Addressing the problem: men who have sex with men in africa are a high risk group for hiv infection


Addressing the problem: men who have sex with men in africa are a high risk group for hiv infection

A review published Online First and in a future edition of The Lancet reports that men who have sex with men (MSM) in sub-Saharan Africa are a high risk group for HIV infection. However, religious, political, and social shame signify that this isolated group cannot access vital services. It is crucial that the HIV/AIDS community take action to deal with this crisis. The review discusses those issues and is the work of Dr Adrian D Smith, of the University of Oxford, UK, and his team.

There are significant challenges for the HIV/AIDS community in assessing and attending MSM needs in sub-Saharan Africa. In this region, homosexuality is illegal in most countries, and political and social hostility are widespread. There is a need for improved strategic information about all risk groups, including MSM, in order to effectively respond to HIV/AIDS. The authors write: "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."

In the 1980s it became apparent that heterosexual transmission route of HIV was predominant in African epidemics. However, the possibility that MSM might be included within this model then quickly vanished from discussion. But just as elsewhere in the world, African MSM exist. They have their own dynamics and particular needs, all of which take place in a socially repressed system.

After consulting data reported from 2003 to 2009, the authors observe that HIV occurrence among African MSM is in general noticeably higher than among adult men in the general population. HIV prevalence in MSM is over ten times that estimated in the male general population, in some West African countries. There are significant variations, but in most of the countries that were studied, incidence was higher in MSM populations. The authors comment: "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 seem to be restricted from the general population. African MSM often have both female and male sexual partners. Early HIV tests in white MSM in South Africa indicated that they had the subtype of HIV associated to European populations. But, tests in Kenya and Senegal showed that African MSM had a combination of strains comparable to those in the general population.

In order to update local policy and resource allocation, methods have been developed. They estimate the proportion of new HIV infections linked to different risk groups. In 2008, all UN member states were requested to report evidence of progress toward the Declaration of Commitment of the 2001 UN General Assembly Session of HIV/AIDS (UNGASS). It included for the first time estimates of risk knowledge and behaviour, HIV prevalence, and access to care among MSM. Thirty five of fifty two African countries were unable to report any information about MSM populations. This is an indication of the challenge ahead.

The authors carry on by considering 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 aimed at heterosexual populations might seem irrelevant to MSM. African MSM might not regard same-sex encounters as sex at all, because this word can also imply reproduction. Perceptions that anal sex or sex between men pose no risk of HIV transmission, have frequently been reported. Male-to-male sex is illegal in thirty one countries, potentially leading to the death penalty in four. MSM face family rejection, public humiliation, harassment by authorities, and derision by health workers. In fear of these repercussions, many MSM hide their behaviour.

Despite this stigma and prejudice, there is some optimism. There is evidence of an exceptional increase in research into MSM. This was apparent at recent African and international HIV/AIDS conferences. The World Health Organization (WHO) held its first technical consultation about MSM. Last year, prevention and treatment of HIV consultation and African HIV researchers, MSM advocates, and national AIDS program managers met in Kenya and South Africa. They discussed the issues. For now, there is no excuse to postpone putting into effect basic elements of HIV risk reduction in MSM (condoms, water-based lubricants, information, counselling, care, and treatment for sexually transmitted infections).

The authors write in conclusion: "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."

"Men who have sex with men and HIV/AIDS in sub-Saharan Africa"

Adrian D Smith, Placide Tapsoba, Norbert Peshu, Eduard J Sanders, Harold W Jaffe

DOI: 10.1016/S0140-6736(09)61118-1

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Section Issues On Medicine: Disease