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Factors Associated With Prevalent HIV Infection Among Kenyan MSM: The Anza Mapema Study

Kunzweiler, Colin P. MS*; Bailey, Robert C. PhD, MPH*; Okall, Duncan O. BSc; Graham, Susan M. MD, MPH, PhD; Mehta, Supriya D. MS, PhD*; Otieno, Fredrick O. DCMS, MPH, PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: November 1, 2017 - Volume 76 - Issue 3 - p 241–249
doi: 10.1097/QAI.0000000000001512
Epidemiology
Free
SDC

Background: To inform future HIV treatment and care programs for men who have sex with men (MSM), we assessed the prevalence of and factors associated with previously diagnosed HIV-positive and out-of-care (PDOC) or newly diagnosed HIV-positive and out-of-care (NDOC) HIV infection among MSM enrolled in the prospective Anza Mapema cohort study.

Methods: Participants were aged 18 years and older, reported oral or anal sex with a man in the past 6 months and were not already in HIV care or taking antiretroviral therapy in the past 3 months. At enrollment, men were tested for HIV infection and completed questionnaires through audio computer–assisted self-interview. Multinomial logistic regression was used to identify associations with PDOC or NDOC HIV infection, relative to HIV-negative status.

Results: Among 711 enrolled men, 75 (10.5%) were seropositive including 21 PDOC and 54 NDOC men. In multivariable modeling, PDOC status was more likely than HIV-negative status among men who had experienced upsetting sexual experiences during childhood, had recently experienced MSM trauma, and did not report harmful alcohol use. NDOC infection status was more common among men aged 30 years and older and who had completed ≤8 years of education, relative to HIV-negative status.

Conclusions: Most HIV-positive men were unaware of their infection, indicating that HIV testing and counseling services tailored to this population are needed. To improve linkage to and retention in care, HIV testing and care services for MSM should screen and provide support for those with hazardous alcohol use and those who have experienced childhood sexual abuse or MSM trauma.

*Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL;

Nyanza Reproductive Health Society, Kisumu, Kenya; and

Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, WA.

Correspondence to: Colin P. Kunzweiler, MS, Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 West, Taylor Street (M/C 923), Room 917, Chicago, IL 60612 (e-mail: ckunzwe2@uic.edu).

The Anza Mapema Study was supported through funding provided by the Centers for Disease Control and Prevention (U01GH000762) and by Evidence for HIV Prevention in Southern Africa (MM/EHPSA/NRHS/0515008).

The authors have no funding or conflicts of interest to disclose.

The conclusions, findings, and opinions expressed by authors do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Received March 09, 2017

Accepted July 14, 2017

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INTRODUCTION

Sub-Saharan Africa continues to have the most burdensome HIV/AIDS epidemic in the world, and in 2013, there were an estimated 24.7 million people living with HIV and 1.5 million new infections in the region.1,2 HIV testing is an essential first step for HIV prevention and a prerequisite for seeking and receiving treatment. The UNAIDS 90-90-90 targets have prioritized awareness of infection status among persons living with HIV.3,4 National campaigns in several countries of sub-Saharan Africa have led to dramatic increases in the uptake of HIV testing and counseling services. However, more than half of people living with HIV in this region are unaware of their infection status, and of those living with HIV, less than half are accessing antiretroviral therapy (ART).2,5

There is increasing evidence that men who have sex with men (MSM) contribute importantly to the HIV epidemic.6–8 For example, in Kenya, more than 15% of all new HIV infections are estimated to be attributable to male–male sex.9–11 In addition, studies conducted throughout sub-Saharan Africa demonstrate that MSM are burdened by HIV prevalence 2–4 times higher than the general male population.12–19 MSM are a vulnerable, hidden population in sub-Saharan Africa. The legal, political, and sociocultural contexts that enable stigma and discrimination based on sexual orientation challenge researchers' and clinicians' ability to identify, test, link, and retain MSM in treatment and care.4 Although Kenya has been at the forefront in recognizing the role of MSM in the HIV epidemic in sub-Saharan Africa over the past 10 years,20 to achieve the UNAIDS 90-90-90 targets, there is need to develop and implement programs that assist MSM to accept testing, to know their status, and to become engaged in treatment and care. In addition, successful programs must be able to offer comprehensive services that address health needs related to sexual abuse and discrimination, alcohol and substance abuse, and depression and mental health symptoms.21

We launched a longitudinal cohort study called “Anza Mapema” (Kiswahili for “Start Early”) to implement a program designed to address many of the needs for gay, bisexual, and other MSM in Kisumu, Kenya, and to provide services that will optimize HIV testing and engagement in care and treatment. The objectives of this analysis were to report the prevalence of HIV infection at baseline among Anza Mapema study participants, and to assess the sociodemographic characteristics and sexual risk behaviors associated with MSM of previously known and unknown HIV status but who were not engaged in care and treatment.

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METHODS

Recruitment and Eligibility

Recruitment occurred between August 31, 2015, and September 17, 2016, and incorporated snowballing and peer outreach at hotspots. Recruitment initially started among an existing network of 200 MSM and was expanded through existing MSM support groups.22 Trained peer outreach workers also recruited men from mapped hotspots—bars, discos, and hotels—and through their own networks using an institutional review board–approved script. Enrolled participants were encouraged to recruit their partners and additional men. All men aged 18 years and older, reporting anal or oral intercourse with another man in the previous 6 months, not participating in another HIV intervention or vaccine study, and not enrolled in an HIV care program or taking ART within the past 3 months were eligible to participate.

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Interview Questionnaires

Study questionnaires were available in DhoLuo, English, and Kiswahili and were administered through audio computer–assisted self-interview (ACASI).23 Data collected through ACASI focused on sociodemographic characteristics; sexual risk behaviors; alcohol and substance use; social support; depressive symptoms; experiences of stigma and trauma related to MSM status; and disclosure of same-sex behavior.

Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT; range: 0–40; Cronbach's alpha = 0.91 for study). To simplify the questionnaire for this low literacy population, participants who responded “never” to the first question: “How often do you have a drink containing alcohol?” did not respond to any of the 10 AUDIT questions and were scored as 0. We dichotomized scores at ≥8, the recommended indicator of harmful alcohol use.24–26 Substance use was assessed using 6 binary questions adapted from the Drug Abuse Screening Test 10 (DAST-10) to reflect patterns and consequences of substance use (nonalcohol, nontobacco, and nonprescription) over the past 12 months (range: 0–6; Cronbach's alpha = 0.85 for study). We summed these questions and dichotomized the score at ≥3 for harmful substance use.25,27 Social support was collected using 11 questions from the Medical Outcomes Study (MOS) Social Support scale (range: 0%–100%; Cronbach's alpha = 0.91 for study).28 Depressive symptoms were collected using the Personal Health Questionnaire-9 (PHQ-9; range: 0–27; Cronbach's alpha = 0.82 for study; dichotomized at ≥15), which assessed the occurrence of severe depressive symptoms over the past 2 weeks.29,30

Experiences of MSM-related discrimination and violence within the past 12 months were collected using 4 binary questions of the United States Agency for International Development (USAID) Health Policy Initiative (HPI) MSM Trauma Screening Tool. Because of high levels of missing data on 2 questions, participants' responses to experiences of physical abuse and threats because of same-sex behavior were examined as a single dichotomous variable reflecting MSM trauma. Because of low internal reliability (Cronbach's alpha = 0.63 for study), we assessed experiences of physical and sexual abuse during childhood through 4 dichotomous questions from the Childhood Experience of Care and Abuse (CECA) tool.31,32 Because these 4 variables were strongly correlated, we examined whether men ever experienced upsetting sexual experiences during childhood with a related adult or person in authority (yes/no) as an indication of childhood sexual abuse. Disclosure of same-sex behavior was assessed by 4 binary (yes/no) questions (Cronbach's alpha = 0.79 for study), and a composite dichotomous variable reflected whether the participant openly discussed same-sex behavior with any of his family members or friends, at work or school, or when in public.

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HIV Infection Status

After all questionnaires were completed, a trained and certified counselor provided pretest counseling, encouraged participants to read and interpret the results of the HIV rapid tests, and provided posttest counseling to all participants. HIV serostatus was determined through a serial testing algorithm that included 2 rapid tests, the Colloidal Gold rapid test kit (KHB Shanghai Kehua Bio-engineering Company, Ltd., Shanghai, China), and later the Determine HIV-1/2 test (Abbott Laboratories, Chicago, IL), and the First Response Rapid HIV test kit (Premier Medical Corporation, Pty., Ltd., Kachigam, India).33 All indeterminate test results were confirmed with enzyme-linked immunosorbent assay. HIV status at baseline was treated as a 3-category variable: HIV-negative, previously diagnosed HIV-positive and out-of-care (PDOC), and newly diagnosed HIV-positive and out-of-care (NDOC). We separated HIV-positive men into PDOC and NDOC infections because the behaviors of men who are already aware of their HIV infection may be different from those who are unaware of their HIV infection.34,35

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Statistical Analysis

The distribution of sociodemographic characteristics, sexual risk behaviors, psychosocial characteristics, and clinical characteristics were tabulated for the entire sample and by HIV status at baseline. We compared medians for non-normally distributed continuous variables using the Kruskal–Wallis test and used Pearson's χ2 or the maximum likelihood ratio χ2 (for cell frequencies ≤5) to assess differences in frequencies and proportions of categorical variables. Multinomial logistic regression was used to analyze associations with PDOC infection status vs. NDOC infection status, with HIV-negative men as the referent outcome category. Variables associated with the outcome categories at P ≤ 0.20 in bivariable regression analyses were entered into an initial multivariable multinomial logistic regression model. In addition, harmful alcohol use was included in an initial multivariable model because of qualitative differences in its association with PDOC and NDOC status in bivariable analysis. Highly correlated variables were eliminated, and a manual backward model selection procedure using likelihood ratio tests was performed, retaining variables where P ≤ 0.05 in the final model. Model fit was assessed using a generalized goodness-of-fit test for the final model. A Wald test was used to assess whether the 2 HIV-positive categories could be combined. The independence of irrelevant alternatives assumption was assessed using the Small–Hsiao test. All P values were 2-sided. All analyses were completed using Stata/SE 14.0.36

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Ethics Statement

The Anza Mapema Study was approved by the Maseno University Ethics Review Committee, the Institutional Review Board of the University of Illinois at Chicago, and the Human Subjects Division of the University of Washington.

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RESULTS

Study Participants

A total of 1012 men were screened and 248 were found to be ineligible. The most frequent reason for ineligibility was reporting no anal or oral intercourse with another man in the past 6 months (n = 180). Three men enrolled twice and 5 declined to participate. Of the 756 men who consented to participate, 35 did not complete all enrollment procedures, 9 were later found to be taking ART at enrollment, and 1 later stated he had never had intercourse with a man; these 45 men were withdrawn. Thus, 711 participants were enrolled in the Anza Mapema Study; 636 (89.5%) were HIV-negative, 21 (3.0%) were PDOC, and 54 (7.6%) were NDOC (Table 1).

TABLE 1-a

TABLE 1-a

TABLE 1-b

TABLE 1-b

Overall, the median age was 24 years [interquartile range (IQR): 21–28], most men (79.1%) had completed at least 9 years of education, and most men were employed (54.7% full time and 18.1% as casual laborers). Also, 73.3% of all men were single (Table 1). Half (50.1%) of all men reported harmful alcohol use (AUDIT ≥ 8), and 23.8% reported harmful substance use over the same period (DAST ≥ 3). Also, 11.4% of all men reported severe depressive symptoms (PHQ-9 ≥15) and the median level of social support was 50% (IQR: 34%–64%). Most men (71.9%) reported having had sex with a female partner, and 49.3% of men reported having had sex with a female partner in the past 3 months.

Several characteristics varied by HIV status. Median age was greater for both PDOC (median = 28; IQR: 22–32) and NDOC (median = 27; IQR: 22–32) men compared with HIV-negative (median = 23; IQR: 21–28) men (P < 0.01; Table 1). Among all men, 10.7% earned income primarily through sex work; 19.0%, 11.1%, and 10.4% for PDOC, NDOC, and HIV-negative men, respectively (P = 0.01). In addition, the proportion of men who always used a condom during anal intercourse (AI) with another man was 19.1%, 30.2%, and 40.9% among PDOC, NDOC, and HIV-negative men, respectively (P = 0.05). Although nearly one-third (30.9%) of all men experienced upsetting sexual experiences during childhood with a related adult or person in authority, this figure was 61.9% for PDOC men, 33.3% for NDOC men, and 29.7% for HIV-negative men (P = 0.01). Similarly, although 39.1% of all men had experienced MSM trauma within the past 12 months, 71.4% of PDOC men, 42.2% of NDOC men, and 37.7% of HIV-negative men had experienced MSM trauma (P = 0.01).

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Clinical Characteristics Among HIV-Positive Men

Among the 75 men diagnosed HIV-positive at enrollment, the median log10 plasma viral load was 4.1 (IQR: 1.3–4.6) and did not differ (P = 0.49) between PDOC and NDOC men (Table 2). Among all HIV-positive men, 23 (31.1%) were virally suppressed (plasma viral load <1000 copies/mL per Kenya Ministry of Health guidelines), 16 of whom were NDOC men. Viral load was <200 copies/mL (considered virally suppressed per the Centers for Disease Control and Prevention guidelines) for 20 men (27.0%), 15 of whom were NDOC men (data not shown). Two men, both of whom were PDOC, reported having previously taken antiretroviral medications (median log10 plasma viral load = 2.7; IQR: 1.3–4.0). Among all HIV-positive men at enrollment, the median CD4 count was 486 (IQR: 338–664). Two NDOC men had a CD4 count less than 200 cells/mm3 reflecting advanced immunosuppression. Among all HIV-positive men, 20.6% had advanced beyond WHO clinical stage 1.

TABLE 2

TABLE 2

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Factors Associated With HIV Status

Older age (≥30 years), ≤8 years of education, being separated or divorced from a female sex partner, condom use during AI with another man, MSM trauma, social support, severe depressive symptoms, and having experienced upsetting sexual experiences during childhood were all associated with HIV status (P ≤ 0.20 for at least 1 pairwise comparison) in unadjusted multinomial logistic regression analyses (Table 3) and were entered into an initial multivariable model. In the final multivariable model, the adjusted relative risk ratio (aRRR) of PDOC status relative to HIV-negative status was higher among men who experienced MSM trauma (aRRR = 3.59; 95% confidence interval (CI): 1.43 to 9.00), those who did not report harmful alcohol use (aRRR = 3.46; 95% CI: 1.63 to 7.37), and those who experienced upsetting sexual experiences during childhood (aRRR = 3.42; 95% CI: 1.44 to 8.12) (Table 4). NDOC infection status at enrollment was associated with older age (for men ≥30 years, compared with men 18–19 years, aRRR = 3.90; 95% CI: 1.01 to 15.04) and completing ≤8 years of education (aRRR = 2.23; 95% CI: 1.00 to 4.97). Postestimation model diagnostics and the Small–Hsiao test indicated that the 3 outcome categories were independent.

TABLE 3

TABLE 3

TABLE 4

TABLE 4

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DISCUSSION

With 711 men completing baseline procedures, the Anza Mapema Study represents one of the largest cohorts of MSM recruited in sub-Saharan Africa. Seventy-five (10.5%) men were HIV-positive at baseline, and most of these (72.0%) were newly diagnosed. The National AIDS and STI Control Programme (NASCOP) of Kenya aims to identify 80% of all persons living with HIV by the end of 2017.10 However, NASCOP estimates that 53% of people living with HIV in Kenya are unaware of their status.11,37 Late diagnosis represents a critical challenge among our sample of MSM. Expanded outreach and testing strategies that can engage MSM will be needed if we are to achieve NASCOP and UNAIDS 90-90-90 targets.11,37 In addition, 21 (28.0%) men were previously diagnosed and out-of-care, indicating that there are linkage and retention-related challenges among this sample of MSM. Poor retention in care can result in adverse individual health consequences, and among the 21 PDOC men, 28.6% had progressed beyond WHO clinical stage 1. Although Kenya has made substantial progress in scaling-up access to HIV care and ART over the past 10 years,10,11 retention efforts responsive to the specific needs for MSM will be necessary to achieve and sustain a retention rate of 90%.

Although the prevalence of HIV among this sample of MSM is approximately double that of general population estimates for Kenyan men (5.6%), it is lower than previous prevalence estimates for men in Kisumu County (17.8%),38–40 as well as estimates among MSM in Coastal Kenya (24.5% among 285 MSM in 2007)7 and in Nairobi (40% among 507 MSM sex workers).41 The lower prevalence of HIV in the Anza Mapema Study may be due to a recruitment focus on a broader MSM population, as opposed to MSM sex workers, to a younger sample than in other studies, and to the exclusion of men who were already enrolled in HIV care or had taken ART within 3 months of enrollment. Among 248 men ineligible to participate, 39 (15.7%) were already enrolled in a HIV care and treatment program. We do not know the number of men with undiagnosed infections who were excluded on the basis of other criteria, or men with known or undiagnosed infections who did not visit the Anza Mapema clinic for eligibility assessment. Thus, the prevalence of HIV among the men enrolled in the Anza Mapema Study should not be considered generalizable to all MSM in Kisumu.

Among all MSM enrolled in the Anza Mapema Study, most (71.9%) had had sex with a female partner and 49.3% had had sex with a female partner in the past 3 months. Of note, condom use at last sexual encounter with a female partner was low at 51.1%, compared with 64.3% reporting condom use at last sex with a man (data not shown). In Kisumu County, HIV prevalence among women is approximately 20%.39 Thus, prevention messages should emphasize consistent condom use and safer sex practices as they relate to the same-sex and male–female sexual behaviors of the MSM enrolled in this study.

The probability of PDOC status relative to HIV-negative status at enrollment was decreased among men reporting harmful alcohol use. Although the temporal relationship of these 2 factors is unclear, this finding is consistent with evidence suggesting that there are reductions in alcohol use after HIV testing and counseling and learning one's serostatus.42 Harmful alcohol use is a barrier to linkage to and retention in HIV prevention and treatment services,11 and it is concerning that 50.2% of HIV-negative and 53.7% of NDOC men reported harmful alcohol use. Among PDOC men, harmful alcohol use still affected 38.1%. In our sample, those who reported harmful drinking were less likely to always use a condom during AI with a man (P = 0.02; data not shown). Thus, alcohol abuse services should be integrated into future HIV prevention and treatment services.

There is growing evidence that childhood sexual abuse among MSM is a widespread challenge.43–46 In this sample, 30.9% of all men, and 61.9% of PDOC men, had experienced upsetting sexual experiences during childhood with a related adult or person in authority. This is consistent with results for a cohort of MSM in Coastal Kenya, where 33.9% of men had an upsetting sexual experience during childhood with a related adult or person in authority.46 In addition, a meta-analysis of 15,622 MSM enrolled in 12 studies in the United States estimated the prevalence of childhood sexual abuse to be 21.8%.47 Childhood sexual abuse may have long-term health consequences and is associated with adverse psychological outcomes including depressive disorders.48–50 Childhood sexual abuse was strongly associated with depressive symptoms in this sample (unadjusted odds ratio = 1.73; 95% CI: 1.08 to 2.77; P = 0.02; data not shown) in which 81 (11.4%) men reported moderately severe or severe depressive symptoms. Among self-identified MSM in Coastal Kenya, the prevalence of major depressive disorder was 16.1%,46 compared with a 5% prevalence among the general population.51 These results suggest that Kenyan MSM are disproportionately burdened by depressive disorders. In addition to adverse psychological challenges, childhood sexual abuse is associated with sexual risk behaviors47–49 and sexually transmitted infections including HIV.47,48,52,53 Most men do not seek or receive services of any kind after experiences of sexual violence.45,54 In the case of the men enrolled in the Anza Mapema Study, childhood sexual abuse may have resulted in poor linkage to HIV treatment and care among PDOC men. HIV prevention interventions for MSM should screen for such abuse and provide men with, or refer men to, appropriate counseling services that address the potential long-term psychological and behavioral implications of such experiences.

MSM trauma is increasingly relevant in the sub-Saharan African HIV epidemic. Although we measured participants' recent experiences of physical abuse and verbal threats through 2 questions of the USAID HPI MSM Trauma Screening Tool, we were unable to perform a comprehensive assessment of stigma, discrimination, and violence. However, multiple studies report that MSM experience high levels of physical violence and verbal threats,55–59 which is consistent with our findings. In addition, 28.0% of all men in the Anza Mapema Study reported having ever been refused health care services because of same-sex behaviors (data not shown), which is consistent with others who have shown that MSM trauma may limit access to and utilization of medical services.60 Although same-sex behavior remains illegal in Kenya, the implementation of a human rights–based approach to HIV treatment as advocated by the Kenya Ministry of Health11 will be necessary to ensure that MSM have unhindered access to HIV screening, prevention, and counseling services.

There are several limitations associated with these results. First, the cross-sectional nature of this analysis prohibits a causal interpretation of associations. Second, in the absence of a sampling frame, we used nonprobability sampling techniques to recruit participants using a known network of ≈200 MSM and outreach at known MSM hotspots. In addition, we excluded men who were already in HIV care to focus on testing and linkage. Therefore, the participants enrolled in the Anza Mapema Study are not representative of the MSM population in Kisumu or in Kenya. Third, participation bias is possible, as MSM who participated in the study may be different from MSM who refused to participate or who were not assessed for study eligibility. Fourth, although we collected baseline questionnaire data through ACASI, which may reduce response bias and interviewer bias that may occur during face-to-face interviews,61,62 misreporting of sexual behaviors is possible. Limitations in recalling sexual behaviors and reporting psychosocial factors for the 12 months before enrollment may also result in misclassification. Fifth, misclassification due to the subjective nature of psychosocial scales is possible, especially as the scales used have not been validated specifically among Kenyan MSM. Although some of the scales were adapted to reduce questionnaire length and increase comprehension, all were based on instruments that were validated among other populations and demonstrated acceptable internal reliability. Finally, it is clear that some men may have misrepresented their HIV care status to join the study, as some HIV-positive men later admitted to taking ART and several had a suppressed viral load at enrollment. Despite these limitations, we have demonstrated the ability to engage a large number of MSM in a rights-constrained setting and capture detailed behavioral data. Longitudinal follow-up of this cohort is expected to clarify psychosocial factors, risk behaviors, adherence to treatment, and HIV/STI outcomes in Anza Mapema participants.

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CONCLUSIONS

Among the 711 MSM enrolled in the Anza Mapema Study, prevalence of PDOC and NDOC HIV infection was high and most HIV-positive men were unaware of their infection. Kenya and other countries in sub-Saharan Africa have made significant progress in encouraging people to know their status to achieve the UNAIDS 90-90-90 goals. However, given that a large proportion of HIV-positive MSM enrolled in this study were newly diagnosed, it is clear that greater efforts are necessary to reach this vulnerable population, and to support innovative ways to engage them in HIV testing, care, and treatment. Alcohol use represents a critical challenge among MSM in Kisumu. In response to these findings, we provided additional training to study personnel and peer educators and implemented both group and individual alcohol and drug reduction counseling for men who report harmful alcohol and drug use. We will conduct ongoing evaluations among men who use these services during follow-up. Men who experienced childhood sexual abuse and same-sex–related trauma were more likely to be previously diagnosed and out-of-care. If we are to successfully engage and retain MSM in HIV care and treatment, researchers and clinicians must screen for these histories and provide supportive counseling. MSM will continue to play an important role in the HIV epidemic of sub-Saharan Africa, and programs specifically targeting MSM such as Anza Mapema are necessary as we expand HIV prevention services and promote and sustain HIV treatment and care for MSM.

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ACKNOWLEDGMENTS

The authors thank the men of the Anza Mapema Study. Special thanks also go to all research and staff members of the Anza Mapema Study and the Nyanza Reproductive Health Society including Leah Osula, Beatrice Achieng, George N'gety, Caroline Oketch, Violet Apondi, Evans Kottonya, Caroline Agwanda, Paula Abuor, Ted Aloo, George Oloo, Caroline Obare, Risper Oyah, Haron Kadieda, Lilian Jumba, Violet Awuor, Eve Obondi, Lucy Atieno, Milcah Ariongo, Peter Oketch, William Oriedo, Francis Etiat, and Edmon Obat. The authors thank Dr. Ross Slotten and the Slotten Scholarship in Global Health at the University of Illinois at Chicago for supporting this work.

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Keywords:

men who have sex with men; MSM; Anza Mapema; Kenya; HIV prevalence

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