Regressive laws on same sex relationships increases stigma and reduces health service use

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.

Schwartz SR, Nowak RG, Orazulike I, Keshinro B, Ake J, Kennedy S, Njoku O, Blattner WA, Charurat ME, Baral SD, TRUST Study Group. Lancet HIV. 2015 Jul 1;2(7):e299-e306.

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 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 chi2 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 healthcare 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.

Abstract access  [1]

Editor’s notes: Despite the recent implementation of progressive laws on same-sex relationships and marriage in several settings, other countries – including Nigeria – have moved to criminalise same sex practises. As well as broader human rights concerns, there is the risk that policies that criminalise same-sex practices, or the community groups addressing the health-related needs of these populations, might restrict the coverage of HIV prevention, treatment and care programmes. However, despite these concerns, there is extremely limited quantitative evidence on the impact of such policies. In Nigeria, the Same-Sex Marriage Prohibition Act was passed in 2011, coming into law in 2014. Before this legislation, consensual sex between male same-sex couples was already prohibited. The new law further criminalised same sex practices, including prohibiting participation in organisations and service provision. This study opportunistically analysed data from an on-going prospective cohort study of gay men and other men who have sex with men in Abuja, which had started prior to the law’s implementation, and continued after its introduction. The study assessed the degree to which this legislation impacted on gay men and other men who have sex with men’s fear and health service use. Unsurprisingly, perhaps, the study illustrates that the law did impact negatively on gay men and other men who have sex with men – significantly increasing their fear of and avoidance of health services, as well as increasing their levels of harassment and experience of blackmail. Prior to the new legislation, levels were already high, with the new law seeming to exacerbate existing barriers and stigma. The findings are important, illustrating how regressive laws can increase the stigmatisation of already marginalised groups, and undermine the gay men and other men who have sex with men’s access to health associated services. Supportive policy environments, along with HIV programmes for marginalised populations, form an essential part of an effective HIV response.

Africa [7]
Nigeria [8]
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