This study explored HIV risk behavior among men who have sex with men (MSM) in Kigali, Rwanda. It found high rates of unprotected sex, multiple partners, and transactional sex. Over 70% of participants reported casual male partners and rates of condom use were low. Many MSM engaged in commercial sex or exchanged sex for goods. Based on these risks, the study recommends improved HIV services for MSM, including dedicated clinics, increased availability of condoms and lubricants, and awareness campaigns to address stigma.

1. Andrew Koleros, MEASURE Evaluation, Rwanda Dr. Agnes Binagwaho, MOH, Rwanda Dr. Jenifer Chapman, MEASURE Evaluation, USA Elisabetta Pegurri, UNAIDS, Rwanda Yves Utazirubanda, MEASURE Evaluation, Rwanda Rose Gahire, AIDS Healthcare Foundation, Rwanda High HIV risk behavior among men who have sex with men (MSM) in Kigali, Rwanda

2. Background African MSM are 4x more likely to be infected than the general population In other African countries, HIV prevalence found to be up to 43% among men reporting sex with other men exclusively (Kenya) Little comparable data on condom use and numbers/types of partners in Africa, although there is a clear trend in the data of: high prevalence of bisexual behavior; low rates of condom use for anal and vaginal sex; and high levels of commercial sex between men

3. Study Design, Aim & Objectives Design: Exploratory study with a convenience snowball sample, with peer recruitment Aim: to describe the population of MSM in Kigali and explore the nature of sexual activity between MSM Objectives: To obtain exploratory data on types of sexual partnerships, condom use in those types of partnerships, STI symptom and diagnostic history, HIV testing history To determine men’s attitudes regarding a number of possible HIV prevention strategies for MSM To explore the feasibility of a more comprehensive Bio-BSS-type study of MSM nationally

4. Sampling Sampling method: Snowball sampling involving peer recruiters Sample size: 99 participants Inclusion criteria: consenting men meeting the operational definition of MSM who are currently resident in Kigali and 18 years or over Definition of MSM: A biological man reporting at least one of the following behaviors in the last 12 months : insertive oral sex with another man; and/or receptive oral sex with another man; and/or insertive anal sex with another man; and/or receptive anal sex with another man.

5. Recruitment Snowball sampling strategy involving peer recruiters 10 peer recruiters or “seeds”, diverse in terms of age, educational attainment, income range and behavior Seeds provided contacts with study information verbally & an invitation slip with Study Coordinator’s contact details Invitation slip did not contain any sensitive text, i.e. no reference to MSM or sexual health/HIV Recruiters received an incentive per new recruit completing the questionnaire.

6. Study management team MSM Study Coordinator MSM (seed) MSM (seed)… MSM recruit MSM recruit MSM recruit MSM recruit Summary of recruitment strategy MSM recruit MSM recruit MSM recruit MSM recruit Wave 1 Wave 2

7. Data collection procedures Recruits initiated contact with Study Coordinator by phone Study Coordinator conducted pre-screening & set up an interview Interviews were carried out in one of two locations: Study site (restricted zone within a public venue), OR Meeting place proposed by recruit Interviewer administered the survey in recruits’ chosen language: 68% of interviews in Kinyarwanda 32% of interviews in French No English interviews

8. Ethics Designed to maximize respondent confidentiality (No names or other identifying information were collected ) , safety and comfort In line with international best practice in research governance Approval from Rwanda National Ethics Committee and US IRB

9. Key Results

10. Age & Education Age : Range of 18 to 52 years; Average age was 26

11. Self-described sexuality (N=94)

12. Number of male partners in last 12 months Number of male sex partners 8% reported no male partners 29% reported no casual male partners 21% reported one male partner (boyfriend) 30% reported 1-2 casual male partners 71% reported at least one casual male partner 26% reported 3-5 male partners 15% reported >5 male partners

13. Sexual mobility Reported anal sex with another man in the last 12 months, by location (N=88) 0% 20% 40% 60% 80% 100% Kigali Gisenyi Butare Another place in Rwanda Another country No Yes

14. Commercial & transactional sex (selling) Table 12: Reported commercial / transactional sex (selling) Ever Last 12 months Exchanged oral and/or anal sex for both money and goods 10 8 Exchanged oral and/or anal sex for money only 12 10 Exchanged oral and/or anal sex for goods only 8 7 TOTAL 30 25

15. Commercial & transactional sex (buying) Ever Last 12 months Exchanged both money and goods for oral and/or anal sex 6 4 (3 anal sex) Exchanged money only for oral and/or anal sex 12 11 (9 anal sex) Exchanged goods only for oral and/or anal sex only 6 5 (4 anal sex) TOTAL 24 20

16. Sexual relationships with women 41% reported previous sex with a woman (N=98) 26% reported sex with a woman in the last 12 months (N=98) 36% reported giving women money, clothes, favors or other items of value in exchange for sex in the last 12 months (N=39)

17. Reported condom use Reported condom use at last sex, by partner type Type of partner n % TOTAL Last sex with boyfriend 23 50% 46 Last casual male partner (among those reporting a boyfriend) 8 n/a 15 Last casual male partner (among those not reporting a boyfriend) 23 55% 42 Last commercial male partner (selling) 10 55% 18 Last transactional male partner (selling) 6 n/a 14 Last commercial male partner (buying) 7 n/a 11 Last transactional male partner (buying) 5 n/a 7 Last female partner 16 64% 25

18. HIV Services needed in Kigali Services needed in Kigali Respondents citing this (multiple responses possible) N = 91 % Dedicated, confidential health clinic for MSM 46 51% Improved availability of condoms designed for anal sex 33 36% Improved availability of lubricants for anal sex 35 39% HIV/AIDS stigma reduction campaigns 28 31% Awareness-raising 16 18% Counseling for MSM 6 6.6% MSM associations / mobilization 4 4.4% Other 11 N/A

19. Conclusions & recommendations Conclusions Results suggest that MSM in Kigali are at elevated risk for HIV infection compared to the general population MSM in Kigali require specific HIV/STI prevention services and support Recommendations Conduct HIV/STI sero-surveillance Seek a better understanding of informal/formal male sex industry, and sexual networks of MSM Support HIV/STI awareness-raising, specifically about transmission through anal sex Improve availability of condoms and lubricants Sensitize medical personnel to MSM issues