Poster from AIDS2012 in July, 2012.

1. Determinants of HIV Risk Behaviors
among MSM in Kigali, Rwanda
A Asiimwe1; J Chapman2; C Basomingera2; S Kiragu3; K. Kirota2; and A Koleros2
1) Rwanda Biomedical Center / Institute of HIV, Other Disease Prevention and Control, Kigali, Rwanda; 2) Futures Group / MEASURE Evaluation; 3) UNAIDS, Rwanda
Introduction These experiences were strongly associated with poverty and lack of economic opportunities;
participants reported limited ability to negotiate condom use with their paying partners.
Internationally, men who have sex with men (MSM) have been identified as a high-risk group “It’s obvious that when he has given you money, you have agreed everything that he will do and it’s
for HIV acquisition. Studies of MSM in Africa have documented high rates of previous and like a professional business. He may penetrate wherever he wants.” (ID 10.11.17.DA.11, aged 25,
current high risk sexual behaviors (1, 2). Rwanda’s 2009 HIV/AIDS strategic plan included secondary school education)
a focus on MSM, following important findings that MSM in Kigali exhibited high-risk
sexual behaviors such as relatively high numbers of male and female partners in both casual Participants had realistic assessments of risk; risk perception influenced behavior. Though
and commercial sexual partnerships, low condom use during both anal and vaginal sex, many participants received some HIV education, many possessed low knowledge of available
and high mobility (3). However, Rwanda still lacked key information on the determinants HIV services including the provision of antiretroviral therapy (ART), cited as a barrier to HIV
and drivers of risk behaviors in the community or potential mitigation strategies, limiting testing. Participants also desired better access to condoms and lubricants.
our understanding of the most effective programming mix to support this group. To help “It’s because most people believe that condom use is for sex between boys and girls…that’s why you
strengthen Rwanda’s evidence base for effective MSM programs, we undertook this qualitative find…for men to men, many people haven’t known much about condom use.” (ID 10.11.24.AM.17,
study to describe the contextual determinants of HIV sexual risk behavior, health-seeking aged 21, secondary school education)
behavior, and the desirability and acceptability of HIV services.
“I have been educated a lot but I was not interested as they were talking about heterosexuals.” (ID
10.11.18.AH.12, aged 24, university student)
Process
“The first obstacle to going for HIV test is that, for us who are still younger, we say if I were to test
This qualitative study involved face-to-face semi-structured interviews and focus group positive, what would happen next? I may lose hope and die sooner. So, you decide not to.” (ID
discussions (FGD). We utilized a snowball sampling methodology and MSM peer data 10.11.10.JH06, aged 23, secondary school education)
collectors. The recruitment and sampling strategy is presented below in Figure 1.
Figure 1: Sampling and Recruitment of Peer Interviewers and Conclusions
Participants Figure 1. Sampling and Recruitment of Peer Interviewers &
Participants
• There is an association between trust and condom use in the MSM community and a
2 MSM participate in Study management team
perception exists that condoms are for commercial and transactional partners, and not
for regular, romantic partners. HIV prevention messages targeting the MSM population
Initial MSM
Peer Leaders should emphasize condom use as an effective HIV prevention tool in any type of
Final MSM Final MSM partnership.
Peer Leaders Peer Leaders
• Participant accounts suggest that there are no specific geographical zones where MSM
MSM
MSM MSM participant
MSM
participant
frequent or congregate to meet new sexual partners, but rather they tend to organize
participant participant
gatherings through existing networks of MSM where friends come together and bring
MSM
MSM MSM
MSM
participant participant
new friends into the circle. Targeting social networks of MSM in Kigali may be an
participant participant
effective strategy to reach them with HIV prevention services and commodities.
• Many participants implied that when alcohol is involved, if condoms are out of sight,
Peer interviewers conducted interviews and FGD with 28 MSM. Analysis was a multi-stage they are out of mind. HIV program planners and managers should ensure that condoms
process involving the MSM community (4, 5). A management committee, including MSM, are available at locations where alcohol is associated with meeting new sexual partners,
designed and oversaw this study. Rwandan and U.S. ethics review boards approved this study. particularly in bars, hotels, and night clubs. Current efforts linking condom promotion
campaigns and points of sale where alcohol is sold and consumed should be continued.
• Many participants shared false beliefs and misconceptions about the availability and
Results existence of some key HIV services. Current efforts to sensitize healthcare workers for the
delivery of MSM-friendly services should be continued and scaled-up, focusing on health
Twenty-eight men aged 18–38 participated in interviews and 15 participated in FGD, education. Equally, outreach efforts should better target general HIV education and the
including three married men and six sex workers. About half of the participants self-identified promotion of the use of health services.
as homosexual at the time of interview. Regular alcohol use was a norm among participants
and contributed to decisions not to use condoms. Acknowledgments
“I actually forgot; I was drunk. I was drunk and it just happened. When I am drunk I use condoms
less.” (ID 10.11.10.JH.04, aged 19, secondary school education) The study was led by the Rwanda Biomedical Center’s Institute of HIV, Disease Prevention,
and Control (RBC/IHDPC), with technical assistance from MEASURE Evaluation and
Trust in sexual partners is a key issue, particularly in relation to condom use. financial assistance from the United Nations Joint Programme on HIV/AIDS and U.S.
“Yeah I wanted to use a condom in that case because I was not romantically involved, so I wanted to Agency for International Development. This project would not have been possible without
use a condom” (ID 10.11.10.JH.04, aged 19, secondary school education) the dedication and commitment of our study staff and MSM peer researchers, whose respect
for the rights of MSM in Rwanda is commendable. Finally, we give our sincere thanks
Participants were members of tight social networks. to study respondents for their generosity and honesty in answering our questions and for
“If you know three or four people, you go together in a bar, you drink…if you are five who agree with sharing their unique experiences with us.
their sexual identity, and at least each of you knows other two people. They will call them as well and
it becomes a big network.” (ID 11.01.31.HC.30, aged 30, university) References
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This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the
United States Agency for International Development (USAID) under the terms of MEASURE Evaluation
cooperative agreement GHA-A-00-08-00003-00. Views expressed are not necessarily those of PEPFAR,
USAID, or the United States government. July 2012. Evaluation