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Try out PMC Labs and tell us what you think. Learn More. A novel, validated daily event and partner diary self-completed by 82 MSM who sold sex over a follow-up period of 42 days with weekly review. Cumulative individual counts of sex and condomless sex were compiled by partner characteristics.

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The incidence of specific partnerships and sex acts were compared within and between bisexual and exclusive Nairobi anal sex. The majority of both male and female partners were cash-paying clients originating locally. Bisexual MSW reported a similar rate of condomless sex with male and female partners, but ificantly fewer male partners than exclusive MSW. Bisexual MSW had lower HIV prevalence, were more likely to only report insertive anal sex roles, and reported lower frequencies of condomless receptive anal sex than exclusive MSW. Bisexually active male sex workers in coastal Kenya create HIV and other sexually transmitted infection transmission pathways to partners and clients in both MSM and heterosexual networks, but differed from exclusive MSW in having lower HIV acquisition and transmission risks.

Epidemiological projection methods are liable to overestimate bridging potential of MSM-SW and MSM populations without for systematic differences in risk within these populations. A of studies of male sex work and HIV risk have been reported from urban settings in Kenya [ 14 — 16 ]. Kenya has a declining generalized HIV epidemic with well characterized concentrated epidemics among key populations, including Nairobi anal sex [ 1718 ].

Nairobi anal sex behavioural surveys suggest that many MSM-SW report female partners recall period: 3 month Mode of transmission models are used across Africa to project the population fraction of new HIV infections attributed to different risk groups using estimates of population sizes, risk behaviour and HIV prevalence, and thereby to as HIV prevention and control resources effectively [ 23 ]. However, this projection method also implicitly assumes that HIV prevalence and behavioural risk among MSM who have female sexual partners is otherwise no different from MSM who do not.

In this study we describe prospectively ascertained sexual partners and behaviours of MSM-SW drawn from a well established key population cohort study in Coastal Kenya, and compare sexual behaviour of MSM-SW who report female partnerships with those who do not. The prospective diary study was nested in two ongoing cohort studies of adults at high risk of HIV infection, or with known HIV infection, in Mtwapa, Kenya [ 2124 ].

In brief, these studies recruited adults considered to be at high risk of HIV infection, including MSM, into follow-up. MSM were identified by a team of 10—15 peer mobilizers who approached individuals via personal networks and social venues. Follow-up comprised quarterly risk assessment socio-demographic and behavioural questionnaireclinical evaluation symptom history, physical examination and laboratory assessment [rapid HIV testing, sexually transmitted infection STI diagnostics].

All MSM cohort participants who reported sex with another man in the 3 months at their most recent risk assessment were invited to participate in the diary study. Diary study volunteers provided written informed consent to participate. Event diaries were developed in a pilot programme over 6 months with a group Nairobi anal sex MSM volunteers. The self-completed event diary was set in pocket book form for ease of carriage and allowed space for 27 consecutive event entries. Sexual acts with each partner were documented using a pictographic disc Fig. Diary keepers recorded specific sexual acts by drawing a line between body parts of themselves and their partners.

Body parts were represented as icons chosen to be meaningful to trained diary users, but not to be interpretable or incriminating if found by someone else. Condom use was indicated by annotation of connecting lines. Characteristics of the sexual partner e. Recorded characteristics of the dyad included visual coding of cash exchanged for sex and the type of partnership. Regular partners were defined as steady boyfriends, girlfriends and spouses. Multiple lines indicate repeated rounds of a sexual act. Partner information right Nairobi anal sex sex, age, ethnicity tribemarital status and location of origin [Mombasa tusksKenya, Africa, or international].

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Participants completed a 4-day training on use of the diary, followed by a 3-week lead-in period during which they were required to demonstrate competence and accuracy in recording. Participants who met this requirement completed a questionnaire at study entry, including data on socio-demographic factors and lifetime sexual behaviour, then were issued with diaries, condoms and lubricants. Thereafter participants completed diaries for 42 consecutive days each during October—Decemberdepositing completed diaries each week. Event diaries demonstrated high agreement with contemporaneous cohort measures, strong user acceptability in exit evaluation, and high predictive validity against subsequent HIV incidence through January [ 25 ].

Diary entries were Nairobi anal sex with participants at weekly collection, then double-entered using a pictographic abstraction program Microsoft FoxPro. Following abstraction, event diaries were archived securely. One MSM participant did not report selling sex, and was excluded from analysis. Discrete event Nairobi anal sex were coded to dichotomous variables for each sex act — insertive anal intercourse IAIreceptive anal intercourse RAI and vaginal intercourse, then by condom use for each sex act.

Penetrative intercourse was defined as an event in which one or more anal or vaginal acts occurred. Condomless sex was defined as an intercourse event including one or more condom-unprotected acts. The condomless event probability was the fraction of occurrences of a sex act that were Nairobi anal sex.

Event data were compiled into summary counts for each participant, specifically the count of sex acts and condomless sex acts per individual. The incidence of sex acts was described as the average count of sexual acts per Nairobi anal sex weeks of follow-up. Count distributions were strongly positively skewed with best fit to the negative binomial distribution assessed against Poisson, zero-inflated Poisson and zero-inflated negative binomial [ 27 ]. To compare sexual behaviour frequency of different participants we used negative binomial regression to estimate the crude incidence rate ratio IRR of partner, sex act and condomless sex act frequency by participant covariates.

Generalized estimating equations GEE with a logit link function and exchangeable correlation matrix were used to estimate the odds ratio OR of condomless intercourse by participant characteristics, adjusting for correlation of repeated events per participant.

Multivariate models were used to estimate independent associations aIRR and aOR between participant category and sexual behaviour, adjusted for other participant covariates HIV status and age. To compare within-individual intercourse and condomless intercourse frequencies, we used GEE with a negative binomial link for panels of paired count measures to estimate the crude within-individual IRR.

Eighty-two diary participants reported at least one male sexual partner who paid cash for sex over an average follow-up of At study entry, 65 Forty-eight Table 1 reports selected characteristics of MSM diary study participants who reported selling sex to men during prospective follow-up. BiMSW were older and more likely to report marriage than exMSW, yet were no more likely to presently be married.

Characteristics of study participants who reported selling sex to men during diary follow-up prospective diary study, Coastal Kenya, MSW diary participants reported sexual events Nairobi anal sex men. About Sexual behaviour with male partners all MSM sex workers, prospective diary study, Coastal Kenya, BiMSW reported lower rates of anal intercourse with men than did exMSW in all transaction and relationship ; however, patterns of male partnership were very similar.

BiMSW reported ificantly fewer male partners who paid cash for sex than did exMSW Table 2but for both groups, paying partners were the vast majority of male sexual contacts biMSW: Anal sex acts with men who paid cash for sex were less often condomless than sex with nontransactional male partners [biMSW OR: 0. Bisexual MSW reported lower rates of anal intercourse and condomless anal intercourse with repeat male partners regular or casual recurrentbut a similar rate of anal intercourse and higher rate of condomless anal intercourse with new partners Table 2.

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Overall, There were no ificant differences in condomless event probability between biMSW and exMSW by relationship category; however, sex with regular male partners was more likely to be unprotected than sex with casual Nairobi anal sex for both biMSW OR 3. Differences in anal intercourse role with male partners were marked. Adjusted associations with frequency of anal intercourse with male partners all MSM sex workers, prospective diary study, Coastal Kenya, Male partners were often in an older age group than participants male Most partners were resident in Kenya male Male partners were more often believed to be married male: Table 4 summarizes rates of penetrative intercourse and condomless sex among biMSW with their male and female partners.

In addition to intercourse with male partners discussed above, all biMSW reported vaginal intercourse and In intercourse reports with female partners, Condom use did not differ for anal and vaginal intercourse with women Table 4. NNairobi anal sex intercourse events; Rate, average count per Nairobi anal sex weeks person-observation. BiMSW reported approximately twice as much penetrative intercourse with men as with women 9. This difference consisted of ificantly higher intercourse rates with casual and cash-paying male partners.

By contrast, more nontransactional intercourse was reported with female rather than male partners, and the vast majority of sex paid for by the participant was with women. A similar proportion of biMSW reported female With both male and female partners, penetrative intercourse was most likely to be condomless with regular partners or nontransactional partners Table 4.

Differences in rates of condomless intercourse with male and female partners were more modest than differences in intercourse frequency due to the consistently lower probability of condom use with female partners, compared to male partners Table 4. As a result, among biMSW, the overall rate of condomless intercourse with female partners was similar to that with male partners 2. Over a brief duration of detailed prospective observation the majority of MSM who sold sex to men also reported sexual behaviours with women, often including anal intercourse. Sexual activity with both men and women was overwhelmingly characterized as transactional.

The existence of female clients who pay for sex from male sex workers on the Kenya coast has ly been indicated by cross-sectional studies of male sex workers on the Kenya Nairobi anal sex [ 1619 ], and one study suggests female sex workers commonly report paying for sex with men [ 28 ].

Analysis of our findings demonstrates that demand from women represents a ificant fraction of male sex work activity, originates mostly from local women and that sex is frequently condomless. These findings both challenge the prevailing characterization of such demand coming from international tourists [ 29 ], and highlights the need to investigate a very poorly understood aspect of sexual culture of potential ificance to HIV and STI control in Kenya. Bisexually active MSM-SW reported higher frequencies of sex with male than female partners, but intercourse events with men were much more likely to be condomprotected than those with women.

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Consequently, overall rates of condomless sex with male and female partners were Nairobi anal sex. From a sexual network perspective, that most MSM-SW report active sexual behavioural links within both MSM and heterosexual sexual networks infers the potential for this group to act as a bridging population between those networks. These data, however, also suggest that male sex workers who interact with both MSM and heterosexual networks have considerably lower behavioural HIV acquisition risk than those who interact exclusively within MSM networks.

HIV prevalence among bisexually active MSM sex workers was markedly lower than among exclusive MSM sex workers, although still higher than estimated prevalence in the local adult male population [ 22 ]. These findings concur with a lower HIV incidence reported among bisexually active MSM in the cohort study from which diary study participants were recruited [ 21 ].

However, whereas seroadaptation may well explain the lower condomless IAI rate and event probability among HIV-positive MSM-SW [ 32 ], ificant negative associations between RAI and heterosexual activity were consistent across analyses restricted to HIV negative MSM-SW data not shownand for both prospective and lifetime measures of sex with female partners suggesting that reverse causation is an insufficient explanation for our findings.

Systematic differences in MSM HIV prevalence and acquisition risks by level of heterosexual activity may be a plausible explanation to resolve the lack of objective phylogenetic evidence of actual HIV transmission bridging across MSM and heterosexual networks to Nairobi anal sex in Kenya [ 3334 ] with existing projections of ificant bridging from models that fail to for such heterogeneity [ 20 ].

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Local and regional data suggest Nairobi anal sex disparities in risk behaviour may well exist in more broadly defined MSM populations. In coastal Kenya, qualitative studies describe Kiswahili MSM identities along very similar behavioural distinctions: basha describing a masculine MSM who takes the insertive sex role, has female partners and passes as heterosexual in wider society, and shoga that evokes notions of femininity, the receptive sex role and which is often appropriated as a term of abuse [ 3536 ].

Few quantitative MSM behavioural studies elsewhere in sub-Saharan Africa and the diaspora report comparable data, but those that do suggest the same differentiation of anal sex role by heterosexual activity and sexual identity [ 113738 ].

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The study had a of limitations. That many male and female partners of participants were thought to be married highlights the need for extended network data to comprehensively quantify bridging pathways. It is questionable whether such studies are feasible — our Nairobi anal sex to engage partners and clients of MSM-SW for research confirm that, as elsewhere [ 39 ], such groups are exceptionally elusive. We elected to categorize MSM-SW by behaviour rather than sexual identity, having found low acceptance amongst participants of international terminology categorizing sexuality in preparatory focus groups.

Behavioural categorization has the advantage of being objective and unambiguous in directly describing sexual risk, but behaviour may not correspond to personally held notions of sexuality, particularly in the context of sex work Nairobi anal sex 40 ]. Ongoing local qualitative work concurs with observations elsewhere that bisexually active and identifying MSM are less likely to disclose same sex behaviour or access health services [ 14142 ], highlighting the need to understand the relationship between behavioural risk and sexual identity in aligning sexual health responses to potentially very diverse notions of individual need and accessibility.

Although the accuracy of prospective event-level measurement in assessing HIV acquisition and transmission risk is well established [ 4344 ], the intensity of follow-up and staff time required was considerable, limiting achievable sample size and the duration of follow-up. Further, findings may not be generalizable to MSM sex workers in other contexts. The study recruited from a research-engaged Nairobi anal sex of MSM, aware of their HIV status and with free access to relevant information, counselling and prevention materials.

Entitlement to services that are otherwise expensive to access is likely to have preferentially selected for recruitment of MSM-SW on low incomes through street-based sex work, which may be unrepresentative of the full spectrum of MSM-SW working locally.

Lastly, inferences are necessarily limited to men who sell sex to men — in light of findings, male sex workers with exclusively female partners and clients may well exist locally, but were not identified or included in this study. Bisexually active male sex workers in coastal Nairobi anal sex create potential transmission pathways for HIV and other sexually transmitted infections to partners and clients in both MSM and heterosexual networks. However, these men are not simply MSM sex workers who happen to have female partners; rather, their behaviour differs from that of exclusive MSM sex workers in important ways that result in a lower risk of HIV infection and transmission.

Modelling projections will tend to overestimate the bridging potential of MSM sex workers and other MSM populations unless they for such risk differences. This article is published with the permission of the Director of the Kenya Medical Research Institute. Contribution of authors: A. National Center for Biotechnology InformationU. Author manuscript; available in PMC Jan 8.

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