Malawi MSM survey reveals very high HIV acquisition and transmission risks

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The first figures released from a series of systematic surveys of men who have sex with men in southern Africa has revealed, at least in the first site analysed in Malawi, very high levels of behaviours likely to enhance the spread of HIV. The figures were presented at the meeting of the Global Forum on Men who have Sex with Men and HIV, a satellite conference on gay men and MSM attended by nearly 500 people in the two days preceding the World AIDS Conference.

Nearly two-thirds of the men surveyed had had sex with women as well as men in the last six months and nearly half had a steady female partner; only a third consistently used condoms in casual sex with other men and only a quarter with women; and although the average number of male partners amongst the group as a whole in the previous six months was four, amongst those with HIV it was 14.

HIV prevalence among MSM was 21%, nearly twice the general-population prevalence of 12%; in early results from the South African survey HIV prevalence was similarly about double that in the general population.



Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

representative sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

acute infection

The very first few weeks of infection, until the body has created antibodies against the infection. During acute HIV infection, HIV is highly infectious because the virus is multiplying at a very rapid rate. The symptoms of acute HIV infection can include fever, rash, chills, headache, fatigue, nausea, diarrhoea, sore throat, night sweats, appetite loss, mouth ulcers, swollen lymph nodes, muscle and joint aches – all of them symptoms of an acute inflammation (immune reaction).


A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

The Malawi survey was the first in a series conducted by the Johns Hopkins School of Public Health, in partnership with local LGBT and sexual rights organisations. The other three are taking place in townships near Cape Town in South Africa; in Gaborone, Botswana; and in Windhoek, Namibia.

Very early results from the Cape Town study were also presented and the community partner from the Botswana study also presented the study background, but was unable to present figures owing to the Botswana government’s initial unwillingness to support a survey of male/male sex in their country. Related surveys had also been conducted in Nigeria and Ghana; the one in Ghana had been completed but the Ghanaian health ministry is at present refusing to publish the findings.

Gift Trapence of the Malawi sexual rights group the Centre for the Development of People (CEDEP) presented the findings from the Malawi study. Each of the four studies had the same methodology. Twenty MSM were originally recruited from researchers’ contacts and each was then asked to contact another ten, leading to a ‘convenience sample’ of 200 men. The men answered a standardised questionnaire on sexual behaviour and gave a saliva sample for an anonymous OraQuick HIV test.

This kind of ‘snowball’ methodology is unlikely, of course, to lead to a sample of people who are truly representative of the population they are investigating because it is dependent on personal contacts. So the findings don’t establish a denominator (they don’t demonstrate how common male/male sex is in Malawi) and they don’t establish if the group studied is representative of all MSM.

However they do give a vivid picture of a previously invisible subculture. Homosexuality is illegal in Malawi and punishable by up to14 years in prison, which has prevented the development of an open gay community.

Because of the survey methodology, this was a well-educated urban population. Their mean age was 26, 91% had been in secondary education and 70% were of urban origin, in this overwhelmingly rural country. In one indication of rapidly-changing sexual opportunity and mores, 44% had met sexual partners on the internet; in another, 12% had at any time injected drugs, though the survey does not say which ones.

Being ‘out’ as gay or bisexual was rare; only 6% had told immediate family members about their sexuality and only 14% a member of their extended family.

Fifty-five per cent said they currently had a boyfriend, 47% a girlfriend and 26% said they had both male and female steady partners. Only 40% defined themselves as gay or homosexual, 53% as bisexual and 7% heterosexual. Forty-five per cent only had casual partners.

The mean number of male partners men had had in the last six months was 3.9 and 1.5 female partners; 17.5% had had six or more male partners. Sixty-three per cent had also had at least one sexual contact with a woman in the six months.

HIV status was related to self-defined sexuality; 15% of the 106 men who defined as bisexual had HIV, 26% of the 79 men who defined as gay, but none of the 15 men who defined as straight. In a multivariate model, the only significant risk factors for HIV were meeting partners on the internet, not always using condoms and being over 25.

Thirty-five per cent said they always used condoms with casual male partners and 25% with any partner. With casual female partners 26% always used condoms and with any partner 19.5%.

With casual male partners 22% ‘sometimes’ used them, 2.5% rarely and 10% never, with the remainder not having casual partners; with casual female partners12.5% ‘sometimes’ used them, 5% ‘rarely’ and 3.5% ‘never’, with the remaining 53% not having casual female partners. Only a third regularly used water-based lubricant for anal sex and only 2.6% said they ‘always’ used both condoms and a water-based lubricant.

In an indication of the human rights context in which these men live, 18% said they had been afraid to seek health services because of their sexuality, 18% had been blackmailed because of their sexuality, 8% had been beaten up by the police or government officials, and 11% had been raped.

The satellite conference also heard early results from the Cape Town survey. Keren Middelkoop of the Mother City Men’s Health Project gave results for 79 men recruited so far out of the target of 200 from black townships around Cape Town. In South Africa sexuality is protected under the constitution, and men had relatively higher levels of awareness and condom use.

Eighty-eight per cent defined as gay or homosexual and 2.7% as transgender (compared with zero in Malawi), 50% ‘always’ used condoms and only 26% (compared with two-thirds in Malawi) used an oil-based lubricant with a condom. The HIV prevalence so far seen was 34% compared with 18-20% for the latest general-population estimate in South Africa, and 31.5% had a current acute STI (gonorrhoea, syphilis or trichonomiasis).

Despite legal protection, 12% said they had been assaulted due to their sexuality (7% by the police), 8% arrested for sexual offences and 13% had been raped.

Feli Motimedi from the Botswana sexual rights organisation BONELA also reported that 117 men had so far been recruited for the Botswana survey. It had been hoped results would be ready for the World AIDS Conference, but the government had at first refused permission for the researchers to conduct the study. There had also been difficulties in recruitment (homosexuality is also illegal in Botswana).

Stefan Barat, co-ordinator of the study series for Johns Hopkins, commented that these surveys would have been impossible a few years ago, but recent reports from countries like Kenya and Uganda “describe a more visible and self-defined MSM community who are asking for help with HIV prevention.”


Barat S et al. HIV epidemics among MSM in Africa: examples from Malawi, Botswana, Namibia, Nigeria and South Africa. Workshop R9 from The Invisible Men: Gay Men and Other MSM in the Global HIV/AIDS Epidemic, pre-conference satellite to the XVII International AIDS Conference, Mexico City, 2008. See