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

Abstract

IntroductionThere 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.MethodsFrom 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.ResultsCrude 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 <16 years (RDS-weighted AOR: 4.3, 95% CI: 1.2–15.0) were independently associated with HIV infection.ConclusionsResults 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.

“In the Fell Clutch of Circumstance”: HIV and Men Who Have Sex With Men in Sub-Saharan Africa

“…Findings from this cross-sectional survey of men in the Eastern Cape and KwaZulu-Natal indicate that while 5.4 % (n=92) of men report consensual same-sex behaviour, 9.6 % (n=164) of the sample reported sexual victimisation by other men and 3 % (n=51) reported perpetrating sexual violence against another man. Similar high levels of violence against MSM have recently been reported by Wirtz et al [14] in Malawi and in Cote d'Ivoire by Aho et al [6]. A particularly important finding from Dunkle et al's study was that men who reported consensual sexual activity with other men were more likely to experience sexual assault and to screen HIV positive, while perpetrators of sexual violence against other men were also more likely to be HIV positive [19••].…”

“…The generalised nature of the HIV epidemics in Southern and Eastern Africa has meant that the focus of most interventions in these regions has been on the prevention of heterosexual and mother to child transmission, with relatively sparse attention being paid to MSM and other key populations [13][14]. Currently, the HIV epidemics across the general population in many of the countries of East and Southern African appear to have slowed, and in several cases, HIV prevalence is decreasing [13].…”

“…Studies conducted in Tanzania [7], Malawi [14,34], Swaziland [9,10] and Uganda [35] point to stigma and homophobia as significant factors affecting HIV risk among the MSM in these countries. Fewer recent works from West and Central Africa focused on the roles of homophobia and stigma in exacerbating HIV risk for MSM, but these factors are almost ubiquitously discussed as the background context for MSM research in this region [cf.…”

“…HIV prevalence rates in recent studies with MSM in East and Southern Africa range from low estimates of 1.2 % in Nairobi, Kenya [15], and 3.8 % in Luanda Province, Angola [16], to 11.1 % [17] in two cities in Tanzania, 12.5 % in Malawi [14], 17.6 % in Swaziland [18] [21].…”

Respondent-driven sampling as a recruitment method for men who have sex with men in southern sub-Saharan Africa: a cross-sectional analysis by wave

“…Participants were recruited from February to June 2014 in Maseru, Lesotho, from July 2011 to March 2012 in Blantyre, Malawi, and from July to December 2011 in Manzini, Swaziland using RDS 16 23. Seeds were recruited from local MSM-affiliated CBOs (although not all seeds were CBO members).…”