AIDS and Behavior

, Volume 22, Issue 5, pp 1517–1529 | Cite as

Depressive Symptoms, Alcohol and Drug Use, and Physical and Sexual Abuse Among Men Who Have Sex with Men in Kisumu, Kenya: The Anza Mapema Study

  • Colin P. Kunzweiler
  • Robert C. Bailey
  • Duncan O. Okall
  • Susan M. Graham
  • Supriya D. Mehta
  • Fredrick O. Otieno
Original Paper


Men who have sex with men (MSM) are disproportionately burdened by depressive symptoms and psychosocial conditions including alcohol and substance abuse as well as physical and sexual abuse. We examined sociodemographic and psychosocial factors associated with depressive symptoms at baseline among a cohort of MSM in Kisumu, Kenya. Depressive symptoms were assessed via the Personal Health Questionnaire 9 instrument and examined dichotomously. We performed multivariable modified Poisson regression with robust standard errors for the binary outcome. Among 711 participants: 11.4% reported severe depressive symptoms; 50.1% reported harmful alcohol abuse; 23.8% reported moderate substance abuse; 80.9% reported any childhood physical or sexual abuse; and 39.1% experienced recent trauma due to same-sex behaviors. In the final multivariable model, severe depressive symptoms were more common for men who were ≥ 30 years old, had completed ≤ 8 years of education, had experienced childhood physical or sexual abuse, and had recently experienced trauma due to same-sex behaviors. Our results demonstrate that comprehensive services capable of identifying and addressing depressive symptoms, alcohol and substance abuse, and physical and sexual abuse must be expanded within this sample of MSM.


Depressive symptoms Psychosocial conditions Men who have sex with men MSM Kenya 



The authors would like to thank the men of the Anza Mapema Study. Special thanks also go to all research and staff members of the Anza Mapema Study and the Nyanza Reproductive Health Society including Leah Osula, Beatrice Achieng, George N’gety, Caroline Oketch, Violet Apondi, Evans Kottonya, Caroline Agwanda, Ted Aloo, George Oloo, Caroline Obare, Eve Obondi, and Edmon Obat, as well as Donath Emusu, Boaz Otieno Nyunya, and Gaston Djomand. We thank the Centers for Disease Control and Prevention (U01GH000762) and the Evidence for HIV Prevention in Southern Africa (MM/EHPSA/NRHS/0515008) for providing financial support for the Anza Mapema Study. Finally, we thank Dr. Ross Slotten and the Slotten Scholarship in Global Health at the University of Illinois at Chicago for supporting this work.


The Anza Mapema Study was supported through funding provided by the Centers for Disease Control and Prevention (U01GH000762) and by Evidence for HIV Prevention in Southern Africa (MM/EHPSA/NRHS/0515008).

Compliance with Ethical Standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in the Anza Mapema Study involving human participants were in accordance with the ethical standards of the Maseno University Ethics Review Committee, the Institutional Review Board of the University of Illinois at Chicago, and the Human Subjects Division of the University of Washington.

Informed Consent

Trained research personnel reviewed all consent materials with the participant and answered any questions related to the Anza Mapema Study. Written informed consent was obtained from all participants enrolled in the Anza Mapema Study.

Supplementary material

10461_2017_1941_MOESM1_ESM.docx (37 kb)
Supplementary material 1 (DOCX 37 kb)


  1. 1.
    Beyrer C, Baral SD, van Griensven F, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380(9839):367–77. Scholar
  2. 2.
    National AIDS Control Council (NACC). Kenya HIV estimates-June 2014. Nairobi, Kenya: Ministry of Health; 2014.
  3. 3.
    National AIDS Control Council (NACC). Kenya HIV county profiles. Nairobi, Kenya: Ministry of Health; 2014.
  4. 4.
    Sanders EJ, Graham SM, Okuku HS, et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS. 2007;21(18):2513–20. Scholar
  5. 5.
    Kimanga DO, Ogola S, Umuro M, et al. Prevalence and incidence of HIV infection, trends, and risk factors among persons aged 15–64 years in Kenya: results from a nationally representative study. JAIDS. 2014;66(Suppl 1):S13–26. Scholar
  6. 6.
    National AIDS Control Council (NACC). Kenya HIV prevention response and modes of transmission analysis: final report. Nairobi, Kenya: Ministry of Health; 2009.
  7. 7.
    Mayer KH, Bekker L-G, Stall R, Grulich AE, Colfax G, Lama JR. Comprehensive clinical care for men who have sex with men: an integrated approach. Lancet. 2012;380(9839):378–87. Scholar
  8. 8.
    Stall R, Mills TC, Williamson J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96(11):1589–601. Scholar
  10. 10.
    Woolf SE, Maisto SA. Alcohol use and risk of HIV infection among men who have sex with men. AIDS Behav. 2009;13(4):757–82. Scholar
  11. 11.
    Heusser S, Elkonin D. Childhood sexual abuse and HIV sexual-risk behaviour among men who have sex with men in South Africa. S Afr J Psychol. 2014;44(1):83–96.Google Scholar
  12. 12.
    Lloyd S, Operario D. HIV risk among men who have sex with men who have experienced childhood sexual abuse: systematic review and meta-analysis. AIDS Educ Prev. 2012;24(3):228–41. Scholar
  13. 13.
    Lalor K. Child sexual abuse in sub-Saharan Africa: a literature review. Child Abuse Negl. 2004;28(4):439–60. Scholar
  14. 14.
    Arreola S, Santos G-M, Beck J, et al. Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide. AIDS Behav. 2015;19(2):227–34. Scholar
  15. 15.
    Stahlman S, Bechtold K, Sweitzer S, et al. Sexual identity stigma and social support among men who have sex with men in Lesotho: a qualitative analysis. Reprod Health Matters. 2015;23(46):127–35. Scholar
  16. 16.
    Stahlman S, Sanchez TH, Sullivan PS, et al. The prevalence of sexual behavior stigma affecting gay men and other men who have sex with men across sub-Saharan Africa and in the United States. JMIR Public Health Surveill. 2016;2(2):e35. Scholar
  17. 17.
    Risher K, Adams D, Sithole B, et al. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc. 2013;16(3 Suppl 2):18715.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Anderson AM, Ross MW, Nyoni JE, McCurdy SA. High prevalence of stigma-related abuse among a sample of men who have sex with men in Tanzania: implications for HIV prevention. AIDS Care. 2015;27(1):63–70. Scholar
  19. 19.
    Mills TC, Paul J, Stall R, et al. Distress and depression in men who have sex with men: the Urban Men’s Health Study. Am J Psychiatry. 2004;161(2):278. Scholar
  20. 20.
    Kingori C, Haile ZT, Ngatia P. Depression symptoms, social support and overall health among HIV-positive individuals in Kenya. Int J STD AIDS. 2015;26(3):165–72. Scholar
  21. 21.
    Secor AM, Wahome E, Micheni M, et al. Depression, substance abuse and stigma among men who have sex with men in coastal Kenya. AIDS. 2015;29(Suppl 3):S251–9. Scholar
  22. 22.
    Mimiaga MJ, Biello KB, Robertson AM, et al. High prevalence of multiple syndemic conditions associated with sexual risk behavior and HIV infection among a large sample of Spanish- and Portuguese-speaking men who have sex with men in Latin America. Arch Sex Behav. 2015;44(7):1869–78. Scholar
  23. 23.
    Mimiaga MJ, OʼCleirigh C, Biello KB, et al. The effect of psychosocial Syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. J Acquir Immune Defic Syndr. 2015;68(3):329–36. Scholar
  24. 24.
    Safren SA, Thomas BE, Mimiaga MJ, et al. Depressive symptoms and human immunodeficiency virus risk behavior among men who have sex with men in Chennai, India. Psychol Health Med. 2009;14(6):705–15. Scholar
  25. 25.
    Singer M. Aids and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–48.CrossRefPubMedGoogle Scholar
  26. 26.
    Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Singer M, Bulled N, Ostrach B, Mendenhall E. Syndemics and the biosocial conception of health. Lancet. 2017;389(10072):941. Scholar
  28. 28.
    Mendenhall E. Syndemics: a new path for global health research. Lancet. 2017;389(10072):889–91. Scholar
  29. 29.
    Horton R, Hart L. Syndemics: committing to a healthier future. Lancet. 2017;389(10072):888–9. Scholar
  30. 30.
    Willen SS, Knipper M, Abadia-Barrero CE, Davidovitch N. Syndemic vulnerability and the right to health. Lancet. 2017;389(10072):964–77. Scholar
  31. 31.
    Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet. 2017;389(10072):951–63. Scholar
  32. 32.
    Pew Research Center. Global views on morality: Kenya. 2014.
  33. 33.
    Kenya National Commission on Human Rights (KNCHR). The outlawed amongst us: a study of the LGBT community’s search for equality and non-discrimination in Kenya. Nairobi, Kenya: Kenya National Commission on Human Rights; 2011.
  34. 34.
    Human Rights Watch. The issue is violence: attacks on LGBT people on Kenya’s Coast. United States: Human Rights Watch; 2015.
  35. 35.
    Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97. Scholar
  36. 36.
    Tucker A, Liht J, de Swardt G, et al. Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model. AIDS Care. 2014;26(7):882–9. Scholar
  37. 37.
    Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Med. 2013;10(11):e1001547. Scholar
  38. 38.
    Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. Lancet. 2013;382(9904):1575–86. Scholar
  39. 39.
    Charlson FJ, Diminic S, Lund C, Degenhardt L, Whiteford HA. Mental and substance use disorders in Sub-Saharan Africa: predictions of epidemiological changes and mental health workforce requirements for the next 40 years. PLoS ONE. 2014;9(10):e110208. Scholar
  40. 40.
    Marangu E, Sands N, Rolley J, Ndetei D, Mansouri F. Mental healthcare in Kenya: exploring optimal conditions for capacity building. Afr J Prim Health Care Fam Med. 2014;6(1):e1–5.CrossRefPubMedGoogle Scholar
  41. 41.
    Ndetei D, Ongecha F, Mutiso V, Kuria M, Khasakhala L, Kokonya D. The challenges of human resources in mental health in Kenya. Afr J Psychiatry. 2007;10(1):33–6.CrossRefGoogle Scholar
  42. 42.
    van der Elst EM, Smith AD, Gichuru E, et al. Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. J Int AIDS Soc. 2013;16(Suppl 3):18748–9.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Muga FA, Jenkins R. Public perceptions, explanatory models and service utilisation regarding mental illness and mental health care in Kenya. Soc Psychiatry Psychiatr Epidemiol. 2008;43(6):469–76. Scholar
  44. 44.
    Kenya National Commission on Human Rights (KNCHR). Silenced minds: the systemic neglect of the mental health system in Kenya. Nairobi, Kenya: Kenya National Commission on Human Rights; 2011.
  45. 45.
    National Academies of Sciences, Engineering, and Medicine. Providing sustainable mental and neurological health care in Ghana and Kenya: workshop summary. Washington, DC: The National Academies Press; 2016.  10.17226/21793.
  46. 46.
    World Health Organization (WHO). Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at “substantial” risk. Geneva, Switzerland: World Health Organization; 2015.
  47. 47.
    World Health Organization (WHO). HIV/AIDS and mental health. Geneva, Switzerland: World Health Organization; 2008.
  48. 48.
    Plenty A. Men’s health study: a cross sectional study of HIV among men who have sex with men in Kisumu, Kenya [Thesis on the internet]. Chicago, IL: University of Illinois at Chicago; 2012.
  49. 49.
    NOVA Research Company. Questionnaire Development Software (QDS). Silver Spring, Maryland.
  50. 50.
    Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann. 2002;32(9):509–15. Scholar
  52. 52.
    Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. J Affect Disor. 2006;96(1–2):89–93. Scholar
  53. 53.
    Bhana A, Rathod SD, Selohilwe O, Kathree T, Petersen I. The validity of the patient health questionnaire for screening depression in chronic care patients in primary health care in South Africa. BMC Psychiatry. 2015;15:118. Scholar
  54. 54.
    Gelaye B, Williams MA, Lemma S, et al. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013;210(2):653–61. Scholar
  55. 55.
    Hanlon C, Medhin G, Selamu M, et al. Validity of brief screening questionnaires to detect depression in primary care in Ethiopia. J Affect Disord. 2015;186:32–9. Scholar
  56. 56.
    Kehbila J, Ekabe CJ, Aminde LN, Noubiap JJ, Fon PN, Monekosso GL. Prevalence and correlates of depressive symptoms in adult patients with pulmonary tuberculosis in the Southwest Region of Cameroon. Infect Dis Poverty. 2016;5(1):51. Scholar
  57. 57.
    Ahaneku H, Ross MW, Nyoni JE, et al. Depression and HIV risk among men who have sex with men in Tanzania. AIDS Care. 2016;28(Suppl 1):140–7. Scholar
  58. 58.
    Monahan PO, Shacham E, Reece M, et al. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in Western Kenya. J Gen Intern Med. 2009;24(2):189–97. Scholar
  59. 59.
    Shacham E, Reece M, Ong’or WO, Omollo O, Monahan PO, Ojwang C. Characteristics of psychosocial support seeking during HIV-related treatment in western Kenya. AIDS Patient Care STDS. 2008;22(7):595–601. Scholar
  60. 60.
    Omoro SAO, Fann JR, Weymuller EA, Macharia IM, Yueh B. Swahili translation and validation of the patient health questionnaire-9 depression scale in the Kenyan head and neck cancer patient population. Int J Psychiatry Med. 2006;36(3):367–81. Scholar
  61. 61.
    Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the patient health questionnaire (PHQ-9): a meta-analysis. Can Med Assoc J. 2012;184(3):e191–6. Scholar
  62. 62.
    Kroenke K, Spitzer RL, Williams JB, Lowe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. Scholar
  63. 63.
    Saunders JB, Aasland OG, Babor TF, De La Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88(6):791–804.CrossRefPubMedGoogle Scholar
  64. 64.
    Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use disorders identification test. Geneva, Switzerland: World Health Organization; 2001.
  65. 65.
    Bohn MJ, Babor TF, Kranzler HR. The alcohol-use disorders identification test (AUDIT)-validation of a screening instrument for use in medical settings. J Stud Alcohol. 1995;56(4):423–32.CrossRefPubMedGoogle Scholar
  66. 66.
    Allen JP, Litten RZ, Fertig JB, Babor T. A review of research on the alcohol use disorders identification test (AUDIT). Alcohol Clin Exp Res. 1997;21(4):613–9.CrossRefPubMedGoogle Scholar
  67. 67.
    Jenkins R, Othieno C, Ongeri L, et al. Alcohol consumption and hazardous drinking in western Kenya-a household survey in a health and demographic surveillance site. BMC Psychiatry. 2015;15:230. Scholar
  68. 68.
    Luchters S, Geibel S, Syengo M, et al. Use of AUDIT, and measures of drinking frequency and patterns to detect associations between alcohol and sexual behaviour in male sex workers in Kenya. BMC Public Health. 2011;11:384. Scholar
  69. 69.
    Chersich MF, Bosire W, King’ola N, Temmerman M, Luchters S. Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers. Global Health. 2014;10:22. Scholar
  70. 70.
    Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness. Psychol Assess. 2000;12(2):186–92.CrossRefPubMedGoogle Scholar
  71. 71.
    Skinner HA. The drug-abuse screening-test. Addict Behav. 1982;7(4):363–71.CrossRefPubMedGoogle Scholar
  72. 72.
    Gavin DR, Ross HE, Skinner HA. Diagnostic validity of the drug-abuse screening test in the assessment of DSM-III drug disorders. Br J Addiction. 1989;84(3):301–7.CrossRefGoogle Scholar
  73. 73.
    Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705–14.CrossRefPubMedGoogle Scholar
  74. 74.
    RAND Corporation. Social support survey instrument scoring instructions: how to score the survey.
  75. 75.
    Bifulco A, Brown GW, Harris TO. Childhood experience of care and abuse (CECA): a retrospective interview measure. J Child Psychol Psychiatry. 1994;35(8):1419–35.CrossRefPubMedGoogle Scholar
  76. 76.
    Smith N, Lam D, Bifulco A, Checkley S. Childhood experience of care and abuse questionnaire (CECA.Q): validation of a screening instrument for childhood adversity in clinical populations. Soc Psychiatry Psychiatr Epidemiol. 2002;37(12):572–9. Scholar
  77. 77.
    Bifulco A, Bernazzani O, Moran PM, Jacobs C. The childhood experience of care and abuse questionnaire (CECA.Q): validation in a community series. Br J Clin Psychol. 2005;44(Pt 4):563–81. Scholar
  78. 78.
    Bifulco A, Brown GW, Moran P, Ball C, Campbell C. Predicting depression in women: the role of past and present vulnerability. Psychol Med. 1998;28(1):39–50.CrossRefPubMedGoogle Scholar
  79. 79.
    Betron M, Gonzalez-Figueroa E. Gender identity and violence in MSM and transgenders: policy implications for HIV services. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009.
  80. 80.
    Betron M. Screening for violence against MSM and transgenders: report on a pilot project in Mexico and Thailand. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009.
  81. 81.
    Egremy G, Betron M, Eckman A. Identifying violence against most-at-risk populations: a focus on MSM and transgenders. Training manual for health providers. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009.
  82. 82.
    Carter RE, Lipsitz SR, Tilley BC. Quasi-likelihood estimation for relative risk regression models. Biostat. 2005;6(1):39–44. Scholar
  83. 83.
    Chen W, Shi J, Qian L, Azen SP. Comparison of robustness to outliers between robust poisson models and log-binomial models when estimating relative risks for common binary outcomes: a simulation study. BMC Med Res Methodol. 2014;14:82. Scholar
  84. 84.
    Petersen MR, Deddens JA. A comparison of two methods for estimating prevalence ratios. BMC Med Res Methodol. 2008;8:9. Scholar
  85. 85.
    Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6.CrossRefPubMedGoogle Scholar
  86. 86.
    Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162(3):199–200. Scholar
  87. 87.
    Stata Corporation. College Station, Texas, USA.
  88. 88.
    Stoloff K, Joska JA, Feast D, et al. A description of common mental disorders in men who have sex with men (MSM) referred for assessment and intervention at an MSM clinic in Cape Town, South Africa. AIDS Behav. 2013;17(Suppl 1):S77–81. Scholar
  89. 89.
    Kwobah E, Epstein S, Mwangi A, Litzelman D, Atwoli L. Prevalence of psychiatric morbidity in a community sample in Western Kenya. BMC Psychiatry. 2017;17(1):30. Scholar
  90. 90.
    Pearlin LI, Menaghan EG, Lieberman MA, Mullan JT. The stress process. J Health Soc Behav. 1981;22(4):337–56.CrossRefPubMedGoogle Scholar
  91. 91.
    Ambugo EA. Cross-country variation in the sociodemographic factors associated with major depressive episode in Norway, the United Kingdom, Ghana, and Kenya. Soc Sci Med. 2014;113:154–60. Scholar
  92. 92.
    United Nations Children’s Fund (UNICEF) Kenya Country Office, Centes for Disease Control and Prevention (CDC), Kenya National Bureau of Statistics (KNBS). Violence against children in Kenya: findings from a 2010 national survey. Summary report on the prevalence of sexual, physical and emotional violence, context of sexual violence, and health and behavioral consequences of violence experienced in childhood. Nairobi, Kenya: 2012.
  93. 93.
    Springer KW, Sheridan J, Kuo D, Carnes M. Long-term physical and mental health consequences of childhood physical abuse: results from a large population-based sample of men and women. Child Abuse Negl. 2007;31(5):517–30. Scholar
  94. 94.
    Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. Scholar
  95. 95.
    Schafer KR, Gupta S, Dillingham R. HIV-infected men who have sex with men and histories of childhood sexual abuse: implications for health and prevention. J Assoc Nurses AIDS Care. 2013;24(4):288–98. Scholar
  96. 96.
    Schilder AJ, Anema A, Pai J, et al. Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada. PLoS ONE. 2014;9(6):e100501. Scholar
  97. 97.
    Wagner GJ, Aunon FM, Kaplan RL, et al. Sexual stigma, psychological well-being and social engagement among men who have sex with men in Beirut, Lebanon. Culture Health Sex. 2013;15(5):570–82. Scholar
  98. 98.
    Finerty CE. Being gay in Kenya: the implications of Kenya’s new constitution for its anti-sodomy laws. Cornell Int Law J. 2012;45(2):431.
  99. 99.
    Harper GW, Wade RM, Onyango DP, et al. Resilience among gay/bisexual young men in Western Kenya: psychosocial and sexual health outcomes. AIDS. 2015;29(Suppl 3):S261–9. Scholar
  100. 100.
    Bruce D, Ramirez-Valles J, Campbell RT. Stigmatization, substance use, and sexual risk behavior among latino gay and bisexual men and transgender persons. J Drug Issues. 2008;38(1):235–60.CrossRefGoogle Scholar
  101. 101.
    National Campaign Against Drug Abuse (NACADA). Rapid situation assessment of the status of drug and substance abuse in Kenya, 2012. Nairobi, Kenya; 2012.
  102. 102.
    Republic of Kenya (ROK). The mental health bill, 2014. Kenya Gazette Supplement No. 61 (National Assembly Bills No. 22). 22 April 2014;2523.
  103. 103.
    Jenkins R, Kiima D, Okonji M, Njenga F, Kingora J, Lock S. Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability. Matern Health Fam Med. 2010;7(1):37–47.Google Scholar
  104. 104.
    Tsai AC, Kawachi I, Mendenhall E, Trostle JA. Co-occurring epidemics, syndemics, and population health. Lancet. 2017;389(10072):978–82. Scholar
  105. 105.
    Office of the Press Secretary. Remarks by president Obama and president Kenyatta of Kenya in a press conference. 25 July 2015.
  106. 106.
    van der Elst EM, Okuku HS, Nakamya P, et al. Is audio computer-assisted self-interview (ACASI) useful in risk behaviour assessment of female and male sex workers, Mombasa, Kenya? PLoS ONE. 2009;4(5):e5340. Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Colin P. Kunzweiler
    • 1
  • Robert C. Bailey
    • 1
  • Duncan O. Okall
    • 2
  • Susan M. Graham
    • 3
  • Supriya D. Mehta
    • 1
  • Fredrick O. Otieno
    • 2
  1. 1.Division of Epidemiology and Biostatistics, School of Public HealthUniversity of Illinois at ChicagoChicagoUSA
  2. 2.Nyanza Reproductive Health SocietyKisumuKenya
  3. 3.Departments of Medicine, Global Health, and EpidemiologyUniversity of WashingtonSeattleUSA

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