Writes Enrique Restoy, What’s Preventing Prevention Campaign Manager.
In many countries in Africa, where the HIV and AIDS epidemic is widespread across society, populations widely seen as most-at-risk of contracting HIV/AIDS (generally considered to be sex workers, men who have sex with men, and drug users) are often regarded as ‘negligible’ from an epidemiological point of view.
As a consequence, very little effort is made to provide focused HIV interventions for these groups who in turn are also often excluded from mainstream HIV prevention services and programmes. Across Africa, only around 0.1% of total expenditure for HIV prevention programmes and services focuses on men who have sex with men as according to the Global HIV Working Group.
However, transmission rates and HIV prevalence among these populations, regardless of their size, can be up to around 10 times higher than across wider society, as it is the case in Kenya, Malawi, Nigeria or Sudan; and more than 12 times in Ghana and Senegal, according to an epidemiological review by Beyrer.
This contradiction can be explained to a large extent by a worrying growing context of discrimination and stigma and even hatred towards these groups, especially men who have sex with men across the continent. This pattern has extended to public policy and legislation in the form of sodomy laws or the criminalisation of homosexuality, and fuelled acts of violence against these groups in countries like Burundi, Uganda, Kenya or Malawi. Mounting social and political rejection has also magnified the notion that these groups are a class apart, isolated from the rest of society. But they are not.
Hidden by stigma
Although often hidden by social stereotypes and hypocrisy, the interaction between most at risk populations and wider society in terms of HIV transmission is evident. For instance, recent research based on mathematic models shows that virtually in any country, including African settings like Kenya, where HIV prevalence is much higher among the heterosexual population, investing heavily in HIV programmes for men who have sex with men does have a positive effect in the reduction of HIV prevalence, not only within the men who have sex with men population, but among the general population too. Watch Stefan Baral, from the Johns Hopkins School of Public Health, present on The Global HIV Epidemic Among MSM: What is Going on in Low- and Middle-Income Countries?
The combination of this interaction between most at risk populations and general society from the point of view of HIV and the social alienation of some most-at-risk populations increases dangerously the vulnerability of other populations in Africa, among who married women in monogamous relationships are particularly at risk. More and more African men who have sex with men are forced to hide their sexual orientation into heterosexual marriage, and married clients of sex workers continue to be exposed to HIV more and more as these workers are excluded from adequate HIV prevention interventions.
Social constructs and assumptions about married women in many parts of Africa put these women and their children in a situation of utter vulnerability to HIV, which often goes unattended by policy makers and HIV response implementers. Married women often lose control over their sexuality and are not supposed to demand safe sex from their partners as that would entail suspicion of their partner’s sexual behaviour outside marriage. Read Cultural barriers prevent Zambian women from protecting themselves against HIV and Experts tackle HIV within married and cohabiting couples, from our Key Correspondents for more.
The level of isolation and vulnerability of marred women is multiplied if they become HIV positive. Automatically, these women will suffer the stigma and rejection society reserves for other categories of most at risk populations not only around them, but in their own households too.
Ultimately the more stigma and discrimination against men who have sex with men, sex workers and other populations grow in society, the less access these populations will have to HIV pretention and treatment and the more exposed and vulnerable not only these groups, but also others like married women and their children will be and the more at risk the entire society will be.
The Alliance’s What’s Preventing Prevention? campaign calls for donors and governments to identify vulnerabilities and risk specific to the context where they operate and reach out for the most vulnerable groups to uphold their rights and guarantee their access to adequate HIV treatment and prevention.