Understanding the HIV prevention needs of male couples in KwaZulu-Natal, South Africa
There is a dearth of research regarding HIV and men who have sex with men (MSM) in African settings: Research on the epidemiology of HIV among MSM populations in sub-Saharan African settings, is just beginning2-8. Cross-sectional surveys across the region have found uniformly high HIV prevalence (1-11), and two vaccine cohort studies in Kenya and South Africa have observed extraordinarily high incidence (12-13). A recent review of the epidemiologic literature suggests that MSM are inadequately studied in many countries, and that despite well-characterized risks for HIV acquisition and transmissions, MSM continue to be under-represented in national HIV surveillance systems and in targeted prevention programs9. MSM populations are inherently difficult to recruit and study in many African countries: sex between consenting adult men is presently criminalized in more than half of African states. However, the last 5 years have seen a re-emergence of international interest in the role of MSM in HIV epidemics globally 10. At least three reviews and editorials published since 2007 have highlighted the high HIV prevalence found among MSM in resource-poor settings, and have acted to refocus prevention efforts for these populations in more sensitive ways 9, 11, 12. These reports have shown that MSM have a markedly greater risk of being infected with HIV compared with general population samples from low and middle income countries in the Americas, Asia and Africa 9, 13-15. Recent studies of MSM in Zanzibar, South Africa, Kenya and Senegal identified HIV prevalence rates upwards of 10% 2, 9, 13-21. Work by Lane and colleagues18 reports that the Soweto Men?s Study found HIV prevalence of 34% among gay-identifying MSM, 6.4% among bi-sexual-identifying MSM, and 10% among heterosexually-identifying MSM; in rural Mpumalanga province, prevalence among all MSM is as high as 29% (Lane, Osmand et al 2014). However, the majority of sub-Saharan African countries have yet to include MSM among their most at-risk populations in national HIV planning22. Most investigations into HIV among MSM in Africa have relied upon convenience or snowball samples of men who self-identify as homosexual, leading to the under-representation of non-homosexually identifying MSM5, 14, 23-25. Moreover, legal frameworks criminalizing same-sex behavior, discrimination and human rights violations pose a challenge for research as well as the scaling up of interventions and services26, 27. A growing body of literature shows that MSM exist in all parts of Africa28, despite strong local convictions that MSM behavior is not compatible with traditional African culture6. Now that HIV epidemics in several African countries have shown encouraging signs of decline 29, 30, the willingness of MSM populations to be engaged in HIV research and prevention provides a unique window of opportunity to research and stem the HIV epidemic as it diversifies into smaller at-risk populations6. van Griensvan6 argues that if we assume that male-to-male sex occurs in 3% of adult males, a high HIV prevalence in MSM may contribute between 10-20% of all prevalent HIV infections. Currently, there are no HIV prevention interventions classified as having ?best evidence? for MSM in resource-poor settings31, 32. Recent studies of MSM in African settings show that the interventions that are appropriate for MSM in developed countries may need to be significantly adapted33. Understanding the factors associated with HIV-risk among MSM in Africa has the potential to provide significant insights into the design of prevention messages and interventions to reduce HIV among MSM in resource-poor settings, while providing significant new information to aide in the design of programs for the roll-out of biomedical interventions.
Funding: UK Department for International Development (subcontract: Research Agreement, Project Number POAGAA)
Funding Period: 6/1/2015 to 11/30/2017