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Africa

Part of MSM, HIV and the Road to Universal Access: How Far Have We Come?

August 2008

More than two out of three HIV-positive adults and nearly 90% of all HIV-positive children live in sub-Saharan Africa, where national HIV prevalence rates range from less than 2% to more than 26% of adult populations. In total, some 22.5 million people were living with HIV/AIDS in the region in 2007, including the 1.7 million who were newly infected during that year. Also in 2007, 1.6 million sub-Saharan Africans died of AIDS. And more than half of all PLWHAs in sub-Saharan Africa (61%) are women.

Southern Africa is the area of the world most affected by HIV/AIDS, with nearly one third of all new HIV infections and AIDS deaths in 2007, and 35% of all PLWHAs. In East Africa, where AIDS first emerged on the continent, most countries are experiencing either a stabilization or a decline in adult HIV prevalence, although it remains high in many places. In West and Central Africa, HIV prevalence is either stable or declining, though conflict has increased the risk for HIV transmission in a number of countries.1 Unprotected heterosexual sex is responsible for the largest number of HIV infections in sub-Saharan Africa. But there is growing evidence of high rates of HIV transmission among MSM in the region.

In North Africa (and the Middle East, represented by a few countries included in the above section on Asia), epidemiological surveillance has been minimal. Available information, however, suggests that some 380,000 people are living with HIV/AIDS in the region. While few HIV/AIDS cases are being reported, men in urban areas account for the majority of infections. In some countries, commercial sex and injection drug use are also important factors in HIV transmission. In most countries, there is little knowledge of HIV/AIDS and few prevention efforts, even among the most vulnerable populations.

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Review of Country Progress Reports

African countries reviewed: Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Mauritania, Mauritius, Morocco, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Tunisia, Uganda, Zambia, Zanzibar, Zimbabwe.


1. Country Reporting: How Many Countries Reported on MSM?

Country reporting of five UNGASS indicators relevant to MSM

Summary: Out of the 52 countries reviewed, 35 did not report on any of the five indicators (Algeria, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Guinea, Guinea Bissau, Lesotho, Liberia, Libya, Madagascar, Malawi, Morocco, Mozambique, Namibia, Rwanda, Sierra Leone, Somalia, South Africa, Tanzania, Togo, Uganda, Zimbabwe). Twelve countries (Angola, Benin, Ghana, Kenya, Mali, Mauritania, Niger, Senegal, Swaziland, Tunisia, Zambia, and Zanzibar) reported on 1-3 indicators. Five countries (Ivory Coast, Mauritius, Nigeria, Sao Tome and Principe, and Sudan) reported on 4-5 indicators.


2. Seroprevalence: What percentage of MSM Are Living With HIV?

UNGASS Indicator: Percentage of MSM who are living with HIV

Summary: Forty-two countries did not report on HIV seroprevalence among MSM (Algeria, Angola, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Guinea, Guinea Bissau, Lesotho, Liberia, Libya, Madagascar, Malawi, Mauritius, Morocco, Mozambique, Namibia, Rwanda, Sao Tome and Principe, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Tunisia, Uganda, Zambia, and Zimbabwe.) Of the countries that reported on HIV seroprevalence rates among MSM, none reported prevalence of 0-10%. Two countries (Ivory Coast and Zanzibar) reported HIV seroprevalence of 11-15%. Eight countries (Benin, Ghana, Kenya, Mali, Mauritania, Niger, Nigeria, and Senegal) reported an HIV seroprevalence rate among MSM exceeding 15%.


3. Testing: What Percentage of MSM Have Taken an HIV Test in the Last Year?

UNGASS Indicator: Percentage of MSM who received an HIV test in the last 12 months and who know their result.

Summary: Forty-two countries in the region did not report on HIV testing among MSM (Algeria, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Morocco, Mozambique, Namibia, Niger, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, Swaziland, Tanzania, Togo, Uganda, Zambia, Zanzibar, and Zimbabwe). Six countries (Benin, Mauritania, Mauritius, Nigeria, Sudan, and Tunisia) reported HIV testing rates among MSM of less than 40%. Three countries (Angola, Ivory Coast, and Kenya) reported testing rates of 40-59% and one country (Sao Tome and Principe) reported a rate of 60% or higher.


4. Knowledge: What Percentage of MSM Know How to Prevent HIV?

UNGASS Indicator: Percentage of MSM who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission

Summary: Forty-nine countries in the region did not report on the level of understanding among MSM of HIV prevention (Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Mauritania, Morocco, Mozambique, Namibia, Niger, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Tunisia, Uganda, Zambia, Zanzibar, and Zimbabwe). Two countries (Mauritius and Nigeria) reported rates of 40-59% and one country (Sao Tome and Principe) reported a rate of 60% or more.


5. Behavior: What Percentage of MSM Used a Condom the Last Time They Had Sex?

UNGASS Indicator: Percentage of men reporting the use of a condom the last time they had anal sex with a male partner

Summary: Forty-one of the 52 African countries did not report on condom use among MSM (Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Guinea, Guinea Bissau, Lesotho, Liberia, Libya, Madagascar, Malawi, Mauritania, Morocco, Mozambique, Namibia, Niger, Rwanda, Sao Tome and Principe, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Togo, Uganda, and Zimbabwe). Two countries (Tunisia and Zanzibar) reported condom use among MSM of 20-39%. Seven countries (Ivory Coast, Ghana, Mali, Mauritius, Nigeria, Senegal, and Tanzania) reported rates of 40-59%. Two countries (Kenya and Zambia) reported rates of 60-79%. No country reported condom use rates among MSM of 80% or higher.


6. Coverage: What Percentage of MSM Are Being Reached by HIV Prevention Programs?

UNGASS Indicator: Percentage of MSM reached with HIV prevention programs

Summary: Forty-six countries in Africa do not know how many MSM are being reached by HIV prevention programs (Algeria, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comores, Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Lesotho, Liberia, Libya, Madagascar, Malawi, Mali, Mauritania, Morocco, Mozambique, Namibia, Niger, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Tunisia, Uganda, Zambia, Zanzibar, and Zimbabwe). One country (Angola) reported reaching less than 20% of MSM. No countries reported reaching 20-39% of MSM. Two countries (Mauritius and Nigeria) reported reaching 40-59% of MSM. Three countries (Benin, Ivory Coast, Sao Tome and Principe) reported reaching 60% or more of MSM.


Case Study: Nigeria

As Africa's most populous country, with 140 million inhabitants, Nigeria has a relatively low national HIV prevalence-4.4% of people aged 15 to 49. However, the West African country is home to the third largest number of people living with HIV in the world (3.86 million).2 The first HIV/STI Integrated Biological and Behavioural Surveillance Survey, conducted in 2007, revealed that HIV prevalence among MSM in Nigeria was 13.5% and concluded that "while Nigeria's HIV epidemic may be classified as 'generalized', the unequal distribution of HIV among different sub-population groups means that the Nigerian epidemic shares characteristics with 'concentrated' epidemics of other countries."3 The survey also stated that only 20-30% of MSM receive HIV outreach in the form of free condoms and safe sex education. Low condom use among MSM increases the risk of exposure to HIV, as does common use of condom-damaging oilbased lubricant.

Homosexuality in Nigeria is a criminal activity that is punishable by death in certain parts of the country. The International Gay and Lesbian Human Rights Commission recently released a report entitled "Voices from Nigeria: Gays, Lesbians, Bisexuals, and Transgenders Speak Out About the Same-Sex Bill," in which anonymous gay Nigerians expressed their opinions on the criminalization of homosexuality in Nigeria and its impact on the HIV epidemic. One man described his situation: "I am a 21-yearold gay man. In June this year I found out I was HIV positive. ... I have learnt that I am not allowed to express myself [about this] at all. I do not tell my family or my work. Being gay, I have to be as discreet as I can. I have to keep it away from the community. I am also scared about what would happen to me if I came out. I know of a man in a college boarding school who was beaten to death in 2001. These issues in society force gay life underground and contribute to the spread of HIV/AIDS."

Another Nigerian gay man remarked, "I am HIV positive. I run an organization that seeks to defend the human rights and well-being of LGBT persons in Nigeria. We do a lot of work in HIV/AIDS prevention. A few months ago my organization, in partnership with other organizations, completed research on HIV/AIDS prevalence among men who have sex with men. We carried out HIV tests on 1,300 men who have sex with men. The results of this study are not finalized but the problem is very great. The worst thing is that many of the people who tested have not come back to get their results."4

According to Dr. Oliver Ezechi, a chief research fellow at the Nigerian Institute of Medical Research, "People don't want to be identified as MSM. Some are married ... [and] they don't categorize themselves because it is derogatory." On the subject of the government's lack of intervention programs for MSM, he added, "The problem is that the church and the Muslim groups have a strong influence, so even when you advise the government they are not likely to make policy recommendations because they are afraid of backlash from the church groups. The government is not likely to do anything now because politicians want to remain in power." Dr. Ezechi stresses the need for more social science research on MSM to make it difficult for the government to ignore the issue of MSM and their link to the HIV epidemic.5


Nigeria 2008 Country Progress Report: UNGASS Indicators Relevant to MSM

Nigeria 2008 Country Progress Report: UNGASS Indicators Relevant to MSM


Case Study: Cameroon

In Cameroon, 5.5% of the population aged 15 to 49 is living with HIV.6 Cameroon's 2007 UNGASS report does not mention MSM, but section 347 of the Cameroonian Penal Code states, "sexual relations with a person of the same sex" are punishable by up to five years in prison and a fine.7 Often, Cameroonian MSM are detained under more general moral laws as well.8 In May 2005, 17 people were arrested on charges of homosexuality; 11 spent more than a year in prison before seven were actually convicted of a crime.9 There is also a significant threat of public outing in Cameroon, as some newspapers in the past few years have taken to printing the names of prominent citizens suspected of being gay.10

The legal and social ramifications of being gay in Cameroon represent a huge barrier to the prevention and care of MSM. According to the director of Alternatives-Cameroon, a human rights organization, HIV-positive MSM are so afraid of being open about their status that some do not access antiretrovirals, even though treatment is free. Alternatives-Cameroon is currently working on collecting data on MSM and HIV/AIDS, in the hopes that facts will force the government to acknowledge the presence of an MSM population; the group is also working to unite civil societies to present a more unified front in demands for HIV/AIDS programs. Although it is unusual for countries to enforce their anti-homosexuality legislation to the degree that this occurs in Cameroon, the country is one of many in which society does not acknowledge the existence of MSM. As a result, prevention efforts ignore MSM, who are even more susceptible to contracting HIV/AIDS and unable to access treatment safely.


Cameroon 2008 Country Progress Report: UNGASS Indicators Relevant to MSM

Cameroon 2008 Country Progress Report: UNGASS Indicators Relevant to MSM


References

  1. Adapted from UNAIDS website. Available online at www.unaids.org/en/CountryResponses/Regions/SubSaharanAfrica.asp.

  2. Nigeria National Agency for the Control of AIDS: Nigeria 2007 UNGASS Country Progress Report (2008).

  3. Federal Republic of Nigeria, Federal Ministry of Health: HIV/STI Integrated Biological and Behavioural Surveillance Survey 2007 (2007).

  4. International Gay and Lesbian Human Rights Commission (IGLHRC): Voices from Nigeria: Gays, Lesbians, Bisexuals, and Transgenders Speak Out About the Same Sex Bill (2006).

  5. Interview with Dr. Oliver Ezechi, Nigerian Institute of Medical Research, May 22, 2008.

  6. Cameroon National AIDS Control Committee: Cameroon 2007 UNGASS Country Progress Report (2008)

  7. Cary Alan Johnson: Off the Map: How HIV/AIDS Programming Is Failing Same-Sex Practicing People in Africa (IGLHRC, 2007).

  8. Interview with Steave Nemande, director of Alternatives-Cameroon, May 23, 2008.

  9. "Human Rights Activists Protest Continued Arrests of Gay Men in Cameroon: Demonstrations in Paris, Pretoria and Washington, D.C." (IGLHRC, 2007).

  10. Johnson.





  
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This article was provided by amfAR, The Foundation for AIDS Research. Visit amfAR's website to find out more about their activities and publications.
 

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