Same-sex sexual behavior of men in Kenya : implications for HIV prevention, programs, and policy

From 2004 through 2008, we conducted the first large-scale behavioral surveys of MSM in Kenya; the first being a descriptive study of MSM in Nairobi [1,2]. Following the success of this initial assessment, a capture-recapture enumeration and an intervention study of male sex workers was conducted in Mombasa [3,4]. These studies utilized two different sampling strategies designed to recruit members of hard-to-reach populations (e.g. drug users or sex workers)—snowball and time-location (also known as time-venue) sampling. Snowball sampling, in which participants randomly recruit peers from their personal networks, was used to reach MSM in Nairobi. Snowball sampling, however, is a non-probability sampling method, and may fail to reach some MSM and produce biased results [5]. Time-location sampling, in which participants are sampled from a list of contact locations and the times in which they are found at these venues, was used to sample male sex workers in Mombasa. First, we successfully implemented a capture-recapture enumeration of male sex workers who sell sex to men. This entailed conducting two enumerations of male sex workers one week apart, whereupon men counted in only one week or both weeks ("recaptures" or matches) enabled a population estimation derived from capture-recapture calculation. This activity also produced detailed data on locations and times where male sex workers were seeking clients. These data were utilized to produce the time-location sampling frame. Some of the key findings from these surveys are highlighted in Table 4. Results from these studies firmly established that some MSM in Kenya were engaging in sexual behaviors that put them at risk of HIV infection. In Nairobi, 47 percent of respondents reported multiple male sexual partner activity in the past one month, while 74 percent of male sex workers in Mombasa reported multiple male sexual partners in the past seven days. Men in both studies also reported ever, or currently having, female sexual partners; including some men who reported having female wives. In Mombasa, 29 percent (2006) and 39 percent (2008) of male sex workers reported having a female paying or nonpaying sex partner in the past 30 days. 131 Self-reported condom use in these studies varied, with as many as 56 percent of MSM in Nairobi reporting consistent condom use in the past 12 months. Only 36 percent of male sex workers in Mombasa, however, reported consistent condom use in the 2006 baseline survey. A majority of participants in both studies, however, reported using oil-based lubricants. Only 26 percent of MSM in Nairobi and 21 percent of male sex workers in Mombasa correctly knew that only water-based lubricants should be used with latex condoms, and only 15% of male sex workers in the 2006 survey had used a water-based lubricant with their last male client. Reported use of oil-based lubricants was significantly associated with ever experiencing condom breakage. While respondents considered condoms to be available and affordable, water-based lubricants were perceived to be scarce and costly. In Nairobi and Mombasa, water-based lubricants are only available in select supermarkets and pharmacies, where a 50-gram tube of K-Y Jelly costs approximately U.S. $4.00 (about 320 Kenya Shillings), compared with U.S. $0.30 (about 25 Kenya Shillings) for a 25-gram container of petroleum jelly.

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