Men who have sex with men (MSM) in sub-Saharan Africa are a high risk group for HIV infection—yet religious, political, and social stigma mean that this isolated group cannot access vital services. The HIV/AIDS community needs to take vital steps to address this crisis. The issues are discussed in a Review published Online First (www.thelancet.com) and in an upcoming edition of the Lancet, written by Dr Adrian D Smith, University of Oxford, UK, and colleagues.
The HIV/AIDS community now has considerable challenges in clarifying and addressing MSM needs in sub-Saharan Africa; homosexuality is illegal in most countries, and political and social hostility are endemic. An effective response to HIV/AIDS requires improved strategic information about all risk groups, including MSM. The authors say: "African MSM bear a considerably higher burden of HIV than do other men, and draw attention to an unmet need for prevention, treatment, and care."
Once it became clear in the 1980s that heterosexual transmission route of HIV was predominant in African epidemics, the possibility that MSM might feature within this model soon disappeared from discussion. Yet just as elsewhere in the world, African MSM exist, and have their own dynamics and specific needs, all of which occur in a socially repressed system.
Using data reported between 2003-09, the authors say that HIV prevalence among African MSM is generally considerably higher than among adult men in the general population. In some West African countries, for example, HIV prevalence in MSM is over 10 times that estimated in the male general population. The difference varies substantially, but prevalence in most countries studied was higher in MSM populations. The authors say: "Important conclusions from behavioural studies of African MSM are that unprotected anal sex is commonplace, knowledge and access to appropriate risk prevention measures are inadequate, and that, in some contexts, many MSM engage in transactional sex. Stigma, violence, detention, and lack of safe social and health resources are widely reported."
HIV transmission among African MSM does not appear to be segregated from the general population. African MSM often have female as well as male sexual partners. Early HIV tests in white MSM in South Africa showed they had the subtype of HIV connected to European populations. However, tests in Kenya and Senegal showed that African MSM had a similar mixture of strains to those in the general population.
Methods to estimate the proportion of new HIV infections attributable to different risk groups, including MSM, have been developed to inform local policy and resource allocation. In 2008, the core data requested from all UN member states reporting evidence of progress toward the Declaration of Commitment of the 2001 UN General Assembly Session of HIV/AIDS (UNGASS) included for the first time estimates of risk knowledge and behaviour, HIV prevalence, and access to care among MSM. Indicative of the challenge ahead, 35 of 52 African countries were unable to report any information about MSM populations.
The authors discuss some of the challenges and misconceptions faced by the MSM community. Condoms and lubricants for safe sex are usually not available or prohibitively expensive. Messages about prevention targeted to heterosexual populations might seem irrelevant to MSM; African MSM might not consider same-sex encounters to be sex at all because this word can also infer reproduction. Perceptions that anal sex or sex between men pose no risk of HIV transmission, even that such behaviours might be actively sought because of this, have repeatedly been reported. Male-to-male sex is illegal in 31 countries, potentially attracting the death penalty in four. MSM face family rejection, public humiliation, harassment by authorities, and ridicule by health workers. Many MSM conceal their behaviour for fear of these repercussions.
There is some hope, despite this stigma and prejudice. An unprecedented increase in research into MSM, evident at recent African and international HIV/AIDS conferences, is in progress. WHO held its first technical consultation about MSM, and the prevention and treatment of HIV consultation and African HIV researchers, MSM advocates, and national AIDS programme managers met in Kenya and South Africa last year to discuss the issues. In the meantime, there is no justification for delay to basic elements of HIV risk reduction in MSM, such as condoms, water-based lubricants, information, counselling, care, and treatment for sexually transmitted infections.
The authors conclude: "In the early 1980s, silence equals death became a rallying cry for MSM activists in the USA to draw attention to a frightening new disease that was largely ignored or denied by government officials and the general public. Nearly three decades later in sub-Saharan African the silence remains, driven by cultural, religious, and political unwillingness to accept MSM as equal members of society. And the effect of silence is the same; the continued denial of MSM from effective HIV/AIDS prevention and care is harmful to national HIV/AIDS responses, the consequence of which is borne not only by MSM, but by everyone. The challenge now is to break that silence, recognise the problem, and begin to move forward in the development and implementation of the prevention and care programmes that are so urgently needed."
Dr Adrian D Smith, University of Oxford, UK T) +44 (0) 1865 289239 E) adrian.smith@dphpc.ox.ac.uk
For full Review see: http://press.thelancet.com/msmafrica.pdf
Journal
The Lancet