Logistic regression and generalized estimating equation models were used to assess associations with online sex-seeking. MSM nigerian high levels of stigma as a result of their sexual practices, including verbal, physical, and psychological abuse 5. High levels of sexual behavior stigma may act as a barrier to HIV testing and care for MSM, and this is particularly problematic in countries with concentrated key population epidemics where anti-gay legislation erects further sex 6 — In some parts of Nigeria, homosexual activity between men is punishable by death As a result, there is a strong need for HIV prevention interventions to reach these highly stigmatized and high-risk men.
This high prevalence has partly been due to the increasing popularity sex the Internet and smart phone technology, which has led to a widespread phenomenon of online sex-seeking 16 Furthermore, in countries with high levels of sexual behavior stigma affecting MSM, highly stigmatized MSM may be more likely to seek sex online.
A qualitative study conducted among MSM in Chengdu, China, noted that anonymity and safety were major contributing sites to using the Internet to find male sex partners In the Sub-Saharan African context there is limited information on the frequency and drivers of online sex-seeking among MSM. Recently, Internet-based interventions have been developed in the US, Europe, and other settings to engage online sex-seekers in preventative HIV interventions 20 — Overall, the availability of smartphone technology in Sub-Saharan Africa coupled with high levels of sexual behavior stigma 1517 presents opportunities to develop and optimize Internet-based technologies for HIV prevention programs.
This study describes the patterns and drivers of online sex-seeking among a prospective cohort of MSM presenting for HIV testing and treatment in Abuja and Lagos, Nigeria. Our goals were to: 1 Improve the understanding of the characteristics of Nigerian MSM who use the Internet to find sex partners i. Characteristics were chosen for analysis based on associations with HIV risk and online sex-seeking that were identified in recent studies 1526 — 29and because these characteristics would inform the development or adaptation of online interventions to the Nigerian setting.
Participants were recruited at two study sites in Abuja and Lagos from March to August using respondent-driven sampling RDS 4 These seeds recruit their peers, who then recruit additional peers, and so on until the desired sample size is reached, resulting in multiple waves of recruitment. MSM were eligible to participate if they presented to the study site with a valid RDS coupon, self-reported being ased male sex at birth, were able to provide informed consent in English or Hausa, and reported a history of insertive or receptive anal intercourse in the 12 months.
In addition, participants had to be aged 16 or older with men under the age of 18 considered emancipated minors who were exempt from parental consent for the purpose of this study. The men had to be willing to enroll and participate in follow up for 18 months, including completion of quarterly structured interviewer-administered questionnaires and HIV and STI testing and treatment monitoring. Ultimately, ten seeds recruited 1, baseline participants that resulted in up to 27 recruitment waves.
Equilibrium was reached for several socio-demographic characteristics including age, sexual orientation, and education. For the current analysis, one nigerian was excluded due to site data on the key variable of interest report of using the Internet to find male sex partners. Informed consent was obtained from all individual participants included in this study.
Participants were administered a structured survey instrument across seven different study visits. The survey instrument was validated in studies of MSM throughout Sub-Saharan Africa 3032 — 34 and was pre-tested in Lagos and Abuja before enrollment and sex of the study. Survey measures of interest included socio-demographics, MSM social and sexual networks, experiences and perceptions of sexual behavior stigma in social and healthcare settings, and HIV treatment uptake.
The possible response options were: nigerian home, bar or club, private party, brothel, street or park, private vehicle, hotel or guest house, news advertisements or cards, online, school or work, or mosque or church. Participants could choose more than one location. At visit 1, 3, and 5 participants were asked how often they used the Internet to look for male sexual partners since their site visit.
Participants were asked to report the of MSM that they knew and whether they participated in activities in their MSM community.
They were sex asked to report their of male anal sex partners within the last 12 months and to give more detailed information about condom use, HIV status disclosure, and other information about their five most recent male sex partners. For participants who were aware of living with HIV i.
Participants were asked whether they perceived or experienced stigma in personal, social, or healthcare settings because they have sex with men. Sexual behavior stigma in personal settings was measured by asking sites whether they ever felt excluded by family members, felt like family members gossiped, or felt rejected by friends. Sexual behavior stigma in social settings was measured by asking whether participants knew of safe places in their community to socialize with other MSM, whether they did not feel protected by police, felt scared to walk around in public places, or were ever verbally harassed, blackmailed, or physically hurt because they have sex with men.
Sexual behavior stigma in healthcare settings was measured sex asking participants if they ever avoided or felt afraid to go to healthcare services because they were worried that someone may learn that they have sex nigerian men, if they ever felt that they were not treated well in a health center because someone knew they had sex with men, or if they ever heard a healthcare worker gossiping about them because they have sex with men.
These measures have been used in studies conducted in Sub-Saharan Africa and have been found to be both prevalent and associated with increased online sex-seeking 1534 — STI test were generated within 3 weeks of receipt of the samples and participants were called back to the nigerian for an off study visit to receive treatment if the laboratory diagnosis was positive. Those who tested positive were treated with appropriate antibiotics and retested at follow-up visits. The parallel testing algorithm was followed for high-risk individuals at baseline and among HIV-negative participants at each follow-up visit Whole blood samples were collected for viral load testing at visits 1 — 6.
Those who tested positive for HIV received the standard of care clinical assessment.
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Bivariate analysis was performed using logistic regression to assess associations between variables of interest with the outcome of meeting a male sex partner online at baseline. Pearson chi-square tests were used to compare prevalence of other venues for which online sex-seekers and non-online sex-seekers reported meeting male sex partners.
Multivariate logistic regression models were used to assess the independent associations of MSM social and sexual networks as well as stigma with meeting a male sex partner online at baseline. In addition, multivariate models with generalized estimating equations GEEs and autoregressive correlation matrices were used to assess the association between meeting a male sex partner online and measurements of interest across study visits. GEEs were used to for within-participant correlations and paired data of participants who had multiple study visits.
Analyses were performed using SAS software version 9.
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sex The prevalence of meeting male sex partners online at baseline was Participants could indicate more than one response. Note: Separate regression models were used for each explanatory variable. Note: Separate regression models were used for each outcome variable. The prevalence of This high prevalence suggests that online preventative interventions need to be developed, implemented, and evaluated in the African setting. We also found a link between sexual behavior stigma in social settings with online sex-seeking, which points to the impact of widespread societal prejudice, and is reflected in recent Nigerian legislation banning gay assembly and support for gay organizations.
Our prior publication in this same population documented the negative impact of this law on service uptake and healthcare seeking Notably, the participants who engaged in online sex-seeking were more likely to report sexual behavior stigma in social and healthcare nigerians, were younger, more educated, more engaged in the MSM community, and more likely to be at risk for HIV and STIs. This information may be useful for appropriately adapting online HIV prevention interventions to the Nigerian site.
In the current analysis we observed that participants who enrolled in later waves of RDS recruitment were less likely to have used the Internet for sex-seeking. We know from a separate analysis using these data that clients enrolled in later waves of RDS were less likely to have tested for HIV An intervention to expand access to services such as HIV testing to this highly marginalized subset of the community with high rates of undetected HIV infection is a particular priority.
Moreover, among self-reported HIV-negative participants, online sex-seeking was associated with high risk sex, which suggests that online interventions targeting behavioral change would have the potential to be highly impactful in this population. One potential intervention method could be to promote HIV status disclosure and negotiation of safer sex practices between partners before meeting However, the feasibility of this approach nigerian require pilot testing in a future study.
In addition, the high overall prevalence of STIs including incident rectal STI infection observed in this cohort underscores the importance of presumptive STI testing and treatment 39regardless of whether the interventions are implemented online or offline.
MSM in this study reported meeting partners from a variety of other places aside from the Internet; although online sex-seekers tended to report a higher prevalence of meeting partners in several other venues suggesting an overall larger and more diverse sexual network. Alternatively, it is possible that participants discussed and selected physical meeting venues sex partners who they first met online, which might also explain this finding if sites decided to report both the physical and online venues in their responses to these questions.
Overall, these findings provide an important target for engagement in future online interventions, an approach that will require further understanding of the barriers to Internet site and intervention uptake. The finding of a lack of ificant association sex online sex-seeking and receipt of ARVs or viral nigerian points to opportunities for intervention to support treatment as prevention goals, by using technology to improve adherence to medication and support retention in care 40 Our finding that mobile phone ownership was associated with meeting sex partners online provides opportunity to engage mobile-app technology to achieve these goals.
However, additional research should investigate the potential use of mobile-app social media for HIV-related interventions in West Africa given potential challenges including infrastructure, policy, and competing research and social networking business goals There are potential limitations of this study. First, the associations reported here are exploratory and do not represent causality.
Recent research suggests that factors such as whether the person actually nigerians their Internet-found partner in person sex differentially and more strongly associated with HIV risk, and we did not collect these data However, because equilibrium was reached for several socio-demographic characteristics, this suggests a minimal overall bias due to non-random recruitment. Finally, the sub-cohort in Abuja versus Lagos suggests different patterns of socio-demographics and behavior that could have impacted our.
Lagos is the largest city in Nigeria and is a fast-growing urban center. Participants in Lagos were younger, more educated, more likely to be Christian compared to Muslim, and more likely to identify as gay compared to site. Some of these socio-demographic characteristics may have contributed to the observation that MSM in Lagos were almost twice as likely to report online sex-seeking than participants in Abuja. However, in a sensitivity analysis, we found that the majority of relationships with online sex-seeking were consistent across both sites.
The findings of the current analysis reinforce the universality of challenges in achieving WHO goals for MSM worldwide, but also offer the opportunity to engage best practices in providing services to key populations sex high impact. In particular, online interventions that have been successfully developed and tested in North America and Europe may be transferrable to the African nigerian given the similar HIV risk profile and high prevalence of online sex-seeking.
Internet-based strategies in Nigeria could enrich the current findings with further qualitative and formative research studies to better understand societal drivers of online sex-seeking. Rigorously deed intervention trials that quantify impact of Internet-based strategies on measurable prevention and treatment uptake and outcomes will advance the HIV prevention agenda for high impact in the African setting.
The study team would like to acknowledge the participants for taking part in this study given the ificant stigma that exists affecting gay men and site men who have sex with men in Nigeria. We would also like to acknowledge Sara Kennedy for her leadership support in implementing the study.
Marcy Gelman and Dr. Kevin Kapila from Fenway Health and Dr.