Elsevier

The Lancet HIV

Volume 2, Issue 7, July 2015, Pages e299-e306
The Lancet HIV

Articles
The immediate effect 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

https://doi.org/10.1016/S2352-3018(15)00078-8Get rights and content

Summary

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 1·29–5·10; p=0·007); loss to follow-up and incident health-care 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.

Introduction

Worldwide, gay men and other men who have sex with men (MSM) are disproportionately affected by HIV.1, 2 In the past few years, data have shown that HIV disparities between MSM and other men observed in the USA and Europe since the start of the pandemic are also present in low-income and middle-income settings.3 In sub-Saharan Africa, HIV prevalence is four times greater in MSM than in other men.1, 3 These health inequities have raised awareness among community groups, donors, public health practitioners, researchers, and national AIDS programmes of the urgent need to improve HIV prevention and treatment services for MSM across the continent.4, 5, 6 However, alongside increased attention to the needs of MSM is a growing social and political pushback to sexual and gender minority rights in many low-income and middle-income countries.

MSM across many countries in sub-Saharan Africa face stigma and discrimination, and anti-sodomy laws date back to the colonial era.7, 8, 9, 10 Targeted hate crimes and new legislation criminalising same-sex practices in several countries continue to undermine the human rights of lesbian, gay, bisexual, and transgender (LGBT) individuals.7 Policies further criminalising same-sex practices or the community groups addressing the health-related needs of these populations might further restrict coverage of HIV prevention, treatment, and care programmes.11, 12, 13, 14

Research in context

Evidence before this study

A systematic review about structural determinants of HIV-related risk emphasised the scarcity of evidence linking the criminalisation of same-sex practices with health-seeking behaviour and HIV-related health outcomes in men who have sex with men (MSM) worldwide. Ecological analyses have emphasised a link between the criminalisation of same-sex practices and insufficient investment in HIV-related surveillance and programming for MSM, together with some cross-sectional assessments of the association. Specifically, a cross-sectional, multicountry, internet-based survey reported a negative association between individual uptake of HIV testing and HIV prevention strategies and residence in countries with laws criminalising same-sex practices. Two other analyses have qualitatively documented the effect of criminalising policies on engagement in health care, including HIV services in MSM, in addition to concerns from health-care providers in these settings about the risks they take in providing services to MSM. Because of the challenges of data collection in the most stigmatising environments, quantitative data documenting the prospective effect of criminalising policies on HIV-related health outcomes for MSM are not available.

Added value of this study

We did these analyses as part of a prospective implementation study of MSM in Nigeria, which began 10 months before introduction of the Same-Sex Marriage Prohibition Act. This is the first study to assess quantitative outcomes related to engagement in HIV prevention, treatment, and care services in a cohort of MSM before and after anti-same-sex legislation was enacted, allowing for a natural examination of the immediate effect of this policy in MSM. We believe that these data are the most compelling reported so far, with characterisation of the negative effects of punitive legislation, including increased reported fear of seeking health services and lower retention in HIV prevention services in HIV-negative than HIV-infected MSM.

Implications of all the available evidence

Combined with results from previous ecological and cross-sectional studies, our findings reinforce the negative HIV-related health effects of anti-homosexuality legislation in young MSM with a high HIV prevalence and incidence. Urgent efforts to characterise safe and trusted HIV prevention and treatment services are needed, particularly in countries with discriminatory legal environments, to minimise the risks of HIV acquisition and transmission and finally achieve an AIDS-free generation.

In Nigeria, the Same-Sex Marriage Prohibition Act was passed by the Senate in 2011, and then by the House of Representatives in July, 2013.15 The bill was signed into law on Jan 7, 2014.16 Before this legislation, consensual sex between male same-sex couples was already prohibited in Nigeria under anti-sodomy laws enacted in the colonial era, and same-sex marriages were not legally recognised.17 The new law further criminalised same-sex practices, including prohibiting participation in organisations, service provision, or meetings that support gay people, and punishes attempts to enter civil unions or publicly show same-sex amorous relationships.18

Although an environment hostile to the rights of the LGBT community existed before enactment of new legislation, the public announcement of the Same-Sex Marriage Prohibition Act in Nigeria was followed by multiple arrests and reports of torture.19, 20 Acts of violence against gay men and other MSM have also been reported in other countries with policies against same-sex intimate behaviours and might result in fear of accessing health services.7 However, few non-ecological data are available, and no prospective data exist assessing the effect of legislation against homosexuality on health outcomes. Furthermore, in Nigeria and other countries criminalising same-sex relationships, investments in HIV/AIDS funding for programmes intended to reach MSM have been scarce.21 We did this study to assess the immediate effect on stigma, discrimination, and engagement in HIV prevention and treatment services in MSM prospectively followed up before and after the passing of the Same-Sex Marriage Prohibition Act in Nigeria.

Section snippets

Study design and participants

MSM in Abuja, Nigeria, were recruited into the TRUST cohort study with respondent-driven sampling. The purpose of the TRUST study is to assess the feasibility and effectiveness of engagement of MSM from Abuja into HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community (the TRUST model). Respondent-driven sampling uses peer referral methods to recruit and enrol eligible study participants and has been previously described.

Results

Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures at visit 0. MSM enrolled before legislation had lower levels of education, were more likely to be Muslim, were more likely to be married or living with a woman, and were less likely to be unemployed than MSM enrolled after legislation (table 1). MSM in the postlaw period were also less likely to have been previously tested for HIV (table 1). Overall 404 (57%) MSM returned to complete the remaining

Discussion

Gay men and MSM in Abuja, Nigeria, experienced increased stigma and discrimination in the period immediately after the signing of the Same-Sex Marriage Prohibition Act. Reports of fear of seeking health care, avoidance of health care, absence of safe spaces to socialise with other MSM, blackmail, and verbal harassment remained steady in the months of enrolment and follow-up before the law, then immediately increased in the post-law period. When limited to participants with available follow-up

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