Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a respondent-led multi-country sample survey
Background
There have been few evaluations of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM), especially in sub-Saharan Africa.
We aimed to examine HIV testing history, HIV status, and stigma among MSM living in ten countries with heterogeneous legal environments.
Methods
This study used pooled data from ten country-specific cross-sectional studies conducted at 25 sites in Burkina Faso, Cameroon, Côte d’Ivoire, Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda and Togo.
Men who have sex with men (MSM) were recruited through respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self-declaration that they were assigned male at birth. and had anal sex with a man in the last 12 months.
Policy related to same-sex sexual behavior for each country was classified as not criminalized or criminalized . Countries were also categorized based on recent reports of prosecutions involving same-sex sexual acts.
Legal barriers were defined as those that legally prevented the registration or operation of civil society organizations (CSOs) related to sexual orientation. Individual data on HIV testing history, HIV status, and stigma were collected through interviewer-administered sociobehavioral questionnaires and HIV testing.
Multilevel logistic regression with random intercepts was used to evaluate the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs.
Results
Between August 3, 2011 and May 27, 2020, we recruited 8,047 MSM with a median age of 23 years (IQR 21–27). 4886 (60·7%) lived in countries that criminalize same-sex sexual acts.
HIV prevalence among MSM was higher in criminalized settings than in non-criminalized settings (aOR 5·15, 95% CI 1·12–23·57); greater in environments with recent processing than in environments without processing (12·06, 7·19–20·25); and higher in environments with CSO barriers than without CSO barriers (9·83, 2·00–48·30).
HIV testing or state awareness were not associated with punitive policies or practices. Stigma was associated with HIV status, but did not vary consistently across legal settings.
Disparities in HIV prevalence between MSM and other adult men were highest in punitive environments.
Interpretation
Structural risks, including national-level discriminatory policies, prosecutions, and legal barriers, could contribute to higher HIV prevalence among MSM. Together, these data highlight the importance of decriminalization and reduced enforcement, along with stigma reduction , as central to effective HIV control.
In sub-Saharan Africa, punitive policies, enforcement practices, and legal barriers were associated with higher HIV prevalence among MSM in this study. These results provide individual empirical data showing how structural risks and discriminatory policies may contribute to HIV prevalence among MSM in sub-Saharan Africa.
The findings of this study highlight the potential effect of decreasing enforcement or decriminalization to optimize HIV prevention and treatment efforts. However, this study also highlighted the complexity of stigma affecting MSM, suggesting that policy reform alone will not eliminate stigma, but that interventions that address social and cultural factors could support a comprehensive reduction in stigma. stigma.
Added value of this study This study uses individual-level sociobehavioral and biological data from 8,047 MSM from ten countries in sub-Saharan Africa to understand the relationships of national-level policies, prosecutions, and legal barriers to HIV testing, prevalence, and status awareness among MSM. Our findings suggest that MSM living in countries that criminalize and enforce discriminatory policies around same-sex relationships have the highest burden of HIV. MSM living in countries that have recent prosecutions related to same-sex sexual acts still have elevated HIV prevalence compared to countries without recent prosecutions. Furthermore, the presence of legal barriers to the registration and operation of civil society organizations was associated with higher HIV prevalence. Implications of all available evidence This study contributes to existing evidence on understanding the role of harmful policies, such as criminalization, on HIV among MSM. Individual-level data from countries in sub-Saharan Africa have shown that structural risks, including national-level discriminatory policies, recent court cases, and legal barriers, may contribute to higher HIV prevalence among MSM. These results provide evidence that decriminalization of same-sex relationships, as well as decreasing the application of criminalizing policies, are essential for effective HIV control. |
Funding : National Institutes of Health.
