title: Geographical disparities in HIV prevalence and care among men who have sex with men in Malawi: results from a multisite cross-sectional survey.
abstract: Epidemiological assessment of geographical heterogeneity of HIV among men who have sex with men (MSM) is necessary to inform HIV prevention and care strategies in the more generalised HIV epidemics across sub-Saharan Africa, including Malawi. We aimed to measure the HIV prevalence, risks, and access to HIV care among MSM across multiple localities to better inform HIV programming for MSM in Malawi.
  
  
  
  Between Aug 1, 2011, and Sept 13, 2014, we recruited MSM into cross-sectional research via respondent-driven sampling (RDS) in seven districts of Malawi. RDS and site weights were used to estimate national HIV prevalence and engagement in care and in multilevel regression models to identify correlates of prevalent HIV infection. The comparative prevalence ratio of HIV among MSM relative to adult men was calculated by use of direct age-stratification.
  
  
  
  2453 MSM were enrolled with a population HIV prevalence of 18·2% (95% CI 15·5-21·2), as low as 4·1% (2·2-7·6) in Mzuzu and as high as 24·5% (19·5-30·3) in Mulanje. The comparative HIV prevalence ratio was 2·52 when comparing MSM with the adult male population. Age-stratified HIV prevalence showed early onset of infection with 11·8% (95% CI 7·3-18·4) of MSM aged 18-19 years HIV infected. Factors positively associated with HIV infection included being aged 21-30 years and reporting female or transgender identity. Among HIV infected MSM, less than 1% reported ever being diagnosed with HIV infection (0·9%, 95% CI 0·4-2·5) and initiated antiretroviral treatment (0·2%, 0·2-0·3).
  
  
  
  HIV disproportionately affects MSM in Malawi with disparities sustained across the HIV care continuum. These issues are geographically heterogeneous and begin among young MSM, supporting geographically focused and age-specific approaches to confidential HIV testing with linkage to HIV services.
  
  
  
  Malawi Department of Nutrition, HIV and AIDS (DNHA), UNDP, UNFPA, UNAIDS, and UNICEF.
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: awirtz1@jhu.edu.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Wirtz
authors.affiliation: Center for the Development of People, Lilongwe, Malawi.
authors.forename: Gift
authors.initials: G
authors.lastname: Trapence
authors.affiliation: Center for the Development of People, Lilongwe, Malawi.
authors.forename: Dunker
authors.initials: D
authors.lastname: Kamba
authors.affiliation: Center for the Development of People, Lilongwe, Malawi.
authors.forename: Victor
authors.initials: V
authors.lastname: Gama
authors.affiliation: Center for the Development of People, Lilongwe, Malawi.
authors.forename: Rodney
authors.initials: R
authors.lastname: Chalera
authors.affiliation: Department of Health Systems and Policy, College of Medicine, Blantyre, Malawi.
authors.forename: Vincent
authors.initials: V
authors.lastname: Jumbe
authors.affiliation: United Nations Development Programme, Lilongwe, Malawi.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Kumwenda
authors.affiliation: Malawi Department of Nutrition, HIV and AIDS, Lilongwe, Malawi.
authors.forename: Marriam
authors.initials: M
authors.lastname: Mangochi
authors.affiliation: Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Stephane
authors.initials: S
authors.lastname: Helleringer
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Beyrer
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Stefan
authors.initials: S
authors.lastname: Baral
mesh_terms: D000293:Adolescent; D000328:Adult; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D018451:Homosexuality, Male / Q000706:statistics & numerical data*; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008403:Mass Screening; D015995:Prevalence; D011795:Surveys and Questionnaires; D055815:Young Adult