South Africa may be experiencing parallel heterosexual and homosexual HIV epidemics, researchers warn.
This was the finding of a study among homosexual men presented at the 4th South African AIDS Conference in Durban earlier this month.
HIV/AIDS is often portrayed as a heterosexual epidemic in SA.
But Professor Laetitia Rispel from Wits University and Dr Carol Metcalf from the Human Sciences Research Council (HSRC), the principal investigators of the Johannesburg/eThekwini’s Men’s Study (JEMS), called for further research to confirm the findings and specific HIV programmes to address the needs of men who have sex with men (MSM).
The study was conducted by the University of the Witwatersrand, the HSRC and the Medical Research Council last year to provide preliminary information on the epidemiology of HIV among MSM in Johannesburg and eThekwini (Durban), and to review the availability of programmes and services to MSM.
The study, which had approval from research ethics committees at the HSRC and Wits, used respondent-driven sampling (RDS) to recruit 285 men from Johannesburg and Durban into a survey.
RDS is a method of recruitment used to obtain representative samples of hidden, hard-to-reach populations.
All those who consented completed a questionnaire and provided finger-prick blood specimens for anonymous HIV testing in a laboratory.
Participants who did not know their HIV status were offered free, on-site voluntary counselling and testing (VCT).
The survey was complemented with qualitative interviews with 32 key informants and approximately 150 men who participated in focus group discussions.
All men in the survey had had sex with at least one other man in the past year. Their age ranged from 18 years to 61 years, with an average age of 24 years.
The majority were black Africans (88%), under 25 years of age (67%) and identified as being homosexual/gay (78%).
HIV prevalence among survey participants
Of the 266 men tested for HIV in the survey, 44% were HIV-positive. This is more than double estimates of HIV prevalence estimates among men in the general population.
Although the results of JEMS cannot be generalised to all MSM in South Africa or in the two cities, these findings are a cause for concern and support evidence from studies in other countries with generalised HIV epidemics of a “hidden epidemic” of HIV among MSM.
Just over half the participants (57%) reported that they “knew” their HIV status, but only two-thirds of those who knew their status had disclosed their status to a sexual partner in the past year.
Other important findings were that high-risk sexual behaviour was widespread; perception of risk was relatively low; and that current policies, programmes and services are not responsive to the HIV prevention and care needs of MSM.
Factors that contribute to HIV risk
High-risk sexual behaviour was widespread among survey participants. HIV-negative men reported an average of five partners in the past year, and HIV-positive men reported an average of 7.5 partners in the past year.
Almost one in two participants reported having unprotected anal intercourse (UAI) in the past year. Compared to HIV-negative participants, HIV-positive participants were more than twice as likely to have had receptive UAI in the past year.
Condom unavailability and condom accidents were common, with 55% of participants reporting not having had a condom available when they needed one, 42% reporting at least one instance of condom slippage, and 58% reporting an instance of condom breakage in the past year.
In addition, many participants reported having used substances that reduce the protective effect of condoms, including Vaseline (32%), lotion (28%).
The majority of participants (73%) reported having had sex while under the influence of alcohol in the past year, with no significant difference by HIV status.
The majority of survey participants (57%) had used public health services in the past year. More than two-thirds (69%) reported that they did not have medical aid. However only 7% of participants reported that they would prefer to receive HIV-prevention services from a government health service, than from other proposed service providers.
Qualitative interviews found that most health programmes targeting MSM were provided by lesbian, gay, bisexual and transgender (LGBT) organisations in large cities.
Existing programmes had limited capacity and resources, and provided services to a very limited number of men. Many key informants and focus group participants reported that health workers often display negative and judgemental attitudes towards MSM, or tailor their clinical management exclusively towards heterosexuals.
This made some men reluctant to use health care services. Due to persisting stigmatisation of homosexuality, some MSM feared to disclose their sexual practices and sexual identity to health workers.
Use of voluntary HIV testing and counselling (VCT) and prevention services
Key informant interviews and focus group discussions found that many MSM are reluctant to be tested for HIV. Although 98% of survey participants knew where they could be tested for HIV, only 48% had been tested for HIV in the past year and given the result.
Only 25 (9%) of participants chose to have VCT, offered as part of the survey. However, almost all participants expressed an interest in attending a workshop (97%) or individual counselling (92%) on HIV prevention.