A structural equation model of factors associated with HIV risk behaviors and mental health among men who have sex with men in Malawi.

BACKGROUND: Men who have sex with men (MSM) bear a disproportionate burden of HIV in Malawi. Early prevention efforts in Malawi have been largely focused on preventing heterosexual and vertical transmission of HIV, and MSM have rarely been the specific benefactors of these efforts, despite facing both higher prevalence of HIV coupled with multiple barriers to prevention and care. To better facilitate the design of culturally relevant HIV prevention programs and prioritize resources among MSM in resource limited settings, the objective of this analysis was to estimate the relationship between social factors and HIV related risk behaviors and mental health. METHODS: 338 MSM were recruited using respondent-driven sampling in Blantyre, Malawi from April 2011 to March 2012. Structural equation models were built to test the association between six latent factors: participation in social activities, social support, stigma and human rights violations, depression symptomatology, condom use, and sexual risk behaviors, including concurrent sexual partnerships and total number of partners. RESULTS: The mean age of participants was 25 years old. Almost 50% (158/338) of the participants were unemployed and 11% (37/338) were married or cohabiting with women. More than 30% (120/338) of the participants reported sexual behavior stigma and 30% (102/338) reported depression symptomatology. Almost 50% (153/338) of the participants reported any kind of HIV-related risk behaviors and 30% (110/338) participated in one of the recorded social activities. Significant associations were identified between stigma and risk behaviors (ß = 0.14, p = 0.03); stigma and depression symptomatology (ß = 0.62, p = 0.01); participation in social activities and depression symptomatology (ß = 0.17, p = 0.01). CONCLUSION: Results suggest MSM reporting stigma are more likely to report sexual risk practices associated with HIV/STI transmission and depressive symptoms, while those reporting participation in social activities related to HIV education are less likely to be depressed. Furthermore, interventions at the community level to support group empowerment and engagement may further reduce risks of HIV transmission and improve mental health outcomes. Taken together, these results suggest the potential additive benefits of mental health services integrated within comprehensive HIV prevention packages to optimize both HIV-related outcomes and general quality of life among MSM in Malawi.

A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi.

BACKGROUND: In the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention. METHODS: Using peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM. RESULTS: Results highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection. CONCLUSIONS: Qualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.

Using factor analyses to estimate the number of female sex workers across Malawi from multiple regional sources.

PURPOSE: Human immunodeficiency virus (HIV) risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist. METHODS: We proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and the Malawi Demographic Household Survey). We used factor analysis to extract information from auxiliary variables and constructed a linear mixed effects model for predicting population size for all districts of Malawi. RESULTS: On average, the predicted proportion of female sex workers among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study Priorities for Local AIDS Control Efforts II (PLACE II). Compared with using a single data source, we observed increased precision and better geographic coverage. CONCLUSIONS: We illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other subpopulations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.

The feasibility of recruiting and retaining men who have sex with men and transgender women in a multinational prospective HIV prevention research cohort study in sub-Saharan Africa (HPTN 075).

INTRODUCTION: Men who have sex with men (MSM) and transgender women (TGW) in sub-Saharan Africa (SSA) are profoundly affected by HIV with high HIV prevalence and incidence. This population also faces strong social stigma and legal barriers, potentially impeding participation in research. To date, few multi-country longitudinal HIV research studies with MSM/TGW have been conducted in SSA. Primary objective of the HIV Prevention Trials Network (HPTN) 075 study was to assess feasibility of recruiting and retaining a multinational prospective cohort of MSM/TGW in SSA for HIV prevention research. METHODS: HPTN 075, conducted from 2015 to 2017, was designed to enroll 400 MSM/TGW at four sites in SSA (100 per site: Kisumu, Kenya; Blantyre, Malawi; Cape Town, South Africa; and Soweto, South Africa). The number of HIV-positive persons was capped at 20 per site; HIV-positive persons already in care were excluded from participation. The one-year study included five biobehavioural assessments. Community-based input and risk mitigation protocols were included in study design and conduct. RESULTS: Of 624 persons screened, 401 were enrolled. One in five participants was classified as transgender. Main reasons for ineligibility included: (a) being HIV positive after the cap was reached (29.6%); (b) not reporting anal intercourse with a man in the preceding three months (20.6%); and (c) being HIV positive and already in care (17.5%). Five (1.2%) participants died during the study (unrelated to study participation). 92.9% of the eligible participants (368/396) completed the final study visit and 86.1% participated in all visits. The main, overlapping reasons for early termination included being (a) unable to adhere to the visit schedule, predominantly because of relocation (46.4%), and (b) unable to contact the participant (32.1%). Participants reported strong motivation to participate and few participation barriers. Four participants reported social harms (loss of confidentiality and sexual harassment by study staff) that were successfully addressed. CONCLUSIONS: HPTN 075 successfully enrolled a multinational sample of MSM/TGW in SSA in a prospective HIV prevention research study with a high retention rate and few documented social harms. This supports the feasibility of conducting large-scale research trials in this population to address its urgent, unmet HIV prevention needs.

Correlates of Water-Based Lubricant Use Among Men Who Have Sex with Men in Blantyre, Malawi.

Condom compatible lubricants (CCLs), including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011 to March 2012 using respondent-driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% [95% confidence interval (CI): 20.3-31.4] of MSM (106/329) reported primarily using WBL during anal sex. In multivariable analysis, higher income [adjusted odds ratio (aOR): 5.9; 95% CI: 2.48-14.19], family being aware of their sexual practices (aOR: 2.52; 95% CI: 1.29-4.92), and reporting consistent condom use in the last 6 months (aOR: 1.27; 95% CI: 1.06-1.52) were positively associated with WBL use. Increasing age (per 1 year increase in age; aOR: 0.89; 95% CI: 0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi, especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL, suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggests the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.

Geographical disparities in HIV prevalence and care among men who have sex with men in Malawi: results from a multisite cross-sectional survey.

BACKGROUND: Epidemiological assessment of geographical heterogeneity of HIV among men who have sex with men (MSM) is necessary to inform HIV prevention and care strategies in the more generalised HIV epidemics across sub-Saharan Africa, including Malawi. We aimed to measure the HIV prevalence, risks, and access to HIV care among MSM across multiple localities to better inform HIV programming for MSM in Malawi. METHODS: Between Aug 1, 2011, and Sept 13, 2014, we recruited MSM into cross-sectional research via respondent-driven sampling (RDS) in seven districts of Malawi. RDS and site weights were used to estimate national HIV prevalence and engagement in care and in multilevel regression models to identify correlates of prevalent HIV infection. The comparative prevalence ratio of HIV among MSM relative to adult men was calculated by use of direct age-stratification. FINDINGS: 2453 MSM were enrolled with a population HIV prevalence of 18·2% (95% CI 15·5-21·2), as low as 4·1% (2·2-7·6) in Mzuzu and as high as 24·5% (19·5-30·3) in Mulanje. The comparative HIV prevalence ratio was 2·52 when comparing MSM with the adult male population. Age-stratified HIV prevalence showed early onset of infection with 11·8% (95% CI 7·3-18·4) of MSM aged 18-19 years HIV infected. Factors positively associated with HIV infection included being aged 21-30 years and reporting female or transgender identity. Among HIV infected MSM, less than 1% reported ever being diagnosed with HIV infection (0·9%, 95% CI 0·4-2·5) and initiated antiretroviral treatment (0·2%, 0·2-0·3). INTERPRETATION: HIV disproportionately affects MSM in Malawi with disparities sustained across the HIV care continuum. These issues are geographically heterogeneous and begin among young MSM, supporting geographically focused and age-specific approaches to confidential HIV testing with linkage to HIV services. FUNDING: Malawi Department of Nutrition, HIV and AIDS (DNHA), UNDP, UNFPA, UNAIDS, and UNICEF.

Feasibility of a Combination HIV Prevention Program for Men Who Have Sex With Men in Blantyre, Malawi.

INTRODUCTION: The use of combination HIV prevention interventions (CHPI) now represent the standard of care to minimize HIV acquisition risks among men who have sex with men (MSM). There has been limited evaluation of these approaches in generalized HIV epidemics and/or where MSM are stigmatized. A peer-based CHPI program to target individual, social, and structural risks for HIV was developed for MSM in Blantyre, Malawi. METHODS: To test the feasibility of CHPI, adult MSM were followed prospectively from January 2012 to May 2013. Participants (N = 103) completed sociobehavioral surveys and HIV testing at each of the 3 follow-up study visits. RESULTS: Approximately 90% of participants attended each study visit and 93.2% (n = 96) completed the final visit. Participants met with peer educators a median of 3 times (range: 1-10) in the follow-up visits 2 and 3. Condom use at last sex improved from baseline through follow-up visit 3 with main (baseline: 62.5%, follow-up 3: 77.0%; P = 0.02) and casual male partners (baseline: 70.7%, follow-up 3: 86.3%; P = 0.01). Disclosure of sexual behaviors/orientation to family increased from 25% in follow-up 1 to 55% in follow-up 3 (P < 0.01). DISCUSSION: Participants maintained a high level of retention in the study highlighting the feasibility of leveraging community-based organizations to recruit and retain MSM in HIV prevention and treatment interventions in stigmatizing settings. Group-level changes in sexual behavior and disclosure in safe settings for MSM were noted. CHPI may represent a useful model to providing access to other HIV prevention for MSM and aiding retention in care and treatment services for MSM living with HIV in challenging environments.

HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to inform HIV prevention.

INTRODUCTION: There are limited data characterizing the burden of HIV among men who have sex with men (MSM) in Malawi. Epidemiologic research and access to HIV prevention, treatment and care services have been traditionally limited in Malawi by criminalization and stigmatization of same-sex practices. To inform the development of a comprehensive HIV prevention intervention for Malawian MSM, we conducted a community-led assessment of HIV prevalence and correlates of infection. METHODS: From April 2011 to March 2012, 338 MSM were enrolled in a cross-sectional study in Blantyre, Malawi. Participants were recruited by respondent-driven sampling methods (RDS), reaching 19 waves. Trained staff administered the socio-behavioural survey and HIV and syphilis voluntary counselling and testing. RESULTS: Crude HIV and syphilis prevalence estimates were 15.4% (RDS-weighted 12.5%, 95% confidence interval (CI): 7.3-17.8) and 5.3% (RDS-weighted 4.4%, 95% CI: 3.1-7.6), respectively. Ninety per cent (90.4%, unweighted) of HIV infections were reported as being previously undiagnosed. Participants were predominantly gay-identified (60.8%) or bisexually identified (36.3%); 50.7% reported recent concurrent relationships. Approximately half reported consistent condom use (always or almost always) with casual male partners, and proportions were relatively uniform across partner types and genders. The prevalence of perceived and experienced stigma exceeded 20% for almost all variables, 11.4% ever experienced physical violence and 7% were ever raped. Current age >25 years (RDS-weighted adjusted odds ratio (AOR) 3.9, 95% CI: 1.2-12.7), single marital status (RDS-weighted AOR: 0.3; 95% CI: 0.1-0.8) and age of first sex with a man <16 years (RDS-weighted AOR: 4.3, 95% CI: 1.2-15.0) were independently associated with HIV infection. CONCLUSIONS: Results demonstrate that MSM represent an underserved, at-risk population for HIV services in Malawi and merit comprehensive HIV prevention services. Results provide a number of priorities for research and prevention programmes for MSM, including providing access to and encouraging regular confidential HIV testing and counselling, and risk reduction counselling related to anal intercourse. Other targets include the provision of condoms and compatible lubricants, HIV prevention information, and HIV and sexually transmitted infection treatment and adherence support. Addressing multiple levels of HIV risk, including structural factors, may help to ensure that programmes have sufficient coverage to impact this HIV epidemic among MSM.