Homophobia, Sexual Violence, and Combination Prevention for MSM – Top2Btm Report #3

Published: July 1, 2011

The Desmond Tutu HIV Foundation is a non-governmental organization whose aim is to be a centre of excellence in research, training and prevention of HIV and related infectious diseases. As a programme manager, I am responsible for facilitating and managing projects which will improve our understanding of how HIV affects men who have sex with men (MSM) locally, as well as informing on policy and programme development. This work is much needed – despite our liberal constitution, many MSM face widespread discrimination, homophobia and other barriers to accessing health and other services in South Africa.

The final session of the symposium included a wide range of research topics ranging from HIV virology and genetic epidemiology to community engagement and planned combination prevention research projects. The expanse of topics covered outlined the manner in which local organizations and their partners are leading the way in gathering evidence to support public health and human rights based approaches to address health issues facing MSM. It was encouraging to see a diverse range of individuals in attendance – there was representation from government departments, service providers, development partners, advocates and MSM community members. The quality of presentations and output are reassuring, and a sign that a broad range of data to inform on issues pertaining to MSM and transgender people are under development.

Carolyn Williamson from the University of Cape Town painted a picture of the changing face of the types of HIV virus found among  HIV infected MSM in Cape Town today compared to the late 1980s.  The results presented were from a recent MSM viral subtyping study completed in collaboration with the Desmond Tutu HIV Foundation. HIV virus of infected MSM was sequenced (analyzed to see its molecular make-up) in order to establish possible pathways of spread and mixing of the HIV virus among MSM in Cape Town. The patterns of HIV virus collected were compared to sequences collected from HIV infected MSM in the 1980s. The diversity of HIV viruses found in the recent study suggests that the sub-types of viruses present today are different to those present previously (a lot of different people have been having sex with each other – among MSM and between men and women). It is important information to know to ensure that any future HIV vaccine targets the HIV subtypes present among MSM in Cape Town.

Kirk Friereck, a PhD candidate, contrasted the laboratory based presentation by exploring the relationships between culture and science, and how both of these entities influence perceptions and understandings of sexuality. A useful conceptual model was provided to illustrate this overlapping relationship in the South African context, where traditional health, biomedical and psychological paradigms overlap to a certain degree, but individuals are not always linked to all of these cultures. As a result, public health initiatives should take multicultural realities into account, specifically when developing and implementing programmes which aim to address and involve individuals from sexual minority groups.

Jeff Jobson from the ANOVA Health Institute presented the findings of a joint venture with the University of Cambridge. Based on an ecological model for assessing risk to HIV, the researchers developed suggestions for interventions to address HIV risk among MSM in Cape Town. Pervasive homoprejudice and stigma experienced by MSM in Cape Town was identified during their work. An evaluation explored situations which place township MSM at risk for HIV infection using a model which viewed temporal, physical, social and geographical components to HIV risk. Their research suggested that personal level factors, as well as proximal and distal factors, need to be considered when developing interventions focusing on MSM, and that HIV prevention strategies for MSM should also include actors beyond the medical and public health spheres. 

In order to contextualize Africa’s HIV combination prevention research agenda, I presented an overview of a recent workshop on MSM Combination Prevention Interventions for MSM in Africa, which was recently co-hosted by Johns Hopkins University and the Desmond Tutu HIV Foundation. The opinions and beliefs of participants from North, West, East and Southern Africa were included in the development of a suggested combination prevention package for African MSM. Participants were empowered to use the resulting conference report and recommendations for furthering the agenda of combination prevention research among MSM in their home countries. This workshop assisted to strengthen the network of African MSM researchers with the vision to collaborate on future multi-site ventures.  

Zukiswa Fipaza presented the results of studies conducted by the Population Council among MSM in Pretoria, Johannesburg and Durban, which focused on sexual risk behaviours and sex work among MSM. A respondent driven sampling study among 324 MSM was conducted in Pretoria, revealing that MSM who reported to sell sex have higher levels of unprotected anal sex and higher numbers of partners, most of whom did not identify as being gay. A study to estimate the size of male sex worker populations in Johannesburg and Durban employing a capture-recapture method identified 496 (95%  CI 437 – 555) MSM engaged in transactional sex in Johannesburg and 612 (95% CI 61 – 1163) in Durban. Qualitative data from the Durban study identified a common belief that receiving rewards for sex with other men was an acceptable practice. The enumeration studies enrolled young MSM, mostly gay-identified, and may not reflect the true magnitude of transactional sex practices in these cities.  It does, however, provide insights into behaviours and provide evidence for the existence thereof.

Tim Lane from UCSF provided an overview of the community empowerment project, which is being implemented in Ermelo, in the North-eastern part of South Africa. The findings of earlier work among MSM in Soweto informed the target areas for this community based intervention, focusing on MSM aged 20 – 30 years, this project aims to address high risk sexual behaviours and structural targets, as well as facilitate entry into health services. Building on the Mpowerment model, which was developed in the USA, this project plans to use peer led activities to empower individuals against HIV infection using a gay- and sex-positive approach. Through fostering community cohesion, health-enhancing behaviour and intervention exposure, empowerment is planned to be achieved. The project activities will occur for 18 months though community & outreach events. An assessment will be made after 12 months to comparing stigmatization in health services between the communities.

Kristin Dunkle from Emory University presented data on the extent of MSM practices in provinces where not much previous work has been done, including the extent to which sexual violence occurs among men. Household surveys eliciting sensitive information about a range of same sex behaviours and sexual violence among men were conducted among middle aged men, using hand held electronic data capturing devises.  HIV testing was done among those who consented. 1,738 men participated, 5.4 % (95% CI 4.4 – 66%) reported some form of voluntary same sex behaviour. High levels of sex with women among MSM was reported. Some form of experienced or perpetrated male-male sexual violence was reported by 10% of respondents, among MSM 22% had experienced oral or anal victimization. Of the 71% who provided blood, the HIV prevalence among MSM ranged between 20% – 50% depending on type of MSM behaviours reported, compared to 17% among non MSM. HIV status was associated with oral/ anal perpetration and consensual sex. Health workers were encouraged not to assume the type of sexual partners among any of their clients.

Overall, I believe that the symposium was a success, and it provided a good opportunity for knowledge sharing. The lack of operational and economic evaluation data appears to be a research gap. Of concern was that none of the research presented was funded by the South African government and that the majority of presenters were non-South Africans, highlighting the dearth of capacity in local, young investigators. However this does outline the potential opportunities which exist for capacity development and mentorship. The presence of a larger number of MSM community members from diverse backgrounds would have contributed to information dissemination beyond researchers and service providers. Well done to all those who worked hard to make this conference work – the community will greatly benefit from the data being gathered, as long as we continue to advocate for its use to inform change!

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