Turning surveillance into support for men who have sex with men in Africa

We need to stop simply doing research into the health and behaviours of gay men and other men who have sex with men (MSM) in resource-poorer countries, and start using research programmes as springboards for programmes of education and support for them. This was the broad consensus from an audience discussion after a session on MSM at the first day of the 7th International AIDS Society conference (IAS 2013) in Kuala Lumpur, Malaysia.

The discussion was sparked by a presentation from Stefan Baral of Johns Hopkins University on a pioneering project for MSM in Blantyre, Malawi, that did just that.

The problem in even finding out data on MSM in Africa, let alone providing effective prevention support, is the extremely hostile climate MSM have to live under in most of the continent.

Dr Baral at first outlined the challenges facing MSM globally and for those who research their needs. HIV prevalence in MSM worldwide is at least as high as it is in heterosexual people in sub-Saharan Africa: regionally, it ranges from 3% in the Middle East to 25% in the Caribbean. In Africa, sporadic studies have found prevalence ranging from 9% in Sudan to no less than 40% in Malawi itself.

HIV incidence studies have only been done rarely in Africa, but found 5% incidence a year in Cape Town, and the extremely high figure of 10% in Nairobi. As for major studies of HIV prevention interventions, not one has been done in the whole of Africa, apart from a single site of the iPrEx pre-exposure prophylaxis study, in Cape Town.

The problem in even finding out data on MSM in Africa, let alone providing effective prevention support, is the extremely hostile climate MSM have to live under in most of the continent. Even in South Africa, community opinion remains homophobic, despite a liberal legal climate.

Besides this, it is intrinsically difficult to get an accurate picture of the true health situation of MSM because it is unfeasible in most situations to interview whole communities and sift out the MSM among them. We therefore have to rely on convenience sampling of various kinds, including respondent-driven sampling (RDS), where initial 'seed' community members are recruited and then refer other members of their sexual and friendship network to the researchers. This, of course, may not give a true picture of the generality of MSM, as it may miss out the more isolated or closeted men. In addition, even RDS can only in itself provide health and behavioural data: it is not a method of providing support or education.

To attempt to address this issue and turn RDS into an ongoing programme of support, the Johns Hopkins researchers initially contacted 330 MSM for health and behavioural surveillance. They then offered an ongoing programme of health monitoring, education and support to 100 of the HIV-negative men. This programme included the training of ten peer educators. By the end of the programme, the researchers were able to point out, the research site had become established as an ongoing HIV prevention and education centre for MSM.

The 330-strong baseline group were all over 18 years old and had had anal sex with another man in the last year. One in eight (12.5%) turned out to have HIV and were referred to the HIV clinic for support. Of these, 90% were not aware of the fact, despite 60% having tested for HIV at least once and 34% in the last year. Five per cent had syphilis.

Only 23% said they had ever received HIV prevention information specifically for MSM, and this was reflected in the fact that a majority (58%) thought that vaginal sex posed a higher HIV transmission risk than anal sex, and only 14% thought anal sex more risky than vaginal.

One hundred of the 289 HIV-negative men were retained in a follow-up cohort who were studied for a year. Criteria for belonging to the follow-up group included that they were HIV negative, planned to stay in Blantyre for the next year, and were willing to give a mobile phone number and pseudonym for contact. Instead of just asking them to return to the centre periodically (which they did, for five scheduled appointments during the year), they trained ten peer support workers (not all MSM) who undertook to support the prevention needs of ten members of the follow-up group apiece. These peer support workers received a monthly stipend and as well as providing HIV education and condoms to their group, took part in a programme of training for local doctors and nurses in the health, mental health and HIV prevention needs of MSM.

HIV incidence in the follow-up group was 7%; the study was not designed to assess whether this was lower than baseline incidence. Retention in the study was almost perfect: only one person in the 100-strong group dropped out of the study during the year.

The session featured other studies of gay men around the world. As audience member Steve Mills of the global health group FHI 360 commented, they were all cross-sectional rather than longitudinal studies with the exception of the Malawi one, unearthing data on the situation of MSM but not acting as an intervention themselves, apart from using the survey to provide one-off information and counselling.

Other studies in the session – married and unmarried MSM in Mumbai

Ken Mayer of Fenway Health presented findings on a respondent-driven sampling survey of 307 MSM in Mumbai, India. Thirty-one per cent of this group was married to a woman and the survey focused on the question of whether the married men had distinct risk factors for HIV.

Apart from expected findings such as married men being older and more likely to have a job, it found relatively little difference in terms of preferred sex role (using Indian terms), except that married men were more likely to be versatile 'double-deckers', taking either sex role. It found high levels of depression, low self-esteem, and suicidal thoughts in the men, though no higher than among surveys of MSM elsewhere, and a significant degree of social isolation from other MSM; over 40% said they had two or fewer other MSM friends who could be called upon for help.

HIV prevalence in the group (adjusting for biases known to be endemic to RDS methods) was 14% and prevalence of any other sexually transmitted infection 19%.

Intimate partner violence and condom negotiation, USA

Catherine Finneran of Emory University in Atlanta reported on a study of intimate partner violence (IPV) in gay men. This was a follow-on study from one reported last year at the 2012 International AIDS Conference in Washington.

The study found high levels of broadly-defined IPV (48%) and of specifically physical or sexual IPV (25%) in the men surveyed. It also found that men reporting IPV in their relationships were 58% more likely to report difficulties in negotiating condom use with their partner, and men reporting physical or sexual violence more than 100% more likely. Dr Finneran recommended that gay men be screened for IPV within their relationships as part of health risk assessments.

Testing for acute HIV, France

Karen Champenois, of the French national research agency INSERM, presented a study of HIV testing and diagnosis in gay men. France has quite low rates of non-diagnosis in people with HIV – only 19% do not know their status – but HIV incidence in gay men, as in the UK, is not declining.

One in five infections (21%) diagnosed were found to be very recent, in the acute HIV stage. It found that in the 30% of men who had never tested and in men who had only tested once, the majority of HIV infections detected were chronic ones. In contrast, although only 15% of men tested less than a year ago, 42% of the acute, recently acquired HIV infections were diagnosed in this group.

Dr Champenois found that whereas most chronic infections were self-referrals, in the majority of acute diagnoses the HIV test was suggested by a health practitioner, and suggested that both promotion of frequent testing in the gay community and raising awareness of indicators for HIV testing in healthcare workers were complementary strategies.

Alcohol, HIV risk and HIV status knowledge, Peru

Finally, Dr Panagiotis Vagenas of Yale University conducted a large survey of 5148 MSM and transgender women in Lima, Peru, concentrating on the relationship between alcohol use and HIV risk. This was a young (average age 27) and relatively well-educated group of whom 57% defined as gay, 30% as bisexual and the rest 'straight'. Fourteen per cent were transgender women.

It used the World Health Organization-accredited AUDIT test to determine whether participants were using alcohol to a potentially hazardous extent. Its results might be called sobering: it found that 63% of this group had alcohol use that was at least classed as 'hazardous', though it did not distinguish between hazardous use and the two more severe categories of harmful or dependent use.

It tested group members anonymously and found an HIV prevalence of 8% in the group. Virtually all of those who had HIV – 89% – were unaware of it.

In multivariate analysis, apart from having unprotected sex with the last partner, the only other variable significantly associated with HIV infection was hazardous alcohol use, and alcohol was the only significantly associated drug (about 9% used cannabis or cocaine: none injected drugs).

Dr Vagenas commented that the study pointed out a need for a huge scale-up of testing in MSM in Peru, as well as education and support for sensible alcohol use in the MSM and transgender communities.