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.