Addressing the HIV prevention needs of men who have sex with men in Africa.

Groundbreaking research by the Population Council is beginning to shed light on the full range of risks for HIV infection faced by men who have sex with men (MSM) in Africa, and on the best ways to reduce these risks. The Council's research has found low consistent condom use, high levels of violence, and widespread resistance to seeking health care among such men, even when they experience symptoms of sexually transmitted infections (STIs). Our findings have greatly benefited ministries of health, which have used this evidence to shape HIV policies and improve services for this vulnerable population.

Men who have sex with men

According to the U.S. State Department's Office of the Global AIDS Coordinator, MSM are "among those who are most marginalized in society and have the least access to basic health care." This is evident in much of the developing world--and in Africa in particular--where the stigmatization, discrimination, and criminalization associated with male same-sex behavior persists. Officially, many African leaders deny the existence of same-sex activity, resulting in HIV prevention policies that ignore the needs of MSM. Nearly all materials in Africa aimed at educating people about HIV risks are targeted to heterosexual couples, and many MSM hold misconceptions about which sexual practices increase HIV risk. Often HIV service providers are not trained, equipped, or willing to meet the specific prevention and treatment needs of MSM; and less than 5 percent of such men have access to HIV prevention and care globally. As a result, even where MSM are aware of general prevention interventions, they may not access them out of fear of mistreatment or even arrest.

The Population Council's work on MSM has helped to dispel the belief that male same-sex behavior in sub-Saharan Africa occurs only among foreigners. A study by Scott Geibel of the Population Council and Eduard Sanders of the Kenya Medical Research Institute estimated that 739 MSM sex workers are active in Mombasa, Kenya. The method Geibel and his team used is an adaptation of a technique used in wildlife biology to estimate the size of hidden populations.

On two separate occasions, one week apart, "peer leader enumerators" distributed leaflets to MSM sex workers at 77 locations in Mombasa. A record was kept of when, where, and by whom the leaflets were given, received, or refused. Using this data, the researchers estimated the size of the MSM sex worker population in that area.

The Population Council and the International Centre for Reproductive Health later conducted a behavioral survey of MSM sex workers in Mombasa. The researchers found that 80 percent of male clients of these sex workers were Kenyan citizens and as a group were extremely likely to engage in behaviors that put them at high risk of HIV infection. "MSM in Africa represent an epidemiologically important population who urgently need to be targeted by HIV prevention strategies," said Geibel.

Council research has identified a high prevalence among MSM of behaviors, experiences, and beliefs that put them at high risk of HIV transmission. Reported condom use was low in most studies: only 14 percent of MSM reported condom use at last receptive sex in Dakar, Senegal. Only 36 percent of MSM sex workers surveyed in Mombasa used condoms consistently with male clients, and 35 percent did not know that HIV could be transmitted during anal intercourse. Further, in a Nairobi, Kenya study, use of oil-based lubricants, which can make condoms vulnerable to breakage, was common: 84 percent of respondents used petroleum jelly. Among those MSM who knew about lubrication, only 26 percent knew that only a water-based lubricant should be used with latex condoms.

Non-consensual sex is also common among MSM and may place them at increased HIV risk. The Council's Dakar study found that 43 percent of respondents had been raped at least once, and 13 percent had been raped by a policeman.

Unprotected anal intercourse among MSM not only increases their risk of HIV transmission, but ultimately the risk of their female partners and children (through mother-to-child transmission). In the Council's Dakar study, 88 percent of MSM reported having had vaginal sex, and nearly one-fifth had had anal sex with a woman. In the Council's Nairobi study, 22 percent of MSM reported having at least one child.

However, not all MSM engage in high-risk behaviors. The Nairobi study found that reported condom use was as high as 75 percent during the last anal sex act, and 21 percent of respondents reported having only one male sexual partner over the past year. In addition, 57 percent reported having ever taken an HIV test--98 percent of whom had received their test results--more than double the rate of the general population as reported by Demographic and Health Surveys in 2003. This suggests some diversity between MSM in different settings.

Innovative programs can work

The Council evaluated a program in Dakar that trained 40 MSM peer educators on ways to communicate about and promote risk-reducing behaviors, as well as on ways to support their peers in starting and continuing these behaviors. These educators were equipped with water-based lubricants, condoms, and educational materials. Twelve health care providers were also trained to deliver "MSM-friendly" services and to raise awareness among media, police, and community-based organizations about the health needs of MSM. The Council assessed the feasibility and acceptability of the intervention, and its outcomes on MSM. We documented that the intervention resulted in 1,200 clinical consultations, with 263 MSM referred for HIV counseling and testing. The Council is now assessing a similar service-delivery project for MSM in Mali.

The Council also evaluated a program launched by the International Centre for Reproductive Health to reduce HIV transmission among MSM sex workers in Mombasa. The program includes a drop-in center, training of peer educators in prevention and basic counseling, distribution of condoms and water-based lubricants, and sensitization and training of providers. The Council's assessment showed significant improvements in HIV-related knowledge and behaviors among MSM sex workers, including correct knowledge of anal HIV transmission and water-based lubrication, and increased condom use.

Going forward

Building on Geibel's estimates of the number of MSM sex workers in Mombasa, the Council, led by epidemiologist Scott Kellerman, will seek to determine the number of MSM sex workers in three cities in Nigeria and three cities in South Africa. "You can't design good HIV prevention strategies without getting a handle on the size of this important but hidden population," says Kellerman.

Also in Nigeria, the Council--led by behavioral scientist Andrew Karlyn--is establishing the Men's Health Network, an association of healthcare providers, community-based organizations, and opinion leaders. The program will use a "social franchise" model through which all men can access comprehensive medical care and HIV prevention services in a hassle-free manner. It will harness both the private and public sectors and use new technologies, such as smart cards and point-of-service machines.

Some people hold the misguided belief that HIV and AIDS were created as a means of genocide. Studies in the United States, for example, have found that up to 50 percent of African Americans believe HIV was created by the government. In Pretoria, South Africa Council researchers Waimar Tun and Kellerman will explore the impact of mistrust and conspiracy beliefs on HIV-preventive behaviors, use of HIV-related services, and willingness among MSM to participate in clinical trials for HIV treatments or vaccines.

Informed discussion among key HIV policymakers in African governments is critical to legitimize the need for MSM-specific HIV prevention and treatment programs, and to develop guidelines for implementing them. To address this need, the Population Council and the National AIDS Control Council of Kenya convened an international meeting in May 2008 to highlight research conducted by the Population Council and other organizations. The meeting, titled The Overlooked Epidemic: Addressing HIV Prevention and Treatment among Men Who Have Sex with Men in Sub-Saharan Africa, brought together more than 60 representatives from national HIV programs, research organizations, donor agencies, and advocacy groups from 16 African countries. "Given common attitudes in Africa about men who have sex with men, the fact that the meeting happened at all is remarkable," commented Geibel. "This was one of the first meetings in Africa to focus on MSM and to present a strong evidence base about this population." The Population Council will present and discuss the meeting's findings at national, regional, and international venues in an effort to garner additional support for policies and programs to improve access to services.

"In Africa, attitudes about and government policies toward men who have sex with men are beginning to change," says Kellerman, "and this is in part due to the Population Council data."

SOURCES

National AIDS Control Council of Kenya and Population Council. "The Overlooked Epidemic: A Regional Consultation of African National HIV/AIDS Programs, Researchers, Programmers, and Advocates," 2008. Report of a meeting, forthcoming.

Geibel, S., S. Luchters, N. Kingola, E. Esu-Williams, A. Rinyiru, and W. Tun. 2008. "Factors associated with self-reported unprotected anal sex among male sex workers in Mombasa, Kenya," Sexually Transmitted Diseases 35(8): 746-752.

Geibel, Scott, Elisabeth M van der Elst, Nzioki King'ola, Staney Luchters, Alun Davies, Esther M. Getambu, Norbert Peshu, Susan M. Graham, R. Scott McClelland, and Eduard J. Sanders. 2007. "'Are you on the market?': A capture-recapture enumeration of men who sell sex to men in and around Mombasa, Kenya," AIDS 21(10): 1349-1354.

Moreau, Amadou, Placide Tapsoba, Abdoulaye Ly, Cheikh Ibrahima Niang, and Abdou Khoudia Diop. 2007. "Implementing STI/HIV prevention and care interventions for men who have sex with men in Dakar, Senegal," Horizons Research Summary. Washington, DC: Population Council. (http://www.popcouncil.org/ pdfs/horizons/Senegal_MSMHealthNeedsSum.pdf)

Niang Cheikh Ibrahima, Moustapha Diagne, Youssoupha Niang, Amadou Mody Moreau, Dominique Gomis, Maye Diouf, Karim Seck, Abdoulaye Sidibe Wade, Placide Tapsoba, and Chris Castle. 2002. "Meeting the Sexual Health Needs of Men Who Have Sex With Men in Senegal," Horizons Final Report. Washington, DC: Population Council. (http://www.popcouncil. org/pdfs/horizons/msmsenegal.pdf)

Onyango-Ouma, W., Harriet Birungi, and Scott Geibel. 2006. "Understanding the HIV/STI prevention needs of men who have sex with men in Kenya," Horizons Research Summary. Washington, DC: Population Council. (http://www.popcouncil.org/pdfs/horizons/ msmkenyasum.pdf)

Onyango-Ouma, W., Harriet Birungi, and Scott Geibel. 2005. "Understanding the HIV/STI risks and prevention needs of men who have sex with men in Nairobi, Kenya," Horizons Final Report. Washington, DC: Population Council. (http://www.popcouncil.org/pdfs/horizons/ msmkenya.pdf)

OUTSIDE FUNDING

The American Foundation for AIDS Research, US Centers for Disease Control and Prevention, the Ford Foundation, President's Emergency Plan for AIDS Relief through the US Agency for International Development, the MAC AIDS Fund, and the Institute for International Education through the Ford Foundation Office of East Africa