Utilizing individual level data to assess the relationship between prevalent HIV infection and punitive same sex policies and legal barriers across 10 countries in Sub-Saharan Africa
BACKGROUND: Gay men other men who have sex with men(MSM) have consistently been shown to be disproportionately affected by HIV across epidemic settings in Sub-Saharan Africa. Evidence from systematic reviews suggests the association of legislation and engagement in HIV services, however empiric, individual-level data, to assess this relationship remains limited. In response, the aims of this study are to use individual data from MSM from ten different countries across Sub-Saharan Africa to examine the relationship between HIV and legal environments.
METHODS: Respondent driven sampling was used to recruit 8,113 MSM over the period of 2011-2018 across 10 countries: Burkina Faso, Cameroon, Côte dâ??Ivoire, Gambia, Guinea-Bissau, Nigeria, Senegal, eSwatini, Rwanda, and Togo. Interviewer-administered socio-behavioral questionnaires and biological testing for HIV were conducted. Same-sex policy categorization was based on ILGA defined legal approach: Not criminalized and not protected; criminalized(< 8 years imprisonment); and severe criminalization(>10 years imprisonment). Legal barriers to civil-society-organizations(CSO) is defined as legal barriers to the registration or operation of sexual orientation-related CSOs. Individual-level data were pooled across countries and multivariable logistic regression models used to measure the association between legal status and HIV.
RESULTS: HIV prevalence among MSM in contexts without criminalization was 8.4%(567/3170);19.7%(341/1729) in criminalized settings; and 51.8%(422/815) in severely criminalized setting(Table 1). Same sex policies was associated with HIV(p-value<0.001). When compared to non-criminalized settings, criminalized(aOR:2.31;95%CI:1.06,5.03), and severely criminalized settings(aOR:8.10;95%CI:5.3112.34) were associated with increased odds of HIV. Legal barriers to CSO engagement was associated with increased odds of HIV(aOR:5.59;95%CI:3.41,9.17).
CONCLUSIONS: Consistently, same-sex policies was associated with prevalent individual HIV infection MSM with the magnitude of this relationship the strongest in the most punitive settings. These results provide empiric data of how laws potentiate suboptimal individual HIV outcomes among MSM across Sub-Saharan Africa and the potential for decriminalization to optimize HIV prevention efforts.
C. Lyons * (1), D. Diouf (2), J.O. Twahirwa Rwema (1), S. Kouanda (3), A. Simplice (4), A. Kouame (5), Z. Mnisi (6), U. Tamoufe (7), B. Cham (8), I. Ba (2), M.A. Djaló (9), T. Mothopeng (10), I.M. Njindam (11), J. Loum (8), S. Matse (12), J.P. Enama (13), E.-P. Obodou (14), E. Karita (15), R. Nowak (16), T. Crowell (17), O. Ky-Zerbo (18), C. Beyrer (1), S. Baral (1)
(1) Johns Hopkins School of Public Health, Epidemiology, Baltimore, United States, (2) Enda Sante, Dakar, Senegal, (3) Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso, (4) ONG Arc-en-Ciel, Lome, Togo, (5) Ministère de la Sante et de lâ??Hygiène Publique, Abidjan, Cote D''Ivoire, (6) Ministry of Health, Health Research Department, Strategic Information Division, Mbabane, Eswatini, (7) Metabiota, Yaoundé, Cameroon, (8) ActionAid, Banjul, Gambia, (9) Enda Santé, Bissau, Guinea-Bissau, (10) Peopleâ??s Matrix Association, Maseru, Lesotho, (11) Johns Hopkins School of Public Health, Yaounde, Cameroon, (12) Health Research Department, Mbabane, Eswatini, (13) The Pact, Yaounde, Cameroon, (14) Enda Sante, Abidjan, Cote D''Ivoire, (15) Project San Fancisco, Kigali, Rwanda, (16) University of Maryland, Institute of Human Virology, Baltimore, United States, (17) Walter Reed Army Institute of Research, U.S. Military HIV Research Program, Silver Spring, United States, (18) Programme d''Appui au Monde Associatif et Communautaire, Ouagadougou, Burkina Faso