Individual and partnership characteristics associated with consistent condom use in a cohort of cisgender men who have sex with men and transgender women in Nigeria

Even in the context of a mixed HIV epidemic in Nigeria, cisgender men who have sex with men (MSM) and transgender women (TGW) bear a disproportionate burden of infection with estimated HIV prevalence 18–66% compared to about 4% among reproductive aged adults [1, 21, 42, 43]. This increased burden is due to the high HIV transmission risks associated with condomless anal intercourse with viremic partners [3, 13, 29]. It has been estimated that the 5-year cumulative incidence of HIV among MSM would be reduced by 80–98% if the efficiency of HIV transmission in anal sex was similar to the efficiency of transmission in condomless vaginal sex [3]. While the use of pre-exposure prophylaxis (PrEP) is effective in reducing transmission of HIV, it is not routinely available in many sub-Saharan African (SSA) countries. Thus, consistent condom use (CCU) remains a cost-effective HIV prevention strategy writ large.

Individual-level determinants of CCU among MSM in Nigeria have been shown to include knowledge of HIV transmission, frequency of sex, and alcohol or drug use before or during sex [39]. However, factors influencing condom use may not be fully captured by a single measure and understanding the dynamics between the attributes of the sexual relationship, partner characteristics, and individual level factors is necessary to fully characterize the determinants of condom usage and opportunities for intervention [5, 24, 41].

Among MSM, research has consistently shown unprotected anal intercourse is more likely in committed or more serious relationships compared to relationships that are more casual [7, 15, 27, 40]. This dynamic has been attributed to higher levels of trust and familiarity with committed partners and the perception that condom use may affect intimacy [10, 15, 18, 23, 48]. Perceived and actual partner characteristics have also been shown to influence individual decisions to use condom. For example, MSM at risk for HIV may be more likely to use condom with partners they perceive to be more likely to be living with HIV and serosorting is common among MSM when both partners have disclosed their HIV statuses [27, 35, 47]. Other factors such as age difference between partners, sexual partner concurrency, and partner norms around condoms use may also impact CCU [5, 26, 27].

Although TGW have been shown to have higher odds of reporting condomless receptive anal sex with male partners compared to MSM, few studies have characterized the factors that drive this association in TGW specifically [32]. A study among TGW in China found that subjective norms, condom use attitude, condom use skills, and self-efficacy were associated with frequent condom use and knowledge of HIV was not related to condom use [6, 45]. Other factors that have been shown to be associated with condomless sex among TGW include feminizing medical intervention, factors related to sex-work [6].

While various studies have provided evidence for the partner and relationship characteristics that may influence individual decisions to consistently use condoms, there is limited research on the subject matter among MSM and TGW in sub-Saharan Africa, where cultural factors, resource limitations and other factors may influence the dynamics of condom negotiation and decision-making in ways that differ from those in westernized settings. Given limited condom uptake among cisgender MSM and TGW in Nigeria [8, 39, 44] and the continued importance of characterizing optimal strategies to encourage CCU, we assessed the individual, relationship and partner-level factors associated with CCU among a cohort of cisgender MSM and TGW enrolled in two community-engaged clinics in Abuja and Lagos, Nigeria, thus identifying characteristics that may aid in developing targeted strategies.

Between April 2013 and April 2019, 2591 eligible MSM and TGW participants were recruited into the study. Of those, 1786 reported on a total of 6432 sexual partners at enrollment and were included in these analyses. The average sex network size was 3.6.

In these analyses among MSM and TGW in Nigeria, the data demonstrated on the individual level, CCU during both insertive and receptive anal sex were positively associated with higher education and disclosure of sexual behavior to a healthcare worker, and on the partnership level was associated with relationship type, partners encouraging condom use, and frequent discussion of HIV by partners. Given that consistent condom use was reported in only 44% of the partnerships reported here and the prevalence of HIV remains high among MSM and TGW in Nigeria, our results highlight possible correlates of condom use which may be leveraged for HIV prevention messaging.

The findings that condom use was more likely in relationships where condom use was encouraged and in relationships where HIV was discussed frequently is consistent with previous studies which highlight that relationship and partner norms influence health behaviors, including condom use [16, 20, 30]. In a study among MSM in the US, it was found that having at least one person in a sexual dyad who did not disapprove of condomless anal sex was associated with an increased likelihood of condomless sex compared to those who did not have such a person in their sexual network [36]. Relationships present opportunities for information exchange and involved parties often influence each other leading to sustained behavior change. This dynamic could be leveraged to create interventions that promote open discussion of safer sex practices. Such interventions may require training for effective communication, as openly discussing sexual behaviors may be uncommon in some communities, particularly ones where HIV and same-sex sexual practices are heavily stigmatized [9, 37].

Results showing that CCU was more likely in casual relationships as compared to regular relationships is also consistent with findings from other studies among MSM where higher rates of unprotected anal intercourse (UAI) have been observed in relationships considered more serious [17, 23, 31]. In these relationships, couples may engage in UAI to increase intimacy and trust in a relationship [15]. While risk perception may decrease with more regular partners, there may be sustained risks for both STIs and HIV in non-exclusive relationships, therefore the importance of prevention modalities should be emphasized for MSM or TGW in non-exclusive relationships. Moreover, previous studies have associated steady partnership as a source of HIV infection among gay men [11, 12]. These findings highlight both the importance and the potential of couple-oriented testing and counseling practices. Couple-based approaches have been shown to be highly effective in several settings and evaluation in the Nigerian context for MSM and TGW may be valuable [14, 38].

Our results also show that participants in relationships where the partners were married to women were less likely to consistently use condoms. The majority of participants in this study reported that they were bisexual and marriage to women was common among their partners. Given the presence of punitive laws prohibiting same sex-relationships in Nigeria, this is unsurprising [37]. Many individuals with gay or bisexual identities may choose to marry women due to fear of stigma, societal pressures, or to avoid being outed [34]. Previous surveys of men who have sex with men and women (MSMW) have shown them to have riskier HIV-related behaviors that potentiate HIV infection, including a higher probability of having an unknown HIV status and a lower probability of encountering HIV prevention activities and materials due to presence of “biphobia” [25]. Thus, MSMW could play a potential role in HIV transmission to women by bridging the epidemics in two different populations. This dynamic could also apply in TGW who have sex with cis-gender women. These results suggest that addressing the prevention needs of MSMW and TGW and all their sex partners is needed for HIV reduction among both KP groups and women. Tailored prevention strategies requires context and understanding of behaviors and sexual networks of TGW who have sex with women and MSMW.

Unlike findings from other studies that have shown age-disparate relationships to be associated with more high-risk HIV-related behaviors including unprotected anal intercourse, our results showed increased odds of condom use during receptive anal sex in relationships where there was a ten year or more difference in age between partners. The risks associated with age-disparate partnerships are often higher in relationships where adolescents have partners who are much older than them. This is due to the increased likelihood for older partners to be living with HIV and a high propensity for condomless sex and alcohol use during sex with older partners [4, 19]. There is also evidence that it may be linked to power dynamics in the relationships [27]. This could lead to a limited ability on the part of younger MSM to adopt or advocate for HIV risk reduction behaviors like condom use even when protected sex is desired. Thus, a ten-year age difference between two middle-aged persons may not be associated with the same risk as a ten-year age difference between an adolescent and a middle-aged person; a nuance which is not sufficiently captured in this analysis and may therefore be the reason for the difference in the results observed.

On the individual level, disclosure of sexual behavior to a healthcare practitioner was also positively associated with CCU. Disclosure of key-population status may indicate more engagement with healthcare services and therefore reduced likelihood for risky behaviors due to more access to targeted HIV prevention messaging. Disclosure of MSM status in Nigeria may be challenged by the presence of laws criminalizing same sex behaviors and the high levels of stigma faced by MSM in the country [9, 37]. Studies have demonstrated that structural elements, where the risks of disclosure of sexual practices for a meaningful risk assessment outweigh the potential benefits of better engagement in HIV prevention services, have affected the uptake of HIV prevention services including condom uptake among MSM at risk for HIV acquisition [9, 37]. This is particularly important as our results showed that participants who reported neither buying condoms nor getting condoms for free were significantly less likely to consistently use condoms, a prevention modality commonly available for free in healthcare centers. Given the importance of the healthcare sector in managing and reducing the HIV epidemic among MSM in the country, training and sensitizing healthcare workers about the impacts of stigmatizing behavior is needed. De-centralization of HIV prevention services by leveraging KP community-engaged facilities such as the trusted community health centers involved in this study may also increase healthcare engagement and alter HIV-related risk behaviors. Longitudinal analysis of data from this cohort showed an improvement in the uptake of condoms and water-based lubricants by MSM and TGW, suggesting effectiveness of these facilities in improving engagement in care [8].

The findings from this study should be interpreted in the context of several limitations. Firstly, all behavioral data collected, including partner and relationship characteristics, were self-reported by the participant in the study. This makes our findings susceptible to multiple biases, including recall and social desirability. The presence of missing data may have biased our results however, missingness was around 1% for many of the variables and is unlikely to significantly impact our interpretation. Additionally, “refusal” and “don’t know” categories were included in models where applicable as these responses may be informative about behavioral risks. Although the study was longitudinal, we carried out cross-sectional analyses using the baseline data. Thus, causality cannot be inferred from our results. While our results may capture the individual and relationship characteristics of MSM and TGW in Lagos and Abuja, Nigeria, our findings may not be generalizable to the broader key population in Nigeria or other countries in sub-Saharan Africa.

HIV prevention programs may benefit from encouraging open communication of safer sex practices as a strategy for HIV risk reduction given that MSM and TGW were more likely to consistently use condoms when their partners encouraged and openly discussed safer sex. Even with the introduction and scale up of other biomedical HIV prevention modalities such as PrEP, condom use remains an important mode for reducing onward transmission of STIs as HIV and STI infection rates remains sustained among MSM. Implementation science research could support the evaluation of optimal strategies that integrate open discussions about safe sex into existing behavioral interventions. However, while research is helpful, leveraging existing strategies to increase condom use including the provision of condoms in safe spaces, ensuring access to better condoms and condom-compatible lubricants, and teaching condom negotiation skills may support increased consistent condom use among men who have sex with men and transgender women across Nigeria.