It has been just over a decade since the first large behavioral survey of men who have sex with men (MSM) in Africa was conducted by the Population Council in Senegal. To uncover what has been learned since then and to explore future directions for research and programs for MSM, Scott Geibel, Nicholas Muraguri, and Marleen Temmerman—all experts at organizations at the forefront of addressing these issues—reviewed the existing research and offered guidelines for the next decade of research and policy.
Geibel is an associate with the Population Council’s HIV and AIDS program based in the Council’s Lusaka, Zambia office. Muraguri is the former head of Kenya’s National AIDS and STI Control Programme and is currently Executive Director of the Secretariat for the Global Task Team on the Elimination of New HIV Infections among Children and Keeping Their Mothers Alive, based in Nairobi. Temmerman is a professor of obstetrics and gynecology at Ghent University and Director of the Department of Reproductive Health and Research at the World Health Organization.
In developed countries, it has long been recognized that MSM are at high risk for HIV and other sexually transmitted infections. However, in Africa, the stigma associated with homosexual behavior—and the fact that it is illegal in some countries—have kept the health needs of MSM largely hidden. As a result, health systems have lacked vital information for creating effective programs and policies that meet the health needs of this at-risk population.
“Our review brings to light how much has been revealed and learned in the past decade about MSM and HIV in Africa, yet also how far there is to go,” says Geibel.
What We Currently Know: Biology and Behaviors
The studies included in the review showed that—while little is known about general rates of sexually transmitted infections (STIs) among MSM—HIV disproportionately affects MSM throughout the region. One analysis estimated that MSM in Africa were nearly four times more likely to be HIV positive than men in the general population.
MSM have high levels of behaviors that raise their risk of HIV. Specifically, many of the MSM surveyed reported that they had multiple partners. Some studies found that as many as 86 percent of men reported having more than five partners in the last six months, some of them concurrently. Consistent condom use and transactional sex among MSM in Africa were found to vary widely. Reported rates of condom use ranged from 9 percent to 80 percent. Several studies documented a high use of products associated with condom breakage, including petroleum products, baby oils, and other lotions used for lubrication during anal sex, indicating an urgent need for further education. Between 6 and 74 percent of respondents reported getting paid to engage in anal sex or engaging in sex work.
While the heightened prevalence of HIV among MSM is well established, the ability to accurately estimate the size of MSM populations is far more difficult. This is particularly true in areas where stigma around homosexuality persists.
As Geibel noted, “MSM are one of the most stigmatized of all HIV risk groups in sub-Saharan Africa.” The often-hostile social, political, and legal environments for MSM, as well as the widespread human rights abuses they suffer, further increase their risk of HIV and complicate the estimation of MSM population size and the prevalence of same-sex sexual behavior. Yet, the ability to more accurately estimate MSM populations in Africa would greatly aid in the appropriate provision of programs for MSM to prevent or treat HIV or care for those affected by it.
Instead, there is limited information on the effectiveness of MSM-targeted interventions, and current HIV testing rates among MSM are very low. While results from recent studies testing the potential use of antiretroviral therapy for the prevention of HIV (pre-exposure prophylaxis or PrEP) hold new promise, more accurate estimates of MSM populations as well as strategies to combat human rights abuses and other structural barriers will still be necessary for their widespread success.
The authors identified key limitations in the studies reviewed—most notably a bias toward urban, sex worker populations and a tendency to treat MSM as a homogeneous group. However, the past decade of research has confirmed the existence of MSM throughout sub-Saharan Africa and described factors that contribute to their risk of acquiring HIV. To produce quality data to inform both policy dialogue and the planning of appropriate HIV prevention and care services for MSM, the authors identified the following research priorities for MSM in sub-Saharan Africa:
- The improvement and harmonization of surveillance and research methodologies and indicators.
- A greater emphasis on qualitative studies, specifically those that explore sexual identities, typologies, and social and cultural contexts of sexual behavior, to enhance the field’s understanding of survey findings.
- The recruitment of MSM to support scientific research.
- Increased research on STIs and STI treatment to inform appropriate health services for MSM and the feasibility of presumptive STI treatment.
- Additional research on the safety of water-based lubricants.
- The continued study of PrEP as an intervention for high-risk MSM.
“We know that there is heightened HIV vulnerability among MSM compared to the general population, and have a better sense of what contributes to this in terms of behaviors, stigma, and discrimination,” reflects Geibel. “But there is so much more to learn with regard to effective prevention and treatment strategies, as well as the need to reach more MSM in countries that still struggle to recognize and address MSM in national HIV policy and programming.”
Muraguri, Nicholas, Marleen Temmerman, and Scott Geibel. 2012. “A decade of research involving men who have sex with men in sub-Saharan Africa: Current knowledge and future directions,” SAHARA-J: Journal of Social Aspects of HIV/AIDS: An Open Access Journal 9(3): 137–147.