The 252 study participants had a mean age of 26.3 years with a range of 18 to 56 years. Study participants were mostly ethnic Basotho (96.4%, 240/249), approximately half were currently employed (49.6%, 124/250), and 59.2% had a tertiary or vocational-level education (Table ). Nearly three-quarters of participants reported being of urban origin, defined as being from cities with a population of greater than 100,000 people (72.6%, 172/237). When asked about sexual orientation, 58.6% (137/234) self-reported as being gay, 26.5% (62/234) self-reported as bisexual, and 13.7% (32/234) self-reported as heterosexual. Seventy-six of 234 participants (32.5%) had disclosed the fact that they engage in same-sex practices with other men to any member of their immediate or extended family, whereas 24.4% (56/230) had disclosed these sexual practices to even a single healthcare worker. In total, 25.2% (56/222) reported ever being married, including 16.7% (37/222) who were currently married, 6.3% (14/222) who were divorced, and 2.3% (5/222) who were widowed. Forty-four of 207 (21.3%) reported having children, all of whom reported ever having been married.
Selected characteristics of men who have sex with men in Lesotho
There was great variability in the estimates of network sizes of MSM with a mean of 65, median of 30 and a range of 0-900. There was similar variability among the number of those seen in the last six months with a mean of 37, a median of 18 and a range of 0-767. Significantly more men had received any information from health providers regarding how to prevent HIV infection from women as compared with preventing infection from men (76.8% vs 63.3%, z = 3.97, p < 0.001). HIV-related information among participants was limited, with 19.0% (47/248) reporting that anal sex was the highest risk sexual practice for HIV transmission.
Moreover, 58.9% (146/248) reported that vaginal, anal and oral sex all carried the equivalent probability of HIV acquisition and transmission; 16.3% (40/245) correctly reported that receptive anal intercourse carried higher per coital act risk than insertive anal intercourse. Finally, less than half of men (44.8%, 98/219) knew that a water-based lubricant was the safest to use for anal intercourse. More than 30% of men (30.6%, 67/219) reported that petroleum-based products were safest to use. Only 3.8% (8/212) of participants gave the correct answers to these three questions regarding sexual transmission.
Fourteen study participants (7.7%, 14/183) reported injecting illicit drugs in the last 12 months, with 30.8% (76/247) of all study participants reporting being unaware that HIV could be transmitted parenterally. Alcohol use was common, with 33.8% (75/222) reported drinking alcohol more than five days per month; nearly half of the sample (47.8%, 110/230) reported being less likely to use condoms during sexual intercourse when drunk. In all, 22.2% (54/243) reported having received money or goods for anal sex with men, and 27.7% (65/235) reported having paid money or goods for anal sex with men; 35.9% (87/242) reported either paying or receiving money or goods for sex.
Table shows key sexual practices among MSM in Lesotho. The majority of men (75.1%, 172/229) reported having a regular male partner; 44.3% (94/212) reported having a regular female partner; 28.6% (58/203) reported concurrent regular male and female partners; and 41% (71/173) reported active bisexuality with both male and female sexual partners in the last year. Fifty-three of 222 (28.4%) reported five or more male sexual partners in the last year, and 20.2% (38/188) reported three or more female partners during the same time frame. Condom use during last sexual encounter with a regular male partner was reported by 62.5% (135/216) of men, and 59.8% (128/214) reported condom during last sex with a non-regular male partner. With women, 32.8% (40/122) reported wearing a condom during last sexual intercourse, which was significantly less than condom use during last sexual intercourse with any male partner (45.5%, 94/207, p < 0.01). Self-reported HIV prevalence was 11.6% (22/190), with 54.5% (128/235) of men reporting being tested for HIV in the last year; 15.4% (35/228) reported having clinical symptoms consistent with a sexually transmitted infection (STI) in the last year, whereas 8.1% (19/235) reported having been diagnosed with an STI at a clinic in the last year.
HIV sexual risk practices among MSM in Lesotho
Bivariate associations of wearing condoms during last intercourse with men include: having easy access to condoms (OR 3.1, 95% CI 1.2-8.5, p < 0.05); being older than 26 (OR 2.3, 95% CI 1.3-4.2, p < 0.01); knowing that receptive anal intercourse is higher risk than insertive anal intercourse (OR 2.6, 95% CI 1.2-5.9, p < 0.05); wearing condoms with female sexual partners (OR 3.5, 95% 1.4-8.3, p < 0.01); using water-based lubricants (OR 2.8, 95% CI 1.4-5.5, p < 0.01); being less likely to report having been diagnosed with a sexually transmitted infection (OR 0.21, 95% CI 0.06-0.76, p < 0.05); being more likely to have been tested for HIV in the last year (OR 2.0, 95% CI 1.2-3.6, p > 0.05); and being less likely to report having been afraid to seek healthcare (OR 0.40, 95% CI 0.20-0.82, p < 0.05). Self-reported HIV infection was significantly associated with: reporting transactional sex (OR 3.1, 95%CI 1.2-7.7, p < 0.05); having more than five male partners in the last year (OR 2.6, 95% CI 1.0-6.7, p < 0.05); having been diagnosed with an STI (OR 8.6, 95% CI 2.8-26.6, p < 0.01); having had symptoms of an STI in the last year (OR 8.2, 95% CI 2.9-23.6, p < 0.01); having been raped (OR 3.4, 95% CI 1.1-10.7, p < 0.05); and partaking in injecting drug use in the last year (OR 5.1, 95% CI 1.1-22.5, p < 0.05).
Table demonstrates that human rights abuses were common among MSM in Lesotho, with 76.2% (170/223) reporting at least one abuse related to their sexuality. Rights abuses include rape (9.8%, 22/225), blackmail (21.3%, 47/221), fear of seeking healthcare (22.2%, 49/221), police discrimination (16.4%, 36/219), verbal or physical harassment (59.8%, 140/234), or having been beaten (18.9%, 43/228). In addition, 9.2% (19/207) reported that their first sexual encounter with a man was with a member of their own family. In bivariate analyses, blackmail was significantly associated with having disclosed sexual orientation to a healthcare worker (OR 3.6, 95% CI 1.8-7.3, p < 0.05) or family member (OR 2.7, 95% CI 1.4-5.3, p < 0.05).
The prevalence of human rights abuses among MSM in Lesotho