Research Brief March 2014 Examining Risk Factors for HIV and Access to Services among Background Female Sex Workers and The HIV epidemic in West and Central Africa (WCA) has dis- tinct characteristics compared to Men who have Sex with Men other regions of sub-Saharan Africa. National prevalence data in Cameroon over time have shown moder- ate prevalence in the general population, with no country in the region currently presenting prev- alence data over 5%.1 Limited but emerging data among key Key Findings populations (KP) at heightened risk of HIV in the WCA region Population size estimates and FSW indicate the burden of disease is characteristics This study estimated that 1.88% of the female disproportionately higher among population in Cameroon is FSW (95% CI: female sex workers (FSW) and men who have sex with men MSM 1.15-2.61). The population size estimate for (MSM). Although some data sug- This study estimated that 1.38% of the male pop- FSW between the ages of 15 and 49 years old gest a more concentrated nature ulation in Cameroon is MSM (95% Confidence in cities of over 50,000 people in Cameroon is of the HIV epidemic in countries where data are available, coun- Interval [CI]: 0.51-2.25). The population size 38,582 (95% CI: 23,563-53,477), and the popu- try-specific studies have either estimate for MSM between the ages of 15 and lation size estimate for FSW between the ages been limited or inconsistent to of 15 and 49 at the national level is 98,102 date for both FSW and MSM 49 in cities of over 50,000 people in Cameroon in the WCA region. In addition, is 28,598 (95% CI: 10,544-46,519), and the popu- (95% CI: 59,914-135,978). emerging HIV research indicates lation size estimate for MSM between the ages that investing and targeting high- A total of 1,817 FSW were surveyed. The risk populations in the cascade or of 15 and 49 at the national level is 66,842 (95% continuum of care for HIV is one CI: 24,645-108,729). highest proportions of FSW were in the 25 long-term solution to address the to 29 years age group in all sites, except in needs of KP living with HIV as A total of 1,606 MSM were surveyed. The high- Bafoussam and Bertoua where those 35 years well as to promote population- level HIV prevention and control. est proportions of MSM were between the ages and older were the largest age group. Most However, little is known about of 21 and 29 years in all cities. The lowest pro- FSW had not completed secondary school, the continuum of HIV care for KP and 33.6% reported they had other income in the region, though data from portions of MSM were those aged 30 years and Cameroon imply a high burden older, except in Bafoussam where 20.2% of par- aside from sex work. In total, 81.3% of FSW of HIV among both populations. ticipants were 35 years and older. Most MSM had at least one biological child. In 2009, a national study among FSW found HIV prevalence to surveyed reported having completed second- be 36.0%, and in 2011, a study ary school or higher, with significant propor- HIV prevalence and associated in Douala and Yaoundé among tions reporting they had university or voca- risk factors MSM found HIV prevalence to 2, 3 tional training, ranging from 20.4% in Kribi to be 37.0%. MSM This study used the Modified 42.5% in both Yaoundé and Bafoussam. The Social Ecological Model proportion of MSM who reported that at least Self-reported HIV prevalence among MSM (MSEM)4 as a framework to across all cities in Cameroon was 7.0% examine the social-, individual- one family member knew their sexual prac- and policy-level factors contrib- tices ranged from 19.4% in Bafoussam to 48.2% (including 6.2% in Yaoundé and 18.0% in uting to heightened risk of HIV in Douala. Across cities, 62.5% identified as Douala). In comparison, previous studies that among KP and limited access to health services related to the bisexual, and 36.9% of participants identified included biological testing found HIV preva- continuum of HIV care among as being gay or homosexual, with the remain- lence among MSM to be 44.4% in Yaoundé KP. This study was part of a larg- and 25.5% in Douala.3 The cities with the er, multi-country study conduct- der who answered this question identifying as ed in the WCA region. Findings heterosexual. highest proportion of MSM surveyed report- specific to Cameroon are pre- sented in this research brief. ing they were living with HIV were Douala (18.0%) and Bafoussam (12.7%). Using male condoms during anal sex every time in the past month was reported by a little over Study Methods & Design half of MSM. Most MSM found it easy to This study used both quantitative and qualitative research find male condoms; however, only 38.2% of methods, as well as an additional mapping technique: MSM across all sites reported that it was easy to find lubricants. Over half of MSM living 1. Quantitative component: MSM and FSW were sampled with HIV had never disclosed their serosta- through snowball sampling and from venues in seven cit- tus to partners. ies selected for the investigation: Bamenda, Bafoussam, Bertoua, Douala, Kribi, Ngaoundéré and Yaoundé. The FSW survey covered condom use, sexual practices, relation- Self-reported HIV prevalence among FSW ship patterns, access to care, stigma and discrimination, across all cities in Cameroon was 5.1%. In con- reproductive health, and community dynamics within trast, the most recent HIV prevalence estimate the given KP group. for FSW in Cameroon in 2009 was 36.0%.2 The 2. Qualitative component: In-depth interviews were con- mean number of clients in the past month ducted with key informants, FSW and MSM. Focus reported by FSW across all sites was 109.5, groups were also held with FSW and MSM. The topics and the mean number of non-paying partners for in-depth interviews and focus groups included expe- in the past month was 1.2. Less than half of riences and practices of the respective KP group, orga- all FSW (40.8%) reported using male con- nization and networks of the respective KP, knowledge doms every time they had sex with clients. and practices regarding HIV and sexually transmitted Almost half of all FSW indicated they had infection (STI) prevention, and experiences with stigma been offered more money for sex without a and discrimination. condom in the past week. Most FSW reported they had tested for HIV and were aware of 3. Health service assessment component: The Priorities for their HIV status. Among those who tested Local AIDS Control Efforts (PLACE) method5 was used positive for HIV, 64.2% were receiving some to recruit MSM and FSW participants and to identify type of HIV treatment. health services accessed by MSM and FSW. The study team then mapped and evaluated the types and quality of Structural barriers to health those services in each selected city. services MSM Seventy-five percent of MSM who reported they were living with HIV were on treatment, and 78.9% of those on treatment were receiving it from a hospital or pharmacy; the remaining pital or pharmacy. Limited individual and laboratory participants were receiving treatment from tra- resources, such as CD4 testing, were also reported ditional doctors. Just one-quarter of MSM had as barriers to services for FSW. Across all sites 45.9% revealed their sexual orientation to a doctor of FSW had ever been forced to have sex, with some or nurse. The sites with no specialized clinical variation across cities. Higher proportions of FSW in services for MSM were the sites with the lowest Bamenda, Bertoua, Ngaoundéré and Kribi reported levels of disclosure to medical personnel. Over they had ever been forced to have sex compared to one-quarter of MSM reported that they had ever FSW in Yaoundé, Douala and Bafoussam. A large been forced to have sex, ranging from 16.7% in number of FSW also reported experiencing denial of Bertoua to 41.1% in Kribi. Over one-third of MSM police protection, arrest, blackmail and acts of physi- reported that they had been blackmailed as a cal aggression as a result of their sex work profession. result of their sexual orientation. Few MSM also reported experiencing acts of physical aggres- Health services for MSM and FSW sion, being denied police protection and feeling There were 103 centers assessed across all seven cities, treated badly in a healthcare center. of which 25 centers were cited by at least 10% of MSM or FSW participants in each city. Centers included FSW public and private facilities and community-based Among FSW who reported they were living with organizations. Very few centers provided care spe- HIV, 64.2% were on treatment, and 78.9% of cifically for MSM or FSW, and results suggest service those on treatment were receiving it from a hos- providers may be unaware they are treating individu- als from these populations. Among centers identified by participants, Barriers to health services 20% offered MSM/FSW specialist among MSM and FSW HIV counseling and testing, 8.1% offered MSM/FSW-sensitive general …if you go and tell the doctor that you are a NKOUADENGUI health services, 44.6% offered free (MSM),, immediately, some doctors, if he is not from that milieu, male condoms, and 36.5% offered he may call a police station, he may call your parents, he can reveal free female condoms.