A decade of research involving men who have sex with men in sub-Saharan Africa :

1. A decade of research involving men who have sex with men in sub-Saharan Africa: Current knowledge and future directions DR Nicholas MuraguriMD, MPH, MBA dnmurags@yahoo.co.uk

2. Five gay men arrested in Mombasa, Kenya; Mobs call fordeath by fire Police drag gay man from KEMRI building and arrest him

3. Outline • Background • Review methodology • Highlights of findings • Study Challenges and Limitations • Future directions • Conclusions

4. Background • UNAIDS estimates MSM account for about 5-10% of the global burden of HIV • Considerable variation between countries and regions • MSM in Africa among the least studied, but data are emerging

5. Review methodology • The first behavioral survey of MSM in sub-Saharan Africa was conducted in 2001 • Reviewed 39 behavioral, bio-behavioral, or cohort study surveys conducted in 14 sub-Saharan African countries since 2001

6. SCOPE OF STUDIES REVIEWED • Prevalence of same sex sexual behavior and MSM size estimation • Biological measurements- HIV , STI, Hepatitis B and C, STI • Sexual risk behaviors • HIV testing and access to Health services • Human rights and HIV , • Human rights abuses and public health consequences • Strategic use of ARVS - iPrEx study • Vaccine development

7. HIV PREVALENCE AND INCIDENCE • HIV rates in several studies have been measured above 10% to 50% throughout the continent • Incidence data only available in kenya • HIV incidence in MSM high—6.8 per 100 person-years (CI): 4.9 to 9.2)

8. HIV Prevalence • Beyer, et al (2010), using a comparative pooled adjusted odds ratio approach, estimated that MSM in Africa were 3.8 times (95% CI: 3.3, 4.3) more likely to be HIV positive than men of reproductive age within the general populations.

10. BEHAVIORAL MEASUREMENT S • General correct knowledge about HIV and other STIs are lower than desirable amongst MSM (Moreau et al., 2007; Fay et al., 2011). • Perceptions that anal sex pose no risk of HIV transmission • Reporting payment for anal sex or being engaged in sex work ranged from 6% to 74%

11. SEXUAL BEHAVIORE • MSM in Africa are involved in high risk sexual behaviors including : • Insertive and receptive anal sex with multiple and concurrent male sexual partnerships, • and with no or inconsistent condom use • Bi-sexual, often concurrent relationships

12. Human rights and HIV among msm • MSM are one of the most stigmatized of all HIV risk groups in sub-Saharan Africa • MSM often subjected to homophobia, harassment, discrimination, and criminalization • Male same sex sexual behavior is illegal in 31 sub-Saharan countries and potentially attracts the death penalty in 4

13. Zimbabwe’s President Robert Mugabe on Saturday told British Prime Minister David Cameron “to hell with you” over his calls to respect gay rights “In their newspapers, that’s one of my sins. That I called (gays) worse than pigs and dogs because pigs know there are males and females”

14. Access to services • There is documented public health consequences of widespread human rights abuses among MSM including increased risk of HIV acquisition and limiting access to lifesaving HIV services • Eg - MSM who suffered homophobic abuse were five times as likely to be HIV-infected as those who were unexposed (Hladiket al., 2012).

15. Access to HIV testing services • limited access to HIV testing due to unavailability of services and other structural barriers such as widespread stigma and discrimination

16. Challenges and limitations of the Africa MSM studies in Africa • Terminologies and typologies of MSM and sexual identities • Possible over-representation of male sex workers in survey populations • Recruitment methodologies and diversity of indicators • Geography and demography of survey populations

17. Future directions • Improve and harmonize surveillance and research methodologies and indicators • Qualitative studies to enhance understanding of survey findings • Some priority studies • Sexual identities and various typologies, • various social and cultural contexts in which male same-sex sexual behavior takes place, • practice of anal sex as part of broader societal or heterosexual contexts.

18. Future reseach directions • Confirm safety of water-based lubricants • Continue study of PrEP as an intervention for high-risk MSM • STI research and presumptive treatment for bacterial STI • Evidence based behavioral interventions • Implementation science studies to guides scale up of inventions

19. Conclusion • Despite the methodological and other limitations noted in studies on MSM in Africa, the current body of evidence across the content clearly establishes that there is widespread existence of MSM groups, and that they are at high risk of acquiring HIV due to behavioral, social, cultural, and structural factors

20. Conclusion • With growing evidence of the epidemiologic importance of MSM in the region, there is need for continued support for expansion of studies and packaging the results for policy advocacy and for informing program and service development for MSM.

21. Acknowledgements • Scott Geibel • Eduard Saunders • Kennedy Nganga • Helga Mutua

22. We need the same in Sub Saharan Africa