Wednesday, August 8, 2012

Welcome Back from Washington DC

It was a great pleasure to able to attend the XIX International AIDS conference in Washington DC. This event is seen as the "Olympics" of HIV where the race to end the epidemic is one based on unity and not on individual efforts.

This year conference theme was "Turning the tide", a theme that many people will agree with me not only drive the topics and the different activities at the event, but also energized the international community to take a stand and have an "HIV free generation".

We had prominent politicians speaking to the delegates at the event including: President Barack Obama, Secretary General Hilary Clinton and President Francois Hollande (well those are the ones I saw). Even President Hollande making a strong statement about using the transactional tax in France to invest in HIV prevention and treatment.

Don't get me wrong, if I have seen or heard of David Cameron speaking to the delegates I would have written about it. However, since I did not see him I will not make assumption and there I will rest my case about UK government's commitment to investing in HIV prevention and treatment research.

Away from the politics and the politicians point scoring, there were many interesting as well as promising data, results and innovation coming out of the conference. As part of my IAS blogging, I will be highlighting this key "expectations" from Treatment as Prevention (TasP), Microbicides, Vaccines, Medical Male Circumcision (MMCV), HIV testing and the most amazing of them all, the Lancet report on HIV and Men who have sex with men and Gay men all over the world.

My commitment is to give you an insight into each topic twice a week starting from this week and all you have to do is just watch out and share your views.

Friday, June 22, 2012

Let’s do the black talk – HIV and black gay men in Europe

Just as I return from Stockholm where I attended the first European conference “The Future of Prevention for MSM in Europe” (FEMP) specifically addressing prevention issues affecting men who have sex with other men (MSM), I am surprised, as much as you should be, that this was the first European conference of its kind since the outbreak of the epidemic 30 years ago.

The US and South Africa have been exemplary in leading the way with innovative approaches to HIV prevention, treatment and advocacy.
As a black gay man of African origin living in the United Kingdom, the challenges I face in my everyday life are in no way different from those faced by black gay, bisexual and other MSM in America.
However, whilst there is a history of over 200 years of black civil rights movement in America, there is little that can be said about similar black organisations in Europe.
But the problem has deeper roots. Most amazingly, the results of the recent HIV prevalence survey conducted by the European Centre for Disease Control (ECDC) do not differentiate the HIV epidemic in Europe according to ethnic origin mostly because the French and the Germans do not allow for identifying and recording racial background.
The hypocrisy of the French “equality” motto is that by denying the existence of epidemiologic differences related to racial background it further oppresses ethnic minorities, mostly black, by denying them the rights to tailored healthcare.
In the UK the Health Protection Agency (HPA) estimates that 86,500 people are living with HIV in 2010.
An estimated 4% of Black Africans living in England have been diagnosed with HIV, compared with 0.1% of the white population. The disease disproportionately affects MSM who represents nearly half of those newly infected with a consistently higher proportion of black MSM.
The latest HIV diagnosis data for 2001-10 from the HPA shows a steady increase in the number of new diagnosis in the black MSM population (Black Caribbean, Black African and Black other) from 100 in 2000 to 112 in 2010.
If these data can be translated to the European scale, the choice of the French and German government to ignore race is raising serious questions about the real HIV prevalence in the black/African community in Europe.
With an incomplete picture and missing data, how can we advocate for black gay, bi and MSM driven and led HIV prevention and treatment?
Unlike the French and the German agencies, the UK Health Protection Agency has one of the most comprehensive datasets on HIV prevalence, taking into account race and ethnicity in the whole of Europe.
This may explain why many UK black gay advocates attended FEMP and why they have been at the forefront of the battle for similar data collecting system in other European countries.
However, these data should not hide structural and cultural issues affecting Black MSM and suggesting that number of infection remains underestimated.
The impact of institutional racism and community discrimination on the self-confidence of young black gay/bisexual men and MSM to access healthcare in the UK was investigated by the Monya project, funded by Newham Primary care trust in London and carried out by Naz Project London.
Surveys showed that more than 60% of MSM of African origin agreed that they did not fit into the mainstream, predominantly white, gay setting.
As many as 45% criticised the healthcare professionals for being heteronormative and almost 70% said the counselling they received at the sexual health clinics did not meet their needs for full sexual happiness and fulfilment.
Whilst the ECDC agreed that there is a need for concrete intervention for HIV prevention for heterosexual migrants from high epidemic countries, there was nothing said about the need for tailored HIV prevalence for MSM from the same region.
We cannot blame the ECDC for being limited by red tape and national policies, but I was shocked that despite 5 plenary and more than 15 breakout sessions, there was not one single session talking about black gay, bisexual men and MSM at the FEMP conference.
The one session on migration was flawed by an ambiguous EMIS definition of migration and data collected on migration that do not distinguish between internal and external migration. Further, the panel consisting of two Spanish researchers could not provide convincing answers about the epidemic of black gay/bi sexual and MSM from high epidemic areas like Africa.
While I strongly believe that there is a need for a European MSM conference, I think that this conference failed in acknowledging and accepting that there is a need to put black and African MSM men on the agenda.
Even the number of black and African gay men at the event was nothing to be proud of, with fewer than 10
of them amongst 200 participants. The HIV Epidemic in the community is a time bomb waiting to explode and we are turning our back to it.
I went to this meeting to assess and investigate the need to establish a European-wide MSM HIV prevention and treatment advocacy, but whilst the conference raised good points, I returned to London having failed to achieve my aim, as there was no platform for black gay men to meet and discuss the issues that matters to
As we plan for the next FEMP conference, it is important we start talking about the hidden and mostly ignored HIV epidemic in the black MSM community and what roles social factors like religion, culture, self confidence and racism are playing in the increasing epidemic in the black community in Europe.
We, the black MSM community in Europe, should be demanding for research-driven prevention policies from health care authorities and our governments. We have a lot to learn from our brothers from America and we need them to help us in organizing and lobbying. We do not want to wait for another five years and then to become the agenda of the “HIV do-gooders” trying to save the endangered species.

Representation: The undefined Job Description

Since the discussion around Pre- Exposure Prophylaxis-PrEP, (the anti HIV drugs to be taken by HIV negative people to prevent them from getting HIV even if they come in contact with virus). I have listened, spoke, argued and even made cases for the cautious implement of the policy so that the people that will be taking the pills know what really they are getting themselves into and be able to make an informed choice about their life, their health and their future.

However, there is been a particular group of people that have been missing in this very important discussion, the people that will be taking the drug. The issue of representation in this case has been taken over by the HIV positive old horses that think that they can speak for everyone. Just like the pope and the Catholics criticizing condoms and contraceptives for women when they are not one that will use it.

This scenario of self appointed speaker/ representative is not limited to the HIV field. I have seen many people speaking on behalf of other people with such authority (mind you I am not excluding myself) and with the use of the word "Community" that you asked yourself when was the election conducted? Who are the opposition party? On which political platform that person stood? These questions brought about the argument of the notable academia Anne-Marie Slaughter when she talked about "Representation and Democratic deficit". 

Just recently I was drag into a twitter argument over racism and representation again. When on BBC Sunday Morning live, a panel discussing racism has no black person on it. The argument was in 21st century, do we really need to have a black person talk about black issues? Do we only need a gay person to voice the concerns of gay people? And since we have no HIV negative community, do we really then have to look for someone to speak for them?

Do we really need to desperately look for someone to speak for a group of people? As an African Gay man living with HIV living in London, I constantly find myself having to speak or represent that community and on many occasion I have asked myself that do I really know what deep down the issues are? Does having those boxes to tick makes me the best person to speak for this group of people?

As much as I asked myself these questions, I have never been able to find an answer to it nor will I ever be able to find an answer to it. However, what makes my case different is that I have to certain degree the support of the group of people I represent. This is clearly different from White people representing Black issues, or an HIV positive man talking about what is best for HIV negative man with such authority.

We all know that there is a difference between taking a pill to stay alive and taking a pill because it is an option not to catch something. Both are different and the level of tolerating the risk differs as well.

I wish we can take the PrEP conversation away from the ball room of HIV positive people to the dinner room of HIV negative people and allow them to take centre stage on the discussion as much as taking the conversation of racism away from the sympathetic white middle class to the reality of black people on the street of the UK.

Tuesday, April 24, 2012

Dont call me "Non-White" its just racism

Human beings with any sense of intellectual prowess are known to be full of rhetorics. These rhetorics are most times their ways of either exercising their wealth of intelligence or simply showing how they can be more stupid than the rest of of us. And if it is the latter, then they find themselves in a situation where they are boxed to the corner and fighting for survival.
David Starkey on Newsnight.

One of such is Prof David Starkey the notable Historian (well many will question my use of "notable" for this honourable gentleman, but you will have to forgive me for that) behaviour during the London riot when he in his almighty stupidity argued on BBC newsnight (you can watch the video here)  that "white has become black" and that is the reason for white kids involvement in the right. 

The fury that followed was one that hell could not contain and this Professor will end up covering his head in shame. Not that it really matters when it comes to David Starkey, he was the same man that made controversial statement about gay people on BBC question time. And for clarification purpose, David himself is gay.

Now this blog is not about David in anyway and I am not sure I want to write about David. This blog is about two presentations at the just conclude British HIV Association (BHIVA) conference held in Birmingham United Kingdom. The two controversial presentations where those from Dr Anthony Mills from Los Angeles and Dr Chloe Orkin from Bart and the London NHS. 

It will be important to note that it was not the content of the presentation that made some people uncomfortable and that includes me but the ethic classification in the presentation. During his presentation on the "non- inferior efficacy and favourable safety of Quad compared to efavirenz/emtricitabine/tenofovir DF in treatment naive HIV-1 infected subjects" He classify the race as "white and non-white". I almost jumped on my seat. My immediate reaction is what really is racially non white? Black, Indians, Chinese, Hispanic or any other race that is not white? 

Also in considering metabolic assumption of HIV drugs in HIV positive people, racial classification is very important because of genetic make up. Saying white and non- white gives no explanation to what is happening to "African American" as they account for the emerging epidemic in America and likely to be on treatment and possibly react to the drugs in a different way compared to their white counterpart.

As if that was not enough insult for one day, Dr Chloe came on and made a presentation on "Efficacy, safety and pharmacokinetic results of an ongoing international phase 3 study comparing Quad with ritonavir-boosted atazanavir plus emtricitabine/tenofovir DF in treatment naive HIV-1 infected subjects at 48 weeks". In the same fashion talked about white and non white.

Angered by this blatantly act of intentional or unintentional racism, I went on twitter and vent my anger about the attitude of clinicians/researchers on not just race classification but recruitment of Black and Hispanic people into HIV trials. The reactions on twitter was nothing but that of anger and disgust. However, I did not stop there, I stood up and went to the microphone to challenged the notion of the concept of "White and non-white". 

I was not doing this to be a hero or become controversial, but to put the record straight that knowing how people are doing differently will help in designing and development of care and support service for HIV positive people from different ethnic background.

To my utter dismay, I was shocked at the way my concern was ignored not just by the researchers but by the chair of the session.

As if ignoring my concerns was not enough, afterwards, I was challenged by many clinician and researchers accusing me of raising a non issue to distract many people from the main issue of the conference.

I left Birmingham not angry, but determined to put this right once and for all. As an African living in the UK already given the Black identity I did not asked for, being tagged "non-white" in 2012 is nothing but blatant act of racism and bigoted insult.

Thursday, April 19, 2012

Growing older with HIV: What do we know?

Its been over 30 years into the HIV epidemic, when the world came to the realisation of what would end up to be a global challenge. However with more advanced drugs to treat the virus, there are evidence of HIV positive people growing older.

This sounds as great news for many people infected and affected by HIV. However, the downside of this is the increasing challenges of co-morbidity, HIV drugs toxicity, and aging. As we grow older, our body will go through a process of breakdown that will require more medical attention. We have to deal with the issue of Alzheimer, Cancer, Diabetes and ever increasing difficulties of care.

Dr Graeme Moyle of Chelsea and Westminster, in a presentation at one of British HIV Association Conference in London, quoting the SMART study concluded that HIV viral load can also be contributing risk to Cardiovascular disease in people over 50 years. This is further compounded with the challenge of late presentation of HIV.

Dr. Graeme Moyle
Increasing the challenges for older HIV positive people is the type of drugs prescribed for the treatment of the virus. Certain protease inhibitors  like Lopinavir and Idinavir have shown an increase in fat accumulation called Lipid in older people living with HIV. This means that these drugs will increase the risk of other diseases like hypertension, Diabetes and other diseases like renal dysfucntion, reduce bone mineral density, fraility, non-AIDS defining cancer and neurocongnitive dysfunction.

 Another factor increasing the risk for older HIV positive people is the CD4 nadir at the time of diagnosis. The lower the CD4 cell counts the more possibility of aggravated old age diseases as listed above.

As HIV positive people grow older and more people get diagnosed late, the challenges to manage the disease in line with other old age diseases will come with more community advocacy around lifestyle changes.

Prof. Peter Kroker of Chelsea and Westminster Hospital London suggested that we should start addressing factors that will increase co-morbidity at old age, these include: Smoking, alcohol, diet, and inactivity. Coupled with this should be the regular assessment of risk factors like: blood pressure, lipids, cardiovascular fitness, vitamin status and renal functions.

Prof. Peter Kroker
He stated that the important thing to know is that living with HIV is a life time challenge on its own, this challenge gets complicated with aging, and old age defining diseases. Supporting older people living with HIV and other diseases should be a priority not just for the community but for the health care providers and the government.

There should also be more community led advocacy and training on HIV and aging. This is because according to the words of Prof Kroker " In 1996, I would never have thought I will stand here today, 30 years after the epidemic to be talking about HIV and aging? Back then we thought living over 5 years               will be more to luck than reality but here we are today"

Wednesday, April 18, 2012

Mandatory HIV testing: Public health vs Human rights

At the ongoing British HIV Association conference (BHIVA) taking place in Birmingham UK, a session on Late presenting of HIV highlights the characteristics of the epidemic in the UK raising the need for more community awareness amongst Men who have sex with Men (MSM) and people of African origin

Dr Valerie Delpech of the HPA in her presentation stated that as at the end of 2011, there are almost 120,000 people living with HIV in the UK, and that since the breakout of the epidemic 30 years ago, the UK has seen 20,000 AIDS related death and of the people living with HIV as at 2012, 25% of them are unaware that they have the virus. And these are mainly the population driving the epidemic. Furthermore, she started the epidemic is concentrated between MSM and African communities in the UK.

However, there is something that sets the African community aside from the MSM, and this is CD4 cell counts at the time of diagnosis. In the UK, African communities account for the highest number of late diagnosis of HIV. In this article, late diagnosis of HIV will be diagnosis of HIV at a CD4 cell count less than 350. This is because at this stage, the immune system (the cells that protect the body from disease attacks and they are the cell the virus needs to reproduce in the body) has weakened and do not have the power to fight the virus anymore.

Dr Valerie Delpech

At this stage of low CD4 cell counts, a person will start developing what is known as opportunistic infections and this will eventually leads to AIDS if not treated on time. The only treatment for HIV still remains Anti-HIV drugs.

In the UK we are seeing the rate of late diagnosis to be as high as 50%, however while more MSM are testing on time for HIV (Prompt testing), we are seeing an increase in late diagnosis amongst Heterosexual men from Africa. Of the 50% of people that presented late for HIV testing last year, 63% of them are heterosexual men of African origin. This data from HPA reaffirms the challenges African HIV charities are facing in the UK.

Age has also been identified as one of the key areas where there is an increasing rate of late diagnosis with 62% of people over 50 years diagnosed so far are diagnosed late.

Dr Marthin Fisher from the Royal Sussex Hospital Brighton raised the challenges of late diagnosis in relations to treatment adherence and effectiveness. He argued the later someone present for HIV the more difficult it is for the person to have better Quality of Care (QoC) and this will further reduce the chances of the individual to respond to treatment and even reduce their options for further treatment with new drugs.

Therefore the question is, should we offer mandatory HIV testing for everyone from high risk population? (When I say high risk, I am talking about the people that belong to the population with high rate of HIV epidemic MSM and Africans). If the answer to this question is yes, then how do we deal with the issue of fundamental human rights of an individual to say NO to HIV testing?

How do we make HIV testing attractive and easy to take up for people and most importantly for African heterosexual men? With the advent of better treatments that are prolonging life span of HIV positive people, it is not then a good public health issue to test people early and put them on treatment as soon as possible?

Dr Marthin Fisher
The other positive outlook to treating HIV early is that as we put people on treatment we reduce the transmission risk of HIV as seen in a study called HPTN 052. And this can only be possible if we test more people and put as many people in treatment as possible.

This is indeed an advocacy need of African communities in the UK but most importantly the need for African men to take the mantle of leadership in the fight against HIV and late diagnosis in the UK.

Though there will continue to be controversy over mandatory testing of HIV and fundamental human rights, but there is always a way out and one of it will be that everyone be offer routine HIV testing irrespective of race, gender or sexual orientation. Another important solution will be looking at the option of non conventional testing centers like community testing.

Finally we need to talk more about the advantages of testing for HIV and confront stigma and discrimination attached to HIV most especially within the African communities in the UK.

Tuesday, April 17, 2012

Funmi Iyanda: A Hero or A Villain

Funmi Iyanda

This lady has created an image for herself, one many people that grew up with her New Dawn with Funmi Iyanda will basically call "amazon". However to many who have loved to loathe her, she is nothing but a thorn in the flesh and one that they will be very happy to get rid off.

 Funmi has an imagine of a non nonsense woman, a social critics and one you will not expect from a social corrupt setting like Nigeria. She reminds one of the "The Man" in Ayi Kwei Armah "The Beautyfuls Are Not Yet Born". And more important many will attribute the personality of a fearless feminist, one who will crush every obstacle on her path.

 Her breakfast show that ran for over 10 years in Nigeria (New Dawn with Funmi Iyanda) was the talking point of social discourse in the 90s, she treats her issues with passion while at the same time tries to remove herself from her passion. During her time on TV, she quizzed many people from high flying politicians to celebrities and to ordinary citizens who are trying to salvage their country. No wonder she got the title "Oprah Winfrey" of Nigeria, one title she does not take lightly to as she believes she is an enigma on her own.

 The major issue in Funmi television history came on the morning of 6th October 2004 when innocently (Yes! innocently)she interviewed Bisi Alimi, the controversial Nigerian gay rights activist. This simple interview sent a shocking waves round Nigeria, and the aftermath left Funmi coming to the reality of the country she so loved.

 So it was not surprising recently when on twitter she started a conversation about a newspaper report of the sexuality of Nigeria female singer Asa.  The backlash was overwhlming. The hate tweet that followed was beyond believe and it was interesting to see her losing many of her followers that day for saying as a matter of principles that she is open to discuss on LGBTI issues in Nigeria, and that she will not in any way discriminate against anyone based on their sexual orientation or gender identity.

 Her religious conservative followers threw tantarum, they called her names and stated in clear terms what a disgrace she is. Many even accused her of being a Lesbian. However, while these group of people were busying themselves slagging her off, there was another group of progressive Nigerians who got drawn into the debate and the interesting thing was, for every one religious conservative she lost, she got 3 progressive followers.

 This shows that even in Nigeria, the war of homosexuality is fought on both sides, and Funmi with her controversial views on the issues and many other issues ranging from Women's rights, abortion and single parenthood is found right in the middle of it. No matter what you think of these fearless woman, whether you see her as someone to love or loathe: Funmi has come to stay as Nigeria mermite.

Thursday, January 5, 2012

In Africa, anal sex goes Hetero

While I was in secondary school, I have always been told that rectal sex is something between two men. Even many anti gay activists have used this sexual practice as a means of attacking the gay movement. It is the core of the sodomy law in Africa and the buggery law in other part of the world.

However, the recent study in Africa has shown an increasing number of straight people and mostly young heterosexual people practising anal sex on a daily basis.

While the notion of sex in itself is a very difficult topic to tackle in the African setting, the mere fact that more and more straight couples in Africa are embarking on a rectal sexual journey for pleasure gives a call for concern – because most of this is unprotected by condoms.

An act of unprotected anal intercourse is 10 to 20 times more likely to result in HIV transmission compared to an act of unprotected vaginal intercourse, due to the different biological characteristics of the rectum which make it much more susceptible to infection.

What do we know?

According to Morenike Ukpong, a Nigerian Microbicide activist ; over 12% of young people in Nigeria are practising anal intercourse. In different studies done across Africa, the following were found as anal sexual practices among heterosexuals.

An anonymous survey of 2593 men and 1818 women in Cape Town according to Kalichman et al (2009), they found out 14% of Men and 10% of Women have engaged in anal sex in the last 3 months, of this only 67% of the men use condoms compared to just 50% of the woman.

Even there is a significant drop of condom use among truck drivers (N=320) in South Africa Ramjee et al (2002) and sex workers (N=147) in Kenya. Schwandt et al (2006). The two studies find 42% of truck drivers having anal sex with female sex workers, while it was 40% among female sex worker who said they have ever practised anal sex.

This is not the end of the surprising data. In Lane et al (2006) findings, it showed that young people between the ages of 15-24 years in South Africa engage in anal sexual behaviour. There is no difference between the sexes, while young male engage at rate of 5.5%, young female are at 5.3%.

More interesting is Matasha (1998) findings that among primary school pupils in Tanzania, 9% had anal sex as their first sexual experience.

Taken together, these studies show that there is a previously unknown anal sexual behaviour among heterosexuals but the focus on anal sex and health for many years has been the limited to gay/MSM communities.

What we are getting wrong

The focus of HIV prevention in Africa has always been primarily targeted at vaginal sex, and thereby prevention messages have always been use condoms. But we are now finding out that as straight people engage in anal sex, the likelihood of using condoms diminishes. For many, anal intercourse may be a form of virginity protection, or contraception, and there is a common belief that anal intercourse carries no risk for HIV infection.

Dr. Karim of the famous CAPRISA 004 argued that this sexual behaviour – when unprotected - could be driving a sizable amount of new HIV infections in Africa. In agreeing with him, I asked the question “is it time for us to broaden our scope of what HIV transmission looks like in Africa?”

If we still argue that HIV transmission in Africa is mainly heterosexual, are we assuming that the risk is only from unprotected vaginal intercourse? Or are we going to acknowledge the prevalence of unprotected anal intercourse among heterosexuals and address heterosexual transmission more broadly, and honestly?

Not only are we overlooking the reality and the prevalence of this sexual behaviour among the general heterosexual population (Note that these are small studies, which means that if we were to conduct bigger and broader survey we will find more), we are also losing the need to do a reassessment of our prevention strategy that will provide safer anal intercourse irrespective of gender or sexual orientation.

Coupled with the myth around anal sex is the lack of using the right lube. In a presentation at the strategic meeting by Dr. Brian Kanyemba from the Desmond Tutu foundation, he said people were using all kinds of things for lubricant: olive oil, Vaseline, Vicks and even mayonnaise - none of which are condom-compatible.

Gay and straight couples need to know the facts about anal intercourse, and need condoms and condom-compatible lubricants to engage in this behaviour in a safer way.

The hope. The future

Anal sex is a pleasurable sexual activities and it can be safe if and when certain conditions are met. These conditions include; using condoms with condom-compatible lubrication.

Another answer to safer anal sex is rectal Microbicides - which would be a lube or a gel with anti-HIV properties.

A safe and effective rectal Microbicides could help everyone engaging in anal sex have a pleasurable and safer sexual experience.

It is important to know however that it is not a replacement for condom use, but it is to be used as an additional option for protection, Ideally, one day we will have rectal Microbicides that not only protect against HIV, but other STDs as well.

As we drive towards zero HIV infection, it is also important we started looking at other prevention technologies that will be very easy for people to use without actually affecting their sexual behaviour.

As IRMA’s rectal Microbicides advocates sat down to work at the Project ARM meeting in Addis in 2010, one of the interesting things that came out was the need to intensify advocacy for rectal Microbicides in many ways and that includes engaging with our community to let people know that anal sex is a human behaviour, both homosexual and heterosexual.

There is increasing need for information on anal sex, anal  health and active involvement of NGOs in Africa. This campaign should also include NGOs working with African communities all over the world. Also we should start the discussion with women; both young and old that there is a need for more discussion on anal sex

Rectal Microbicides are looking like the future of HIV prevention, but for the dream to be achieved, there is the need for everyone to be involved in the process – on both the research and advocacy fronts.

From civil societies to clinicians, doctors to government officials, international organizations and funders the world over.

But while we await the rectal Microbicides reality, we should not forget that when we talk anal sex, we should also scream……… AND LUBE.

As without the right use of the right lube, anal sex will not only be painful and unpleasant, but also puts the receptive partner at the danger of sexually transmitted infections including HIV.

Anal sex is great, condom use is pleasure, but don’t forget AND LUBE.


Matasha et al (1998) Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention.