State of African research on topics related to Rectal Microbicides

Zoe DubyDoctoral Research Fellow

Desmond Tutu HIV Foundation

& University of Cape Town

Brian KanyembaResearch Assistant /

AVAC FellowDesmond Tutu HIV

Foundation

Project ARMAfrica for Rectal Microbicides

2nd & 3rd December 2011Addis Ababa, Ethiopia

Ben BrownMSM Division

Programmes ManagerDesmond Tutu HIV

Foundation

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 sex is a behaviour practiced by men, women & transgendered individuals, regardless of sexual orientation or sexual identity

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.

What data is out there?

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 Morhason-Bello 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

Prevalence of anal sex practice in Africa

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 of epithelial cells (one cell thick)

Vagina much thicker epithelial layer (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

• 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?”

Anal sex taboo

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

…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]

• 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

• 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

Misguided focus on penile-vaginal penetrative sex as primary vector for sexual transmission of HIV in Africa

So….

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 everyday”

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!