore the need to view HCWs

as an integral, but not absolute, component in addressing

HIV and other health adversities among Kenyan MSM.

Trained HCWs might benefit from continued opportunities

for peer support, to counter feelings of professional isolation

and motivate engagement in best practices. As participants

noted, multi-component programmes and long-term com-

mitments are necessary to achieve the goal of providing

appropriate, effective services to MSM.

Authors’ affiliations

Centre for Geographic Medicine Research (Coast), Kenya Medical Research

Institute, Nairobi, Kenya;

Provincial Medical Office, Ministry of Public Health

and Sanitation, Mombasa, Kenya;

Desmond Tutu HIV Foundation, Cape Town,

South Africa;

School of Public Health, Brown University Providence, RI,

USA;

Department of Global Health, University of Washington Seattle,

Washington, DC, USA;

Department of Public Health, University of Oxford,

Headington, Oxford, UK

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

EMvdE, EG, AO, JK, ZD, SMG, ADS, EJS and DO conceived and designed the

focus group discussions. EG, JK and EMvdE conducted the focus group

discussions. EMvdE, MM, SS and DO analyzed the data. EMvdE, DO, MM

and SS wrote this article. JK acted as the Study Coordinator. All authors have

seen and approved the final version of this manuscript.

Acknowledgements

The authors acknowledge NASCOP’s team at the Ministry of Health for their

ongoing support, NASCOP’s director, Dr. Muraguri, and the national AIDS and

STI coordinator for MARPs Helgar Musyoki. At the district level, they thank the

District AIDS and STI coordinators, Maria Mulwa, Ibrahim Fauz, George

Kissinger and Rahmah Hashim for their significant input and excellent

facilitation provision. They thank Shadrack Babu and Mohamed Shally for

their administrative support, and the LGTBI organization ‘‘Tamba Pwani’’ for its

input and enthusiasm in discussions. The authors acknowledge all HCWs who

participated in the FGDs for their willingness to share ‘‘lived’’ experiences,

building meaning to discussions. Finally, the authors thank Stephan Baral at

Johns Hopkins School of Public Health, USA, for support of our work with MSM

in Coastal Kenya.

Funding

This research was supported by Johns Hopkins University on behalf of its

Bloomberg School of Public Health (Prime award Number GHH-I-00-07-00032-

00), entitled ‘‘HIV Prevention Program Research Task Order 2,’’ funded by US

Agency for International Development. Work with key populations in Kilifi,

Kenya is funded by the International AIDS Vaccine Initiative. They also thank

the KEMRI-Wellcome Trust Research Programme (KEMRI-WTRP) for their

support to this study. The KWTRP receives core funding from the Wellcome

Trust (#077092). The content is solely the responsibility of the authors and

does not necessarily represent the official views of the US Agency for

International Development.

This report was published with permission from KEMRI.

References

1. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet Infect Dis. 2012;380(9839):36777.

2. Muraguri N, Temmerman M, Geibel S. A decade of research involving men

who have sex with men in sub-Saharan Africa: current knowledge and future

directions. SAHARA J. 2012;9:13747.

3. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe HW. Men who have sex with

men and HIV/AIDS in sub-Saharan Africa. Lancet. 2009;374:41622.

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

4. Sanders EJ, Graham SM, Okuku HS, van der Elst EM, Muhaari A, Davies A,

et al. HIV-1 infection in high risk men who have sex with men in Mombasa,

Kenya. AIDS. 2007;21:251320.

5. Sanders EJ, Okuku HS, Smith AD, Mwangome M, Wahome E, Fegan G, et al.

High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads

following seroconversion among MSM. AIDS. 2013;27:43746.

6. Gouws E, Cuchi P, International Collaboration on Estimating HIV Incidence

by Modes of Transmission. Focusing the HIV response through estimating the

major modes of HIV transmission: a multi-country analysis. Sex Transm Infect.

2012;88(Suppl 2):i7685.

7. Price MA, Rida W, Mwangome M, Mutua G, Middelkoop K, Roux S, et al.

Identifying at-risk populations in Kenya and South Africa: HIV incidence in

cohorts of men who report sex with men, sex workers, and youth. J Acquir

Immune Defic Syndr. 2012;59:18593.

8. NACC. Kenya national AIDS strategic plan 2009/10 2012/13: delivering on

universal access to services. Nairobi: National AIDS Control Council; 2009.

9. NASCOP, Ministry of Health. MARPs surveillance report: unveiling new

evidence for accelerating programming. Nairobi: National AIDS and STI

Coordination Programme; 2012.

10. WHO. Prevention and treatment of HIV and other sexually transmitted

infections among men who have sex with men and transgender people:

recommendations for a public health apporach. Geneva: World Health

Organization; 2011.

11. Eden A, Taegtmeyer, M. Kenya national manual for training counsellors in

voluntary counselling and testing for HIV. Nairobi: National AIDS and STD

Control Program; 2003.

12. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical

education. Acad Med. 2006;81(3):20712.

13. Zimitat C. Designing effective on-line continuing medical education. Med

Teach. 2001;23:11722.

14. van der Elst EM, Smith AD, Gichuru E, Wahome E, Musyoki H, Muraguri N,

et al. Men who have sex with men sensitivity training reduces homoprejudice

and increases knowledge among Kenyan healthcare providers in coastal Kenya.

J Int AIDS Soc. 2013;16(4). doi: 10.7448/IAS.16.4.18748.

15. Ritchie J, Spencer L. Qualitative data analysis for applied policy research.

In: Bryman A, Burgess RG, editors. Analyzing qualitative data. London, UK:

Routledge; 1994. p. 17394.

van der Elst EM et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18741

http://www.jiasociety.org/index.php/jias/article/view/18741 | http://dx.doi.org/10.7448/IAS.16.4.18741

Research article

HIV among men who have sex with men in Malawi:

elucidating HIV prevalence and correlates of infection

to inform HIV prevention

Andrea L Wirtz

§,1,2

, Vincent Jumbe

3,4

, Gift Trapence

, Dunker Kamba

, Eric Umar

, Sosthenes Ketende

, Mark Berry

Susanne Stro

¨mdahl

, Chris Beyrer

and Stefan D Baral

Corresponding author: Andrea L Wirtz, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room E7143, Baltimore, MD 21205, USA. Tel: 1 410

502 0800. (awirtz@jhsph.edu)

Abstract

Introduction: There are limited data characterizing the burden of HIV among men who have sex with men (MSM) in Malawi.

Epidemiologic research and access to HIV prevention, treatment and care services have been traditionally limited in Malawi by

criminalization and stigmatization of same-sex practices. To inform the development of a comprehensive HIV prevention

intervention for Malawian MSM, we conducted a community-led assessment of HIV prevalence and correlates of infection.

Methods: From April 2011 to March 2012, 338 MSM were enrolled in a cross-sectional study in Blantyre, Malawi. Participants

were recruited by respondent-driven sampling methods (RDS), reaching 19 waves. Trained staff administered the socio-

behavioural survey and HIV and syphilis voluntary counselling and testing.

Results: Crude HIV and syphilis prevalence estimates were 15.4% (RDS-weighted 12.5%, 95% confidence interval (CI): 7.3 17.8)

and 5.3% (RDS-weighted 4.4%, 95% CI: 3.17.6), respectively. Ninety per cent (90.4%, unweighted) of HIV infections were

reported as being previously undiagnosed. Participants were predominantly gay-identified (60.8%) or bisexually identified

(36.3%); 50.7% reported recent concurrent relationships. Approximately half reported consistent condom use (always or almost

always) with casual male partners, and proportions were relatively uniform across partner types and genders. The prevalence of

perceived and experienced stigma exceeded 20% for almost all variables, 11.4% ever experienced physical violence and 7% were

ever raped. Current age 25 years (RDS-weighted adjusted odds ratio (AOR) 3.9, 95% CI: 1.212.7), single marital status (RDS-

weighted AOR: 0.3; 95% CI: 0.10.8) and age of first sex with a man B16 years (RDS-weighted AOR: 4.3, 95% CI: 1.215.0) were

independently associated with HIV infection.

Conclusions: Results demonstrate that MSM represent an underserved, at-risk population for HIV services in Malawi and merit

comprehensive HIV prevention services. Results provide a number of priorities for research and prevention programmes for MSM,

including providing access to and encouraging regular confidential HIV testing and counselling, and risk reduction counselling

related to anal intercourse. Other targets include the provision of condoms and compatible lubricants, HIV prevention information,

and HIV and sexually transmitted infection treatment and adherence support. Addressing multiple levels of HIV risk, including

structural factors, may help to ensure that programmes have sufficient coverage to impact this HIV epidemic among MSM.

Keywords: HIV; men who have sex with men (MSM); behavioural risks; stigma; Malawi; prevention.

Received 21 May 2013; Revised 26 August 2013; Accepted 25 September 2013; Published 2 December 2013

Copyright: –2013 Wirtz AL et al; licensee International AIDS Society.This is an Open Access article distributed under the terms of the Creative Commons Attribution

3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Introduction

Recent years have witnessed an increased awareness of the

high burden of HIV among men who have sex with men (MSM)

across the globe [13]. Emerging research suggests a greater

transmission efficiency of HIV through receptive anal inter-

course that is approximately 18 times higher than that of

penile-vaginal sexual contact, increasing the risk among MSM

for acquisition of HIV during sexual intercourse [4,5]. National

HIV strategies and funding priorities, however, remain inequi-

table in many countries [6,7], particularly where structural

factors, such as the criminalization of homosexuality, play

critical roles in the level of research and programming

available to MSM [8,9].

The HIV response in Malawi has focused on the prevention

of heterosexual and vertical transmission of HIV to counter-

act the observed HIV incidence rates of 24% among adults

in the 1990s. Today, the epidemic remains a generalized one,

with an estimated 8.0% HIV prevalence among adult men

[10]. Like neighbouring countries, assessments of specific risk

factors for the acquisition and transmission of HIV, including

transmission among MSM and other populations such as

female sex workers, have been limited in the country [11].

Criminalization and stigmatization of homosexuality, as in

other settings [8,12,13], are likely underlying factors for the

limited targeted research and programming in the Malawian

context.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

To our knowledge, only two studies in Malawi have

assessed sexual and social exposures that place MSM at

risk for HIV infection. In 2008, our research team conducted a

rapid HIV screening and socio-behavioural assessment among

201 MSM in Lilongwe and Blantyre, Malawi, as part of a

comprehensive study across Southern African countries,

including Namibia and Botswana, where homosexuality is

criminalized [14]. This study documented HIV prevalence at

approximately 21% [14], individual risk for HIV infections

associated with increased age of the participant and incon-

sistent condom use [14] and high levels of violence and

perceived stigma [15].

Another exploratory study examined socio-demographic

and sexual behaviour characteristics among 97 MSM in

central and southern Malawi. Although HIV prevalence was

not assessed, the study found evidence of high-risk beha-

viours such as inconsistent condom use (32.5%), transac-

tional sex (23.7%), low exposure to HIV messaging (17.5%)

and a low history of HIV testing (58.8% ever tested) [16].

Although these studies were the first and only to elucidate

the socio-behavioural factors among MSM in Malawi, they

were rapid assessments and served to highlight areas for

future research and prevention.

In response to the global epidemic of HIV among MSM,

combination prevention packages have been put forth as a

key method to curb the HIV epidemic among MSM [17,18]. To

inform the content and scale of a combination HIV preven-

tion intervention (CHPI) for MSM in Malawi, we conducted

this study to estimate HIV prevalence, characterize associa-

tions of prevalent HIV infections, and evaluate barriers and

facilitators to uptake of HIV prevention services among MSM

in Blantyre, Malawi. Research was conducted in collaboration

with a community-based organization, the Centre for the

Development of People (CEDEP), and the Malawi College of

Medicine, University of Malawi.

Methods

Study population and setting

This cross-sectional assessment was conducted from August

2011 to March 2012 in Blantyre, Malawi. Eligibility require-

ments for participation included being born male, being aged

18 years or older, being fluent in Chichewa or English, having

reported anal sex with another man in the last 12 months,

having no prior participation in this study, and providing

informed verbal consent to participate. Study activities were

conducted in private rooms of CEDEP’s study site and

implemented by staff from CEDEP, which provides HIV

prevention activities for MSM in Malawi, and the Malawi

College of Medicine. All staff members were trained in

confidentiality and human subjects protection, qualitative

and survey research and respondent-driven sampling (RDS)

methods.

Recruitment method

Participants were recruited via RDS, a chain recruitment

method often used to achieve more representative samples

of hard-to-reach populations [19]. Recruitment began with

10 purposively selected seeds who were each provided with

three study-specific coupons with which to recruit peer MSM

from their social network into the study. Initiation of seeds

was staggered over the duration of the study, taking into

consideration potential propagation failure by some seeds

and eventual die-out of the chains. Seeds were recruited

from the pool of MSM who were involved in local HIV

prevention programmes or had participated in prior forma-

tive research, and they were selected to represent a range of

characteristics, including age, education, employment and

sexual identity. Individuals who were recruited by seeds and

enrolled in the study were then provided with three study

coupons for further recruitment of peers. This process

continued until the target sample size was reached. Partici-

pants were reimbursed K1500.00 (US$5.00) for transporta-

tion costs for participation in the study and K500.00

(US$1.50) for recruitment of each peer into the study.

A full description of traditional RDS methodology can be

found elsewhere [20]. Netdraw software (Analytic Technolo-

gies) was used to monitor RDS recruitment [21].

Sample size

The sample size calculation was powered on the assumed 85%

effectiveness of condoms in preventing the transmission of

HIV during intercourse [22]. Thus, we assumed that approxi-

mately 30% of the sample would be consistent condom users

and that they would be 85% less likely to be living with HIV

than the 70% who are not consistent condom users. Based on

previous research, we estimated that the HIV prevalence in

the population would be about 20%, equating to 27% among

non-consistent condom users, 4% among consistent condom

users and a 30% population prevalence of consistent condom

usage. We used a design effect of 1.5 [23], power set at 80%

and a significance level of 95%, which resulted in an effective

sample size estimate of 345 participants for which we had

targeted 350 MSM.

Measures

Participation included a structured survey instrument and a

biological assessment of HIV and syphilis. Trained interviewers

administered surveys in the Chichewa language, following

pilot testing. Measures included sociodemographic character-

istics, substance use, mental health and depression symp-

toms, sexual relationships and disclosure of orientation or

sexual practices to family and peers. Measures of sexual

practices included practices with men and women, including

anal, oral and vaginal sex; number of sexual partners and

partner characteristics; concurrent relationships, defined as

‘‘two sexual partnerships at the same time or two ongoing

sexual partnerships (male and/or female genders)’’; and

transactional sex (purchased or sold). We measured HIV

knowledge and prevention, including aspects of condom and

condom-compatible lubricant use; HIV testing and counselling

exposures; and access to and uptake of health services.

Human rights measures included experiences of physical and

sexual violence, experienced and perceived stigma and history

of imprisonment. Recall periods were lifetime, last 12 months

or both, and they are specified in the results tables. The

development of survey questions, recruitment methods,

coupons and study procedures was informed by formative

research that was conducted in MayJuly, 2011 [24].

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Biologic specimens

Following completion of the interview, participants proceeded

to HIV and syphilis testing. A trained nurse from the College of

Medicine conducted HIV testing, blood specimen collection

and pre- and post-test counselling. Blood-based rapid HIV

tests were conducted simultaneously using the Determine†

HIV-1/2 and Uni-Gold rapid HIV tests (manufactured, respec-

tively, by Inverness Medical, Chiba, Japan; and Trinity Biotech,

Bray, Ireland). Participants received their HIV test results and

post-test counselling within 15 minutes of collection. Separate

specimens were collected for confirmatory testing of discre-

pant or indeterminate HIV rapid tests using Western blot

in accordance with Malawian National Guidelines [25].

Approximately 5 ml of whole blood was collected for TPHA

(treponema pallidum haemagglutination test) syphilis testing

(Bio-rad, Hercules, CA, USA). Resource constraints prevented

the use of the nontreponemal test, which would differentiate

active from past syphilis infections. Confirmatory HIV and

syphilis tests were analysed at the Malawi College of Medicine

laboratory in Blantyre. Participants returned within one to

two weeks to receive their syphilis test results. Participants

testing positive for HIV and/or syphilis were referred to the

local hospital or to the Johns Hopkins antiretroviral therapy

and sexually transmitted infection clinic located at Queens

Hospital. Participants were provided with information about

local health centres that had, as part of the study, received

training for the provision of services to MSM. One trained

team member (EU) provided counselling services to MSM

participants as needed.

Analysis

Johns Hopkins University conducted secondary data analysis

of collected data. The principal outcome of interest was HIV

diagnosis with predictor variables that included demographics

(education, age, number of children and marital status), socio-

economic variables, lifetime residence in urban or rural

locations, recent sexual behaviours, human rights exposures,

HIV prevention methods, health-seeking behaviour and labo-

ratory markers of syphilis infection. Variable-specific indivi-

dualized weights, which take into account estimates for

individual degrees, were computed by a data-smoothing

algorithm using RDS for Stata [26]. The estimated weights

were used in univariate RDS-weighted analyses. HIV status

individualized weights were used in the bivariate and multi-

variate RDS-weighted analyses. Bootstrapped 95% confidence

intervals (CIs) were computed using 1000 iterations for the

estimated descriptive statistics [23]. Homophily, a measure of

to what extent respondents prefer to recruit from their own

group rather than at random, was estimated where appro-

priate and presented in the results in Table 1.

To develop the statistical model, we first carried out

bivariate analysis to assess the association of HIV status with

the control variables (Table 4). Demographic variables were

included in the multivariate logistic regression model regard-

less of the estimated strength of their bivariate association

with HIV status. Selected non-demographic variables were

included in the multivariate model if the chi-square p-value of

association with HIV status was 50.25. Some variables such

as HIV testing were not included in the multivariate model due

to collinearity. The final model, presented in Table 4, includes

demographics and variables left in the final model following

goodness-of-fit tests. All statistical analyses were conducted

using Stata 12.1 [27]. Results provided in the text report RDS-

weighted estimates (unless otherwise specified), while tables

display unweighted and RDS-weighted estimates as well as

95% CIs for weighted estimates. Table 4 presents the results of

bivariate and final multivariate analyses, including unweighted

and RDS-weighted odds ratios (ORs) and adjusted ORs (AORs)

for the final multivariate model.

Human subjects

Research activities were reviewed and approved by the

Malawi College of Medicine Ethics and Research Committee

and for secondary analysis by the Johns Hopkins Bloomberg

School of Public Health Institutional Review Board.

Results

A total of 338 MSM (including original seeds) were recruited

via RDS and enrolled into the study, reaching 19 waves of

recruitment. Out of 10 seeds, five recruited participants; one

recruitment chain was responsible for the recruitment of

70% of the study population. Three recruitment chains are

reflective of later seed initiation. A total of 706 coupons

were distributed with a return rate of 48%. The majority of

participants reported recruitment by a friend (60.5%) or sex

partner (32.3%). Median MSM network size was 8 (range 1 to

800). Figure 1 displays the RDS recruitment diagram, high-

lighted by HIV diagnosis. We used this method to monitor

recruitment and to assess whether HIV diagnosis inhibited

recruitment, which appeared not to be the case.

Participants’ median age was 25.1 years (range: 18 to 49).

Based on RDS-weighted estimates, 51% were unemployed

and 21.6% had ever been in jail or prison. Eighty per cent

identified as male gender. Sixty-one per cent identified as gay

or homosexual, and 36.3% reported bisexual identity. Sixteen

per cent were married or cohabitating with a woman. Table 1

displays sociodemographic characteristics.

The crude prevalence of HIV infection in this population

was 15.4%, with an RDS-weighted estimate of 12.5% (Table 1).

The majority, 90.4% (unweighted), of these infections were

previously undiagnosed; these participants had either self-

reported as negative or reported never being tested for HIV

infection. Positive syphilis diagnosis was low at 4.4%.

Table 2 presents sexual practices, partner characteristics

and social exposures. Only 18.1% had ever disclosed sexual

practices or orientation to their family, and equally few

(18.9%), had ever disclosed to a health provider. Participants

reported a mean of four male partners (range: 1 to 50), and

31% reported having female partners in the last 12 months.

Half of the population reported concurrent sexual relation-

ships, and, among those in a relationship, 61.3% believed

their partner was also involved in a concurrent relationship.

Prevalence of perceived and experienced stigma and dis-

crimination exceeded 20% of the population for almost

all variables, 7.0% were ever raped and 11.4% had ever

experienced physical violence.

Responses to questions on knowledge of HIV risk,

prevention methods and practices are reported in Table 3.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Approximately half of the participants with casual male

partners (n256) reported using condoms always or almost

always with casual male partners; frequencies were approxi-

mately similar across partner type (e.g., casual or main) and

partner gender. Approximately 44.3% had never been

tested for HIV. Among those ever tested for HIV infection,

45.5% (unweighted) had not been tested within the last

year.

Figure 1. RDS recruitment diagram from 338 MSM recruited in Blantyre, Malawi. Large nodesseeds; small nodes recruits; grey HIV

according to Determine rapid HIV test; blackHIV- on Determine rapid HIV test.

Table 1. Demographics, identity and health characteristics of RDS-recruited MSM in Blantyre, Malawi (August 2011March 2012;

n338)

Crude RDS weighted

Variable Categories n(%) (%) (95% CI) Homophily

Demographics

Age 1825 years 192 56.8 58.5 [50.266.8] 0.261

]26 years 146 43.2 41.5 [33.249.8] 0.231

Highest level of education (completed) Less than secondary 146 43.2 46.3 [38.9 53.8] 0.115

Secondary or higher 192 56.8 53.7 [46.261.1] 0.147

Employment status Unemployed 158 46.8 51.7 [44.2 59.3] 0.008

Employed 136 40.2 36.8 [29.644.1] 0.153

Student 44 13.0 11.5 [0.74 15.5] 0.044

Gender identity Male 263 77.8 80.2 [74.885.6] 0.008

Female 65 19.2 17.0 [11.822.1] 0.153

Transgender 10 2.9 2.8 [0.84.9] 0.044

Sexual orientation Gay or homosexual 210 62.3 60.8 [53.668.1] 0.092

Bisexual 125 37.1 36.3 [29.143.4] 0.070

Heterosexual or straight 2 0.6 2.9 [0.06.7] 0.029

Marital status (with a woman) Married or cohabiting 54 16.0 16.2 [9.722.7] 0.196

Single, divorced or separated 284 84.0 83.7 [77.4 90.1] 0.255

Number of children None 285 84.6 84.9 [78.291.6] 0.224

One or more 52 15.4 15.1 [0.821.8] 0.142

Type of location where majority of life was spent Urban 279 82.5 78.3 [72.184.6] 0.231

Rural 59 17.5 21.7 [15.4 27.9] 0.050

Health indicators

HIV diagnosis Negative 286 84.6 87.5 [82.2 92.8] 0.090

Positive 52 15.4 12.5 [7.217.8] 0.022

Syphilis diagnosis Negative 319 94.7 95.6 [92.998.3] 0.195

Positive 18 5.3 4.4 [1.77.1] 0.009

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Several sociodemographic variables were associated with

HIV infection in the bivariate analysis (Table 4). These included

current age 25 years (RDS-weighted OR: 8.1, 95% CI: 2.9 

22.2), single marital status (RDS-weighted OR: 0.2, 95% CI:

0.10.4) and having more than one child (RDS-weighted OR:

5.3, 95% CI: 1.815.6). Age B16 years at first sex with a man

was associated with HIV infection (RDS-weighted OR: 1.7, 95%

CI: 0.47.5). Considering water-based lubricants to be the

safest lubricant (RDS-weighted OR: 0.9, 95% CI: 0.23.6) and

use of water-based lubricant (RDS-weighted OR: 0.6, 95% CI:

0.22.0) were also marginally protective.

The final multivariate model included age, marital status,

number of children, knowledge of risk related to positioning

(insertive or receptive anal intercourse), lubricant type used,

age of first sex with another man, history of rape, number of

male anal or oral sex partners and other known confounders

such as employment, education and syphilis diagnosis. Of

these, current age 25 years (RDS-weighted AOR 3.9, 95%

CI: 1.212.7), single marital status (RDS adjusted AOR: 0.3,

95% CI: 0.10. 8) and age of first sex with a man B16 years

(RDS adjusted AOR: 4.3, 95% CI: 1.215.0) were indepen-

dently associated with HIV infection.

Discussion

This cross-sectional study, the most comprehensive yet

conducted among MSM in Malawi, describes the high

prevalence of HIV infection as well as the limited uptake of

HIV prevention, testing and care services among MSM in

Blantyre, Malawi.

HIV prevalence was high among MSM, and nearly all HIV

infections were among men who reported being unaware of

their status of HIV infection. Only slightly more than half of

the population reported ever having been tested, and only

half of those were within the last year, potentially explaining

this level of undiagnosed HIV infections. Knowing one’s status

is increasingly more important for HIV prevention. Novel HIV

interventions, including pre-exposure prophylaxis for HIV-

uninfected men [28,29] and early treatment for people living

with HIV [30], represent a new generation of HIV-status-

dependent interventions. Awareness of one’s HIV status has

also been associated with decreased self-reported prevalence

of high-risk sexual practices that are associated with HIV

transmission [31]. Recent US Centers for Disease Control

guidelines have suggested more frequent testing (every 3

or 6 months) based on individual assessment of sexual risk

Table 2. Sexuality, partnerships and risk exposures of RDS-recruited MSM in Blantyre, Malawi (August 2011 March 2012; n338)

Unweighted RDS weighted

Variable Categories n(%) (%) (95% CI)

Ever disclosed sexual practice to family Yes 69 20.4 18.1 [12.923.2]

Ever disclosed sexual practice to health provider Yes 70 20.8 18.9 [13.324.5]

Gender of first sex partner Male 226 67.1 69.4 [62.576.3]

Female 111 32.9 30.6 [23.737.5]

Age at first sex with another man B16 Years old 55 16.3 14.9 [8.9 21.0]

1620 Years old 174 51.6 53.1 [45.560.8]

2125 Years old 74 22.0 22.4 [16.128.8]

25 34 10.1 9.6 [5.313.9]

Sexual partners in last 12 months: mean (range) Male partners [n334] 3.8 (1 50) N/A N/A

Female partners [n107] 2.9 (120) N/A N/A

Concurrent relationships, last 12 months* None 160 47.3 49.5 [42.356.8]

Yes, two or more male and/or female

partners

178 52.7 50.7 [43.357.9]

Believes partner has concurrent relationship* (n76) Yes 59 77.6 61.3 [30.190.9]

Normally has sex with men in a private home Yes 224 66.3 67.6 [60.574.8]

... in bar or clubs Yes 98 29.0 26.1 [20.232.1]

... in a hotel Yes 78 23.1 20.1 [14.226.0]

Social exposures

Ever felt excluded from family gatherings Yes 87 25.7 26.1 [20.032.2]

Ever felt rejected by friends Yes 118 35.0 27.2 [20.734.]

Feels there are safe places to go to socialize with other

MSM

Yes 223 66.8 66.0 [59.172.9]

Ever felt afraid to seek health services Yes 68 20.1 21.5 [15.127.9]

Ever been in jail or prison Yes 74 22.1 21.6 [14.129.1]

Ever experienced physical violence Yes 40 11.8 11.4 [6.116.8]

Ever raped (N337) Yes 26 7.7 7.0 [3.5 10.5]

*Concurrent sexual partnership: two or more male or female sexual partners during the same time period.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

behaviours [32], representing a strategy which may also be

relevant for MSM in Malawi.

Young age of first sexual intercourse with a man (B16

years) was independently associated with HIV infection in this

population, with almost four times greater odds of HIV

infection compared to the referent group. This association

may suggest biologic susceptibility during physical develop-

ment, high-risk sexual behaviours and lack of access to or low

use of condoms at a young age, and/or an association with

duration of sexual activity [33,34]. Likewise, the association

of prevalent HIV infection with older current age may be due

to higher cumulative risk exposures for acquisition of HIV.

However, estimating the duration of sexual activity is challen-

ging as sexual behaviours are not static, but vary across the life

course and as partnerships change [34]. While study-related

factors such as low power and potential misclassification of

behaviours may partially explain insignificant findings, broader

factors such as high background prevalence of HIV in the MSM

population [35], biologic susceptibility of rectal mucosa [36]

and network-level characteristics may also be more determi-

native in driving HIV transmission and acquisition risks among

these men [35,37]. Nonetheless, this study described a

population reporting high-risk behaviours, suggesting the

need to ensure accessibility to HIV prevention interventions

Table 3. Knowledge of HIV risk, prevention methods and practices of RDS-recruited MSM in Blantyre, Malawi (August 2011March

2012; n338)

Unweighted RDS weighted

Variable Categories n(%) (%) (95% CI)

Condom use in last sex with main male partner (n316) Yes 119 63.0 59.6 [51.767.4]

Condom use in last sex with casual male partner (n256) Yes 174 68.0 66.3 [57.4 75.2]

Condom frequency with main male partners (n316) Never 44 14.1 15.3 [9.9 20.6]

Almost never 52 16.7 18.4 [11.725.0]

Sometimes 63 20.2 19.9 [13.825.9]

Almost always 41 13.1 10.8 [6.315.2]

Always 112 35.9 35.7 [27.943.6]

Condom frequency with casual male partners (n256) Never 34 13.3 15.6 [9.5 21.7]

Almost never 30 11.7 14.0 [6.221.9]

Sometimes 53 20.7 21.4 [14.128.6]

Almost always 28 10.9 4.8 [1.87.8]

Always 111 43.4 44.2 [34.553.8]

Condom use at last sex with main female partner (n101) Yes 45 44.5 50.3 [23.9 76.6]

Condom use at last sex with casual female partner (n71) Yes 46 64.8 58.2 [27.5 88.8]

Condom frequency with main female partners Never 25 25.0 22.5 [2.642.4]

Almost never 27 27.0 27.3 [6.548.2]

Sometimes 15 15.0 3.4 [0.015.4]

Almost always 12 12.0 7.7 [0.018.0]

Always 21 21.0 39.1 [8.369.8]

HIV testing (ever; n336) Never 134 39.9 44.3 [37.051.6]

Once 123 36.6 32.8 [26.439.2]

More than once 79 23.5 22.9 [17.328.6]

Considered vaginal sex most ‘‘risky’’ type of sex Yes 180 53.4 52.8 [45.759.9]

Considered anal sex most ‘‘risky’’ type of sex Yes 59 17.5 15.4 [10.020.8]

Considered both equally ‘‘risky’’ types of sex Yes 119 35.2 35.6 [28.642.6]

Ever received information about HIV prevention for sex with men Yes 75 22.5 18.8 [12.924.7]

Ever received information about HIV prevention for sex with women Yes 183 54.3 53.7 [46.361.0]

Knowledge of risk related to positioning Insertive (top) 56 16.7 15.2 [10.220.3]

Receptive (bottom) 112 33.4 38.0 [30.745.3]

Both carry equal risk 167 49.9 46.7 [39.853.6]

Considers safest lubricants to use during anal sex Petroleum jelly or Vaseline 133 43.6 49.7 [41.258.5]

Water-based lubricant 43 14.1 14.5 [8.021.1]

Others or none 130 42.5 35.6 [27.243.9]

Lubricant use Petroleum jelly or Vaseline 149 45.3 48.3 [40.156.0]

Water-based lubricant 74 22.5 25.2 [18.132.3]

Others or none 106 32.2 26.5 [19.833.2]

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Table 4. Bivariate and multivariate associations of HIV infection among RDS-recruited MSM in Blantyre, Malawi (August 2011March 2012; n338)

HIV

negative

HIV

positive Total OR [unweighted] OR [RDS weighted]

Multivariate AOR

[unweighted]

Mulitvariate RDS-

weighted AOR

Variable Categories No. (%) No. (%) No. (%) pEstimate (95% CI) Estimate (95% CI) Estimate (95% CI) Estimate (95% CI)

Socio-demographics

Age 1825 181 94.2 11 5.7 192 56.8 B0.001 1 1 1 1

]26 105 71.9 41 28.1 146 43.2 6.4 [3.213.0] 8.1 [2.922.2] 3.2** [1.37.9] 3.9** [1.2 12.7]

Education Less than secondary 126 86.3 20 13.7 146 43.2 0.454 1 1 1 1

Secondary or higher 160 83.3 32 16.7 192 56.8 1.3 [0.6 2.3] 0.8 [0.32.0] 0.6 [0.3 1.4] 0.5 [0.21.6]

Employment status Unemployed 140 88.6 18 11.4 158 46.8 B0.001 1 1 1 1

Employed or self-employed 103 75.7 33 24.3 136 40.2 2.5 [1.34.7] 2.1 [0.85.8] 2.5* [1.1 5.4] 2.4 [0.96.7]

Student 43 84.7 1 2.3 44 13.0 0.2 [0.10.2] 0.2 [0.01.5] 0.3 [0.02.8] 0.5 [0.06.4]

Marital status

(with a woman)

Not single, or widowed 35 64.8 19 35.2 54 16.0 B0.001 1 1 1 1

Single or never married 251 88.4 33 11.6 284 84.0 0.2 [0.10.5] 0.2 [0.10.4] 0.7 [0.22.0] 0.3* [0.1 0.8]

Number of children None 253 88.8 32 11.2 285 84.6 B0.001 1 1 1 1

]1 child 32 61.5 20 38.5 52 15.4 4.9 [2.5 9.6] 5.3 [1.815.6] 2.2 [0.76.5] 1.2 [0.44.1]

Place where respondent

grew up

Urban 233 83.5 46 16.5 279 82.5 0.222 1 1 1 1

Rural 53 89.8 6 10.2 59 17.5 0.6 [0.21.4] 0.7 [0.22.4] 0.3 [0.11.0] 0.4 [0.11.7]

Sexuality, partnerships and risk exposures

Sexual orientation Gay or homosexual 178 84.8 32 15.2 210 62.3 0.398 1 1

Bisexual 106 84.8 19 15.2 125 37.1 1.0 [0.51.9] 1.1 [0.52.6]

Straight or heterosexual 1 50.0 1 50.0 2 0.6 5.6 [0.4 91.2] 24.8 [1.5420.1]

Ever disclosed sexual

practice to health

provider

No 228 85.4 39 14.6 267 79.2 0.414 1

Yes 57 81.4 13 18.6 70 20.8 1.3 [0.72.7] 1.1 [0.43.2]

Age at first sex with

another man

B16 Years old 42 76.4 13 23.6 55 16.3 B0.001 1.6 [0.73.8] 1.7 [0.47.5] 2.7 [0.97.5] 4.3* [1.2 5.0]

1620 Years old 160 92.0 14 8.0 174 51.6 0.5 [0.2 1.0] 0.3 [0.10.9] 0.8 [0.32.2] 0.6 [0.22.2]

2125 Years old 62 83.9 12 16.2 74 22.0 1 1 1 1

25 21 61.8 13 38.2 34 10.0 3.2 [0.10.4] 3.4 [1.011.4] 2.2 [0.7 6.5] 2.6 [0.88.6]

Normally has sex with men

in a private home

No 90 79.0 24 21.0 114 33.7 0.039 1 1

Yes 196 87.5 28 12.5 224 66.3 0.5 [0.31.0] 0.8 [0.31.9]

... in bars or clubs No 208 86.8 32 13.3 240 71.0 0.102 1

Yes 78 79.6 20 20.4 98 29.0 1.7 [0.93.1] 0.9 [0.42.03]

... in a hotel No 225 86.5 35 13.5 260 76.9 0.074 1

Yes 61 78.2 17 21.8 78 23.1 1.8 [0.93.4] 0.9 [0.42.2]

Condom use at last sex

with main male partner

Yes 103 88.0 14 12.0 117 37.0 0.221 1 1

No 165 82.9 34 17.1 199 63.0 1.5 [0.83.0] 0.9 [0.32.6]

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Table 4 (Continued )

HIV

negative

HIV

positive Total OR [unweighted] OR [RDS weighted]

Multivariate AOR

[unweighted]

Mulitvariate RDS-

weighted AOR

Variable Categories No. (%) No. (%) No. (%) pEstimate (95% CI) Estimate (95% CI) Estimate (95% CI) Estimate (95% CI)

Social and human rights contexts

Feels there are safe places

to go to socialize with

other MSM

No 88 79.3 23 20.7 111 33.2 0.067 1 1

Yes 194 87.0 29 13.0 223 66.8 0.6 [0.31.0] 0.4 [0.21.1]

Ever felt afraid to seek

health services

No 229 84.8 41 15.2 270 79.9 0.840 1 1

Yes 57 83.8 11 16.2 68 20.1 1.1 [0.52.2] 0.7 [0.32.2]

Ever in jail No 227 87.0 34 13.0 261 77.9 0.018 1 1

Yes 56 75.7 18 24.3 74 22.1 2.2 [1.14.1] 1.4 [0.63.4]

Raped (N337) No 266 85.5 45 14.5 311 93.3 0.090 1 1 1 1

Yes 19 73.1 7 26.9 26 7.7 2.2 [0.95.5] 0.6 [0.22.0] 2.9 [0.9 9.5] 15 [0.29.6]

Knowledge of HIV risk, prevention methods and practices by HIV diagnosis

HIV testing (ever; n336) Never 113 84.3 21 15.7 134 39.9 0.938 1 1

Once 105 85.4 18 14.6 123 36.6 0.9 [0.5 1.8] 0.8 [0.32.2]

More than once 66 83.5 13 16.5 79 23.5 1.1 [0.5 2.3] 0.5 [0.21.5]

Last 12 months (of ever

tested; N202)

Never 79 83.2 16 16.8 95 45.5 0.854 1 1

Once 74 86.0 12 14.0 86 41.1 0.8 [0.41.8] 0.5 [0.11.8]

More than once 24 85.7 4 14.3 28 13.4 0.8 [0.3 2.7] 0.5 [0.12.3]

Considered anal sex most

‘‘risky’’ type of sex

No 235 84.2 44 15.8 279 82.5 0.669 1 1

Yes 51 86.4 8 13.6 59 17.5 0.8 [0.41.9] 0.4 [0.11.1]

Considers safest lubricants

to use during anal sex

Petroleum jelly or Vaseline 119 91.5 14 8.49 133 43.5 0.102 1 1

Water-based lubricant 104 83.5 26 16.4 130 42.5 1.7 [0.64.4] 0.9 [0.23.6]

Others or none 36 86.7 7 13.2 15 4.9 2.1 [1.1 4.3] 1.2 [0.43.2]

Lubricant use Petroleum jelly or Vaseline 132 88.6 17 11.4 149 45.3 0.124 1 1 1 1

Water-based lubricant 84 79.3 22 20.7 106 32.2 1.5 [0.7 3.3] 0.6 [0.22.0] 1.8 [0.74.6] 0.9 [0.32.4]

None or others 62 83.8 12 16.2 74 22.5 2.0 [1.14.1] 1.3 [0.53.4] 2.8* [1.26.5] 2.7 [0.98.4]

How many men have you had anal or oral sex with in the past 12 months? 0.9 [0.7 1.1] 0.8 [0.61.1]

Exponentiated coefficients; 95% confidence intervals in brackets, *pB0.05, **pB0.01, analysis sample318.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

across ages [3840]. These behavioural risks, combined with

the high proportion of undiagnosed HIV infection in this study,

also suggests there is a high likelihood of someone with a high

viral load within a sexual network potentially driving onward

transmission [41,42]. Future research among MSM in Malawi

to better characterize different risk strata among MSM,

including reported sexual practices and sexual network char-

acteristics, is needed to better tailor the content of interven-

tions and enable the identification of infection.

While addressing the unique needs of the individual is

fundamental, stigma and discrimination have been reported

commonly as structural barriers to the uptake of services

[43,44]. Experienced and perceived stigma as well as other

physical and sexual violence were common among MSM in

this study, consistent with earlier quantitative and qualitative

studies in Malawi [15,24]. Stigma has been shown to limit

health-seeking behaviours and use of HIV prevention methods,

disclosure of sexual practices to health providers, and pro-

viders’ liberty to provide services to MSM [14,15,24,45,46].

The need to keep male-male partnerships hidden may lead to

more frequent, short-term relationships and increased high-

risk behaviours [24]. Such responses to stigma and social

pressures may explain the high prevalence of concurrency, the

high-risk sexual practices reported in this study, the proportion

of men who are married or cohabitating with women and

the protective effect of single marital status in this analysis. Ad-

dressing these social issues is a necessity for improving access

to and uptake of effective HIV prevention interventions [8].

Taken together, these data demonstrate that MSM are an

underserved and important population for targeted HIV

prevention interventions; MSM may specifically benefit from

the CHPI that we subsequently developed based on the

quantitative results presented here. Mathematical models

have shown that high levels of coverage among MSM (i.e., 60

80%) are required to change the trajectory of the HIV epidemic

among MSM, and such findings are likely to be relevant

in Malawi [2,47,48]. To address low coverage of prevention

options among Blantyre MSM and the limitations of single

interventions, comprehensive packages of interventions that

include behavioural, biomedical and structural approaches

may be the most effective approach to reducing HIV among

MSM [17]. Such interventions may be feasible in Malawi and

may have the same positive impact on sexual transmission

that has been observed in other settings, including countries

where same-sex practices are criminalized [30,47,49,50].

The method of intervention delivery is critical to the success

of HIV prevention programmes in the context of complex

social environments. The success of RDS recruitment suggests

that interventions leveraging existing peer networks, which

have demonstrated efficacy in other settings [51,52], may

serve as a feasible approach to providing and supporting HIV

prevention interventions for MSM in Malawi. Addressing

stigma in healthcare settings may improve provider-patient

relationships, facilitate disclosure and meaningful discussion

of risk practices, and foster linkage to HIV testingand care [53].

While the subsequent feasibility assessment of the CHPI

programme for MSM in Blantyre will be informative for

understanding how a comprehensive package may address

individual social and behavioural risks for HIV infection,

broader social acceptance of MSM may take time and remains

a crucial step towards improving the health status of MSM and

thus all Malawians [8].

Limitations

The cross-sectional nature of this study limits the investiga-

tion of temporal associations and thus the causality of the

exposures and HIV-related outcomes. Additional limitations

are related to the ability to fully assess correlates of prevalent

HIV infection through behavioural surveys, which may have

limited the significance of findings in this study. This may also

be amplified by the potential response bias related to asking

sensitive questions of a highly stigmatized population. We

attempted to address these limitations to the fullest extent

possible, including using lifetime and recent recall periods,

developing survey questions based on formative research

and prior research studies among MSM, and taking measures

to ensure the confidentiality and privacy of participants and

inform them of these privacy control measures. This study

provides equipoise for prospective cohorts of MSM to better

characterize HIV incidence and, ultimately, appropriately

powered HIV prevention and implementation science studies

to assess effective strategies in HIV risk reduction.

There are limitations associated with the use of RDS

methodology [54]. Specifically, there is debate around appro-

priate interpretation of the measures of association and

optimal strategies to handle variance in studies using RDS.

For example, use of water-based lubricants appeared to be

independently protective in the model that did not adjust for

RDS, but this association is no longer significant with the

introduction of the increased variance associated with RDS

adjustment in the model. Despite these analytic challenges,

RDS represents a relevant sampling strategy to obtain a diverse

sample of a hidden population in the absence of a sampling

frame or a sufficient number of established venues [19].

Conclusions

This study presents an assessment of individual, sexual-

network and structural factors and their relationship with

prevalent HIV infections among MSM in Blantyre, Malawi.

The burden of HIV is high among these men, with the vast

majority apparently unaware of their HIV status. Approaches

rooted in engagement in the continuum of HIV care will be

central moving forward in Malawi [55]. Addressing stigma

and discrimination should also represent a core program-

matic and policy element of the HIV response, to ensure that

these efficacious approaches are translated into effective

ones and to optimize the health of MSM living with HIV in

Malawi while preventing onward HIV transmission.

Authors’ affiliations

Center for Public Health and Human Rights, Department of Epidemiology,

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,

USA;

Department of Emergency Medicine, Johns Hopkins Medical Institute,

Baltimore, MD, USA;

Department of Community Health, University of Malawi,

College of Medicine, Blantyre, Malawi;

Centre for Global Health, Trinity

College, Dublin, Ireland;

Centre for the Development of People, Blantyre,

Malawi

Competing interests

The authors declare that they have no competing interests.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Authors’ contributions

SB, CB, GT, AW and EU collaborated in the design and oversight of the study.

SB, AW, MB and VJ developed survey instruments; VJ and DK oversaw data

collection; and SK and AW conducted statistical analysis. AW wrote the initial

drafts of this manuscript. All authors had full access to the data and reviewed

and edited the manuscript, and all take responsibility for its integrity as well as

the accuracy of the analysis.

Acknowledgements

We would like to express our sincere thanks to Brad Wagenaar (Emory

University), Ian Phiri (CEDEP), Rodney Chalera (CEDEP), Daniel Banda and Dr

Rajab Mkakosya (Malawi College of Medicine) for their involvement in the

CHPI project. To Deanna Kerrigan (Johns Hopkins University (JHU)), Caitlin

Kennedy (JHU) and Beth Deutsch (US Agency for International Development

(USAID)) for their leadership from the Research to Prevention project and

USAID. Andrea Vazzano (JHU) is thanked for her thorough review and copy edit

of the manuscript. We extend appreciation to Fenway Health, particularly

Rodney Vanderwarker, Kevin Kapila and Marcy Gelman, for their support to

provide health sector training in Blantyre.

Funding

The USAID jProject SEARCH, Task Order No. 2, is funded by the US Agency for

International Development under Contract No. GHH-I-00-07-00032-00, begin-

ning September 30, 2008, and is supported by the President’s Emergency Plan

for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns

Hopkins Center for Global Health and managed by the Johns Hopkins

Bloomberg School of Public Health Center for Communication Programs

(CCP). Additional support from the United Nations Development Programme

(UNDP), United Nations Population Fund (UNFPA), UNAIDS and Voluntary

Services Overseas (VSO) towards this research is gratefully acknowledged. The

content and ideas expressed within the manuscript do not engage the

responsibility of UNAIDS, USAID, VSO or UNDP.

References

1. Beyrer C, Baral S, Walker D, Wirtz A, Johns B, Sifakis F. The expanding

epidemics of HIV-1 among men who have sex with men in low and middle

income countries: diversity and consistency. Epidemiol Rev. 2010;32(1):

13751.

2. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz

AL, et al. Global epidemiology of HIV infection in men who have sex with men.

Lancet. 2012;380(9839):36777.

3. Muraguri N, Temmerman M, Geibel S. A decade of research involving men

who have sex with men in sub-Saharan Africa: current knowledge and future

directions. SAHARA J. 2012;9(3):13747.

4. Baggaley RF, White RG, Boily MC. HIV transmission risk through anal

intercourse: systematic review, meta-analysis and implications for HIV preven-

tion. Int J Epidemiol. 2010;39(4):104863.

5. Jin F, Jansson J, Law M, Prestage GP, Zablotska I, Imrie JC, et al. Per-contact

probability of HIV transmission in homosexual men in Sydney in the era of

HAART. AIDS. 2010;24(6):90713.

6. Grosso AL, Tram KH, Ryan O, Baral S. Countries where HIV is concentrated

among most-at-risk populations get disproportionally lower funding from

PEPFAR. Health Aff (Millwood). 2012;31(7):151928.

7. Beyrer C, Wirtz A, Walker D, Johns B, Sifakis F, Baral S. The global HIV

epidemics among men who have sex with men. Washington, DC: The World

Bank; 2011.

8. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men

who have sex with men: stigma and discrimination. Lancet. 2012;380(9839):

43945.

9. amfAR, Johns Hopkins Center for Public Health and Human Rights.

Achieving an AIDS-free generation for gay men and other MSM: financing

and implementation of HIV programs targeting MSM. Washington, DC: amfAR;

2012. Available from: http://www.amfar.org/uploadedFiles/_amfar.org/In_The_

Community/Publications/MSM-GlobalRept2012.pdf

10. Malawi National Government. 2012 Global AIDS response progress

report: Malawi country report for 2010 and 2011. Lilongwe: Malawi National

Government; 2012.

11. Baral S, Phaswana-Mafuya N. Rewriting the narrative of the epidemiology

of HIV in sub-Saharan Africa. SAHARA J. 2012;9(3):12730.

12. Penal Code Cap. 7:01 Laws of Malawi, Sections 153, 156.

13. Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaffe HW. Men who have sex

with men and HIV/AIDS in sub-Saharan Africa. Lancet. 2009;374(9687):41622.

14. Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV

prevalence, risks for HIV infection, and human rights among men who have sex

with men (MSM) in Malawi, Namibia, and Botswana. PLoS One. 2009;4(3):

e4997.

15. Fay H, Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, et al. Stigma,

health care access, and HIV knowledge among men who have sex with men in

Malawi, Namibia, and Botswana. AIDS Behav. 2011;15(6):108897.

16. Ntata PR, Muula AS, Siziya S. Socio-demographic characteristics and sexual

health related attitudes and practices of men having sex with men in central

and southern Malawi. Tanzan J Health Res. 2008;10(3):12430.

17. Sullivan PS, Carballo-Die

´guez A, Coates T, Goodreau SM, McGowan I,

Sanders EJ, et al. Successes and challenges of HIV prevention in men who have

sex with men. Lancet. 2012;380(9839):38899.

18. World Health Organization. Prevention and treatment of HIV and other

sexually transmitted infections among men who have sex with men and

transgender populations: report of a technical consultation. Geneva: World

Health Organization; 2009.

19. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-

to-reach and hidden populations for HIV surveillance. Aids. 2005;19(Suppl 2):

S6772.

20. Malekinejad M, Johnston LG, Kendall C, Kerr LR, Rifkin MR, Rutherford GW.

Using respondent-driven sampling methodology for HIV biological and

behavioral surveillance in international settings: a systematic review. AIDS

Behav. 2008;12(Suppl 4):S10530.

21. Borgatti S. NetDraw software for network visualization. Lexington, KY:

Analytic Technologies; 2002.

22. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV

transmission. Cochrane Database Syst Rev. 2002;(1):CD003255.

23. Salganik MJ. Variance estimation, design effects, and sample size calcula-

tions for respondent-driven sampling. J Urban Health. 2006;83(Suppl 6):

i98112.

24. Wirtz A, Trapence G, Jumbe V, Kamba D, Baral S. ‘‘We are doing these

things in an underground way’’: structural barriers to HIV prevention and

service utilization among men who have sex with men (MSM) in Malawi

(Abstract #TUPE580). XIX International AIDS Conference; 23 July 2012;

Washington, DC; 2013.

25. Ministry of Health. Prevention of mother to child transmission of HIV and

paediatric HIV care guidelines. Lilongwe: Government of Malawi; 2008.

26. Schonlau M, Liebau E. Respondent-driven sampling. Stata J. 2012;12(1):

7293.

27. StataCorp. Stata statistical software: release 12. College Station, TX:

StataCorp, LP; 2011.

28. Kelesidis T, Landovitz RJ. Preexposure prophylaxis for HIV prevention. Curr

HIV/AIDS Rep. 2011;8(2):94103.

29. Smith D, Grant R, Weidle P, Lansky A, Mermin J, Fenton K. Interim

guidance: preexposure prophylaxis for the prevention of HIV infection in men

who have sex with men. MMWR Morb Mortal Wkly Rep. 2011;60(3):658.

30. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC,

Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral

therapy. N Engl J Med. 2011;365(6):493505.

31. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk

sexual behavior in persons aware and unaware they are infected with HIV in

the United States: implications for HIV prevention programs. J Acquir Immune

Defic Syndr. 2005;39(4):44653.

32. Center for Disease Control and Prevention. Sexually transmitted

diseases treatment guidelines, 2010: special populations (MSM). Atlanta:

CDC; 2011.

33. Doyle AM, Mavedzenge SN, Plummer ML, Ross DA. The sexual behaviour

of adolescents in sub-Saharan Africa: patterns and trends from national

surveys. Trop Med Int Health. 2012;17(7):796 807.

34. Stockl H, Kalra N, Jacobi J, Watts C. Is early sexual debut a risk factor

for HIV infection among women in sub-Saharan Africa? A systematic review.

Am J Reprod Immunol. 2013;69(Suppl 1):2740.

35. Kelley CF, Rosenberg ES, O’Hara BM, Frew PM, Sanchez T, Peterson JL,

et al. Measuring population transmission risk for HIV: an alternative metric of

exposure risk in men who have sex with men (MSM) in the US. PLoS One.

2012;7(12):e53284.

36. McKinnon LR, Kaul R. Quality and quantity: mucosal CD4T cells and HIV

susceptibility. Curr Opin HIV AIDS. 2012;7(2):195 202.

37. Millett GA, Peterson JL, Flores SA, Hart TA, Jeffries WL, 4th, Wilson PA,

et al. Comparisons of disparities and risks of HIV infection in black and other

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

men who have sex with men in Canada, UK, and USA: a meta-analysis. Lancet.

2012;380(9839):3418.

38. Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker LG. HIV risk and

associations of HIV infection among men who have sex with men in peri-urban

Cape Town, South Africa. BMC Public Health. 2011;11:766.

39. Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al.

High HIV prevalence among men who have sex with men in Soweto,

South Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):

62634.

40. Hladik W, Barker J, Ssenkusu JM, Opio A, Tappero JW, Hakim A, et al. HIV

infection among men who have sex with men in Kampala, Uganda a

respondent driven sampling survey. PLoS One. 2012;7(5):e38143.

41. Bohl DD, Raymond HF, Arnold M, McFarland W. Concurrent sexual

partnerships and racial disparities in HIV infection among men who have sex

with men. Sex Transm Infect. 2009;85(5):3679.

42. Mah T, Halperin D. Concurrent sexual partnerships and the HIV epidemics

in Africa: evidence to move forward. AIDS Behav. 2010;14(1):1116. English.

43. Lorenc T, Marrero-Guillamon I, Llewellyn A, Aggleton P, Cooper C,

Lehmann A, et al. HIV testing among men who have sex with men (MSM):

systematic review of qualitative evidence. Health Educ Res. 2011;26(5):

83446.

44. Parry C, Petersen P, Dewing S, Carney T, Needle R, Kroeger K, et al. Rapid

assessment of drug-related HIV risk among men who have sex with men in

three South African cities. Drug and Alcohol Depend. 2008;95(12):45 53.

45. Rispel LC, Metcalf CA, Cloete A, Moorman J, Reddy V.You become afraid to

tell them that you are gay: health service utilization by men who have sex with

men in South African cities. J Public Health Policy. 2011;32(Suppl 1):S13751.

46. Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. ‘‘They see you as a

different thing’’: the experiences of men who have sex with men with

healthcare workers in South African township communities. Sex Transm Infect.

2008;84(6):4303.

47. Wirtz A, Walker D, Bollinger L, Sifakis F, Baral S, Johns B, et al. Modelling

the impact of HIV prevention and treatment for men who have sex with men

on HIV epidemic trajectories in low-and middle-income countries. Int J STD

AIDS. 2013;24(1):1830.

48. Gray RT, Prestage GP, Down I, Ghaus MH, Hoare A, Bradley J, et al.

Increased HIV testing will modestly reduce HIV incidence among gay men in

NSW and would be acceptable if HIV testing becomes convenient. PLoS One.

2013;8(2):e55449.

49. Larmarange J, Wade AS, Diop AK, Diop O, Gueye K, Marra A, et al. Men

who have sex with men (MSM) and factors associated with not using a condom

at last sexual intercourse with a man and with a woman in Senegal. PLoS One.

2010;5(10):e13189.

50. Wade AS, Larmarange J, Diop AK, Diop O, Gueye K, Marra A, et al.

Reduction in risk-taking behaviors among MSM in Senegal between 2004 and

2007 and prevalence of HIV and other STIs. ELIHoS Project, ANRS 12139. AIDS

Care. 2010;22(4):40914.

51. Higa D, Crepaz N, Marshall K, Kay L, Vosburgh HW, Spikes P, et al.

A systematic review to identify challenges of demonstrating efficacy of HIV

behavioral interventions for gay, bisexual, and other men who have sex with

men (MSM). AIDS Behav. 2013;17(4):123144. English.

52. Lorenc T, Marrero-Guillamon I, Aggleton P, Cooper C, Llewellyn A,

Lehmann A, et al. Promoting the uptake of HIV testing among men who have

sex with men: systematic review of effectiveness and cost-effectiveness. Sex

Transm Infect. 2011;87(4):2728.

53. Mayer KH, Bekker L-G, Stall R, Grulich AE, Colfax G, Lama JR. Compre-

hensive clinical care for men who have sex with men: an integrated approach.

Lancet. 2012;380(9839):37887.

54. Gelman A. Struggles with survey weighting and regression modeling. Stat

Sci. 2007;22(2):15364.

55. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum

of engagement in HIV care and its relevance to test-and-treat strategies for

prevention of HIV infection. Clin Infect Dis. 2011;52(6):793800.

Wirtz AL et al. Journal of the International AIDS Society 2013, 16(Suppl 3):18742

http://www.jiasociety.org/index.php/jias/article/view/18742 | http://dx.doi.org/10.7448/IAS.16.4.18742

Journal Information

About the journal

The Journal of the International AIDS Society, an ocial journal of

the Society, provides a peer-reviewed, open access forum for

essential and innovative HIV research, across all disciplines.

All articles published by the Journal of the International AIDS Society

are freely accessible online. The editorial decisions are made

independently by the journal’s editors-in-chief.

Email: editorial@jiasociety.org

Website: http://www.jiasociety.org

eISSN: 1758-2652

Publisher

International AIDS Society

Avenue de France 23

1202 Geneva, Switzerland

Tel: +41 (0) 22 710 0800

Email: info@iasociety.org

Website: http://www.iasociety.org

Indexing/abstracting

The Journal of the International AIDS Society is indexed in a variety

of databases including PubMed, PubMed Central, MEDLINE,

Science Citation Index Expanded and Google Scholar. The journal’s

impact factor is 3.936 (*2012 Journal Citation Reports® Science

Edition - a Thomson Reuters product).

Advertising, sponsorship and donations

Please contact the editorial oce if you are interested in

advertising on our journal’s website. We also gladly receive

inquiries on sponsorship and donations to support open access

publications from authors in low- and middle-income countries.

Supplements

The Journal of the International AIDS Society publishes supplements,

special issues and thematic series on own initiative or based on

proposals by external organizations or authors. Inquiries can be

sent to the editorial oce at editorial@jiasociety.org. All articles

submitted for publication in supplements are subject to peer

review. Published supplements are fully searchable and freely

accessible online and can also be produced in print.

Disclaimer

The authors of the articles in this supplement carry the

responsibility for the content and opinions expressed therein.

The editors have made every eort to ensure that no inaccurate

or misleading content or statements appear in this supplement.

However, in all cases, the publisher, the editors and editorial board,

and employees involved accept no liability for the consequences of

any inaccurate or misleading content or statement.

The content in this supplement is published under the

CreativeCommons Attribution- 3.0 Unported (http://

creativecommons.org/licenses/by/3.0/) license. The license allows

third parties to share the published work (copy, print, distribute,

transmit) and to adapt it, under the condition that the authors are

given credit.Authors retain the copyright of their articles, with

ﬁrst publication rights granted to the Journal of the International

AIDS Society.

Editors

Editors-in-Chief:

Susan Kippax (Australia)

Papa Salif Sow (Senegal)

Mark Wainberg (Canada)

Associate Editors:

Martin Holt (Australia)

Kayvon Modjarrad (United States)

Executive Editor: Shirin Heidari (Switzerland)

Managing Editor: Mirjam Curno (Switzerland)

Editorial Assistant: Helen Etya’ale (Switzerland)

Editorial Board

Quarraisha Abdool Karim (South Africa)

Laith J. Abu-Raddad (Qatar)

Dennis Altman (Australia)

Joseph Amon (United States)

Jintanat Ananworanich (Thailand)

Judith Auerbach (United States)

Françoise Barré-Sinoussi (France)

Chris Beyrer (United States)

Andrew Boulle (South Africa)

Carlos Cáceres (Peru)

Elizabeth Connick (United States)

Mark Cotton (South Africa)

Jocelyn DeJong (Lebanon)

Diana Dickinson (Botswana)

Sergii Dvoriak (Ukraine)

Nathan Ford (South Africa)

Omar Galárraga (Mexico)

Diane Havlir (United States)

Aikichi Iwamoto (Japan)

Adeeba Kamarulzaman (Malaysia)

Rami Kantor (United States)

Elly Katabira (Uganda)

Sukhontha Kongsin (Thailand)

Kathleen MacQueen (United States)

Navid Madani (United States)

Jacques Mokhbat (Lebanon)

Julio Montaner (Canada)

Nelly Mugo (Kenya)

Paula Munderi (Uganda)

Christy Newman (Australia)

Héctor Pérez (Argentina)

Sai Subhasree Raghavan (India)

Renata Reis (Brazil)

Linda Richter (South Africa)

Jürgen Rockstroh (Germany)

Naomi Rutenberg (United States)

Gabriella Scarlatti (Italy)

Tim Spelman (Australia)

Ndèye Coumba Touré-Kane (Senegal)

Ian Weller (United Kingdom)

Alan Whiteside (South Africa)

David Wilson (Australia)

Iryna Zablotska (Australia)

Influence of stigma and homophobia on mental health and on the uptake of HIV/sexually transmissible infection services for Cameroonian men who have sex with men

Article

Full-text available

Jun 2015

Background Men who have sex with men (MSM) in Cameroon consistently face significant stigma and discrimination. The urban HIV prevalence in MSM is estimated at 35%. This study investigates the effect of stigma, discrimination and alienation on Cameroonian MSM’s engagement of the HIV treatment cascade. Methods: Qualitative interviews were semi-structured using a guide. Participants in Douala, Ngaoundere, Bamenda, Bertoua and Yaoundé were asked to describe the MSM social and structural context, MSM knowledge of existing HIV-related services in public and MSM-focussed non-governmental organisation (NGO) clinics. Using a codebook, coded text was extracted from 40 transcripts with Microsoft Word Macros. These texts were analysed for recurring themes that were developed into results. Results: There were three main themes that emerged. First, among those MSM participants seeking HIV services, many commonly reported experiences of discrimination and physical violence outside the healthcare setting. Second, a few respondents used services provided by the Ministry of Health and local NGOs. However, most participants observed limited clinical and cultural competency of public clinic staff. Third, MSM declared that lack of social support and healthcare access caused them much stress. Several individuals recounted their alienation greatly discouraged them from seeking HIV prevention, treatment and care services. Conclusions: Community-level and public healthcare-related stigma impacts the mental wellbeing of Cameroonian MSM. Alienation among MSM also represents a common obstacle to the uptake of MSM-oriented HIV/AIDS services. Improving provider cultural and clinical competency among Cameroonian health care workers combined with a broader stigma-reduction intervention for Cameroonian healthcare may increase the uptake of HIV prevention, treatment and care among MSM.

Assessment of Knowledge on Cervical Cancer among Women with a View to Develop Information Booklet

Article

Full-text available

Jun 2024

Introduction Cervical cancer manifests in the cervix cells, the lower part of the uterus connecting to the vagina. Similar to other cancers, the exact cause of cervical cancer remains uncertain and idiopathic. However, it is established that the human papilloma virus plays a significant role in initiating cellular changes in the cervix. In India, the lack of cancer awareness and screening facilities results in many women presenting at an advanced and deadly stage of the disease, negatively impacting their prognosis and clinical outcomes. Methods A total of 255 women aged between 18 and 45 years, who were either patients or accompanying bystanders at a tertiary care hospital, were selected using purposive sampling technique. Statistical Analysis Descriptive statistics were used to represent the sociodemographic characteristics levels. Association of sociodemographic variables levels is determined using chi-squared test. Results The mean age of the participants was 31.83 ± 6.83 years, majority (162 [63.5%]) were living in a rural area, most (175 [68.6%]) of the participants were married, majority (254 [99.6%]) of the subjects were not having any family history of cervical cancer, most (202 [79.2%]) of the participants were having a single sexual partner, majority (108 [42.4%]) were not having any information on cervical cancer, most (134 [52.5%]) of the participants were unaware of cervical cancer screening, 39 (15.3%) were aware but delaying, 26 (10.2%) were aware, 17 (6.7%) were aware but not decided to do, 16 (6.3%) were aware but undecided, and 21 (8.2%) were in “others” category. Conclusion Although women are having good knowledge and positive attitude toward cervical cancer screening and prevention, still there is a gap to transform it into practice. There is a need for more educational programs to connect identified knowledge slits and uplift regular practice of cervical cancer screening.

Fatty liver in Hispanics with HIV

Article

Mar 2016

Liver disease is the leading cause of death not related to AIDS in persons infected with human immunodeficiency virus (HIV). As patients with HIV live longer, hepatic steatosis has become a growing problem. We prospectively evaluated 59 treatment naïve HIV-infected persons in Argentina before and during ART. We found that 66% of cohort participants had evidence of hepatic steatosis by the Ultrasound Steatosis Score. Seventeen percent had evidence of liver fibrosis based on their AST to platelet ratio index (APRI) score. AST and ALT blood levels significantly decreased 6 and 12 weeks post ART and decreases in ALT directly correlated with increases in CD4 counts (p=0.005). In summary, in our cohort the prevalence of fatty liver in Hispanics was higher than reported before. ART led to decreased liver enzyme levels and decreases in ALT correlated with CD4 recovery.

Characterizing the Individual, Social, and Structural Determinants of Condom Use Among Men Who Have Sex with Men in Swaziland

Article

Dec 2015
AIDS RES HUM RETROV

Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence-informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.

The Impact of E-Learning in Medical Education

Article

Full-text available

Jan 2006
ACAD MED

The authors provide an introduction to e-learning and its role in medical education by outlining key terms, the components of e-learning, the evidence for its effectiveness, faculty development needs for implementation, evaluation strategies for e-learning and its technology, and how e-learning might be considered evidence of academic scholarship. E-learning is the use of Internet technologies to enhance knowledge and performance. E-learning technologies offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives. In diverse medical education contexts, e-learning appears to be at least as effective as traditional instructor-led methods such as lectures. Students do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy. A developing infrastructure to support e-learning within medical education includes repositories, or digital libraries, to manage access to e-learning materials, consensus on technical standardization, and methods for peer review of these resources. E-learning presents numerous research opportunities for faculty, along with continuing challenges for documenting scholarship. Innovations in e-learning technologies point toward a revolution in education, allowing learning to be individualized (adaptive learning), enhancing learners' interactions with others (collaborative learning), and transforming the role of the teacher. The integration of e-learning into medical education can catalyze the shift toward applying adult learning theory, where educators will no longer serve mainly as the distributors of content, but will become more involved as facilitators of learning and assessors of competency.

Towards 'men who have sex with menappropriate' health services in South Africa

Article

Full-text available

Jun 2013

Health programming for men who have sex with men (MSM) in South Africa has been ignored or absent until fairly recently, despite this population being at high risk for HIV acquisition and transmission. Anova Health Institute, with support from the US President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID) and in collaboration with the South African National Department of Health, launched the first state sector MSM-targeted sexual health clinic in 2010. The clinic has been successful in attracting and retaining MSM in care, and lessons learned are described in this article. Components contributing to the creation of MSM-appropriate healthcare services are discussed.

Implementing STI/HIV Prevention and Care Interventions for Men who Have Sex with Men in Dakar, Senegal

Technical Report

Full-text available

Dec 2007

Amadou Moreau

Preexposure chemoprophylaxis for HIV prevention in men who have sex with men

Article

Jan 2010

High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa

Article

Feb 2013

The landmark HIV Prevention Trials Network (HPTN) 052 trial in HIV-discordant couples demonstrated unequivocally that treatment with antiretroviral therapy (ART) substantially lowers the probability of HIV transmission to the HIV-uninfected partner. However, it has been vigorously debated whether substantial population-level reductions in the rate of new HIV infections could be achieved in "real-world" sub-Saharan African settings where stable, cohabiting couples are often not the norm and where considerable operational challenges exist to the successful and sustainable delivery of treatment and care to large numbers of patients. We used data from one of Africa's largest population-based prospective cohort studies (in rural KwaZulu-Natal, South Africa) to follow up a total of 16,667 individuals who were HIV-uninfected at baseline, observing individual HIV seroconversions over the period 2004 to 2011. Holding other key HIV risk factors constant, individual HIV acquisition risk declined significantly with increasing ART coverage in the surrounding local community. For example, an HIV-uninfected individual living in a community with high ART coverage (30 to 40% of all HIV-infected individuals on ART) was 38% less likely to acquire HIV than someone living in a community where ART coverage was low (<10% of all HIV-infected individuals on ART).

Scenario 3 Country Studies: Kenya, Malawi, and Senegal

Chapter

May 2011

Positive prevention: HIV transmission risk reduction interventions for people living with HIV/AIDS

Article

Mar 2007

Seth C. Kalichman

HIV prevention programmes require scaling up in southern Africa, and interventions that target people living with HIV/AIDS (positive prevention) should be included in all comprehensive HIV prevention plans. Positive prevention interventions have been tested in the USA and have been demonstrated effective in reducing HIV transmission risks. Lessons learned from US trials can be used in selecting and adapting positive prevention interventions for use in southern Africa. Efforts to implement positive prevention will be enhanced by reducing institutionalised AIDS stigmas and culturally held AIDS denialism and by increasing access to HIV/AIDS care services including antiretroviral therapies and sexually transmitted infection detection and treatment. Positive prevention should not replace, but rather should augment, generalised HIV prevention interventions targeting high-risk populations.

Qualitative Data Analysis For Applied Policy Research

Article

Jan 1994

The international drug epidemic

Article

Dec 2008

The injection of medications and the development of intravenous infusions have saved countless lives since these tools of modern medicine were developed. Injection as a route of drug administration provides some obvious advantages to medicine: doses can be measured precisely; the absorptive limitations of the skin, gut, or respiratory mucosa can be bypassed; and agents can be introduced directly into the bloodstream for rapid distribution to target tissues. But these tremendous advantages can be misused and can lead to grave complications. As the epidermal barrier of the immune system is effectively bypassed, unclean needle and syringes can result in direct inoculation of pathogens into the system. As such, risk of bacterial endocarditis in drug users, along with acquisition and transmission of classic blood-borne pathogens, including HIV, HCV, HBV, malaria, tetanus, and syphilis, is exacerbated in IDU. Further, the direct introduction of agents into the bloodstream means rapid intake and distribution of psychoactive agents to the brain-markedly increasing the speed and intensity of the "high," but also increasing the likelihood of overdose and dependence or addiction. The greater efficiency of drug action with injected doses is one of the key drivers of transitions to injection from other less efficient means, like snorting, sniffing, or smoking drugs, and has been reported in multiple settings. As users become addicts and spend down their resources on drugs, the need to get the greatest effect from the drug used drives injection behavior.

HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention

Article

Apr 2010

The epidemiology of HIV and prevention needs among men who have sex with men in Africa

Abstract and Figures

Recommended publications

Building the evidence base for urgent action: HIV epidemiology and innovative programming for men wh...

“In the Fell Clutch of Circumstance”: HIV and Men Who Have Sex With Men in Sub-Saharan Africa

Outcomes of a community-based HIV-prevention pilot programme for township men who have sex with men...

The epidemiology of HIV among men who have sex with men in countries with generalized HIV epidemics