Epidemiological Profile of Men Who Have Sex with Men: First Data about Male Sex Workers in Central African Republic (CAR) ()
1. Introduction
Key populations are those most at risk of contracting HIV/AIDS. Often marginalized, their social stigmatization fuels their vulnerability to HIV, and vice versa [1] . They include among others men who have sex with men (MSM) [1] [2] . These are so-called priority or essential population groups in the dynamics of the HIV epidemic [2] . Key populations account for 70% of the 1.3 million people newly infected with HIV in 2023 [3] [4] , whereas they represent only 5% of the world's population [3] . The proportion of MSM among new infections is 21% worldwide, 6% in sub-Saharan Africa, and 41% in the rest of the world [3] . This sub-Saharan proportion of MSM does not reflect reality; they hide their status.
Worldwide, the relative risk of acquiring HIV for MSM is 28 times higher than for the general population [3] . Key populations, and particularly MSM in Africa, deserve special attention in HIV control strategies to minimize the risk of contamination and benefit from early care for those infected, with a view to achieving the UNAIDS 95-95-95 targets. In addition, studies have recently shown that MSM sex workers have a higher risk of contracting HIV than other MSM and even female sex workers [5] [6] [7] . In addition, clandestine activities linked to the fear of stigmatization make it difficult to assess the contamination risks of MSM sex workers [8] [9] , who are therefore workers in the informal sector. These findings call for targeted studies to identify MSM who are sex workers among all MSM, in order to adapt control strategies.
The Central African Republic (CAR) is no exception. The country has 6.1 million inhabitants [10] . With a general prevalence of 3.4%, CAR has 120,000 people living with HIV [11] . HIV prevalence among MSM was 34.0% in 2013 [12] and 7.4% in 2019 in Bangui [13] , respectively 10 times and 2 times the HIV prevalence in the general population. While sex work is well known and documented among women [14] , the phenomenon does not seem to be studied among men let alone MSM. In CAR, a working hypothesis is based on rigid gender stereotypes, according to which sexual violence mainly affects women [15] . The aim of this study was to describe the epidemiological profile of MSM, to determine the proportion of sex workers among them and the proportion of MSM who have been victims of gender-based violence.
2. Methods
This is a descriptive cross-sectional study coordinated by the Direction de la Médecine du Travail in the Département de Santé Publique of the Faculty of Health Sciences at the University of Bangui. The study which took place from July 1 to October 31, 2021, a duration of 4 months, at the headquarters of ALTER-NATIVES (French acronym for “Association for Freedom, Tolerance, Expression and Respect for People of an Indigent, Vulnerable or Socially Excluded Nature”). ALTERNATIVES-CENTRAFRIQUE is a community-based Non-Governmental Organization created on August 10, 2009 and recognized by the Central African State on September 04, 2020 under the full name of “ALTERNATIVES pour le Développement de Centrafrique” in accordance with the law regulating associations in CAR. The organization has some 1000 members spread across CAR’s 20 prefectures and Bangui’s 10 arrondissements. His main objective is to promote respect for human rights and the social reintegration of vulnerable people and victims of discrimination.
The study population consisted of MSM present in Bangui during the study period. All MSM present during the data collection period and having given signed informed consent were included in the study. They had to be at least 15 years old to be included. MSM passing through Bangui and belonging to the ALTERNATIVES branch in another locality were not included. The sample size required to estimate a proportion was determined using the SHWARTZ formula [16] . Application of this formula requires knowledge of the proportion of MSM in the general population. As this was not known in CAR, the world proportion of key populations (5%) was used [3] . Applying Schwartz’s formula [16] with this 5% proportion [3] , the sample size obtained was 73 MSM. Sampling was exhaustive up to the selected sample size.
Data were collected using a standard questionnaire extracted from the form used in 2019 for the International behavioral and biological survey of sex workers and MSM [13] [14] . The questionnaire provided information about socio-demographic variables, variables relating to future vision of MSM activity and gender-based violence. The completed forms are stored, entered and analyzed at the Direction de la Médecine du Travail in the Département de Santé Publique using Epi-Info version 7 software. Proportions of categorical variables and means of quantitative variables were determined. The study was conducted in compliance with the ethical guidelines of the Ethical and Scientific Committee of the Faculty of Health Sciences and the Pasteur Institute of Bangui and the 2000 version of the Declaration of Helsinki. The signed informed consent was obtanied from each participant.
3. Resultats
During the study period, 40 MSM were interviewed. Their average age was 23, with a minimum of 15 and a maximum of 47. Almost a third, 62.5%, of the participants were in the 15 - 24 age bracket, followed by the 25 - 35 age bracket, which accounted for 32.5% of the population. Almost all MSM (95.0%) therefore belonged to these two age groups. The MSM age group over 35 was represented by 5% (Table 1).
Participants who had never attended school or who had reached university
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Table 1. Sociodemographical charasteristics of MSS surveyed.
level each represented 7.5%, and those who had reached primary level 10%. Those with secondary education predominated, representing 75.0% of our sample. Thirty-seven (92.5%) had not gone beyond secondary school. In terms of occupation, the vast majority of MSM were unemployed (85.0%). This was followed by private-sector workers, who accounted for 10% of our sample. Public sector employees were represented at 5%. The total proportion of MSM working in the formal sector was 15% (Table 1).
Eighteen MSM (45.0%) reported ever having been victims of violence during their MSM activity. Among the 18 MSM who reported having been victims of gender-based violence, sexual violence predominated with 32.5%, including sexual exploitation by a third party (7.5%). Economic violence (refusal to pay the bill) was the second most frequent type of violence reported, and was present in 22.5%.
Physical violence came third, reported by 20.0% of MSM surveyed, while verbal and psychological violence each accounted for 12.5% (Figure 1).
Nineteen (47.5%) said they would stop working as an MSM. Twenty-six (65.0%) said they would accept another income-generating activity in exchange for MSM activity (Figure 2).
Among the 18 MSM victims of gender-based violence, the violence suffered was verbal or psychological (12.5%), physical (20.0%), economic (refusal to pay the bill 22.5%) and sexual (32.5% including 7.5% exploitation by a third party).
Over 80% of MSM had already been tested for HIV for HIV at least once in their lives, and 65.0% of them were in the habit of using condoms. Concerning the ability of use of condoms during sexual intercourse was negotiated by was
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Figure 1. Distribution of MSM according to gender based violence expérienced and desire to change activity.
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Figure 2. Distribution of MSM according to types of gender based violence suffered.
negotiated by 18.9% of MSM.
4. Discussion
This study aimed to describe the epidemiological profile of MSM, to estimate the proportion of sex workers among them, as well as the proportion of MSM who had been victims of gender-based violence. It included 40 MSM with an average age of 23 years (minimum 15). Three-quarters had a high school level, and 58.0% were unemployed. Victims of gender-based violence in the exercise of MSM activity are 45.0% while 47.5% wished to stop MSM practices and 65.0% wanted to switch for another income-generating activity. The nature of the gender-based violence suffered by MSM was verbal or psychological (12.5%), physical (20.0%), economic refusal to pay the bill (22.5%) and sexual (32.5%), including sexual exploitation by a third party (7.5%).
This study is the first in CAR to address the issue of sex work among men, particularly MSM. While sex work is well known for women, often addressed in research [17] [18] , that of men is scarcely addressed, and even less so among MSM who operate clandestinely, because of discrimination and stigmatization. The results of this study showed that the average age of MSM was 23 (minimum 15). The majority were aged between 15 and 24 (62.5%). The average age in our series was very close to those of Billong, Cameroon in 2018 which was 24 years [19] and Hessou in Benin, 25 years [20] . The predominance of this age group corresponds to that observed among jobseekers in Bangui who needed medical certificat [21] . On the other hand, it was lower than that of Congo in 2012, which was 28.8 years [22] . This difference could be explained by the fact that in the CAR, young people enter sexual activity early, around the age of 15 or even 12 [23] . This young age, corresponding to the minimum age in our series, like that of the International behavioral and Biological Survey among female sex workers in the CAR [22] . It raises the issue of accessibility of key populations or so-called emancipated minors to the continuum of HIV care [24] . Indeed, ethical principles require that the consent of one of the parents of a minor be obtained before HIV testing. Given that in CAR sexual activity begins around the age of 15, which is a minor’s age, it often takes place without the parents’ knowledge, as is the case for MSM activities. Requiring parental consent would exclude them from care, which is a serious handicap for the elimination of HIV by 2030, as this global goal necessarily requires the elimination of HIV among key populations, including MSM. Thus, the debate was launched before our study to reduce the age of access to HIV screening without the need for parental consent when conditions require it. Studies were approved by the Ethics Committee and carried out including key populations, PS aged 16 and over [14] . Finally, the debate led to the promulgation of a law on HIV and AIDS in the CAR, which stipulates that “anyone aged 12 or under has the right to be tested for HIV”, without recourse to parental consent in the case of an emancipated minor [23] . The young age of the MSM was superimposed on their education level.
Overall, 75.0% of MSM had completed high school, 10.0% primary school and 7.5% had never attended school, with a total of 92.5% who had not gone beyond high school. Few MSM had reached university level. These results confirm those of the 2019 behavioral and biological study of MSM in CAR with 76.3% at high school level [13] and those of Congo in 2013 (69.2%) [22] . This proportion in CAR is higher than in Benin (41.3%), which on the other hand has a high proportion of MSM with university level: 48.3% [20] . The proportion of MSM with higher education in CAR was only 7.5%. This difference can be explained by the size of the population. Similarly, with the multiple crises experienced in the CAR, the standard of living of CAR people is constantly falling, which can translate into subsistence difficulties in continuing to study, and would discourage those with the will to pursue studies up to university level. This low level corroborates the difficulty MSM have in getting employment, and therefore encourages the exchange of sexual services for some form of remuneration.
The results of our study showed that only 6 MSM (15.0%) were employed, in both the public and private formal sectors; thus, 34 MSM (85.0%) were unemployed. This frequency is higher than that found in Benin, which was 76.6% [20] . In contrast, the survey carried out by the Comité National de Lutte contre le Sida in CAR in 2019 showed that 49.1% of MSM worked in the informal sector and 31.7% were pupils or students [13] . This difference can be explained by the fact that our study was carried out only in Bangui and included a small number of MSM. The study in 2019 was conducted in Bangui and 4 other provincial towns. The low instruction level would encourage MSM to engage in activities that would expose them more to gender-based violence.
In addition to professional activities, 45.0% of MSM reported having been victims of violence related to their sexual activities and practices (Figure 1): the gender-based violence. Indeed, gender-based violence refers to any type of harmful act perpetrated against a person or group of people because of their real or perceived sex, gender, sexual orientation and/or gender identity [25] . The frequency of 45.0% of our series, similar to that of Nigeria (42.1%) [26] , is higher than that obtained on the same population in Bangui and 4 provincial towns in 2019 (13.8%) and on their Beninese counterparts in 2019 (25.1%) [13] [20] . MSM sex workers are particularly vulnerable to GBV because of their deviation from “norms of masculinity” [8] . These data would suggest that gender-based violence against MSM could be on the rise in CAR, rising from 13.8% in 2019 to 45.0% in 2022. This means that gender-based violence can also affect men and boys [15] . Among the different categories of gender-based violence, sexual violence ranks first with 32.5%, including 7.5% sexual exploitation by a third party. It is followed by economic violence (22.5%), mainly reflected in the partner’s refusal to pay the bill in. Physical violence came third with 20.0%, followed by verbal and psychological violence, each accounting for 12.5%. These results show that MSM regularly experience all the different categories of gender-based violence. But the high frequency of sexual violence (32.5%) observed among MSM as well as men and boys not belonging to this population category during the crisis period the CAR has been experiencing since late 2012, show that “sexual violence can strike anyone” [15] . This sexual violence could compromise the implementation of prevention measures that the MSM would like to observe during the sexual act. This high frequency of violence could prompt the desire to stop being MSM.
While 45.0% of MSM were victims of gender-based violence, 47.5% had declared their desire to stop activities related to their MSM status. Even if these 2 frequencies are very close, gender-based violence could not be the only motivation for wanting to stop activities linked to their MSM status, especially as 65.0% of MSM had declared that they wanted to accept another income-generating activity to replace activities linked to their MSM status. This willingness to change activity in favor of another income-generating activity could lead to the hypothesis that MSM activities would constitute an income-generating activity, and therefore a profession, for more than half of the MSM. This could explain the age groups most represented in our study corresponding to that of jobseekers [21] . These MSM would then be sex workers and therefore workers in the informal sector. Other clues reinforce this hypothesis. In CAR, the fact that 68.7% of MSM declared in 2019 that they had been paid for their first sexual intercourse (58.2% with money and 20.5% with an object) could encourage them to practice more paid than unpaid sex [13] . In Congo in 2012, 81.7% of MSM reported having paid sex [22] . Paid sex is put to good use in our series, with 7.5% of MSM who were victims of sexual violence in the form of exploitation by a third party. The person is exploited with or against her will, but the exploiter generally passes on part of the income generated by this activity to the exploited person, which would be equivalent to a salary. According to UNAIDS, “Sex workers include consenting adult women, men and transgender people, as well as young people over the age of 18, who receive money or goods in exchange for sexual services, on a regular or occasional basis” [2] [27] . MSM in our series therefore fit well this definition. All these elements, combined with the definition of MSM [2] could establish with certainty that among MSM there was a non-negligible proportion of sex workers. The refusal to pay the bill for the sex act noted by the MSM is therefore confirmation of the definition of sex work. These MSM are therefore workers in the informal sector, like female sex workers and GBV is then occupational hazard [9] . In addition, the clandestine activity of MSM makes them hidden GBV victims [8] [26] [28] , and as workers in the informal sector are not covered by occupational medicine, implementing preventive actions for them becomes complex. Hence the importance of characterizing MSM sex worker status, especially as it has been shown that MSM sex workers are at greater risk than other MSM [5] [6] [7] . Establishing MSM status is necessary to adjust preventive strategies to the level of risk with a view to eliminating HIV by 2030.
This study has limitations. The sample size of 40 MSM is small compared with the theoretical minimum sample size of 73 MSM, but as the study lasted 4 months, it was unrealistic to extend this period in the hope of obtaining a larger sample. The data were collected by interview, and it was not possible to verify the reality of what the participants were declaring, as is the case with all studies based on declarative data. Nevertheless, this study provided preliminary data on gender-based violence and the notion of male sex worker, among MSM and even among men in CAR. Further studies should be carried out on larger samples in order to verify the results obtained here and, above all, to explore all the reasons for the desire to change activity. These subsequent studies would form the basis for support to “ALTERNATIVES Centrafrique” in developing income-generating activities.
5. Conclusion
The results of this study show that the MSM were especially young, poorly educated and unemployed. Many were victims of gender-based violence, wanted to change their activity and would accept another income-generating activity. The majority are sex workers. Further studies on a much larger sample are needed to confirm the results obtained here on a small sample, and to understand the reasons for the desire to change activity.
Authors’ Contributions
HDMK, designed the study, PJD and AB the data, HSCD, AB and HDMK performed the statistical analysis of the data, HDMK, developed the first draft, all read and approved the latest version.