Many southern African MSM have concurrent sexual relationships with both men and women

The majority of men who have sex with men in southern Africa are bisexual, and a significant proportion have concurrent sexual relationships with both men and women, investigators report in the online edition of Sexually Transmitted Infections.

The investigators suggest that this finding should occasion a rethinking of the factors driving the HIV epidemic in the region. However, they were encouraged that men in concurrent relationships with men and women (which the investigators term bisexual concurrency) reported high levels of condom use.

Sexual concurrency has been identified as an important contributory factor to the high levels of HIV transmission in southern Africa.

Men who have sex with men in this region are highly stigmatised and often criminalised, and there has been little research into their sexual behaviour and HIV prevention needs.

However, the limited research that has been conducted has shown that many men who have sex with men in sub-Saharan Africa also have sex with women. Therefore, an international team of investigators conducted a cross-sectional study, interviewing 537 men who had ever had sex with men about the gender of their sex partners, partnerships and sexual risk behaviours.

Overall, 17% of men were HIV-positive. Factors associated with being infected with HIV were older age (over 25), and not always using condoms for sex.

Just over a third of men reported that they were married or had a stable female partner, and 54% said that they had had both male and female sex partners in the previous six months.

Bisexual concurrency was common and was reported by 17% of men.

Factors associated with any bisexual behaviour included a lower level of education (OR, 1.6; 95% CI, 1.1 to 2.3), higher condom use (OR, 6.6; 95% CI, 3.2 to 13.9), and a lower likelihood of ever having had an HIV test (OR, 0.47; 95% CI, 0.32 to 0.67).

Analysis showed that having a concurrent relationship with both men and women was associated with higher levels of reported condom use (OR, 1.7; 95% CI, 1.0 to 3.1), and a lower likelihood of being 'out' to family (OR, 0.37; 95% CI, 0.22 to 0.65). Bisexual concurrency was also associated with having paid men for sex (OR, 2.0; 95% CI, 1.2 to 3.2).

“This is the first analysis known to the authors that attempts to explore patterns and associations of bisexual partnership and of bisexual concurrency among men who have sex with men in Malawi, Namibia, and Botswana,” write the investigators.

They continue: “The majority of men who have sex with men sampled were sexually active with both men and women, about a third … were married to women, and about one in six were in a stable relationship with a man and a woman.”

The authors were “encouraged” that men in concurrent relationships with both men and women reported less sexual risk and higher levels of condom use than men who reported exclusively homosexual behaviour.

“Further research is needed to assess the extent to which bisexual partnership may be a driver of HIV in southern African sexual networks,” conclude the investigators.