Abstract
The HIV/AIDS epidemic in South Africa has largely focused on the needs of heterosexual men and women. However, little is known about the sexual risk histories of men who have sex with both men and women (MSMW). Furthermore, we know very little about the psychosocial health needs or of the possibility of a syndemic (numerous interrelated epidemics) among MSMW. We surveyed 1,203 men attending drinking establishments in a township located in Cape Town, South Africa. We compared the behaviors and experiences of MSMW to men reporting only having sex with women (MSW). Twelve percent of the sample reported having sex with both men and women in the past 4 months. MSMW were twice as likely as MSW to report being HIV positive (10.5 vs. 4.6 %). MSW were more likely to be married than MSMW but reported similar numbers of female sex partners. MSMW were more likely to report a history of childhood sexual abuse, recent experienced and perpetrated physical and sexual partner violence, both receiving and giving sex for money, drugs, or shelter, and a recent STI. These factors were found to be interrelated among MSW but not MSMW. Although MSMW demonstrate considerable risk taking and report higher rates of HIV infection than MSW, their needs are largely unmet and underemphasized. Findings suggest the need to better understand factors contributing to sexual risk taking among MSMW. HIV prevention interventions should consider psychosocial health problems unique to MSMW residing in South African townships.
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References
Bengtsson, L., & Thorson, A. (2010). Global HIV surveillance among MSM: Is risk behavior seriously underestimated? AIDS, 24, 2301–2303.
Beyrer, C., Baral, S. D., van Griensven, F., Goodreau, S. M., Chariyalertsak, S., Wirtz, A.L., & Brookmeyer, R. (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380, 367–377.
Beyrer, C., Trapence, G., Motimedi, F., Umar, E., Iipinge, S., Dausab, F., & Baral, S. (2010). Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men. Sexually Transmitted Infections, 86, 323–327.
Brennan, D. J., Hellerstedt, W. L., Ross, M. W., & Welles, S. L. (2007). History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men. American Journal of Public Health, 97, 1107–1112.
Burrell, E., Mark, D., Grant, R., Wood, R., & Bekker, L. G. (2010). Sexual risk behaviours and HIV-1 prevalence among urban men who have sex with men in Cape Town, South Africa. Sexual Health, 7, 149–153.
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: Making the case for supportive prevention policy. AIDS Care, 23, 449–455.
Cook, D. J., Guyatt, G. H., Juniper, E., Griffith, L., McIlroy, W., Willan, A.,… Epstein, R. (1993). Interviewer versus self-administered questionnaires in developing a disease-specific, health-related quality of life instrument for asthma. Journal of Clinical Epidemiology, 46, 529–534.
Gebreyesus, S. H., & Mariam, D. H. (2009). Assessment of HIV/AIDS related risks among men having sex with men (MSM) in Addis Ababa, Ethiopia. Journal Public Health Policy, 30, 269–279.
Geibel, S., Tun, W., Tapsoba, P., & Kellerman, S. (2010). HIV vulnerability of men who have sex with men in developing countries: Horizons studies, 2001–2008. Public Health Reports, 125, 316–324.
Gonzalez-Guarda, R. M., Florom-Smith, A. L., & Thomas, T. (2011a). A syndemic model of substance abuse, intimate partner violence, HIV infection, and mental health among hispanics. Public Health Nursing, 28, 366–378.
Gonzalez-Guarda, R. M., McCabe, B. E., Florom-Smith, A., Cianelli, R., & Peragallo, N. (2011b). Substance abuse, violence, HIV, and depression: An underlying syndemic factor among Latinas. Nursing Research, 60, 182–189.
Gorbach, P. M., Murphy, R., Weiss, R. E., Hucks-Ortiz, C., & Shoptaw, S. (2009). Bridging sexual boundaries: Men who have sex with men and women in a street-based sample in Los Angeles. Journal Urban Health, 86(Suppl. 1), 63–76.
Herrick, A. L., Lim, S. H., Wei, C., Smith, H., Guadamuz, T., Friedman, M. S., & Stall, R. (2011). Resilience as an untapped resource in behavioral intervention design for gay men. AIDS and Behavior, 15(Suppl. 1), S25–S29
Hightow, L. B., Leone, P. A., Macdonald, P. D., McCoy, S. I., Sampson, L. A., & Kaplan, A. H. (2006). Men who have sex with men and women: A unique risk group for HIV transmission on North Carolina college campuses. Sexually Transmitted Disease, 33, 585–593.
Kalichman, S. C., Cain, D., Eaton, L., Jooste, S., & Simbayi, L. C. (2011a). Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa. American Journal of Public Health, 101(9), e9–e17.
Kalichman, S. C., Pinkerton, S. D., Carey, M. P., Cain, D., Mehlomakulu, V., Carey, K. B.,… Harel, O. (2011). Heterosexual anal intercourse and HIV infection risks in the context of alcohol serving venues, Cape Town, South Africa. BMC Public Health, 11, 807.
King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8, 70.
Lane, T., Raymond, H. F., Dladla, S., Rasethe, J., Struthers, H., McFarland, W., & McIntyre, J. (2011). High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto Men’s Study. AIDS and Behavior, 15, 626–634.
Lane, T., Shade, S. B., McIntyre, J., & Morin, S. F. (2008). Alcohol and sexual risk behavior among men who have sex with men in South African township communities. AIDS and Behavior, 12(4 Suppl.), S78–S85.
Lyons, A., Pitts, M., Grierson, J., Smith, A., McNally, S., & Couch, M. (2012). Sexual behavior and HIV testing among bisexual men: A nationwide comparison of Australian bisexual-identifying and gay-identifying men. AIDS and Behavior, 16, 1934–1943.
Malebranche, D. J., Arriola, K. J., Jenkins, T. R., Dauria, E., & Patel, S. N. (2010). Exploring the “bisexual bridge”: A qualitative study of risk behavior and disclosure of same-sex behavior among black bisexual men. American Journal of Public Health, 100, 159–164.
McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T., & Boyd, C. J. (2010). The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100, 1946–1952.
McLaughlin, K. A., Hatzenbuehler, M. L., & Keyes, K. M. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100, 1477–1484.
Mercer, C. H., Hart, G. J., Johnson, A. M., & Cassell, J. A. (2009). Behaviourally bisexual men as a bridge population for HIV and sexually transmitted infections? Evidence from a national probability survey. International Journal of STD and AIDS, 20, 87–94.
Merrigan, M., Azeez, A., Afolabi, B., Chabikuli, O. N., Onyekwena, O., Eluwa, G.,… Hamelmann, C. (2011). HIV prevalence and risk behaviours among men having sex with men in Nigeria. Sexually Transmitted Infections, 87, 65–70.
Meyer, J. P., Springer, S. A., & Altice, F. L. (2011). Substance abuse, violence, and HIV in women: A literature review of the syndemic. Journal of Womens Health, 20, 991–1006.
Mustanski, B., Garofalo, R., Herrick, A., & Donenberg, G. (2007). Psychosocial health problems increase risk for HIV among urban young men who have sex with men: Preliminary evidence of a syndemic in need of attention. Annals of Behavioral Medicine, 34, 37–45.
Napper, L. E., Fisher, D. G., Reynolds, G. L., & Johnson, M. E. (2010). HIV risk behavior self-report reliability at different recall periods. AIDS and Behavior, 14, 152–161.
Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review, 30, 1019–1029.
Operario, D., Smith, C. D., Arnold, E., & Kegeles, S. (2011). Sexual risk and substance use behaviors among African American men who have sex with men and women. AIDS and Behavior, 15, 576–583.
Parsons, J. T., Grov, C., & Golub, S. A. (2012). Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: Further evidence of a syndemic. American Journal of Public Health, 102, 156–162.
Pitpitan, E. V., Kalichman, S. C., Eaton, L. A., Cain, D., Sikkema, K. J., Skinner, D.,… Pieterse, D. (2012). AIDS-related stigma, HIV testing, and transmission risk among patrons of informal drinking places in Cape Town, South Africa. Annals of Behavioral Medicine, 43, 362–371.
Puhan, M. A., Ahuja, A., Van Natta, M. L., Ackatz, L. E., & Meinert, C. (2011). Interviewer versus self-administered health-related quality of life questionnaires: Does it matter? Health and Quality of Life Outcomes, 9(30), 1–11.
Ras, G. J., Simson, I. W., Anderson, R., Prozesky, O. W., & Hamersma, T. (1983). Acquired immunodeficiency syndrome: A report of 2 South African cases. South African Medical Journal, 64, 140–142.
Raymond, H. F., Kajubi, P., Kamya, M. R., Rutherford, G. W., Mandel, J. S., & McFarland, W. (2009). Correlates of unprotected receptive anal intercourse among gay and bisexual men: Kampala, Uganda. AIDS and Behavior, 13, 677–681.
Rispel, L. C., & Metcalf, C. A. (2009). Breaking the silence: South African HIV policies and the needs of men who have sex with men. Reproductive Health Matters, 17, 133–142.
Rispel, L. C., Metcalf, C. A., Cloete, A., Reddy, V., & Lombard, C. (2011). HIV prevalence and risk practices among men who have sex with men in two South African cities. Journal of Acquired Immune Deficiency Syndrome, 57, 69–76.
Rohde Bowers, J., Branson, C. M., Fletcher, J., & Reback, C. J. (2011). Differences in substance use and sexual partnering between men who have sex with men, men who have sex with men and women and transgender women. Culture Health & Sexuality, 13, 629–642.
Ross, M. W., Smolenski, D. J., Kajubi, P., Mandel, J. S., McFarland, W., & Raymond, F. H. (2010). Measurement of internalized homonegativity in gay and bisexual men in Uganda: Cross-cultural properties of the Internalized Homonegativity scale. Psychology, Health & Medicine, 15, 159–165.
SANAC. (2007). HIV and AIDS and STI Strategic Plan for South Africa, 2007–2011. http://www.doh.gov.za.
Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II. Addiction, 88, 791–804.
Scott-Sheldon, L. A., Carey, M. P., Carey, K. B., Cain, D., Vermaak, R., Mthembu, J.,… Kalichman, S. C. (2011). Impact of HIV testing on sexual health communication in South Africa. Sexually Transmitted Infections, 87, 242–247.
Siegel, K., Schrimshaw, E. W., Lekas, H. M., & Parsons, J. T. (2008). Sexual behaviors of non-gay identified non-disclosing men who have sex with men and women. Archives of Sexual Behavior, 37, 720–735.
Sikkema, K. J., Watt, M. H., Meade, C. S., Ranby, K. W., Kalichman, S. C., Skinner, D., & Pieterse, D. (2011). Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa. Journal of Acquired Immune Deficiency Syndrome, 57, 230–237.
Singer, M. (2009). Introduction to syndemics: A critical systems approach to public and community health. San Francisco, CA: Wiley.
Smith, A. D., Tapsoba, P., Peshu, N., Sanders, E. J., & Jaffe, H. W. (2009). Men who have sex with men and HIV/AIDS in sub-Saharan Africa. Lancet, 374, 416–422.
Stall, R., Mills, T. C., Williamson, J., Hart, T., Greenwood, G., Paul, J.,… Catania, J. A. (2003). Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health, 93, 939–942.
van Griensven, F., de Lind van Wijngaarden, J. W., Baral, S., & Grulich, A. (2009). The global epidemic of HIV infection among men who have sex with men. Current Opinions in HIV/AIDS, 4, 300–307.
Washington, T., & Brocato, J. (2010). Exploring the perspectives of substance abusing black men who have sex with men and women in addiction treatment programs: A need for a human sexuality educational model for addiction professionals. American Journal of Men’s Health, 5, 402–412.
Weatherburn, P., Hickson, F., Reid, D. S., Davies, P. M., & Crosier, A. (1998). Sexual HIV risk behaviour among men who have sex with both men and women. AIDS Care, 10, 463–471.
Weir, S. S., Pailman, C., Mahlalela, X., Coetzee, N., Meidany, F., & Boerma, J. T. (2003). From people to places: Focusing AIDS prevention efforts where it matters most. AIDS, 17, 895–903.
Wold, C., Seage, G. R., III, Lenderking, W. R., Mayer, K. H., Cai, B., Heeren, T., & Goldstein, R. (1998). Unsafe sex in men who have sex with both men and women. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology, 17, 361–367.
Wolitski, R. J., & Fenton, K. A. (2011). Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States. AIDS and Behavior, 15(Suppl. 1), S9–S17.
Zule, W. A., Bobashev, G. V., Wechsberg, W. M., Costenbader, E. C., & Coomes, C. M. (2009). Behaviorally bisexual men and their risk behaviors with men and women. Journal of Urban Health, 86(Suppl. 1), 48–62.
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United States Public Health Service grants R01MH094230 and R01AA018074 supported this research directly or indirectly. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Public Health Service.
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Eaton, L.A., Pitpitan, E.V., Kalichman, S.C. et al. Men Who Report Recent Male and Female Sex Partners in Cape Town, South Africa: An Understudied and Underserved Population. Arch Sex Behav 42, 1299–1308 (2013). https://doi.org/10.1007/s10508-013-0077-1
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DOI: https://doi.org/10.1007/s10508-013-0077-1