Trends in Sexual Behaviors in the General Population of Madagascar: Increase in High-Risk Sex and Decrease in Condom Use.

Madagascar has a lower HIV prevalence than countries on the African continent. The 2003-4, 2008-9 and 2021 Demographic and Health surveys and the 2018 Multiple Indicator Cluster survey reports were analysed. Between 2003 and 2021, there was a significant increase in the percentage of people reporting sex with multiple partners: for women from 2.6% [95% CI 2.3% - 2.9%] to 3% [95% CI 2.8% - 3.2%], and for men from 16.7% [95% CI 15.1% - 18.3%] to 24.1% [95% CI 23.2% -25.0%]. Similarly, there was a significant increase in the percentage of people reporting sex with a non-marital, non-cohabitating sex partner for women from 13.1% [95% CI 12.4% - 13.9%] to 18.5% [95% CI 17.9% - 19.1%] and for men from 31.8% [95% CI 29.9% - 33.8%] to 38.1% [95% CI 37.0% - 39.2%]. Between 2008 and 2021, among those reporting sex with multiple partners, condom use had significantly decreased for women from 7.6% [95% CI 4.9% - 10.3%] to 3.3% [95% CI 1.8% - 4.8%] and for men from 7.4% [95% CI 5.9% - 8.9%] to 3.8% [95% CI 2.9% - 4.7%]. Between 2003 and 2021 condom use among men reporting non-marital, non-cohabitating partners decreased significantly from 13.1% [95% CI 10.6% - 15.6%] to 9.1% [95% CI 8.1% - 10.1%]. The trends in risky sexual behavior and condom use are possible drivers of Madagascar's evolving HIV epidemic. An HIV prevalence study among pregnant women could help elucidate the current status of the HIV epidemic among the general population in Madagascar.