Exposing a hidden HIV epidemic among men who have sex with men

One of the first studies among men who have sex with men (MSM) found a ‘hidden epidemic' of HIV among MSM in South Africa in keeping with findings in other countries with generalised HIV epidemics. The results also suggest that South Africa may be experiencing  parallel heterosexual and homosexual HIV epidemics with limited bridging between the two. CAROL METCALF and LAETITIA RISPEL, who presented these findings at the SA AIDS Conference in Durban in April, describe the study.

   

HIV in South Africa was first recognised among gay men in the early 1980s. However, from the time that a generalised HIV epidemic emerged in the 1990s until recently, very little attention was paid to the ongoing HIV epidemic among MSM. The term ‘MSM' includes all men who have sex with men, irrespective of their sexual orientation or gender identity.

The National Strategic Plan on HIV & AIDS and STIs, 2007-2011 (NSP) draws attention to the limited information on HIV among MSM in South Africa. This led to the Johannesburg/eThekwini's Men's Study (JEMS), which was conducted to provide preliminary information on the epidemiology of HIV among MSM in Johannesburg and eThekwini (Durban), and to describe the availability of programmes and services to MSM.

JEMS is one of three recent studies of HIV among MSM in South Africa released in April 2009 at the South African AIDS Conference in Durban. The two other studies are the Soweto Men's Study led by Tim Lane from the University of California, San Francisco (UCSF), and a Mother City Men's Health Project study in Cape Town led by Earl Burrell of the Desmond Tutu HIV Foundation at the University of Cape Town (UCT).

How the study was done

JEMS, which had approval from research ethics committees at the HSRC and Wits, used respondent-driven sampling (RDS) to recruit 285 men from Johannesburg and Durban into a survey. RDS is a method of recruitment used to obtain representative samples of hidden, hard-to-reach populations. Most participants were black Africans, under 25 years of age, and identified as being homosexual/gay. The survey was complemented with qualitative interviews with 32 key informants and focus group discussions with approximately 150 men.

The men who agreed to participate, completed a questionnaire and provided finger-prick blood specimens for anonymous HIV testing in a laboratory. Participants who did not know their HIV status were offered free, on-site voluntary counselling and testing (VCT). All men in the survey had had sex with at least one other man in the past year.

Almost one in two participants reported having unprotected anal intercourse in the past year, with this being more than twice as common among HIV-positive participants than among HIV-negative participants  

Findings of high HIV among SMS

Of the 266 men tested for HIV in the survey, 43.6% were HIV positive. After adjusting for the sampling method, the estimated HIV prevalence was 38.3%. Even after this adjustment, the HIV prevalence among survey participants was more than double that of men in the general population. The finding of a high HIV prevalence among MSM is a cause for concern and suggests that there is a ‘hidden epidemic' of HIV among MSM in South Africa in keeping with findings in many other countries with generalised HIV epidemics. The results also suggest that South Africa may be experiencing parallel heterosexual and homosexual HIV epidemics with limited bridging between the two.

Factors that contribute to HIV risk

High-risk sexual behaviour was widespread among JEMS participants. HIV-negative men reported an average of 5 partners in the past year, and HIV-positive men reported an average of 7.5 partners in the past year. Almost one in two participants reported having unprotected anal intercourse in the past year, with this being more than twice as common among HIV-positive participants than among HIV-negative participants. Condom unavailability, or slippage and breakage, were common and many participants reported using substances such as Vaseline that reduce the protective effect of condoms. The majority of participants reported having had sex while under the influence of alcohol.

Availability of health services and HIV-prevention programmes

Over half the participants reported that they had used a government health service in the past year, and over two-thirds reported that they did not have medical aid. However, only less than one in ten participants reported that they would prefer to receive HIV-prevention services from a government health service, rather than from other proposed service providers. Many participants reported that health workers often display negative and judgemental attitudes towards MSM, or tailor their clinical management exclusively towards heterosexuals. This made some men reluctant to use healthcare services. Due to persisting stigmatisation of homosexuality, some MSM feared to disclose their sexual practices and sexual identity to health workers. Qualitative interviews found that health services and HIV-prevention, care and support programmes for MSM are provided mainly by lesbian, gay, bisexual and transgender (LGBT) organisations. These programmes had limited capacity and resources, limited hours of operation, were available in only a few centres, and provided services to a very limited number of men.

Use of voluntary HIV testing and counselling (VCT) services

Both qualitative interviews and the survey found that many MSM are reluctant to be tested for HIV, and often do not disclose their HIV status to their sexual partners. Over half the survey participants reported that they ‘knew' their HIV status, but only two-thirds of those who knew their status had disclosed their status to a sexual partner in the past year. Although almost all survey participants knew where they could be tested for HIV, less than half had been tested for HIV in the past year and given the result, and only 25 of 285 participants chose to have VCT, offered as part of the survey.

The final JEMS results have not yet been released because further analyses are in progress using special methods developed for analysing RDS surveys.

Due to persisting stigmatisation of  homosexuality, some MSM feared to disclose their sexual practices and sexual identity to health workers.  

Further initiatives

Building on the lessons learned from JEMS, HSRC researchers plan to do further work to expand surveillance of HIV among MSM in South Africa. As a first step, a stakeholder meeting was held in Johannesburg on 21 May 2009 to share knowledge and expertise and to develop partnerships. The meeting was attended by a diverse range of stakeholders, including researchers, representatives of LGBT organisations, the National Department of Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Development Programme (UNDP), and the US Centers for Disease Control and Prevention (CDC).

HSRC researchers, led by Carol Metcalf and Geoff Setswe, are now in the process of planning a new study which will be funded by the US President's Fund for AIDS Relief (PEPFAR) through the CDC. In order to provide a more complete picture of HIV among MSM in South Africa, this new study will include a wider diversity of MSM, including men other than black Africans, older men, men of higher socio-economic status, and men from geographic areas not yet studied. In the long run, it is hoped that by documenting and exposing the ‘hidden epidemic', this work will help to promote improved HIV-prevention, treatment and care programmes and services for MSM in South Africa.

Professor Laetitia Rispel, who led the study, is from the Centre for Health Policy at the  University of the Witwatersrand, and Dr Carol Metcalf is a chief research specialist in the Social Aspects of HIV/AIDS and Health programme, HSRC.