Background Epidemiological assessment of geographical heterogeneity of HIV among men who have sex with
men (MSM) is necessary to inform HIV prevention and care strategies in the more generalised HIV epidemics across
sub-Saharan Africa, including Malawi. We aimed to measure the HIV prevalence, risks, and access to HIV care
among MSM across multiple localities to better inform HIV programming for MSM in Malawi.
Methods Between Aug 1, 2011, and Sept 13, 2014, we recruited MSM into cross-sectional research via respondent-driven
sampling (RDS) in seven districts of Malawi. RDS and site weights were used to estimate national HIV prevalence and
engagement in care and in multilevel regression models to identify correlates of prevalent HIV infection. The
comparative prevalence ratio of HIV among MSM relative to adult men was calculated by use of direct age-stratification.
Findings 2453 MSM were enrolled with a population HIV prevalence of 18·2% (95% CI 15·5–21·2), as low as 4·1%
(2·2–7·6) in Mzuzu and as high as 24·5% (19·5–30·3) in Mulanje. The comparative HIV prevalence ratio was 2·52 when
comparing MSM with the adult male population. Age-stratified HIV prevalence showed early onset of infection with 11·8%
(95% CI 7·3–18·4) of MSM aged 18–19 years HIV infected. Factors positively associated with HIV infection included
being aged 21–30 years and reporting female or transgender identity. Among HIV infected MSM, less than 1% reported
ever being diagnosed with HIV infection (0·9%, 95% CI 0·4–2·5) and initiated antiretroviral treatment (0·2%, 0·2–0·3).
Interpretation HIV disproportionately affects MSM in Malawi with disparities sustained across the HIV care
continuum. These issues are geographically heterogeneous and begin among young MSM, supporting geographically
focused and age-specific approaches to confidential HIV testing with linkage to HIV services.