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MSM in Nigeria less likely to engage in HIV care due to anti gay law
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In Nigeria, men who have sex with men have reported increased discrimination and fear of seeking health care since new anti-gay legislation was enacted early this year, according to two reports presented during AIDS 2014. This law could significantly affect public health in the area.
"This is a population that already faces a lot of discrimination and already is afraid to seek health care," Sheree Schwartz, PhD, of the Johns Hopkins Bloomberg School of Public Health, told Infectious Disease News. "We saw that before the law, about 25% of the population in our study said that they had experienced fear and avoidance of health care in the past. Our concern is that when policies are put in place that put people further underground, they're going to be less engaged in care and more likely to default on their [antiretrovirals], less likely to come in and get tested and find out that they're living with HIV and get on treatment."
The Same Sex Marriage Prohibition Act, signed by Nigerian President Goodluck Jonathan in January, prohibits gay marriage and civil unions; it imposes prison terms of up to 14 years for those prosecuted under the legislation. In addition, it criminalizes participation in gay clubs, societies and organizations. Anyone who is caught engaging in a public display of an amorous same-sex relationship could face a 10-year prison term.
The atmosphere in Nigeria has never been friendly toward people involved in same-sex relationships. Therefore, passage of the law was not surprising, according to some experts, including Stefan Baral, MD, director of the key populations program and associate professor in the department of epidemiology at Johns Hopkins Bloomberg School of Public Health.
Sheree Schwartz
"Same-sex practices have always been criminalized in Nigeria," Baral said. "It's written into their penal code 377 and into laws written under a constitution that dates back to British colonial times."
Different type of epidemic
The researchers involved in the TRUST Project were alarmed by the swift and dramatic effect the legislation had on MSM in Nigeria. Fewer MSM were willing to seek health care and to participate in HIV/AIDS research.
The TRUST Project is a collaboration of multiple institutions that include Johns Hopkins, the Institute of Human Virology at the University of Maryland School of Medicine, Walter Reed Army Institute of Research, Military Health Research Program and the International Centre for Advocacy on Rights to Health.
In one TRUST Project cohort, Baral and colleagues assessed the effect of HIV interventions that target MSM in Abuja, Nigeria. They saw a significant decrease in the number of MSM accessing health services since the law was passed. In this study, 572 MSM participated between March and December 2013 for an average participation of 63 MSM per month. After the law was passed, only 10 MSM participated from Jan. 7 to Jan. 25, for an average participation of 15 MSM.
Furthermore, of the 115 MSM interviewed, 84 cited the new law as the reason for declining participation, the researchers wrote in their abstract. Fear of persecution, extortion and blackmail were the most common reasons for not participating.
More fear, discrimination
"What it tells us is that while many believe that the laws don't really seem to change things, that on the ground, the situation is the same," Baral said. "These analyses appear to tell us that you do see statistically significant increases in fear of seeking care because of the law."
In another cohort of the TRUST Project, Schwartz and colleagues documented the discrimination and potential effect of the law. The researchers enrolled participants in a prospective cohort in Abuja, Nigeria. At enrollment and then every 3 months, they evaluated stigma, discrimination, HIV-related testing, treatment and clinical outcomes.
Stefan Baral
From March 2013 to March 2014, 606 MSM made 758 health care visits before the law was passed; after passage, the number of visits dropped to 106.
Before the legislation, the most common complaint among MSM was a fear of seeking health care and a lack of safe places to socialize; those fears increased significantly after the law.
"Basically, what we saw was comparing visits before and right after the law went into effect, we saw an increased reporting of experiencing fear of seeking health care, an increased reporting of men telling us they have no safe place to go as MSM, increased reporting of having avoided seeking health care, verbal harassment of MSM," Schwartz said. "To us, it is evidence of increased discrimination."
This analysis also demonstrated a positive correlation between open communication with providers and viral suppression and treatment uptake. At baseline, 20.8% of MSM disclosed their status to a health care provider. Schwartz and colleagues found that baseline viral suppression was more common among HIV-infected men who had discussed their sexual habits with a health care provider (31.2% vs. 15.7%;
MSM less likely to access care
For health researchers, these findings raise major public health concerns, especially given the high burden of HIV and AIDS in Nigeria.
"Nigeria as a whole has a different type of epidemic," Baral said. "Nigeria's epidemic appears to be far more concentrated than you would see in southern Africa or in countries like Uganda."
The 4% prevalence rate is lower than these other countries; however, "given the vastness of the population — there are 160 million people in the country — the actual number of people living with HIV in the country becomes extremely high." Nigeria has the second largest population of people living with HIV, according to Baral.
"What we're really worried about is that you have a group of individuals such as these men, who are already disproportionately affected by HIV [who] are becoming more afraid of seeking health care," Schwartz said.
This group is less likely to access HIV and AIDS care, get HIV testing and are less likely to engage in HIV prevention than they were before the legislation was passed.
"You can imagine in an environment in which you don't feel that you can be out about your status to a health care provider, that you can't have the same sort of conversations about your sexual risks and about your sexual health," she said. "That's definitely something that we're worried about if people won't engage with health care providers honestly, then they won't get the services that they need in terms of sexual health. All of these have implications in terms of HIV prevention, transmission and outcomes that are negative."
Furthermore, Baral said these laws negatively influence the provision of care: "These laws have an effect on the ability to provide these services, feeling safe to provide them, ensuring competency to provide them in terms of having the appropriate training. They also affects people's willingness to seek these services in terms of disclosing the fact that they are a member of this targeted population, which would then allow them to get more clinically and culturally competent services."
For example, the southeastern African country of Malawi has a similar law. Health care providers there expressed considerable concern with their ability to provide care without fear of prosecution.
"They are really afraid of the implications related to these laws and how it's going to affect the rest of their practice or themselves getting arrested," Baral said. "You are seeing a significant amount of increased concern about the normal provision of simple services to people."
Prevention, outreach affected
There has been a demonstrated reduction in prevention and outreach efforts in Nigeria, according to the findings of a survey by The Initiative for Equal Rights, a Nigerian human rights organization.
From December to May, survey results showed that prevention and outreach efforts fell significantly across Nigeria: In Lagos, efforts were down 40%, in Abuja they were down 30%, and in Kano, they were down 70%.
HIV research can also be negatively influenced.
"These laws end up in what we call a data paradox, where you end up not having enough data on the populations where there is the most stigma," Baral said. "For example, in countries like Iran, it's so difficult to do these studies, not because there are not large populations of men who have sex with men but because there is no safety in terms of staff or participants to do this type of work."
"When you further criminalize it, further stigmatize it, it continues to drive people down and down in a way that they don't want to seek care," Baral said. "They don't want to be included in these sorts of studies. And you end up learning less about them. You end up in a scenario where you don't really understand the epidemic because you can't study those who are most at risk." — by Colleen Owens
Sheree Schwartz, PhD, can be reached at the Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Room E7146, Baltimore, MD21205; phone: 410-502-8975; email:sschwartz@jhu.edu.
Disclosure: Baral and Schwartz report no relevant financial disclosures.