It is a well-established fact that men who have sex with men (MSM) are vulnerable to HIV & AIDS infection.⁽²⁾ In developed countries, grass root communities and national governments have been explicitly tackling MSM vulnerability to HIV & AIDS for over two decades now. In Africa however, this fight has been very limited in its success. While there is a desperate need for HIV & AIDS prevention interventions, African countries are not making enough effort to curb the rates of HIV & AIDS amongst MSM.⁽³⁾ The challenges that hinder this progress include continued stigma, discrimination and the banning of homosexuality. The aforementioned factors are rampant in African countries to the extent that some heads of state repudiate the existence of homosexuality. Legislators have overlooked MSM and in doing so, excluded them from invaluable health services.

This paper provides a brief overview of the discrimination and exclusion of MSM in the context of the HIV & AIDS epidemic. It will look at factors that make MSM vulnerable, the consequences of this vulnerability and finally, discuss the challenge of how to respond to HIV & AIDS amongst MSM.

Population estimates

While the term MSM seemingly exclusively applies to men who have sex with men, the term in fact incorporates a wide range of sexual and gender identities, including homosexual, gay, bisexual, and transgendered; within various socio-cultural contexts.⁽⁴⁾ Approximating the size of populations at high risk of HIV & AIDS, such as MSM, is critical to areas of informing programme and policy activities, as the size of the population being targeted is closely related to programme management and projection, as well as response planning, allocation and advocacy. Despite the fact that an estimate of the size of MSM populations is important, these figures may not always be available in many countries and, furthermore, are likely to be underestimated.

Worldwide, it is estimated that sex between men accounts for between 5 and 10% of HIV & AIDS infections,⁽⁵⁾ with less than 1 out of 20 MSM having access to HIV & AIDS prevention and care.⁽⁶⁾ While in the past studies in Africa are said to have reported HIV transmission as consistently heterosexual, recent studies indicate the existence of MSM and high levels of HIV & AIDS infection among them. HIV & AIDS prevalence in Africa is said to be significantly higher in MSM than among adult men in the general population. Reports show that HIV & AIDS prevalence among MSM in some West African countries is over ten times that estimated in the general population,⁽⁷⁾ and 20 times higher than the general population in many parts of the world.⁽⁸⁾

The UNAIDS Global Epidemic Report shows that “up to 20% of new infections in Senegal, and 15% in Kenya and Rwanda, could be linked to unprotected sex between men.”⁽⁹⁾ The increasing incidence of HIV in the MSM and transgender groups in Africa referred to as a “crisis” demonstrates that collective responses to HIV & AIDS have failed.⁽¹⁰⁾

Determinants of vulnerability among MSM

Before moving forward to the reasons why these figures above exist, an important point worth noting is that “most behaviour and epidemiological studies with MSM as the target population have relied on convenience and snowball samples of men who self-identify as homosexual within their cultural context.”⁽¹¹⁾ Although these studies have been important to the investigation of the HIV & AIDS epidemic amongst MSM, important information on those MSM who choose not to take part or do not identify themselves as the target population for such studies, and as such, may differ from those that do, is missing from the data.

The first reason as to why MSM are vulnerable reflects biological risks factors. Sex between men is a significant factor within the perspective of the global HIV & AIDS epidemic because it involves anal sex, which, when no protection is used, carries a higher risk of HIV transmission than unprotected vaginal sex.⁽¹²⁾ Similarly, sexually transmitted infections (STIs) can also be more easily transmitted through anal sex and this is another biological vulnerability as STIs increase the chance of spreading HIV infection.⁽¹³⁾ Adding to the biological factors are the behavioural risk factors found in MSM populations that increase the possibility of the biological factors coming to the fore. For instance, it has been found that MSM are more likely to be involved with risky HIV behaviours such as being less likely to use condoms reliably and learn about HIV & AIDS and more likely to have multiple partners.⁽¹⁴⁾ Furthermore, drugs and alcohol are typical ways in which MSM socialise which increases the likelihood of the aforementioned risky sexual behaviours.⁽¹⁵⁾

MSM vulnerability is not however merely at the individual level. The very apparent antagonistic attitudes towards homosexuality in African cultures and societies cause neglect of MSM, leading them to be vulnerable to risky HIV behaviour.⁽¹⁶⁾ Epidemiological research indicates that MSM are largely ignored in HIV & AIDS research and HIV & AIDS follow-up actions, including prevention, treatment and care programmes for MSM. This neglect makes MSM more vulnerable as they are less likely to know their HIV status, have access to the necessary HIV prevention knowledge to protect themselves and others, and more likely to be excluded from invaluable health services such as those for STI symptoms and access to condoms and lubricants, which can all contribute to HIV infection risk. Where HIV & AIDS awareness information is available, campaigns in Africa focus on the risks of heterosexual sex, thus not providing the relevant information for MSM.⁽¹⁷⁾

The determinants of MSM vulnerability are therefore combined in a vicious cycle. The socio-cultural factors increase behavioural risk factors including unprotected sex, multiple partners and lack of access to health resources. These (combined with drug and alcohol use) then increase the likelihood of the biological mechanisms to act.

Challenges of HIV & AIDS responses for MSM: Socio-cultural determinants

Although MSM may be at higher biological risk to HIV & AIDS compared with the heterosexual population, socio-cultural factors possibly cause higher vulnerability and, in practical terms, are the determinants that need to be addressed to reduce MSM vulnerability. A Pew Global Attitudes Project (PGAP) survey in ten Sub-Saharan countries reported that MSM who disclosed their orientation through choice or necessity reported “family rejection, public humiliation, harassment by authorities and ridicule by health care.”⁽¹⁸⁾ Similarly, the International Gay and Lesbian Human Rights Commission (IGLHC) reported discrimination against MSM including “widespread arrest, extortion, violence, threats and instances of forcible anal examination of MSM suspected people.”⁽¹⁹⁾

These preceding behaviours are a consequence of social stigma, which aid in keeping MSM a vulnerable population.⁽²⁰⁾ The term stigma, originating from the Greek language, refers to the attitudes and perceptions that denote “marks of… persons deemed inferior.”⁽²¹⁾ Such negative stigma is found in African countries and is based around the notion that there is no place for homosexuality in African society. In the PGAP study for example, it was found that majority of respondents were in favour of rejecting homosexuality.⁽²²⁾

It is possible that African MSM experience different forms of stigma from other regions. For most African societies, the community precedes the individual and becomes mostly the standard through which the individual chooses goals, values, and life plans.⁽²³⁾ African traditions ‘train’ the individual to be conscious of his own being, duties, privileges and responsibilities in terms of other people.⁽²⁴⁾ In such milieus, individual, family, religion and society are interdependent and interrelated and thus, decisions to be marriage or not, to have children or not, are community concerns. In light of this background, African MSM could be facing a ‘different’ kind of stigma compared to societies that are less dependent on these structures.⁽²⁵⁾ Such cultural norms exert pressure on homosexual men who then do not disclose their sexual orientation or attend the necessary healthcare appointments and awareness programs.

Policymakers and public figures have also been known to discriminate and even criminalise MSM, which adds to the exclusion of MSM from invaluable HIV & AIDS health services.⁽²⁶⁾ Studies show that “political, cultural and religious hostilities towards MSM present a barrier in implementation of HIV & AIDS research, policy and health programmes for African MSM.”⁽²⁷⁾ In as many as 31 countries in Sub-Saharan Africa, male-to-male sex is illegal, with possible death penalty as a sentence for it in four. Recently, a number of governments have strengthened their laws against homosexuality, with political and religious leaders publicly denouncing MSM as immoral and undeserving of attention.⁽²⁸⁾ For example, in 2005, 11 men were jailed on sodomy charges in Cameroon while in Nigeria, the army fired 10 soldiers for engaging in sexual acts with other men.⁽²⁹⁾ Similarly, Kenyan police broke up a gay wedding, arresting many wedding guests. The police spokesman, when asked to explain their actions responded saying: “It’s culture, just culture. It’s what you are taught when you are young and what you hear in church. Homosexuality is unnatural. It’s wrong.”⁽³⁰⁾ Therefore in the context of homosexuality not being tolerated, men who have sex with men often hide their same-sex relations from their friends and families to avoid persecution. In terms of the consequences, because many MSM have wives, or have sex with women as well as men, not only can HIV be passed between the two men involved in anal sex, the individuals may also transmit HIV to their female partners if they become infected.⁽³¹⁾

Clearly socio-cultural factors are imperative for interventions to target MSM as they are at the root of the challenge posed against successful interventions. Delivery of intervention and health services is weakened by the recognition that possibly most MSM might remain beyond reach since they obscure their behaviour for fear of repercussions.⁽³²⁾ Because of biased laws and fear of social stigma, MSM may well choose to remain married,⁽³³⁾ which consequently diminishes the chances of prevention and intervention strategies reaching them.

Regardless of challenges that besiege issues relating to homosexuality, there are a number of positive developments that offer optimism for a change in attitudes toward homosexuality in Africa.⁽³⁴⁾ As more academia circles, cultural and political leaders continue to take a stand against homophobia,⁽³⁵⁾ there is reason to hope that eventually social structures will be more accepting, if not of homosexuality, then of human rights and liberties.

Interventions

Given that the critical challenge towards acceptance of MSM in most Sub-Saharan countries is the domination of deep cultural, political and religious anti-homosexuality ideas, interventions need to first and foremost target these social institutions.⁽³⁶⁾ As advocated by the Executive Director of UNAIDS, in order to reverse this crisis, efforts that are grounded in “human rights and underpinned by decriminalisation of homosexuality are needed.⁽³⁷⁾ There is urgent need for political, religious as well as cultural spheres to be educated on the intricate and almost inseparable relationship between MSM, heterosexual, transgender and bisexual lifestyles, so that legal protection can be given to MSM, which can then enable better access to HIV & AIDS services.

For this to happen, public health sectors in Africa must develop anti-stigmatisation interventions and increase awareness among different stakeholders. It is important that interventions are expounded and realised with the partnership of all stakeholders including political, legal, religious and cultural systems. Public political figures, including religious and cultural leaders, must be included in the initiative as there is the risk that efforts to better understand the problem of HIV & AIDS among African MSM could unintentionally increase social stigma towards MSM if such initiatives do not have political commitment and ownership of the African people.⁽³⁸⁾ Minority groups within countries that are against homosexuality and the international community can potentially complement this movement.

Such behaviour change interventions could be achieved through entertainment education (EE), a process of designing and implementing media messages to entertain and educate in order to increase audience knowledge about educational issues, as well as create positive attitudes, change social norms and alter overt behaviour.⁽³⁹⁾ Entertainment education as a communication tool has the ability to interact with and engage the audience and could be useful in communicating non-stigmatisation messages to individuals across different social spheres. In addition to EE, social programs that are not health related could also be useful for support among MSM.

As the change in attitude from religious and cultural societies will be difficult,⁽⁴⁰⁾ and may be slow to resonate, perhaps the message to educate stakeholders could be ‘accept that homosexuality does exist in society - whatever your belief may be’. Secondly but most importantly, make the institutions aware of the vital role they can play, and should be playing, to help and lend a hand on humanitarian grounds to anyone (be they homosexual or not) suffering from poor health and well-being. Making these contextual changes can hopefully help prevention initiatives to identify and reach vulnerable MSM and, at the same time empower MSM to seek healthcare resources and services.⁽⁴¹⁾

Concluding remarks

It is unlikely that bias against MSM will abate soon in Sub-Saharan Africa. MSM and HIV & AIDS related stigma remains the greatest challenge when fighting HIV & AIDS in Africa. Therefore, addressing legal, policy, cultural and religious barriers may be a daunting but necessary task. While the desirable change may take long, change is taking place all the same, and a step in the right direction will not only help in the long-term but might allow short-term opportunities and openings to be realised. Sitting back and marginalising MSM is not an option. As United Nations Secretary-General Ban Ki-moon has stated “Not only is it unethical not to protect these groups; it makes no sense from a health perspective. It hurts all of us.”

NOTES:

(1) Contact Anne Wachira through Consultancy Africa Intelligence's Africa HIV/AIDS Unit ( public.health@consultancyafrica.com).
(2) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(3) 'Bringing HIV prevention to scale: An urgent global priority', The Global HIV Prevention Working Group, June 2007, http://www.globalhivprevention.org.
(4) ‘The overlooked epidemic: Addressing HIV prevention and treatment among men who have sex with men in Sub-Saharan Africa’, Population Council National and AIDS Control Council of Kenya, 2009, http://www.popcouncil.org
(5) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa, The Lancet. 374(9687), pp. 1–7, http://www.sciencedirect.com.
(6) Ibid.
(7) Ibid.
(8) Sallar, A. M. and Somda, D. A. K., 2011. Homosexuality and HIV in Africa: An essay on using entertainment education as a vehicle for stigma reduction. Sexuality & Culture, 5(3), pp. 279-309.
(9) ‘Report on global AIDS epidemic’, UNAIDS, 2010, http://www.unaids.org.
(10) ‘Universal access for men who have sex with men and transgender people’, UNAIDS, 2009, http://data.unaids.org.
(11) Lame, T., et al., 2009. HIV prevalence among men who have sex with men in Soweto South Africa: Results from Soweto men’s study. AIDS Behaviour, 15, pp. 626-634.
(12) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(13) Ibid.

(14) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa, The Lancet, 374(9687), pp. 1–7, http://www.sciencedirect.com.

(15) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(16) Ibid.
(17) Ibid.
(18) Ibid.
(19) Johnson, C. A., ‘Off the map’, International gay and lesbian Human Rights Commission, 2007, http://www.iglhrc.org.
(20) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(21) ‘Breaking the cycle: Stigma, discrimination, internal stigma, and HIV’, USAID, 2006, http://pdf.usaid.gov.
(22) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(23) Gyekye, K., 1998. “Person and community in African thought”, in Coetzee, P. H. and Roux, A. P. J., (eds.). Philosophy from Africa. Routledge U.K.
(24) Mbiti, J. S., 1969. African religion and philosophy. London: Heinemann.
(25) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa, The Lancet, 374(9687) pp. 1–7, http://www.sciencedirect.com
(26) Parker, R.G. and Carballo, M. 1990. Qualitative research on homosexual and bisexual behavior relevant to HIV/AIDS. The Journal of Sex Research, 27(4), pp. 497-525.
(27) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa. The Lancet, 374(9687), pp.1–7, http://www.sciencedirect.com.
(28) Ibid.
(29) Anon., 2006. It’s tough being queer in Africa, but Nigerians begin organizing. Contemporary Sexuality, 40, pp. 8-9.
(30) Gentleman, J., ‘Kenyan police disperse gay wedding’, New York Times, 12 February 2010, http://www.nytimes.com.
(31) ‘Universal access for men who have sex with men and transgender people’, UNAIDS, 2009, http://data.unaids.org.
(32) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa. The Lancet, 374(9687), pp. 1–7, http://www.sciencedirect.com.
(33) ‘The overlooked epidemic: Addressing HIV prevention and treatment among men who have sex with men in Sub-Saharan Africa’, Population Council National and AIDS Control Council of Kenya, 2009, http://www.popcouncil.org
(34) Johnson, C. A., ‘International gay and lesbian Human Rights Commission: Off the map’, International gay and lesbian Human Rights Commission, 2007, http://www.iglhrc.org.
(35) Ibid.
(36) Smith, A.D., et al., 2009. Men who have sex with men and HIV/AIDS in Sub-Saharan Africa. The Lancet, 374(9687), pp. 1–7, http://www.sciencedirect.com.
(37) Ibid.
(38) Gupta R. G., et al., 2008. Structural approaches to HIV prevention. The Lancet, 372, pp. 764-75.
(39) Singhal A. and Rogers, E. M., 1999. Entertainment-education a communication strategy for social change. Mahwah New Jersey: Lawrence Erlbaum Associates.
(40) ‘Men who have sex with men-the global picture’, AVERT, http://www.avert.org.
(41) ‘UNAIDS Action Framework: Universal access for men who have sex with men and transgender people

Written by Anne Wachira ⁽¹⁾