ARM-ing Africa for Rectal Microbicides

Original content from the Mapping Pathways blog team

These are exciting times in the HIV-prevention landscape.  In an earlier Mapping Pathways post, we covered our colleague, Jim Pickett’s experiences at the Microbicides 2012 (M2012) conference in Sydney in April.  At M2012, advocates discussed a number of important issues, including the importance of adherence in clinical trials. 

A major development at M2012 was a report released by the International Rectal Microbicide Advocates (IRMA), a global network that Jim leads, as a cornerstone of their Project ARM (Africa for Rectal Microbicides). The report, titled “On the Map: Ensuring Africa’s place in Rectal Microbicide Research and Advocacy” outlines priority actions to ensure Africa is involved in rectal microbicide research and advocacy activities.

On The Map is the result of a two-day consultation that took place before the ICASA conference in Addis Ababa in December with African and international stakeholders. Says Pickett, “The central question of the consultation was ‘How can we be more strategic and proactive to make sure Africa is on the map when it comes to rectal microbicide research and advocacy?’”

The Project ARM report lays out seven key action areas specific to rectal microbicide research and advocacy in the African context:

Knowledge, Attitudes and Behaviors (KAB) studies on anal health and anal sex to generate data that can be analyzed across countries and populations

Rectal microbicide acceptability studies

Mapping of sex education curricula to determine what content on anal health is included

Advocacy for lubricant access through the “And Lube” campaign of the Global Lube Advocacy Mobilisation (GLAM)

Documentation of best practices for integrating anal health, anal intercourse and rectal microbicides into sexual health and HIV prevention education

Capacity-building activities for community leaders, advocates, and researchers

Awareness raising and education about anal health, anal intercourse, and rectal microbicides, including development of educational materials and other communications efforts specific to the African context

According to Pickett, members of the Project ARM working group further prioritized the key activities. While the members agreed that all the activities are important, the top three are the KAB studies, awareness raising and education on anal health and anal intercourse, and improving access to condom-compatible lubricants, which are in very short supply across most of Africa.

Pickett explained that the HIV epidemic in Africa is often wrongly considered as solely heterosexual, with sexual transmission driven entirely by unprotected vaginal sex between men and women. “There has been little to no official recognition of the fact that there are gay men and other men who have sex with men in Africa who are enduring high rates of HIV, and that plenty of heterosexuals also have anal sex. Unprotected anal intercourse is 10 to 20 times more likely to result in an HIV infection compared to unprotected vaginal intercourse,” says Pickett.

As mentioned, increasing access to condom-compatible lubricant is a key goal of Project ARM. Access to appropriate lubricants on the continent is quite abysmal. “In the absence of appropriate, safe lubricants, people use things like shampoo, cooking oil, hand lotion, antibiotic creams – even motor oil – that break down the latex in the condom, erasing the protective benefits.. People also use saliva, which dries out quickly – and can cause tears in the condom as well as harm the fragile rectal environment. For safer anal sex, lubrication that is condom-compatible is absolutely necessary,” says Pickett.

 “There is an immediate need for appropriate lubricants for people who have anal intercourse in Africa. If we can’t get lubricant to people now, how will we be able to deliver rectal microbicides to them when they become available? Increasing access to appropriate lube is absolutely critical, and paves the way for access to rectal microbicides down the line. We can’t have campaigns and programs that deliver condoms without also delivering condom-compatible lubes. Period.”

Stay tuned to the blog as we bring you more information on this exciting project. Until then, read a vivid snapshot of advocacy in Africa through the eyes of Brian Kanyemba here. Brian has been very involved with IRMA's Project ARM, and is an integral member of the Project ARM video working group, which is trying to produce an African-focused video on anal health and anal intercourse.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

Update on IRMA’s Project ARM – Africa for Rectal Microbicides Strategy Meeting in Addis: Dedication and passion are paving the way forward

  Original content from our Mapping Pathways blog team

“It was an amazing group, and one that moved me to near tears on a number of occasions”

Our colleague Jim Pickett from the AIDS Foundation of Chicago, a Mapping Pathways partner organization, just returned from an inspiring week in Addis Ababa, Ethiopia, where he led a strategy meeting for the International Rectal Microbicide Advocates (IRMA) and then attended the ICASA 2011 conference (read more about both here and here). We checked in with Jim for an update on IRMA's Project ARM (Africa for Rectal Microbicides) strategy meeting, which was held in Dec 2 and 3 (click here for a fact sheet on Project ARM).

The meeting, which was the result of 18 months of planning and coordination, convened about 40 individuals - both invited speakers and guests, including 16 individuals who secured scholarships to attend (out of 145 applicants.) The meeting participants represented countries including Ethiopia, Rwanda, Cameroon, Kenya, Nigeria, Zambia, Malawi, Zimbabwe, South Africa, Uganda, Canada, United Kingdom, and the United States  -researchers, advocates, LGBT people, heterosexual people, and those representing sex workers, prison populations and more.

“It was an amazing group, and one that moved me to near tears on a number of occasions,” says Pickett, who explained that the aim of this meeting was for people to come together and create a strategy, a road map, around rectal microbicide research and advocacy specific to the African context. “I've been to many, many meetings – too many –  in my day and I think the Project ARM meeting was, by far, one of the most productive, inspiring, exciting, energizing, and emotionally moving ones I've ever had the privilege to attend. Yes, I am obviously biased - but it isn't often that events like these make me misty-eyed and put a lump in my throat – repeatedly.”

The journey to getting all these people together for this meeting was not easy, as many faced multiple challenges securing the required visas for travel to Ethiopia. Says Pickett, “There was this incredible energy in the room. We’d been planning this meeting for the past 18 months, and it has been a long journey for all of us to make this happen. A number of the people attending went to extraordinary lengths to get to Addis Ababa. They had to make so many trips to embassies and consulates for visas, so many obstacles were placed in their way to dissuade them from attending, but none of them took no for an answer. The incredible perseverance they exhibited simply to show up was extremely moving.”

The participants spent the two days together getting informed – including sharing the latest updates on rectal microbicide science, rectal microbicide advocacy, issues around LGBT crimininalization, anal sex prevalence, the gay/MSM epidemic, and more. “But we didn't just passively listen to others speak - we broke out into small groups a number of times to unpack what we learned and to come up with priorities and plans for moving forward,” says Pickett.

Four advocacy-focused items and four research-focused items were prioritized, and action steps were developed for each. These included expanded rectal microbicide scientific research activities in Africa, expanded research into anal sex behaviors among African straight and gay/MSM populations, communication/education efforts, and the birth of  the Global Lube Access Mobilization (GLAM) campaign called "And Lube" to support increased access and availability of condom-compatible lubes throughout Africa. Current lubricant access across the continent is absolutely abysmal.

What especially surprised and moved Pickett was the level of enthusiasm and positivity in the room. “A lot of these people come from countries that have seriously troubling environments and where advancing HIV prevention and advocacy is met with extreme homophobia. So I thought that a lot of the discussion would be on the challenges and obstacles-- I mean, so many of the countries we were focusing on are settings where you can’t even think of doing a microbicide trial, let alone discussing sexuality openly without worrying for your safety – yet the participants didn’t get stuck on these negatives. These are men and women who are brave and strong and are committed to fighting for better health and civil rights for the people in their country. It was extraordinarily fulfilling to witness their passion and energy first hand; to see them standing up and doing this work despite the numerous challenges and obstacles in their way.”

Dr. Ian McGowan, co-principal investigator of the Microbicide Trials Network (MTN) attended the meeting, presenting the latest in rectal microbicide science. He also addressed some of the questions regarding the recent closure of the VOICE trial’s study arm testing tenofovir gel. The decision was made due to futility – while tenofovir gel was found to be safe, the trial was not able to prove the gel worked to prevent HIV. See the statement from the MTN for more information. Previously the trial had to drop its tenofovir tablet arm due to futility as well. The Truvada tablet arm in the trial is continuing. “There was a lot of speculation in the room about why it was closed,” said Pickett. Many of the people present speculated that a lack of adherence might have been a factor, said Pickett. “But of course, it’s all speculation at this point, we don’t know what happened, and we won’t till the end of next year likely.” He added that McGowan confirmed that it is still important to move forward on both vaginal and rectal microbicide research and to keep exploring ways to create a more diversified microbicide pipeline (learn more about the microbicide pipeline here and here).

For Pickett, another big highlight was McGowan’s strong validation for Project ARM’s objectives. McGowan, a highly respected veteran in microbicides research, publicly offered MTN support for future Project ARM activities and commended the participants for their collective intellect and passion. Said Pickett, “Ian participated in many of the small break-out groups, and I think he was impressed by the high quality of thought, curiosity, and energy in the room. And to have that kind of validation from someone who is one of the key rectal microbicide researchers on the planet… it was a really big moment for us. There isn’t a doubt in my mind now that Africa is squarely on the rectal microbicide map.”

Pickett also felt that an interesting backdrop to the IRMA meeting was Hillary Clinton’s speech that formalized the Obama administration’s prioritization of LGBT rights globally, helping to bolster rights’ groups on the ground in their fight against discrimination. “At the end of the day,” said Pickett, “if people aren’t free to be who they are, wherever they are, they won’t be able to make use of any prevention technology, let alone rectal microbicides. There’s no point in having a really great microbicide on the shelf if people are not safe, and therefore unable, to access it.”

Jim Pickett is the Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago. He is chair of IRMA (International Rectal Microbicide Advocates), and a member of the Mapping Pathways team. A full report from the Project ARM meeting in Addis, laying out a rectal microbicide research and advocacy strategy for Africa will be released at the Microbicides 2012 conference in Sydney in April 2012. Until then, find updates here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

On the Ground with Brian Kanyemba: A snapshot of advocacy in Africa

It’s one thing to read about HIV advocacy and prevention and another to experience it first-hand, on the ground, day to day. That’s how Brian Kanyemba experiences it. He is the research assistant at the Desmond Tutu HIV Foundation, a Mapping Pathways partner organization. A core part of Brian’s job involves traveling through South Africa’s villages and cities, talking to people about issues surrounding men who have sex with men (MSM), and what the prevalence of HIV means within this group of people. Of late, his focus has been on putting forward the “meaningfulness of Pre-Exposure Prophylaxis (PrEP)” within the South African context, especially for the MSM community. This is no easy task.

Let’s talk about sex
“South Africa is a really interesting and dynamic place,” says Brian. “We might have gay rights and rights access of services across all sexual orientations, but when you start to talk about MSM, or about PrEP as an intervention among MSM, this is faced by a huge mental wall.” This wall extends to talking about rectal microbocides as well, mostly due to the taboo against anal sex. Currently in development, rectal microbocides, or “topical PrEP”, are ARV-based products that might reduce the risk of HIV infection when used topically in the rectum during anal intercourse. These are in phase II, with an expected phase III to be carried out in Africa and possibly Cape Town (to learn more about rectal microbocides and PrEP click here and here). “No one will come forward to talk about this openly,” says Brian, “because in Africa, anal sex is associated with homosexuality, and homosexuality in Africa is not okay.”

One way Brian goes around this taboo is by using a simple game about sexual pleasure called “Mapping the Body”. While talking to people, he introduces the discussion on rectal microbicides by drawing three images on the board: a simple figure of a man, a woman, and another man. “I say, ‘Guys let’s put stars on areas where one can be sexually stimulated’,” says Brian. “You get amazing ideas from the group. And some people will say to put a star on the anal area, and then from there it is easier to link to PrEP and to introduce rectal microbocides.” By conducting a matter-of-fact discussion focused on pleasure and the body, Brian finds the group is much better able to accept the idea of rectal microbocides as a form of protection.

“Heck no… I am not interested.”
Despite his innovative methods, Brian has run into some pretty big walls where the topic of MSM and PrEP is concerned, especially within the healthcare sector and even the government. At a meeting with a parliament member who represents HIV issues, Brian recalls that when he brought up the topic of MSM and PrEP, she said, “’Oh no, can you please stop there because that doesn’t exist in my frame of mind.’” Says Brian, “This was a woman in the parliament whose job was to discuss issues of HIV. So, I’m talking to her about MSM being a group of people who have a high prevalence of HIV infection and she just says, ‘Heck no, we’re not going to talk about that topic now. I am not interested.’”

Brian clearly remembers his most unexpected encounter with homonegativity – it was at a focus-group PrEP presentation that he conducted in Durban, the third-largest city in South Africa. Recalls Brian, “I put the word MSM on the board, and do you know what one woman participant said? She said, ‘By MSM do you mean men who have sex with men? Yes, they must die; and if not, they must be killed!’” The woman participant who said this was on the community advisory board for one of the major HIV trials in South Africa, which made the statement all the more startling for Brian. “I was so taken aback. I thought, ‘Oh my God, this is where the advocacy has to start from.’”

A personal quest and mission
For Brian, the advocacy began many years ago in Zimbabwe, when he was just 19 and right out of college. He says, “As I was growing up, it was just accepted that being gay is bad. That is one of the reasons I left Zimbabwe, because of the way gay people are treated, are not spoken about.” He vividly remembers the moment that he began on his path as an HIV advocate, “A very close friend of mine was diagnosed with HIV and he was gay and, at the end of the day, he committed suicide. He didn’t understand HIV, he didn’t understand that it’s not a death penalty, he didn’t know that you can access treatment, he didn’t know that ARV treatment and care is available… and so advocacy become a passion, it was so personal to me.”

Despite the intense societal taboo, Brian worked in Zimbabwe on HIV and gay rights issues for almost a decade. His first job was with the National Army, working at the provisional hospitals on HIV and AIDS issues, ARV rollout, and providing counseling services for homosexuals. Says Brian, “I was working in the psychiatric department of the hospital… they realized I was gay, so they sent me to the lunatic asylum!”

Brian’s journey hasn’t been easy, and yet he continues with dedication, enthusiasm and hope. Why? Why not choose an easier job, an easier path? Brian’s response is prompt, “They say in my culture that when a funeral happens next door, you say ‘Ah ok, there is a funeral.’ But when a funeral happens in your house, it becomes a personal issue. When my friend passed away, I thought, ‘Ok, I need to put on my armour and start fighting this war now. I am going to stop this. I am going to stop thinking like a young person, and I am going to fight and go forward fighting for all my friends and for my community.’ It was very early in my life that I decided this, and I am not going to stop.”

Brian is a research assistant with the Desmond Tutu HIV Foundation, a Mapping Pathways partner organization. He is also an advocate fellow with the AIDS Vaccine Advocacy Coalition (AVAC), and is an active member of the International Rectal Microbicide Advocates (IRMA). He has been very involved with IRMA's Project ARM - Africa for Rectal Microbicides, and is an integral member of the Project ARM video working group, which is producing an African-focused video on anal sex and rectal microbicides.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]