1. 81 MSM-SW participated in the study. They recorded 1738 sexual encounters with 1212 different partners over 6 weeks follow up in 2007. Gender exclusivity Most MSM-SW reported both male and female partners (i.e. non-exclusive), however sex with men accounted for 80% of encounters on follow up. 23% (19/81) MSM-SW were currently or previously married, whilst 40% of male and 34% of female partners were known to be married Transactional sex Most male and female partners were clients and paid for sex (table 2). Female partners were more likely to be non-transactional partners, or to have sold sex themselves to the MSM-SW. A. D. Smith 1, A. Ferguson 2, D. Kowuor 3, E. van der Elst 3, C. Agwanda 3, A. Muhaari 3, A.Davies 3, S.M.Graham 4, E.J.Sanders 3 Role Versatility and Female Partnerships amongst MSM Sex Workers in Mombasa, Kenya 1. Department of Public Health, University of Oxford, UK 2. HIV and AIDS Prevention and Care Project, Kenya 3. Centre for Geographic Medicine Research-Coast, Kenya 4. University of Washington, Seattle, USA ABSTRACT METHODS REFERENCES CONCLUSIONS MSM-SW within an HIV-1 vaccine preparedness cohort study completed prospective sexual behaviour diaries (see below) and a computer assisted questionnaire recording sociodemographic information, recall of lifetime and recent sexual behaviour, and detailed characteristics of three most recent sexual relationships. A visual prospective diary was developed and piloted (figure 1). Participants were assessed on the use of the diary after a three week training period, and reflected (anonymously) on the accuracy and honesty of responses at the end of the study. Aggregate diary data were validated against existing, recall based sexual behaviour data collections. Diaries recorded each episode of anal, vaginal and oral sex for each sexual encounter over a six week period, including condom use and failure. Diary entries were reviewed weekly, accompanied by HIV risk reduction counselling and provision of condoms and water-based lubricants. CONCLUSIONS Figure 1 Visual Sexual Behaviour Disc. Sexual acts recorded by joining the symbolic body part of the participant (left, ‘me’: symbols for hand, mouth, penis, anus) to symbolic body part of partner (right, ‘them’). Multiple lines indicate repeated rounds of a sexual act. Condom use and breakage for each round indicated as code (bottom right). A open cohort of high risk volunteers, including MSM sex workers (MSM- SW) was established in Mombasa, Coastal Kenya in 2005. Over 480 MSM-SW have been screened for HIV and currently 150 HIV-negative MSM-SW are in follow up. HIV-1 prevalence is 21% at enrolment, compared to 6% amongst adult men in the general population. Cohort incidence is extremely high (10.2 per 100 person-years at risk). HIV-1 prevalence is higher amongst MSM- SW with exclusively male sexual partners (OR 6.3), independent of risk associated with recent receptive anal sex (OR 4.7) [1]. Genotype studies suggest little difference between HIV-1 genotype circulating amongst MSM and the general population (predominantly subtype A), suggesting transmission bridges between MSM and generalised epidemics may be important in this context [2] Sex work and male same sex activities are illegal in Kenya. REFERENCES BACKGROUND Background Men who sell sex to men (MSM-SW) in Mombasa have a high HIV incidence and prevalence. Risk factors for HIV infection include receptive anal intercourse (AI) and exclusively male partners. Methods 81 MSM-SW in a high risk cohort completed prospective sexual behaviour diaries for 6 weeks and a questionnaire at intake. Diaries prospectively recorded each round of anal, vaginal and oral sex, including condom use, using a novel visual recording tool. Questionnaires recorded sexual debut and lifetime sexual behaviour. Diaries were validated between MSM-SW and study staff each week. Results Median age of sexual debut was 15 yrs (IQR 13-18), and in 43% (35/81) this was with a man. 17 reported only ever having sex with men (21%), 9 (53%) of whom reported >500 lifetime partners compared to 13 (20.3%) of men who also reported lifetime sex with women (exact p=0.013). Prospectively, MSM-SW reported a median of 2 (IQR 1-3) new partners and 1 (IQR 1-2) act with established partners per week. 16% (138/866) of new partners were women versus 22% (76/345) established partners (p=0.013). 89% (893/998) of male partners paid for sex compared to 68% (146/214) of women (p <0.001). Over follow up, 59% (48/81) of MSM-SW reported sex with both men and women. 40% (44/111) of recent male and 34% (12/35) female partners were known to be married. 21% (162/779) receptive AI was unprotected. 33% (213/654) of insertive AI with men was unprotected, compared to 42.2% (76/180) AI with women (p = 0.016) and 38% (117/305) vaginal sex acts with women (p=0.07). Only 9% of encounters between men involved both receptive and insertive AI (123/1388), however 59% (48/81) of participants reported both receptive and insertive AI with different partners during follow up. Of MSM-SW reporting receptive AI, many also reported vaginal sex (28%, 23/81) or AI (21%, 17/81) with a woman. Conclusions MSM-SW in Mombasa are frequently sexually active with women, which is often transactional. MSM-SW are not only versatile in anal sex roles with men, but also in their insertive and receptive roles between men and women. Partners of MSM-SW are frequently married. Unprotected sex is common, even in a research population exposed to MSM-specific HIV prevention however protection is even less likely in encounters with women. Together, these data suggest behavioural links, and possibly transmission bridges, between MSM and the general population. As an emerging risk group in Africa, MSM and MSM-SW are a high priority for public health response. METHODS 16 th Conference on Retroviruses and Opportunistic Infections, Montreal, 2009 Abstract W-169 The epidemic of HIV-1 amongst Kenyan MSM has only recently been recognised, and initial behavioural and viral genetic studies imply that transmission occurs between MSM and general populations. These data suggest direct potential bridges between MSM-SW and general populations on the Kenya Coast, including transactional and non- transactional sex with female partners, and sex with male clients in heterosexual relationships. Differences in reported prevention practice by gender suggest the need to broaden risk prevention messages. However, most partners of MSM-SW are men in this context. The previously observed association between exclusive same sex practice and HIV-1 risk may be related to higher numbers of partners and receptive AI practice, rather than differences in per episode prevention practice. Male partners only Male and female partnersTotal MSM-SW Lifetime *17 (21%)64 (79%)81 Last 3 months *28 (35%)53 (65%)81 Diary follow up **33 (41%)48 (59%)81 Partners of MSM-SW Partner counts ** (median (IQR)) Men 15 (7 to 20) Men 8(4 to 14) Women 3 (2 to 6) 13 (9 -20) Encounters in follow up ** 686 (39%)702 (40%)350 (20%)1738 INTRODUCTION Male partner (% total)Female partner (% total) New Steady / ongoingAnyNew Steady / ongoingAny Partner paid 673 92% 220 81% 893 * 89% 101 73% 45 59% 146 * 68% Participant paid 18 2% 10 4% 28 ** 3% 23 17% 16 21% 39 ** 18% No transaction 37 5% 40 15% 77 *** 8% 14 10% 15 20% 29 *** 14% Total72827099813876214 Sexual behaviours MSM-SW with exclusively male partners were more likely to report receptive anal intercourse (RAI) than non-exclusive MSM-SW, although a similar proportion reported both IAI (insertive anal intercourse) & RAI in the same encounter. Condom use for anal sex with men was similar for exclusive and non-exclusive MSM-SW (table 3). Exclusive MSM-SW were more likely to vary AI role between partners (76%) and had receptive anal sex with more partners than non-exclusive MSM-SW (figure 2). 50% of MSM-SW with female partners only reported IAI with men. Unprotected sex was more likely with female partners than male. METHODSRESULTS SUMMARY Figure 2. Insertive and receptive anal sex with partners (diary) Table 2. Transactional encounters, by gender and relationship type (diary) Table 1. Partners and partner frequency by gender exclusivity Table 3. Sexual behaviours with men and women (diary) MSM-SW with male partners only MSM-SW with male and female partners Encounters n (% total ) Unprotected encounters n (% encounters) Encounters n (% total) Unprotected encounters n (% encounters ) Men Receptive 536 120 (22%) 243 42 (17%) 78%*35%* Insertive 177 68 (38%) 477 145 (30%) 26% 68% Both 55 10 (18%) 68 14 (21%) 8%10% Total 686178 (26%)**702173 (25%)** Women Vaginal N/A 305 117 (38%) 87% Anal N/A 180 76 (42%) 51% Both N/A 140 45 (32%) 40% Total N/A 350148 (42%)** median (IQR) RAI 10 (5 to 18)* IAI 2 (1 to 6) ** median (IQR) RAI 0 (0 to 6)* IAI 6 (3 to 10)** Wilcoxian ranksum: * p<0.0001 ** p=0014 Chi-squared * p<0.0001 ** p<0.0001 Correspondence to: Dr. Adrian Smith, Department of Public Health, Old Road Campus, University of Oxford, OX7 7AG +44 1865 289239 adrian.smith@dphpc.ox.ac.uk Chi-squared *p<0.0001 ** p<0.0001 ***p=0.0061 [1] Sanders EJ, et al AIDS 2007;21(18):2513-20. [2] Tovanabutra S et al15th Intl Workshop on HIV Dynamics and Evolution 2008. Source * questionnaire ** diaries