MSM-HIV Epidemic in Africa: Integrated Response to Diverse

Implementation of Comprehensive Package of Integrated Evidence-based HIV prevention
services for MSM
MSM-HIV Epidemic in Africa:
Integrated Response to Diverse epidemics
James McIntyre
MSM: Diverse and Often Hidden:
“Sex between men occurs in every culture and
society, though its extent and public
acknowledgement vary
from place to place”
UNAIDS 2006
What are “MSM”?
• “Men who have sex with men” is an inclusive public health construct used to
define the sexual behaviours of males who have sex with other males,
regardless of the motivation for engaging in sex or identification with any or
no particular “community
• A medicalised term describing a BEHAVIOUR, not an IDENTITY
• A very diverse grouping of men:
• Differences in race, culture, education,
class, religion, age, health status
• Only one factor in common –
sexual behaviour – but even here
there is variance in:
• Who they have sex with
• What type of sex they have
He looks
gay, I should
buy him a
drink
He looks
MSM, I
should buy
him a drink
MSM Myths and Stereotypes
All Men who have sex with men ...
…are transgender (aspire to be women)
... were abused as children
... are sexually interested in children
... are promiscuous or highly sexed
... are unAfrican, unChristian, unNatural
... are effeminate, visibly identifiable
... 'chose' their orientation
... are failed heterosexuals (inferior beings)
Who are “African MSM”?
• Hidden African MSM populations who do not identify with “gay
culture”
• Large proportion of African MSM also have sex with women
• MSM don’t assess their own HIV risk (lack of education and
prevention)
• Fear of stigma and judgement (and local recognition)
• MSM are not being identified in existing client cohorts
• Health care providers lack confidence and skills in identifying and
caring for MSM
HIV prevalence in MSM in Africa
• Recent studies from sub- Saharan Africa report HIV prevalence among MSM ranges
from 6% to 31%
• Very little incidence data: HIV incidence of 21.7 per 100 person years among MSM
in a small cohort from Coastal Kenya.
• Little African data on HIV in diverse populations of MSM, or by risk factor
Sanders, E. HIV epidemic among MSM in Africa. Technical consultation on MSM,
WHO, Geneva, 15-17 September, 2008, Bongaarts J et al, 2008
The “criminal” connection
• Homosexuality is outlawed in 38 African
countries.
• In 13 nations homosexuality is either legal or
there are no laws pertaining to it.
• Providing MSM focused services, or enrolling
MSM into studies in these countries becomes
a major challenge
http://en.wikipedia.org/wiki/LGBT_rights_in_Africa
“Traditional” culture, queer identity, and HIV
‘South Africa remains a
homophobic, heterosexist society
where, across cultures,
homosexuality is pathologised, and
where cultural discourses such as
the notion that “homosexuality is
not African” continue to play
themselves out.’
Henderson and Shefer 2008
Diverse attitudes
"When I was growing up an
ungqingili (a gay) would not
have stood in front of me. I
would knock him out."
“[same-sex marriages are] a
disgrace to the nation and to
God".
“Today, we are faced with
different challenges .
challenges of
reconciliation and of
building a nation that
does not discriminate
against other people
because of their colour or
sexual orientation.”
Jacob Zuma, 2006
Jacob Zuma 2012
Demonstrating political will
“heterosexism and homophobia are often key
drivers of many negative things in society ...
I don't believe that anyone is born
homophobic in the same sense that no-one is
born racist. These are norms we acquire
because of our socialisation. And, in turn,
other human beings can move us away from
these prejudices,......
"all people - regardless of race, culture,
gender, HIV status or sexual orientation - have
equal rights to the provision of services".
Dr Aaron Motsoaledi,
Minister of Health, South Africa
September 2010
Why diversity matters
• MSM are not “one population”
• Different men have different needs, do different things, hear
different messages
© Health4men, 2009
Diversity of sexual behaviour
• Sex between men occurs in diverse circumstances and among men whose
experiences, lifestyles, behaviours and associated risks for HIV vary greatly.
• MSM may also have sex with women, if infected they can transmit the virus
to their female partners or wives, or be infected from female partners
• Men who have sex with men are often married, particularly where
discriminatory laws or social stigma of male sexual relations exist.
• Sex between adolescent males can also be a part of sexual experimentation.
• In all-male environments, such as prisons, sex between men can be
common regardless of sexual identity and may be coerced.
Adapted from UNAIDS, 2008
Why sexual identity matters
HIV risk is impacted by sexual identity and behaviour
HIV Prevalence among MSM in Soweto
Sexual
Identifier
% of
Sample
Female
partner
HIV
Prevalenc
e
Gay
34
3
48
Bisexual
30
63
10
Straight
36
83
16
Total
100
(n-368)
50
25
Lane et al, 2008
Soweto Men’s Study
• High degree of concurrent female sexual partners
• High rates of HIV : estimated at 13%, and 34%
among the sub-set of gay-identified men. These
estimates are higher than men in the general
population, and among 20-24 year old MSM HIV
prevalence surpasses that of women
• Inconsistent condom use
Specific programming needs for
transgender people
• The few existing epidemiological studies among
transgender people have shown disproportionately high
HIV prevalence ranging from 8% to 68%, and HIV
incidence from 3.4 to 7.8 per 100 person-years.
• Underlying correlates of HIV and STI risk as well as the
specific sexual health needs of transgender people may
be distinct from those of MSM.
• Although the same basic HIV and STI prevention
interventions may be indicated for the two groups, public
health professionals should avoid conflating the two
groups and work towards a more nuanced understanding
of each group’s needs.
WHO, 2011
MSM HIV Risk Assessment
• Personal risk
– Increased HIV risk compared to general population
(OR 3.8 in Africa)
Baral S et al. PLOS Medicine 2007 Dec. (4)12
• Unprotected anal intercourse (UAI) is common
– 59% of township men had UAI
• Inconsistent condom use
• Condom breakages
– ↑ associated with alcohol and more rectal trauma
– ↓ associated exclusively with latex compatible lube
Lane, T et al. AIDS Behav. 2008
Why sexual behaviour matters
• Unprotected Anal sex is main risk for MSM
(Most anal sex occurs between men and women!)
• Previous health & risk reduction messaging has not targeted MSM, largely
silent about anal sex
Vagina
Adapted for sex
Thick mucosal surface
Self lubricating before sex
Anus
Not adapted for sex
Thin mucosal surface
Not self lubricating
 Mucosal tears  HIV entry-point
Challenges in an integrated response to MSM HIV
prevention
Key considerations for an integrated
response:
• Identity, discrimination and vulnerability
• Sexual practices and spaces
• Negotiations of identity, family and community
• Navigating the health system
Reeders 2010
An integrated package of interventions to reach diverse
MSM
STRUCTURAL
BEHAVIOURAL
BIOMEDICAL
An integrated response
• New evidence base for promising biomedical
interventions to reduce HIV risk
• No single intervention is sufficient alone to control HIV
spread
• Treatment for HIV positive persons can be effective
prevention
• Combination HIV preventive interventions may have
synergistic impacts on incidence
Beyrer 2011
From ABC to A-Z: integrating biomedical
and behavioural interventions
• Need to acknowledge the false divide between “biomedical”
and “behavioural” strategies
• Implementation of successful biomedical interventions also
provide opportunities to refocus on behaviour modifications,
including:
• Strategies to reduce HIV risk linked to alcohol use
• Delaying sexual debut
• Decreasing HIV risk from drug abuse, including needle
exchange programmes
• Reducing the risk from multiple concurrent partnerships
Community preferences and values for HIV
prevention strategies
1) Existing prevention strategies may serve
too few individuals who need them if barriers
such as stigma, violence, and homo- and
trans-phobia remain unaddressed (especially
among physicians and other health care providers).
2) Strong community support for integration of services that could provide a
comprehensive and more holistic approach to the prevention and
treatment of STIs and HIV.
3) MSM and transgender people commonly share experiences of sexual
oppression and human rights violations, but there is a need to address
transgender sexual health concerns separately from those of MSM.
MSM health services as the intersection between
behavioural and medical responses
HIV testing services
•Supplying condoms and
water-based lubrication;
•Individual and same-sex
couple counselling;
•Support groups
•Prevention with positives
•Needle exchange and IDU
interventions
•Education on sexual and
psychosocial health;
•Promotion of
“responsible sex “
• Sexual health checkups
HIV-related counselling
• CD4 and viral load
testing;
• HIV care and treatment
including access to ARVs;
• Diagnosis and treatment
for STIs;
• Vaccinations against viral
STIs;
• Sex worker-targeted
services
Healthcare, homophobia and HIV
‘They said ‘are you a man, a real man? What you
want here?’, they said ‘ooh wait I’m going to help
you’, those people they stay there for a long time,
they won’t get help they just laugh, laugh…’
Focus Group Participants, Cape Town
Jobson 2010
Healthcare, homophobia and HIV
• The experience of discrimination based on sexual orientation
at clinics and health facilities acts an important deterrent to
seeking medical care and going for HIV tests.
• Health facilities viewed as places where health care workers
constantly threatened MSM’s rights to privacy and
confidentiality by engaging in gossip and homophobic verbal
harassment
• Non-gay-identified MSM presented masculine, heterosexual
identities when presenting for sexual health problems and
avoided discussing their sexuality with HCW. (Lane, 2008)
‘‘They see you as a different thing’’
• ‘‘People are aware of gay and lesbian people
but accepting those people like human beings
is another story, because they don’t
understand what they are going through
inside, so that causes a problem, in terms of
when you need help from them,
they see you as a different thing.’’
Lane et al; Sex Transm Infect 2008;84:430–433
‘‘They see you as a different thing’’
‘‘I once went to the clinic and there were two gay men at the
clinic, apparently one of them had an STD, then a nurse said to
them she expected that, she wasn’t expecting them to have flu
but an STD, because they sleep around and God is punishing
them.’’
“Then you go to the clinic, the nurse will ask questions like ‘What
was in here?’—she means in the anus. And that makes us afraid
of going to the clinic to get treatment on time and that’s why
many gay men get sick.’’
Lane et al; Sex Transm Infect 2008;84:430–433
Challenges in providing MSM friendly health
services
• Reaching hidden, non-gay
identified MSM
• Stigma and discrimination
• Real and perceived barriers
to HIV testing and treatment
Integrating treatment and prevention
TREATMENT
PREVENTION
HIV prevention within MSM health services
• HIV prevention messaging should link to MSM-targeted health
services
• Health service outreach activities should promote more
holistic men’s health, and not only HIV risk
H4M sex-positive model of prevention
A sex-positive paradigm that…
• acknowledges the alienating effect of heteronormative messaging and the need for gayfriendly messaging that both normalises and
celebrates male-to-male sexuality
• recognises the effects of homoprejudice and the
ensuing defenses against shame and guilt, and
aims to instill a sense of respect for self and
others
• Identifies a paradigm for messaging MSM who
are often ‘resistant’ to such messaging
• Does not alienate MSM living with HIV
Reaching Young MSM
• Need to reach young MSM in their
spaces
• Highest HIV prevalence in Soweto
Men’s Study is in gay identifying under
25 year olds
• Young MSM in our Cape Town
research are more likely to identify as
gay – may make access to messaging
easier for younger MSM
• Higher percentage of young MSM
would opt to receive messaging via
cell phone (though not significant)
than older MSM
H4M sex-positive model
Context-relevant and respectful messaging
Combination prevention as an integrated response
Providing a package of combination
prevention can enable men to choose and
use the most appropriate strategies for their
lives and behaviours
Key Recommendations on MSM Prevention
Needs in South Africa
• Ensure adequate provision of standard commodities :
condoms and lubrication at all DOH sites
• Develop and implement a combination prevention package
• Development of nation-wide HIV prevention messaging:
specifically to target unprotected anal intercourse
• Expansion of biomedical prevention – ART as prevention in
PEP and PrEP and early treatment for high risk population
• Integration of MSM package within general prevention
package in attempt to address stigma
• Focused interventions on positive prevention
• Utilise social media and new technologies
h4m.mobi
Combination Prevention for MSM
PEPFAR defines the core elements of a
comprehensive package of HIV-prevention
services for MSM and their partners to be:
• Community-based outreach;
• Distribution of condoms and condomcompatible lubricants;
• HIV counseling and testing;
• Active linkage to health care and
antiretroviral treatment (ART);
• Targeted information, education and
communication (IEC); and
• Sexually transmitted infection (STI)
prevention, screening and treatment.
Integrating combination prevention
• Combination approaches need to be developed and tested for MSM
• Combination packages need to be be population targeted and context
sensitive
• Oral PreP is the first biomedical intervention with specific efficacy for
MSM – policy decisions needed on how to utilise PreP
• Role of circumcision in African programmes is complex,
given high rates of MSMW: less likely to be included
in other settings
• Rectal microbicides are a promising potential component
Integrating Structural Interventions
BIOMEDICAL:
•
•
•
•
•
•
•
Condoms & lube
Behavioural interventions
VCT
STI treatment
Circumcision
ARV strategies
Rectal microbicides
STRUCTURAL:
• Decriminalization
• Government-sponsored
anti-homophobia policy
• Mass media engagement
• Male engagement
programs
• Community systems
strengthening
• Health Sector
Interventions
Integrating Structural Interventions
Linking community attitude change to prevention messaging
Health4Men Ukwazana project
Integrating new technology to reach
MSM
Harnessing a continuum of electronic communication to reach
men with discreet and appropriate information
• Mobi site with information, polls and
referral links
• Accessible at low cost from most cell
phones
• http://h4m.mobi
• 93,000 ‘hits” May 2011 – February 2012
Integrating internet opportunities
• Mamba Online: SA gay men’s news
and dating site
• Anova Sponsored HIV prevention
messaging
• 30,000 active users:
• Age breakdown
• 18-20 : 5%,
20-25: 33%,
• 25-30: 24%,
> 30: 38%
• Racial mix:
• 61% white;
• 39% are black/coloured
An integrated response to
diversity
Integrated packages of combination prevention
strategies can reach diverse populations of MSM
With thanks for the generous help from:
• Glenn De Swardt
• Kevin Rebe
• Tim Lane
• Helen Struthers
• Geoff Jobson