I was born and educated in Johannesburg, South Africa before moving to Cape Town to attend medical school at the University of Cape Town. I specialized in internal medicine and then sub-specialized in Infectious Diseases. I obtained diplomas in Tropical medicine and hygiene (University of the Witwatersrand) and HIV management (College of Medicine South Africa). My interests over the past few years included clinical management of HIV positive people in resource-constrained settings, with an emphasis on treatment of HIV, TB, cryptotoccal meningitis and other opportunistic infections. I have worked for ANOVA Health Institute for the past three years which has allowed me to pursue my interests in working with STI and HIV prevention and treatment among high risk groups, especially MSM, male drug users and sex workers. I am medical director of the Ivan Toms Centre for Men’s Health, the first government sanctioned clinic providing targeted prevention and treatment services to MSM in South Africa.
The Top2Btm symposium on prevention, treatment and care of men-who-have-sex-with-men (MSM) was recently convened in Cape Town by the Anova Health Institute with funding and support from USAID and PEPFAR. The conference attracted speakers and delegates from African and developed nations and included local MSM community representatives, a variety of NGOs, government leaders and health care workers as well as prominent MSM researchers.
It is extremely encouraging that this conference took place in South Africa, a notion that would have been unthinkable as recently as five years previously. South Africa is well placed to play a leadership role in evolving our understanding of African MSM and to promote effective health care for this "most-at-risk-population" (MARP). Infrastructure and skills exist here that can facilitate clinical and other research which will refine prevention and treatment interventions for African MSM.
Dr Yogan Pillay, South Africa’s Deputy Director General of Strategic Planning in the Department of Health, opened the conference. He affirmed the government’s commitment to implementing targeted HIV and STI prevention and treatment programs for MARPs, including MSM. He highlighted the importance of MSM-targeted HIV testing programs, considering PrEP, promoting 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 or less; MSM would benefit individually and collectively should this materialise. The importance of a human rights agenda was stressed with a quotation from UN Secretary-General, Ban Ki-Moon, “Not only is it unethical not to protect these groups; it makes no sense from a health perspective, it hurts all of us.”
1. The epidemiology of MSM in Africa
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. Systematic reviews of HIV living in low and middle-income countries, from which data are available, consistently show that MSM are at high risk of HIV compared to 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 are not generalizable but highlight a concentrated MSM HIV epidemic in countries with more generalized heterosexual epidemics.
Biologically, unprotected anal sex, particularly receptive anal sex carries a high risk of transmitting HIV (Estimated to be approx. 1.4% with each episode which is 18 times higher than for vaginal sex.)
Individual level risks therefore include unprotected anal sex, higher numbers of sex partners, 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 stigmatized and even criminalized environments.
2. HIV-Prevention interventions for MSM
A number of presentations addressed HIV prevention for MSM. In Sub-Saharan Africa HIV incidence is declining among heterosexual people but continues to rise among MSM illustrating the need for innovative prevention programs. Professor Linda-Gail Bekker called for a time of “highly active HIV prevention”.
The role of ART as prevention is gaining ground and this was visible during discussion at the conference. Evidence cited included the iPrEx pre-exposure prophylaxis study, the CAPRISA study of 1% tenofovir vaginal gel and the recently released results of the HPTN 052 study.
iPrEX recruited 2499 HIV negative high-risk MSM and randomized them to receive either Truvada or placebo daily in addition to risk reduction counseling, monthly HIV testing, condom and lube provision and treatment of sexual infections (STIs). Most recruitment occurred in South America but 90 MSM (4%) were recruited at 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 adherers gaining even more 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 study recruited 1763 discordant couples (only 3% MSM) and randomized them to early (CD4 350-550) or late (CD4 250) ART for the positive partner. 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.
Prevention strategies discussed by speakers for inclusion on the prevention menu for MSM include:
Biomedical: Post exposure prophylaxis, innovative marketing and distribution of condoms (including the female condom for anal sex) and sexual lubricants, STI screening and treatment. Anal microbicides are desirable but not yet fully developed or 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. Programs targeting MSM who use substances, particularly alcohol and crystal methamphetamine are required as are needle exchange programs.
Behavioral: Counseling programs to modify risky behavior were emphasized. Serosorting and seropositioning 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 form general society and from health care providers. Dr Patrick Sullivan emphasized the role of using technology, specifically internet-based and mobile phone based platforms in prevention. Health4Men announced a new mobi site where MSM in South Africa can access HIV information and ask questions from their cellphones [http://h4m.mobi].
3. Treatment of HIV-positive MSM
Prof James McIntyre detailed the history of the Health4Men project that lead to the establishment of holistic sexual health and HIV prevention and treatment services for MSM in South Africa. Two clinics operate in Cape Town (The Ivan Toms Centre for Men’s Health) and Soweto (The Simon Nkoli Clinic). These clinics are supported by USAID/PEPFAR and the Department of Health and are at the forefront of health provision for MSM in Africa.
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. Country-specific HIV-treatment and ART guidelines need to be adhered to, but initiating ART at a CD4 count of 350/mm3 is appropriate in population groups with high HIV transmission rates, even in resource-limited settings like South Africa. When treating MSM, there are some considerations that must be borne in mind; some groups of MSM are very body conscious and adherence to drugs causing lipoatrophy may be low. Similarly, MSM who develop erectile dysfunction may default protease inhibitors if these contribute to the problem. High levels of anxiety, depression, personality disorders, internalized homopredjudice, substance abuse and other mental health challenges make adherence-support vital for MSM. Drug use is common and some cities in South Africa are experiencing an explosive increase in crystal methamphetamine use, this can lead to unanticipated drug-drug interactions and side effects.
A presentation about anal cancer and anal intra-epithelial neoplasia highlighted the complete absence of screening and treatment services in South Africa. Advocacy is urgently needed.
Dr Anita Radix from the Callen-Lorde clinic in New York provided valuable insights into care for transgender people (TG). TG face individual and structural barriers to healthcare access which 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 sensitization and education programs are required.
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 consisting of various other subtypes. This may have consequences for future vaccine research for MSM in Africa.
The Anova Health Institute and Health4men presented a several collaborative research projects including township MSM social empowerment programs (the Ukwazana or “getting to know one another” study in Cape Town in collaboration with Cambridge University, and the Health Empowerment project in Mpumalanga, with UCSF) .
In summary, the Top2Btm conference offered an extremely full program with topics covering issues in epidemiology, prevention, treatment and research relating to MSM in Africa. The program included two workshops aimed at providing skills to health care providers on sexual history taking and provision of PEP.
The conference provided an opportunity to learn new information, share new ideas, identify new opportunities to improve the health of MSM and further a research agenda for MSM in Africa. Hopefully conference delegates will be able to use the information shared, to advocate for improved human rights and healthcare for MSM in their countries.
Presentations from the symposium are available at the Anova Health institute website: http://www.anovahealth.co.za/resources/entry/top2btm_msm_symposium/