Assessment of the immediate HIV-related impact of the anti-gay law in Nigeria

S. Schwartz, I. Orazulike, R. Nowak, S. Kennedy, S. Ketende, K. Ugoh, B. Keshinro, J. Ake, O. Njoku, M. Charurat, W. Blattner, S. Baral

Introduction

• Globally, men who have sex with men (MSM) are disproportionately affected by HIV

• In Nigeria HIV prevalence among adults is 3.1%, but among MSM prevalence estimates ~17.2%

• Across Sub-Saharan, MSM have limited engagement in the HIV treatment programs

• Affirmation of human rights and social capital may help to reduce risk to HIV infection and empower uptake of HIV-related services

The Nigerian Context• Anti-sodomy laws have existed in Nigeria since British

colonization

• Same-sex Marriage Prohibition Act passed by parliament in May 2013 & signed into law January 2014 by the President

• Prohibits marriage or civil union between persons of the same sex

• Prohibits the public show of same sex relationship directly or indirectly

• Prohibits and punishes for up to 10 years imprisonment those who register, operate or participate in gay clubs, societies and organisations

• Prohibits and punishes for up to 10 years imprisonment a person or group of persons that witness, abet and aid the solemnization of a same sex marriage or supports the registration, operation and sustenance of gay clubs, societies, organisations, processions or meetings in Nigeria

Methods

• MSM recruited through respondent-driven sampling and enrolled into a prospective cohort in Abuja from March 2013-June 2014

• Stigma and access to health care, as well as HIV-related clinical outcomes were assessed at enrollment and every 3 months

• Characteristics related to discrimination and HIV care are described and compared pre-post legislation using chi-squared statistics

Characteristics of enrolled MSM

Baseline characteristics (n=671)Age, median (IQR) 23 [20-27]Employment, n (%) Self or formal employment 366 (54.5%) Student 153 (22.8%) Unemployed 152 (22.6%)Sexual orientation, n (%) Gay/Homosexual 236 (35.2%) Bi-sexual 434 (64.7%) Don’t know 1 (0.1%)HIV status at baseline test, n (%) 162/371 (43.7%) On ART at baseline, n (%) 46/162 (28.4%)

Immediate Impact of the Law

Cumulative reported fear of seeking health care

Mar-Jun 13 Jul-Sep 13 Oct-Dec 13 Jan-Mar 14 Apr-Jun 140.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

24.4 25.4 24.3

37.834.8

Fear of seeking healthcare because MSM

Prop

ortio

n (%

)

Cumulative reported avoidance of health care

Mar-Jun 13 Jul-Sep 13 Oct-Dec 13 Jan-Mar 14 Apr-Jun 140.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

19.721.4

17.9

30.5

25.8

Avoided seeking health care

Prop

ortio

n (%

)

Importance of open communication with providers

Importance of open communication with providers

Conclusions

• Fear of seeking health care and avoidance of services increased for MSM in the immediate post-law period

• MSM who communicate openly with health care providers are more likely to engage in treatment and achieve viral suppression

• Continued monitoring of the impact of the law and sustained efforts to ensure safe health care access for MSM are necessary to ensure that discriminatory policies do not prevent engagement in HIV care

AcknowledgmentsThank you to the community members and research team

Collaborating Institutions• Institute of Human Virology at the University of Maryland School of Medicine

(IHV-UMB)• Johns Hopkins Bloomberg School of Public Health (JHSPH)• Walter Reed Army Institute of Research, Military Health Research Program

(MHRP)• Department of Defense, Walter Reed Program, Nigeria (WRP)• Institute of Human Virology Nigeria (IHVN)• International Centre for Advocacy for the Right to Health (ICARH)• The Initiative for Equal Rights (TIER)• Population Council (Pop Council)

Funders• U.S. PEPFAR Implementation Science Grant supported by the U.S. National

Institutes of Health (R01 MH099001-01)