Background: Most men who have sex with men (MSM) in Nigeria are said to engage in high-risk sexual practices. This study aims to highlight these risk practices and proffer probable control solutions. Materials and Methods: A descriptive cross-sectional design and a purposive sampling method were used to interview 101 MSM linked to a clandestine network in a city suburb in Port Harcourt in October 2014. Data was analyzed using SPSS version 21.0. Univariate analysis was done to establish associated risk factors. Confidence limit was set at P = 0.05. Results: The age of study participants ranged between 18 and 45 years (mean = 25.35 years). The majority, 88 (87.1%) were single, had tertiary education and bisexuals, 85 (84.2%). Most, 62 (61.4%) reported to have between two and five sexual partners, while only 57 (53.4%) used condoms consistently with casual partners. All participants have heard about HIV, but only 70 (69.3%) had ever tested for HIV, while only 25 (28.1%) knew the HIV status of their sex partners. In the last 6 months preceding the study, 62 (61.4%) had insertive anal intercourse, while 57 (54.4%) had receptive anal intercourse. Also, 42 (41.6%) and 20 (19.8%), respectively, admitted to regular alcohol and Indian hemp use before sex. Finally, 70 (69.3%) used the internet in search of sex partners. Conclusions: MSM in Port Harcourt city engage in high-risk sexual practices. Emphasis on condom programming and promotion of pre-exposure prophylaxis in the National antiretroviral program might be useful in curbing the HIV epidemic among MSM.
Keywords: Men who have sex with men, Nigeria, Port Harcourt, Sexual risk
Sub-Saharan Africa still remains the most severely affected the region with HIV, with about 1 in every 20 adults living with the virus, thus accounting for about 71% of the people living with HIV/AIDS globally. The United Nations Programme on AIDS (UNAIDS) and the World Health Organization (WHO) identified four populations that are most at risk of HIV/AIDS to be sex workers, clients of sex workers, people who inject drugs, and men who have sex with men. These sub-populations continue to bear the high burden of HIV and are an important target for interventions in many countries. In sub-Saharan Africa, however, where the most devastating HIV epidemics have been recorded, most HIV health programs have not included men who have sex with men (MSM). Rather, while the global incidence of HIV infection is generally on a gradual decline, the epidemic is “gaining recognition” in middle and low-income countries, among “men who have sex with men.”
The term “Men who have sex with men” describes a behavior rather than a specific group of people. It includes self-identified gay, bisexual, or heterosexual men, men who do not consider themselves gay or bisexual but have had sex with men. Men who have sex with men remain the most HIV-infected and affected group in many parts of the world and the infection rates among MSM are substantially higher than those of the general population. In a review of low and middle-income countries, Baral and colleagues also found that the odds of living with HIV infection are significantly and consistently higher among MSM than in adults of reproductive age in the general population across Asia, Africa, the Americas, and the former Soviet Union. Furthermore, MSM were 19.3 times more likely to be infected with HIV compared with the general population; MSM in low-income countries were 7.8 times more likely to be living with HIV, while MSM in middle-income countries were 23.4 times at risk; but the higher the population prevalence the more the prevalence in the MSM population equals that of the population. Similarly, two meta-analytic studies in China reported that HIV prevalence among MSM was 5.3% and 6.5% in 2011 and 2014, respectively, which was more than 90 times higher compared to the general population prevalence., The transmission rate of the virus among men who have sex with men and people who inject drugs remains high due to poor intervention coverage, strict policies, and stringent laws and enforcement practices. The HIV prevalence rate for Nigeria is currently estimated at 3.2% and MSM accounts for an unknown proportion of new HIV infections.
However, Vu et al. reported that HIV prevalence among MSM in some select cities was 4–10 times higher than that of the general population. Similarly, Adebajo et al. documented a larger population of MSM sex workers in some Nigerian cities where there was higher HIV prevalence among MSM compared to the general population. Studies carried out on risk behaviors of MSM in Nigeria agree with the findings of other research on MSM populations globally with similar peculiarities. Reports from Nigeria indicate that particular behaviors of MSM in Nigeria include high mobility, multiple sexual partners, and frequent unprotected anal and vaginal intercourse. In addition, bisexual behavior, not been tested for HIV, transactional sex, and internalized homophobia have also been identified as common behavioral characteristics among MSM in the country.,,
Most of the MSM also have homosexual orientation, while maintaining a heterosexual public identity. This bisexual disposition serves as a bridge of transmission to the rest of the population.
Furthermore, the criminalization of MSM as it is in Nigeria has the tendency to drive the MSM network further underground, making the HIV epidemic in Nigeria more challenging to contain. The use of online social MSM networks is also on the increase and has been associated with increased HIV infection., A comprehensive study is needed to ascertain the peculiarities of sexual risk practices among MSM in localized settings that could be generalized. It is against this background that the study was conducted to describe the HIV-related risk practices of a cohort of MSM in Port Harcourt city, Nigeria, challenges with control efforts and probable solutions among this vulnerable population group, in the face of criminalization of the same sex sexual relationships by law in Nigeria.
The study was carried out in Port Harcourt, a port city and the capital city of Rivers State in southern Nigeria. The city lies along the Bonny River (an eastern tributary of the Niger river), 41 miles (66 km) upstream from the Gulf of Guinea. According to the Nigerian census of 2006, Port Harcourt city has a population of 1,382,592. Port Harcourt is a cosmopolitan city and one of the centres of commerce and industry in Nigeria. It is the hub of the oil and gas industry in Nigeria in addition to hosting several other industrial concerns. It also harbours a number of secondary and tertiary educational institutions. There are also several health care service points in the city, essentially based on fee-for-services rendered. HIV/AIDS prevention and control in the city is coordinated by the State Agency for the Control of AIDS (RivSACA) set up by the Rivers State government to respond to the HIV/AIDS epidemic in the state. Rivers State has one of the highest prevalence of HIV/AIDS in Nigeria with a seroprevalence rate of 15.2%. This agency is responsible for the advocacy, information, education, and communication of all aspects of HIV/AIDS as well as support to treatment centres in the state.
The term “Men who have sex with men (MSM)” in this study, refers to gay, bisexual, or heterosexual men, and men who do not consider themselves gay or bisexual but have had sex with men in the last 12 months. They include biologically male, age ≥16 years, who had anal and/or oral sex with a biological male in the past 12 months. It also included those with the ability to answer screening questions to verify knowledge of MSM sexual behavior and willing to provide informed consent. While those who did not understand the English language in the absence capable interpreters, were excluded.
Study design and sampling method
The study focused on self-identified MSM living within the Port Harcourt metropolis. It was carried out in October, 2014 and employed a descriptive cross-sectional design. A purposive sampling method was used to recruit respondents linked to a clandestine network of MSM located in a suburb Port Harcourt metropolis. Peer referral and venue-based sampling were adopted for the study.
Sample size determination
The sample size for this study was calculated by means of EPI info statistical software version 7. Using a prevalence rate of 7.0%, a confidence interval of 95% and a confidence limit of 5%, a minimum sample size of 100 respondents was determined to be adequate.
A standardized self-administered questionnaire was used. The questionnaire was divided into four sections which are bio data, sexual orientation, safe sex practice, and other HIV risk factors. The data tool was pretested among a purposively selected cohort of MSM in another area of the Port Harcourt metropolis. The result of the pretest was used to standardize the tool prior to the commencement of data collection.
Data entry and analysis were done using SPSS version 21.0. Univariate analysis was done to establish sociodemographic variables, prevalence, and associated risk factors. Confidence limit was set at P = 0.05.
Ethical approval was obtained from the Ethics Committee of the University of Port Harcourt. Written Informed consent was obtained from all subjects. Due to the sensitive nature of the study, special precautions were taken when conducting the study to maximize the safety and confidentiality of participants. Names of participants were not recorded; rather participants were coded and used instead in order to conceal the identities. The subjects were free to leave the study at any time without any sanctions.
Sociodemographics characteristics of study participants
A total of 101 MSM participated in this study. Their ages ranged from 18 years to 45 years, but about 62% were 25 years and below. Their mean age was 25.35 (±6.046). Those with tertiary level of education constituted the highest population 44 (43%), while those with primary education the least three (3%). The majority, 58 (57.4%) were students, followed by professionals 33 (32.7%). Majority of them, 75 (74.2%) earned about N20, 000 ($100) or below monthly [Table 1].
Only 13 (12.9%) of the participants were married, while 88 (87.1%) were not. On sexual orientation, 10 (9.9%) were self-identified as gay, 85 (84.2%) as bisexuals, while three (3.0%) as heterosexuals, and three (3.0%) as transgender. A third, 33 (33.7%) had not disclosed their sexual orientation to anybody, while 46 (45.5%) had disclosed to their friends. In all, 57 (56.4%) had had sex with women in the past 6 months, while 83 (82.2%) had had sex with men over the same period. The mean age at sexual induction was 16.29 (±4.495), but 21 (20.8%) had had sex before the age of 12 years. The mean age at first sex with a male was 17.86 (±5.096) [Table 2].
HIV risk behaviors
Only 32 (31.7%) of the respondents reported condom use at first anal sex. However, 92 (91.1%) said that they had ever used a condom with a sex partner, but only 57 (53.4%) used condoms always, while 34 (33.7%) used it occasionally. Furthermore, 54 (53.5%) reported having had sex without a condom in the last 6 months. In all, 62 (61.4%) of the respondents reported to have between 2 and 5 sexual partners, 14 (13.9%) reported between 5 and 10 partners [Table 3].
HIV-related knowledge and prevention practice
All the participants reported having heard about HIV, but only 56 (55.4%) identified condom as a prevention tool, while 25 (24.8%) mentioned abstinence, and 23 (22.8%) identified having a single partner as a preventive measure. Overall, 70 (69.3%) had ever tested for HIV, 45 (64.3%) of those tested in the last 6 months, while 25 (37.5%) tested more than 6 months ago. Nevertheless, only 25 (28.1%) knew the HIV status of their sex partners, while only 13 (22.0%) had disclosed their HIV status to their partners. Also, 14 (13.9%) disclosed that they had HIV-positive partners.
HIV risk factors
Fifty (49.5%) had ever paid for anal sex, while 46 (45.5%) had ever been paid for sex. Only 18 (17.8%) admitted ever been forced to have anal sex, while 15 (14.9%) have experienced physical violence. A total of 42 (41.6%) admitted to regular alcohol use, while 20 (19.8%) reported the use of Indian hemp. However, 32 (31.7%) participants denied the indulgence in the use of any form of illicit substances. When asked if they used the internet to search for sexual partners, 70 (69.3%) admitted, 32 (45.7%) had gotten between 1 and 5 sexual partners, 9 (12%) had gotten between 6 and 10 partners, while 18 (25.7 %) had gotten more than 10 partners. Overall, 62 (61.4%) had insertive anal intercourse in the last 6 months, while 57 (54.4%) had receptive anal intercourse.[Table 4] and [Table 5].
Most of the study participants were young MSM with an average age of 25.4 years. They were predominantly students of tertiary institutions. According to the UNAIDS, young men who have sex with men (YMSM) are notably exposed to higher risk of sexually transmitted infections, including HIV/AIDS if preventive measures were ignored. This might be associated with their higher risk taking tendencies, which include a higher number of sexual partners, lower condom use rate, and substance abuse, etc., all of which were found among our study population. It also probably explains why young people are at the centre of sexually transmitted infections and the HIV epidemic in Nigeria with attendant consequences for the country’s educational system, productivity, and overall economic wellbeing.
The study further revealed a high prevalence of alcohol use as well as soaring transactional sex among the respondents and this calls for serious concern. High alcohol intake has been linked with unprotected male anal sex, bisexual personality, more male sex partners, and drug use., This is because high alcohol or drug intake is known to alter an individual’s sense of judgment that may incline them toward sexual risk practices, like ignoring the use of condoms, or multiple unprotected sexual exposures, with dare consequences for sexually transmitted infections., This is important in the sense that condom use rate was low among nearly two-thirds of the respondents. There were also significant concerns that over half of the MSM were involved in receptive anal intercourse with its acknowledged consequences in the speed and spread of dual-variant and multiple-variant HIV infections than among heterosexuals in the same population. This is because an unprotected receptive anal intercourse has a probability to increase the risk of HIV transmission by over 40% per act, approximately 18-fold higher than for vaginal intercourse. On the other hand, transactional sex measured in this study by paying for or being paid for anal sex, was acknowledged by nearly half of the respondents. The practice has severe implications for condom use in resource-limited settings, where the average income of MSM is less than $100 per month as was observed in this study. A similar finding was also reported in another setting in Nigeria by Adebajo et al. The result perhaps corroborates reports linking sexual risk taking in sub-Saharan Africa with poverty and poses a serious threat to HIV/AIDS control efforts among MSM in resource constrained environments., In West African countries, significant proportion of new HIV infections has been linked to sex workers, their clients, and clients’ regular partners. Nevertheless, it contradicts the rising body of evidence indicating increased risk of STIs and HIV among individuals with higher wealth indices in developing countries.
The majority of the study population, over 80%, identified themselves as bisexuals. This agrees with other studies from Nigeria and across Africa, which shows that the majority of MSM keep homosexual orientation, while maintaining a heterosexual identity in public., This position is also supported by Sheehy et al. whose study not only revealed that high levels of bisexual behavior existed among MSM in Nigeria, but that these men engage in risky sexual behaviors with both male and female sex partners alike. The bisexual disposition may serve as a bridge of transmission of sexual infections to the rest of the population, making the HIV epidemic more intractable to control. The situation becomes more disturbing when many of the MSM are keeping their personality discrete, even from sexual partners as was also reported by Ayoola et al. in Lagos, Nigeria. Although such occurs more often in countries like Nigeria, where moral and religious norms do not favor open disclosure of sexual orientation or where homosexual activities are prohibited by law. The outcome is that most MSM go into hiding, and resort to using clandestine hotspots to express themselves, as reported by Adebajo et al. This may also probably explain why many MSM now make use of the internet in search of sexual partners as found in this study and elsewhere in Malawi, Namibia, and Botswana. The increased outbreaks of sexually transmitted infections, including HIV among online and underground networks of MSM are well known and documented., However, this study did not reveal any significant association between an online search for sexual partners and having an STI or being HIV positive, even though the number of respondents reported to have ever had an STI was relatively high.
Other plausible reasons why MSM go into hiding might be attempts to avoid intolerance, stigmatization, and criminalization of their sexual orientation and acts. It will be recalled that in 2013, the Nigeria government passed a law: “Same-sex marriage (Prohibition) Act 2013,” criminalizing same-sex marriage, gay relationships, and associations, meetings or organizations, and prescribing various jail terms for culprits. The effect of this law might most likely damage Nigeria’s efforts to prevent the spread of HIV/AIDS, as it is likely to promote sexual risk behaviors, hinder access to prevention tools and treatment, and exacerbate the stigma and social inequalities that make people more vulnerable to HIV infection and illness.
Limitations of study
First, since same-sex sexual relationship is criminalized in Nigeria, it might have been uncomfortable for participants to speak up freely. Participants were however, assured of the protection of their identities and responses. Second, the study was also based on self-reports known to be prone to information bias. This was mitigated by a simplified questionnaire and adequate time for participants to respond to the questions.
MSM in Nigeria are engaged in substantial level of sexual risks, while constituting a bridge of transmission of HIV to the rest of the population. With the total absence of government support for prevention and control programmes for MSM, HIV prevention strategies like condom programming and promotion of pre-exposure prophylaxis can be beneficial to clandestine networks in curbing the severe epidemic of HIV among men who have sex with men.
We acknowledge the immense support Heartland Alliance, a non-governmental organization whose premises was used to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]