Determinants of HIV Risk Behaviors among MSM in Kigali, Rwanda

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Determinants of HIV Risk Behaviors among MSM in Kigali, Rwanda

  1. 1. Determinants of HIV Risk Behaviors among MSM in Kigali, Rwanda A Asiimwe1; J Chapman2; C Basomingera2; S Kiragu3; K. Kirota2; and A Koleros2 1) Rwanda Biomedical Center / Institute of HIV, Other Disease Prevention and Control, Kigali, Rwanda; 2) Futures Group / MEASURE Evaluation; 3) UNAIDS, RwandaIntroduction These experiences were strongly associated with poverty and lack of economic opportunities; participants reported limited ability to negotiate condom use with their paying partners.Internationally, men who have sex with men (MSM) have been identified as a high-risk group “It’s obvious that when he has given you money, you have agreed everything that he will do and it’sfor HIV acquisition. Studies of MSM in Africa have documented high rates of previous and like a professional business. He may penetrate wherever he wants.” (ID 10.11.17.DA.11, aged 25,current high risk sexual behaviors (1, 2). Rwanda’s 2009 HIV/AIDS strategic plan included secondary school education)a focus on MSM, following important findings that MSM in Kigali exhibited high-risksexual behaviors such as relatively high numbers of male and female partners in both casual Participants had realistic assessments of risk; risk perception influenced behavior. Thoughand commercial sexual partnerships, low condom use during both anal and vaginal sex, many participants received some HIV education, many possessed low knowledge of availableand high mobility (3). However, Rwanda still lacked key information on the determinants HIV services including the provision of antiretroviral therapy (ART), cited as a barrier to HIVand drivers of risk behaviors in the community or potential mitigation strategies, limiting testing. Participants also desired better access to condoms and lubricants.our understanding of the most effective programming mix to support this group. To help “It’s because most people believe that condom use is for sex between boys and girls…that’s why youstrengthen Rwanda’s evidence base for effective MSM programs, we undertook this qualitative find…for men to men, many people haven’t known much about condom use.” (ID 10.11.24.AM.17,study to describe the contextual determinants of HIV sexual risk behavior, health-seeking aged 21, secondary school education)behavior, and the desirability and acceptability of HIV services. “I have been educated a lot but I was not interested as they were talking about heterosexuals.” (ID 10.11.18.AH.12, aged 24, university student)Process “The first obstacle to going for HIV test is that, for us who are still younger, we say if I were to testThis qualitative study involved face-to-face semi-structured interviews and focus group positive, what would happen next? I may lose hope and die sooner. So, you decide not to.” (IDdiscussions (FGD). We utilized a snowball sampling methodology and MSM peer data 10.11.10.JH06, aged 23, secondary school education)collectors. The recruitment and sampling strategy is presented below in Figure 1.Figure 1: Sampling and Recruitment of Peer Interviewers and ConclusionsParticipants Figure 1. Sampling and Recruitment of Peer Interviewers & Participants • There is an association between trust and condom use in the MSM community and a 2 MSM participate in Study management team perception exists that condoms are for commercial and transactional partners, and not for regular, romantic partners. HIV prevention messages targeting the MSM population Initial MSM Peer Leaders should emphasize condom use as an effective HIV prevention tool in any type of Final MSM Final MSM partnership. Peer Leaders Peer Leaders • Participant accounts suggest that there are no specific geographical zones where MSM MSM MSM MSM participant MSM participant frequent or congregate to meet new sexual partners, but rather they tend to organize participant participant gatherings through existing networks of MSM where friends come together and bring MSM MSM MSM MSM participant participant new friends into the circle. Targeting social networks of MSM in Kigali may be an participant participant effective strategy to reach them with HIV prevention services and commodities. • Many participants implied that when alcohol is involved, if condoms are out of sight,Peer interviewers conducted interviews and FGD with 28 MSM. Analysis was a multi-stage they are out of mind. HIV program planners and managers should ensure that condomsprocess involving the MSM community (4, 5). A management committee, including MSM, are available at locations where alcohol is associated with meeting new sexual partners,designed and oversaw this study. Rwandan and U.S. ethics review boards approved this study. particularly in bars, hotels, and night clubs. Current efforts linking condom promotion campaigns and points of sale where alcohol is sold and consumed should be continued. • Many participants shared false beliefs and misconceptions about the availability andResults existence of some key HIV services. Current efforts to sensitize healthcare workers for the delivery of MSM-friendly services should be continued and scaled-up, focusing on healthTwenty-eight men aged 18–38 participated in interviews and 15 participated in FGD, education. Equally, outreach efforts should better target general HIV education and theincluding three married men and six sex workers. About half of the participants self-identified promotion of the use of health services.as homosexual at the time of interview. Regular alcohol use was a norm among participantsand contributed to decisions not to use condoms. Acknowledgments “I actually forgot; I was drunk. I was drunk and it just happened. When I am drunk I use condoms less.” (ID 10.11.10.JH.04, aged 19, secondary school education) The study was led by the Rwanda Biomedical Center’s Institute of HIV, Disease Prevention, and Control (RBC/IHDPC), with technical assistance from MEASURE Evaluation andTrust in sexual partners is a key issue, particularly in relation to condom use. financial assistance from the United Nations Joint Programme on HIV/AIDS and U.S. “Yeah I wanted to use a condom in that case because I was not romantically involved, so I wanted to Agency for International Development. This project would not have been possible without use a condom” (ID 10.11.10.JH.04, aged 19, secondary school education) the dedication and commitment of our study staff and MSM peer researchers, whose respect for the rights of MSM in Rwanda is commendable. Finally, we give our sincere thanksParticipants were members of tight social networks. to study respondents for their generosity and honesty in answering our questions and for “If you know three or four people, you go together in a bar, you drink…if you are five who agree with sharing their unique experiences with us. their sexual identity, and at least each of you knows other two people. They will call them as well and it becomes a big network.” (ID 11.01.31.HC.30, aged 30, university) ReferencesMany men reported shared and in some cases learned sexual behavior among network 1. Baral, S., Trapence, G., Motimedi, F., et al. (2009). HIV prevalence, risks for HIVmembers. infection, and human rights among men who have sex with men (MSM) in Malawi, “I do it because I learned from friends two years ago. [I] started doing it for free and my friends started Namibia, and Botswana. PLoS One, 4, e4997. telling me that people who do it should be paying me at least some thousands [Rwandan francs]. And 2. Smith, A.D., Tapsoba, P., Peshu, N., Sanders, E.J., Jaffe, H.W. (2009). Men who have sex I got used to it progressively and now, I ask for money.” (ID 11.01.05.BM.23, aged 20, secondary school with men and HIV/AIDS in sub-Saharan Africa. The Lancet, 374, 416–22. education) 3. Chapman, J., Koleros, A., Delmont, Y., Pegurri, E., Gahire, R., Binagwaho, A. (2011). High HIV risk behavior among men who have sex with men in Kigali, Rwanda: makingCommercial and transactional sex characterized most young men’s first homosexual the case for supportive prevention policy. AIDS Care, 24 January 2011 (iFirst).encounter, and participants commonly cited sharing paying sexual partners within social 4. Ritchie, J., Spencer, L. (1994). Qualitative Data Analysis for Applied Policy Research, innetworks. A. Bryman and R. Burgess (eds) Analyzing Qualitative Data, pp. 173–94. London: SAGE. “I can give him the phone number of one of our friends or even more than one or even three 5. Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide through Qualitative depending on what he needs.” (ID 10.11.10.HH.04, a ged 19, secondary school education) Analysis. London: SAGE.This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through theUnited States Agency for International Development (USAID) under the terms of MEASURE Evaluationcooperative agreement GHA-A-00-08-00003-00. Views expressed are not necessarily those of PEPFAR,USAID, or the United States government. July 2012. Evaluation

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