SOUTH AFRICA: MSM still sidelined in HIV programming

Published: May 27, 2011

CAPE TOWN, 27 May 2011 (PlusNews) – South African men who have sex with men are twice as likely to be HIV-positive as heterosexual men, but spending on research, prevention and treatment for this group remains low, delegates at a conference on MSM and HIV in Cape Town heard.

"We see HIV incidence rates for MSM continue to increase in all studied countries; we must advocate for more research," Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre, said in a statement.

Bekker called for the introduction of specific HIV packages tailored to the needs of particular groups, including one for MSM.

Studies show that the risk of contracting HIV during anal sex is 18 times higher than during penile-vaginal sex.

According to research whose results were revealed at the conference, held on 23-25 May, more than one in 20 men taking part in the survey reported consensual participation in a sexual act with another man and MSM were twice as likely to be HIV-positive as their heterosexual peers.

The survey of 1,737 men – conducted by South Africa’s Gender Health Research Unit (GHRU) and the Medical Research Council (MRC) in the Eastern Cape and KwaZulu-Natal provinces – also revealed that MSM were more likely to be poorly educated and suffer from food insecurity than non-MSM. Across the board there was no difference between the various race groups in South Africa.

"MSM are at risk [of HIV] because of the nature of their activities, which is underground," said Kristin Dunkle, co-author of the study and assistant professor of behavioural sciences at the Emory Rollins School of Public Health in Atlanta.

The term MSM refers to men who engage in sexual activity with other men but who may also have sex with women; they do not necessarily consider themselves to be homosexual. MSM are considered to be a bridging population for HIV into the general population.

Three-quarters of the study participants who reported being MSM had a female partner; one-third had a male partner; 20 percent had both and half those questioned had children. One in 10 MSM had also been sexually assaulted by another man.

According to Glenn de Swardt, director of the Cape Town-based Health4Men, which established the first clinic in Africa dedicated to MSM, gay people have a sense of identity that is formed through their sexuality, while MSM often view themselves as heterosexuals who take part in same-sex sexual acts purely for pleasure.


No one really wants to talk about anal sex and what is the safest way to practise it, even though the risks associated with it are huge

"Hidden group"

"Men who engage in this activity try to keep it a secret from most people in their communities; they are a hidden group in our society," he told IRIN/PlusNews.

"No one really wants to talk about anal sex and what is the safest way to practise it, even though the risks associated with it are huge," he added. "For instance, in the townships people use substances like butter, margarine and cooking oil as a lubricant when having anal sex, but these substances are harmful to condoms.

"We are trying to get the message out there that water-based lubricants need to be used, but then the question for most people is, where do you get it?"

Training health workers

Delegates were told one of the main barriers MSM encountered when trying to seek HIV-related care was the attitude held by many medical and healthcare providers who were not trained properly to deal with this group.

Nelis Grobbelaar from the public health NGO, Anova Health Institute’s West Coast Winelands Project, said his experience of training health professionals was that they were initially uncomfortable talking about sex to their patients.

"When we started some of the MSM sensitivity training, the clinic staff were very clearly very opposed to the idea of [homosexual] sex and were not comfortable talking openly with their patients about their sexual practices," he said. "Through MSM training we are changing people’s minds – not just about homosexual sex but about sex in general."

Stefan Baral of the Centre for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health noted that HIV prevention strategies needed to happen in a stigma-free environment.

May 26, 2011 (Miami, Florida) — HIV-infected Latino men who have sex with men and who experience chronic discrimination for a variety of reasons, including their ethnicity and sexual orientation, develop a mistrust of the healthcare system and avoid seeking treatment, researchers reported here at the 6th International Conference on HIV Treatment and Prevention Adherence, sponsored by the International Association of Physicians in AIDS Care (IAPAC).
"Our theory in doing this study was that men who experience a lot of chronic discrimination over time in different areas of their life and in different amounts and intensity would grow to have more medical mistrust of the healthcare system and of public health messages," Laura M. Bogart, PhD, from Children’s Hospital Boston and Harvard Medical School, Massachusetts, told Medscape Medical News.
Constantly being the victim of discrimination "can lead to a suspicion of outsiders, of new treatments, of whether one should listen to what the government is saying or not, and then to not necessarily believing provider recommendations. You may not know who to believe and who to trust," she said.
In this study, Dr. Bogart and her colleagues worked with an organization that serves Latinos living with HIV in Southern California, called Bienestar Human Services.
"These men are a very hidden population. Many of them were undocumented — most were not legal residents of the United States — so we needed to work with a community organization that is well trusted in the community, [with workers] who could relate well to the people who participated in our study," she explained.
Aided by Bienestar, 137 Latino men on antiretroviral treatment completed interviews that measured adherence, medical mistrust and discrimination due to HIV status, race/ethnicity, and sexual orientation.
The researchers found high levels of discrimination. Thirty-eight percent said they had been discriminated against because of their HIV status, 38% because they were Latino, and 47% because of their sexual orientation.
The researchers found that 23% of the men reported they had missed a medication dose on the day before the interview. Greater medical mistrust was significantly associated with nonadherence (odds ratio [OR], 0.37; P < .01).
Also associated with nonadherence were perceived discrimination because of HIV serostatus (OR, 0.78; P < .01), race/ethnicity (OR, 0.82; P < .05), and sexual orientation (OR, 0.82; P < .05).
The study also found that discrimination related to being Latino and being HIV-positive were significantly correlated with medical mistrust.
"When these men were discriminated because they were Latino, it was more likely to affect their adherence. We are not sure exactly why and we are trying to understand the reasons for this," Dr. Bogart said.
Mistrust of the healthcare system often tends to be ignored when it comes to figuring out why people are not adherent to treatment, she added.
"We don’t think about the factors that we can’t see. We think about whether someone can get to the doctor. Do they have transportation? Do they have access to healthcare? We think about these more traditional barriers to healthcare. But what our study is saying is that there may be other barriers to treatment that prevent people from being adherent — barriers that we can’t see that are more cultural, more social, and that we need to pay more attention to," she said.

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