In Nigeria, fear of seeking health care and avoidance of health care rose significantly among men who have sex with men after the implementation of a law that criminalized same-sex sexual relationships.¹ In a prospective study conducted in 2013–2014 in Abuja, participants reported fear of seeking health care at 25% of study visits during the prelaw period, and the proportion increased to 38% during the postlaw period. Similarly, before the law took effect, 20% of the men reported health care avoidance; afterward, 28% of respondents did. In incidence analyses, fear of seeking health care was 2.9 times as great, and the risk of reporting no safe spaces to socialize was 3.3 times as great, in the postlaw period as in the prelaw period.

To address the lack of individual-level data assessing the effect of anti–same-sex legislation on health outcomes among men who have sex with men, the researchers assessed the associations between the 2014 law—which prohibits not only same-sex marriages and sexual relationships, but also participation in organizations and clubs for homosexuals—and reports of stigma, discrimination and use of HIV-related services. Men were eligible to participate if they were aged 16 or older, had engaged in insertive or receptive anal sex with a man in the previous year, were willing to undergo regular HIV testing and clinical monitoring for up to 18 months, and spoke English or Hausa. Participants completed a behavioral questionnaire at baseline and returned two weeks later to receive HIV counseling and testing, STI screening, and clinical and laboratory examination. Quarterly visits were scheduled and included a condensed questionnaire, STI testing, and HIV counseling and testing or treatment monitoring; all participants with HIV were offered antiretroviral treatment (ART). Because the passage of the law was not anticipated at the time the primary study was initiated, the analysis of the law’s possible impact was not planned beforehand, but constituted a secondary analysis of data collected before and after implementation. In all, 707 men who have sex with men participated at baseline, of whom 404 (57%) returned for at least one follow-up visit; overall, they contributed 756 prelaw and 420 postlaw visits.

The study questionnaire asked participants about their demographic characteristics, as well as their experiences with five types of stigma and discrimination: whether the participant had ever feared seeking or avoided obtaining health care because he had sex with men, whether he had ever been verbally harassed or blackmailed, and whether he had been unable to find safe places to be with male partners. Outcomes of interest included not only reports of stigma and discrimination, but also loss to follow-up, ART status and viral suppression (having a serum HIV RNA level below 50 copies/mL). The investigators used chi-square tests to compare the demographic characteristics of prelaw participants with those of postlaw participants, as well as associations between the law and open communication with a health care provider, ART use and viral suppression. The incidence of stigma, discrimination and loss to follow-up were estimated with Poisson regression models that adjusted for age, education, religion, marital status, employment and having ever been tested for HIV.

Most men in the study were aged 25 or younger (59%), and more than 99% identified as gay or bisexual. Some 71% had attended at least secondary school; 56% were employed, 22% were unemployed and 22% were students. Fifty-eight percent of participants were Christian, while 41% were Muslim. Most participants (86%) had never married or were living with a man; 11% were married or living with a woman, and 3% were divorced, separated or widowed. More than half of the men (58%) had had an HIV test; of those who underwent testing at enrollment, 45% were HIV-positive. Only 21% of men reported ever having discussed their sexual orientation with a health care provider. Participants who enrolled before the legislation had higher levels of education, were more likely to be unemployed, and were less likely to be Muslim and to be married to or living with a woman than those enrolled after legislation.

For all five of the stigma and discrimination measures, reports of having experienced the outcome were significantly more common during the postlaw period than during the prelaw period. For example, participants reported having ever feared seeking health care during 25% of prelaw visits and 38% of postlaw visits; they reported health care avoidance during 20% of prelaw visits and 28% of postlaw visits. Those comparisons included both baseline and follow-up visits; in analyses restricted to baseline visits, lifetime prevalence of stigma and discrimination did not differ between prelaw and postlaw visits, suggesting that those enrolled in the postlaw period were not substantially different in their lifetime experience of stigma from those enrolled before the law went into effect, and that increases in reports of stigma may be attributable to an increase in incidence.

To further explore this issue, the researchers conducted incidence analyses among the 192 participants who had completed both a baseline visit and at least one follow-up visit. For each stigma measure, the sample was further restricted to participants who had not reported that type of stigma at baseline, so that any reports of lifetime stigma experiences presumably reflected events that had occurred between baseline and follow-up. In the adjusted models, the incidence rate ratio for fear of seeking health care was 2.9 times as great in the postlaw period as in the prelaw period, while that of reporting not having safe spaces to socialize was 3.3 times as great. Other analyses suggested that being unable or unwilling to reveal homosexual behavior was associated with poorer health outcomes: HIV-positive men who had never discussed their sexual orientation with a health care provider were significantly less likely to be on ART (23% vs. 45%) and to have achieved suppression of HIV (13% vs. 29%) at enrollment than were those who had.

The researchers acknowledge several limitations, including that although they used the law’s public announcement date to separate the prelaw and postlaw periods, there were concerns within the community of men who have sex with men before that date; this may have contributed to an underestimation of the negative effect of the law. In addition, those most likely to report avoiding health care were also the most likely to self-censor and would therefore not be available to report this outcome. Despite the limitations, the researchers note that their findings "emphasize the negative public health effect [that anti- homosexuality] legislation can cause via its restrictions on uptake of HIV prevention, treatment and care services in those most at risk for HIV transmission." They conclude that "safe and trusted HIV prevention and treatment services are needed, particularly in countries with discriminatory legal environments." —L. Melhado

REFERENCE

1. Schwartz SR et al., 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, Lancet HIV, 2015, 2(7):e299–e306, doi: 10.1016/S2352-3018(15)00078-8.