Persistent high-risk behavior and escalating HIV, syphilis and hepatitis B incidences among men who have sex with men living in Bangui, Central African Republic

Introduction HIV in sub-Saharan Africa remains a great concern in men who have sex with men (MSM). Intervention on MSM is a key strategy to control the burden of HIV among this population. Herein we assessed the effect of 2 years of HIV testing and counseling on risk-tacking and HIV and STI incidences among MSM living in Bangui in the Central African Republic. Methods The incidences of HIV, syphilis and hepatitis B and the sexual behavior characteristics were assessed at inclusion and after 2 years of follow up in the prospective MSM cohort. Results 99 MSM were included and followed up during 2 years. The mean age of study MSM was 24 years (range, 14-39); among those, the majority was single (84.8%) and unemployed (33.3%) or students (23.9%). The majority (up to 80%) were living in only 4 (out of 10) neighboring district of Bangui. Insertive anal intercourse showed significant decrease from 54% at inclusion to 46% after 2 years of follow up (P < 0.001). In contrast, we observed slight increase in receptive anal intercourse (60% versus 66%) and oral sex (70% versus 74%), but the difference did not reach statistical significance. Finally, the prevalences of HIV, syphilis and hepatitis B increased significantly from 29% to 41%, 12% to 21% and 14% to 23%, respectively. Conclusion These observations indicate that medical care and counseling on MSM does not provide significant changes in risk-taking, whereas the incidences of HIV, syphilis and hepatitis B remained high. Innovative interventions should be conceived for the MSM population living in Bangui.


Introduction
The burden of HIV epidemic in sub-Saharan Africa remains a great concern in high-risk populations such as men who have sex with men (MSM), who constitute a core group for HIV and several sexually transmitted infections (STI) such as syphilis and hepatitis B [1][2][3][4][5][6][7][8][9]. High-risk sexual behaviors such as unprotected anal intercourse and multiple sexual partners are the main factors closely associated with this high burden of HIV and STIs in this vulnerable population [10,11]. Other factors such as social vulnerability, criminalization, stigma and lack of national intervention strategies for prevention and access to care for MSM are also recognized contributive factors in most of sub-Saharan African countries [12,13]. Therefore, the implementation of interventions strategies for prevention and medical care towards the MSM population is a key strategy to control the burden of HIV infection and associated STIs in this vulnerable group [14,15]. Indeed, through intervention strategies such as HIV and STIs testing and counseling, infected MSM can be identified and treated as early as possible. In other hand, promoting HIV counseling in MSM has proved to be an effective strategy to reduce HIV-related sexual risk behaviors, thereby decreasing the incidence of HIV infection among MSM [15][16][17][18]. In the Central African Republic, the HIV epidemic is generalized with a prevalence of 4.9% in adult population [19,20]. Relatively little has been reported until now about MSM and their sexual health. One preliminary serosurvey conducted in 2010 on MSM in Bangui highlighted that MSM are an identifiable core group accumulating high-risk sexual behaviors and high prevalence of HIV (25%), hepatitis B (17%) and syphilis (4%) [20]. With 25%, the prevalence of HIV in MSM living in Bangui was about 5 times higher than the prevalence of HIV in general population. These data advocate the implementation of specific and targeted MSM interventions to reduce unsafe sexual practices, facilitate access to specialized health service for key vulnerable populations, thereby a priori rendering effective the reduction and control of HIV and associated STIs in this high-risk group [21][22][23]  variable ("changes in sexual behavior") was estimated from behavioral variables such as the "sexual partner numbers in the last three months" and the "frequency of condom use with the last sexual partner" in the three categorical variables "never use condom", "occasionally (irregularly) condom use" and "systematically (consistent) use condom".

Results
Study population: A total of 99 MSM were included ( Figure 1).

Discussion
In the present study, we report for the first time in MSM living in the  [28,29]. Young men early starting sexual intercourse, especially before the age of 16 years, are facing psychological problems related to drugs and may be at risk of suicide [28]. Although the stigma and criminalization of MSM population in many sub-Saharan African countries forces these populations to remain hide, this vulnerable group at high risk for HIV infection and associated STI appears well present in sub-Saharan countries and needs to be taken into account in order to control the HIV epidemic. Thus, it is well admitted that behavior change interventions can reduce unsafe sexual practices [15][16][17][18]. showing that HIV and STI testing and counseling did not significantly reduce the prevalence of HIV and sexual risk behaviors in MSM [31]. In Lau's study, HIV prevalence ranged from 2.5% at baseline to 6.3% after 21 months of intervention and participants interviewed at month 21 self-reported increased in unprotected anal intercourse and other risk behaviors, comparing recent and prebaseline experiences [31]. However, in another Chinese study, it was shown that after 3 months of HIV and STI testing and risk reduction counseling, anal intercourses decrease significantly among STI-infected MSM from 73.1% to 38.5%, group sex decrease from 19.2% to 5.8% and unprotected anal intercourse decrease from 23.1% to 5.8% [32]. Among STI-negative MSM, risk sexual behaviors could also decrease significantly [32]. Likewise, Huan and colleagues reported in China significant decrease in both unprotected anal intercourse from 60.9% to 42.9% and in the number of MSM having sex with several partners, following 1.5 years intervention [33]. The possibility that relapse in high risk sexual behavior could have occurred in our study MSM should be further investigated, as suggested by previous studies showing that significant positive effects of intervention may wane over time [22,33,34].

Conclusion
In

Competing interests
The authors declare no competing interests.