MSM AND HIV/AIDS IN AFRICA WITH FOCUS ON MALAWI

Transcription

1 Center for Public Health and Human Rights MSM AND HIV/AIDS IN AFRICA WITH FOCUS ON MALAWI Malawi College of Medicine: Eric Umar Vincent Jumbe CEDEP: Gift Trapence Dunker Kamba Rodney Chalera Johns Hopkins University: Stefan D. Baral Chris Beyrer Andrea L. Wirtz UNAIDS, Lilongwe, Malawi

2 Overview Over of MSM and HIV IN AFRICA Results and emerging issues in Malawi new studies Discuss challenges and success; implications for studies in similar contexts Present a research agenda for key populations in Malawi 2

3 MSM AND HIV IN AFRICA 3

4 Background Preliminary data highlight HIV-related vulnerabilities among key populations Limited understanding of vulnerabilities among MSM in Africa Global and Regional Prevalence of HIV among MSM Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, , Johns Hopkins University. All rights reserved.

5 A call for new evidence interventions: A survey conducted among men who have sex with men (MSM) in Blantyre in 2007 found a HIV prevalence of 21.4%. The prevalence of HIV among MSM was higher than the general population. However, recent studies looking at HIV prevalence among high risk groups are not available and there is no system which routinely collects such prevalence data. Periodic studies are required which will provide HIV prevalence among high risk groups and demonstrate Malawi s progress in its response to HIV and AIDS especially among such groups. - UNAIDS Report

6 New MSM studies in Malawi Fill a gap on knowledge on HIV and HIV prevention among MSM in Malawi Provide population-based estimates of HIV prevalence Associations of infection among MSM in Malawi Understand how to reach, provide services, and follow-up MSM in prevention programs and do this in a criminalized and stigmatizing environment Provide a model for roll-out across Malawi and other settings of similar epidemic and social contexts 6

7 Baseline Funded by UNDP and VSO, UNAIDS and UNFPA Data collection: August 2011-March 2012 in Blantyre, Malawi In-depth training: confidentiality & protection, qualitative and survey research, RDS recruitment Qualitative, formative phase: interviews with MSM and service providers Structured survey instrument: sociodemographics, human rights, social & sexual relationships, HIV and sexual health awareness and prevention Biological tests: Rapid HIV test and syphilis, confirmatory testing Eligibility: > 18 yr, Born male, Report anal sex with a man (last 12mo) RDS recruitment: three coupons per seed or recruiter 7

8 Respondent Driven Sampling RDS Recruitment Diagram (N= 338) Majority reported recruitment by friend (60.5%) or sex partner (32.3%) Coupon return: 48%; maximum of 19 waves reached 8

9 Results: Demographics Item: No. % Employment status: Marital Status (with a woman): Children: N=338 Age: median (range) 25.1 (18-49) Unemployed Employed Self-employed Student Married Cohabiting Divorced/ Separated Single / Never Married None > 1 child (range: 1-7 children)

10 Results: Sexuality and partnerships Item: No. % Gender Identity Man Woman Transgender Orientation Gay or homosexual Sexual partners in last 12 mos.: Mean (range) Bisexual Male partners (n=334) 3 (1-50) Female (n=107) 1 (1-20) Concurrency, last 12 mo.* Two or more men With regular male partner (n=312): Consistent condom use With casual male partner (always or almost always) (n=256): N=338; *significant With female partner (n=100):

11 Results: HIV prevalence, testing/prevention 11 Item: No. % Syphilis Prevalence HIV Testing (Ever, n=336) HIV Prevalence Considered most risky type of sex Ever received HIV prevention information (for same sex practices; N=334) N=338 Unadjusted RDS Adjusted (%, 95% CI) 4.90% ( %) Never Once More than once Last 12 mo. (of ever tested; n=202) Unadjusted (%) RDS Adjusted (%, 95% CI) 12.5% ( %) Undiagnosed HIV infection (n=52) Vaginal Anal All equal

12 Results: Other exposures Item: No % Lubricant use with condom (n=329) Jail/prison Human rights violations as a result of orientation/sexual practice Disclosure Petroleum jelly or Vaseline Water-based lubricant made for sex No lubricant use Ever in jail Access to condoms in jail (n=72) Sex with other men in jail (n=74) Beaten up Raped (n=337) Ever felt rejected by friends because of sexual practices/preferences Ever afraid to seek health services because of sexual practices Ever disclosed same sex practices to health worker Depressed mood for > 2 weeks (within last 3 yrs) N=338

13 Mapping quantitative to qualitative results Qualitative: Low awareness of risk: Most HIV prevention information targeted to heterosexual, married couples Belief that transmission happens between wife and husband Disclosure fears MSM concerned about unintentional disclosure to others/family Men walk around with untreated STI Fear behavior would be reported Providers concerned that they would be seen condoning illegal behavior 14

14 NEEDS ASSESSMENT AMONG 100 MSM 23% of MSM were afraid to seek healthcare services 12% of MSM had heard healthcare providers gossip about them as a result of their sexual orientation 13% denied health services or received low quality services 13% withheld information for fear of disclosing their sexual orientation. Few were ill-treated in history taking No complaint mechanisms within hospitals Many participants felt were not protected by the laws of the country No freedom to express themselves who they really are Government Legal Aid is only available in major cities 15

15 Conclusions: High risk practice, high undiagnosed HIV infection, and low knowledge of risk and prevention related to anal sex practices History of imprisonment, rape, lack of access to condoms in prison, HIV/STI prevalence in prisons is concerning Know your status: few traditional behavioral risks were predictors of HIV; prevalence pools play an important role in HIV transmission New services and enhancement of existing services are necessary to ensure confidential prevention and care to MSM. Confidential testing for HIV/STI, care for anorectal health, psychosocial services Provide HIV information to MSM with information about same sex transmission risk Assurance of confidentiality and freedom from requirement for health providers Must have community input Demonstrates that MSM are an important population to be considered in Malawi s HIV epidemic, deserve access to comprehensive HIV services. 16

16 CHPI Cohort: 100 HIV negative men enrolled from the baseline study Participants will be followed through April 2013 Undergo a total of two additional follow-up assessments Follow-up activities include Sociobehavioral assessment HIV and syphilis testing Qualitative research among subsample to asses experiences Ongoing intervention Peer educators serve as medium, providing the intervention and linkage to the study Funded by USAID 17

17 Comprehensive HIV Prevention Intervention Health Sector Training: collaboration with Fenway Health Institute Two-day training, December 2011 Provided training to nurses and physicians from BLM and Blantyre District Health Office Curriculum: MSM health, not limited to HIV 18

18 Comprehensive HIV Prevention Intervention Peer Educators: from MSM community Trained on MSM health Dec. 2011, April 2012 Provide information on prevention and trained clinics, condoms & CCL, Available when participants have questions/ needs Source of social support to participants Remind participants of follow-up appointments 19

19 Progress to date Retention: 99% have completed their second follow-up visit HIV Incidence: 7 participants have seroconverted Demonstrated capacity to conduct ethical research and provide comprehensive prevention for MSM Demonstrated capacity to engage and follow a cohort of MSM, with a range of identities, demographics and needs To conclude the study: Final follow-up assessment in April 2013 Complete follow-up qualitative research Separate health policy and social analysis: assess stakeholder perspectives and how to facilitate change following decriminalization (May- July 2013) 20

20 Limitations & Challenges: Sociobehavioral risks are self-reported, thus subject to social desirability and recall biases Stigmatization and fear of unintentional disclosure are a concern for participants and impact participation Security risks have led to temporary closure and relocation of the office 21

21 Overcoming challenges Work closely with community: include in design, solicit feedback during implementation study, interpret data Ensure participant privacy and security throughout Must be staff priority and communicated to participants Regular staff retraining Rapid communication to study team, participants, and collaborators during security breach Ensure other benefits to participation are communicated to participants, benefits are more than participation incentive 22

22 Additional Outcomes: Dissemination at international fora: International AIDS Conference, SAHARA Conference Peer reviewed publications Capacity building across organizations Cross-discipline collaborations 23

23 Research and intervention agenda Roll out biobehavioral surveillance among MSM in Malawi (RDS) Incorporate stigma and human rights survey items Targeting interventions Provide information on structural and health sector barriers BBS among FSW using RDS sampling, Incorporate stigma, GBV, and human rights survey items Rationale: High HIV burden among sex workers (70%), few programs BBS among transgender women Global pooled prevalence is 19.1% (OR:48.8%), no African data Expand CHPI and empowerment interventions for key populations Evaluate link between prison and rape of MSM, condoms Men s health clinic - Blantyre 24