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Positively Aware
Got Lube?
The Slippery Slope for African Men Who Don't

By Jim Pickett

November/December 2009

The main draw for me to attend the 5th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town this past summer was the chance to spread the gospel of rectal microbicides and recruit, recruit, recruit new followers into research and advocacy efforts to make these new prevention tools a reality.

Reminder -- microbicides are products currently in development that can be applied vaginally or rectally to protect against HIV transmission. Safe, effective, acceptable, and accessible microbicides would be important additions to the prevention "buffet" for millions of women and men.

Got Lube?Thanks to the fabulous support of the AIDS Vaccine Advocacy Coalition, and in conjuction with the advocacy network I lead -- International Rectal Microbicide Advocates (IRMA) -- we were able to pull together a satellite session at the IAS meeting with the Microbicide Trials Network and a new South African program called Health4Men. Titled "Rectal Microbicide Development -- An African Perspective," we brought together five speakers (researchers and one advocate -- moi) to discuss the latest in rectal microbicide science and advocacy, placing a special focus on HIV among gay men and other men who have sex with men (MSM) in Africa, including ways to access these populations for health care and HIV prevention studies.

These men will certainly benefit from prevention options beyond condoms, such as rectal microbicides.

Contrary to rampant, pernicious mischaracterizations -- fueled by structural homophobia that negates the existence of gay/MSM and completely devalues their lives -- gay men and other MSM exist in Africa. Hello! Despite official HIV/AIDS estimates that mostly ignore this fact, these men constitute a substantial percentage of people living with HIV/AIDS on the continent.

You can click http://rectalmicrobicides.org/community.php to check out the slides from each of the presentations, by the way. Meanwhile, I want to focus on the talk presented by Chris Beyrer of Johns Hopkins Bloomberg School of Public Health, which kept my jaw dropped throughout.

After contextualizing the challenges faced by African gay/MSM -- including criminalization, stigma, discrimination, human rights abuses, lack of access to prevention and care, and limited HIV surveillance -- Chris shared some numbers from Senegal, Ghana, Nigeria, Mauritania, Cote D'Ivoire, Kenya, Tanzania, Uganda, Sudan, Egypt, South Africa, Zambia, Malawi, Namibia, and Botswana. The data revealed high burdens of HIV among gay/MSM across all these countries -- significantly higher than prevalence rates among males from the general population in each country save South Africa, Botswana, and Namibia, where there are similar rates of HIV among gay/MSM compared to heterosexual men of reproductive age.

Got Lube?Another quick reminder: prevalence refers to the overall number of people with HIV in a specific population.

So let's take a look at Kenya -- where Chris told us the prevalence rates among gay/MSM is 15.6% in contrast to 7.49% prevalence among Kenyan men of reproductive age. This means that about 1 in 6 or 7 gay Kenyans are HIV-positive. How about Sudan? Men of reproductive age represent 1.26% prevalence; gay/MSM 8.8% in that North African country. Malawi? 21.4% for gay/MSM; 11.46% for men of reproductive age.

In Senegal, the prevalence of HIV among gay/MSM is 21 times higher than other men. In Nigeria, seven times higher.

Pretty dismal, yes?

You can check out the rest of these sobering (criminal) statistics in his slides.

Where is the rectal microbicide connection? First, according to Chris, anal intercourse is common among gay/MSM in Africa, and most of these men are using some sort of lubricant. A sexual lubricant is an ideal vehicle to deliver a rectal microbicide -- commonly used, highly acceptable. But here is the rub: in a 2008 study of gay/MSM in Namibia, Botswana, and Malawi -- only one quarter of them used water-based lubricants. Of the men who indicated they always used condoms, 12.9% used a water-based lubricant. Nearly half of the men had used petroleum-based products during their last episode of anal intercourse with another man, and one fifth used nothing.

Nothing.

Got Lube?For those of us acquainted with the finer points of anal intercourse, the thought of engaging in this activity without any type of lubrication takes that dropped jaw and turns it into a grimace. And the fact that lube-free anal sex hurts, and tears, and burns creates a perfect storm in the rectum for HIV transmission.

And we all know that oil-based lubes are a big no-no with latex condoms -- though using these lubes in the absence of condoms is still much, much better than using nothing.

What's going on here? There are huge barriers to lubricant use, including cost and very limited availability, as well as the stigma attached to buying lubricant (you shouldn't need to buy lube for vaginal sex, right? If you're buying lube, you must be doing bad things.) Many African men who have the ability to travel come back from the West with suitcases packed with lubricant for their friends -- the demand is extremely high. But this is not the best distribution system, is it?

It was this last set of facts around lubricant use in general (high) and the amount of men using water-based lubes (low) that hit me like the proverbial ton of bricks. How in the hell can we even talk about getting rectal microbicides to these men when, currently, they don't even have proper lubricant?

Got Lube?Beyond addressing the huge issues faced by African gay/MSM -- egregious human rights violations, criminalization, invisibility in official data sets, meaning zero resources and zero programs -- we need to do the basics. We need to get these guys lube. Proper water-based lube. Stat.

It seems so simple, doesn't it?

Jim Pickett, a long-time AIDS advocate, works for the AIDS Foundation of Chicago and spends his time on projects ranging from rectal microbicdes to holistic gay men's health, in addition to championing sound, sane policy and fighting for adequate resources. He has been HIV-positive since 1995, and ran four marathons between 2004 and 2007. Now the only time he runs is when he hears the words "cookies" or "pie" -- perhaps a side-effect of (finally) settling down with Mr. Wonderful.

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