Factors Associated with Having both Male and Female Recent Sexual Partnerships Among Men Who Have Sex with Men in Harare and Bulawayo, Zimbabwe

The prevalence of both male and female recent partnerships within the 6 months before the survey (31%) is lower among Zimbabwean MSM in this survey than in other biobehavioral surveys in sub-Saharan Africa. Surveys in Botswana in 2012 and Mali in 2015 found that 38% and 53% of MSM with male partners in the previous 6 months also had female sexual partners in the previous 6 months, respectively [22, 23]. Another study in Malawi, Botswana, and Namibia in 2008 reported a pooled prevalence of 54% among all MSM participants with lifetime history of anal sex with a male [12]. However, surveys in South Africa in 2009 and 2013 provided prevalence estimates of 2–17% [24, 25]. This suggests that there may be a wide range of engagement in both male and female sexual partnerships among MSM throughout sub-Saharan Africa, possibly based on socio-cultural differences between countries or evolving attitudes and norms at the time of data collection.

Our finding that being married or cohabiting versus being single was associated with higher odds of both male and female recent partnerships is consistent with literature from sub-Saharan Africa that reports marriage among many MSM. Some studies in the region have posed the idea that female sexual partnerships among MSM often occur due to desire or social pressure to be married and have a family [8, 12]. This is one possible explanation for the association we found between marriage/cohabitation and having recent female partners, although social pressure cannot be distinguished from bisexuality or bisexual preferences as the reason for having both male and female partnerships among MSM in this survey as participants were not asked about their motivation for seeking out female partners. Additionally, in the final multivariable model, older MSM had lower odds of having both male and female recent partners. It is difficult to determine how this finding compares to other surveys among MSM in sub-Saharan Africa. One study found no significant association between being young (less than 24 years old) and having at least one male and one female partner in the past 6 months among MSM in Namibia, Botswana, and Malawi [12]. Similarly, a survey in Nigeria reported that the association between being age 18–25 (compared to being age 26 or older) and having intercourse with both men and women in the past 2 months was not significant [11]. A paper from Kenya reported that among MSM in the study, participants who reported sex with both men and women were older than those with exclusively male partners, but the statistical association between age and having female partners was not significant [26]. Other cited analyses did not examine a direct association between age and female sexual partnerships among MSM. Marriage or cohabitation may alter the relationship between age and having both male and female partnerships such that when controlling for marital status, older MSM have significantly lower odds of having both male and female sexual partnerships. Although it is possible that marriage or cohabitation plays a role in having both male and female sexual partners, it is not clear from this analysis if other factors unrelated to marriage among older MSM explain this observation. Further exploration is needed to assess the relationship between age and having both male and female partnerships among MSM in Zimbabwe.

Stigma-related experiences such as having been arrested, rejected, harassed, or abused because of being MSM were all associated with lower odds of having both male and female recent partnerships in bivariate analyses. This is consistent with findings from a qualitative study in which MSM in Zimbabwe report facing less social stigma if they are known to have female sexual partners [8]. However, based on our data, we cannot determine whether avoiding social stigma was an explicit motivation for having female partners or a result of such activity among this sample of MSM.

The association between experiencing harassment or abuse because you have sex with men and having both male and female recent partnerships appears to vary by city. MSM who had experienced harassment or abuse because they have sex with men in Harare had higher odds of having both male and female recent partnerships than MSM who experienced harassment or abuse in Bulawayo. Further research is needed to understand whether there are social or cultural differences between cities in Zimbabwe that may contribute to an altered association between experiences of MSM-related stigma and seeking out female sexual partnerships. We cannot determine based on this data whether there is a causal relationship between experiencing harassment or abuse and having female sexual partners among MSM, only that the observed association differs by city.

CRAI was associated with lower odds of having both male and female recent partners. This aligns with a study among MSM in Namibia, Malawi, and Botswana, in which participants with both male and female recent partnerships reported higher rates of condom usage with casual and regular partners than participants with only male recent partners [12]. Additionally, we found that MSM living with HIV had lower odds of having both male and female recent partnerships. Our finding of an inverse association of both CRAI and positive HIV status with having both male and female sexual partners among MSM is consistent with other studies from sub-Saharan Africa [26‐28]. A study among Kenyan MSM reported that those with only male partners were more likely to have had receptive anal sex and less likely to have had insertive anal sex than MSM who also had female sexual partners [26]. Similarly, a study in two cities in Mozambique found that a higher percentage of MSM who had only insertive anal sex with men reported both male and female sexual partners than MSM who had any receptive anal sex with men [14]. This indicates that a partial explanation for the inverse association between CRAI and having female partners may be that those with female partners less commonly engage in receptive anal intercourse. Furthermore, MSM who engage in insertive anal sex are considered to have less risk for HIV acquisition than those who engage in receptive anal sex [26, 29], which is consistent with lower odds of positive HIV status among MSM with both male and female partners compared to those with only male partners. Another explanation could be that MSM with both male and female partners may engage in HIV preventative behaviors with their male sexual partners more than MSM without female partners. Given the cross-sectional nature of the survey, it is unknown whether this is a result of female partners’ influence on MSM, a desire to engage in safer sexual behaviors given the variety of sexual partners, or MSM with recent female partners accessing better HIV education. It is also possible that some of those who know they have HIV practice risk-reducing behaviors such as using condoms consistently [30, 31] and are less likely to have female partners for reasons related to knowledge of status, including the intentional limitation of number of partners. More research is needed to explore the roles of female partners and knowledge of positive HIV status in determining sexual behaviors of MSM.

Hazardous alcohol consumption and alcohol use disorders are often considered HIV risk factors because of their association with other risks such as condomless sex; this has been documented in Zimbabwe [23, 32‐34]. This association does not seem to be consistent among this sample of MSM with both male and female recent partnerships given that hazardous alcohol use was associated with having both male and female recent partnerships and those with both male and female recent partnerships have lower odds of having a positive HIV status. Literature examining factors associated with female partnerships among MSM from countries surrounding Zimbabwe lacks similar associations with hazardous alcohol consumption [12, 25, 26, 28]. There are likely other unknown factors not included in this analysis that may explain this positive association between hazardous alcohol consumption and having both male and female recent partners. For example, hazardous alcohol use and alcohol use disorders may be related to stress and mental health or other HIV-associated experiences among MSM [23, 35, 36] that cannot be fully assessed using the data from this survey.

This analysis has several limitations. Because some key variables did not reach equilibrium to meet RDS estimator conditions, the analyses were unweighted and did not account for sampling design. Additionally, the survey was conducted in only two cities in Zimbabwe and may not be representative of the entire population of MSM in Zimbabwe. The survey data is cross sectional, meaning that temporal or causal relationships between factors we examined and having both male and female partnerships cannot be determined based on findings from this analysis. While participants reported having both male and female partners in the past 6 months, we cannot determine if there was concurrency between any of these partnerships and how that may influence sexual behaviors. Further, many behaviors assessed in the survey reflect recent behaviors, but HIV may have been acquired at a time when typical behaviors were different than what was captured in the survey. All self-reported data is subject to information bias due to participant recall and social desirability biases; some behaviors recorded in the survey, especially those that may be highly stigmatized or criminalized, may not have been accurately reported by participants. The survey also had several strengths. A major strength was that it utilized RDS to recruit key populations, population groups which lack a sampling frame, especially in a setting where homosexual behavior is illegal and heavily stigmatized. This allowed a more diverse and representative sample of this key population to be recruited into the survey than would have been possible with some other sampling methods. In addition, the combination of questionnaire and biomarker data allows for a more accurate look at the relationship between attitudes or behaviors and HIV.

The results of this analysis are important in that they highlight some of the contexts in which MSM may engage in both male and female sexual partnerships and provide insight into the behaviors or experiences associated with such partnerships. More research is needed to examine the motivation for having both male and female partners and the behaviors associated with these partnerships among MSM. These behaviors and motivations are important to the understanding of how sexual networks of MSM in Zimbabwe may intertwine with the general population and play a role in transmission dynamics contributing to the generalized HIV epidemic. Other studies from sub-Saharan Africa have suggested that the contribution of MSM as a key population to the generalized HIV epidemic through the heterosexual population varies geographically and by sexual role (receptive vs. insertive). These studies have also reported that despite some evidence of HIV transmission between populations, there is a substantial amount of HIV transmission within MSM sexual networks that indicates a need for better services for this population [14‐16].

MSM who participate in sexual networks that could overlap with the general population (by having both male and female partners) may engage in unique behaviors that result in a difference in HIV odds compared to MSM without female partners. HIV services in Zimbabwe that are catered specifically toward MSM or heterosexual networks separately without considering such overlap may not reach all MSM, especially given the stigmatization and criminalization of homosexual behavior. A concerted effort to ensure access to adequate, stigma-free HIV testing services and risk-reduction education programs which address both male and female sexual partnerships for MSM will be crucial to Zimbabwe’s success in achieving HIV elimination.