Background: Studies in sub-Saharan Africa (SSA) among men who have sex with men and transgender women (MSM&TW) have primarily focused on the epidemiology of HIV infection. However, little is known about important behavioral variations within this population, despite the critical role it plays in the ongoing general epidemic. We set out to identify personal, interpersonal and contextual characteristics of MSM&TW in SSA, who engage in sex with both men and women versus those who only have sex with men.
Methods: Four sites (Kisumu, Kenya; Blantyre, Malawi; Cape Town and Soweto, South Africa) enrolled a total of 401 adult MSM&TW. Psychosocial and behavioral data were collected using a structured questionnaire. Participants who had sex with both men and women (PSMW) were compared with those who only had sex with men (PSMO). For this analysis, data from the enrollment visit were available for 387 participants. For all reported differences: P<.05.
Results: Overall, 21.7% (84/387) of the MSM&TW reported having had sex with both men and women in the preceding three months. PSMW were more likely to be married (17.9% vs. 4.0 %) have children (46.4% versus 15.5%), identify as bisexual (64.3% versus 30.0%), and less likely to identify as female or transgender (9.6% versus 23.3%). Compared to PSMO, PSMW were on average older (26.0 versus 23.8 years) and more likely to be from Blantyre (43.3%) and less likely from Cape Town and Soweto (7.5% and 7.1%). PSMO had on average more lifetime sexual partners but few sexual partners in the previous three months than PSMW (7.3 versus 5.3 and 1.8 versus 2.3, respectively). Furthermore, PSMW were more likely to prefer to be the insertive partner in anal sex (75.0% versus 33.3%) respectively. Finally, PSMW were less likely to test HIV positive (10.7% versus 19.8%).
Conclusions: Our findings demonstrate that there is a substantial proportion of sub-Saharan African MSM&TW who recently have engaged in sex with both men and women. We also found significant differences in sexual behavior and risk factors that may place these populations at risk for HIV infection. In-depth understanding of their practices presents an opportunity for developing targeted public health interventions.