Oscar Radebe/Johan Hugo MSM and HIV in Southern Africa
• HIV prevalence among MSM in cross- sectional surveys in South Africa has ranged from 10-50%
• 8% of the new HIV infections in South Africa are among MSM population.
• South Africa – Emerging data show rates of 10.4 to 33.9% in various studies – 45% Johannesburg / 27.5% Durban
JEMS Study. HIV prevalence and risk practices among men who have sex with men in two South African cities. J Acquir Immune Defic Syndr. 2011 Feb 4 South Africa: constitution supports same sex marriages
• Section 9 (3) of South Africa's Constitution expressly prohibits unfair discrimination on the grounds of sexual orientation.
Read more: http://www.southafrica.info/services/rights/sa me-sex- marriage.htm#.UewhQaMaL4g#ixzz2Zhj9hls7 Prevention Intervention strategies for MSM
HIV screening (HCT)
HIV/STI Treatment & Prevention Preventing Biomedical strategies new intervention infections
Prevention for Positive Core Prevention Principles
• Expanding existing prevention services • Increasing opportunities for diagnosing and treating HIV/STIs • Developing new, effective prevention interventions for Key Populations • Mobilizing broader community awareness Risk reduction counselling for MSM
• Requires competent staff to perform counselling and HCT
• Risk assessment is important and couple counselling
• Sero-adaptive behaviour ¾ Sero-sorting ¾ Sero-positioning
• Combination prevention package
• Support groups Prevention strategies
Barrier methods
Biomedical
Psychosocial /behavioural
Structural The Menu of HIV Prevention for Men • ABC… •Biomedical – Devices such as condoms / lube – Medicines including early ART, PEP, PrEP – Microbicides and vaccines – Medical male circumcision • Structural – Decreasing institutionalised prejudice • Psychosocial / behavioural – Decrease partner numbers, increasing HCT Barriers to condom usage in MSM
• Limited choice
• Not sexy enough
• Poor messaging
• No condom and lubricant distribution • ? Female condoms Biomedical Prevention strategies
• Post-exposure prophylaxis (PEP)
• Pre-exposure prophylaxis (PrEP)
• Treating HIV to lower viral load (TasP)
• Treating and preventing STIs
• Male circumcision
• Vaccine and Microbocides PEP (Post exposure Prophylaxis)
• Indicated for high risk groups • Risk assessment is required - sexual history • Documented HIV negative status • Counselling and support are vital! • Not freely available in state facilities PrEP (Pre-exposure Prophylaxis)
• Limited knowledge and use of PrEP among African MSM • Scientific evidence indicates safe use of PrEP • Support for clinicians for safe use of PrEP is available online Æ Yeoville H4M clients are requesting PrEP and 1 clients already using PrEP PrEP Works for MSM too!
2500 MSM: Tenofovir vs placebo Æ 50% reduction in HIV seroconversion
004 052 1% Tenofovir gel used vaginally by women Æ 39% reduction in HIV seroconversion Pre-exposure Prophylaxis PrEP
• Using ART in negative patients on a long term basis to reduce infection risk if they are exposed to the virus • Seems safe • High adherence • Global iPrEx study: – 2499 MSM HIV-ve received truvada or placebo – 44% overall risk reduction on truvada – More than 90% for adherent Study participants (Grant et al: NEJM, 2010) TasP (Treatment as Prevention)
• Early initiation of ART in high risk group in reducing viral load. • WHO recommends now early initiation of ART at CD4:500 to reduces mortality in general population.
• South African government is committed to new strategies reduction of HIV in key population Treatment as Prevention
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Early vs delayed ART in discordant heterosexual couples Æ 96% reduction in HIV transmission
Health4Men clinical sites does consider starting early ART if possible & appropriate: • Medically insured or can self-fund ART • Discordant couples / CSW / MSM who use drugs Is Medical Male Circumcision Effective for MSM?
• Some people might benefit – Men who are exclusively penetrative – Bisexual men – 60% reduction of STI and HIV among men • MMC should be offered to all men regardless of their sexual orientation to reduce stigma. • Now part of DOH prevention strategy • Part of a package of risk-reduction strategies • Appropriate wound healing • Appropriate counselling Rectal Microbicides and HIV vaccines
• Rectal microbicides – Would be acceptable to many groups of MSM – TDF gel seems safe and acceptable to use rectally but need data on efficacy • Vaccines – No available products
• More scientific evidence is needed on African MSM appropriate prevention strategies MSM Health Care in SA
Anti-apartheid and gay rights activist Simon Nkoli with Ivan Toms in 1989. Before his death in 1998, Nkoli was instrumental in early court battles to remove discrimination against gays and lesbian Acknowledgement
• Prof James Mcintyre (CEO of Anova) • Helen Struthers (COO of Anova) • Glenn de Swardt (Program manager Health4Men) • Limpopo Provincial DOH • Top to Bottom organisers • Health4Men Team Soweto • All staff working in these facilities • To all the funders for their continuous support