Men becoming visible: more light shed on men who have sex with men in Africa and India

The majority of men who have sex with men (MSM) in three different African countries and in Tamil Nadu State in India also have sex with women, according to two presentations and a poster at the 16th Conference on Retroviruses and Opportunistic Infections (CROI) in Montreal.

In Tamil Nadu, HIV prevalence is substantially higher in MSM than the general population and they could serve as a ‘bridge’ for HIV transmission between minority communities and women, researchers found.

In Africa, in the first-ever surveys of their kind, researchers uncovered communities of men with high levels of HIV risk behaviour, including injecting drug use. They found that the already-noted tendency in Africa to have long-term concurrent relationships with more than one partner – one explanation advanced for the high HIV prevalence there – was the same for MSM, with a high proportion of men engaging in "bisexually concurrent" relationships.

Chris Beyrer of the Center for Public Health and Human Rights at the Johns Hopkins School of Medicine in Baltimore presented updated findings from a programme of surveys of MSM and HIV in a number of African countries. Preliminary findings from the first of these surveys in Malawi were presented at the pre-International AIDS Conference satellite meeting in Mexico City last year. Beyrer added data from Namibia and Botswana – other surveys are ongoing in Nigeria and South Africa.

In most of these countries there has hitherto been literally no data on MSM, Beyrer said. Male/male sex is illegal and stigmatised and, until recently, surveys of MSM would have been impossible. Recently, however, health ministries in some African countries have become more supportive of research and prevention work among this community and local non-governmental and community organisations have been willing to act as local hosts for the research programme.

Three human rights organisations - The Center for the Development of People (CEDEP) in Malawi, Botswana Network on Ethics, Law and HIV/AIDS (BONELA), and The Rainbow Project (TRP) in Namibia - collaborated with the researchers to recruit interviewees.

In order to reach such an invisible and stigmatised population, the researchers had to use ‘snowball sampling’ in which individual members of the NGOs or men known to them invited friends to answer the research questionnaire, who then invited other friends until they reached the figure of 150 men per site. A strictly anonymised HIV screening test using the OraQuick saliva HIV test was used to determine HIV prevalence. Snowball sampling does not usually produce a representative sample of the entire population as it is essentially reliant on networks of friends and therefore all residents may come from a particular stratum of society. This proved to be the case in these studies, which uncovered a population of MSM that was relatively urban, educated and prosperous (unlike Tamil Nadu – see below).

In order to be in the survey, respondents had to be over 18 and to have had,at some point, anal sex with another man. ‘Bisexual behaviour’ was defined as at least one male and one female partner in the last six months. ‘Bisexual concurrency’ meant maintaining long-term, committed relationships with a man and a woman at the same time.

In terms of self-identity, two-thirds of men in Botswana identified as ‘gay’, 48% in Namibia and 40% in Malawi. In Malawi, 53% identified as ‘bisexual’. The average age was similar in all countries, around 25. The lowest HIV prevalence was 12.4% in Namibia (national prevalence is about 15%) and the highest was 21.4% in Malawi (national prevalence about 12%) – so MSM prevalence was not always higher than that seen generally.

A relatively high proportion of men had disclosed their sexuality to at least one family member in Botswana (60%) and Namibia (44%) but only 17% in Malawi. A quarter of respondents had disclosed to a healthcare worker in Botswana but only 9% in Malawi. Disclosure did not always have good consequences (see below).

The men had had around 3.9 male sex partners in the previous six months in Malawi and 2.8 in the other two countries and a median of one female partner. Just over half (53.7%) had also had a female partner in the last six months and a third were married or cohabiting with a woman. One in six (one in four in Malawi) was ‘bisexually concurrent’ with long-term relationships with at least one partner of either sex. One in six (Botswana) to one in eight (Malawi) had had over five male partners in the last six months.

Being HIV-positive was associated with age (men over 25 were four times more likely to have HIV) and with not always using condoms. Condom use was, in fact, quite common (Beyrer did not give exact figures).

“We were surprised at the high levels of condom use,” commented Beyrer. “These guys help and support each other. Every time they travel abroad they bring back KY jelly and condoms.”

As already reported from the Malawi survey last year, a surprisingly high proportion of men had met partners over the internet (57% in Botswana, 44% in Malawi and 38% in Namibia). Equally surprising was a high level of injecting drug use amongst respondents: 3.4% in Botswana, 8% in Namibia and 12% in Malawi had injected illegal drugs.

Homosexuality is illegal and stigmatised in each of these countries. One consequence of this is blackmail; between 18% (in Malawi) and 26% (in Botswana) of study participants said they had been blackmailed because of their sexuality. Alarmingly, the men were most often blackmailed by the very people they had trusted and come out to: family members and even healthcare workers.

Beyrer commented that his snowball recruiting had “very likely oversampled urban MSM and social networks” but that it was the only method possible in the context of stigma and criminalisation. However, he sensed that things were changing. After the study’s findings were published in Malawi, the ministry of health invited the research team to give talks on it all over the country. “It is possible to mainstream MSM services,” Beyrer commented.

The study in Tamil Nadu State in southern India, also conducted by Johns Hopkins University in collaboration with a local NGO, uncovered a very different group of MSM, largely rural or semi-urban and poor. Presenter Sunil Suhas Solomon commented that in India, it is the middle-class gay men who are hard to contact and research.

This survey used a version of snowball sampling called respondent-driven sampling, which uses a more structured approach and can be corrected for bias, to contact 721 participants from 18 sites in just over a month. They started with 19 ‘seed’ community researchers – five of them HIV-positive, three married and the majority having 'sold' sex – who committed themselves to recruiting three more researchers each, who each recruited three, and so on. Each person recruited was given a demographic and sexual-behaviour questionnaire and an anonymised OraQuick HIV test, as in Africa.

In this population, HIV was far more common than in the general population. Nine per cent of the men in the study had it, which is 10 to 15 times the overall Tamil Nadu prevalence (0.6 to 0.8%). Half of the participants (361) had tested for HIV before, but only 18 out of the 85 who did have HIV knew it.

The average age of respondents was 28, with 76% having had at least some secondary education. Eighty-five per cent of them had also had sex with a woman, 60% defined themselves as bisexual and a third (34%) were married. The median number of male partners men had had in the previous year was 15 and every single participant had had unprotected anal intercourse with at least one other man, while a quarter of respondents had never used condoms during the year of the study. The median number of female partners men had had in a year was one, but 23% of men had had more than one female partner and 65% of men had had unprotected sex with a woman.

Being married rather than single was significantly associated with HIV: 13% of married men had HIV versus 7% of single men, and HIV-positive men were 1.9 times more likely to be married than HIV-negative men. This association with marriage persisted across other STIs: with herpes (HSV-2: 32% of married men had herpes compared with 21% of single) and with syphilis (11% versus 6%), for instance. HIV-positive men were 3.7 times more likely to have the Herpes simplex virus than HIV-negative men. This was not because men with HIV and STIs were older, and the real reason is unclear.

Future directions for research include HIV and sex role (insertive and/or receptive), drug use, mental health, healthcare access, and attempting to survey the wives of MSM. Dr Solomon commented that, as in Africa, research was continuing to be hampered by national laws criminalising homosexuality.

There were three other poster presentations documenting MSM behaviour in the developing world, all of them extensions of previous surveys. In Senegal, a phylogenetic survey of HIV in HIV-positive MSM found very different patterns of viral subtype than in the general population. It found that the vast majority (82%) of MSM also had sex with women. And it found that about 50 out of 70 genotype samples gathered together in clusters of closely related infections, with a third of clusters containing more than five members and a fifth containing men from different cities.

An ongoing survey of male commercial sex workers in Mombasa confirmed that women buying sex from men was nearly as common as men buying it, as was anal intercourse.

Finally, a survey of MSM in Thailand confirmed that the epidemic amongst MSM is still expanding rapidly there. Baseline HIV prevalence in 2006 in this predominantly young population was 12.2%; nearly a year later this had risen to 17.6%, corresponding to an annual incidence of 5.7%. this compares with annual incidence rates of 2 to 3.5% in gay urban centres like London and New York.