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 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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