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Project ARM Africa for Rectal Microbicides 2nd & 3rd December 2011 Addis Ababa, Ethiopia State of African research on topics related to Rectal Microbicides Zoe Duby Ben Brown Brian Kanyemba Doctoral Research Fellow MSM Division Programmes Manager Desmond Tutu HIV Foundation Research Assistant / AVAC Fellow Desmond Tutu HIV Foundation Desmond Tutu HIV Foundation & University of Cape Town 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? 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 What data is out there? Prevalence of anal sex practice in Africa Population Location Percentage engaging in Anal Intercourse (AI) Reference University students South Africa 1/13 male & female students (in past year) HEAIDS, 2009 Women South Africa 10% of women and 14% of men (in last 3 months) Kalichman et al., 2009 Sexually active in school adolescents Nigeria 15.2% reported having had AI MorhasonBello et al., 2008 Youth aged 15-24 South Africa 5.5% of males & 5.3% of females had ever Lane et al., 2006 University students Northern Nigeria 12.1% reported having had AI Kabir et al., 2004 General population Rural KZN, South Africa 20% had ever Karim, 2003 Primary school children Tanzania 9% reported anal sex as their first sexual act Matasha et al., 1998 Female sex workers South Africa 43% had with clients Karim & Ramjee, 1998 Why do people have anal sex? 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] Risks of anal sex • 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 • Higher rates of infection in receptors of anal sex and higher presence of other STIs (e.g. syphilis & rectal gonorrhoea) Penile-anal sex versus penile-vaginal sex Penile-anal sex Penile-vaginal sex No natural lubrication in anus Vagina produces natural lubrication when sexually aroused Anus has limited elasticity Vagina has elasticity and stretches Colon and rectum only a single layer Vagina much thicker epithelial layer of epithelial cells (one cell thick) (approximately 40 cells thick) Tears easily with no lubrication Vagina doesn’t tear as easily, and is more robust Presence of faecal matter possible (containing bacteria) No faecal matter present Many inflammatory cells (CD4 receptors) under surface in rectum Fewer CD4 receptor cells in vagina than rectum 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 Lack of Service Provision for anal health • 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 yes 12% “Have you ever discussed anal sexual practices with any of your clients, male or female?” no 88% DTHF MSM Training 2010/2011 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] • 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 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] 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 African Research with MSM • Mostly Southern and Eastern Africa • Convenience sampling • Information on AI with MSM Anal Sex, Lube, and MSM in Africa • High number of sexual partners • frequent episodes of URAI • inability to access lube • lack of education regarding lube Related biomedical research • The Global iPrEX study and OLE • MTN 017 • Caprisa • Voice Caprisa 004 • Vaginal Microbicide • 39.9% Additional protection • Conducted in Durban • Anal sex report The Global iPrEX Study • International PrEP Study for MSM • 2499 Participants • 44% Additional Protection • Adherence challenges Voice • 5 arm trial • Multiple African Countries • 2 arms have been closed due to futility • Low reports of adherence FACTS • Recent initiation of enrollment • Female Vaginal Microbicide • Multiple African Sites MTN 017 • Phase II – safety/acceptability for RM • 40 Expected MSM participants in SA • Oral PrEP and Rectal Microbicide • Initiation in 2012 Applications to RM research • The need for surveillance information • Community Engagement • Recruitment • Adherence Need for Surveillance & Mapping • to better under behaviour • access to community • provides much needed direction Community Engagement • fundamental • builds capacity • establishes trust • education for HIV prevention Recruitment & Retention • Participant Accrual is critical • Requires multiple strategies • Early initiation is necessary Recruitment & Retention • Community Events • social networking • Peer Recruiters • Internet recruitment 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? Adherence • Has significant impact on prevention trials “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 Adherence • Has significant impact on prevention trials • Integrated “pill taking” counseling • Encourages accurate reporting • Anecdotally more useful to participants Rectal Microbicides: a way forward • Creating Synergy between advocacy, research, and community • Start now!