HIV-related risks among men who have sex with men in sub-Saharan Africa has detected an important, previously undocumented, component of many national epidemics (Figure 6). In most countries in which such serosurveys have been conducted, researchers have identified HIV preva- lence among men who have sex with men that is substantially higher than among the general male population (Smith et al., 2009).
In a study in Mombasa, Kenya, 43.0% of men who have sex only with other men tested HIV-positive, compared with 12.3% of men who reported having sex with both men and women (Sander et al., 2007). More than one in four (25.4%) men who have sex with men surveyed in Lagos in 2007 tested HIV-positive (Federal Ministry of Health, 2007). In a 2008 study of 378 men who have sex with men in Soweto, South Africa, researchers found an overall HIV prevalence of 13.2%, increasing to 33.9% among gay-identified men (Lane et al., 2009). One third of men who have sex with men surveyed in Cape Town, Durban and Pretoria, South Africa, tested HIV-positive (Parry et al., 2008). A cross-sectional anonymous survey of 537 men who have sex with men in Malawi, Namibia and Botswana found HIV prevalences of 21.4%, 12.4% and 19.7% among study participants in the three countries, respectively. HIV prevalence among study participants over the age of 30 was twice as high as among all men who have sex with men surveyed (Baral et al., 2009). In five urban sites in Senegal, a low-prevalence country, 21.5%
of men who have sex with men surveyed tested HIV-positive (Wade et al., 2005).
A recent modes of transmission analysis indicates that men who have sex with men may account for as many as 20% of incident HIV infections in Senegal (Lowndes et al., 2008). In Kenya, men who have sex with men (including men in prison settings) accounted for an estimated 15% of inci- dent HIV infections nationwide in 2006 (Gelmon et al., 2009). Similarly, a recent modelling exer- cise concluded that men who have sex with men accounted for an estimated 15% of new infections in Rwanda (Asiimwe, Koleros, Chapman, 2009). In Ghana, men who have sex with men showed the highest HIV incidence (9.6%) of any popula- tion and accounted for 7.2% of all new infections in 2008 (Bosu et al., 2009). Reliable data on the epidemic’s burden among men who have sex with men are not available in many countries (see Mngadi et al., 2009).
In studies in Botswana, Malawi and Namibia, lack of consistent condom use with male partners was significantly associated with HIV infection (Baral
et al., 2009). The same study also found that many men apply petroleum-based lubricants when they use a condom, which potentially contributes to condom failure (Baral et al., 2009).
In a study of men who have sex with men in Gauteng province in South Africa, the likelihood of unprotected anal intercourse was significantly associated with regular alcohol drinking (Lane et al., 2008). Surveys in Cape Town, Durban and Pretoria, South Africa, found that use of crack cocaine, methamphetamine and other drugs to facilitate sexual encounters is common among men who have sex with men (Parry et al., 2008). Although common in sub-Saharan Africa, homo- sexual behaviour is highly stigmatized in the region. More than 42% of men who have sex with men surveyed in Botswana, Malawi and Namibia reported experiencing at least one human rights abuse, such as blackmail or denial of housing or health care (Baral et al., 2009).
More than 30 countries in sub-Saharan Africa have laws prohibiting same-sex activity between consenting adults (Ottosson, 2009). Punishments
Source: Smith et al. (2009) and Baral (2009). 0 10 20 30 40 50 Botsw ana Mala wi Nam ibia Sout h Afri ca Zam bia Keny a Unite d Re publ ic of Ta nzan ia Ugan da Côte d'Iv oire Ghan a Nige ria Mau ritani a Sene gal Southern Africa H IV p re va le nc e (% )
East Africa West Africa
HIV prevalence among men who have sex with men in countries in sub-Saharan Africa, 2000–2008
for violations of anti-sodomy laws are often severe, with several countries authorizing the death penalty and others providing for criminal penal- ties in excess of 10 years imprisonment (Ottosson, 2009). In contrast with some other regions, no trend towards the repeal of such laws is visible in sub-Saharan Africa. In April 2009, Burundi enacted the country’s first prohibition of consensual sexual contact between members of the same sex.
Injecting drug use
Although less extensively studied than other key populations, injecting drug users in sub-Saharan Africa appear to be at high risk of HIV infection. In the region as a whole, an estimated 221 000 injecting drug users are HIV-positive, representing 12.4% of all injecting drug users in the region (Mathers et al., 2008). In Ghana, a modelling exercise suggested that injecting drug users had an estimated annual seroincidence rate of 4.0% in 2008 (Bosu et al., 2009). In 2007, 10% of injecting drug users surveyed in the Kano region of Nigeria tested HIV-positive (Federal Ministry of Health, 2007). In Nairobi, 36% of injecting drug users surveyed tested HIV-positive (Odek-Ogunde et al., 2004). Survey-based estimates of HIV prevalence among injecting drug users in other African coun- tries range from 12.4% in South Africa to 42.9% in Kenya (Mathers et al., 2008).
The lack of reliable evidence on the size of national populations of injecting drug users inhibits the development of sound prevention strategies (see Bosu et al., 2009). In Nigeria, researchers found evidence of injecting drug use in all regions of the country, but no indication of the existence of specific HIV prevention and treatment services for drug users (Adelakan & Lawal, 2006). While studies have often found elevated levels of HIV infection among communities of injecting drug users in sub-Saharan Africa, this form of transmission appears to be significantly outweighed by sexual transmission with respect to prevalent and incident infections. In Kenya, transmis- sion during injecting drug use accounted for an estimated 3.8% of new HIV infections in 2006 (Gelmon et al., 2009).