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Sexual Concurrency, Bisexual Practices, and HIV among Men Who Have Sex with Men: Malawi, Namibia, and Botswana
Chris Beyrer*1, G Trapence2, F Motimedi3, E Umar4, S Iipinge5, F Dausab6, and S Baral1,7
1Ctr for Publ Hlth and Human Rights, Johns Hopkins Univ Bloomberg Sch of Publ Hlth, Baltimore, MD, US; 2Ctr for the Devt of People, Blantyre, Malawi; 3Botswana Network on Ethics, Law, and HIV/AIDS, Gaborone; 4Univ of Malawi Coll of Med, Blantyre; 5Univ of Namibia, Windhoek; 6Rainbow Project, Windhoek, Namibia; and 7Univ of Toronto, Canada
Background: Men
who have sex with men (MSM) have been markedly understudied in the high
prevalence epidemics of Southern Africa. We present here the first data on
sexual patterns, partnerships, and concurrency and HIV risks among MSM in Malawi, Namibia, and Botswana.
Methods: A
2008 cross-sectional anonymous probe of 537 men recruited through snowball
sampling who reported ever having had sex with another man in Malawi, Namibia,
and Botswana using a structured survey instrument and HIV screening with the OraQuick©
rapid test kit.
Results: The
HIV prevalence among MSM varied from 12.4% in Namibia to 21.4% in Malawi and 17.4% (95%CI 14.4 to 20.8) overall. Prevalence was strongly age dependent. In
multivariate logistic regression, being older than 25 (aOR 4.0, 95%CI 2.0 to 8.0),
and not always wearing condoms during sex (aOR 2.6, 95%CI 1.3 to 4.9) were
significantly associated with HIV infection. Some 34.1% of MSM were married or
had a stable female partner and 53.7% reported both male and female sexual
partners in the past 6 months. Sexual concurrency was common with 16.6% of MSM
having ongoing concurrent relationships with both a man and a woman. Any
bisexual behavior was associated with lower education (p <0.05),
higher condom use (p <0.01), less likelihood of having ever tested
for HIV (p <0.01), less likelihood of having disclosed sexual
orientation to family (p <0.001), more likely to have received money
for casual sex (p <0.001). Bisexual concurrency was associated with
higher self-reported condom use with men (p <0.05), being employed (p
<0.01), lower likelihood of disclosure of sexual orientation to family (p
<0.001), and having paid for sex with men (p <0.01).
Conclusions: MSM
are a high-risk group for HIV infection in Southern Africa. The majority report
some bisexual behavior in the previous 6 months. Concurrency of sexual
partnerships with partners of both genders is common. Encouragingly, men
reporting any and concurrent bisexual activity were more likely to report
condom use, and these men were not more likely to have HIV infection than men
reporting only male partners. They were less likely to disclose orientation and
to have sought HIV testing. Further research is needed on MSM identities,
practices, and risks in southern Africa and to verify self-reported behaviors. National
programs should initiate and fund evidence-based and targeted HIV prevention
programs for MSM.
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