Brian Kanyemba, Research Assistant/AVAC Fellow/IRMA Advocate

PrEP and Criminalization of Men who Have sex with Men in Africa

Overview Definition of PrEP Studies of PrEP Among MSM Discussions Prep and MSM; Way Forward Crimilization MSM in Africa Examples Case studies Epidemiology of HIV among MSM in Africa Studies of PrEP Among MSM Definition of PrEP M2012 Presenation by Brian Kanyemba

General Definition Chemoprophylaxis before Exposure * Oral Prep: TDF/FTC - Currently used as part of treatment. - Can be prescribed by private physician as PrEP (MSM, Sero-discordant couples) - Waiting for FDA Licensure * (Topical PrEP) Medicated lubrication Tenofivir gel MTN007, incoming MTN017 M2012 Presenation by Brian Kanyemba

Global iPrEX Results 2010 iPrEX study showed that taking the study medication daily reduced HIV infection among MSM by an average of 43.8% overall. Was combined with standard prevention tools (condoms, risk reduction, HCT) M2012 Presenation by Brian Kanyemba

iPrEx Open Label Studies iPrEx Ole iPrEx Open Label Extension will provide unique opportunities to address questions on PrEP safety and how efficacy might affect risk behavior and pill use. Results expected in 2013 HPTN 067 Phase II, Randomized, Open-Label, Pharmacokinetic and Behavioral Study of Intermittent use of Prep Among MSM in Thailand and WSM in South Africa. M2012 Presenation by Brian Kanyemba

PrEP as Comprehensive Package of Care Consistent use of condoms Lubrication use/water based lubricants Risk reduction counseling Regular HCT We saying this is a provision to the MSM community in Africa. Mind the defination men who have sex with other men which include, gay identified,transgender women,bisexual and any bilogical men who have sex with men. M2012 Presenation by Brian Kanyemba

Men Who Have Sex With Men MSM = Men who have sex with men Includes: gay-identified, bisexual, transgendered (male to female), straight-identified Any individual who was born male and has sex with other men. M2012 Presenation by Brian Kanyemba

Epidemiology of HIV of MSM in Africa M2012 Presenation by Brian Kanyemba

HIV Prevalence among MSM in Africa Legend 2002 2003 2004 2005 2006 2007 2008 Senegal 21.5% (463) 21.8% (501) Ghana 25.0% (N/A) Nigeria 13.4% (1,125) Sudan 9.3% (713) 7.3% (406) Kenya 24.6% (285) Tanzania 12.3% (509) Malawi 21.4% (201) Soweto 28.9% (249) Botswana 19.7% (117) (200) Cape Town (Township) Cape Town 10.6% (538) Namibia 12.4% (218) Egypt 6.2% (267) 4.9% (1,778) 4.4% (90) Morocco Tunisia 5.7% (259) 5.9% (262) Data is predominantly Prevalence Data from Convenience Samples Tells us where epidemic was and not where it is going May not be generalizable to general population of MSM Samples are among young MSM—so likely very conservative estimates of disease burden Compared against age standardized data (15-49) in general population HIV Incidence has been characterized in cohort studies in Kenya ~ 10% Incidence 17.2% (1,291) 13.3% (215) The Gambia 13.2% (306) Uganda 40.7% (285) 2009 2010 2011 M2012 Presenation by Brian Kanyemba Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009

Data Quality Data is predominantly Prevalence Data from Convenience Samples Tells us where epidemic was and not where it is going May not be generalizable to general population of MSM Samples are among young MSM—so likely very conservative estimates of disease burden Compared against age standardized data (15-49) in general population HIV Incidence has been characterized in cohort studies in Kenya ~ 10% Incidence Disease burden among MSM in Africa Potential Risk Misclassification? Prevalence of Same-Sex Practices are unknown in most of Africa I suggest that you delete M2012 Presenation by Brian Kanyemba

Sources of HIV Infection 1. Low risk heterosexual 57.6% 2. Casual heterosexual 7.5% 3. Partners of casual heterosexual 18.8% 4. Clients of heterosexual 6.4% 5. Men who have sex with men (MSM) 4.0% 6. Male partners of MSM 2.7% 7. Female partners of MSM 0.4% 8. Sex workers 1.4% 9. Injecting Drug Users (IDU) 1.1% 10. Partners of IDU 0.1% Medical Injections 0.1% Interestingly ZNASP II has targeted MSM as a key population Prevention strategies such as condoms,HCT and prevention and control of STIs are not available or easily accessible for this community. A need of acceleration of education and awereness. Source: ZNASP 2011-2015 This slide is misplaced. If you’re to use it, I suggest tht it goes before the criminalization slides.

Ecological Model for HIV Risk in MSM HIV Epidemic Stage Exclusion from National Surveillance, Criminalization, Human Rights Contexts, Sexual Health Education Access to preventive services, Stigma, VCT Access, ARV Access STI Prevalence, Condom knowledge, IDUs, MSW, Transgenders Unprotected Receptive Anal Intercourse, GUD, frequency of male partners, high lifetime partners, IDU, NIDU Stage of Epidemic Individual Community Public Policy Network Level of Risks M2012 Presenation by Brian Kanyemba Source: Baral and Beyrer, 2006

Crimilization of MSM in Africa M2012 Presenation by Brian Kanyemba

The Challenge of Politics and Discrimination Homosexuality is outlawed in 38 African countries. In 13 nations homosexuality is either legal or there are no laws pertaining to it. Providing MSM focused services, or enrolling MSM into studies in these countries becomes a major challenge Unique – no sexual contact with men M2012 Presenation by Brian Kanyemba

Zimbabwe No data in HIV prevalence among MSM Advocates and activists struggling advocate for condom use and other safe HIV prevention methods for the community. Any interference from any funder towards prevention is deemed political. M2012 Presenation by Brian Kanyemba

ZIMBABWE Mugabe said gays are "worse than pigs and dogs because pigs know there are males and females. I won’t even call him (gay) a dog because my own dog will complain." Mugabe, according to Daily Mail, made it clear in the speech broadcast by the country's state-owned television network that his country Zimbabwe, would never tolerate homosexuality or give support to gay rights. M2012 Presenation by Brian Kanyemba

ZAMBIA Legislation Zambian penal code explicitly criminalizes same sex sexual relations between men …..Or any person who has carnal knowledge of any person against this order of nature” . MSM, who lack accurate prevention strategies and information, engage in unsafe sex practices and thus risk being at the forefront of further spreading the epidemic. One common misapprehension is that HIV cannot be transmitted through anal intercourse”. For more details on these and other statement, see HRBA Helpdesk: http://msc.st/ThemeLGBT.html#BF Friends of Rainka again attempted at an MSM research/ prevalence study in August 2010 but this attempt has failed. The National Aids Council has refused to endorse such a study because it states that a Christian nation cannot condone such activity. This has created a gap in the proposed National Health Strategic Plan of 2011, most at risk populations and hard to reach vulnerable groups will not be included in the National Prevention/Intervention rollout programmes. M2012 Presenation by Brian Kanyemba

Zambia No data exists. Friends of Rainka again attempted an MSM research/ prevalence study in August 2010 but this attempt has failed. The National Aids Council has refused to endorse such a study because it states that a Christian nation cannot condone such activity. Created a gap in the proposed National Health Strategic Plan of 2011, MSM will not be included in the National Prevention/Intervention rollout programmes. M2012 Presenation by Brian Kanyemba

Malawi, May, 2011 M2012 Presenation by Brian Kanyemba

Arrests in Malawi M2012 Presenation by Brian Kanyemba

David Kato in Uganda (1969-2011) M2012 Presenation by Brian Kanyemba

PEPFAR Sub-Grantee of PSI, 2004 Uganda, May, 2011 We also know of efforts by some MPs to turn it around and get rid of the bill in favor of the gays.” Pastor Martin Ssempa PEPFAR Sub-Grantee of PSI, 2004 http://www.pepfar.gov/partners/76136.htm M2012 Presenation by Brian Kanyemba

Anti-Homosexuality Bill Uganda 2009-to date Increased criminalization of MSM, Death. Removal of Support structure by demanding relatives and friends report. Criminalizing Services and support programs as ‘Promotion of Homosexuality’ M2012 Presenation by Brian Kanyemba

Kenya Laws criminalizing the MSM have stiff Human Capital and Financial Price tag. Criminalization of MSM undermines Cost Efficiency and Effectiveness of HIV Response. Strategies for Decriminalization with Reduced Political and Social Cost Source: Breaking the Wall of Criminalization, David Kuria Mbote M2012 Presenation by Brian Kanyemba

Perspectives from African Countries Advocacy for PrEP as 'immoral', encouraging homosexuality, encouraging illegal sex. iPrex study done on MSM as immoral, against cultures and values. Why PrEP for MSM, talk about Malaria for the whole Population. Issue of diversion of resources to an 'illegal group' - Funding does not reach the group - Funds diverted for other issues MSM, Illegal, thus invisible M2012 Presenation by Brian Kanyemba

PrEP and MSM Way Forward M2012 Presenation by Brian Kanyemba

South African Model Laws protects MSM Successful MSM studies done.(DTHF) Community engagement towards PrEP information dissemination(DTHF,AVAC) Data disseminated and influenced NSP and Prep Guidelines. More information please see poster 147 Challenges? Change of community perspectives. M2012 Presenation by Brian Kanyemba

PrEP, MSM and Crimilization Set a stage of an ongoing advocacy to condone Crimilization. Hold governments accountable on what they mean as MARPs/Key Populations, where funding is going. More research in MSM is needed as an evidence base to influence changes of policies on HIV prevention. Beyond Crimilization. M2012 Presenation by Brian Kanyemba

The Champions-A team of ex-presidents and states persons that are on a crusade to influence African governments to decriminalize homosexuality if countries were to see a reduction in HIV infections by 2015. M2012 Presenation by Brian Kanyemba

Acknowledgements Stefan Baral, Baltmore David Kuria Mbote, Nairobi Paul Semugoma, Cape Town/Kampala Samuel Matsikure, Harare Lundu Mazoka, Lusaka Lloyd Rugara,Cape Town Ben Brown and DTHF Study Manju Chatani and AVAC family Alliance Nikuze, Stockholm M2012 Presenation by Brian Kanyemba

Contact details Desmond Tutu HIV Foundation Men’s Research Division Brian.Kanyemba@hiv-research.org.za +27 21 650 6969 www.desmondtutuhivfoundation.org.za M2012 Presenation by Brian Kanyemba