Stigma and outness about sexual behaviors among cisgender men who have sex with men and transgender women in Eswatini: a latent class analysis.

BACKGROUND: Men who have sex with men (MSM) and transgender women in Sub-Saharan Africa are subjected to high levels of sexual behavior-related stigma, which may affect mental health and sexual risk behaviors. MSM and transgender women who are open about, or have disclosed their sexual behaviors appear to be most affected by stigma. Characterizing the mechanism of action of stigma in potentiating HIV-risks among these key populations is important to support the development of interventions. METHODS: In this study, a total of 532 individuals were recruited across Eswatini (Swaziland) through chain-referral-sampling from October - December 2014, including 419 cisgender MSM and 109 transgender women. Participants were surveyed about demographics, stigma, outness of same-sex practices to family members and healthcare workers, and mental and sexual health. This study used latent class analysis (LCA) to determine latent constructs of stigma/outness, and used multinomial logistic regression to determine associations with underlying constructs and sexual risk behaviors. RESULTS: Three latent classes emerged: 1) Those who reported low probabilities of stigma (55%; 276/502); 2) Those who reported high probabilities of stigma including physical violence and fear/avoidance of healthcare, and were not "out" (11%; 54/502); and 3) Those who reported high probabilities of stigma including verbal harassment and stigma from family and friends, and were "out" (34%; 172/502). Relative to the "low stigma" class, participants from an urban area (adjusted odds ratio [AOR] = 2.78, 95% Confidence Interval [CI] = 1.53-5.07) and who engaged in condomless anal sex (AOR = 1.85, 95% CI = 1.17-2.91) were more likely to belong to the "high stigma, 'out'" class. In contrast, those who had a concurrent male or female partner were more likely to belong to the "high stigma, not 'out'" class AOR = 2.73, 95% CI = 1.05-7.07). Depression was associated with membership in both high-stigma classes (AOR = 3.14, 95% CI = 1.50-6.55 "not out", AOR = 2.42, 95% CI = 1.51-3.87 "out"). CONCLUSIONS: Sexual behavior stigma at a community level is associated with individual-level risk behaviors among MSM and transgender women, and these associations vary by level of outness about sexual practices. Achieving sufficient coverage of evidence-based stigma interventions may be key to realizing the potential impact of HIV prevention and treatment interventions for MSM and transgender women in Eswatini.

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.

OBJECTIVES: Respondent-driven sampling (RDS) is a popular method for recruiting men who have sex with men (MSM). Our objective is to describe the ability of RDS to reach MSM for HIV testing in three southern African nations. METHODS: Data collected via RDS among MSM in Lesotho (N=318), Swaziland (N=310) and Malawi (N=334) were analysed by wave in order to characterise differences in sample characteristics. Seeds were recruited from MSM-affiliated community-based organisations. Men were interviewed during a single study visit and tested for HIV. χ(2) tests for trend were used to examine differences in the proportions across wave category. RESULTS: A maximum of 13-19 recruitment waves were achieved in each study site. The percentage of those who identified as gay/homosexual decreased as waves increased in Lesotho (49% to 27%, p<0.01). In Swaziland and Lesotho, knowledge that anal sex was the riskiest type of sex for HIV transmission decreased across waves (39% to 23%, p<0.05, and 37% to 19%, p<0.05). The percentage of participants who had ever received more than one HIV test decreased across waves in Malawi (31% to 12%, p<0.01). In Lesotho and Malawi, the prevalence of testing positive for HIV decreased across waves (48% to 15%, p<0.01 and 23% to 11%, p<0.05). Among those living with HIV, the proportion of those unaware of their status increased across waves in all study sites although this finding was not statistically significant. CONCLUSIONS: RDS that extends deeper into recruitment waves may be a promising method of reaching MSM with varying levels of HIV prevention needs.

Social cohesion, social participation and HIV testing among men who have sex with men in Swaziland.

Social cohesion and social participation are social factors that may help reduce HIV risks and optimize health-seeking behaviors. We examined the association between these factors and HIV testing in the last 12 months among men who have sex with men (MSM) in Swaziland using a cross-sectional survey conducted with 326 men, 18 years of age or older reporting having sex with another man in the last 12 months. Social capital analyses included measures of social cohesion and social participation. The social cohesion measurement scale was created through exploratory factor analysis using polychoric correlations to determine unidimensionality and Cronbach's Alpha to assess internal consistency. The measurement scale was divided at the 25th and 75th percentiles using "high," "medium" and "low" levels of social cohesion for between-group comparisons. The social participation index included four questions regarding participation, resulting in a participation index ranging from 0 to 4. In the final multivariate logistic regression model, an increase in the level of social participation was found to be significantly associated with HIV testing in the last 12 months, adjusting for age, income, reporting a casual partner, family exclusion and rejection by other MSM due to sexual orientation (adjusted odds ratio [aOR]: 1.3, 95% confidence interval [CI] 1.1-1.7, p < .01). MSM with high social cohesion had almost twice the odds of HIV testing in the last 12 months (aOR: 1.8, 95% CI 1.1-3.3, p < .05) as MSM with medium social cohesion, though the overall social cohesion variable was not found to be significant using a Wald test in either the adjusted or unadjusted logistic regression models. These data suggest that building solidarity and trust within and between groups may be a strategy to improve uptake of HIV testing.

Use of emergency contraceptive pills among female sex workers in Swaziland.

OBJECTIVES: Female sex workers (FSW) often have unprotected sex. Emergency contraceptive pills (ECP) are an important back-up method to prevent unwanted pregnancy among FSW. We examine ECP use among FSW in Swaziland. METHODS: Using data from a 2011 respondent-driven sampling survey of 325 Swazi FSW, we explored the association between individual characteristics and ever having used ECP. RESULTS: In weighted analyses, 27.5% of FSW had ever used ECP. Most (77.8%) had ever been pregnant, among whom 48.7% had had an unwanted pregnancy and 11.7% had had an abortion. Nearly half (47.5%) had experienced condom failure in the past month. Significant independent correlates of ECP use were younger age, higher education, higher income, having two or more children, and never having been married. CONCLUSIONS: FSW who are older or of lower socioeconomic status may not have adequate access to ECP. By better addressing these women's family planning needs, the dual goals of preventing unwanted pregnancy and preventing vertical transmission of HIV can be achieved.

Characterizing the Individual, Social, and Structural Determinants of Condom Use Among Men Who Have Sex with Men in Swaziland.

Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression analyses were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner, respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence of informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.

A cross-sectional assessment of the burden of HIV and associated individual- and structural-level characteristics among men who have sex with men in Swaziland.

INTRODUCTION: Similar to other Southern African countries, Swaziland has been severely affected by HIV, with over a quarter of its reproductive-age adults estimated to be living with the virus, equating to an estimate of 170,000 people living with HIV. The last several years have witnessed an increase in the understanding of the potential vulnerabilities among men who have sex with men (MSM) in neighbouring countries with similarly widespread HIV epidemics. To date, there are no data characterizing the burden of HIV and the HIV prevention, treatment and care needs of MSM in Swaziland. METHODS: In 2011, 324 men who reported sex with another man in the last 12 months were accrued using respondent-driven sampling (RDS). Participants completed HIV testing using Swazi national guidelines as well as structured survey instruments administered by trained staff, including modules on demographics, individual-level behavioural and biological risk factors, social and structural characteristics and uptake of HIV services. Population and individual weights were computed separately for each variable with a data-smoothing algorithm. The weights were used to estimate RDS-adjusted univariate estimates with 95% bootstrapped confidence intervals (BCIs). Crude and RDS-adjusted bivariate and multivariate analyses were completed with HIV as the dependent variable. RESULTS: Overall, HIV prevalence was 17.6% (n=50/284), although it was strongly correlated with age in bivariate- [odds ratio (OR) 1.2, 95% BCI 1.15-1.21] and multivariate-adjusted analyses (adjusted OR 1.24, 95% BCI 1.14-1.35) for each additional year of age. Nearly, 70.8% (n=34/48) were unaware of their status of living with HIV. Condom use with all sexual partners and condom-compatible-lubricant use with men were reported by 1.3% (95% CI 0.0-9.7). CONCLUSIONS: Although the epidemic in Swaziland is driven by high-risk heterosexual transmission, the burden of HIV and the HIV prevention, treatment and care needs of MSM have been understudied. The data presented here suggest that these men have specific HIV acquisition and transmission risks that differ from those of other reproductive-age adults. The scale-up in HIV services over the past decade has likely had limited benefit for MSM, potentially resulting in a scenario where epidemics of HIV among MSM expand in the context of slowing epidemics in the general population, a reality observed in most of the world.