This study, conducted in Mombasa among PLHIV not accessing HIV treatment, shows the population has high levels of unsafe sex. Almost sixty percent of the participants were sexually-active during the last 6 months. This is significantly higher than that reported in our previous study in Mombasa among PLHIV receiving ART (44%) and PLHIV receiving co-trimoxazole prophylaxis without ART (47%) [
7], and in other studies among PLHIV accessing care services in Cote d' Ivoire (47%), Uganda (48%) and Cameroon (47%) [
8,
10,
39]. Further, participants reported unprotected sex with more than half their sexual partners, significantly more with regular partners than non-regular partners. This is much higher than that reported among ART-naïve PLHIV in Uganda and South Africa [
4,
9,
37] as well as among PLHIV on ART and those on co-trimoxazole prophylaxis without ART in Mombasa [
2,
7]. It is of concern that unprotected sex was reported with a third of HIV-negative partners and half of untested partners (people with unknown HIV status). This presents a serious HIV prevention challenge, particularly as 75 percent of the partners were untested and only 37 percent of the PLHIV had disclosed their HIV status to their partners. In a review article, Kalichman et al. (2000), have also reported high levels of unsafe sex with HIV-negative and unknown status partners [
17]. Disclosure of HIV serostatus to partners and perceived stigma emerged as independent determinants of safe sex behaviors. It is important to note the intersection of the two determinants where PLHIV are reluctant to disclose for fear of rejection (perceived stigma) which may or may not happen [
18,
19]. Loubiere et al. (2009) and King et al. (2008) also link disclosure of HIV status with safe sex behavior in studies from Cameroon and Uganda [
21,
35]. Our study also highlights the role that the belief that condoms reduce pleasure and condom-use fatigue play in influencing safe sex. Conley and Collins (2005) found condom non-users to be more likely to believe that condom use interferes with pleasure; more commonly among males. Randolph et al. (2007) report similar results on condom use [
40,
41]. Prevention programs need to develop and implement strategies to change attitudes and beliefs about condoms. Further, more than half of the participants who did not want to have children were not using contraception, indicating high levels of unmet family planning need. Although it has been discussed extensively, effective integration of family planning counseling and services into HIV prevention programs has not been implemented and merits urgent action [
42,
43].
We documented other risky sexual practices such as unprotected sex during menstruation and unprotected anal sex. Sexual exposure to genital blood during menstruation is believed to facilitate transmission of HIV and other STIs [
44,
45]. We also report same sex behaviors among male participants: almost a quarter of all sexual partners reported by male participants were male. It is possible that a MSM peer could have recruited MSM participants. Mombasa has a fairly large population of male sex workers and unprotected anal sex is frequently reported in this population [
46,
47]. Anal intercourse is reported relatively less frequently by women. Fifteen percent of female participants in our study reported ever anal sex and the vast majority did not use condoms. Kalichman et al. (2009) report a 10% prevalence of heterosexual anal sex reported by women interviewed from community and clinic settings in South Africa [
48]. The relatively low prevalence of anal intercourse among heterosexual individuals may be offset by its greater efficiency for transmitting HIV [
49]. Health workers need to specifically discuss these forms of risky sexual behaviors during prevention counselling.
The study provides evidence that prevention programs can reach PLHIV who are not accessing HIV care services through community health workers or peer counsellors. About three-quarter of the participants were not accessing any HIV care and support services that they could benefit from; and more than half of them had been tested positive more than 12 months previously and were therefore, more likely to have forgotten any prevention messaging at the time of post-test counselling. This occurred despite the increased availability of HIV care services and ART in recent years. Further research is needed to examine why some PLHIV are not accessing HIV care services.
The study is not without limitations. We recruited participants using non-probability modified targeted snowball sampling. Although our sample is not a randomly recruited representative sample, this technique did allow us to reach PLHIV within the community who are otherwise not accessible. We believe we were able to recruit a sufficiently diverse and representative sample for this study. We did not use Respondent Driven Sampling, a technique used commonly for hidden hard-to-reach populations such as MSM and injecting drug users, as this sampling method relies heavily on the recruitment of peers through their social networks, and we felt this to be unsuitable for our population and setting. In Mombasa, the network of positive people is small and poorly organized and, our previous study showed that PLHIV were reluctant to reveal their status and were poorly networked, with high levels of internalized stigma. This has also been reported by other African studies [
11,
12,
28]. Our study sample consisted of 76% female participants. There could be several reasons for this: women tend to stay at home and therefore may be more easily contacted by health workers, women may access care earlier than men and so are more likely to know their HIV status, and in general, women make up more than 60% of the HIV-positive population in sub-Saharan Africa [
1]. Women constituted 64% and 66% of our sample in our two previous studies in Mombasa [
2,
7].
In our data analysis we did not control for clustering at the recruiter level, which could lead to increased variance in reported behaviors. We did not do so because we did not link data on individual recruiters to participants; we recorded only type of recruiters (CHW or PTC counsellor). However, the fact that we found no significant socio-demographic differences between PLHIV recruited by CHWs and those recruited by PCs, and that each health worker could bring in a limited number of participants into the study and health workers were able to reach different risk groups as there are no geographic areas in Mombasa with a concentration of particular high-risk populations, may have reduced the bias due to clustering at the recruiter level. The study relies on self-reported sexual risk and condom use behaviors which may be subject to social desirability and recall bias. For the partner level analysis, we limited the number of partners each participant could describe to a maximum of six in the reference period; this afforded us the ability to obtain more reliable recall and limit the influence of the outliers in the sample. Reviews of validity and reliability of HIV research have, however, found that sexual behavior data are fairly consistent and self-reported data on sexual acts are reasonably congruent, especially for infrequent acts and short recall periods [
50,
51]. However, recent studies using biomarkers to validate self-reported condom use suggest over reporting of condom use and recommend interpreting self-reported behaviors with caution [
52]. Over reporting would further raise the level of risk found in this study. Finally, the study would have benefited if a control group of PLHIV on treatment had been included for a comparison of sexual behaviors.
In conclusion, a significantly large number of PLHIV in the community are not accessing ART or HIV care services in Mombasa and high risk sexual behaviors are widely prevalent in this population. HIV programs need to bring this population into the ambit of prevention and care services.
1 Stanley Luchters,2 Melissa Pickett,3 Matthew Chersich,2,4 Jerry Okal,5 Scott Geibel,5 Nzioki Kingola,6 and Marleen Temmerman2