[Authors not provided]. HIV prevalence and risk practices among men who have sex with men in two South African cities. J Acquir Immune Defic Syndr. 2011 February 4. [Epub proof ahead of print]
To determine the HIV prevalence and risk factors for HIV infection among men who have sex with men (MSM) in two cities in South Africa.
Johannesburg and the municipality of eThekwini in Durban, South Africa; men who reported having sex with another man in the preceding 12 months.
This was a cross-sectional study, using respondent driven sampling (RDS) for recruitment. This paper describes the survey component of a larger rapid assessment of MSM in South Africa, call the Johannesburg/eThekwini Men's Study (JEMS).
Initially, semi-structured interviews and focus group discussions were held with key informants and MSM to understand local challenges and to help design the survey. For the RDS survey, eligible participants had to be at least 18 years old, live, work or socialize in Durban or Johannesburg, and be biologically male. Volunteer seeds (14 in Johannesburg and 15 in Durban) were recruited and provided with three recruitment coupons to give to other MSM who would then be enrolled and in turn given recruitment coupons. Participants were reimbursed for time and travel, as well as for each additional person recruited.
Enrolled MSM completed a questionnaire in English or the local language (self- or interviewer-administered). Anonymous HIV testing for the purposes of the study was performed using finger-prick dried blood spot (DBS) samples. All participants were also offered separate, free HIV counseling and testing if they wished to learn their results. The authors decided not to adjust the results for the RDS sampling method to develop probabilistic prevalence estimates because of failure to reach the target sample size of 200 in Durban, and the failure to recruit a demographically diverse group of participants. To identify factors associated with being HIV positive, data from both cities were combined.
In Johannesburg, 204 men were recruited in 15 waves over 21 weeks; in Durban, 81 participants were recruited in 11 waves over 17 weeks. The median age was 22 years, median age of first male-male sex was 17 years, 88% were black Africans, 77% identified as homosexual/gay, 19% as bisexual. Thirty-six percent had had sex with a woman sometime in the past, 62% had a main male partner, and 62% had not disclosed their sexual orientation to family or friends.
Among the 266 men for whom valid HIV test results were available, 116 were HIV positive (43.6%). In Johannesburg, the prevalence among men was 49.5% (95% CI 42.5-56.5%), and among men from Durban, prevalence was 27.5% (95% CI 17.0-38.1%). The prevalence among those who were gay-identified was 52.2% compared to those who were bisexual (13.7% or 14.8%: note that this was reported differently between the article's table and text). None of those who were heterosexually-identified (n=5) were HIV infected. HIV positive men were somewhat older (median age 24.5 years vs. 21.0 years) and reported a greater number of male partners compared with HIV negative men (15.0 vs. 5.0, both p<0.05). Among those who had had receptive anal intercourse, 54% were HIV positive vs. 11% among those who had not. Among those (41%) who had had unprotected receptive anal intercourse (UAI), 63% were HIV positive (vs. 30% who had not); 62% had had sex with a person of unknown HIV status and 15% had sex with someone known to be HIV positive; 73% had had sex while under the influence of alcohol. Among men who had had sex with women, 24% were HIV infected.
Factors associated with being HIV positive (adjusting for age, city, relationship status and level of education), included: being gay-identified (aOR= 8.4), having had receptive UAI (aOR=4.3), age ≥25 years (adjusted odds ratio (aOR)=3.5), having had UAI of any type (aOR=2.5), having disclosed one's sexual orientation (aOR=2.4), reporting an STI diagnosis in the past (aOR=2.4), perceiving oneself at high risk for HIV (aOR=2.3), and having had sex with someone known to be HIV positive (aOR=2.3),. Ever having had sex with a woman was negatively associated with being HIV positive (aOR=0.25).
This study found a higher HIV prevalence among MSM in both Johannesburg and Durban than the prevalence found in other South African studies.1-2 A large proportion of men reported having unprotected receptive intercourse and sex with a person of unknown HIV status. The authors found it striking that there was no relationship between HIV status and having sex with alcohol, but this may have been because such a high proportion of men reported this behavior and because questions about drinking lacked detail.
This was a good quality study. However, there are several serious limitations to the representativeness of the sample and interpretation of data due to the inability to achieve sample size requirements and to reported staff performance problems; these issues were acknowledged by the authors. The sample failed to achieve the desired diversity of subjects, with very few non-black African or higher socio-economic status participants. The authors also state that some questions in the survey were poorly understood.
There have been a number of other studies of HIV prevalence among MSM in South Africa, although this is the first one to report data from these two cities. A study from Soweto(1) found that 33.9% of gay-identified MSM were HIV infected; in Cape Town, 11.2% of MSM were found to be HIV positive(2), and in the 2008 South African national household HIV survey, approximately 10-12% of those who admitted to male-male sex were infected.(3) These differences may be due to the different demographics of those surveyed, different sampling methods, and regional variations in HIV prevalence. Risk factors shown to be associated with HIV (UAI, and a history of STI) are similar to other studies. In contrast, other studies including among MSM and from Africa, have found associations between sex under the influence of alcohol and HIV.(4, 5)
This study indicates that there is a high prevalence of HIV infection among MSM in urban areas of South Africa. Given the difficulties experienced by the authors with RDS, other methods of accessing hard-to-find populations, such as time-venue and snowball sampling might be tried. Nevertheless, these results clearly point to the HIV risk among black-African MSM. Targeted interventions need to be made available, as well as efforts to de-stigmatize these groups so they can access prevention as well as care and treatment. It is important to note that one third of men in this study had had sex with women. These behaviorally bisexual men may act as a bridge to the female population, or vice-versa
- Lane T, Raymond HF, Dladla S, et al. High HIV Prevalence Among Men Who have Sex with Men in Soweto, South Africa: Results from the Soweto Men's Study. AIDS Behav. 2009;DOI 10.1007/s10461-009-9598-y.
- Burrell E, Mark D, Grant R, Wood R, Bekker L-G. Sexual risk behaviors and HIV prevalence among urban men who have sex with men in Cape Town, South Africa. Sex Health. 2010;7:149-153.
- Shisana O, Rehle T, Simbayi LC, et al. South African National Prevalence, Incidence, Behaviour and Communication Survey 2008: A turning tide among teenagers? Cape Town: Human Sciences Research Council 2009.
- Fisher JC, Bang H, Kapiga SH. The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies. Sex Transm Infect. 2007;34:856-863.
- Lane T, S.B. S, McIntyre J, Morin SF. Alcohol and sexual risk behavior among men who have sex with men in South African township communities. AIDS Behav. 2008;12(Supplement 4):S78-85; 33-34.