South Africa has a generalized HIV epidemic with an estimated HIV prevalence of 16.9% among adults 15 and older and 13.1% among men aged 15 and older . HIV transmission has been most commonly linked with high risk heterosexual and vertical transmission and consequently this is where the majority of HIV prevention efforts have been targeted. However, across the African continent, the sexual transmission of HIV between men has been increasingly recognized . HIV prevalence studies among men who have sex with men (MSM) have been completed in numerous countries in Southern and Eastern Africa including Malawi, Namibia, Botswana, Tanzania, Uganda, Kenya, and South Africa [3–5].
Notably, the initial presentation of the HIV epidemic in major urban centers of South Africa was among gay men and other MSM . A study of 250 MSM in Johannesburg in 1983 demonstrated an HIV prevalence of 12.8% with 35.6% infected with syphilis, and another 41.2% positive for Hepatitis B virus antibody . The last few years has seen a resurgence of studies focused on MSM, but there was limited epidemiologic research conducted in the interim three decades. In 2006, a study of rural South African men found that approximately 3.6% of men studied (n = 46/1277) reported a history of having had sex with another man . The adjusted odds ratio for prevalent HIV infections was 3.6 (95% CI 1.0-13.0, p = 0.05) for those reporting same sex practices . One of the first studies published that targeted MSM was completed using respondent driven sampling (RDS) by Lane et al. in Soweto, a peri-urban community south-west of Johannesburg, in 2008 [9, 10]. Among 378 MSM, the RDS-weighted HIV prevalence was 13.2% (95% CI 12.4-13.9) with independent associations of prevalent HIV infection being older than 25 (adjusted odds ratio (aOR) 3.8, 95% CI 3.2-4.6), reporting any unprotected receptive anal intercourse (aOR 4.4, 95% CI 3.5-5.7), and having between 6 and 9 male partners in preceding 6 months (aOR 5.7, 95% CI 4.0-8.2). In 2009, an HIV prevalence and risk assessment of 542 MSM attending lesbian, gay, and bisexual (LGBT) venues in urban Cape Town showed an HIV prevalence of 10.4% (56/539). Self-identifying as gay, homosexual, or queer (aOR 4.5, 95% CI 1.0-20.0), and reporting ever having had a sexually transmitted infection (STI) (aOR 4.3, 95% CI: 2.3-8.3) were significantly associated with testing HIV positive .
More recently published studies have demonstrated higher HIV prevalence rates including the Johannesburg/eThekwini Men's Study (JEMS) which demonstrated a HIV prevalence rate of 49.5% among 204 MSM in Johannesburg and 27.5% among 81 MSM in Durban . MSM in urban Cape Town also participated in the first multisite randomized controlled trial of antiviral chemoprophylaxis completed . While the HIV prevalence was higher than previous estimates, associations of infection were similar with self-reporting as gay or homosexual (aOR, 8.4; 95% CI, 3.7-19), receptive unprotected anal intercourse (aOR 4.3; 95% CI 2.4-7.6); sex with a person known to be HIV positive (aOR 2.3; 95% CI 1.1-4.9); and a sexually transmitted infection diagnosis (aOR 2.4; 95% CI 1.1-5.2).
South Africa has an HIV epidemic that has disproportionately affected women and girls, especially among those aged 15-29 where prevalence rates have been shown to be significantly higher than their male age counterparts . Fortunately, there is evidence that there have been marginal recent declines in incident HIV infections especially among women and girls resulting in declines in the overall epidemic . Among similarly aged men, HIV prevalence rates have been consistently under 10% HIV prevalence in South Africa [14, 15]. While there is significant variability among the estimates of the burden of HIV among MSM in South Africa, when comparing the rates to age-matched men not reporting same-sex practices, the rates are uniformly and significantly higher. Comparisons of prevalence across sampling designs and time frames are always problematic, but this is particularly challenging for hidden and hard-to-reach populations, where behaviours are stigmatized, and for populations for which size estimates are uncertain. All of these potential sources of measurement error pertain to MSM in African settings. Nevertheless, enough data has emerged to suggest significant HIV disease burdens among these men.
The study presented here represents the first evaluation of HIV prevalence among MSM in the peri-urban townships of Cape Town. The study was designed as an epidemiologic probe of MSM in the townships in terms of socio-demographic characteristics, HIV-risk practices, HIV prevalence and associations with being seropositive, and prevalence of human rights violations. The aims of this project were to characterize this population, assess levels of need, and identify barriers to access to HIV preventive services.