An assessment of stigma and human right violations among men who have sex with men in Abuja, Nigeria.

BACKGROUND: There have been several barriers in effectively engaging men who have sex with men for STI/HIV prevention and treatment programming in Nigeria including social stigma, policies, and laws criminalizing same-sex practices. The objective of this study was to describe the human rights context for MSM in Abuja and characterize factors associated with having had a genital ulcer disease in the previous 12 months, a health outcome associated with increased risk of HIV acquisition and transmission. METHODS: A convenience sample of 297 men reporting ever having had anal intercourse with another man participated in the study in 2008. A structured survey instrument including sexual risk behaviour for STI/HIV, disclosure of sexual orientation, perceived and enacted human rights violations were performed. Descriptive and inferential data analyses were conducted using Stata11 software. RESULTS: 36% reported having been discriminated due to sexual orientation and 17% reported being afraid to walk the streets of their community. Enacted rights violations included 41% having been blackmailed, 36% been beaten, 13% been denied housing, and 11% been jailed due to sexual orientation. Having been blackmailed due to sexual orientation (aOR 3.40, 95%CI: 1.35-8.56) was significantly associated with reporting having had a genital ulcer in the last 12 months. Having been beaten due to sexual orientation (aOR 2.36, 95%CI:0.96-5.82) was moderately significantly associated with reporting having had a genital ulcer in the last 12 months. CONCLUSIONS: High levels of experienced stigma, discrimination and human rights violations among MSM in Abuja was reported, constituting structural risks that are linked to sexual risk behaviour for STI/HIV. Given data on the high prevalence and incidence of HIV among MSM in Abuja, these findings reinforce the need for structural interventions to mediate access to STI/HIV prevention and treatment services.

The Synergistic Impact of Sexual Stigma and Psychosocial Well-Being on HIV Testing: A Mixed-Methods Study Among Nigerian Men who have Sex with Men.

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013-February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Individual and Network Factors Associated With HIV Care Continuum Outcomes Among Nigerian MSM Accessing Health Care Services.

BACKGROUND AND SETTING: Because data on the determinants of the HIV care continuum from key populations such as men who have sex with men (MSM) in resource-limited settings are limited, the study aimed to characterize HIV care continuum outcomes and assess individual and network barriers to progression through the HIV care continuum among MSM in Abuja and Lagos, Nigeria. METHODS: TRUST/RV368 study used respondent-driven sampling to accrue MSM into community-based clinics in Nigeria. Participants received HIV testing at enrollment. HIV-infected participants were offered antiretroviral therapy (ART) with HIV RNA testing every 3 months (Abuja) or 6 months (Lagos). Multiple logistic regression models were used to calculate adjusted odds ratios for factors associated with each point in the HIV care continuum, including HIV testing, ART initiation, and 6-month viral suppression. RESULTS: A total of 1506 MSM were recruited, 1178 (78.2%) tested for HIV and 369 (31.3%) were HIV positive newly diagnosed. Of these, 188 (50.1%) initiated ART, 136 (72.3%) completed 6 months, and 96 (70.6%) were virally suppressed. Larger network size and stronger social network support were each positively associated with HIV testing uptake. Factors associated with ART initiation were higher education and stronger social network support. Having stronger social network support was associated with increased odds of viral suppression at 6 months. CONCLUSIONS: Social determinants of health potentiated increased HIV care continuum outcomes. Integration of HIV prevention, HIV counseling and testing services, and universal coverage of ART into a community-based clinic is critical in achieving better HIV care continuum outcomes.

Sexual Stigma Patterns Among Nigerian Men Who Have Sex with Men and Their Link to HIV and Sexually Transmitted Infection Prevalence.

Sexual stigma facilitates the spread of HIV and sexually transmitted infections (STIs) but little is known about stigma affecting Nigerian men who have sex with men (MSM). We assessed patterns of sexual stigma across Nigerian MSM and their relationship to HIV and STIs. Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 Nigerian MSM enrolled from March 2013 to February 2016 using respondent driven sampling. Structural equation modeling was utilized to assess the association between stigma classes and HIV and STI prevalence, adjusting for participants' characteristics. A dose-response association was found between stigma class and HIV prevalence (27, 40, 55%, overall χ2 p < 0.001) and STI prevalence (15, 21, 24%, overall χ2 p = 0.011). These data suggest that stigma mitigation strategies, combined with increased engagement of MSM and retention in the HIV care continuum, need to be a component of interventions focused on reducing HIV transmission risks among MSM in Nigeria.

Pathways from sexual stigma to incident HIV and sexually transmitted infections among Nigerian MSM.

OBJECTIVES: Sexual stigma affecting MSM in Nigeria may be an important driver of HIV and other sexually transmitted infections (STIs), but potential mechanisms through which this occurs are not well understood. This study assessed the contributions of suicidal ideation and sexual risk behaviors to causal pathways between stigma and HIV/STIs. DESIGN: Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 MSM from Abuja and Lagos, Nigeria. METHODS: Participants enrolled from March 2013 to February 2016 were classified into three stigma subgroups based on a latent class analysis of nine stigma indicators. Path analysis was used to test a model where disclosure led to stigma, then suicidal ideation, then condomless sex with casual sex partners, and finally incident HIV infection and/or newly diagnosed STIs, adjusting the model for age, education, having had female sex partners in the past 12 months, and sex position. Both direct and indirect (mediational) paths were tested for significance and analyses were clustered by city. RESULTS: As stigma increased in severity, the proportion of incident HIV/STI infections increased in a dose-response relationship (low: 10.6%, medium: 14.2%, high 19.0%, P = 0.008). All direct relationships in the model were significant and suicidal ideation and condomless sex partially mediated the association between stigma and incident HIV/STI infection. CONCLUSION: These findings highlight the importance of the meaningful integration of stigma-mitigation strategies in conjunction with mental health services as part of a broader strategy to reduce STI and HIV acquisitions among Nigerian MSM.

Towards Equity in Service Provision for Gay Men and Other Men Who Have Sex with Men in Repressive Contexts.

Chris Beyrer and colleagues reflect on an underappreciated trend in multiple African, Asian, and Caribbean settings, in which the provision of HIV and other essential health services for sexual and gender minorities is expanding despite challenging legal and social environments.

Serosorting and Sexual Risk for HIV Infection at the Ego-Alter Dyadic Level: An Egocentric Sexual Network Study Among MSM in Nigeria.

The objective of this egocentric network study was to investigate engagement in serosorting by HIV status and risk for HIV between seroconcordant and serodiscordant ego-alter dyads. Respondent-driving sampling was used to recruit 433 Nigerian men who have sex with men (MSM) from 2013 to 2014. Participant (ego) characteristics and that of five sex partners (alters) were collected. Seroconcordancy was assessed at the ego level and for each dyad. Among 433 egos, 18 % were seroconcordant with all partners. Among 880 dyads where participants knew their HIV status, 226 (25.7 %) were seroconcordant, with 11.7 % of HIV positive dyads seroconcordant and 37.0 % of HIV negative dyads seroconcordant. Seroconcordant dyads reported fewer casual sex partners, less partner concurrency, and partners who had ever injected drugs, but condom use did not differ significantly. Serosorting may be a viable risk reduction strategy among Nigerian MSM, but awareness of and communication about HIV status should be increased. Future studies should assess serosorting on a partner-by-partner basis.

The immediate eff ect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort.

BACKGROUND: In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria. METHODS: The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with χ2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression. FINDINGS: Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0・0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0・001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2・57, 95% CI 1・29­5・10; p=0・007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0・013). INTERPRETATION: These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment. FUNDING: National Institutes of Health.

Evaluating respondent-driven sampling as an implementation tool for universal coverage of antiretroviral studies among men who have sex with men living with HIV.

INTRODUCTION: The TRUST model based on experimental and observational data posits that integration of HIV prevention and universal coverage of antiretroviral treatment at a trusted community venue provides a framework for achieving effective reduction in HIV-related morbidity and mortality among men who have sex with men (MSM) living with HIV, as well as reducing HIV incidence. The analyses presented here evaluate the utility of respondent-driven sampling as an implementation tool for engaging MSM in the TRUST intervention. METHODS: The TRUST integrated prevention and treatment model was established at a trusted community center serving MSM in Abuja, Nigeria. Five seeds have resulted in 3-26 waves of accrual between March 2013 and August 2014, with results presented here characterizing HIV burden and engagement in HIV care for 722 men across study recruitment waves. For analytic purposes, the waves were collapsed into 5 groups: 4 equally spaced (0-4, 5-9, 10-14, and 15-19) and 1 ranging from the 20th to the 26th wave with significance assessed using Pearson χ2 test. RESULTS: In earlier waves, MSM were more likely to have reported testing for HIV (82.9% in waves 0-4, 47.7% in waves 20-26; P < 0.01). In addition, biologically confirmed HIV prevalence decreased from an average of 59.1% to 42.9% (P < 0.05) in later waves. In earlier waves, about 80% of participants correctly reported their HIV status as compared with less than 25% in the later waves (P < 0.01). Finally, participants reporting being on ART decreased from 50% to 22.2% in later waves (P < 0.01). CONCLUSIONS: Implementation science studies focused on demonstrating impact of universal HIV treatment programs among people living with HIV necessitate different accrual methods than those focused on preventing HIV acquisition. Here, respondent-driven sampling was shown to be an efficient method for reaching marginalized populations of MSM living with HIV in Nigeria, and engaging them in universal HIV treatment services.

Uptake of treatment as prevention for HIV and continuum of care among HIV-positive men who have sex with men in Nigeria.

BACKGROUND: Experimental evidence has shown that treatment of HIV infection with antiretroviral therapy (ART) prevents heterosexual transmission of HIV to an uninfected partner. However, the "real-world" application of this strategy to key populations such as men who have sex with men (MSM) has been limited. We report findings on acceptability of a treatment as prevention (TasP) strategy among HIV-infected MSM at a Trusted Community Center providing comprehensive HIV prevention and treatment services to MSM in Abuja, Nigeria. METHODS: Using respondent-driven sampling (RDS), MSM who were 16 years and older and have engaged in either receptive or insertive anal intercourse within the previous 12 months were recruited into a prospective combination HIV prevention and treatment study (TRUST). Two weeks after enrollment, HIV testing and counseling was conducted. At each 3-month follow-up visits, HIV-infected individuals underwent clinical and laboratory evaluation, including CD4 count, plasma HIV viral load, immediate 3 weekly sessions of ART preparation, and then ART initiation per TasP strategy irrespective of CD4 count. Reasons for not engaging in pre-TasP preparation and TasP were documented. Characteristics associated with TasP engagement and loss to follow-up (LTFU) were determined using logistic and Cox regression, respectively. RESULTS: Of 186 HIV-positive MSM enrolled, 58 (31.2%) were on ART at the time of recruitment, whereas 128 (68.8%) were ART-naive and provided opportunity for engaging TasP. Of these, 70 (54.7%) engaged in TasP. Compared with MSM who did not engage in TasP, those who engaged had significantly lower mean CD4 count (P = 0.001), were more likely to be Christian (P = 0.01), and had disclosed being MSM to family (P = 0.02) or health care providers (P = 0.02). In multivariate models, disclosure of being MSM to health care providers remained significantly associated with uptake of TasP. Among individuals engaged in TasP, 10% were LTFU in care at 18 months since enrollment. Being engaged in TasP (relative hazards = 0.08, P < 0.001) and on ART (relative hazards = 0.17, P < 0.001) were associated with decreased risk of LTFU. CONCLUSIONS: Although there was high acceptance of HIV testing and low LTFU among individuals who were already on ART or engaged in TasP, a higher than expected proportion did not engage in TasP, suggesting the need for customized treatment preparation and an increase in enabling environments to support HIV treatment access with this key population.

Associations of consistent condom use among men who have sex with men in Abuja, Nigeria.

The objective of the study was to characterize factors associated with consistent condom use among men who had sex with men (MSM) in Abuja, Nigeria. A convenience sample consisting of 297 MSM was recruited during 2008 using a combination of peer referral and venue-based sampling. Descriptive statistics with chi square and t-test were used for demographic, sexual identity, and practices variables. Univariate and multivariate logistic regressions were used to identify factors associated with consistent condom use with male partners in the past 6 months. Approximately more than half (53%, n=155/290) reported always using condoms with male partner in the past 6 months and 43% (n=95/219) reported always using condoms with female partners in the past 6 months. In all, 11% (n=16/144) reported always engaging in safe sex defined as always using condoms with both male and female partners and always using a water-based condom compatible lubricant with male partners in the past 6 months. Independent associations with consistent condom use with male partners in the past 6 months were knowledge of at least one sexually transmitted infection (STI) that can be transmitted through unprotected anal intercourse (OR 2.47, 95% CI: 1.27-4.83, p<0.01) and having been tested for HIV (OR 2.40, 95% CI: 1.27-4.54, p<0.01). MSM who had been HIV tested at least once were more likely to use condoms consistently during anal intercourse in multivariate analyses. In addition, STI knowledge was also associated with consistent condom use during anal intercourse implying that interventions targeting high-risk practices are effective as HIV prevention for this high-risk group. Future directions include intervention research to determine the appropriate package of services for MSM in Nigeria. In addition, implementation science evaluations of how best to operationalize combination HIV prevention interventions for MSM given the criminalization and stigmatization of same-sex practices are crucial.