Article original

Épidémiologie du VIH, comportements à risque et obstacles structurels chez les hommes ayant des rapports sexuels avec des hommes au Cabo Verde : données issues de trois enquêtes bio-comportementales (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)

Adilson José DePina¹, Nelson Neide Furtado Ribeiro¹, Maria Celina Moreira Ferreira¹, José Manuel Marques², Marta Freire³, Artur Jorge Correia²

¹National AIDS Coordination Committee, Ministry of Health, Praia, Cabo Verde.
²Department of Studies and Research, Analyses Business Consulting, Praia, Cabo Verde.
³National Program to Fight HIV, AIDS, Tuberculosis and other STIs, Ministry of Health, Praia, Cabo Verde.

Correspondance : Adilson José DePina — Adilson.Pina@ccssida.gov.cv

DOI : https://doi.org/10.68500/bh.v1i2.1

Reçu : 18 août 2026 · Accepté : 10 octobre 2026 · Publié : 15 octobre 2026

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 [13,23]. 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 [24].

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 [25]. 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 disproportionate burden of HIV among MSM and the structural barriers affecting this population, this study aimed to provide a comprehensive overview of the HIV situation among MSM in Cabo Verde. Specifically, it compared epidemiological patterns across three bio-behavioural surveys conducted between 2013 and 2023 and examined sociodemographic and sexual characteristics, HIV prevention practices, and experiences of stigma, discrimination, and violence [14,15,26]. The study also considered the implications of these findings for HIV prevention, care, programme development, and policy.

2. Patients and methods

Study design and setting

We conducted a comparative analysis of three repeated cross-sectional bio-behavioural surveys among 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 surveys aimed to estimate sample-based HIV prevalence and describe sociodemographic characteristics, sexual behaviours, HIV prevention practices, service utilization, and experiences of stigma, discrimination, and violence among participating MSM.

The geographic scope expanded across survey rounds. The 2013 survey was conducted in Praia and Mindelo, on the island of São Vicente. Subsequent survey rounds expanded to additional islands and municipalities. The 2023 survey covered six municipalities: Praia, Santa Catarina, Santa Cruz, São Vicente, Sal, and Boa Vista. In the 2023 survey report, Santa Catarina and Santa Cruz were grouped operationally as « Santiago Norte. » This expansion should be considered when comparing findings across survey years because observed differences may partly reflect changes in geographic coverage and the sociodemographic composition of the samples.

Sampling strategy

Because MSM constitute a population for which no complete sampling frame was available, participants were recruited using respondent-driven sampling and snowball sampling. Initial participants, referred to as seeds, were purposively selected with support from community organisations and MSM networks. Seeds were selected to reflect diversity in age, place of residence, socioeconomic characteristics, and social networks. Eligible participants were invited to recruit peers from their social networks until the target sample size for each survey was reached [26–30].

Eligibility criteria included being aged 15 years or older; identifying as a man; reporting having had sexual relations with another man, regardless of sexual relations with women or self-identified sexual orientation; residing in one of the survey locations; and providing informed consent or assent, as applicable. The final analytical samples included 316 participants in 2013, 243 in 2016, and 295 in 2023. Although respondent-driven recruitment was used, the analyses presented in this manuscript were not adjusted using RDS weights. The estimates should therefore be interpreted as describing the recruited samples and not as population-representative estimates for all MSM in Cabo Verde.

Data collection

Three consecutive rounds of bio-behavioural 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: i) sexual behaviours (condom use, number of partners, engagement in transactional sex); ii) HIV testing uptake; iii) STI symptoms; iv) experiences of stigma, discrimination, and violence; v) knowledge of HIV prevention and PrEP (2023 survey only); and vi) self-reported mental health outcomes (2023 survey only). These variables align with WHO and UNAIDS guidance for monitoring key populations [15,26,27].

Statistical analysis

Quantitative data were analysed using Stata 17 (StataCorp, College Station, TX, USA). Categorical variables were summarized using frequencies and percentages, while continuous variables were summarized using means and standard deviations or medians and interquartile ranges, as appropriate. HIV prevalence and other indicators were presented separately for each survey round.

The estimates were based on the observed survey samples and were not adjusted using RDS weights. They should therefore be interpreted as sample-based estimates rather than population-representative estimates for all MSM in Cabo Verde. Comparisons across survey rounds were descriptive because the surveys differed in geographic coverage, recruitment procedures, and sample composition.

Factors associated with HIV-positive status were examined using pooled individual-level data from the 2013, 2016, and 2023 surveys. Separate univariate logistic regression models were used to estimate crude odds ratios and 95% confidence intervals for age group, education level, and area of residence. A multivariable logistic regression model containing these variables and survey year was then fitted to estimate adjusted odds ratios and 95% confidence intervals. Survey year was included to account partly for differences between survey rounds. Statistical significance was defined as p < 0.05.

Qualitative methods

Qualitative approaches were included across the 2013, 2016, and 2023 survey rounds to complement the quantitative questionnaires. In 2013, information obtained from MSM through focus group discussions was used to support population estimation and contextualize participants’ social experiences, sexual practices, and access to HIV prevention and care. The 2016 survey similarly combined structured questionnaires with interviews and focus group discussions, supported by key informants and civil society organisations involved in identifying MSM networks and locations of social concentration.

In 2023, the qualitative component consisted of documentary analysis, interviews with managers from central and decentralized services, and focus group discussions involving members of the technical committee and professionals working in HIV prevention and treatment. These activities explored the implementation of HIV-related interventions, access to services, stigma and discrimination, and the prevention needs of key populations. Information from the different methods was triangulated to complement and contextualize the quantitative findings.

The survey reports did not specify the number of qualitative interviews or focus group discussions, the languages used, whether sessions were audio-recorded and transcribed, or whether a formal thematic coding procedure was applied. Consequently, the qualitative evidence is used in this comparative analysis primarily for contextual interpretation rather than as a separately reported qualitative dataset.

Mental-health measurement

The 2023 survey included nine self-reported questions concerning feelings and experiences associated with depression, anxiety, and stress during the seven days preceding the survey. The items addressed being upset by things that would not normally be disturbing, difficulty concentrating, fear, sleep quality, happiness, loneliness, confidence in the future, lack of energy, and depressed mood. Responses were recorded on a five-point frequency scale ranging from 1, « rarely or less than one day, » to 5, « always or five to seven days. » The survey report did not identify a validated mental-health instrument, specify a total score, or establish a diagnostic or screening cut-off. The findings were therefore interpreted descriptively as self-reported emotional and mental-health symptoms and not as clinical diagnoses or positive psychological-distress screening results.

PrEP measurement

PrEP-related indicators were assessed only in the 2023 survey. Participants were first asked whether they knew or had heard of PrEP as a method used to prevent HIV infection. They were subsequently asked: « If this method were included in the national prevention protocol, would you feel confident using it? » The response categories were: (1) « with some concern because I do not know its effectiveness in preventing HIV »; (2) « with considerable concern because more information about its effect and effectiveness is needed »; (3) « no opinion, but I would use it if the authorities provided more information about the method »; and (4) « without concern, because the method has been approved internationally. » The results were summarized descriptively according to participants’ reported level of confidence or concern regarding PrEP use.

Ethical considerations

The surveys received approval from the National Ethics Committee for Health Research of Cabo Verde under Deliberations No. 44/2013, No. 59/2016, and No. 12/CNEPS/2023. The 2023 survey also received authorization from the National Commission for Data Protection (No. 76/2023/CNPD). All participants provided written informed consent before participation. Participation was voluntary, and confidentiality was maintained throughout data collection and analysis. No directly identifying information was included in the analytical datasets. Participants received pre- and post-test counselling and were offered condoms and referral to appropriate HIV and sexually transmitted infection services when needed.

3. 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).

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 2016, and further to 9.5% in 2023 (Figure 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).

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).

Figure 1

Knowledge, HIV testing, mental health and PrEP

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. In 2023, participants reported different frequencies of emotional and mental-health symptoms during the seven days preceding the survey. Across the indicators used in the report, an average of 31.1% of participants presented responses interpreted by the survey authors as signs associated with stress, anxiety, or depression. The corresponding descriptive proportions were 33.1% for stress-related signs, 32.2% for anxiety-related signs, and 29.2% for depressive signs. Because the survey did not use an identified validated screening instrument or specify a diagnostic cut-off, these percentages should not be interpreted as estimates of clinically diagnosed psychological distress. Also in 2023, 79.3% of participants reported knowing or having heard of PrEP, 4.4% had not heard of it, and 16.3% did not know or did not respond. Regarding confidence in using PrEP if it were incorporated into the national prevention protocol, 13.6% reported some concern because they were uncertain about its effectiveness, 31.2% reported considerable concern and a need for more information, 21.4% had no definite opinion but indicated that they would use it if the authorities provided additional information, and 33.9% reported that they would use it without concern because it had been approved internationally. Overall, 55.3% were classified in the report as having no concern about PrEP use, whereas 44.7% expressed some degree of concern.

Correlation between HIV prevalence and sociodemographic 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).

Qualitative findings on stigma, service access, and prevention needs

The qualitative analysis identified three main themes: experiences of stigma and social acceptance, barriers to accessing HIV services, and perceptions of HIV prevention programmes.

Stigma and social acceptance: Participants described concerns about disclosing their sexual orientation because of anticipated rejection, discrimination, family conflict, or damage to their social relationships. Some participants who had disclosed their sexual orientation reported pressure to change their behaviour, disrespect, or threats of exclusion from the family home. These experiences helped contextualize the low levels of disclosure and the continued reports of verbal and physical violence documented in the quantitative surveys.

Access to HIV services: Confidentiality, respectful treatment, and trust in service providers were central to participants’ decisions to seek HIV testing and prevention services. Fear of judgement or involuntary disclosure was described as a barrier to service utilization. Participants emphasized the importance of receiving services in settings where privacy was protected and providers were sensitive to the needs of MSM.

HIV prevention needs: Participants supported community-based and peer-led approaches to HIV prevention. They identified a need for information specifically addressing anal and oral sex, greater access to appropriate lubricants, and expanded availability of PrEP. Employment insecurity and limited economic opportunities were also described as factors that could contribute to transactional sex and reduce participants’ ability to negotiate safer sexual practices.

These qualitative findings provide context for the coexistence of high HIV-prevention knowledge and increasing testing uptake with persistent behavioural and structural vulnerabilities.

4. 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 [28–30]. 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 associations between sociodemographic characteristics and HIV-positive status illustrate the multifactorial nature of HIV vulnerability. Participants aged ≥25 years had higher odds of HIV-positive status, which may reflect longer cumulative exposure to HIV risk. Secondary or higher education was associated with lower odds of HIV-positive status, although the cross-sectional design does not establish that education itself produced this difference [49–51]. Urban residence was associated with higher odds of HIV-positive status, potentially reflecting differences in sexual-network structure, population density, access to testing, or the composition of the recruited samples [52–54]. These associations should be interpreted cautiously because the analysis was based on non-probability samples and residual confounding cannot be excluded.

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.

The qualitative findings provide important context for interpreting the persistent behavioural and structural vulnerabilities observed across the surveys. Interviews and focus group discussions indicated that stigma and anticipated discrimination shaped MSM experiences within families, education and employment, as well as decisions concerning disclosure and engagement with HIV prevention services. Earlier participants described discrimination, family conflict, social exclusion and economic insecurity, with some reporting transactional sex as a means of economic survival and expressing a need for greater vocational and employment opportunities. Participants also identified gaps in prevention programming, including insufficient information tailored to anal and oral sex and limited access to appropriate lubricants. These structural concerns remained relevant in subsequent surveys: stigma and discrimination contributed to strategies of social and sexual invisibility, while the most recent survey showed that many MSM had not disclosed their sexual orientation to their families and that some of those who had disclosed experienced pressure to change their behaviour, threats of expulsion, or disrespect. Taken together, these findings help contextualize the coexistence of high HIV prevention knowledge and increasing testing uptake with persistent behavioural and structural vulnerabilities. They support a comprehensive response that combines biomedical and behavioural prevention with confidential, non-judgmental and community-responsive services, while addressing stigma, social acceptance and economic vulnerability. Greater involvement of MSM and community-based organizations in intervention design and delivery may further strengthen trust, acceptability and engagement with HIV prevention and care, consistent with evidence supporting community-led and peer-based approaches [41–46, 73–75].

This study draws on three bio-behavioural surveys conducted over a ten-year period and provides valuable comparative evidence concerning HIV, sexual behaviours, prevention practices, and structural vulnerabilities among MSM in Cabo Verde. The inclusion of quantitative and qualitative evidence also provides contextual information for interpreting the observed patterns.

Several limitations should nevertheless be considered. First, the surveys were repeated cross-sectional studies and did not follow the same individuals over time; consequently, differences between survey rounds should not be interpreted as individual-level changes. Second, participants were recruited using respondent-driven and snowball sampling, and the estimates were not adjusted using RDS weights. The findings may therefore have been influenced by participants’ network sizes, recruitment patterns, and selection probabilities and should not be considered representative of all MSM in Cabo Verde. Third, the geographic coverage expanded from two principal cities in the earlier survey to seven municipalities in 2023. The observed differences, including the increase in HIV prevalence, may consequently reflect changes in geographic coverage, recruitment procedures, and sample composition rather than temporal changes alone. Fourth, rural MSM were likely underrepresented. Finally, sexual behaviours, mental-health symptoms, and experiences of stigma or violence were self-reported and may have been affected by recall and social-desirability bias.

5. Conclusion

HIV prevalence was higher in the MSM sample recruited in 2023 than in the samples recruited in 2013 and 2016. However, this difference should be interpreted cautiously because the surveys used non-probability sampling, were not RDS-weighted, and differed in geographic coverage and sample composition. Across the survey rounds, inconsistent condom use, transactional sex, stigma, violence, and barriers to confidential services remained important concerns. Cabo Verde’s HIV response should expand access to PrEP, appropriate condoms and lubricants, HIV testing, mental-health support, and confidential MSM-responsive care. Community-led and rights-based interventions addressing stigma, discrimination, violence, and economic vulnerability will be important for improving prevention and service engagement among MSM.

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