Too Little Data and Old Strategy on Prevention for MSM in Africa: Time for Change
Despite decades of advances in HIV prevention, HIV continues to burden gay and bisexual men disproportionately, especially younger gay men, and men who have sex with men. This is truly a global health issue -- applying equally to the US and to Africa. Vulnerability to HIV exposure is propelled by key structural drivers: antigay stigma laws, poverty and inadequate understanding of how to prevent HIV.
One major difference between the epidemics among men who have sex with men (MSM) in the US vs Africa is the level of information available. In the US, HIV was first diagnosed in gay men and there are decades of data, including on racial disparities. Yet in every report that I read about gay men and HIV in Africa, there is always this disclaimer: "Data on men who have sex with men (MSM) is very limited for sub-Saharan Africa." This famous line is getting boring!
I remember when I was preparing for my AIDS 2016 plenary presentation and was looking for the most up-to-date data on MSM on the continent. It felt like I was looking for a pin under the ocean! And of course, only a handful of people had information for me, including Chris Beyrer and Linda-Gail Bekker (the immediate past and current presidents of IAS) and Stefan Baral, who I like to call the data guru (Stefan is Associate Professor at John Hopkins) and friends at MSMGF. My good friend Brian Kanyemba (a former fellow of AVAC who now works with the Desmond Tutu HIV Center in South Africa and Advocacy for Prevention of HIV and AIDS-APHA) and I were moved to tears in Zimbabwe during the African AIDS Conference when MSM where not mentioned at all at the opening ceremony by one of our most important allies, Michel Sidibe who is the current Executive Director of UNAIDS.
The very few data that exist give us evidence of emerging HIV epidemics among MSM, often in settings marked by discrimination, homophobia and criminalization. MSM in Africa are understudied, tokenized and then often denied a more meaningful role in advocacy because they are told they lack adequate capacity! High HIV prevalence among MSM in Africa is evidence that prevention strategies are failing to reach this group. Real prevention -- prevention that works -- demands real engagement with MSM in Africa. This means counting our numbers and supporting the development of leadership among MSM advocates, and sustaining a comprehensive dialogue with the MSM community on the subject of prevention. It's time to respect gay men in Africa.
What Will HIV Prevention Mean for Gay Men and Other MSM in Africa?
For many of them, that still means using condoms consistently with lubricant that is most times not available! But as we know around the world, HIV prevention has gone far beyond condoms and lubricant, so you might want to ask why Africa isn't moving along with oral PrEP? In fact, Africa is making some hard-won progress. Activists on the continent are engaging in discussions about HIV prevention through AVAC's PxROAR Program and more. PxROAR trains US, European and African partners in HIV prevention research and implementation advocacy through mentorship, peer support, networking opportunities and technical and financial assistance.
To go beyond condoms and lubricant, activists are getting involved and learning about prevention research, about PrEP, about cure, about vaccines and long-acting injectables. But is that enough? What else can we do?
It is time to go back the drawing board. We can build on some of the success we've had in the past and go further. PEPFAR now has funds directed to key populations (KP), groups such as gay men or sex workers who are considered vulnerable to HIV. These KP funds can be used to build and improve upon programs like PxROAR. We need a targeted effort to inform and work with Africa MSM beyond the known faces. We need to engage with a hidden generation, invite them to conferences like CROI, HIVR4P and IAS, provide direct funding to understand and overcome barriers to HIV prevention for KPs in Africa. If we really want to help, then MSM must participate directly in the design of that help. AVAC is creating new opportunities through the PxROAR Program and other initiatives to inform and work with Africa KP around HIV prevention research, would you join us?