Background
Few assessments of associations between structural-level factors and HIV among gay
men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan
Africa. Our objective was to examine HIV testing history, HIV status, and stigmas
among MSM living in ten countries with heterogeneous legal environments.
Methods
This study used pooled data from ten country-specific, cross-sectional studies done
in 25 sites in Burkina Faso, Cameroon, Côte d’Ivoire, The Gambia, Guinea-Bissau, Nigeria,
Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling
and were eligible if they met country-specific requirements for age, area of residence,
and self reported being assigned male sex at birth and having anal sex with a man
in the past 12 months. Policy related to same-sex sexual behaviour for each country
was categorised as not criminalised or criminalised. Countries were also categorised
on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal
barriers were defined as those that legally prevented registration or operation of
sexual orientation related civil society organisations (CSOs). Individual data on
HIV testing history, HIV status, and stigma were collected via interviewer-administered
sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with
random intercepts was used to assess the association between policies, recent prosecutions,
legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and
95% CIs.
Findings
Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of
23 years (IQR 21–27). 4886 (60·7%) lived in countries that criminalise same-sex sexual
acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised
settings (aOR 5·15, 95% CI 1·12–23·57); higher in settings with recent prosecutions
than in settings without prosecutions (12·06, 7·19–20·25); and higher in settings
with barriers to CSOs than without barriers to CSOs (9·83, 2·00–48·30). HIV testing
or status awareness was not associated with punitive policies or practices. Stigma
was associated with HIV status but did not consistently vary across legal environments.
Disparities in HIV prevalence between MSM and other adult men were highest in punitive
settings.
Interpretation
Structural risks including discriminatory country-level policies, prosecutions, and
legal barriers might contribute to higher HIV prevalence among MSM. Taken together,
these data highlight the importance of decriminalisation and decreasing enforcement,
alongside stigma reduction, as central to effective control for HIV.
Funding
National Institutes of Health.
Translation
For the French translation of the abstract see Supplementary Materials section.
