Keletso Makofane

Sexual Stigma, Criminalization, Investment, and Access to HIV Services Among Men Who Have Sex with Men Worldwide

Abstract Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.ResumenGlobalmente, el VIH afecta desproporcionadamente a los HSH. Este estudio exploró las asociaciones entre el acceso a servicios para el VIH y (1) la percepción del estigma sexual a nivel individual; (2) la criminalización de la homosexualidad en cada país; y (3) el nivel de inversión financiera por país en servicios para el VIH dirigidos a HSH. Un total de 3,340 HSH completaron una encuesta a través del internet sobre el acceso a servicios para el VIH. HSH de más de 115 países fueron clasificados según las legislaciones sobre la criminalización de la homosexualidad y el nivel de inversión en servicios para el VIH dirigido a HSH. Un menor acceso a condones, lubricantes y pruebas del VIH fueron asociados con una mayor percepción del estigma sexual, la existencia de legislación sobre la criminalización de la homosexualidad y menos inversión en servicios para el VIH. Menos acceso a tratamientos para el VIH, fue asociado con una mayor percepción de estigma sexual y la criminalización de la homosexualidad. A su vez, la criminalización de la homosexualidad y la baja inversión en servicios para el VIH, fueron asociados con una mayor percepción del estigma sexual. Los esfuerzos para prevenir y tratar el VIH entre HSH necesitan ser ligados a intervenciones estructurales para reducir el estigma, reformar legislaciones de criminalización de la homosexualidad y aumentar las inversiones en los servicios para el VIH específicamente diseñados para HSH.

Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men

Objective We evaluated the relationship among syndemic conditions (defined as a cluster of interconnected psychosocial health conditions), sexual behaviours and self-reported HIV infection in a global sample of men who have sex with men (MSM). Methods We used generalised estimating equations logistic regression models with robust SEs to assess the relationships among cumulative number of syndemic conditions—including depression, substance use, violence, sexual stigma and homelessness—and unprotected anal intercourse (UAI) and HIV infection, while accounting for clustering within-country in a global cross-sectional survey of 3934 MSM across 151 countries. Results We observed parallel, significant dose–response associations between the number of syndemic conditions and UAI, as well as number of syndemic conditions and HIV infection. Compared with participants without syndemics, the adjusted OR (aOR) for UAI among those with 1, 2 and 3 or more syndemic conditions were 1.44 (Bonferroni-adjusted 95% CI 1.23 to 1.68), 1.89 (1.51 to 2.36) and 2.03 (1.43 to 2.89), respectively. Compared with participants without syndemics, the aOR for HIV infection among those with 1, 2 and 3 or more syndemic conditions were 1.67 (1.24 to 2.26), 2.02 (1.44 to 2.85) and 2.35 (1.31 to 4.21), respectively. Conclusions This analysis provides evidence of intertwining syndemics that may operate synergistically to increase HIV risk among MSM globally. To curb HIV effectively and advance the health of MSM, multiple conditions must be addressed concurrently using multi-level approaches that target both individual and structural risk factors.

Access to Basic HIV-Related Services and PrEP Acceptability among Men Who Have Sex with Men Worldwide:: Barriers, Facilitators, and Implications for Combination Prevention

Introduction. Men who have sex with men (MSM) are disproportionately impacted by HIV globally. Easily accessible combination HIV prevention strategies, tailored to the needs of MSM, are needed to effectively address the AIDS pandemic. Methods and Materials. We conducted a cross-sectional study among MSM (n = 3748) from 145 countries from April to August 2012. Using multivariable random effects models, we examined factors associated with acceptability of preexposure prophylaxis (PrEP) and access to condoms, lubricants, HIV testing, and HIV treatment. Results. Condoms and lubricants were accessible to 35% and 22% of all respondents, respectively. HIV testing was accessible to 35% of HIV-negative respondents. Forty-three percent of all HIV-positive respondents reported that antiretroviral therapy was easily accessible. Homophobia, outness, and service provider stigma were significantly associated with reduced access to services. Conversely, community engagement, connection to gay community, and comfort with service providers were associated with increased access. PrEP acceptability was associated with lower PrEP-related stigma, less knowledge about PrEP, less outness, higher service provider stigma, and having experienced violence for being MSM. Conclusions. Ensuring HIV service access among MSM will be critical in maximizing the potential effectiveness of combination approaches, especially given the interdependence of both basic and newer interventions like PrEP. Barriers and facilitators of HIV service access for MSM should be better understood and addressed.

Homophobia as a barrier to HIV prevention service access for young men who have sex with men.

To the Editors: Men who have sex with men (MSM) bear a disproportionate HIV burden across lowand middle-income countries, and there has been a reemergence of HIV among MSM in high-income regions. Despite this excess burden, it is estimated that only 1.2% of all HIV prevention funding is targeted toward MSM. Globally, HIV prevention services only reach an estimated 10% of MSM, demonstrating that coverage of HIV services for MSM is not commensurate with need. Among MSM, young men who have sex with men (YMSM) face a unique set of challenges that make them particularly vulnerable to HIV infection and poorer HIVrelated health outcomes. YMSM account for a large proportion of incident and newly diagnosed HIV cases in many parts of the world. Increased HIV risk among YMSM has been connected with a myriad of risk factors, including disparities in access to health services and structural factors like homophobia (ie, sexual stigma, defined as the “shared belief system through which homosexuality is denigrated, discredited, and constructed as invalid relative to heterosexuality(p1)”), which have been associated with increased HIV risk behaviors and decreased rates of HIV testing among MSM. Despite their heightened vulnerability, there is a paucity of research examining the social and structural determinants of accessibility of HIV prevention services among YMSM, especially outside the United States. Moreover, programmatic data concerning MSM are rarely disaggregated by age, and data on youth are seldom broken out by sexual orientation. Finally, there is an extremely limited amount of data regarding the effects of structural factors on access to evidencebased interventions among YMSM, underscoring a major gap in public health research. We characterized disparities in access to HIV prevention services and structural factors among YMSM relative to older MSM. We also assessed the association between social and structural factors and access to HIV services among YMSM. We conducted a secondary analysis on data from a larger cross-sectional study of MSM and their health providers (n = 5066) on access to HIV services, implemented by the Global Forum on MSM & HIV. The methodology of this study has been previously described. In brief, from June to August 2010, participants completed an anonymous online survey administered in Chinese, English, French, Russian, and Spanish. The survey measured 12 psychometric constructs, including scales previously validated on homophobia and internalized homophobia (ie, internalized sexual stigma or internalized homonegativity, broadly defined as the process in which MSM internalize society’s negative attitudes about homosexuality) and an 18-item measure on access to recommended HIV prevention services (eg, condoms, lubricants, and HIV testing). The items in the homophobia measure have Likert scales ranging from 1 to 4; low to high responses correspond with strong disagreement to strong agreement with statements on perceived homophobia. The items in the internalized homophobia measure also have responses ranging from 1 to 4; low to high responses correspond with “never” to “often” endorsing statements that reflect internalized homophobia. The items in the accessibility measures have responses ranging from 1 to 5; low to high responses correspond with low to high accessibility of different HIV services (Table 1). Male participants who reported having sex with men and provided complete data on the exposures and outcomes of interest were included in this study. This subset did not differ from the overall sample with respect to age, education, income, and region (data not shown). The x2 and Wilcoxon rank sum tests were used to evaluate differences between YMSM and older MSM. Among YMSM, multivariable linear regression using a stepwise (backward elimination) procedure was used to identify correlates of access to HIV prevention services while controlling for HIV status. The final model used did not show evidence of departure from linearity in qnorm plots. This study was approved by Research Triangle Institute International’s Internal Review Board. Among the 2981 MSM included and eligible, 47% (n = 1402) were YMSM. YMSM respondents were from Asia (73%), Latin America (9%), Australasia (7%), North America (6%), Europe (3%), and Africa (2%). The median age among YMSM was 25 (interquartile range, 22–28). Self-reported HIV prevalence among YMSM was 14%. The majority of YMSM self-identified as gay (86%) and had 2 or more sexual partners in the past year (67%). Over a third (34%) had never been tested for HIV, 30% reported unstable housing, and 3% were homeless. Results revealed that significantly fewer YMSM reported “easy access” to 17 out of the 18 HIV prevention services measured when compared with older MSM (Table 1). For example, compared with older MSM, YMSM reported lower access to HIV testing [36% vs. 52% (P , 0.001)], condoms [35% vs. 46% (P , 0.001)], and lubricants [21% vs. 33% (P, 0.001)]. Furthermore, YMSM had a significantly lower overall mean score for access to HIV prevention services compared with older MSM [3.1 vs. 3.6 (P , 0.001)]. In addition, we found that a greater percentage of YMSM, relative to older MSM, perceived a high degree of social discrimination based on sexual orientation in their country of residence. A greater proportion of YMSM reported that, in the country where they reside, MSM are not treated like everyone else [95% vs. 93% (P = 0.02)], most people have a poor perception of MSM [68% vs. 63% (P = 0.001)], and most people think that MSM are dangerous [65% vs. 48% (P , 0.001)]. YMSM had significantly higher mean homophobia scores than older MSM [2.5 vs. 2.3 (P , Supported by a grant from the Bill and Melinda Gates Foundation (Grant Number: OPP52767). The funder did not play any role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the preparation, review, or approval of the article. The authors have no conflicts of interest to disclose. J Acquir Immune Defic Syndr Volume 63, Number 5, August 15, 2013 Letters to the Editor

Internalized homophobia and reduced HIV testing among men who have sex with men in China.

Although previous research has examined barriers and facilitators of HIV testing among men who have sex with men (MSM) in China, few studies have focused on social factors, including homophobia and internalized homophobia. This study utilized data from a global online survey to determine correlates of HIV testing as part of a subanalysis focused on Chinese MSM. Controlling for age, HIV knowledge, number of sexual partners, and other covariates, ever having tested for HIV was significantly correlated with lower internalized homophobia. This study suggests that stigma associated with sexual orientation may serve as a barrier to participation in HIV testing and other health-promoting behaviors.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men

Free or low‐cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non‐transgender) MSM.

HIV treatment cascades that leak: Correlates of drop-off from the HIV Care continuum among men who have sex with men worldwide

Objectives: The health and prevention benefits of antiretroviral therapies (ART), delivered as part of comprehensive HIV care programs remain unrealized for men who have sex with men (MSM). This multilevel study explores the correlates of drop-off from the HIV care continuum in an international study of MSM, taking into account individual and regional differences in access to and utilization of care. Methods: We conducted a study of the continuum of HIV diagnosis and care among 6095 MSM using data collected from an international online survey of MSM conducted in 2012. In this model of the HIV treatment cascade, we treated each point along the continuum as an outcome variable. We then investigated the relationships between clinical care outcomes and a set of demographic and psychosocial factors that were hypothesized to correlate with the outcomes using bivariate and multivariable statistical techniques. Results: Among MSM living with HIV for longer than 12 months (n=632), 50%(n=319) were virologically suppressed. Among MSM recently infected with HIV (n=91), the proportion was relatively smaller at 33%. Significant correlates of being on ART and retained in care included: accessibility of HIV treatment; comfort with a healthcare provider; and engagement in a gay community. Perceptions of homophobia were negatively associated with being on ART and being retained in care. Conclusions: These findings underscore the need for service delivery models that sensitively address HIV among MSM. Public health officials should adopt comprehensive HIV programs that include mutually reinforcing components and that address varying needs of MSM newly diagnosed and living with HIV. Comprehensive HIV programs must also support the critical role communities play in linking and retaining MSM into HIV services. Further studies validating the findings in country-specific contexts are warranted.

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men

Objectives Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. Methods Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, ‘how accessible are ____’ services) between MSM who responded ‘yes’/‘no’ to: ‘have you ever been arrested or convicted for being gay/MSM?’ Results Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. Conclusions Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.

Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission

Author(s): Bekker, Linda-Gail; Alleyne, George; Baral, Stefan; Cepeda, Javier; Daskalakis, Demetre; Dowdy, David; Dybul, Mark; Eholie, Serge; Esom, Kene; Garnett, Geoff; Grimsrud, Anna; Hakim, James; Havlir, Diane; Isbell, Michael T; Johnson, Leigh; Kamarulzaman, Adeeba; Kasaie, Parastu; Kazatchkine, Michel; Kilonzo, Nduku; Klag, Michael; Klein, Marina; Lewin, Sharon R; Luo, Chewe; Makofane, Keletso; Martin, Natasha K; Mayer, Kenneth; Millett, Gregorio; Ntusi, Ntobeko; Pace, Loyce; Pike, Carey; Piot, Peter; Pozniak, Anton; Quinn, Thomas C; Rockstroh, Jurgen; Ratevosian, Jirair; Ryan, Owen; Sippel, Serra; Spire, Bruno; Soucat, Agnes; Starrs, Ann; Strathdee, Steffanie A; Thomson, Nicholas; Vella, Stefano; Schechter, Mauro; Vickerman, Peter; Weir, Brian; Beyrer, Chris

Homophobic legislation and its impact on human security

Despite sustained opposition, legislation criminalising homosexuality persists and threatens human security in Africa in numerous ways. This paper explores the circumstances around the enactment of new anti-homosexual legislation in Nigeria and Uganda, examining five categories of insecurity faced by lesbian, gay, bisexual, and transgender (LGBT) people in the context of these laws: physical violence; extortion and blackmail; arbitrary arrest and detention; displacement from home; and loss of work.