HIV Epidemiology, Risk Behaviours, and Structural Barriers among Men Who Have Sex with Men in Cabo Verde: Evidence from Three Bio-behavioural Surveys (2013–2023)

HIV Epidemiology, Risk Behaviours, and Structural Barriers among Men Who Have Sex with Men in Cabo Verde: Evidence from Three Bio-behavioural Surveys (2013–2023) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article HIV Epidemiology, Risk Behaviours, and Structural Barriers among Men Who Have Sex with Men in Cabo Verde: Evidence from Three Bio-behavioural Surveys (2013–2023) Adilson José DePina, Nelson Neide Furtado Ribeiro, Maria Celina Moreira Ferreira, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8933663/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Men who have sex with men (MSM) remain disproportionately affected by HIV globally. Cabo Verde, while maintaining a low HIV prevalence in the general population (< 1%), has reported a rising burden among MSM. This study synthesises findings from three consecutive bio-behavioral surveys (2013, 2017, 2023), providing the first longitudinal evidence on HIV epidemiology, risk behaviours, and vulnerabilities among MSM in Cabo Verde. Methods : Cross-sectional bio-behavioral surveys were conducted in 2013 (n = 316), 2017 (n = 243), and 2023 (n = 295). Respondent-driven and snowball sampling strategies recruited MSM in Praia, Mindelo, and other urban areas. Data collection combined structured questionnaires, in-depth interviews, and rapid HIV testing. Descriptive analyses compared prevalence, behaviours, and structural determinants across survey years. Multivariate logistic regression was performed on 2023 data. Results: HIV prevalence rose from 4.4% (2013) to 5.4% (2017) and 9.5% (2023). Condom use during anal intercourse declined from 72% (2013) to 63% (2023). Transactional sex increased, reaching 29% in 2023. Verbal (11–14%) and physical violence (6–8%) persisted, alongside police harassment (13–18%). Despite > 90% knowledge of prevention, consistent condom use remained low, and disclosure to family and partners was limited. In 2023, 80% reported HIV testing in the past year, 54% screened positive for mental health distress, and 72% expressed willingness to use pre-exposure prophylaxis (PrEP). Logistic regression indicated higher HIV risk among older MSM (≥ 25 years, AOR 1.8, 95% CI 1.1–2.9) and urban residents (AOR 1.6, 95% CI 1.0–2.5), with secondary or higher education protective (AOR 0.62, 95% CI 0.39–0.98). Conclusions: D espite progress in HIV awareness and testing, HIV prevalence among MSM in Cabo Verde nearly doubled over the past decade. Persisting stigma, violence, and declining condom use undermine prevention. Urgent scale-up of pre-exposure prophylaxis (PrEP), community-led stigma reduction, and MSM-friendly health services is essential to reverse current trends and achieve UNAIDS 2030 targets. HIV MSM Cabo Verde key populations stigma PrEP epidemiology Figures Figure 1 Introduction The HIV epidemic continues to disproportionately affect men who have sex with men (MSM) globally. Despite substantial advances in antiretroviral therapy (ART) and combination prevention strategies, MSM remain one of the populations most vulnerable to HIV acquisition and poor clinical outcomes [ 1 – 3 ]. Globally, MSM are estimated to be nearly 28 times more likely to acquire HIV than the general population, a disparity shaped by a complex interplay of biological, behavioural, and structural factors [ 4 ]. Although overall HIV incidence has declined in many regions, rates among MSM have often remained stable or have even increased, reflecting persistent inequities in access to prevention, testing, and treatment services [ 5 , 6 ]. In sub-Saharan Africa, HIV prevalence among MSM is consistently higher than in the general population, with studies reporting rates five to ten times greater than among heterosexual men [ 7 – 9 ]. In West and Central Africa, prevalence estimates among MSM range widely, often exceeding 10–30% [ 10 – 12 ], highlighting the concentrated nature of the epidemic within this population. Historically, national HIV responses have prioritised generalized heterosexual transmission, resulting in under-investment in programmes and services specifically tailored to MSM [ 13 ]. Consequently, gaps persist in access to HIV testing, pre-exposure prophylaxis (PrEP), mental health support, and stigma-free care, despite evidence that interventions targeting MSM are both cost-effective and essential to achieve the UNAIDS 95–95–95 targets [ 1 , 14 , 15 ]. Cabo Verde, a small island developing state located off the coast of West Africa, presents a unique epidemiological profile. HIV prevalence in the general population remains below 1%, situating the country among those with a low-level generalized epidemic [ 16 ]. However, national averages mask substantial disparities in key populations, including sex workers, people who inject drugs, and MSM [ 17 ]. Among MSM, the intersection of biological susceptibility, behavioural risks, and structural vulnerabilities contributes to ongoing HIV transmission. Biological risk factors, including unprotected receptive anal intercourse, inconsistent use of lubricants, and untreated sexually transmitted infections (STIs), heighten HIV susceptibility in MSM [ 18 – 20 ]. Behavioural drivers—such as multiple and concurrent sexual partnerships, engagement in transactional sex, and substance use in sexual contexts—further amplify risk [ 21 , 22 ]. Structural barriers, including stigma, family rejection, community discrimination, and police harassment, constrain MSM’s access to HIV services and discourage disclosure of sexual orientation or HIV status [ 23 , 24 ]. Although same-sex relations are not criminalized in Cabo Verde, prevailing social norms remain conservative, and MSM often experience marginalisation in both public and private spheres [ 25 ]. Bio-behavioural surveys, which integrate socio-behavioural data with biological testing, provide crucial evidence on HIV prevalence, risk behaviours, and service coverage among key populations in settings where routine surveillance is limited [ 26 ]. Such surveys also allow for the identification of structural and behavioural drivers of HIV vulnerability, providing an evidence base to inform targeted, rights-based interventions. Given the concentrated epidemic among MSM and the structural barriers they face, understanding HIV epidemiology and associated vulnerabilities in this population is essential for designing effective interventions. This study current knowledge on HIV among MSM in Cabo Verde with four overarching objectives: i) To describe HIV epidemiology and trends among MSM; ii) To characterise socio-demographic profiles, sexual behaviours, and prevention practices; iii) To assess experiences of stigma, discrimination, and violence; and iv) To discuss implications for policy and programming to strengthen HIV prevention and care for MSM. By examining these aspects comprehensively, this work aims to provide a scientific foundation for evidence-based, community-led, and rights-focused interventions that align with the WHO Consolidated Guidelines and the UNAIDS 2030 Fast-Track strategy [ 14 , 15 , 27 ]. Methods Study Design and Setting We conducted a series of cross-sectional bio-behavioural surveys (BBS) among men who have sex with men (MSM) in Cabo Verde. The surveys were implemented by the National AIDS Coordination Committee (CCS-SIDA) in collaboration with civil society organisations and technical partners. The primary objectives were to estimate HIV prevalence and characterize socio-behavioural determinants of HIV risk among MSM. The surveys were conducted in multiple urban centres to capture areas with higher MSM social and sexual networks. Initial data collection focused on Praia and São Vicente, while subsequent rounds expanded to Sal and Fogo, and later to Boa Vista, Santa Catarina, and Santa Cruz, reflecting the need for broader geographic coverage and representation of urban MSM populations. Sampling Strategy Given the hidden nature of MSM populations and the absence of a reliable sampling frame, respondent-driven sampling (RDS) and snowball sampling techniques were employed across all survey rounds. Initial “seeds” were purposively selected through key informants and established MSM networks. Each seed subsequently recruited peers to participate until the target sample size was achieved, in accordance with established best practices for hard-to-reach populations [ 26 , 28 – 30 ]. Eligibility criteria included: self-identification as a man who has sex with men, age ≥ 18 years, and provision of informed consent. Target sample sizes ranged from ~ 240 to 300 participants per survey, consistent with recommended standards for population-specific bio-behavioural studies. Data Collection Three consecutive rounds of bio-behavioral surveys were conducted in Cabo Verde at different time points. The first survey was conducted between September and October 2013 over a period of six weeks. The second round was conducted from November to December 2016, spanning a period of six weeks. The third and most recent survey was conducted from November 2 to 28, 2023. Each survey was implemented during the specified periods to capture comparable information across time while accounting for logistical feasibility and population availability. Quantitative data were obtained through structured questionnaires capturing socio-demographic characteristics, sexual behaviours, condom and lubricant use, STI knowledge, HIV testing history, and experiences of stigma, discrimination, or violence. Qualitative data were collected through in-depth interviews and focus group discussions with MSM and key informants, exploring contextual factors including community acceptance, barriers to service access, and perceptions of HIV prevention programmes. This mixed-methods approach allowed triangulation of behavioural, structural, and psychosocial determinants of HIV risk. Biological data were obtained via rapid HIV testing conducted by trained nurses and laboratory technicians according to national algorithms. All reactive results were confirmed through confirmatory testing, and participants testing positive were linked to HIV care services promptly, following national HIV treatment guidelines. Variables and Indicators The primary outcome was laboratory-confirmed HIV prevalence. Secondary outcomes included: Sexual behaviours (condom use, number of partners, engagement in transactional sex) HIV testing uptake STI symptoms Experiences of stigma, discrimination, and violence Knowledge of HIV prevention and PrEP (2023 survey only) Self-reported mental health outcomes (2023 survey only) These variables align with WHO and UNAIDS guidance for monitoring key populations [ 15 , 27 ]. Statistical Analysis Quantitative data were analysed using Stata 17 (StataCorp, College Station, TX, USA). Descriptive statistics summarized socio-demographic characteristics, sexual behaviours, and structural vulnerabilities. Categorical variables were presented as frequencies and percentages; continuous variables were summarized as means with standard deviations or medians with interquartile ranges, depending on distribution. Trends in HIV prevalence over time and across subgroups were assessed using chi-square tests for categorical variables and t-tests or ANOVA for continuous variables, with significance set at p < 0.05. To identify factors independently associated with HIV infection, multivariate logistic regression models were fitted. Covariates were selected based on theoretical relevance and bivariate associations (p < 0.20). Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. Variables included in the final models typically comprised age, education, area of residence (urban vs. other municipalities), sexual behaviours (condom use, transactional sex), and experiences of stigma or discrimination. Model fit was assessed using the Hosmer–Lemeshow goodness-of-fit test, and multicollinearity was evaluated using variance inflation factors. Ethical Considerations All surveys received approval from the National Ethics Committee of Cabo Verde, being Deliberations Nº 44/2013, 59/2016 and 12/CNEPS/2023, and the last study had a deliberation from the National Commission for Data Protection (authorisation nº 76/2023/CNPD). Participants provided written informed consent and were assured confidentiality. No identifying information was collected, and participants received counselling, condoms, and referrals to HIV or STI services as needed. The study adhered to international ethical standards for research with key populations, including voluntary participation, confidentiality, and minimisation of harm. Results Sociodemographic Characteristics Participants were predominantly young, with a mean age of 25–27 years and over 60% under 30. The majority were single (> 90%), consistent with limited opportunities for stable partnerships. Educational attainment improved modestly over time, with 53% reporting secondary education or higher in 2023. Economic precarity remained high, with 44% reporting unemployment or unstable work in 2023 (Table 1 ). Table 1 Sociodemographic profile of MSM (2013–2023) Variable 2013 2017 2023 Mean age (years) 25 26 27 Single (%) 88 92 92 Secondary+ education (%) 41 47 53 Unemployed/unstable (%) 35 39 44 HIV Prevalence HIV prevalence among MSM in Cabo Verde demonstrated a clear upward trend over the decade. Prevalence increased from 4.4% in 2013 to 5.4% in 2017, and further to 9.5% in 2023 (Fig. 1 ), indicating a near doubling over ten years and reflecting ongoing transmission within MSM networks. Sexual Behaviours and Prevention Condom use at last anal intercourse declined from 72% in 2013 to 63% in 2023, with consistent condom use similarly decreasing to 55%. Transactional sex was reported by 29% of participants in 2023, highlighting ongoing exposure to high-risk sexual networks. The mean age at first same-sex sexual encounter remained 19 years. Lubricant use was inconsistent, with some participants still using petroleum-based products, which can compromise condom effectiveness (Table 2 ). Table 2 Sexual behaviours and HIV prevention indicators Indicator 2013 2017 2023 Condom use at last anal sex (%) 72 68 63 Consistent condom use (%) 61 59 55 Transactional sex (%) 22 26 29 HIV test in last 12 months (%) 64 71 80 Stigma, Violence, and Discrimination Structural vulnerabilities persisted across survey rounds. Between 11–14% of participants reported verbal harassment, 6–8% reported physical violence, and 13–18% experienced police harassment. Family rejection was consistently reported, and disclosure of sexual orientation and HIV status to family remained low (< 15%) (Table 3 ). Table 3 Stigma, violence, and discrimination among MSM Indicator 2013 2017 2023 Verbal violence (%) 14 12 11 Physical violence (%) 8 7 6 Police harassment (%) 18 15 13 Disclosed HIV status to family (%) – 9 10 Knowledge, HIV Testing, and Mental Health Awareness of HIV prevention remained consistently high (> 90%). In 2023, 92% of participants knew where to access HIV testing, and 80% reported testing in the previous 12 months. Awareness of pre-exposure prophylaxis (PrEP) was introduced in 2023, with strong interest in uptake among MSM. Mental health challenges were prevalent, with high self-reported rates of anxiety, depression, and stress, highlighting the need for integrated psychosocial support. Correlation between HIV prevalence and socio-demographic characteristics To explore socio-demographic correlates of HIV prevalence, bivariate and multivariate analyses were conducted using aggregated data from the three surveys. HIV prevalence was stratified by age group (< 25 years vs. ≥25 years), educational attainment (primary or less vs. secondary or higher), and area of residence (capital city vs. other municipalities). Across surveys, HIV prevalence was higher among older MSM (≥ 25 years: 8.7%) compared to younger participants (< 25 years: 5.1%). A positive correlation was observed between age and HIV prevalence (Pearson’s r = 0.42, p = 0.03). Educational attainment showed an inverse relationship: MSM with secondary education or higher had lower HIV prevalence (6.2%) than those with primary education or less (9.8%). The correlation between education level and HIV prevalence was statistically significant (r = − 0.37, p = 0.04). Geographic disparities were also documented. HIV prevalence was higher in Praia and São Vicente (urban centres) compared to other municipalities (10.1% vs. 6.8%, χ² = 5.9, p = 0.015). In multivariate logistic regression (adjusted for age and education), older age and residence in urban centres remained independently associated with HIV-positive status (Adjusted Odds Ratio [AOR] 1.8, 95% CI 1.1–2.9 for age ≥ 25; AOR 1.6, 95% CI 1.0–2.5 for urban residence). Higher educational attainment was protective (AOR 0.62, 95% CI 0.39–0.98) (Table 4 ). Table 4 Multivariate logistic regression of factors associated with HIV prevalence among MSM (2013–2023) Variable HIV prevalence (%) Crude OR (95% CI) Adjusted OR (95% CI)* p-value Age < 25 years 5.1 1.0 1.0 – ≥ 25 years 8.7 1.78 (1.05–3.01) 1.80 (1.10–2.90) 0.021 Education Primary or less 9.8 1.0 1.0 – Secondary or higher 6.2 0.61 (0.39–0.96) 0.62 (0.39–0.98) 0.039 Area of residence Other municipalities 6.8 1.0 1.0 – Urban centres 10.1 1.55 (0.99–2.43) 1.60 (1.01–2.53) 0.046 *Adjusted for age and education. Discussion The findings from these bio-behavioral surveys provide a compelling portrait of the evolving HIV epidemic among men who have sex with men (MSM) in Cabo Verde over the past decade. The nearly twofold increase in HIV prevalence highlights an urgent public health concern and underscores that high knowledge of HIV prevention alone is insufficient to curb transmission. Despite high awareness of condoms and HIV testing, behavioural, biological, and structural vulnerabilities continue to drive risk, reflecting patterns observed in other West African contexts where MSM consistently experience HIV prevalence several times higher than the general population [ 1 – 3 , 31 – 33 ]. The Biological and behavioural determinants of HIV risk remain salient. Unprotected anal intercourse, particularly receptive anal sex, continues to contribute disproportionately to new infections, consistent with findings from similar epidemiological settings [ 18 , 34 ]. The persistence of transactional sex and multiple concurrent partnerships amplifies exposure risk, while inconsistent condom and lubricant use demonstrates gaps in prevention practice, despite widespread knowledge [ 35 , 36 ]. Moreover, while new prevention technologies such as pre-exposure prophylaxis (PrEP) have shown high efficacy, their limited availability and uptake in Cabo Verde during the survey periods highlight a critical gap in combination prevention [ 37 , 38 ]. The integration of biomedical interventions alongside behavioural strategies is therefore essential to reduce HIV incidence in this key population [ 39 , 40 ]. The Structural determinants represent another central axis of vulnerability for this population in Cabo Verde. Pervasive stigma, discrimination, family rejection, and police harassment continue to restrict access to HIV services and undermine trust in healthcare systems [ 41 – 44 ]. Even in a context where same-sex sexual activity is not criminalized, conservative societal attitudes contribute to marginalization and concealment of sexual behaviour, limiting engagement in HIV testing, care, and prevention [ 6 , 45 ]. The observed persistence of stigma and violence echoes regional findings that structural oppression significantly mediates HIV risk among MSM, emphasizing the need for interventions that go beyond individual-level behaviour change [ 46 – 48 ]. The correlation of the Socio-demographic with HIV infection reinforces the multifactorial nature of vulnerability. Older age was positively associated with HIV prevalence, suggesting cumulative exposure risk over time, while higher educational attainment demonstrated a protective effect, likely reflecting greater health literacy, enhanced condom negotiation skills, and higher utilization of healthcare services [ 49 – 51 ]. Geographic disparities were evident, with urban centres such as Praia and São Vicente showing higher prevalence, consistent with the epidemiology of concentrated epidemics where dense social and sexual networks facilitate transmission [ 52 – 54 ]. These findings underscore the need for targeted interventions tailored to specific subgroups within the MSM population, including younger men who may be at risk of early infection and those residing in high-transmission urban hubs. Socio-economic vulnerabilities remain highly relevant. The persistence of unemployment and reliance on transactional sex expose MSM to economic pressures that may limit negotiation of safer sexual practices, increase risk-taking behaviour, and reduce adherence to prevention measures [ 55 – 58 ]. Addressing these structural determinants through social protection, livelihood programs, and policy reforms is likely to produce long-term reductions in HIV risk and improve overall well-being [ 59 , 60 ]. Mental health challenges identified in the most recent survey are of particular concern. High prevalence of anxiety, depression, and stress among MSM can undermine adherence to HIV prevention and treatment interventions, negatively influence sexual risk behaviours, and reduce engagement with health services [ 61 – 63 ]. Integration of mental health support within HIV programs is therefore critical, aligning with evidence that psychosocial interventions can enhance adherence and retention in care [ 64 , 65 ]. Prevention gaps are evident despite high HIV knowledge. Condom promotion, while necessary, is insufficient to curb HIV transmission in this context, highlighting the urgency of implementing a combination prevention approach, including PrEP, HIV self-testing, and tailored health education campaigns. PrEP rollout represents a transformative opportunity to reduce HIV incidence; however, success requires addressing barriers such as stigma, acceptability, access, and integration into routine health services for MSM [ 37 , 38 , 66 ]. Community-led initiatives and peer-based outreach have been shown to enhance uptake of prevention services and improve linkage to care, suggesting that local MSM organizations should play a central role in programme design and delivery [ 67 – 69 ]. Policy implications are clear. Effective HIV response for MSM must integrate biomedical, behavioural, and structural interventions within a rights-based framework. Legal protections against discrimination, active enforcement of anti-harassment measures, and the promotion of social inclusion are crucial to enhancing access to services. The findings also emphasize the importance of urban-focused interventions, given the elevated prevalence in densely populated municipalities, while maintaining outreach to rural or less visible MSM networks [ 70 – 72 ]. Educational attainment emerges as a modifiable protective factor, suggesting that programmes promoting access to formal education and health literacy may have long-term benefits in HIV prevention. Strengths and limitations of the study warrant consideration. The surveys leveraged multiple rounds of data collection spanning a decade, enabling longitudinal insights into trends and correlates of HIV among MSM in Cabo Verde. The use of respondent-driven and snowball sampling approaches allowed access to a hidden population, although these non-probability methods may limit generalizability. Underreporting of sensitive behaviours, including sexual practices and experiences of stigma or violence, may introduce reporting bias. Furthermore, rural MSM populations were likely underrepresented, potentially underestimating prevalence and risk behaviours in these settings. Nonetheless, triangulation of quantitative and qualitative data across three survey waves strengthens the robustness of observed patterns. It provides a comprehensive understanding of HIV epidemiology, behavioural risk, and structural vulnerabilities among MSM in Cabo Verde [ 73 – 75 ]. Conclusions The MSM in Cabo Verde face a growing HIV burden, with prevalence increasing from 4.4% in 2013 to 9.5% in 2023. Despite high knowledge levels and improved testing uptake, inconsistent condom use, transactional sex, and structural vulnerabilities persist. Addressing these challenges requires comprehensive interventions that integrate biomedical tools such as PrEP, behavioural support, structural reforms, and mental health care. Rights-based, community-led approaches are essential to halt the trajectory of HIV among MSM and ensure that Cabo Verde advances toward the UNAIDS 95-95-95 targets and the 2030 elimination goals. Declarations Competing interests The authors declare no competing interests. Clinical trial number not applicable. Funding The study was implemented by the CCS-SIDA, with financial support from the Global Fund for HIV, Tuberculosis and Malaria, in partnership with the United Nations Joint Office and supported locally by the Health Delegations and the NGO´s Morabi and Verdefam. Author Contribution ADP, NNR MMC and AJC designed the study, the program methodology, the data collection indicators and supervisoned the activities. ADP, NNR and JMM designed the data analysis protocol, analysed the data and conducted statistical analyses. AJP led the writing of the paper. NNR, MCM, JMM, MF and AJC contributed to the writing of the paper. Acknowledgement We thank the participants, field investigators, supervisors and all technical staff involved in the surveys. We acknowledge CCS-SIDA, the Ministry of Health of Cabo Verde, community-based organisations including MORABI and VERDEFAM, and international partners including UNAIDS and WHO for their support. We also thank all the participants in the study, as well as the community and social community organisations. Data Availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. References Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380:367–77. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006: a systematic review. 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Individual and Social Network Factors Associated with High Self-efficacy of Communicating about Men's Health Issues with Peers among Black MSM in an Urban Setting. J Urban Health. 2020;97(5):668–78. Tanser F, de Oliveira T, Maheu-Giroux M, Bärnighausen T. Concentrated HIV subepidemics in generalized epidemic settings. Curr Opin HIV AIDS. 2014;9(2):115–25. Amirkhanian YA. Social networks, sexual networks and HIV risk in men who have sex with men. Curr HIV/AIDS Rep. 2014;11(1):81–92. Bärnighausen T, Hosegood V, Timaeus IM, Newell ML. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS. 2007;21(Suppl 7):S29–38. Sandfort TGM, Knox JR, Alcala C, El-Bassel N, Kuo I, Smith LR. Substance Use and HIV Risk Among Men Who Have Sex With Men in Africa: A Systematic Review. J Acquir Immune Defic Syndr. 2017;76(2):e34–46. Freitas CAM, Rossi TA, Dourado I, Castellanos MEP, Guimarães NS, Magno L. Mapping evidence on health promotion in HIV testing among men who have sex with men and transgender women using the social-ecological model and the vulnerability theoretical framework: a scoping review. BMC Public Health. 2023;23(1):1946. Sipe TA, Barham TL, Johnson WD, Joseph HA, Tungol-Ashmon ML, O'Leary A. Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review. AIDS Behav. 2017;21(12):3366–430. Rimmler S, Golin C, Coleman J, Welgus H, Shaughnessy S, Taraskiewicz L, et al. Structural Barriers to HIV Prevention and Services: Perspectives of African American Women in Low-Income Communities. Health Educ Behav. 2022;49(6):1022–32. Ahaneku H, Ross MW, Nyoni JE, Selwyn B, Troisi C, Mbwambo J. Depression and HIV risk among men who have sex with men in Tanzania. AIDS Care. 2016;28(Suppl 1sup1):140–7. Tao J, Qian HZ, Kipp AM, Ruan Y, Shepherd BE, Amico KR, et al. Effects of depression and anxiety on antiretroviral therapy adherence among newly diagnosed HIV-infected Chinese MSM. AIDS. 2017;31(3):401–6. Silvestri F, Tilchin C, Wagner J, Hamill MM, Rompalo A, Ghanem KG, et al. Enacted Sexual Minority Stigma, Psychological Distress, and Sexual and Drug Risk Behaviors Among Urban Men Who Have Sex with Men (MSM). AIDS Behav. 2023;27(2):496–505. Yu Y, Wang X, Wu Y, Weng W, Zhang M, Li J, et al. The benefits of psychosocial interventions for mental health in men who have sex with men living with HIV: a systematic review and meta-analysis. BMC Psychiatry. 2022;22(1):440. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019;33(9):1411–20. Ngcobo SJ, Zhandire T. Pre-Exposure Prophylaxis Uptake, Implementation and Barriers in Africa: A Scoping Review Protocol. Int J Environ Res Public Health. 2025;22(8):1300. Simoni JM, Nelson KM, Franks JC, Yard SS, Lehavot K. Are peer interventions for HIV efficacious? A systematic review. AIDS Behav. 2011;15(8):1589–95. Moyo E, Moyo P, Murewanhema G, Mhlanga-Gunda R, Dzinamarira T. Community-led interventions for HIV and AIDS prevention, treatment, and care in Southern Africa: a scoping review. Discov Public Health. 2025;22:78. Zhang TP, Liu C, Han L, Tang W, Mao J, Wong T, et al. Community engagement in sexual health and uptake of HIV testing and syphilis testing among MSM in China: a cross-sectional online survey. J Int AIDS Soc. 2017;20(1):21372. Gamarel KE, King WM, Operario D. Behavioral and social interventions to promote optimal HIV prevention and care continua outcomes in the United States. Curr Opin HIV. Onovo A, Kalaiwo A, Katbi M, Ogorry O, Jaquet A, Keiser O. Geographical Disparities in HIV Seroprevalence Among Men Who Have Sex with Men and People Who Inject Drugs in Nigeria: Exploratory Spatial Data Analysis. JMIR Public Health Surveill. 2021;7(5):e19587. Bangar S, Mohan U, Kumar S, Mahapatra A, Singh SK, Kohli R, et al. Exploring access to HIV-related services and programmatic gaps for Men having Sex with Men (MSM) in rural India- a qualitative study. PLoS ONE. 2023;18(5):e0284901. Risher K, Mayer KH, Beyrer C. HIV treatment cascade in MSM, people who inject drugs, and sex workers. Curr Opin HIV AIDS. 2015;10(6):420–9. Kerr LR, Mota RS, Kendall C, Pinho Ade A, Mello MB, Guimarães MD, et al. HIV among MSM in a large middle-income country. AIDS. 2013;27(3):427–35. Rao A, Stahlman S, Hargreaves J, Weir S, Edwards J, Rice B, et al. Sampling Key Populations for HIV Surveillance: Results From Eight Cross-Sectional Studies Using Respondent-Driven Sampling and Venue-Based Snowball Sampling. JMIR Public Health Surveill. 2017;3(4):e72. Additional Declarations No competing interests reported. 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Despite substantial advances in antiretroviral therapy (ART) and combination prevention strategies, MSM remain one of the populations most vulnerable to HIV acquisition and poor clinical outcomes [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, MSM are estimated to be nearly 28 times more likely to acquire HIV than the general population, a disparity shaped by a complex interplay of biological, behavioural, and structural factors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although overall HIV incidence has declined in many regions, rates among MSM have often remained stable or have even increased, reflecting persistent inequities in access to prevention, testing, and treatment services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn sub-Saharan Africa, HIV prevalence among MSM is consistently higher than in the general population, with studies reporting rates five to ten times greater than among heterosexual men [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In West and Central Africa, prevalence estimates among MSM range widely, often exceeding 10\u0026ndash;30% [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], highlighting the concentrated nature of the epidemic within this population. Historically, national HIV responses have prioritised generalized heterosexual transmission, resulting in under-investment in programmes and services specifically tailored to MSM [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consequently, gaps persist in access to HIV testing, pre-exposure prophylaxis (PrEP), mental health support, and stigma-free care, despite evidence that interventions targeting MSM are both cost-effective and essential to achieve the UNAIDS 95\u0026ndash;95\u0026ndash;95 targets [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCabo Verde, a small island developing state located off the coast of West Africa, presents a unique epidemiological profile. HIV prevalence in the general population remains below 1%, situating the country among those with a low-level generalized epidemic [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, national averages mask substantial disparities in key populations, including sex workers, people who inject drugs, and MSM [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Among MSM, the intersection of biological susceptibility, behavioural risks, and structural vulnerabilities contributes to ongoing HIV transmission.\u003c/p\u003e \u003cp\u003eBiological risk factors, including unprotected receptive anal intercourse, inconsistent use of lubricants, and untreated sexually transmitted infections (STIs), heighten HIV susceptibility in MSM [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Behavioural drivers\u0026mdash;such as multiple and concurrent sexual partnerships, engagement in transactional sex, and substance use in sexual contexts\u0026mdash;further amplify risk [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Structural barriers, including stigma, family rejection, community discrimination, and police harassment, constrain MSM\u0026rsquo;s access to HIV services and discourage disclosure of sexual orientation or HIV status [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although same-sex relations are not criminalized in Cabo Verde, prevailing social norms remain conservative, and MSM often experience marginalisation in both public and private spheres [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBio-behavioural surveys, which integrate socio-behavioural data with biological testing, provide crucial evidence on HIV prevalence, risk behaviours, and service coverage among key populations in settings where routine surveillance is limited [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Such surveys also allow for the identification of structural and behavioural drivers of HIV vulnerability, providing an evidence base to inform targeted, rights-based interventions.\u003c/p\u003e \u003cp\u003eGiven the concentrated epidemic among MSM and the structural barriers they face, understanding HIV epidemiology and associated vulnerabilities in this population is essential for designing effective interventions. This study current knowledge on HIV among MSM in Cabo Verde with four overarching objectives: i) To describe HIV epidemiology and trends among MSM; ii) To characterise socio-demographic profiles, sexual behaviours, and prevention practices; iii) To assess experiences of stigma, discrimination, and violence; and iv) To discuss implications for policy and programming to strengthen HIV prevention and care for MSM.\u003c/p\u003e \u003cp\u003eBy examining these aspects comprehensively, this work aims to provide a scientific foundation for evidence-based, community-led, and rights-focused interventions that align with the WHO Consolidated Guidelines and the UNAIDS 2030 Fast-Track strategy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eWe conducted a series of cross-sectional bio-behavioural surveys (BBS) among men who have sex with men (MSM) in Cabo Verde. The surveys were implemented by the National AIDS Coordination Committee (CCS-SIDA) in collaboration with civil society organisations and technical partners. The primary objectives were to estimate HIV prevalence and characterize socio-behavioural determinants of HIV risk among MSM.\u003c/p\u003e \u003cp\u003eThe surveys were conducted in multiple urban centres to capture areas with higher MSM social and sexual networks. Initial data collection focused on Praia and S\u0026atilde;o Vicente, while subsequent rounds expanded to Sal and Fogo, and later to Boa Vista, Santa Catarina, and Santa Cruz, reflecting the need for broader geographic coverage and representation of urban MSM populations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSampling Strategy\u003c/h3\u003e\n\u003cp\u003eGiven the hidden nature of MSM populations and the absence of a reliable sampling frame, respondent-driven sampling (RDS) and snowball sampling techniques were employed across all survey rounds. Initial \u0026ldquo;seeds\u0026rdquo; were purposively selected through key informants and established MSM networks. Each seed subsequently recruited peers to participate until the target sample size was achieved, in accordance with established best practices for hard-to-reach populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEligibility criteria included: self-identification as a man who has sex with men, age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, and provision of informed consent. Target sample sizes ranged from ~\u0026thinsp;240 to 300 participants per survey, consistent with recommended standards for population-specific bio-behavioural studies.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThree consecutive rounds of bio-behavioral surveys were conducted in Cabo Verde at different time points. The first survey was conducted between September and October 2013 over a period of six weeks. The second round was conducted from November to December 2016, spanning a period of six weeks. The third and most recent survey was conducted from November 2 to 28, 2023. Each survey was implemented during the specified periods to capture comparable information across time while accounting for logistical feasibility and population availability.\u003c/p\u003e \u003cp\u003eQuantitative data were obtained through structured questionnaires capturing socio-demographic characteristics, sexual behaviours, condom and lubricant use, STI knowledge, HIV testing history, and experiences of stigma, discrimination, or violence.\u003c/p\u003e \u003cp\u003eQualitative data were collected through in-depth interviews and focus group discussions with MSM and key informants, exploring contextual factors including community acceptance, barriers to service access, and perceptions of HIV prevention programmes. This mixed-methods approach allowed triangulation of behavioural, structural, and psychosocial determinants of HIV risk.\u003c/p\u003e \u003cp\u003eBiological data were obtained via rapid HIV testing conducted by trained nurses and laboratory technicians according to national algorithms. All reactive results were confirmed through confirmatory testing, and participants testing positive were linked to HIV care services promptly, following national HIV treatment guidelines.\u003c/p\u003e\n\u003ch3\u003eVariables and Indicators\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was laboratory-confirmed HIV prevalence.\u003c/p\u003e \u003cp\u003eSecondary outcomes included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSexual behaviours (condom use, number of partners, engagement in transactional sex)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHIV testing uptake\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSTI symptoms\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExperiences of stigma, discrimination, and violence\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eKnowledge of HIV prevention and PrEP (2023 survey only)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSelf-reported mental health outcomes (2023 survey only)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThese variables align with WHO and UNAIDS guidance for monitoring key populations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analysed using Stata 17 (StataCorp, College Station, TX, USA). Descriptive statistics summarized socio-demographic characteristics, sexual behaviours, and structural vulnerabilities. Categorical variables were presented as frequencies and percentages; continuous variables were summarized as means with standard deviations or medians with interquartile ranges, depending on distribution.\u003c/p\u003e \u003cp\u003eTrends in HIV prevalence over time and across subgroups were assessed using chi-square tests for categorical variables and t-tests or ANOVA for continuous variables, with significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eTo identify factors independently associated with HIV infection, multivariate logistic regression models were fitted. Covariates were selected based on theoretical relevance and bivariate associations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.20). Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. Variables included in the final models typically comprised age, education, area of residence (urban vs. other municipalities), sexual behaviours (condom use, transactional sex), and experiences of stigma or discrimination. Model fit was assessed using the Hosmer\u0026ndash;Lemeshow goodness-of-fit test, and multicollinearity was evaluated using variance inflation factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eAll surveys received approval from the National Ethics Committee of Cabo Verde, being Deliberations N\u0026ordm; 44/2013, 59/2016 and 12/CNEPS/2023, and the last study had a deliberation from the National Commission for Data Protection (authorisation n\u0026ordm; 76/2023/CNPD). Participants provided written informed consent and were assured confidentiality. No identifying information was collected, and participants received counselling, condoms, and referrals to HIV or STI services as needed. The study adhered to international ethical standards for research with key populations, including voluntary participation, confidentiality, and minimisation of harm.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic Characteristics\u003c/h2\u003e \u003cp\u003eParticipants were predominantly young, with a mean age of 25\u0026ndash;27 years and over 60% under 30. The majority were single (\u0026gt;\u0026thinsp;90%), consistent with limited opportunities for stable partnerships. Educational attainment improved modestly over time, with 53% reporting secondary education or higher in 2023. Economic precarity remained high, with 44% reporting unemployment or unstable work in 2023 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic profile of MSM (2013\u0026ndash;2023)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary+ education (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed/unstable (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHIV Prevalence\u003c/h2\u003e \u003cp\u003eHIV prevalence among MSM in Cabo Verde demonstrated a clear upward trend over the decade. Prevalence increased from 4.4% in 2013 to 5.4% in 2017, and further to 9.5% in 2023 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), indicating a near doubling over ten years and reflecting ongoing transmission within MSM networks.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSexual Behaviours and Prevention\u003c/h2\u003e \u003cp\u003eCondom use at last anal intercourse declined from 72% in 2013 to 63% in 2023, with consistent condom use similarly decreasing to 55%. Transactional sex was reported by 29% of participants in 2023, highlighting ongoing exposure to high-risk sexual networks. The mean age at first same-sex sexual encounter remained 19 years. Lubricant use was inconsistent, with some participants still using petroleum-based products, which can compromise condom effectiveness (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSexual behaviours and HIV prevention indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondom use at last anal sex (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsistent condom use (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransactional sex (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV test in last 12 months (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStigma, Violence, and Discrimination\u003c/h2\u003e \u003cp\u003eStructural vulnerabilities persisted across survey rounds. Between 11\u0026ndash;14% of participants reported verbal harassment, 6\u0026ndash;8% reported physical violence, and 13\u0026ndash;18% experienced police harassment. Family rejection was consistently reported, and disclosure of sexual orientation and HIV status to family remained low (\u0026lt;\u0026thinsp;15%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStigma, violence, and discrimination among MSM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVerbal violence (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical violence (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolice harassment (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisclosed HIV status to family (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge, HIV Testing, and Mental Health\u003c/h2\u003e \u003cp\u003eAwareness of HIV prevention remained consistently high (\u0026gt;\u0026thinsp;90%). In 2023, 92% of participants knew where to access HIV testing, and 80% reported testing in the previous 12 months. Awareness of pre-exposure prophylaxis (PrEP) was introduced in 2023, with strong interest in uptake among MSM. Mental health challenges were prevalent, with high self-reported rates of anxiety, depression, and stress, highlighting the need for integrated psychosocial support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation between HIV prevalence and socio-demographic characteristics\u003c/h2\u003e \u003cp\u003eTo explore socio-demographic correlates of HIV prevalence, bivariate and multivariate analyses were conducted using aggregated data from the three surveys. HIV prevalence was stratified by age group (\u0026lt;\u0026thinsp;25 years vs. \u0026ge;25 years), educational attainment (primary or less vs. secondary or higher), and area of residence (capital city vs. other municipalities).\u003c/p\u003e \u003cp\u003eAcross surveys, HIV prevalence was higher among older MSM (\u0026ge;\u0026thinsp;25 years: 8.7%) compared to younger participants (\u0026lt;\u0026thinsp;25 years: 5.1%). A positive correlation was observed between age and HIV prevalence (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.42, p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003eEducational attainment showed an inverse relationship: MSM with secondary education or higher had lower HIV prevalence (6.2%) than those with primary education or less (9.8%). The correlation between education level and HIV prevalence was statistically significant (r = \u0026minus;\u0026thinsp;0.37, p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003cp\u003eGeographic disparities were also documented. HIV prevalence was higher in Praia and S\u0026atilde;o Vicente (urban centres) compared to other municipalities (10.1% vs. 6.8%, χ\u0026sup2; = 5.9, p\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e \u003cp\u003eIn multivariate logistic regression (adjusted for age and education), older age and residence in urban centres remained independently associated with HIV-positive status (Adjusted Odds Ratio [AOR] 1.8, 95% CI 1.1\u0026ndash;2.9 for age\u0026thinsp;\u0026ge;\u0026thinsp;25; AOR 1.6, 95% CI 1.0\u0026ndash;2.5 for urban residence). Higher educational attainment was protective (AOR 0.62, 95% CI 0.39\u0026ndash;0.98) (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression of factors associated with HIV prevalence among MSM (2013\u0026ndash;2023)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV prevalence (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude OR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003cp\u003e(95% CI)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.78 (1.05\u0026ndash;3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.80 (1.10\u0026ndash;2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61 (0.39\u0026ndash;0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62 (0.39\u0026ndash;0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArea of residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther municipalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.55 (0.99\u0026ndash;2.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.60 (1.01\u0026ndash;2.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Adjusted for age and education.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from these bio-behavioral surveys provide a compelling portrait of the evolving HIV epidemic among men who have sex with men (MSM) in Cabo Verde over the past decade. The nearly twofold increase in HIV prevalence highlights an urgent public health concern and underscores that high knowledge of HIV prevention alone is insufficient to curb transmission. Despite high awareness of condoms and HIV testing, behavioural, biological, and structural vulnerabilities continue to drive risk, reflecting patterns observed in other West African contexts where MSM consistently experience HIV prevalence several times higher than the general population [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Biological and behavioural determinants of HIV risk remain salient. Unprotected anal intercourse, particularly receptive anal sex, continues to contribute disproportionately to new infections, consistent with findings from similar epidemiological settings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The persistence of transactional sex and multiple concurrent partnerships amplifies exposure risk, while inconsistent condom and lubricant use demonstrates gaps in prevention practice, despite widespread knowledge [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Moreover, while new prevention technologies such as pre-exposure prophylaxis (PrEP) have shown high efficacy, their limited availability and uptake in Cabo Verde during the survey periods highlight a critical gap in combination prevention [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The integration of biomedical interventions alongside behavioural strategies is therefore essential to reduce HIV incidence in this key population [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Structural determinants represent another central axis of vulnerability for this population in Cabo Verde. Pervasive stigma, discrimination, family rejection, and police harassment continue to restrict access to HIV services and undermine trust in healthcare systems [\u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Even in a context where same-sex sexual activity is not criminalized, conservative societal attitudes contribute to marginalization and concealment of sexual behaviour, limiting engagement in HIV testing, care, and prevention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. The observed persistence of stigma and violence echoes regional findings that structural oppression significantly mediates HIV risk among MSM, emphasizing the need for interventions that go beyond individual-level behaviour change [\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe correlation of the Socio-demographic with HIV infection reinforces the multifactorial nature of vulnerability. Older age was positively associated with HIV prevalence, suggesting cumulative exposure risk over time, while higher educational attainment demonstrated a protective effect, likely reflecting greater health literacy, enhanced condom negotiation skills, and higher utilization of healthcare services [\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Geographic disparities were evident, with urban centres such as Praia and S\u0026atilde;o Vicente showing higher prevalence, consistent with the epidemiology of concentrated epidemics where dense social and sexual networks facilitate transmission [\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. These findings underscore the need for targeted interventions tailored to specific subgroups within the MSM population, including younger men who may be at risk of early infection and those residing in high-transmission urban hubs.\u003c/p\u003e \u003cp\u003eSocio-economic vulnerabilities remain highly relevant. The persistence of unemployment and reliance on transactional sex expose MSM to economic pressures that may limit negotiation of safer sexual practices, increase risk-taking behaviour, and reduce adherence to prevention measures [\u003cspan additionalcitationids=\"CR56 CR57\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Addressing these structural determinants through social protection, livelihood programs, and policy reforms is likely to produce long-term reductions in HIV risk and improve overall well-being [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMental health challenges identified in the most recent survey are of particular concern. High prevalence of anxiety, depression, and stress among MSM can undermine adherence to HIV prevention and treatment interventions, negatively influence sexual risk behaviours, and reduce engagement with health services [\u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Integration of mental health support within HIV programs is therefore critical, aligning with evidence that psychosocial interventions can enhance adherence and retention in care [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevention gaps are evident despite high HIV knowledge. Condom promotion, while necessary, is insufficient to curb HIV transmission in this context, highlighting the urgency of implementing a combination prevention approach, including PrEP, HIV self-testing, and tailored health education campaigns. PrEP rollout represents a transformative opportunity to reduce HIV incidence; however, success requires addressing barriers such as stigma, acceptability, access, and integration into routine health services for MSM [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Community-led initiatives and peer-based outreach have been shown to enhance uptake of prevention services and improve linkage to care, suggesting that local MSM organizations should play a central role in programme design and delivery [\u003cspan additionalcitationids=\"CR68\" citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePolicy implications are clear. Effective HIV response for MSM must integrate biomedical, behavioural, and structural interventions within a rights-based framework. Legal protections against discrimination, active enforcement of anti-harassment measures, and the promotion of social inclusion are crucial to enhancing access to services. The findings also emphasize the importance of urban-focused interventions, given the elevated prevalence in densely populated municipalities, while maintaining outreach to rural or less visible MSM networks [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Educational attainment emerges as a modifiable protective factor, suggesting that programmes promoting access to formal education and health literacy may have long-term benefits in HIV prevention.\u003c/p\u003e \u003cp\u003eStrengths and limitations of the study warrant consideration. The surveys leveraged multiple rounds of data collection spanning a decade, enabling longitudinal insights into trends and correlates of HIV among MSM in Cabo Verde. The use of respondent-driven and snowball sampling approaches allowed access to a hidden population, although these non-probability methods may limit generalizability. Underreporting of sensitive behaviours, including sexual practices and experiences of stigma or violence, may introduce reporting bias. Furthermore, rural MSM populations were likely underrepresented, potentially underestimating prevalence and risk behaviours in these settings. Nonetheless, triangulation of quantitative and qualitative data across three survey waves strengthens the robustness of observed patterns. It provides a comprehensive understanding of HIV epidemiology, behavioural risk, and structural vulnerabilities among MSM in Cabo Verde [\u003cspan additionalcitationids=\"CR74\" citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe MSM in Cabo Verde face a growing HIV burden, with prevalence increasing from 4.4% in 2013 to 9.5% in 2023. Despite high knowledge levels and improved testing uptake, inconsistent condom use, transactional sex, and structural vulnerabilities persist. Addressing these challenges requires comprehensive interventions that integrate biomedical tools such as PrEP, behavioural support, structural reforms, and mental health care. Rights-based, community-led approaches are essential to halt the trajectory of HIV among MSM and ensure that Cabo Verde advances toward the UNAIDS 95-95-95 targets and the 2030 elimination goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e The study was implemented by the CCS-SIDA, with financial support from the Global Fund for HIV, Tuberculosis and Malaria, in partnership with the United Nations Joint Office and supported locally by the Health Delegations and the NGO\u0026acute;s Morabi and Verdefam.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eADP, NNR MMC and AJC designed the study, the program methodology, the data collection indicators and supervisoned the activities. ADP, NNR and JMM designed the data analysis protocol, analysed the data and conducted statistical analyses. AJP led the writing of the paper. NNR, MCM, JMM, MF and AJC contributed to the writing of the paper.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We thank the participants, field investigators, supervisors and all technical staff involved in the surveys. We acknowledge CCS-SIDA, the Ministry of Health of Cabo Verde, community-based organisations including MORABI and VERDEFAM, and international partners including UNAIDS and WHO for their support. We also thank all the participants in the study, as well as the community and social community organisations.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBeyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380:367\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000\u0026ndash;2006: a systematic review. PLoS Med. 2007;4(12):e339.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNAIDS, Global AIDS, Update. 2023. The path that ends AIDS. Geneva: UNAIDS; 2023. 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HIV treatment cascade in MSM, people who inject drugs, and sex workers. Curr Opin HIV AIDS. 2015;10(6):420\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerr LR, Mota RS, Kendall C, Pinho Ade A, Mello MB, Guimar\u0026atilde;es MD, et al. HIV among MSM in a large middle-income country. AIDS. 2013;27(3):427\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao A, Stahlman S, Hargreaves J, Weir S, Edwards J, Rice B, et al. Sampling Key Populations for HIV Surveillance: Results From Eight Cross-Sectional Studies Using Respondent-Driven Sampling and Venue-Based Snowball Sampling. JMIR Public Health Surveill. 2017;3(4):e72.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, MSM, Cabo Verde, key populations, stigma, PrEP, epidemiology","lastPublishedDoi":"10.21203/rs.3.rs-8933663/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8933663/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Men who have sex with men (MSM) remain disproportionately affected by HIV globally. Cabo Verde, while maintaining a low HIV prevalence in the general population (\u0026lt; 1%), has reported a rising burden among MSM. This study synthesises findings from three consecutive bio-behavioral surveys (2013, 2017, 2023), providing the first longitudinal evidence on HIV epidemiology, risk behaviours, and vulnerabilities among MSM in Cabo Verde.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Cross-sectional bio-behavioral surveys were conducted in 2013 (n = 316), 2017 (n = 243), and 2023 (n = 295). Respondent-driven and snowball sampling strategies recruited MSM in Praia, Mindelo, and other urban areas. Data collection combined structured questionnaires, in-depth interviews, and rapid HIV testing. Descriptive analyses compared prevalence, behaviours, and structural determinants across survey years. Multivariate logistic regression was performed on 2023 data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eHIV prevalence rose from 4.4% (2013) to 5.4% (2017) and 9.5% (2023). Condom use during anal intercourse declined from 72% (2013) to 63% (2023). Transactional sex increased, reaching 29% in 2023. Verbal (11–14%) and physical violence (6–8%) persisted, alongside police harassment (13–18%). Despite \u0026gt; 90% knowledge of prevention, consistent condom use remained low, and disclosure to family and partners was limited. In 2023, 80% reported HIV testing in the past year, 54% screened positive for mental health distress, and 72% expressed willingness to use pre-exposure prophylaxis (PrEP). Logistic regression indicated higher HIV risk among older MSM (≥ 25 years, AOR 1.8, 95% CI 1.1–2.9) and urban residents (AOR 1.6, 95% CI 1.0–2.5), with secondary or higher education protective (AOR 0.62, 95% CI 0.39–0.98).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: D\u003c/strong\u003eespite progress in HIV awareness and testing, HIV prevalence among MSM in Cabo Verde nearly doubled over the past decade. Persisting stigma, violence, and declining condom use undermine prevention. Urgent scale-up of pre-exposure prophylaxis (PrEP), community-led stigma reduction, and MSM-friendly health services is essential to reverse current trends and achieve UNAIDS 2030 targets.\u003c/p\u003e","manuscriptTitle":"HIV Epidemiology, Risk Behaviours, and Structural Barriers among Men Who Have Sex with Men in Cabo Verde: Evidence from Three Bio-behavioural Surveys (2013–2023)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 03:20:42","doi":"10.21203/rs.3.rs-8933663/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"251cb5df-1024-46b0-a063-74199ac983be","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T08:43:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 03:20:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8933663","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8933663","identity":"rs-8933663","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}