This is the first study to investigate HIV status and risks for HIV infection among MSM in Namibia, Botswana, and Malawi. It is also the first attempt, to our knowledge, to evaluate the human rights contexts among MSM and to link individual level rights abrogation to HIV biological outcomes in the African context.
Overall, HIV rates were substantial, and risks for HIV infection from sex with both were men and women were common. The participants were generally young, though there was a significant association between HIV and age. Excluding the few men above the age of 49, overall more than one-third (35.7%, 95%CI 26.3–46.4) of MSM between the ages of 30–49 were HIV infected. These data suggest that this is not a new epidemic of HIV among African MSM which is spreading more rapidly among younger MSM, as has been seen observed among MSM in other settings such as Russia 
. Because younger men were much less likely to be HIV infected, prevention programs targeting younger MSM in these populations could have marked potential for avoiding future infections. All possible combinations of biomedical and behavioural interventions need to be evaluated including those directed at MSM who are already HIV seropositive
. While very little is known about the benefit of targeted HIV prevention programming among MSM in Africa, in other contexts these approaches are known to be very effective in decreasing unprotected anal intercourse (UAI) 
. Prevention research and optimization of existing prevention tools for MSM are a clear public health priority for Southern Africa.
Approximately two-thirds of MSM had received any information about preventing HIV infection from other men, which was higher than expected. However, given that these men were largely recruited from within the same networks of men who are served by these CBOs, this likely overestimates the men exposed to this information in each country. Basic knowledge and condom access and availability are necessary for increased condom usage, but not sufficient. Recent studies have demonstrated that African MSM are less likely to have UAI if they use water-based lubricants (WBL), have been counseled about the risks of UAI, and more likely to have UAI if they regularly drink alcohol or do not know that HIV can be transmitted via anal intercourse 
. Understanding condom use among MSM in the African context is especially relevant as in all three countries, not always wearing condoms was highly predictive of being HIV positive. If safe sex is defined as the usage of WBL in addition to always wearing condoms, then less than 1 in 20 MSM practiced safe sex in this study. The more common use of oil-based products, including vaseline and body/fatty creams appears partly due to cost and partly to availability. Increasing the availability of affordable and practical WBL should be a key focus of prevention strategies.
A significant proportion of MSM self-identified as either heterosexual or bisexual, and many were married or had at least one female sexual partner in the preceding six months. These results were consistent with a previous knowledge, attitudes, and perceptions study of MSM in Malawi
. Concurrency of sexual relationships, which has been posited by many investigators as a key driver of heterosexual transmission in this region, appears to be relevant to MSM as well
. Some 17% of men overall were in concurrent stable relationships with men and women and over half of the respondents had both male and female sexual partners in previous 6 months, suggesting that concurrency of sexual relationships which include both same and opposite sex partnerships may be an under—appreciated component of HIV spread in this region.
Approximately one tenth of men reported the injection of illegal drugs. There is an increasing appreciation that IDU behavior is also a reality in the African context, and more work is needed to better characterize this risk and its relationship to sexual risk exposures among African men 
The use of the internet to find male sexual partners was common across all three countries with nearly half of the respondents reporting using the internet for this purpose. In settings where homosexuality is criminalized and the police harass MSM, with no open venues for gay people to congregate, the internet has preceded the development of openly gay physical venues. Given the hidden nature of this population, the internet may represent a powerful tool in efficiently accessing and delivering HIV prevention education to these men 
Self-reported sexual orientation as homosexual or bisexual compared to heterosexual was significantly associated with HIV. While not explored here, this differential risk between identities may relate to sexual positioning, and will be relevant to HIV prevention programming 
. Disclosure of sexual orientation to either any one member of their immediate or extended family, or any one health care worker was very low. These are hidden populations of men, currently only accessible for study and prevention programming through sexual and social networks with other MSM. In Kenya, where being MSM has become more of an accepted identity, the MSM community continues to evolve a gay identity and become more socially visible 
. While there is a real risk for backlash, the self-identification of these men and community development may allow for better dissemination of education and prevention measures.
This study served as an assessment of human rights contexts for MSM in these countries. The results are a powerful reminder of the level of stigma, discrimination and human rights abuses that these men face in their everyday lives, including being denied housing and healthcare, being afraid to walk down the streets of one's community, or being afraid to seek health care services. Though each of these rights abrogation likely limit access to HIV preventive services, none were significantly associated with HIV at the individual level. This could have been because abrogations were so common that ceiling effects made attribution difficult, as well as the fact that country sample sizes were small. However, having disclosed sexual orientation to family members was significantly associated with blackmail, and, having disclosed sexual orientation to a health care provider was significantly associated with having been denied health care. In the short term, these two factors will continue to limit disclosure of sexual orientation. In addition, those who reported blackmail were also less likely to have been tested for HIV in last 6 months. These structural barriers to available health care services will limit the efficacy of any interventions targeting individual level determinants of HIV transmission among MSM and must arguably, be mitigated to effectively decrease HIV incidence 
There are several limitations to this cross-sectional study. Resources and the constraints of working with small CBOs in these rights constrained environments limited the scale and scope of these probe studies. Due to the nature of the study we were unable to establish directions of causality. There are known biases in questionnaire-based estimates of sexual violence 
. Specifically, using narrowly defined terms of sexual violence such as rape in a study instrument, as was done in this study, may underestimate its prevalence. The study samples are convenience samples generated by use of chain-referral techniques rather than population-based samples, which is a key limitation with this study methodology and limit the generalizability of the results to the wider population of MSM in respective countries. This problem, referred to as homophily, will likely be best addressed by larger respondent-driven sampling (RDS) studies, and by venue-time sampling approaches, where feasible
. Even with RDS or venue-based sampling, there will be biases in the sample recruited and calculated estimates, though likely of lesser magnitude than when using convenience samples. Non-random sampling may also have overestimated the level of HIV-related knowledge seen in the results
. Finally, MSM tend to congregate in urban areas, which is why recruitment took place in urban centers; again, this may limit generalizability.
One conclusion of this research perhaps bears stating openly: MSM exist in Malawi, Namibia, and Botswana, and are at high risk for HIV infection and human rights abuses. Piot et al. recently published a call to action for HIV prevention indicating that each country should appropriate HIV prevention expenditures in an evidence-based manner 
. To date, there have been no dedicated government expenditures funding evidence-based and targeted HIV prevention programs for MSM in these three countries. To comprehensively address the HIV epidemic, African national AIDS strategies should allocate funds based on evidence such as presented here, ensuring that the right to health care is respected for all. Community partners willing and able to do this challenging work also exist, and supporting these partners and including them in HIV/AIDS fora in country and internationally is likely critical to the success of prevention, treatment, and care programs in these countries.