Principal findings

The results from this study describe levels of sexual risk behaviour and factors influencing UAI and HIV testing among MSM in three cities of Nigeria. In this study, 43.4% of participants reported UAI at last sex. The level of UAI reported by participants is consistent with reports of low consistent condom use among MSM in other West African countries15 ,16—for example, in Senegal, UAI at last sex with a man was reported at 23.2% among a sample of 501 MSM16 and, in a convenience sample of MSM in Cameroon, 57% reported UAI in the previous 6 months.15 Participants who lived in Ibadan, who were married or cohabitating with a woman, self-identified as bisexual or straight, were HIV-positive and who had not tested for HIV prior to the survey were more likely to report UAI.

A substantial proportion of MSM in our sample (43.4%) had never been tested for HIV prior to the survey. This finding is problematic given the efforts that have been made through the Men's Health Network of Nigeria to provide access to HTC for high-risk men in these three cities. However, this finding is consistent with reports from other studies among MSM in Africa that indicate testing rates ranging from 17.7% up to 65.2%. HIV testing reported among samples of MSM include 17.7% ever testing in Kano, Nigeria17; 19.2% in Zanzibar, Tanzania18; 25.3% in Mombasa, Kenya19; 26.7% in Cross River, Nigeria17; 35.2% in Malawi20; 40.9% in Lagos, Nigeria17; 54.5% in Lesotho21; 59.4% in Namibia20; 60.5% in Tanzania22; and 65.2% in Nigeria.23 This summary suggests a wide variation in testing across countries and sites within countries, which may reflect differences in levels of access to and delivery of testing services, stigma in these societies or variations in sampling. Our findings add to this empirical work by demonstrating a need to reach more MSM with HTC services using innovative approaches tailored to the population and specific context. In this regard, it is noteworthy that the proportion never having tested for HIV was higher in Ibadan, as was the frequency of bisexuality and UAI. Ibadan is a traditional indigenous and old city, while Lagos is a more modern highly cosmopolitan megacity and Abuja is a young city made up of mostly recent migrants. MSM in Abuja and Lagos have better prospects of meeting other MSM and seeking testing services because these cities have more MSM-targeted interventions and HTC centres. HIV and prevention strategies may require different approaches based on the social context and health system in each city.

Bisexuality is an important characteristic of MSM populations across African contexts.24 In this study, 55.4% of participants self-reported their sexual orientation as bisexual. Research from South African MSM suggests that internalised homonegativity is higher among MSM with a bisexual orientation, and that this has negative consequences for health-seeking behaviour including not testing for HIV and UAI.13 Cognitive approaches towards behaviour change in relation to sexual risk and health-seeking behaviour for HIV must be tailored towards an individual's stage in development of sexual identity and overall perception of self, in a context where homosexual orientation is incongruent with larger group norms.

The results of this study indicate that MSM at highest risk for HIV based on the report of sexual risk behaviour are not being reached with HIV testing services. Participants who had never been tested for HIV were more likely to report UAI. There was no difference in HIV testing between participants who reported exchange of sex for resources and those who did not. This is a gap in HTC coverage among a group at ‘double’ risk for HIV through both MSM exposure and sex work. Increased attention among the general population is being paid to testing modalities that might reach higher risk persons (eg, provider-initiated, outreach, couples testing, community-based approaches and self-testing).12 This same attention should be devoted to increasing HIV testing among higher risk MSM. For example, HIV self-testing ensures privacy and convenience that may by particularly important for MSM concerned about disclosure of sexual orientation when seeking HIV services. Studies in some African countries have found HIV self-testing highly accepted and feasible.25–28

Slightly more than half (53.9%) of participants reported receiving resources for providing sex in the last 6 months. High levels of commercial sex are also noted in other studies of MSM in countries in Western and Central Africa (24.4% in Lagos, Nigeria; 36.0% in Kano, Nigeria; 35% in Cross River, Nigeria,17 61.7% in Nigeria23; 20.1% in Senegal29) and East and Southern Africa (27.7% ever in Lesotho21; 74% in Mombasa, Kenya19; 29.3% in Botswana; 37.3% in Namibia; 62.6% in Malawi20; 12% in Cape Town, South Africa30; and 84% in Zanzibar, Tanzania18). A high prevalence of transactional sex indicates the need to address the increased risk of sex work among MSM, and the vulnerabilities that arise from being MSM in this context that may lead to engaging in sex exchange.

Persons with less education and no employment were less likely to test. These barriers to accessing services are not unique to MSM, and rather demonstrate that sexual orientation intersects with other individual characteristics related to class and economics in determining health service utilisation. Thus, while it is important to consider that psychosocial barriers to testing uptake are highly relevant for MSM (eg, stigma), other commonly noted access barriers including cognitive (knowledge about health benefit of HIV testing), economic and geographical barriers should also be considered.12 In fact, increased intensity of HTC services and a focus on reducing these barriers is important in Nigeria overall, as only an estimated 11.7% of women and men aged 15–49 were tested for HIV and received their result in the last 12 months.11

Persons who were younger were less likely to have ever tested for HIV in our sample, similar to results from a study in Tanzania among MSM which found that younger participants were less likely to have ever tested.22 This finding makes intuitive sense, as older age implies cumulative exposure and access to testing over a longer period of time for HTC. It is important to note, however, that overall the age of our sample was young, with a mean age of 25 years (median 23, range 18–55). Younger age representation among this sample of MSM is not unique to our study. The average age for MSM samples from African countries in the literature reviewed also ranged from 22 to 27 years.17 ,19–23 ,30 ,31 The failure to engage older MSM may be due to the use of social network referrals that may be biased towards younger age groups, who also might be more likely to socialise together and be more open about their sexual orientation. It is also possible that older men are less likely to identify as MSM. This challenge is also an important barrier to engaging older MSM programmatically given the cumulative risk of HIV in older MSM. Targeting of services towards older men should be a focus of future research and HIV prevention and testing strategies.

Limitations

One limitation of this study is the possibility of bias in self-reporting of sensitive sexual risks in a homophobic and hostile environment such as Nigeria. Another limitation is that data were pooled across three cities and RDSAT weights were not used in the regression analyses. However, we have adjusted for differences across study sites in the regression analyses.

It is a challenge to draw comparisons across research available among MSM in Africa given the inherent differences in social geographies. Sampling and analysis methods used in the available literature vary substantially. The current study attempted to address this issue by using RDS sampling methodology, presenting weighted and unweighted data, and presenting data across three different cities representing different contexts in Nigeria.

Conclusions and implications

The level of sexual risk behaviour including UAI, multiple partnerships and sex work among MSM in Nigeria is high and highlights the need for targeted and innovative HIV prevention approaches for this group. The criminalisation of homosexuality in countries like Nigeria will continue to prevent MSM from accessing the basic prevention package including HIV testing. Thus, access to HIV prevention for MSM should be viewed as an urgent public health need and human right. Promotion of HIV testing among this group is warranted, and should focus on increasing testing among persons who are younger, report UAI and are unemployed with less formal education.