State of African research on topics related to Rectal Microbicides

1. State of African research on topics related to Rectal Microbicides Zoe Duby Doctoral Research Fellow Desmond Tutu HIV Foundation & University of Cape Town Project ARM Africa for Rectal Microbicides 2nd & 3rd December 2011 Addis Ababa, Ethiopia Brian Kanyemba Research Assistant / AVAC Fellow Desmond Tutu HIV Foundation Ben Brown MSM Division Programmes Manager Desmond Tutu HIV Foundation

2. What do we need to know for RM research in Africa? • Who’s having anal sex? • Why, when, where, how, with who? • What’s already being done? • What have we learned? • What gaps are there? ?

3. Penile-anal penetrative intercourse (“Anal Sex”) Anal intercourse is a sex act where the penis is inserted into the anus of a sexual partner. The term can also include other sexual acts involving the anus, including pegging, analingus (anal–oral sex), fingering, and object insertion. Anal sex is a behaviour practiced by men, women & transgendered individuals, regardless of sexual orientation or sexual identity

4. What data is out there?

5. Prevalence of anal sex practice in Africa

6.  Curiosity and exploration  Faster ejaculation  Boredom  Pleasure  Tighter sensation  Anus is drier, more friction  To please male partner  Money  Prestige product Anus more ‘exclusive’  Contraception  Menstruation During Pregnancy  Drugs and alcohol  To be ‘faithful’  In the presence of vaginal STIs  Part of normal sexual repertoire  If you have a small penis  Globalisation and pornography  To get large buttocks  Virginity Maintenance  Intimacy Deviance [Duby, 2009, 2011] Why do people have anal sex?

7. Both males & females practicing anal sex are vulnerable to infection - especially the receptive partner Lack of natural lubrication in anus increases risk of rupturing membrane & blood vessels Risks of anal sex • Higher rates of infection in receptors of anal sex and higher presence of other STIs (e.g. syphilis & rectal gonorrhoea)

8. Penile-anal sex versus penile-vaginal sex

10. What we do know • Unprotected anal sex is the most efficient way to transmit HIV sexually • Condoms are less likely to be used with steady partners during anal intercourse than vaginal intercourse • Anal intercourse may account for higher proportion of HIV transmission to both men and women than commonly believed

11. Syndromic management STI guidelines don’t include anal STIs in routine examination Lack of communication and knowledge about non-genital STIs Providers do not inquire as to clients’ particular sexual behaviour: “sex” uniformly refers only to vaginal sex IEC/BCC materials providing safer sex information on anal/oral sex not widely available Lack of Service Provision for anal health “Have you ever discussed anal sexual practices with any of your clients, male or female?”

12. Anal sex taboo …you go to the clinic, the nurse will ask questions like “what was in here?” - she means in the anus. And that makes us afraid if going to the clinic… [Brown et al., 2011] Nurses (in South Africa)… especially in government hospitals, they’ve got a reputation of being really really bad, communication wise. You know they ask people “why did you do this?” if you have some type of infection ‘there’ (in the anus): they say “why did you do this?” [Respondent in Duby, 2009] • Stigma and discrimination means that anal STI sufferers do not seek/access treatment • Clinic staff not sensitised to deal appropriately with anal, rectal & oral STIs - individuals with anal/rectal STI symptoms, may not seek services they require out of fear of abuse, stigma & discrimination

13. So…. Misguided focus on penile-vaginal penetrative sex as primary vector for sexual transmission of HIV in Africa • Greater attention must be paid to non-vaginal sexual practices, in the light of their frequency as well as potential risks, in order to ensure a comprehensive approach to HIV prevention • Unprotected penile-anal penetrative sex, carrying the highest risk of HIV transmission sexually, needs to be addressed

14. Mostly Southern and Eastern Africa Convenience sampling Information on AI with MSM African Research with MSM

15. High number of sexual partners frequent episodes of URAI inability to access lube lack of education regarding lube Anal Sex, Lube, and MSM in Africa

17. The Global iPrEX study and OLE MTN 017 Caprisa Voice Related biomedical research

18. Vaginal Microbicide 39.9% Additional protection Conducted in Durban Anal sex report Caprisa 004

19. International PrEP Study for MSM 2499 Participants 44% Additional Protection Adherence challenges The Global iPrEX Study

20. 5 arm trial Multiple African Countries 2 arms have been closed due to futility Low reports of adherence Voice

21. Recent initiation of enrollment Female Vaginal Microbicide Multiple African Sites FACTS

22. Phase II – safety/acceptability for RM 40 Expected MSM participants in SA Oral PrEP and Rectal Microbicide Initiation in 2012 MTN 017

23. The need for surveillance information Community Engagement Recruitment Adherence Applications to RM research

24. to better under behaviour access to community provides much needed direction Need for Surveillance & Mapping

25. fundamental builds capacity establishes trust education for HIV prevention Community Engagement

29. Participant Accrual is critical Requires multiple strategies Early initiation is necessary Recruitment & Retention

30. Community Events social networking Peer Recruiters Internet recruitment Recruitment & Retention

31. What is your phone number? Whats your other phone number? Do you have another number, what is it? Whats your facebook? What’s your twitter? Whats’s your linked in? Are you on gaydar? Manhunt? What’s mom’s number? What’s your address? Whats your friend’s phone number? Where do you work? What’s your favorite restaurant? Whats your boyfriends number?

32. Has significant impact on prevention trials Adherence

33. “Take your pill, take it everyday” “Take your pill, take it everyday” “Take your pill, take it everyday” “Take your pill, take it everyday” “Take your pill, take it everyday”

34. Has significant impact on prevention trials Integrated “pill taking” counseling Encourages accurate reporting Anecdotally more useful to participants Adherence

35. Creating Synergy between advocacy, research, and community Start now! Rectal Microbicides: a way forward