RJ is a member of the Editorial Board of
Conceived and designed the experiments: KLD RKJ YS RM. Performed the experiments: KLD RKJ YS RM. Analyzed the data: KLD DWM RKJ. Wrote the first draft of the manuscript: KLD DWM RKJ. Contributed to the writing of the manuscript: YS RM.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
AIDS first emerged in the early 1980s among gay men living in the US, but it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
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In the concentrated HIV epidemics of high-income countries, men who have sex with men (MSM) have a higher HIV prevalence than heterosexual men
Male–male sexual behavior is criminalized in many African countries
MSM in Africa, as elsewhere, are diverse in identities, attractions, and sexual behavior. Research suggests that many African MSM do not self-identify as gay or homosexual
The analyses presented here address the following questions: What is the population prevalence of consensual male–male sexual behavior among South African men? What is the population prevalence of male-on-male sexual violence victimization and perpetration? What socio-demographic factors are associated with these experiences? Are these experiences associated with a greater risk of prevalent HIV infection? To answer these questions, we draw on data from a population-based household survey of adult men in two South African provinces that included information on lifetime history of consensual sex with men, history of male-on-male sexual violence victimization and perpetration, and HIV serostatus.
A cross-sectional household survey was conducted in 2008 in three adjoining districts of the Eastern Cape and KwaZulu-Natal provinces of South Africa, spanning rural areas, commercial farmland, towns, and a major city. Detailed methods are described elsewhere
Among 222 sampled EAs, two (0.9%) had no human dwellings. In the remaining 220, one (0.45%) was excluded because gatekeepers refused access, and four (1.8%) were excluded because no homes with eligible men were identified following multiple visits at different times of day. We sampled a total of 4,473 visiting points. Of these, 822 (18.4%) could not be rostered for eligibility after a minimum of three attempts at contact. Among the remaining 3,651 visiting points, 1,353 (37.1%) were found to contain no eligible man, while 2,298 (62.9%) contained at least one eligible man. We thus estimated a total eligible population of 2,815 men in our sampling frame. Of this estimated population, 27% could not be contacted (estimated
Participants self-completed a survey using audio-enhanced personal digital assistants (APDAs). The text of each question and associated answer choices were presented on the APDA screen, while an accompanying voice recording read the question and answers aloud. The questions could be read, or listened to, in isiXhosa or isiZulu and English. All questions had fixed multiple choice answers (including a “refuse to answer” option). Answer choices were pre-translated and cross-validated across all three languages by multilingual study staff with native fluency in isiXhosa and isiZulu. Interested readers may contact the corresponding author, R. K. J., for further details on the questionnaire. Participants listened to questions through headphones, and answered by tapping their answer choice with a stylus.
This environment provided complete privacy for respondents. Fieldworkers were nearby during questionnaire completion so they could assist respondents if requested, but interviews were otherwise private. Questions included demographics (including self-identified race because it is strongly associated with HIV prevalence), socioeconomic status (SES), and detailed sexual histories. Participants were also asked for a finger-prick blood spot that was dried for HIV testing. To guarantee total anonymity, no identifying information was collected nor retained after an interview was completed.
Sexual attraction was asked as “Which gender attracts you sexually?” Response options included “women,” “men,” “both,” and “unsure.” Lifetime history of consensual male–male sexual activity was assessed by asking: “Have you ever had sex or done something sexual with a man? By sex we mean: Anal sex: where a man sticks his penis in another man's anus; Oral sex: when a man sticks his penis in another man's mouth; Masturbation: when one or both men play with each others' sex organs; Thigh sex: when a man has sex by putting his penis between another man's closed thighs.” If yes, we asked individual yes/no questions about each named act “done with a man because you wanted to.” Participants reporting a history of consensual sex with men were asked whether they had a current male partner. Men who indicated any consensual sex with a man in response to these questions are referred to as MSM in this paper; those with only victim or perpetrator experiences are not.
To measure the lifetime history of male-on-male sexual violence victimization we asked “Did a man ever persuade or force you to have sex when you did not want to?” If yes, we asked, “Which of the following acts took place with a man when you did not want to?” with yes/no response categories for anal, oral, masturbation, and thigh sex. Lifetime history of sexual violence perpetration was queried as, “Have you ever done anything sexual with a boy or man when he didn't consent or you forced him?” and “Have you ever done anything sexual with a boy or man where you put your penis in his mouth or anus when he didn't consent or you forced him?” Male-on-male rape victimization and perpetration were defined in analyses as any nonconsensual oral and/or anal penetration.
Dried blood spots were tested for HIV with a screening ELISA (Genscreen, Bio-Rad), and positive results were confirmed with a second ELISA (Vironostika, bioMérieux).
71.6% (
Ethics approval was granted by the Medical Research Council's Ethics Committee. Participants signed informed consent separately for interviews and dried blood spots. An incentive of ZAR 25 (∼US$3.50) was offered for each component, giving a total of ZAR 50 for both. The APDAs ensured that participant answers were entirely anonymous, and we retained no identifying information on any participant. This was necessary to protect participants who reported illegal activities from possible repercussions. It also meant that HIV results could not be given to the participants. Free HIV testing is widely available from government clinics in South Africa, and all participants were advised to learn their status.
The sample was self-weighting. Questionnaire data were linked to HIV data using anonymous codes. Analyses were performed using Stata 12.0 and accounted for the two-stage sampling structure, with stratification by district and data clustered in EAs. No imputation methods were used to replace missing data.
The distribution of socio-demographic characteristics, sexual attraction, sexual behaviors, and experiences with violence were summarized as percentages (or means), using standard methods for estimating confidence intervals from complex multistage sample surveys (Taylor linearization). Pearson's chi-square was used to test two-way associations between categorical variables and consensual male–male sexual behavior, male-on-male sexual violence victimization, or male-on-male sexual violence perpetration. Socio-demographic correlates of consensual male–male sexual experience, male-on-male sexual violence victimization, and male-on-male sexual violence perpetration were described using maximum likelihood multivariable logistic regression. All variables significant at
Associations between the three experiences of interest (consensual male–male sexual experience, male-on-male sexual violence victimization, and male-on-male sexual violence perpetration) and HIV status were also described using maximum likelihood multivariable logistic regression. All theoretically relevant variables and all variables shown to be significantly associated with any of the three experiences of interest were tested as potential confounding variables, and were retained in the final models if they altered the point estimate for any association between male–male contact and HIV by 10% or more
Overall, 5.4% (
As shown in
Category | Characteristic | Ever Engaged in Consensual Male–Male Sexual Behavior ( |
Never Engaged in Consensual Male–Male Sexual Behavior ( |
Odds Ratio (95% CI) | aOR |
|||
Percent (Number) | 95% CI | Percent (Number) | 95% CI | |||||
Non-black African | 86.2 (81) | (77.7–97.8) | 84.9 (1,350) | (80.1–88.7) | 0.74 | Ref | ||
Black African | 13.8 (13) | (8.2–22.3) | 15.2 (241) | (11.3–19.9) | 1.11 (0.60–2.04) | |||
18–24 y | 47.9 (45) | (37.3–58.6) | 51.9 (826) | (48.8–54.9) | 0.47 | Ref | ||
25 y and older | 52.1 (49) | (41.4–62.7) | 48.1 (766) | (45.1–51.2) | 1.17 (0.77–1.78) | |||
36.3 (33) | (26.9–46.7) | 40.8 (647) | (37.8–43.9) | 0.37 | 0.83 (0.53–1.28) | |||
Mean SES score (range: 6–19) | 11.6 (n/a) | (11.1–12.2) | 12.6 (n/a) | (12.5–12.8) | ||||
Hunger in household | 63.5 (54) | (52.6–73.2) | 51.1 (748) | (48.0–54.2) | ||||
Employed | 62.8 (59) | (51.8–72.6) | 54.2 (857) | (51.3–57.0) | 0.13 | 1.44 (0.93–2.22) | ||
Ever had sex with a woman | 98.9 (93) | (92.7–99.9) | 95.3 (1,512) | (94.0–96.3) | 0.10 | 4.61 (0.63–33.6) | ||
Ever married a woman | 54.8 (51) | (45.1–64.3) | 45.5 (714) | (42.6–48.4) | 0.43 | 1.46 (0.96–2.24) | ||
Ever fathered children | 54.8 (51) | (44.0–65.3) | 45.3 (707) | (42.6–48.1) | 0.09 | 1.47 (0.96–2.23) | ||
Current female partner | 85.0 (79) | (75.9–91.0) | 86.9 (1,373) | (84.9–88.7) | 0.60 | 0.85 (0.47–1.53) | ||
Current male partner | 27.7 (26) | (20.1–36.8) | n/a | n/a | n/a | n/a | ||
Current male and female partners (both) | 22.6 (21) | (15.5–31.7) | n/a | n/a | n/a | n/a | ||
Women | 64.9 (61) | (54.8–73.8) | 87.4 (1,384) | (85.7–89.1) | Ref | Ref | ||
Men/both | 21.3 (20) | (14.1–30.7) | 6.8 (108) | (5.7–8.2) | ||||
Not sure | 13.8 (13) | (8.3–22.2) | 5.8 (91) | (4.6–7.1) | ||||
Male SV victim | 34.4 (32) | (25.7–44.4) | 8.1 (129) | (6.8–9.7) | ||||
Male SV perpetrator | 10.9 (10) | (6.1–18.5) | 2.6 (40) | (1.9–3.5) |
Values in bold are significant at
Only correlates significant at
n/a, not applicable; Ref, reference value; SV, sexual violence.
Overall, 9.5% (
Category | Characteristic | SV Victims ( |
Non-Victims ( |
Odds Ratio (95% CI) | aOR |
|||
Percent (Number) | 95% CI | Percent (Number) | 95% CI | |||||
Non-black African | 9.4 (15) | (5.4–15.7) | 15.7 (240) | (11.9–20.5) | Ref | Ref | ||
Black African | 90.6 (145) | (84.3–94.6) | 84.3 (1,286) | (79.5–88.1) | ||||
18–24 y | 34.6 (56) | (48.7–54.7) | 53.5 (817) | (50.4–56.6) | Ref | Ref | ||
25 y and older | 65.4 (106) | (57.2–72.9) | 46.5 (709) | (43.4–49.6) | ||||
41.0 (66) | (33.0–49.5) | 40.5 (615) | (37.5–43.6) | 0.91 | 1.00 (0.71–1.41) | |||
Mean SES score (range: 6–19) | 11.7 (n/a) | (11.3–12.2) | 12.6 (n/a) | (12.5–12.8) | ||||
Hunger in household | 65.5 (93) | (57.3–72.9) | 50.3 (708) | (47.1–53.5) | ||||
Employed | 60.4 (96) | (51.6–68.6) | 54.0 (820) | (51.1–56.8) | 0.15 | 1.32 (0.94–1.85) | ||
Ever had sex with a woman | 98.8 (160) | (95.2–99.7) | 95.2 (1,449) | (93.8–96.3) | 4.02 (0.97–16.7) | |||
Ever married a woman | 59.8 (95) | (51.7–67.3) | 44.6 (671) | (41.7–47.4) | 0.06 | 1.85 (1.32–2.59) | ||
Ever fathered children | 63.4 (102) | (55.8–70.4) | 44.0 (657) | (41.1–46.9) | ||||
Current female partner | 79.9 (127) | (73.1–85.3) | 76.4 (1,158) | (73.6–79.0) | 0.33 | 1.22 (0.73–2.06) | ||
Current male partner | 5.6 (9) | (3.0–10.0) | 1.2 (18) | (0.8–1.8) | ||||
Current male and female partners (both) | 4.4 (7) | (2.1–8.9) | 1.0 (15) | (0.6–1.6) | ||||
Women | 82.7 (134) | (76.0–87.8) | 86.6 (1,313) | (84.7–88.3) | Ref | |||
Men/both | 14.8 (24) | (10.1–21.3) | 6.8 (103) | (5.6–8.2) | ||||
Not sure | 2.5 (4) | (0.9–6.5) | 6.7 (101) | (5.4–8.1) | 0.39 (0.14–1.09) | |||
Consensual male–male sex | 19.9 (32) | (14.7–26.3) | 4.0 (61) | (3.1–5.2) | ||||
Male SV perpetrator | 5.8 (9) | (3.1–10.6) | 2.7 (41) | (2.0–3.7) |
Values in bold are significant at
Only correlates significant at
n/a, not applicable; Ref, reference value; SV, sexual violence.
Overall, 2.9% (
Category | Characteristic | SV Perpetrators ( |
Non-Perpetrators ( |
Odds Ratio (95% CI) | aOR |
|||
Percent (Number) | 95% CI | Percent (Number) | 95% CI | |||||
Racial group | ||||||||
Non-black African | 20.0 (10) | (10.4–35.1) | 14.7 (239) | (11.1–19.3) | 0.33 | Ref | ||
Black African | 80.0 (40) | (64.9–89.6) | 85.3 (1,382) | (80.7–88.9) | 0.67 (0.30–1.48) | |||
18–24 y | 54.0 (27) | (41.6–65.9) | 51.5 (836) | (48.4–54.6) | 0.70 | Ref | ||
25 y and older | 46.0 (23) | (34.1–58.4) | 48.5 (787) | (45.4–51.6) | 0.94 (0.52–1.69) | |||
46.9 (23) | (33.0–61.4) | 40.1 (648) | (37.1–43.2) | 0.35 | 1.43 (0.78–2.61) | |||
Mean SES score (range: 6–19) | 12.2 (n/a) | (11.5–13.0) | 12.6 (n/a) | (12.4–12.7) | 0.44 | 0.95 (0.85–1.07) | ||
Hunger in household | 70.2 (33) | (57.3–80.6) | 51.3 (773) | (48.2–54.4) | ||||
Employed | 56.0 | (41.7–69.4) | 54.4 | (51.6–57.2) | 0.82 | 1.08 (0.60–1.95) | ||
Ever had sex with a woman | 98.0 (49) | (87.2–99.7) | 95.5 (1,543) | (94.3–96.6) | 0.40 | 2.32 (0.31–17.6) | ||
Ever married a woman | 64.0 (32) | (50.7–75.4) | 44.9 (720) | (42.1–47.8) | 0.58 | |||
Ever fathered children | 53.1 (26) | (39.6–66.1) | 45.5 (725) | (42.9–48.3) | 0.28 | 1.35 (0.75–2.41) | ||
Current female partner | 71.4 (35) | (59.5–81.0) | 87.0 (1,403) | (85.1–88.8) | ||||
Current male partner | 12.0 (6) | (5.7–23.7) | 1.2 (20) | (0.8–1.9) | ||||
Current male and female partners (both) | 8.2 (4) | (3.2–19.5) | 1.1 (18) | (0.7–1.7) | ||||
Women | 60.0 (30) | (44.2–74.0) | 87.0 (1,402) | (85.2–88.6) | Ref | Ref | ||
Men/both | 26.0 (7) | (15.1–40.9) | 7.0 (76) | (5.8–8.4) | ||||
Not sure | 14.0 (7) | (7.3–25.3) | 6.0 (97) | (4.9–7.4) | ||||
Consensual male–male sex | 20.0 (10) | (11.6–32.4) | 5.1 (82) | (4.2–6.3) | ||||
Male SV victim | 18.0 (9) | (10.5–29.2) | 9.1 (146) | (7.7–10.7) |
Values in bold are significant at
Only correlates significant at
n/a, not applicable; Ref, reference value; SV, sexual violence.
Men with a history of consensual male–male sexual behavior were over seven times more likely than other men to report sexual violence victimization (aOR = 7.34; 95% CI 4.30–12.5) after controlling for other demographic correlates associated with victimization (
In general, men reporting no consensual male–male sexual behavior, no sexual violence victimization, and no sexual violence perpetration had the lowest HIV prevalence, at 17.0% (
Group | Category of Potential Exposure to HIV through Male–Male Contact | Percent (Number) HIV+ | 95% CI |
No male-on-male contact (consensual or nonconsensual) ( |
17.0 (170) | 14.2–20.2 | |
No oral/anal contact (consensual or nonconsensual) ( |
18.1 (206) | 15.5–21.2 | |
Any consensual male–male sexual behavior ( |
27.4 (20) | 17.6–40.0 | |
Consensual oral/anal male–male sexual behavior ( |
31.4 (11) | 18.0–48.9 | |
Any male-on-male victimization ( |
23.7 (31) | 16.3–33.1 | |
Oral/anal male-on-male victimization ( |
17.4 (8) | 8.9–31.1 | |
Any male-on-male perpetration ( |
27.8 (10) | 17.3–41.5 | |
Oral/anal male-on-male perpetration ( |
34.8 (6) | 20.2–52.9 |
Participants reporting multiple different types of contact may be classified within more than one of these groups.
In multivariable regression modeling (
Model | Independent Variable | aOR | 95% CI |
Any consensual male–male sexual activity | 1.62 | 0.80–3.24 | |
Any male–male sexual violence victimization | 1.10 | 0.64–1.86 | |
Any male–male sexual violence perpetration | |||
Age >25 y | |||
Black | |||
Circumcised | |||
Hunger in household | |||
Consensual oral/anal male–male sex | |||
Rape victimization | 0.74 | 0.29–1.89 | |
Rape perpetration | |||
Age >25 y | |||
Black | |||
Circumcised | |||
Hunger in household |
Values in bold are significant at
In our population-based sample, approximately one in 20 men (5.4%) reported at least one lifetime occurrence of consensual sexual contact with a man, and nearly twice this proportion (9.6%) reported experience of male-on-male sexual violence victimization. MSM were over seven times more likely than other men to report male-on-male sexual violence victimization, and about three times more likely to report perpetration of such violence. Among the participants who provided blood for HIV testing, HIV prevalence was higher among men reporting a lifetime history of consensual oral/anal sex with a man, and also higher among men who had perpetrated male-on-male rape or other acts of male-on-male sexual violence. However, male rape survivors were not more likely than other men to be HIV+, a finding that parallels data among female rape survivors in South Africa
Our estimates of any consensual sexual activity between men, including consensual oral or anal sex, are consistent with reports from other developing countries
Men who reported consensual male–male sexual behavior did not differ from those reporting sex only with women in their lifetime sexual behavior with women, marriage history with women (same-sex marriage is legal in South Africa), or having a current female partner. These findings contrast sharply with those of Baral et al., garnered through venue-based sampling of self-identified MSM, who found that only 8% of MSM had a regular female partner and 18% identified as bisexual
The high population prevalence of male–female sexual concurrency reported here suggests that HIV prevention efforts must address men who have sex with both men and women and their male and female partners. It further suggests that the MSM who can be readily accessed through venues and social and sexual networks may represent a biased subset of the total population of MSM. Further population-based research using more standardized measures of current male–male sexual behavior and identity will be needed to confirm the proportions of MSM potentially reachable through targeted intervention. However, it seems likely that new strategies will be required to reach the full South African population of MSM for both research and prevention, and that it will be of benefit to mainstream MSM messaging in broader HIV prevention efforts.
Rethinking sexual health among men in South Africa must include addressing the high levels of male-on-male sexual violence and enabling victims to come forward for assistance from the police and health services. While male violence against women is rightly understood to be a public health crisis in South Africa because of its very high prevalence
Previous research from southern Africa on the prevalence of HIV among MSM has yielded mixed figures: 13.9% in a respondent-driven sampling survey in Soweto
A key strength of this study was the use of APDAs for data collection; these provided a totally private and anonymous environment for disclosure of illegal and stigmatized behavior. Social desirability bias is nonetheless a concern and may have led to underreporting or misclassification of all outcomes of interest. This study was not primarily designed to collect data regarding male–male sexual behavior, and the relevant questions were limited. In particular, we did not measure the frequency or timing of male–male sexual behavior, and so those actively engaged in MSM networks are pooled here with those who have had only one experience, which may not have been recent. Similarly, information was not collected on the situational contexts of experiences of sexual assault. Consequently, despite some hints in the data that point towards likely intimate partner violence, we are unable to distinguish categories of sexual violence (i.e., we cannot tell partner violence from non-partner violence or childhood sexual assault).
Self-completion of the questionnaire resulted in some missing data on some items. We did not retain information on the number of eligible men per household and so were not able to weight the analysis for this, but we have no reason to believe this would have made much difference to the estimates of association and are aware that it usually makes no difference to estimates
In this population-based household survey of adult South African men, approximately one in 20 men reported consensual sexual contact with a man, while approximately one in ten reported being sexually assaulted by another man, and around 3% reported perpetrating such assault. These data emerge from one of the first African datasets to directly compare MSM and non-MSM from the same sampling frame, as well as one of the first to link male-on-male sexual violence with HIV serostatus. HIV prevalence was significantly higher among men reporting a lifetime history of consensual penetrative sex with men and among men who had sexually assaulted other men than it was among men in the general population. Male–female concurrency was common among MSM in these data, suggesting that prevention messaging about the risks associated with male–male sex needs to be mainstreamed into HIV prevention messaging for the general population in a way that does not invite homophobic stigmatization. Also required are further efforts to promote access to post-rape services for male survivors of sexual violence. These interventions will be effective and accessible only if they are provided in a context of active efforts to destigmatize lesbian, gay, bisexual, and transgender (LGBT) identities, and of active enforcement of South Africa's constitutional protections against anti-LGBT discrimination and in support of marriage equality. While this work offers important insight into the sexual health needs of South African men, it requires replication in other African countries, where decriminalization of consensual homosexual behavior will be a prerequisite for the broad success of any public health research or intervention.
We thank the men who agreed to complete the interviews, Statistics South Africa for drawing the sample, Scott Johnson and his team from the University of Kentucky for development of the APDA systems, the National Institute for Communicable Diseases for testing the blood, and all the project staff.
adjusted odds ratio
audio-enhanced personal digital assistant
enumeration area
men who have sex with men
socioeconomic status