A decade of research involving men who have sex with men in Sub-Saharan Africa : current knowledge and future directions

It has been just over 10 years since the first large behavioral survey of men who have sex with men (MSM) was implemented in Senegal in 2001. Since then, behavioral and/or HIV prevalence surveys have been conducted in over 14 other countries in sub-Saharan Africa. Current available evidence and review have established that HIV prevalence among MSM in these countries are significantly higher than corresponding general populations, that MSM engage in sexual risk behaviors that place them and sexual partners at higher risk, and that issues of discrimination and stigmatization inhibit HIV interventions for MSM. This paper summarizes the existing knowledge, describes limitations of this evidence, and proposes new and enhanced research approaches to fulfill needed gaps to inform national HIV responses for MSM populations

Understanding the HIV/STI risks and prevention needs of men who have sex with men in Nairobi, Kenya

Despite increasing awareness of the role men who have sex with men (MSM) can play in the dynamics of HIV transmission in Africa, research on MSM in Kenya has been limited. In response to this gap, researchers from the Institute of African Studies at the University of Nairobi and the Horizons and FRONTIERS programs of the Population Council undertook a study of MSM in Nairobi. The overall goals of the study were to understand the extent to which MSM are at risk of HIV and other STIs, identify the factors associated with risk behaviors, and identify MSM sexual health needs in order to develop appropriate interventions. The ease with which this study recruited 500 men through snowball sampling suggests that the population of Kenyan MSM living in Nairobi is larger than is commonly believed. This situation, combined with the existence of risk behaviors, such as unprotected sex, among the study sample may have implications for the development of localized STI and HIV epidemics. The report recommends urgently needed interventions targeted to this population

Male Sex Workers Who Sell Sex to Men Also Engage in Anal Intercourse with Women: Evidence from Mombasa, Kenya

Objective: To investigate self-report of heterosexual anal intercourse among male sex workers who sell sex to men, and to identify the socio-demographic characteristics associated with practice of the behavior. Design: Two cross-sectional surveys of male sex workers who sell sex to men in Mombasa, Kenya. Methods: Male sex workers selling sex to men were invited to participate in surveys undertaken in 2006 and 2008. A structured questionnaire administered by trained interviewers was used to collect information on socio-demographic characteristics, sexual behaviors, HIV and STI knowledge, and health service usage. Data were analyzed through descriptive and inferential statistics. Bivariate logistic regression, after controlling for year of survey, was used to identify socio- demographic characteristics associated with heterosexual anal intercourse. Results: From a sample of 867 male sex workers, 297 men had sex with a woman during the previous 30 days – of whom 45% did so with a female client and 86% with a non-paying female partner. Within these groups, 66% and 43% of male sex workers had anal intercourse with a female client and non-paying partner respectively. Factors associated with reporting recent heterosexual anal intercourse in bivariate logistic regression after controlling for year of survey participation were being Muslim, ever or currently married, living with wife only, living with a female partner only, living with more than one sexual partner, self-identifying as basha/king/bisexual, having one’s own children, and lower education. Conclusions: We found unexpectedly high levels of self-reported anal sex with women by male sex workers, including selling sex to female clients as well as with their own partners. Further investigation among women in Mombasa is needed to understand heterosexual anal sex practices, and how HIV programming may respond

Prevention with positives: How do we reach them in the community?

In the past, HIV prevention efforts have focused primarily on developing risk-reduction interventions for those presumed to be HIV-negative and therefore at risk of becoming infected with HIV. In recognition of the need for prevention among people living with HIV (PLHIV), programs have been initiated in Africa, but primarily in clinical settings for those who are on antiretroviral therapy (ART). There is little knowledge about how to reach those PLHIV not on ART, and therefore not in regular contact with the health system or with effective prevention messages. This diagnostic study aimed to address the gap in information on how to identify and access HIV-positive persons who are not accessing care and treatment services as a first step in designing and implementing a community-based project in Mombasa, Kenya. The study found gaps in HIV knowledge, high levels of sexual risk behaviors, and unmet need for HIV-related information and education. Recommendations aim to improve the reach and content of HIV-prevention programs

Involving young people in the care and support of people living with HIV/AIDS in Zambia

The Population Council, in collaboration with CARE International and Family Health Trust, conducted a study in Zambia to determine which care and support needs of people living with HIV and AIDS and their families could be met by trained youth, and to establish whether youth engaged in formalized care and support activities would increase their adoption of protective behaviors or reduce the stigma faced by members of AIDS-affected households. Discussions with caregivers and clients demonstrated that trained youth are able to meet a range of the needs of clients and orphans and vulnerable children, and that their efforts may be laying the foundation for decreased isolation and stigmatization of AIDS-affected families. This study also demonstrated that NGOs and youth clubs working in relatively isolated rural and semi-urban areas can meet with positive and enthusiastic responses and high levels of participation. A particular focus of the continuing study is to further strengthen local partnerships and expand network linkages in order to promote community ownership and sustainability

Looking back, moving forward: Understanding the HIV risk and sexual health needs of men who have sex with men, Horizons studies 2001 to 2008

In 1997, the Population Council initiated the Horizons Program—a decade-long USAID-funded collaboration with the International Center for Research on Women, the International HIV/AIDS Alliance, PATH, Tulane University, Family Health International, and Johns Hopkins University—designing, implementing, evaluating, and expanding innovative strategies for HIV prevention and care. Horizons developed and tested ways to optimize HIV prevention, care, and treatment programs; worked to reduce stigma and improve gender-biased behaviors; and greatly expanded knowledge about the best ways to support, protect, and treat children affected by HIV and AIDS. In all its projects, Horizons strengthened the capacity of local institutions by providing support and training to colleagues. This synthesis paper presents lessons learned and best practices on one of the key topics that Horizons investigated: understanding the HIV risk and sexual health needs of men who have sex with men

Understanding the HIV/STI prevention needs of men who have sex with men in Kenya

Understanding the sexual behaviors of populations who are vulnerable to HIV is an important component in the battle against AIDS. Yet policymakers in developing countries, particularly in Africa, have often overlooked men who have sex with men (MSM) as a vulnerable group because of stigmatization of homosexual behavior and denial of the existence of MSM and the role they may play in HIV transmission. A growing body of literature not only documents the presence of this population in Africa but also the importance of reaching them with information and services to prevent HIV and other sexually transmitted infections (STIs). In response to this gap, researchers from the Institute of African Studies at the University of Nairobi and the Horizons and FRONTIERS Programs of the Population Council undertook a study of MSM in Nairobi. The goals were to understand the extent to which MSM are at risk of HIV and other STIs, identify factors associated with risk behaviors, and determine their sexual health needs to develop appropriate interventions. As this research summary states, targeted interventions, such as confidential counseling and peer education are needed

Community-based approaches to prevention of mother-to-child transmission of HIV: Findings from a low-income community in Kenya

The Horizons program, in partnership with International Medical Corps and Steadman Research Services International, conducted an intervention study in Kibera, an urban slum in Nairobi, Kenya to determine what effect three different community-based activities had on utilization of key prevention of mother-to-child transmission (PMTCT) services. The interventions included moving services closer to the population via mobile clinics, as well as increasing psychosocial support through the use of traditional birth attendants and peer counselors as PMTCT promoters. Data from the study showed that there were positive trends during the study period in most of the PMTCT indicators, including knowledge of MTCT, antenatal care utilization, and delivery in health facilities. However, it is not possible to attribute all these positive trends to the community-based interventions because similar positive trends were observed at the comparison site on most indicators. The report offers recommendations to other organizations exploring community-based PMTCT activities in a similar context

Sexual behavior of HIV-positive adults not accessing HIV treatment in Mombasa, Kenya: Defining their prevention needs

<p>Abstract</p> <p>Background</p> <p>HIV spread continues at high rates from infected persons to their sexual partners. In 2009, an estimated 2.6 million new infections occurred globally. People living with HIV (PLHIV) receiving treatment are in contact with health workers and therefore exposed to prevention messages. By contrast, PLHIV not receiving ART often fall outside the ambit of prevention programs. There is little information on their sexual risk behaviors. This study in Mombasa Kenya therefore explored sexual behaviors of PLHIV not receiving any HIV treatment.</p> <p>Results</p> <p>Using modified targeted snowball sampling, 698 PLHIV were recruited through community health workers and HIV-positive peer counsellors. Of the 59.2% sexually-active PLHIV, 24.5% reported multiple sexual partners. Of all sexual partners, 10.2% were HIV negative, while 74.5% were of unknown HIV status. Overall, unprotected sex occurred in 52% of sexual partnerships; notably with 32% of HIV-negative partners and 54% of partners of unknown HIV status in the last 6 months. Multivariate analysis, controlling for intra-client clustering, showed non-disclosure of HIV status (AOR: 2.38, 95%CI: 1.47-3.84, p < 0.001); experiencing moderate levels of perceived stigma (AOR: 2.94, 95%CI: 1.50-5.75, p = 0.002); and believing condoms reduce sexual pleasure (AOR: 2.81, 95%CI: 1.60-4.91, p < 0.001) were independently associated with unsafe sex. Unsafe sex was also higher in those using contraceptive methods other than condoms (AOR: 5.47, 95%CI: 2.57-11.65, p < 0.001); or no method (AOR: 3.99, 95%CI: 2.06-7.75, p < 0.001), compared to condom users.</p> <p>Conclusions</p> <p>High-risk sexual behaviors are common among PLHIV not accessing treatment services, raising the risk of HIV transmission to discordant partners. This population can be identified and reached in the community. Prevention programs need to urgently bring this population into the ambit of prevention and care services. Moreover, beginning HIV treatment earlier might assist in bringing this group into contact with providers and HIV prevention services, and in reducing risk behaviors.</p