Oscar Radebe/Johan Hugo MSM and HIV in Southern Africa

• HIV prevalence among MSM in cross- sectional surveys in 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% / 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

052

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 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 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 • All staff working in these facilities • To all the funders for their continuous support