This study was the first one to assess the prevalence of HIV infection and STIs among MSW in Côte d'Ivoire. The HIV prevalence of 50.0% found in this study stands in large contrast with the HIV prevalence in the general male population of 15–49 years in Côte d'Ivoire, which was 2.9% in 2005.12
The HIV prevalence among MSW (50%, CI 40% to 60%) was also higher than the HIV prevalence among FSW found in a similar study at the same site and time (40%, CI 33% to 46%), although this difference did not reach statistical significance.6
HIV was associated with the duration of sex work, which is an indicator of the duration of risk taking. Men who had attended school were less likely to be HIV infected. Possible explanations for this association include more easy access to prevention messages by men with higher levels of education and greater assertiveness in negotiations about condom use. In general, the literacy level of MSW was rather high in this study and certainly higher than the literacy level of the general male population in Côte d'Ivoire (84% vs 66%).12
Our sample may be not representative for the population of MSW in general because clinic visits are more likely done by HIV-infected sex workers, introducing a bias towards higher HIV prevalence rates. This is particularly the case for repeat visits, as 14% of these men in our sample said that the reason for attending the clinic was to collect medicine. For men attending the clinic for the first time however, the main reasons for coming to the clinic were check-ups and wanting to discover the clinic.
was detected in 8.5% of the rectal swabs and in 5.3% of the urine samples. The rate of N gonorrhoeae
found in the urine is relatively high considering that MSW in Abidjan are known to usually engage in receptive anal intercourse. Unfortunately, we did not collect detailed data on sexual behaviour, so cannot be sure that they did not have insertive anal intercourse or intercourse with women. We did not take any oropharyngal swabs and it is thus likely that we have missed a number of infections. In Australia, urethral gonorrhoea was present in 2% of the MSM, as was pharyngeal gonorrhoea, but the prevalence of rectal gonorrhoea was slightly higher.13
Due to the lack of studies, we could not compare our results with African MSM.
Chlamydia prevalence was 3%. We tested the stored left-over aliquots of the two C trachomatis-positive specimens using the real-time-PCR, and both specimens did not belong to the C trachomatis L. genotypes, which are causing Lymphogranuloma venereum (LGV) (results not shown).
We found a rather low prevalence of T vaginalis
among MSW in Abidjan compared with FSW in a similar study (13%) or with heterosexual men in two studies in Tanzania (11% in Mwanza and 10% in Moshi).6
In only two men, T vaginalis
was found in rectal samples. This low prevalence in the rectal samples is not surprising. In a study among MSM in San Francisco, only 3 of 500 rectal samples were positive for T vaginalis
with Transcription Mediated Amplification assay.16
probably does not thrive in the rectum and as a result is not often found in men who have sex only with men.17
Furthermore, T vaginalis
was not detected in the urine samples of our study population. It is possible that we missed a few cases due to a less than optimal sensitivity of PCR on urine. It has previously been described that PCR for T vaginalis
on urine does not always perform well.18
Since the questionnaire did not include detailed questions on sexual behaviour, we do not know whether the absence of sex with women may play a role in the rates of different STI found in this population. Future studies among MSW should explore their sexual behaviour with men and women in more detail.
The DNA amplification for the detection of STIs was performed in Antwerp since these techniques were not available in Côte d'Ivoire at that time. However, even if PCR tests are available in reference centres, they are too complicated and expensive for widespread use and routine diagnostics in a setting such as Côte d'Ivoire. In low-resource countries, a more realistic and simple approach is needed for the screening and diagnosis of STI. The syndromic approach has been adapted and validated for the diagnosis of symptomatic STI in FSW in many settings.19–21
For MSW and MSM however, algorithms for urethral infections were for a long time the only tools available. The recent WHO guidelines for the prevention and treatment of HIV and other STI among MSM and transgender people propose diagnostic algorithms for STI, including rectal STI, for which no validation has been done.22
Our results show the need for developing and validating algorithms for the diagnosis of urethral and rectal STI in MSM and MSW. In addition, simple and rapid point of care tests are urgently needed, and research for these tests should be a public health priority.
In this study, 69% of MSW reported always using a condom with their clients. The proportion of MSW who reported always using a condom with their regular partners was somewhat less, 59%. This is in contrast to the study we conducted with FSW in Abidjan where 81% reported always using a condom with their clients and only 25% with their regular partners. The level of intimacy and emotional ties with the sexual partner regardless of assessed risk seems an important factor for condom use.6
More research is needed to better understand condom use and barriers to condom use among MSW.
In conclusion, HIV and STI rates found in this study confirm the high risk and vulnerability status of MSW in Côte d'Ivoire. There is a definite need for more studies exploring risk and risk perceptions among MSW in more depth, including the risk taking with different types of clients and with other male and female partners. There is also a need for developing and validating simple and rapid point of care tests in addition to specific algorithms for the diagnosis of STI in MSW and MSM. Finally, better understanding of the needs and size of this target population will contribute to the provision of adapted low-threshold services, including the promotion of condoms and lubricant gel, STI diagnosis and treatment, as well as HIV testing and treatment for the infected.
- Male sex workers (MSW) are at high risk for sexually transmitted infections (STI) and HIV in Côte d'Ivoire, with 50% of them infected with HIV and 13% with Neisseria gonorrhoeae.
- Condom use is relatively high among MSW; however, more studies are needed to explore risk and risk perceptions among MSW in more depth.
- There is an urgent need for the development of simple and rapid point of care tests for the diagnosis of STI in MSW and MSM.
- There is a need for tailored services and simple STI algorithms for MSM and MSW.