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CONFERENCE REPORT
TOP2BTM SYMPOSIUM ON HEALTH CARE FOR MEN WHO HAVE SEX WITH MEN (MSM)
K Rebe, MB ChB, FCP (SA), DTM&H, Dip HIV Man (SA)
G de Swardt, BA (MW)
H Struthers, MSc, MBA
J A McIntyre, MB ChB, FRCOG
Anova Health Institute, Johannesburg and Cape Town, South Africa
Men who have sex with men (MSM) are at high risk of HIV acquisition
and transmission, and country-specific HIV prevalence rates are always
higher in MSM than among heterosexual men. South African data confirm
this, with reported HIV prevalences of 10.4 - 33.9% across various
studies. Donors and government health planners have recognised the need
for targeted programmes that address the high burden of HIV
transmission and disease in stigmatised populations such as MSM, as
well as other ‘most at risk populations’ (MARPS) such as
commercial sex workers, drug users and displaced refugees. Specific
programmes targeting MSM and other MARPS have been included in the
South African government’s current National Strategic Plan for
health care and will feature in the new plan under development.
Until recently, African MSM have been under-researched and
under-resourced, and this has contributed to their stigmatisation.
Fortunately this deficiency has been recognised locally and a number of
innovative programmes have been developed to address this. The Top2btm
symposium on prevention, treatment and care of MSM sought to bring
together these programmes to share experiences. The symposium was held
in Cape Town, organised by the Anova Health Institute with support from
USAID and PEPFAR. The conference attracted 188 delegates from across
Africa as well as Europe and North America, including local MSM
community representatives, a variety of NGOs, government leaders and
health care workers as well as prominent MSM researchers.
Dr Yogan Pillay, South Africa’s Deputy Director General of
Strategic Planning in the Department of Health, opened the conference
on behalf of the Minister of Health. He affirmed government’s
commitment to implementing targeted HIV and sexually transmitted
infection (STI) prevention and treatment programmes for MARPs,
including MSM. He highlighted the importance of MSM-targeted HIV
testing programmes, considering pre-exposure prophylaxis (PrEP),
promoting post-exposure prophylaxis (PEP), encouraging MSM-related
research and embracing the concept of antiretroviral treatment as
prevention. Consideration is being given to providing state-funded ART
to everyone at a CD4 count of 350 cells/µl or less; this would be
especially beneficial to MSM, since the risk of HIV transmission is
much higher during unprotected penile-anal sex than during unprotected
penile-vaginal sex, and lowering the viral load of positive MSM is
likely to provide a large reduction in HIV transmission.
The conference incorporated four main themes:
1. Understanding the epidemiology of African (and South African) MSM
2. Prevention interventions to address HIV among MSM in Africa
3. Health care services for HIV-positive MSM
4. Research to improve understanding of African MSM.
THE EPIDEMIOLOGY OF MSM IN AFRICA
The conference proceedings were underpinned by several key
concepts in thinking about MSM and HIV/AIDS. First, it is important to
recognise that ‘MSM’ is a medicalised term describing the
behaviour of sex between men; it does not describe a particular
identity or population group. MSM are extremely diverse and probably
have many differences from each other and only one main commonality,
having sex with other men. MSM vary in the way they conduct their lives
and in the sex that they have (for example, not all MSM engage in anal
sex). They may identify as heterosexual, homosexual or bisexual. They
may possess a masculine or feminine identity and they may identify with
‘gay’ or mainstream culture.
Related to this, it is common throughout Africa to find MSM who
identify as heterosexual and are even married, appear masculine but
sometimes have sex with men in addition to women. These MSM are
particularly difficult to reach with traditional health programmes, as
they are in many ways invisible in mainstream society.
Second, MSM experience a range of barriers to accessing health care,
not least stigma and prejudice from health care providers themselves.
MSM often receive counselling that is inappropriate to the lives they
lead. For example, HIV prevention messages aimed solely at
heterosexuals may ignore the risks of HIV transmission associated with
anal sex. MSM are concerned about the double stigma they may experience
in health centres relating to their sexual orientation and their HIV
status, and are often reluctant to seek care.
With this background, the keynote address entitled ‘Time to
act: Responding to the HIV pandemic among MSM’ was delivered by
Professor Chris Beyrer of Johns Hopkins Bloomberg School of Public
Health (USA). Systematic reviews of HIV in low- and middle-income
countries from which data are available consistently show that MSM are
at higher risk of HIV compared with the local heterosexual population.
Aggregate HIV prevalences among African MSM are reported to range from
8.8% in Sudan to 32.9% in Zambia. Many of these studies were performed
using respondent-driven or ‘snowball’ sampling and
therefore may not be generalisable; however, they do highlight the
concentrated MSM HIV epidemic in countries where there is also a
heterosexual epidemic. In addition, pooled data from studies in Malawi,
Botswana and Namibia demonstrate health provider stigma: 5.1% of MSM
sampled report being denied health care services because of their
sexual orientation, and 22.3% reported ‘any discriminatory
event’ based on sexuality. Provider stigma is just one of the
challenges currently facing MSM.
For HIV transmission to occur, transfer of an HIV-containing fluid
needs to gain entry into a new individual. The anal mucosal lining is
thin, does not self-lubricate and is more liable to mucosal tears than
vaginal mucosa. Biologically, unprotected anal sex, particularly
receptive anal sex, carries a high risk of transmitting HIV (estimated
to be approximately 1.4% with each episode, which is roughly 18 times
higher than for vaginal sex). Condoms and other HIV-risk reducing
interventions are therefore extremely important for MSM.
Individual-level HIV risks include unprotected anal sex, high
numbers of sex partners, and injecting and non-injecting drug use.
Structural level risks for MSM relate to stigma, discrimination and
human rights concerns. A study in Namibia, Malawi and Botswana showed
self-reporting of human rights abuse to be high; for example, 5.1% of
MSM studied had been denied health services based on their sexuality
and 23% reported any form of discrimination. This and similar studies
show the difficulty faced by MSM trying to access healthcare in
stigmatised and even criminalised environments.
HIV PREVENTION INTERVENTIONS FOR MSM
A number of presentations addressed HIV prevention for MSM. In
sub-Saharan Africa the incidence of HIV is declining among heterosexual
people but continues to rise in MSM, illustrating the need for
innovative prevention programmes. Professor Linda-Gail Bekker from UCT
called for a time of ‘highly active HIV prevention’. In
particular, the role of ART as prevention is gaining ground, and this
was visible during discussion at the conference. Evidence cited
included the Pre-Exposure Prophylaxis Initiative (iPrEx) and the
recently released results of the HPTN 052 trial.
iPrEx recruited 2 499 HIV negative high-risk MSM and randomised them
to receive either Truvada or placebo daily in addition to risk
reduction counselling, monthly HIV testing, condom and lube provision
and treatment of STIs. Most recruitment occurred in South America, but
90 MSM (4%) were recruited at a Cape Town site. Results showed a 44%
reduction in HIV infections in the treatment arm and there was a
significant dose-response relationship with better adherence associated
with increased protection. Guideline documents for the use of PrEP are
available and should be included as an option in the ‘prevention
package’ for MSM.
The HPTN 052 trial recruited 1 763 discordant couples (only 3% MSM)
and randomised them to either early (CD4 count 350 - 550
cells/µl) or late (CD4 <250) ART initiation for the positive
partner. The trial found that earlier treatment decreased HIV
transmission by 96% over the duration of follow-up. The study was
stopped early by its monitoring board, and we await full publication.
Early indications are good that ART did provide significant protection
in heterosexual discordant couples, but the study was underpowered for
MSM.
Other prevention strategies discussed by speakers for inclusion on the prevention ‘menu’ for MSM include:
Biomedical. In addition to PrEP,
biomedical prevention options for MSM include post-exposure prophylaxis
(PEP), innovative marketing and distribution of condoms (including the
female condom for anal sex) and sexual lubricants, STI screening and
treatment. Rectal microbicides are desirable but are not yet fully
developed or proven to be effective. Medical male circumcision has not
been shown to confer protection for MSM, except perhaps if they are
exclusively the penetrative partner in anal sex or have concurrent
sexual relationships with women, where the infective risk is from
penile-vaginal sex. Programmes targeting MSM who use substances,
particularly alcohol and crystal methamphetamine, are required, as are
needle exchange programmes.
Behavioural. Counselling programmes
to modify high-risk behaviour were emphasised.
‘Serosorting’ and ‘seropositioning’ (choosing
sexual partners on the basis of their HIV status, or deciding on
insertive or receptive anal intercourse depending on partner status)
were discussed and may be of value but could be construed as
‘sero-guessing’ in areas where MSM do not know their status
or misinform potential sex partners.
Structural. Advocacy is needed to decrease
stigma and discrimination from general society and from health care
providers. Dr Patrick Sullivan emphasised the role of using technology,
specifically Internet-based and mobile phone-based platforms in
prevention. Related to this, Health4Men announced a new mobi site where
MSM in South Africa can access HIV information and ask questions from
their cellphones (http://h4m.mobi).
HEALTH CARE SERVICES FOR HIV-POSITIVE MSM
Professor James McIntyre detailed the history of the Anova Health
Institute’s Health4Men project that led to the establishment of
holistic sexual health and HIV prevention and treatment services for
MSM in South Africa. Two MSM-targeted clinics operate in Cape Town (the
Ivan Toms Centre for Men’s Health) and Soweto (the Simon Nkoli
Centre for Men’s Health), with a satellite clinic in Pretoria.
These clinics are supported by USAID/PEPFAR and the Department of
Health and are at the forefront of health provision for MSM in Africa.
The Ivan Toms Centre for Men’s Health in Cape Town has been
operating for more than 2 years. The clinic offers a primary-care
level, holistic package of HIV and STI prevention and treatment
services, including the provision of government-funded ART for
HIV-positive MSM who qualify for treatment according to national
guidelines. The clinic includes an extensive mental health component in
collaboration with the Department of Psychiatry at Groote Schuur
Hospital. Approximately 3 000 clients have utilised the clinic’s
services so far. About half of these clients are HIV-positive and
approximately 500 are currently receiving ARVs. The clinic addresses a
large non-HIV STI burden, with syphilis and human papillomavirus
infection being particularly common. For example, approximately 15% of
individuals screened at the clinic are positive for syphilis infection.
This clinic is unique in not marketing itself as a ‘gay
clinic’ or an ‘HIV clinic’. The client cohort
includes both negative and positive people, some of whom receive ART,
and some remain in wellness programmes prior to initiating treatment.
This model has advantages in terms of enabling health-seeking behaviour
of MSM, as individuals are not identifiable as HIV-positive because of
the clinic they attend. Many attend for other STIs, or for counselling
or other services.
MSM treatment challenges were addressed in a number of sessions at
the conference. The importance of training of health care workers to
decrease homoprejudice in the health sector was stressed. Homoprejudice
from the health sector acts as a structural barrier to health care
access for MSM. Already organisations in South Africa, including the
Anova Health Institute and the Desmond Tutu HIV Foundation, are
conducting training programmes for health care providers to address
this.
The conference discussions emphasised that there are some
considerations that must be borne in mind when providing ART to MSM.
Some groups of MSM are very body conscious, and adherence to drugs
causing lipo-atrophy may be low. Similarly, MSM who develop erectile
dysfunction may default protease inhibitors if these are perceived as
contributing to the problem. Mental health and drug use, and how these
may influence adherence, also need to be considered when initiating ART
in HIV-positive MSM.
MENTAL HEALTH
The need to incorporate mental health services into the package of
care for MSM was highlighted by Dr Kevin Stoloff from the Department of
Psychiatry at Groote Schuur Hospital. His presentation, based on
literature review and clinical experience at the Ivan Toms Centre for
Men’s Health, stressed that high levels of anxiety, depression,
personality disorders, internalised homoprejudice, substance abuse and
other mental health challenges make adherence support vital for MSM.
These same mental health challenges may precipitate or enhance risk
taking among MSM.
DRUG USE
Drug use is common, and some communities in South Africa are
experiencing an explosive increase in crystal methamphetamine use. It
is recongised that a large percentage of incident HIV infections in the
developed world are related to crystal methamphetamine use, and the
same may be true of some groups of South African MSM. Crystal
methamphetamine use lowers inhibitions, increases risky sexual
behaviours and may increase biological susceptibility to HIV infection.
The drug can also be injected, which raises concerns about needle
sharing and transmission of other blood-borne viruses such as hepatitis
B and C. Crystal methamphetamine and other recreational drugs can have
unanticipated drug-drug interactions and side-effects for HIV-positive
individuals taking antiretroviral medications, making treatment of such
people difficult from medication choice and adherence perspectives.
ANAL INTRA-EPITHELIAL NEOPLASIA
An under-recognised health care problem for MSM is anal
intra-epithelial neoplasia (AIN) and anal cancer. A presentation on
this issue highlighted the complete absence of screening and treatment
services in South Africa. AIN is a precursor to anal cancer and
parallels cervical intra-epithelial neoplasia in women. AIN is
HPV-associated and may lead to cancers that involve peri-anal and anal
skin. Screening for and early detection and management of AIN may
prevent anal cancers. Many experts now advocate for the inclusion of
AIN screening in routine care of MSM. Not doing so represents a missed
opportunity to prevent serious malignancies.
TRANSGENDER ISSUES
Dr Anita Radix from the Callen-Lorde clinic in New York provided
valuable insights into the health care needs of transgender people
(TG). TG face individual and structural barriers to health care access
that are sometimes different from those experienced by MSM. There is a
dearth of services for TG in Africa and many health care providers lack
the skills to manage complex psychological and medical issues,
including management of complex drug-drug interactions between hormones
and ART. Health care worker sensitisation and education programmes are
required.
4. RESEARCH
Professor Carolyn Williamson, a medical virologist at the University
of Cape Town, discussed HIV subtypes that circulate in Cape Town. The
predominant HIV subtype in MSM in developed nations is subtype B,
contrasting with heterosexual epidemics where subtype C predominates,
as in South Africa. Phylogenetic studies performed with 147 HIV samples
from mixed urban and rural South African MSM showed approximately 80%
to be subtype C, 13% to be subtype B and the balance to consist of
various other subtypes. This may have consequences for future vaccine
research for MSM in Africa, as a vaccine directed primarily against
subtype B virus may be less effective in a subtype C or recombinant
subtype epidemic.
CLINICAL SKILLS FOR HEALTH SERVICE PROVIDERS
Two workshops were included in the symposium, both aimed at
improving the clinical skills of health providers who service MSM. The
first workshop addressed discussing sex and taking a sexual history in
a clinical setting. Participants received guidance in this arena and
learned skills were reinforced by role-play activities with concrete
examples of sexual histories taken from MSM who had recently attended
the Ivan Toms Clinic. The second workshop addressed the use of
post-exposure prophylaxis. Workshop attendees received background
information and practical advice about the administration of PEP and
for including this HIV transmission reducing intervention into the
scope of services provided at their clinics. Key learning points from
each of these workshops are presented in Boxes 1 and 2.
SUMMARY
In summary, the Top2Btm conference offered a full and broad-ranging
programmme with topics covering issues in epidemiology, prevention,
treatment and research relating to MSM in Africa.
Throughout the conference the diversity of MSM communities in South
Africa was stressed, as was the need for innovative and tailored
programmes to address the health needs of these often hidden
communities. Clinics such as the Ivan Toms Centre for Men’s
Health in Cape Town have developed expertise and a model for
disseminating the knowledge and skills required to achieve the aim of
targeted health care for MARPS, including MSM, in the country’s
National Strategic Plan for Healthcare.
Box 1. Taking a sexual history in a clinical setting
• Do not assume heterosexuality among men attending HIV clinics.
• Ensure privacy and confidentiality of information.
• Ensure staff training to enable them to confidently address a broad range of sexualities and sexual problems.
•
Explain the context of the sexual history in terms of identifying
health risks and individualising an HIV risk reduction plan.
• Build rapport with patients by asking generalised questions.
• Thereafter, ask all clients if they have sex with women, men or both.
• Use local colloquial language that is accessible to clients.
•
Do not moralise about clients’ sexual activities. The aim is to
normalise all consensual sex while identifying areas where HIV
transmission risk can be reduced.
Box 2. Post exposure prophylaxis (PEP)
• PEP is an effective strategy of using ARVs to reduce HIV transmission.
• Evidence for PEP efficacy among MSM is limited, as conducting randomised placebo controlled trials would be unethical.
• PEP is indicated for HIV-negative individuals who have
been exposed to HI virus-containing body fluids (semen and blood).
• PEP should be initiated within 72 hours of exposure.
•
Owing to the high HIV transmission risk associated with anal sex,
possible HIV exposure during this sex act should be managed with
triple-therapy PEP.
• Clients on PEP require counselling and support to minimise
medication side-effects and psychological stress.
• Advocacy is required to increase PEP in Department of Health
facilities, especially outside normal clinic hours.
Both prevention and treatment of HIV among MSM were addressed at
the symposium. Antiretroviral medications are finding a new role as
prevention and not just treatment. Intervention such as PEP, PrEP and
earlier treatment initiation should feature in MSM-targeted health
programmes. Successful ART for MSM requires special consideration of
medication choice and appropriate counselling that is not
heteronormative. MSM-specific diseases such as anal dysplasia and
cancer should be included as part of the package of services for MSM.
Despite South Africa’s progressive constitution, MSM still
experience high levels of structural homophobia which negatively
affects risk-taking and health-seeking behaviours, and advocacy is
required to decrease this.
South Africa has produced a substantial body of MSM research and has
contributed significantly to the global body of knowledge regarding
African MSM. Organisations currently active in this field should
continue their efforts. Symposia such as Top2Btm provide an opportunity
for information sharing, identification of new opportunities to improve
the health of MSM, and discussion aimed at furthering a research agenda
for MSM throughout Africa.
All presentation slides delivered at the
Top2Btm symposium are available on the Anova Health Institute Website
(www.anovahealth.co.za) by following the link
http://www.anovahealth.co.za/resources/entry/top2btm_msm_symposium/.
For more information, please contact Health4Men on (021) 447-2844.
ABOUT ANOVA HEALTH INSTITUTE & HEALTH4MEN
Health4Men is a special interest programme of the Anova Health
Institute, which receives support from USAID / PEPFAR. This programme
targets men who have sex with men (MSM) for HIV and STI prevention and
treatment. The programme has a strong community focus aimed at
improving social support and decreasing stigma experienced by
township-based MSM. Health4Men seeks to improve access to health care
services and provides education and training for MSM as well as for
health care providers who deliver care to MSM clients. Educational
programming includes regular training activities and academic symposia.
The most recent of these was the Top2btm symposium held in Cape Town in
May 2011.