AIDS: Living between the lines

HIV feeds on discrimination, writes Pierre Brouard, Dawie Nel and Allanise Cloete.

In the Western Cape, HIV infection was first characterised by male to male transmission, and during the early 1980s considered a ‘homosexual’ epidemic. The epidemic, among what is epidemiologically termed men who have sex with men (MSM), was not taken seriously by the apartheid government, partly because same-sex sexuality was punishable under the law.

Historically, targeted sexual health information and services for MSM have been largely undertaken by the country’s few lesbian, gay, bisexual, transgender and intersex (LGBTI) organisations. Often working with financial and resource constraints, and hampered by a lack of comprehensive and country-wide evidence of the scope and scale of HIV in MSM and other marginalised (and often minority) populations, such work has needed support and resources. This has begun to emerge, with larger

HIV organisations taking on MSM projects and building a national agenda and programmatic base.

It is therefore imperative that this work is informed by HIV surveillance that documents HIV prevalence among MSM; addresses related behavioural, social and structural drivers; advocates for HIV prevention programmes to
be specifically tailored to the needs of MSM and their networks and communities, and redresses the imbalances and neglect of the past.
Criminal activity and transactional sex may be informed by a lack of access to money, education and decent life opportunities. 

The HSRC released the results of the South African Marang Men’s Project, which measured levels of HIV among MSM in South Africa on 11 November. In Cape Town, of the 286 MSM surveyed, an overall HIV prevalence of 22.3% was recorded. In Johannesburg, among 349 MSM, an HIV prevalence estimate of 26.8% was found. These high HIV prevalence estimates demonstrated that MSM was among the hardest hit by the HIV epidemic in these two cities.

In our study, we used a sampling method that allowed us to systematically access members of traditionally hard-to-reach target populations who were otherwise not easy to connect with (i.e. those who did not frequent public venues, who did not access facility-based services or who were not in contact with outreach workers). Using this method we were able to survey hidden populations within minority groups. For instance, the Marang Men’s Project found high estimates of previous incarceration and of ‘selling sex to men’ in these two cities.

Same-sex identities and practices are still widely perceived as ‘unAfrican’.

Both contexts reflect challenges for equal and fairly negotiated sex, a factor in increasing vulnerability to HIV. They also raise questions about social inequality – both criminal activity and transactional sex may be informed, partly at least, by a lack of access to money, resources, education and decent life opportunities.

Of course sex work can be a choice, and the criminalisation of sex work does not help the HIV epidemic, but where it is accompanied by inadequate support and resources for protection against HIV remains a risk. These social and economic vulnerabilities experienced by the men recruited into the study might go some way towards explaining the high estimates of HIV infection reported in Cape Town and Johannesburg.

In spite of our constitutional protections and progressive laws and policies, social attitudes towards MSM remain negative. Same-sex identities and practices are still  widely perceived as ‘unAfrican’ and are frowned upon or socially marginalised. Ongoing reports of violence and discrimination towards MSM who may appear gender non-conforming (these are often men who identify as gay) show that constitutional protections may not shield these men from harm.

This situation is often worsened by the attitudes and practices of public servants, including police, health workers and educators, both in basic and higher education contexts. The Marang Men’s Project found unusually high estimates of police discrimination due to sexual identification among respondents in Cape Town.

As a result, many men who engage in same-sex relationships may do so secretively while still fulfilling their expected heterosexual gender roles and responsibilities, while others are excluded from accessing services that are their right as citizens. But some MSM may also self-exclude from health and other services, not only because they perceive these as unhelpful, but because their internalisation of negative attitudes may mean they feel they do not deserve equal treatment. This ‘internalised’ prejudice also goes some way to explain various forms of sexual risk taking, and sexual partner choices and variety.

All these factors may hamper HIV prevention and support efforts, since sexual relationships may remain ‘hidden’; vital health and other services may be avoided; campaign messages may be denied or ignored; harmful choices may be made, and rights may not be claimed.

In light of this, a policy and programmatic agenda would thus need to do some of the following. Firstly, it would need to address the human rights of MSM (along with other sexual and gender minorities) as equal citizens of our country. In a sense, HIV feeds on prejudice and discrimination. Secondly, there is a need for more in-depth research on, and insight into, hidden populations within minority groups such as those found in the Marang Men’s Project.

These findings tell us social inequality is a key driver of HIV, and this requires a response from the government if it is to meet its mandate of a better life for all South Africans.

Authors: Pierre Brouard, Centre for the Study of AIDS, University of Pretoria; Dawie Nel, OUT LGBTI Wellbeing; and Allanise Cloete, PhD intern, HSRC