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MSM and HIV/AIDS in sub-Saharan Africa

In sub-Saharan Africa, a number of studies have highlighted how men who have sex with men (MSM) are disproportionately affected by the HIV epidemic. In this region, HIV prevalence is estimated to be three to four times higher for this group than among the general population. 1

This is due to a number of factors including sexual risk behaviours (unprotected anal intercourse and multiple partners), network factors (e.g. sex work) as well as a lack of knowledge about HIV transmission risks and access to prevention services. Many MSM in sub-Saharan Africa do not have safe access to HIV services and information, with some countries not including their needs in national HIV prevention programmes, or make homosexuality illegal.

As a result, MSM face a myriad of political, social and cultural barriers which present significant challenges to addressing the epidemic among this group. 2

MSM, homophobia and HIV in sub-Saharan Africa

The criminalisation of homosexuality and the stigmatisation of MSM in sub-Saharan Africa make the monitoring, assessment and programming of the HIV and AIDS epidemic among this group complicated. 3

At an individual level, homophobia has been found to lead to increased unprotected anal intercourse among men not previously diagnosed with HIV, and higher risk sexual behaviour among men who already knew they were living with HIV. 4 This has serious implications for HIV transmission both among MSM and the wider population.

Anti-homosexuality laws in Africa

Anti-homosexuality laws often contradict the constitutions of many countries in sub-Saharan Africa and their commitment to human rights. 5 The AIDS Coalition in New York protesting against the Anti-Homosexuality Bill in Uganda

Currently, 38 of the 54 countries on the African continent (see table below) have laws which make homosexuality a criminal offence. However, these laws, and the punishments that accompany them, differ markedly both between countries and sometimes, within countries themselves (e.g. Nigeria). 6 Most recently, Uganda passed the Anti-Homosexuality (or "Bahati Bill"), which enforces life imprisonment for 'aggravated homosexuality' and includes lesbians for the first time. 7

Imprisonment is the most common form of punishment, the term of which can vary dramatically depending on the country - from 10 days in Eritrea, to a life sentence in Sierra Leone. Other punishments include the death penalty, flogging, hard labour or a fine. The type of punishment and its severity is ruled in accordance with the details of an offence (e.g. public/private; with a minor; against ‘the will’ of another person; a repeated act; whether the act involved actual intercourse or gross indecency). 8

Even in countries that do not have laws against homosexuality, stigma and discrimination still occurs, and in some cases, MSM are still subject to arrest for crimes such as vagrancy (e.g. political demonstration, rioting, loitering). 9

Homosexuality is not criminalised in all countries. There is no specific legislation outlawing homosexual acts in 12 African countries, while gay rights are formally recognised in South Africa. 10

African anti-homosexuality laws and respective punishments

CountryPunishmentTerm
AlgeriaImprisonment2 months - 2 years
AngolaLabour campN/A
BotswanaImprisonmentup to 5 years
BurundiImprisonment3 months - 2 years
CameroonImprisonment6 months - 5 years
ComorosImprisonment1 year - 5 years
EgyptImprisonment6 months - 5 years
EritreaImprisonment10 days - 3 years
EthiopiaImprisonment10 days - 15 years
GambiaImprisonmentup to 14 years
GhanaImprisonment5 years - 25 years
GuineaImprisonment6 months - 3 years
KenyaImprisonmentup to 21 years
LesothoCommon law offenceN/A
LiberiaFirst degree misdemeanorup to 1 year
LibyaImprisonmentup to 5 years
MalawiImprisonmentup to 14 years
MauritaniaDeath by public stoningN/A
MauritiusImprisonment with
hard labour
up to 5 years
MoroccoImprisonment6 months - 3 years
MozambiqueLabour camp6 months - 3 years
NambiaCommon law offenceN/A
NigeriaFederal Law: Imprisonment [*In Northern Nigeria - Sharia Law]up to 14 years [*Death penalty (for men); imprisonment or whipping (for women)]
São Tomé and PríncipeLabour campN/A
SenegalImprisonment1 year - 5 years
SeychellesImprisonmentup to 14 years
Sierra LeoneImprisonmentFor life
SomaliaImprisonment3 months - 3 years
South SudanImprisonmentup to 10 years
SudanFlogging and imprisonment [Death penalty or life imprisonment for third offence]up to 5 years [or life imprisonment]
SwazilandCommon law offenceN/A
TanzaniaImprisonmentup to life imprisonment
TogoImprisonment1 year - 3 years
TunisiaImprisonment3 years
UgandaImprisonment7 years - life imprisonment
ZambiaImprisonment7 years - life imprisonment
ZimbabweImprisonmentup to 1 year

The impact of homophobia on MSM in sub-Saharan Africa

Homophobia and other forms of stigma and discrimination prevent many MSM from disclosing their sexuality, condemning them to a life of secrecy. In fact, many MSM have girlfriends, are married, and in some cases, have children. 11

One study of MSM in Cameroon found that 49 percent of participants had sex with a woman in the last 6 months. Moreover, 29 percent had at least one child, and 13 percent were married. 12 Likewise, a 2006 study of 88,738 men attending VCT clinics in Kenya reported that of the 780 people who identified themselves as MSM, 69 percent reported having had sex with a woman. 13 These complex sexual networks of MSM mean that they act as a 'bridge population', transmitting HIV among the general population as well. 14

Alternatively, men who choose to live an open life, or who are exposed and identified as MSM, are often subject to unrelenting stigma and discrimination, which can have profound effects on their life. 15 16 17

Attacks, random arrests and murder have been reported across the region. 18 This reinforces feelings of fear and anxiety among MSM which deter many from seeking and accessing vital HIV prevention, treatment and care services.

Most of us choose to stay home and wait for our fate rather than go to hospital and face discrimination19Anonymous homosexual man living in Kenya

High profile examples of homophobia in sub-Saharan Africa

Over the past decade there have been a number of reports of hostility towards MSM in sub-Saharan Africa. Listed below are some of the high profile ones.

Uganda: David Kato, an LGBT rights activist considered the leader of Uganda's gay rights movement, was murdered in 2011 following a lawsuit he won against a magazine which had published his name and photograph identifying him as gay and calling for him to be executed. 20

A Ugandan newspaper headline

Senegal: In February 2008, the "gay marriage scandal" saw police round up men suspected of being homosexual after a Senegalese newspaper published photographs of a secret gay wedding in Dakar. Since then, there have been a host of instances where MSM have been attacked and accused of organising weddings. 21

Malawi: In December 2009, two men in Malawi were arrested after holding an engagement ceremony. The men were reportedly beaten and one was forced to undergo an anal examination in an effort to prove they had engaged in homosexual acts. 22

Nigeria: In Abuja, Nigeria 12 MSM were attacked by a group who dragged them from their homes and beat them with nail studded clubs and whips. They claimed that they were "cleansing the community". 23

High-risk behaviour among MSM in sub-Saharan Africa

The level of stigma and discrimination faced by MSM can lead many to engage in behaviours, which put them at risk of HIV transmission.

  • Injecting drug use

For example, a number of studies have pointed to a growing number of MSM in sub-Saharan Africa who inject drugs

One study of three South African cities showed how injecting drug use was leading to low condom use as well as a number of other high-risk sexual activities despite a good level of HIV knowledge among MSM. 24

This is a particular problem in sub-Saharan Africa, which lags behind other regions in the implementation and scale-up of harm reduction initiatives for people who inject drugs (PWID). 25

  • Sex work

In other cases, homophobia and other forms of stigmatisation can leave some MSM economically vulnerable. They may lose their jobs, their homes, and be forced out of their communities, resorting to sex work for financial reasons.

A study from Mombassa, Kenya, which illustrated the high vulnerability to HIV infection among MSM, found 739 MSM who sold sex in the city, and were in vital need of HIV prevention services. 26

MSM who engage in these practices are at risk of becoming infected with HIV if they do not take preventative measures such as using condoms.

Homophobia and access to HIV services

Stigma and discrimination in society, the enforcement of anti-homosexuality laws, as well as an increase in high-risk sexual behaviour make MSM in sub-Saharan Africa difficult for HIV service providers to reach.

With little access to HIV information, especially in traditional heath settings, there is a lack of knowledge about how HIV is transmitted, risk behaviours (e.g. multiple partners), how to practice safe sex (particularly anal sex) and how to access HIV treatment, support and care. 27

For example, a study from Nigeria of over one thousand MSM found that 31 percent believed that HIV is less likely to be transmitted during sex between men, than during sex with a woman. 28 Anal sex carriers a higher risk of HIV transmission than vaginal sex.

Low usage of condoms and lubricants is also commonly reported among MSM in sub-Saharan Africa. For example, a study from Douala and Yaounde, Cameroon, found 64 percent of MSM used condoms with regular male partners, falling to 48.5 percent with casual male and female partners. Only 26 percent reported using the appropriate lubricants with their condoms. 29

A GMHR survey found that across sub-Saharan Africa, only a small proportion of MSM are able to access free or low-cost HIV services. These services include affordable condoms (47 percent), the appropriate lubricants (19 percent), HIV testing (48 percent), antiretroviral treatment (27 percent) and HIV education materials for MSM (14 percent). 30

However, in many places, affordable condoms and lubricant are difficult to access. 31 A report on HIV prevention and care interventions in Senegal highlighted the difficulty of accessing water-based lubricants in particular. 32 Shop attendant advertises condoms at a medicine shop in Ghana

Non-governmental organisations that deliver basic HIV and sexual health education to MSM are often subject to harassment, particularly in countries that criminalise same-sex partnerships. Indeed, there have been numerous accounts where the staff of HIV and lesbian, gay, bisexual and transgender (LGBT) organisations have been targeted by domestic authorities. 33 34

Following the high-profile arrest of nine HIV prevention workers in Senegal for “acts against nature”, many MSM no longer felt safe attending educational meetings. Social networks, which are vital for the mental health and well being of people who feel marginalised by society often disintegrate.

“MSM dare not receive or go to talks or to seek condoms. They continue to have unprotected sex…our association fell apart” - Member of an association for MSM in Senegal 35

MSM who are living with HIV also face discrimination because of their HIV status. 36 One study from Swaziland that assessed the fear of seeking healthcare and disclosing same-sex behaviours has highlighted the importance of including stigma reduction strategies in HIV prevention strategies. 37

These factors create an environment where HIV infection among many MSM remains undiagnosed and untreated. This has serious implications for those living with HIV who are at risk of early progression to AIDS as well as onward transmission to others, hampering efforts to fight the epidemic in sub-Saharan Africa. 38

“The barriers to access to HIV services, including education and support, stand before us like mountains - mountains of fear, mountains of prejudice, mountains of ignorance. These barriers, including those that come from within us, need to be overcome.” - Dr Paul Semugoma, Ugandan gay rights activist and medical doctor. 39

Why is there discrimination against MSM in sub-Saharan Africa?

Colonialism and the first anti-homosexuality laws

In sub-Saharan Africa, it is widely believed that homosexuality is a Western evil; an imported concept that is ‘un-African’. This belief is often used to justify homophobia and other forms of stigma and discrimination towards MSM. 40

However, a number of studies say this is actually a misconception, and that homosexuality existed in society prior to colonialism. Moreover, many of the anti-homosexual laws that are currently enforced throughout the region were initially implemented by colonial powers that encouraged intolerance of MSM. 41

The role of religious leaders

Religion, along with other cultural values, play a major role in justifying discrimination, particularly homophobia towards MSM.

Many religious leaders have publicly denounced sex between men as "immoral" and not deserving of attention or support from governments. 42 A study of churches in Zambia showed how HIV testing is sometimes mandatory before allowing marriage, and in other cases, how individuals living with HIV were excommunicated because they were deemed “sinners’’. 43

Their position of power and influence among communities has meant that these views are rarely, if ever opposed. As leaders of anti-gay marches, petitioners for anti-homosexuality bills, and outspoken critics of political leaders who support the rights of MSM, religious leaders have become one of the main drivers of homophobia in sub-Saharan Africa.

“Our politicians have great respect for religious leaders and are careful not to disagree with them, especially not on homosexuality…they pretend that homosexuals do not exist or that they can be 'cured' and communicate this message to the community” - Monica Mbaru, International Gay and Lesbian Human Rights Commission 44

Cooperation between people living with HIV and religious leaders is vital to successful faith-based HIV prevention in sub-Saharan Africa. 45

Government and media endorsement

Governments that continue to enforce anti-homosexuality laws legitimise the discrimination of MSM. 46

As a result, the media often supports these points of view. 47 For example, it has been reported that newspapers in Cameroon were printing the names of prominent members of the community they believe to be gay. 48

Desmond Tutu, Archbishop Emeritus of Cape Town and social rights activist

In countries where homosexuality is not criminalised, there are concerns over a lack of media coverage, which can prevent targeted HIV prevention and testing for vulnerable groups such as MSM. 49

By contrast, some religious leaders in sub-Saharan Africa support the rights of MSM and belong to organisations such as ‘The Other Sheep' that confront the stigma and discrimination individuals face based on their sexual orientation. 50

In 2010, Desmond Tutu, the Archbishop Emeritus of Cape Town, and a prominent advocate for the rights of MSM said:

Show me where Christ said, Love thy fellow man, except for the gay ones. Gay people, too, are made in my God's image 51

Preventing homophobia and discrimination of MSM in sub-Saharan Africa

It is widely acknowledged that in order to deliver effective HIV prevention, treatment and care to MSM in sub-Saharan Africa, a number of steps must be taken both by both domestic governments as well as local and international organisations.

The 20th annual Johannesburg Gay Pride, South Africa

Abolishing anti-homosexuality laws

Criminalisation of same-sex activity is often argued to be in violation of international human rights standards. 52

In sub-Saharan Africa, some countries even impose the death penalty for men convicted of having sex with men. Progress in this area has been inconsistent with many countries actually taking a step backwards, most recently Uganda.

A body of research has shown how outlawing this behaviour can increase the risk of MSM getting HIV. For example, in Caribbean countries where homosexuality is forbidden by law, 1 in 4 MSM are living with HIV. Where there are no such laws, it is only 1 in 15. 53

The abolition of anti-homosexuality laws could significantly reduce HIV prevalence among MSM throughout this region.

Anti-discrimination legislation and a right to sexuality

Even where same-sex relationships are not criminalised, governments often do not provide legal protection from discrimination on the basis of sexual orientation. 54 In some countries, laws allow young people to consent to heterosexual sex at a younger age than they allow minors to consent to homosexual sex. 55

Regardless of HIV status, the ability of high-risk groups such as MSM to express themselves sexually is essential to fulfilling their basic human rights. 56 For this reason, the provision of sexual health and HIV services for people living with HIV must be a priority, particularly in sub-Saharan Africa.

The way forward

Men who have sex with men (MSM) are one of the groups most affected by the HIV epidemic in sub-Saharan Africa.

However, high levels of homophobia, stigma and discrimination, and in many cases violence, deter many MSM from seeking the HIV services they need. The enforcement of anti-homosexuality laws as well as other punitive laws in many countries only serves to reinforce these views towards MSM and makes the implementation of HIV prevention measures targeting this group very challenging.

Only when these social, cultural and legal barriers are broken down will MSM as well as other members of the LGBT community feel able to access HIV-related treatment, care and support.

The failure to respond effectively has allowed HIV to reach crisis levels in many communities of men who have sex with men. Efforts to reverse this crisis must be evidence informed, grounded in human rights and underpinned by the decriminalisation of homosexuality...we must work together to end homophobia and ensure the barriers that stop access to HIV services are removed” - Michel Sidibé, Executive Director of UNAIDS 57

Where next?

References

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