HIV This Week

Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men.

Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Baral S. Sex Transm Infect. 2010. [Epub ahead of print]

The sexual behaviour of men who have sex with men in southern Africa has been little studied. Beyrer et al present here the first data on bisexual partnerships and bisexual concurrency among men who have sex with men in Malawi, Namibia and Botswana. The authors conducted a cross-sectional probe of a convenience sample of 537 men who have ever reported anal sex with another man using a structured survey instrument and rapid-kit HIV screening. 34.1% of men who have sex with men were married or had a stable female partner, and 53.7% reported both male and female sexual partners in the past 6 months. Bisexual concurrency was common, with 16.6% of men who have sex with men having concurrent relationships with both a man and a woman. In bivariate analyses, any bisexual partnerships were associated with lower education (OR 1.6, 95% CI 1.1 to 2.3), higher condom use (OR 6.6, 95% CI 3.2 to 13.9), less likelihood of having ever     tested for HIV (OR 1.6, 95% CI 1.1 to 2.3), less likelihood of having disclosed sexual orientation to family (OR 0.47, 95% CI 0.32 to 0.67) and being more likely to have received money for casual sex (OR 1.9, 95% CI 1.3 to 2.7). Bisexual concurrency was associated with a higher self-reported condom use (OR 1.7, 95% CI 1.0 to 3.1), being employed (OR 1.8, 95% CI 1.2 to 2.9), lower likelihood of disclosure of sexual orientation to family (OR 0.37, 95% CI 0.22 to 0.65) and having paid for sex with men (OR 2.0, 95% CI 1.2 to 3.2).The majority of men who have sex with men in this study report some bisexual partnerships in the previous 6 months. Concurrency with sexual partners of both genders is common. Encouragingly, men reporting any concurrent bisexual activity were more likely to report condom use with sexual partners, and these men were not more likely to have HIV infection than men reporting only male partners. HIV-prevention programmes focussing on decreasing concurrent sexual partners in the African context should also target bisexual concurrency among men who have sex with men. Decriminalisation of same-sex practices will potentiate evidence-based HIV-prevention programmes targeting men who have sex with men.

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Editors’ note:  Historical and current labour migration patterns in southern Africa are thought to be major contributors to sexual concurrency, most often defined as men having two or more female sexual partners and women having two or more male partners at the same time. This is the first study of bisexual concurrency among men who have sex with men, defined as being in an ongoing sexual relationship with both a male and a female partner. Bisexuality was defined as sex with at least one man and one woman in the previous 6 months. The study population in Botswana, Namibia, and Malawi was urban and more likely to be gay-identified because the men were recruited through local human rights organisations with links to these communities of men. All three countries criminalise same sex behaviour. Although the findings cannot be generalised to the entire population of men who have sex with men, they are nonetheless thought provoking. Overall, more than half were sexually active with both men and women, one third were married to women, and one in six was in a stable relationship with a man and a woman. Men were more likely to identify as bisexual and report bisexual concurrency in settings where the social pressure to marry women was strong, such as Malawi. HIV infection prevalence was about twice as high as national estimates of HIV prevalence for men of reproductive age; however, condom use with regular and casual sex partners was higher among those in concurrent bisexual partnerships. Further research is needed to better understand the contribution of bisexuality and bisexual concurrency to African epidemics but the capacity to undertake such research and design tailored prevention programmes will depend on how quickly these countries move to decriminalise homosexuality.