Barriers to Condom Use among High Risk Men Who Have Sex with Men in Uganda: A Qualitative Study

A surge in female condom distribution during the COVID-19 pandemic in Gauteng province, South Africa

BACKGROUND

Female Condoms are 90-95% effective against HIV transmission when correctly and consistently used and are also cost-effective. In general, condoms prevent sexually transmitted infections (STIs) and unwanted pregnancies. Although the COVID-19 pandemic had the potential to undermine routine healthcare services delivery and utilisation, there is limited evidence about the pandemic's effect on Female Condom uptake in Gauteng, one of the hardest-hit provinces in South Africa. This study aimed to compare female condom distribution in Gauteng Province, South Africa, before and during COVID-19, to inform decision-making for the attainment of universal access to sexual and reproductive health (SRH) by 2023 as per the sustainable development goal 3.7 and also, to empower women over their SRH during future pandemics.

METHODS

This secondary data anslysis examined the percentage change in routine female condom distribution in Gauteng province and its five districts as an indirect effect (lockdown) of the COVID-19 pandemic, by comparing the aggregated District Health Information System (DHIS) data collated from primary health care facilities within the ditrict, before COVID-19 (2018-2019) and during COVID-19 (2020). Analysis in MS Excel 2016 illustrates the changes in the patterns and the trend in female condom distribution over the study period.

RESULTS

In 2020, during the COVID-19 pandemic, Gauteng province experienced a 43.7% increase in female condom distribution compared to the pre-COVID-19 period of 2019. The highest female condom distribution during the pandemic was observed in the Ekurhuleni Metropolitan (150.0%), followed by the Sedibeng (92.8%) and the Johannesburg Metropolitan (67.9%) districts respectively. However, the Tshwane Metropolitan (-8.5%) and the West Rand (-16.6%) districts experienced a decline in female condom distribution during COVID-19.

CONCLUSION

Gauteng province witnessed a substantial surge in female condom distribution during COVID-19 in 2020, with a disproportionate district variation in demand. Female condom distribution is crucial, necessitating its enhancement and the continuum of distribution and stakeholders stockpiling at all times with particular attention to a potential increase in demand during outbreaks with lockdowns. Undisrupted access to female condoms will enable a consistent and correct use and empower women against HIV, STIs and unintended pregnancies, as a strive towards universal access to SRH.

An Open Letter on Advancing HIV prevention: Augmenting an ecosystem-based approach to understand prevention decision-making

In the last two decades, HIV programs have been able to avert millions of AIDS-related deaths and reduce HIV incidence. However, the 1.3 million new HIV infections in 2022 remain significantly above the UNAIDS target of fewer than 370,000 new infections by 2025. HIV programs worldwide also did not achieve the UN's 90-90-90 target for testing and treatment set for 2020. Within this broader picture, HIV continues to disproportionately affect key and at-risk populations, including gay men and other men who have sex with men, female sex workers, and adolescent girls and young women. As HIV incidence declines and biomedical advances continue, it will become critical for public-health practitioners to reach key and at-risk populations with prevention services and limit primary transmission. In this Open Letter, we focus on factors that influence uptake of HIV prevention products and thereby demand for HIV prevention products and services. These factors exist at three levels of the decision-making ecosystem - the individual level, interaction level and systemic level. We argue that approaching HIV prevention solely through the lens of these levels creates a static view of prevention decision-making. There is a need instead for a dynamic viewpoint that can mirror the changing contexts in which users find themselves and make prevention decisions. We demonstrate that the current ecosystem viewpoint is useful to understand the gaps that exist in program implementation, but does not provide adequate insights into the underlying behaviors that contribute to these gaps. To address this, we suggest an approach to include dynamic aspects of decision-making with factors that influence the individual's assessment of risk, their evaluation of the opportunities to use HIV prevention, and their effective use of prevention products.

Scoping review of qualitative studies on family planning in Uganda

Family planning (FP) is an essential component of public health programs and significantly impacts maternal and child health outcomes. In Uganda, there is a need for a comprehensive review of the existing literature on FP to inform future research and programmatic efforts. This scoping review aims to identify factors shaping the use of FP in Uganda. We conducted a systematic search of eight scholarly databases, for qualitative studies on FP in Uganda. We screened the titles and abstracts of identified articles published between 2002-2023 and assessed their eligibility based on predefined criteria. We extracted data from the 71 eligible studies and synthesized the findings using thematic analysis and the Ecological Systems Theory (EST) individual, interpersonal, community, institutional, and policy-level determinants. Findings reveal the interplay of factors at different socio-ecological levels influencing family planning decisions. At the individual level, the most common determinants related to the EST were knowledge and attitudes of FP. Interpersonal dynamics, including partner communication and social support networks, played pivotal roles. Community-level factors, such as cultural norms and accessibility of services, significantly influenced family planning practices. Institutional and policy-level factors, particularly a healthcare system's quality and policies, also shaped use. Other themes included the intersection of HIV/AIDS on FP practice and Ugandan views of comprehensive abortion care. This scoping review underscores the intricate socio-ecological fabric shaping FP in Uganda. The findings highlight the need for targeted interventions to increase knowledge and awareness of FP, improve access to services, and address social and cultural norms that discourage contraceptive use. Policymakers and program implementers should also consider gender dynamics and power imbalances in FP programs to ensure they are equitable and effective.

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana's slums-BSGH-005

Despite significant progress in Ghana's HIV response, disparities in HIV prevalence persist among different populations. Gays, bisexuals, and other men who have sex with men (GBMSM) in the country remain vulnerable to HIV infection due to high levels of stigma and discrimination, limited access to healthcare services, and low HIV knowledge levels. While limited studies focus on HIV prevention and care in the Ghanaian GBMSM context, we did not find studies on GBMSM in slums. We, therefore, explored stigma and motivations of HIV testing among GBMSM in slums. In collaboration with our community partners, we recruited and conducted face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi, Ghana. Our multiple-reviewer summative content analysis identified the following: under HIV stigma, we identified two categories, avoidance of GBMSM living with HIV and fear of testing positive for HIV. Under motivations for HIV testing, we identified three categories; HIV vulnerability, knowing one's HIV status, and positive messaging about HIV. Our findings provide valuable insights into stigma and motivations for HIV testing among GBMSM in Ghanaian slums. They also highlight the importance of targeted HIV education interventions to empower GBMSM to take responsibility for their sexual health and address the unique challenges they face accessing HIV testing services.

Exploring HIV risk perception mechanisms among youth in a test-and-treat trial in Kenya and Uganda

Understanding risk perception and risk-taking among youth can inform targeted prevention efforts. Using a health beliefs model-informed framework, we analysed 8 semi-structured, gender-specific focus group discussions with 93 youth 15-24 years old (48% male, 52% female), drawn from the SEARCH trial in rural Kenya and Uganda in 2017-2018, coinciding with the widespread introduction of PrEP. Highly connected social networks and widespread uptake of antiretrovirals shaped youth HIV risk perception. Amid conflicting information about HIV prevention methods, youth felt exposed to multiple HIV risk factors like the high prevalence of HIV, belief that people with HIV(PWH) purposefully infect others, dislike of condoms, and doubts about PrEP efficacy. Young women also reported minimal sexual autonomy in the context of economic disadvantages, the ubiquity of intergenerational and transactional sex, and peer pressure from other women to have many boyfriends. Young men likewise reported vulnerability to intergenerational sex, but also adopted a sexual conquest mentality. Comprehensive sexuality education and economic empowerment, through credible and trusted sources, may moderate risk-taking. Messaging should leverage youth's social networks to spread fact-based, gender- and age-appropriate information. PrEP should be offered alongside other reproductive health services to address both pregnancy concerns and reduce HIV risk.

Condom-Related Stigma Scale among Men Who Have Sex with Men in China: Development and Psychometric Tests

Condom-related stigma is a frequently mentioned barrier to consistent condom use among men who have sex with men (MSM). Based on the concept and operational definition of condom-related stigma recently defined by our team, we developed the 20-item condom-related stigma scale (CRSS) and examined its psychometric properties among 433 MSM in China, following DeVellis's scale development guidelines. The content validity, convergent validity, empirical validity, factorial validity, scale score reliability, split-half reliability, and test-retest reliability for the CRSS were all assessed. The scale consists of four domains: perceived distrust, perceived potential HIV/STI risk, perceived embarrassment, and perceived violation of the traditional understanding of sexual intercourse. The CRSS has good validity (the scale-level content validity index was 0.99; the empirical validity was greater than 0.70) and high reliability (the Cronbach's alpha coefficient overall was 0.926; the split-half reliability overall was 0.795; the test-retest reliability overall was 0.950). This scale is recommended for assessing the level of condom-related stigma among Chinese MSM, which can serve as an evaluating indicator for safer-sex interventions to prevent HIV infection among the MSM population in a Chinese cultural context.

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.

Cultivating resilience and hope: A qualitative study of a pilot program using patient navigators to assist men who have sex with men with retention in the HIV care continuum in Uganda

In Uganda, due to the criminalization of same-sex sexual practices, men who have sex with men (MSM) experience barriers to accessing HIV care. To retain patients within the HIV Care Continuum, some health interventions have used patient navigators as an ancillary support service. To understand the potential care benefits of using patient navigators for marginalized populations experiencing challenges to HIV care and treatment access in a Ugandan context, this qualitative study explored the experiences of newly diagnosed MSM using patient navigators for ARV retention in care in Kampala. Additionally, to gain insight into the feasibility of patient navigator interventions, this study also aimed to understand the perspectives and experiences of patient navigators working with HIV positive MSM. Individual in-depth, semi structured interviews were conducted with 24 HIV positive MSM and four patient navigators that were part of a patient navigator pilot program from January 2019 -December 2020. Analysis was done using manifest and latent qualitative content analysis. Results showed that HIV positive MSM in Uganda experienced a variety of social, emotional, and financial challenges that placed them at risk for dropping off the HIV Care Continuum. Patient navigators provided HIV positive MSM with the skills, support, and resources necessary to overcome these challenges. Based on study results, we conclude that within the patient navigator pilot program, patient navigators improved MSM participants' quality of life by helping them to achieve the HIV Care Continuum stages: diagnosis, linked to care, receiving HIV treatment, and retention in care. Study results suggest future research is needed on the psychosocial support needs of patient navigators, how the support needs of MSM change throughout their lifetime on the HIV Care Continuum, and how potential benefits of patient navigators may differ in rural Ugandan contexts.

Why do men who have sex with men practice condomless sex? A systematic review and meta-synthesis

Background

Despite a large amount of behavioral interventions to reduce human immunodeficiency virus (HIV)-related high-risk sexual behaviors, consistent condom use remains suboptimal among men who have sex with men (MSM). However, current databases are lack of synthesized evidence to explain why MSM practiced condomless sex.

Objective

Our study aims to conduct a systematic review and meta-synthesis of 39 eligible qualitative studies to explore the barriers to condom use among MSM.

Methods

A systematic review and meta-synthesis of qualitative studies (1994–2021). On March 4, 2021, a comprehensive search was conducted in 14 electronic databases. The study was conducted based on the Joanna Briggs Institute’s recommendations.

Results

Thematic analysis produced six synthesized themes, which were classified into three levels according to the Social-ecology Model. Individual level barriers to condom use included physical discomfort, lack of HIV/STI-related knowledge and substance use; interpersonal-level barrier was mainly the condom stigma, namely regarding using condom as symbols of distrust or HIV/sexually transmitted infections (STIs) prevention, or as violating traditional cognition of sex, or as an embarrassing topic; environmental/structural-level barriers included situational unavailability, unaffordability of condoms and power imbalance in the sexual relationship.

Conclusion

This meta-synthesis offered in-depth understanding of condom use barriers for MSM and could guide the development of multifactorial interventions according to the identified barriers, especially targeting to reduce condom stigma, which has not been focused and intervened previously.

Evaluating the effectiveness of enhanced family planning education on knowledge and use of family planning in fishing communities of Lake Victoria in Uganda: a randomized controlled trial

Introduction

Family planning knowledge is poor and use is low in Ugandan fishing communities. We compared the effectiveness of enhanced family planning (FP) education with routine counselling on FP knowledge and use.

Methods

Individuals aged 15–49 years were randomly assigned to intervention or control arm. The intervention constituted enhanced FP education based on a simplified handout extracted from the WHO FP guidance tool called, “Family planning: A global handbook for FP providers” which participants took home for additional reading. The control arm constituted FP counselling following Uganda Ministry of Health guidelines. FP knowledge score and contraceptive prevalence rate (CPR) were compared between trial arms at baseline and at 12 months. Negative binomial regression models were used to estimate the effect of the intervention on FP knowledge and use.

Results

Overall, 1410 participants were screened to enrol 1004 (502 per study arm, 48.5% women). Subsequently, 384 (76.5%) and 383 (76.3%) completed the 12 months’ follow-up in the intervention and control arms respectively. At baseline, a median FP knowledge score of 8 and a < 70% FP knowledge score was observed for all participants with a CPR of 36.8%. At month-12, the median FP knowledge score improved in both arms, higher in the intervention arm than the control arm (46 vs 30; p < 0.001). In the intervention arm, 304 (79.2%) had a score of ≥70 compared with 21 (5.5%) in the control arm (p < 0.001). In the negative binomial regression model, the change in FP knowledge score was 47% higher in the intervention arm than in the control arm (score ratio: 1.47, 95%CI: 1. 43-1.51, p < 0.001). The change in CPR was 16% higher in the intervention arm than in the control arm (Prevalence ratio: 1.16, 95%CI: 1.01-1.34, p < 0.040).

Interpretation

Enhanced FP education using a simplified FP education handout was more effective in increasing FP knowledge and use compared to routine FP counselling for people living in fishing communities. Innovative FP education interventions are recommended for improving FP knowledge and optimizing uptake in remote-rural settings where literacy levels are low.

Trial registration

The study was registered by the Pan African Clinical Trial Registry on 03 July 2021 with a Trial Registration Number PACTR202107891858045. “Retrospectively registered”.

Understanding and managing HIV infection risk among men who have sex with men in rural Uganda: a qualitative study

Background

Same-sex sexual relations are criminalised in Uganda, and men who have sex with men (MSM) experience a high burden of HIV infection. In Uganda, health promotion policies focus on equity in healthcare and creating enabling environments. At present there is limited evidence upon which to enhance engagement of MSM in rural settings into effective HIV prevention. To fill this gap, our study explored MSM’s understandings of HIV risk and strategies used to reduce HIV risk in their sexual lives.

Methods

In-depth interviews were conducted with sixteen MSM in rural communities in Southwestern Uganda. Inductive thematic analysis examined men’s perceptions of HIV risk and strategies of reducing their own HIV risks.

Results

Understandings of HIV risk and risk practices were framed by lack of access to condoms, challenges negotiating condom and pre-exposure prophylaxis (PrEP) use, and condomless sex being reported as more pleasurable than sex with condoms. Strategies men perceived as enabling them to manage HIV risk included: PrEP use; condom use; knowing partners’ HIV status; avoiding partners associated with HIV risk; oral sex; withdrawal before ejaculation and washing one’s penis after sex. There were several misconceptions arising from poor HIV prevention knowledge. Strategies reliant on communication and negotiation with sexual partners were inhibited by gendered powered imbalances.

Conclusions

Our findings illustrate that MSM in rural settings in Uganda are making concerted efforts to implement strategies that might reduce risk of HIV transmission and infection within their sexual relationships. Key HIV health promotion and service-related strategies to support MSM with these efforts include an effective condom and lubricant supply chain; a PrEP program in trusted local health units, implemented via discreet community-outreach mechanisms; and same-sex specific HIV-related health promotion.

Factors Associated With Condom Failure in a Longitudinal Cohort of Men Who Have Sex With Men and Transgender Women in Abuja and Lagos, Nigeria

BACKGROUND

Effective condom use is a critical intervention to limit the spread of HIV and other sexually transmitted infections, particularly among individuals in high-risk networks who practice anal sex. We characterized condom failures in cisgender men who have sex with men and transgender women in Nigeria.

SETTING

The TRUST/RV368 cohort provided condoms, compatible lubricants, and safer sex education to men who have sex with men and transgender women at community-engaged health centers in Abuja and Lagos, Nigeria.

METHODS

Participants completed structured interview questions about condom usage and failure every 3-6 months. Robust Poisson regression models with generalized estimating equations were used to estimate relative risks and 95% confidence intervals for prespecified factors potentially associated with condom failure in the previous month.

RESULTS

From September 2013 to September 2019, 2221 of 2737 participants (81.1%) reported condom use for anal sex with a male partner in the last month, and 305 (13.7%) reported condom failure during this time. Multivariate analyses demonstrated an increased risk of condom failure at postenrollment visits, as well as in participants who reported frequent Internet use, 2 or more casual sexual partners, and 2-4 main sexual partners. Those who cohabited with a woman had reduced risk.

CONCLUSIONS

Condom failure was common in this population despite freely available condoms, compatible lubrication, and education. Increased risk of condom failure over time could reflect message fatigue a ceiling for effective condom use, or new uptake of condoms by inexperienced users.

Condom Use and Related Factors among Rural and Urban Men Who Have Sex With Men in Western China: Based on Information-Motivation-Behavioral Skills Model

This study aimed to determine the differences in condom use and related factors among rural–urban men who have sex with men (MSM) in Western China. A cross-sectional survey was conducted in Chongqing, Sichuan, and Guangxi, which recruited MSM by non-probability sampling. Data were collected through an anonymous, standardized, and self-reported questionnaire guided by an information–motivation–behavioral skills model. Structural equation model was applied to analyze the related factors. Out of the 1141 MSM included in this analysis, 856 (75%) and 285 (25%) were from urban and rural areas, respectively. The median age was 27 years for both groups. Self-reported consistent condom use for anal sex in the past 6 months was 57.58%. The rate of consistent condom use was lower in rural MSM than in urban MSM (50.88% vs. 59.81%, p = .008). Behavioral skills, HIV/AIDS intervention services, and response costs had direct positive and negative influences on condom use, respectively. By contrast, motivation and information exhibited indirect influence. All the factors were mediated by behavioral skills in rural and urban MSM, except for the information that had no effect among urban MSM but had an indirect effect among rural MSM. These findings suggest that service providers should pay attention to substantial rural–urban differences and design different AIDS prevention and intervention strategies targeting rural and urban MSM.

Factors Affecting the Intent to Use HIV Testing Services of Filipino Men Who Have Sex With Men: A Structural Equation Model

In recent years, the Philippines has seen significant increases in the uptake of HIV testing services (HTSs) but considerably lags in achieving the 2030 goal of achieving 90% of the people knowing their HIV status. The purpose of this study was to determine the utility of the Health Belief Model, using partial least squares structural equation modeling (PLS-SEM), in identifying factors that affect the intentions of Filipino men who have sex with men to seek and get tested for HIV. A sample of 471 Filipino men who have sex with men completed the web-based survey. The mean age of the participants was 25.93 years (SD = 6.02), with a majority reporting having been tested at least once (n = 349; 74.10%) and planning to follow-up with HTS providers in 3 months (73.4%; n = 386). The final model was identified that predicted HTS utilization (R = 0.08); self-efficacy, perceived susceptibility, and benefits were most predictive of HTS utilization. The model produced may be useful in identifying gaps in HTS program planning and implementation.

Acceptability of a feasibility randomized clinical trial of a microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices (EMERGE) in young adults: a mixed methods assessment

BACKGROUND

Acceptability is a critical requisite in establishing feasibility when planning a larger effectiveness trial. This study assessed the acceptability of conducting a feasibility randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults, aged 18 to 24, in Baltimore, Maryland. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

METHODS

Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19). The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Qualitative and quantitative post-intervention, in-person interviews were used in addition to process documentation of study methods.

RESULTS

Our results found that the study design and interventions showed promise for being acceptable to economically-vulnerable African-American young adults. The largely positive endorsement suggested that factors contributing to acceptability included perceived economic potential, sexual health education, convenience, incentives, and encouraging, personalized feedback to participants. Barriers to acceptability for some participants included low cell phone connectivity, perceived payment delays, small cohort size, and disappointment with one's randomization assignment to comparison group. Use of peer referral, network, or wait-list designs, in addition to online options may enhance acceptability in a future definitive trial. Expanding administrative and mentoring support may improve overall experience.

CONCLUSION

Microenterprise interventions are acceptable ways of providing young adults with important financial and sexual health content to address HIV risks associated with economic vulnerability.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT03766165 . Registered 04 December 2018.

Facilitators and barriers to condom use among Filipinos: A systematic review of literature

Background: Between 2010 and 2018, the Philippines had a 203% increase in new human immunodeficiency virus (HIV) infections. The use of condoms is an effective and practical means to prevent HIV transmission. The purpose of this study was to identify facilitators and barriers to condom use among Filipinos guided by the Ecological Model of Health Promotion.

Methods: A systematic review of literature using electronic databases was performed using the following keywords: "condom," "Filipinos," and "Philippines." To be included in this review, papers should be (1) research studies, (2) studies that examined condom use, and (3) studies that sampled Filipinos residing in the Philippines. The final sample comprised of 27 articles.

Results: Multiple and interrelated factors at the individual and social environment levels influence condom use among different groups of Filipinos. Majority of these factors originated at the intrapersonal level. Some of the facilitators to condom use were knowledge on HIV, higher perceived HIV risk, peer support, positive manager attitude, health provider engagement, and city ordinances. In contrast, some of the barriers to condom use were discomfort and displeasure on condom use, low parental communication, lack of sex education, social stigma, and the high price of condoms.

Conclusion: A collaborative, culturally-sensitive, and population-specific approach is essential to develop and implement acceptable, sustainable, and successful condom use interventions.

Correlates of knowledge of family planning among people living in fishing communities of Lake Victoria, Uganda

Background

Knowledge of family planning (FP) is a key determinant of contraceptive use which ultimately plays a role in attainment of good health and in conduct of clinical research. People living in fishing communities (FCs) have limited access to health services including FP and are targeted for future clinical research but their knowledge of FP and its correlates are scantily known. We determined correlates of knowledge of FP among people living in FCs of L. victoria in Uganda to inform future FP education programs in FCs.

Methods

We conducted a comparative cross-sectional survey among participants aged 15–49 years from Kigungu and Nsazi. Participants were asked if they were aware of any FP method. All those who responded in the affirmative were further asked to mention what FP methods they had heard of or knew. Those who reported knowledge of at least one FP method were asked a series of questions about FP methods and their side effects. Knowledge was categorized into good or poor knowledge based on their mean total score. Poor knowledge constituted a score below the mean while good knowledge constituted a score of more than or equal to the mean total score. To further explore attitudes and perceptions of FP, ten in-depth interviews and four focus group discussions were conducted.

Results

Of the 1410 screened participants, 94.5% were aware of at least one FP method. Pills and injectable hormonal methods were the most commonly known methods. Slightly over a third (38%) had good knowledge of FP. Correlates of knowledge of FP were; being female (aOR: 1.92 95% CI: 1.39–2.67), residing in Kigungu (aOR: 4.01 95% CI: 2.77–5.81), being married (aOR: 1.59 95% CI: 1.11–2.28) and currently being in a sexual relationship (aOR: 1.75 95% CI: 1.18–2.60). Concerns about safety and effectiveness of some modern FP methods exist. Misconceptions on effects of FP like sterility, cancers and foetal abnormalities were common.

Conclusion

FP awareness among people living in FCs of L. Victoria in Uganda is high. However, good knowledge about specific methods tends to be low. Correlates of knowledge of FP include gender, residence, marital status and sexual engagement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09762-7.

Association of age with healthcare needs and engagement among Nigerian men who have sex with men and transgender women: cross-sectional and longitudinal analyses from an observational cohort

INTRODUCTION

Young men who have sex with men (MSM) and transgender women (TGW) face stigmas that hinder access to healthcare. The aim of the study was to understand age-related determinants of healthcare needs and engagement among MSM and TGW.

METHODS

The TRUST/RV368 cohort provides integrated prevention and treatment services for HIV and other sexually transmitted infections (STIs) tailored to the needs of sexual and gender minorities. MSM and TGW aged ≥16 years in Abuja and ≥18 years Lagos, Nigeria, completed standardized behavioural questionnaires and were tested for HIV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) every three months for up to 18 months. Logistic regression was used to estimate adjusted odds ratios (aORs) for associations of age and other factors with outcomes of interest upon enrolment, including HIV care continuum steps - HIV testing, ART initiation and viral suppression <1000 copies/mL. Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) for associations with incident infections.

RESULTS

Between March 2013 and February 2019, 2123 participants were enrolled with median age 23 (interquartile range 21 to 27) years. Of 1745 tested, 865 (49.6%) were living with HIV. HIV incidence was 11.6/100 person-years [PY], including 23.1/100PY (95% CI 15.5 to 33.1) among participants aged 16 to 19 years and 23.8/100 PY (95% CI 13.6 to 39.1) among TGW. Compared to participants aged ≥25 years, those aged 16 to 19 years had decreased odds of prior HIV testing (aOR 0.40 [95% CI 0.11 to 0.92]), disclosing same-sex sexual practices to healthcare workers (aOR 0.53 [95% CI 0.36 to 0.77]) and receiving HIV prevention information (aOR 0.60 [95% CI 0.41 to 0.87]). They had increased odds of avoiding healthcare (aOR 1.94 [95% CI 1.3 to 2.83]) and engaging in transactional sex (aOR 2.76 [95% CI 1.92 to 3.71]). Age 16 to 19 years was independently associated with increased incidence of HIV (aHR 4.09 [95% CI 2.33 to 7.49]), NG (aHR 3.91 [95% CI 1.90 to 8.11]) and CT (aHR 2.74 [95% CI 1.48 to 5.81]).

CONCLUSIONS

Young MSM and TGW demonstrated decreased healthcare engagement and higher incidence of HIV and other STIs as compared to older participants in this Nigerian cohort. Interventions to address unique obstacles to healthcare engagement by adolescents and young adults are needed to curb the spread of HIV and other STIs among MSM and TGW in Nigeria.

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 (β = 0.14, p = 0.03); stigma and depression symptomatology (β = 0.62, p = 0.01); participation in social activities and depression symptomatology (β = 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.

An Internet-Based, Peer-Delivered Messaging Intervention for HIV Testing and Condom Use Among Men Who Have Sex With Men in India (CHALO!): Pilot Randomized Comparative Trial

Background

Leveraging internet-based communication tools (eg, messaging apps, SMS text messaging, and email) may be an effective avenue for delivery of HIV prevention messages to men who have sex with men (MSM) in India, but there are limited models for such internet-based interventions.

Objective

The CHALO! pilot was an online educational and behavioral intervention aimed to determine the feasibility, acceptability, and preliminary impact of a peer-delivered, internet-based messaging intervention for HIV testing and consistent condom use for MSM in India. The messages addressed barriers to HIV testing and condom use and were theoretically based on the information-motivation-behavioral skills model.

Methods

Between February and March 2015, we recruited, enrolled, and randomized 244 participants via online advertisements on mobile dating apps and Facebook. Eligible men (18 years or older, sexually active with other men, and self-reported HIV-negative or unknown status) were randomized to receive educational and motivational messages framed as either approach (ie, a desirable outcome to be achieved) or avoidance (an undesirable outcome to be avoided) over 12 weeks via internet-based messaging platforms. Participants completed online surveys at baseline and immediately postintervention.

Results

Participants were similar across arms with respect to sociodemographic and behavioral characteristics. Over 82.0% (200/244) of participants were retained (ie, viewed final messages), and 52.3% (130/244) of them completed the follow-up survey. Of those completing the follow-up survey, 82.3% (107/130) liked or strongly liked participating in CHALO!. The results showed a significant increase in self-reported HIV testing in the past 6 months from baseline to follow-up (41/130, 31.5% to 57/130, 43.8%; P=.04). When including those who reported intentions to test, this percentage increased from 44.6% (58/130) at baseline to 65.4% (85/130) at follow-up (P<.01). When examining intentions to test among those without prior HIV testing, intentions increased from 32% (16/50) of the sample at baseline to 56% (28/50) of the sample at follow-up (P=.02). Condom use during anal sex did not significantly change from baseline to follow-up. HIV testing and condom use did not significantly differ between approach and avoidance conditions at follow-up.

Conclusions

As one of the first studies of an online HIV prevention intervention for Indian MSM, CHALO! was feasible to implement by a community-based organization, was acceptable to participants, and demonstrated potential to improve HIV testing rates.

Barriers to condom use among key populations in Namibia

Key populations (KPs), particularly female sex workers (FSWs) and men who have sex with men (MSM), are at increased risk for HIV. Namibia is a global priority for HIV prevention interventions. Marginalized communities must be provided effective and culturally appropriate means to prevent HIV, namely condom use. This cross-sectional analysis of data collected by The Society for Family Health was conducted from 2016 to 2017 in Namibia. Demographics and consistent condom use (CCU) barriers were analyzed among 621 FSWs, MSM, and Other KPs. From the data, 37% FSWs, 24% MSM, and 28% Other KPs were HIV-positive. One-quarter of FSWs and Other KPs reported CCU, while 46% MSM reported CCU. Consistent condom users were more likely to be HIV-negative, have achieved a higher education and use condom-compatible lubricant (CCL). In a multivariate model, higher education, being HIV-negative, and always using CCL remained independent correlates of CCU. Substance use and condom unavailability were the most commonly identified barriers to CCU. FSWs reported client-focused reasons for not using condoms. To the best of our knowledge, this is the first peer-reviewed study assessing condom use behavior and associated factors among FSWs and MSM in Namibia.

Seizing opportunities for intervention: Changing HIV-related knowledge among men who have sex with men and transgender women attending trusted community centers in Nigeria

BACKGROUND

Knowledge of HIV risk factors and reduction strategies is essential for prevention in key populations such as men who have sex with men (MSM) and transgender women (TGW). We evaluated factors associated with HIV-related knowledge among MSM and TGW and the impact of engagement in care at trusted community health centers in Nigeria.

METHODS

The TRUST/RV368 cohort recruited MSM and TGW in Lagos and Abuja, Nigeria via respondent driven sampling. During study visits every three months, participants underwent structured interviews to collect behavioral data, received HIV education, and were provided free condoms and condom compatible lubricants. Five HIV-related knowledge questions were asked at enrollment and repeated after 9 and 15 months. The mean number of correct responses was calculated for each visit with 95% confidence intervals (CIs). Multivariable Poisson regression was used to calculate adjusted risk ratios and CIs for factors associated with answering more knowledge questions correctly.

RESULTS

From March 2013 to April 2018, 2122 persons assigned male sex at birth were enrolled, including 234 TGW (11.2%). The mean number of correct responses at enrollment was 2.36 (95% CI: 2.31-2.41) and increased to 2.95 (95% CI: 2.86-3.04) and 3.06 (95% CI: 2.97-3.16) after 9 and 15 months in the study, respectively. Among 534 participants who completed all three HIV-related knowledge assessments, mean number of correct responses rose from 2.70 (95% CI: 2.60-2.80) to 3.02 (95% CI: 2.93-3.13) and then 3.06 (95% CI: 2.96-3.16). Factors associated with increased overall HIV-related knowledge included longer duration of study participation, HIV seropositivity, higher education level, and more frequent internet use.

CONCLUSIONS

There was suboptimal HIV-related knowledge among Nigerian MSM and TGW at that improved modestly with engagement in care. These data demonstrate unmet HIV education needs among Nigerian MSM and TGW and provide insights into modalities that could be used to address these needs.

"I Couldn't Afford to Resist": Condom Negotiations Between Male Sex Workers and Male Clients in Mombasa, Kenya

Male sex workers in Kenya face a disproportionate burden of HIV and often engage in condomless sex with their commercial partners, yet little is known about how condom negotiations between male sex workers and clients take place. We conducted semi-structured interviews with 25 male sex workers and 11 male clients of male sex workers in Mombasa, Kenya, to examine barriers and facilitators to condom use and how condom use negotiation takes place in these interactions. Participants reported positive attitudes toward condom use and perceived condom use to be a health-promoting behavior. Barriers to condom use included extra-payment for condomless sex, low perceived HIV/STI risk with some sexual partners, perceived reduced pleasure associated with using condoms, alcohol use, and violence against male sex workers by clients. Future interventions should address individual- and structural-level barriers to condom use to promote effective condom use negotiation between male sex workers and male clients.

Transactional sex among men who have sex with men participating in the CohMSM prospective cohort study in West Africa

Although the HIV epidemic is generalized in West Africa, some population groups such as men who have sex with men (MSM), especially those engaged in transactional sex (TS), are thought to be particularly more vulnerable to HIV than others. However, few data are available to help identify their health-related needs with a view to implementing targeted prevention interventions. To fill this knowledge gap, we aimed to characterize MSM reporting TS (MSM-TS) and to identify factors associated with their sexual practices using data from the prospective cohort study CohMSM, which was conducted in Burkina Faso, Côte d’Ivoire, Mali and Togo. Three stigmatization sub-scores were constructed (experienced, perceived and internalized). The generalized estimating equation method was used for data analysis. Of the total 630 HIV-negative MSM recruited in CohMSM, 463, 410 and 244 had a follow-up visit at 6, 12 and 18 months, respectively. In a total of 1747 follow-up visits, 478 TS encounters were reported by 289 MSM-TS (45.9%). Of the latter, 91 regularly reported TS (31.5%), 55 (19.0%) stopped reporting TS after baseline, and 53 (18.3%) reported TS after baseline and 90 (31.1%) occasionally reported TS. The following variables, regarding the previous 6 months, were positively associated with TS: being younger (aOR[95%CI]:1.86[1.39–2.50]), less educated (aOR[95%CI]:1.49[1.09–2.03]), unmarried status (aOR[95%CI]:1.79[1.10–2.93]), satisfaction with current sex life (aOR[95%CI]:1.41[1.06–1.88]), group sex with men (aOR[95%CI]:2.07[1.46–2.94]), multiple male sexual partners (aOR[95%CI]:1.85[1.40–2.44]), receptive or versatile anal sex with male partners (aOR [95%CI]:1.48[1.12–1.96]), giving benefits in exchange for sex with a man (aOR[95%CI]:2.80[1.97–3.98]), alcohol consumption (aOR[95%CI]:1.44[1.08–1.93]) and drug use (aOR[95%CI]:1.82[1.24–2.68]) during sex, and finally experiencing stigmatization (aOR [95%CI]:1.15[1.07–1.25]). Condom use during anal sex (aOR[95%CI]:0.73[0.53–0.99]) was negatively associated with TS.

Reimagining Health Communication: A Noninferiority Randomized Controlled Trial of Crowdsourced Intervention in China

BACKGROUND

Crowdsourcing, the process of shifting individual tasks to a large group, may be useful for health communication, making it more people-centered. We aimed to evaluate whether a crowdsourced video is noninferior to a social marketing video in promoting condom use.

METHODS

Men who have sex with men (≥16 years old, had condomless sex within 3 months) were recruited and randomly assigned to watch 1 of the 2 videos in 2015. The crowdsourced video was developed through an open contest, and the social marketing video was designed by using social marketing principles. Participants completed a baseline survey and follow-up surveys at 3 weeks and 3 months postintervention. The outcome was compared with a noninferiority margin of +10%.

RESULTS

Among the 1173 participants, 907 (77%) and 791 (67%) completed the 3-week and 3-month follow-ups. At 3 weeks, condomless sex was reported by 146 (33.6%) of 434 participants and 153 (32.3%) 473 participants in the crowdsourced and social marketing arms, respectively. The crowdsourced intervention achieved noninferiority (estimated difference, +1.3%; 95% confidence interval, -4.8% to 7.4%). At 3 months, 196 (52.1%) of 376 individuals and 206 (49.6%) of 415 individuals reported condomless sex in the crowdsourced and social-marketing arms (estimated difference: +2.5%, 95% confidence interval, -4.5 to 9.5%). The 2 arms also had similar human immunodeficiency virus testing rates and other condom-related secondary outcomes.

CONCLUSIONS

Our study demonstrates that crowdsourced message is noninferior to a social marketing intervention in promoting condom use among Chinese men who have sex with men. Crowdsourcing contests could have a wider reach than other approaches and create more people-centered intervention tools for human immunodeficiency virus control.

Time to change the paradigm: limited condom and lubricant use among Nigerian men who have sex with men and transgender women despite availability and counseling

PURPOSE

This study characterized availability and uptake of condoms and condom-compatible lubricants (CCLs) at community-engaged condom education and distribution programs serving cisgender men who have sex with men and transgender women in Abuja and Lagos, Nigeria.

METHODS

Condoms and water-based CCLs were freely available to participants in the TRUST/RV368 cohort. Factors associated with their consistent use were assessed using Poisson regression with robust error variance to estimate relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

From March 2013-November 2017, 2090 cisgender men who have sex with men and transgender women enrolled with HIV prevalence 40.4% and incidence 12.8 cases per 100 person-years. Fifteen months after enrollment, the proportion who reported consistent condom and CCL use increased during receptive anal sex (21.7%-67.1%, P < .001) and insertive anal sex (25.4%-67.8%, P < .001). Multivariable analyses demonstrated independent impact of 15 months in care on uptake during both receptive (RR 2.62 [95% CI 2.29-3.00]) and insertive (RR 2.27 [95% CI 2.01-2.57]) sex.

CONCLUSIONS

Engagement in care improved condom and CCL uptake over time but inconsistent use remained common. Novel approaches to further increase uptake must be pursued alongside complementary strategies, such as sustained access to antiretroviral therapy for those living with HIV and provision of pre and postexposure prophylaxis for those at risk.

Prevalence and Factors Associated with Inconsistent Condom Use among Men who Have Sex with Men (MSM) who use Mobile Geo-Social Networking Applications in Greater Tokyo

This study examined the prevalence and factors associated with inconsistent condom use among men who have sex with men (MSM) who use gay mobile geo-social networking applications (gay mobile apps) in Greater Tokyo. Among a sample of 1657 MSM recruited through advertisements on gay mobile apps, inconsistent condom use was reported by over one-third (37%) of participants with regular male partners, 18% with casual male partners, and 20% with female partners. In multiple regression analysis, inconsistent condom use with both regular and casual male partners was more commonly reported among participants without a university education, and among participants reporting lower self-efficacy for safer sex. Inconsistent condom use with casual male partners was more commonly reported among participants living in the central 23 wards of Tokyo. Inconsistent condom use with regular male partners was more commonly reported among participants who identified as a member of the gay community, and who only had male partners. These results indicate that a substantial proportion of Greater Tokyo gay mobile app users use condoms inconsistently, particularly with regular partners, and may be at risk for HIV. This paper provides useful information to help design tailored strategies to reduce inconsistent condom use.

Condom use social norms and self-efficacy with different kinds of male partners among Chinese men who have sex with men: results from an online survey

Background

Social norms and self-efficacy play important roles in promoting consistent condom use among men who have sex with men (MSM). Few studies have investigated the association between social norms, self-efficacy and consistent condom use with different kinds of male partners among MSM. We conducted an online survey of MSM to evaluate this in China.

Methods

A cross-sectional online survey was conducted in 2015. Participants completed a validated questionnaire covering socio-demographic information, consistent condom use, condom use social norms and self-efficacy. Eligible participants were 16 or older, born biologically as a male, engaged in anal sex with a man at least once during their lifetime, engaged in condomless anal or vaginal sex in the last three months. In this study, we further restricted to people who had sex with male partners in the last three months. Participants were classified into three groups: engaged in sex only with regular partners, engaged in sex only with casual partners and engaged in sex with both regular partners and casual partners.

Results

Participants were recruited from 32 provinces in China. Among 1057 participants, 451(42.7%), 217(20.5%), and 389(36.8%) engaged in sex with regular partners only, casual partners only and both types in the last three months, respectively. Men engaged in sex only with regular partners in the last three months had a higher condom use self-efficacy than with other two types of partners (P < 0.01). Both social norms (regular partners: adjusted OR:1.59, 95% CI: 0.97–2.60; casual partners: adjusted OR: 1.58, 95% CI: 1.19–2.09; both types: adjusted OR: 1.48, 95% CI: 1.13–1.95) and self-efficacy (regular partners: adjusted OR: 2.88, 95% CI: 1.59–5.22; casual partners: adjusted OR: 2.35, 95% CI: 1.69–3.26; both types: adjusted OR: 2.45, 95% CI: 1.81–3.32) were positively associated with consistent condom use. No interaction effect was detected between condom social norms and self-efficacy on consistent condom use among Chinese MSM (p > 0.05).

Conclusions

Both social norms and self-efficacy were positively correlated with consistent condom use with any types of partners among Chinese MSM. Tailored interventions that aimed to improve social norms and self-efficacy has the potential to improve overall condom use among Chinese MSM.

Trial registration

ClinicalTrials.gov: NCT02516930. August 6, 2015.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6090-5) contains supplementary material, which is available to authorized users.

South African Men Who Have Sex With Both Men and Women and How They Differ From Men Who Have Sex With Men Exclusively

The label "men who have sex with men" (MSM) is used to categorize a diverse population exclusively on the basis of its sexual behavior. Understanding the diversity that this label comprises is critical for the development of health interventions that effectively reach the various populations subsumed under this label. In this cross-sectional study of South African MSM (N = 480) recruited through respondent-driven sampling (RDS), we explored differences between men who had sex with both men and women (MSMW) and men who had sex with men exclusively (MSME). We found significant differences between these two groups in terms of sexual attraction, sexual identity, sexual preferences, sexual histories, and current sexual practices. MSMW were more likely to be confused about their same-sex attraction, to experience internalized homophobia, and to have paid for sex in the previous year, while MSME were more gender nonconforming and more likely to have been forced to have sex in the previous year. These findings underscore that the MSM label comprises a diverse population and that exclusive sexual engagement with other men is a critical distinction to take into account in understanding this diversity and fully grasping the lived experiences of men who have sex with men.

Predictors of HIV Testing and Their Influence on PrEP Acceptance in Men Who Have Sex with Men: A Cross-Sectional Study

HIV testing is the gateway to biomedical means of prevention and treatment. Identifying predictors of HIV testing is important to inform future preventive interventions. Of 444 men who have sex with men without known HIV infection enrolled in a study in Hong Kong, 64% had ever been HIV-tested. Testers were generally older, better educated, had a higher monthly income, and more likely self-identified as gay. Testers often used Internet and frequented saunas for sex networking, compared with non-testers attending bars, massage centres and public toilets. HIV testing habit also varied with the profile of body image type and preferred type in sex networking. Higher acceptance of pre-exposure prophylaxis (PrEP) was observed among testers. Overall, socioeconomic status played an important role in both HIV testing and access to PrEP. Interventions targeting sex networking venues and alternative means of testing provision are needed to increase coverage of HIV testing.

Cross-country Association of Press Freedom and LGBT freedom with prevalence of persons living with HIV: implication for global strategy against HIV/AIDS

BACKGROUND

Human behaviors are affected by attitudes and beliefs, which in turn are shaped by higher-level values to which we have ascribed. In this study, we explore the relationship between two higher-level values, press freedom and LGBT freedom, and HIV infection with national data at the population level.

METHODS

Data were the number of persons living with HIV (PLWH, n = 35,468,911) for 148 countries during 2011-15, press freedom index (PFI) determined by the Reporters Without Borders, and LGBT freedom index (LGBT-FI) based on laws regulating same-sex relationships and expression. PLWH prevalence (1/1000), PFI and LGBT-FI were mapped first. Multiple regression was thus used to associate the logarithm of PLWH prevalence with PFI, LGBT-FI and PFI × LGBT-FI interaction, controlling for per capita GDP and weighted by population size.

RESULTS

Global prevalence of PLWH during 2011-15 was 0.51 per 1000 population. The prevalence showed a geographic pattern moving from high at the south and west ends of the world map to low at the north and east. Both PFI and LGBT-FI were positively associated with PLWH prevalence with a negative interaction between the two.

CONCLUSIONS

More people are infected with HIV in countries with higher press freedom and higher LGBT freedom. Furthermore, press freedom can attenuate the positive association between levels of LGBT freedom and risk of HIV infection. This study demonstrated the urgency for and provided data supporting further research to investigate potential cultural and socioecological mechanisms underpinning the complex relationship among press freedom, LGBT freedom and HIV infection, with data collected at the individual level.

Gender Differences in Sexual Behaviors in Korean Adolescents

PURPOSE

The purposes of this study were to identify whether there are gender differences in sexual behaviors among Korean adolescents and to explore the factors that influence safe sex practices across both sexes.

METHODS

A secondary analysis was conducted using nationally representative data obtained from the 2014 Youth Risk Behavior Web-based Survey. Sample consisted of 3,210 adolescents who had experience of sexual intercourse. The dependent variable in this study was practicing safe sex. The independent variables included a range of individual, family, and school factors.

RESULTS

Female adolescents were less likely to practice safe sex (i.e., always using a condom). Individual (smoking, no drinking before sexual intercourse), family (living with parents, higher allowance per week) and school factors (non-coeducational school students, had received school-based sex education) were significant predictors of practicing safe sex in males. In contrast, family (lower economic status) and school factors (middle school students) predicted practicing safe sex among female adolescents.

CONCLUSION

We demonstrated that gender plays an important role in the sexual behavior of adolescents. The findings of this study indicate a need to design and implement gender-specific interventions.

Modeling Beliefs, Attitudes, and Intentions of Condom Use Among Secondary School Students in Kenya

As in other parts of sub-Saharan Africa, youth in Kenya report low rates of condom use. Although several studies have explored reasons for the low condom use among Kenyan youth, not many have established linkages between lack of use and normative beliefs and attitudes around condoms. Using the Theory of Planned Behavior (TPB), this article examined whether beliefs and attitudes around condoms influenced intentions and actual condom use. Data for the study were restricted to 1453 sexually active youth during the last school break. Path analysis was used to examine the relationship between the TPB constructs and condom use among Kenyan youth. Results indicated a direct relationship between attitudes and condom use for male respondents and an indirect relationship between these two variables for females. Both males and females who expressed greater intentions to use condoms were significantly more likely to report they used condoms consistently. Also, male and female youth with higher perceived behavioral control were significantly more likely to have used condoms consistently. Males with friends who used condoms were significantly more likely to use condoms consistently. The findings suggest the importance of examining young people's attitudes toward condoms-in particular, those deeply rooted in misconceptions that serve to discourage safer sexual behaviors.

Substance Use and HIV Risk Among Men Who Have Sex With Men in Africa: A Systematic Review

BACKGROUND

Substance use and its relation to HIV risk among men who have sex in Africa, a population at high risk for HIV, has received little attention.

METHODS

This systematic review summarizes and discusses findings from 68 empirical studies, published between 1980 and 2016 that included data about substance use in men who have sex with men (MSM) in Africa.

RESULTS

Substance use has rarely been the primary focus of studies in African MSM. In general, measurement of substance use was suboptimal. Whereas prevalence of alcohol use varied across studies, partly resulting from variety in assessment strategies, it seemed higher than in the general male population across countries. Alcohol use was associated with sexual risk practices, but not with HIV infection. The most frequently reported drug used by African MSM was cannabis. The use of other drugs, such as cocaine and heroin seemed relatively rare, although injection drug use was exceptionally high in a few studies. As alcohol, drugs were regularly used in conjunction with sex. Both alcohol and drug use were often associated with other risk factors for HIV infection, including violence and transactional sex. No interventions were found addressing substance use among African MSM.

CONCLUSIONS

Given high HIV risk and prevalence in this population, substance use should be studied more in-depth, taking into account the specific social and cultural context. Assessment of substance use practices in this population has to be improved. The available information suggests, though, that there is an urgent need for interventions addressing substance use tailored to the needs of this critical population.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

Condomless sex and HIV transmission among serodifferent couples: current evidence and recommendations

Human immunodeficiency virus (HIV) infection remains a global pandemic. The primary driver of HIV incidence is sexual transmission between serodifferent individuals. Condoms, when used consistently and correctly, are effective at preventing sexually transmitted HIV infections and are considered an integral component of a comprehensive approach to HIV prevention. However, the demonstrated effectiveness of antiretroviral therapy (ART) to prevent HIV transmission, known as treatment as prevention and of pre-exposure prophylaxis, have raised an intriguing dilemma on the necessity and additive preventive benefit of condom use among individuals in serodifferent relationships utilizing these prevention strategies. Recent published evidence, although of limited follow-up duration, has shown no linked HIV transmissions with condomless sex among serodifferent couples where the infected partner was on ART and virologically suppressed. This paper will review the evidence surrounding HIV transmission risk among serodifferent couples with and without the use of condoms and will highlight factors that increase or attenuate this risk. It will also address the important benefits that condomless sex offers couples. This paper aims to provide a template for providers to have personalized discussions with their patients, particularly those with an HIV-positive sexual partner, around their individual risk of HIV transmission and the role of condom use.

Acting within an increasingly confined space: A qualitative study of sexual behaviours and healthcare needs among men who have sex with men in a provincial Tanzanian city

Objective

To explore risk perceptions, sexual practices and healthcare needs among men who have sex with men in the provincial city of Tanga in northern Tanzania. Previous research suggests that HIV/STIs are increasing problems for this population. Yet, few studies have been conducted outside the urban area of Dar es Salaam, which has limited our knowledge about the HIV/STI risk factors and healthcare needs among men who have sex with men who live outside major metropolitan areas.

Method

During three months in 2013, 10 in-depth interviews with men who have sex with men were conducted in Tanga. Data were interpreted through qualitative content analysis.

Results

The theme that emerged was labelled “Acting within an increasingly confined space”. The theme reflects the interference of stigma in men’s lives, and in the face of potential discrimination, men perceived their sexual and healthcare choices as limited. This created obstacles for forming romantic and sexual relationships, insisting on consistent condom use with sexual partners, maintaining open and conducive relationships with family, and accessing healthcare services when required.

Conclusions

Sexual stigma is a concern as it contributes to HIV/STI risk-related behaviours among men who have sex with men. Priority should be given to programmes that support same-sex practicing men in their efforts to make informed choices regarding their sexual health. Creating safe cyber networks provides an opportunity to reach this population with targeted sexual health education messages. Such programmes might be even more urgent in smaller towns and rural areas where gay specific initiatives are more limited than in urban areas.

"When they know that you are a sex worker, you will be the last person to be treated": Perceptions and experiences of female sex workers in accessing HIV services in Uganda

Background

HIV prevalence among female sex workers (FSWs) in high burden countries in sub-Saharan Africa varies between 24 and 72%, however their access to HIV services remains limited. This study explored FSWs’ perspectives of the barriers and opportunities to HIV service access in Uganda.

Methods

The cross-sectional qualitative study was conducted between October and December 2013. Twenty-four focus group discussions were conducted with 190 FSWs in 12 districts. Data were analysed using manifest content analysis, using Atlas.ti software, based on the socio-ecological model.

Results

FSWs indicated that HIV services were available and these included condoms, HIV testing and treatment, and management of sexually transmitted infections. However, access to HIV services was affected by several individual, societal, structural, and policy related barriers. Individual level factors included limited awareness of some prevention services, fears, and misconceptions while societal stigma was prominent. Structural and policy level barriers included inconvenient hours of operation of the clinics, inflexible facility based distribution of condoms, interuptions in the supply of condoms and other commodities, and limited package of services with virtually no access to lubricants, HIV pre- and post-exposure prophylaxis, and support following client perpetrated violence. Policies such as partner testing and involvement at antenatal care, and using only one facility for antiretroviral drug refills hindered HIV service uptake and retention in care. FSWs had major concerns with the quality of services especially discrimination and rude remarks from providers, denial or delay of services, and potential for breach of confidentiality. However, some FSWs reported positive experiences including interface with friendly providers and participated in formal and informal FSW groups, which supported them to access health services.

Conclusion

Despite availability of services, FSWs faced major challenges in access to services. Comprehensive multilevel interventions targeting individual, societal, structural and policy level barriers are required to increase access to HIVservices among FSWs in Uganda. Policy and institutional adjustments should emphasize quality friendly services and expanding the package of services to meet the needs of FSWs.

Breakage is the norm: use of condoms and lubrication in anal sex among Black South African men who have sex with men

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men's subjectivities - their perceptions of and preferences for specific brands, types and flavours of condoms and lubricants - influenced engagement with such safer-sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer-sex supplies, health services and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

"If You Tell People That You Had Sex with a Fellow Man, It Is Hard to Be Helped and Treated": Barriers and Opportunities for Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda

BACKGROUND

Despite the high HIV prevalence among men who have sex with men (MSM) in sub-Saharan Africa, little is known about their access to HIV services. This study assessed barriers and opportunities for expanding access to HIV services among MSM in Uganda.

METHODS

In October-December 2013, a cross-sectional qualitative study was conducted in 12 districts of Uganda. Semi-structured in-depth interviews were conducted with 85 self-identified MSM by snowball sampling and 61 key informants including HIV service providers and policy makers. Data were analysed using manifest content analysis and Atlas.ti software.

RESULTS

Three quarters of the MSM (n = 62, 72.9%) were not comfortable disclosing their sexual orientation to providers and 69 (81.1%) felt providers did not respect MSM. Half (n = 44, 51.8%) experienced difficulties in accessing health services. Nine major barriers to access were identified, including: (i) unwelcoming provider behaviours; (ii) limited provider skills and knowledge; (iii) negative community perceptions towards MSM; (iv) fear of being exposed as MSM; (v) limited access to MSM-specific services; (vi) high mobility of MSM, (vii) lack of guidelines on MSM health services; viii) a harsh legal environment; and ix) HIV related stigma. Two-thirds (n = 56, 66%) participated in MSM social networks and 86% of these (48) received support from the networks to overcome barriers to accessing services.

CONCLUSIONS

Negative perceptions among providers and the community present barriers to service access among MSM. Guidelines, provider skills building and use of social networks for mobilization and service delivery could expand access to HIV services among MSM in Uganda.