PhD Proposal

The role of stigma against individuals in key HIV population in sustaining HIV epidemic in
Sub-Saharan Africa.
Abstract
The HIV epidemics has shown no benevolence in developing countries of Africa where the disease
burden is highest compared to other regions. The reason for the high disease burden in Africa has
been attributed to poor economic condition, poor health service and cultural and social factors.
Even though people living in HIV key population serve as main engine for the epidemics, people
of the HIV Key population in Africa are faced with stigma for their choice of life style. This study
aims at using systematic review and mathematical modeling approach to obtain a holistic
understanding of the role stigma for the life style of people in the HIV key population has on the
transmission of HIV in Africa.

Introduction

The HIV epidemic in Africa has remained a big burden on health services providers since the virus
was first identified in an African population three decades ago. The Sub-Saharan Africa region
bears the highest of the disease burden in terms of the global picture with Eastern and Southern
Africa accounting for more than 57% of the global disease burden (UNAIDS, 2013). Even though,
the fight for attaining an HIV free generation has recorded significant gains with the improvement
in health delivery and improved access to Anti-Retroviral Treatment (ART) (Damle, 2013), there
remain a long way ahead to eliminating the HIV epidemic. HIV vaccine if efficacious, will
augment the other control strategies which will expedite the eradication of HIV even though
clinical trials of HIV vaccine have shown little evidence of reduction in HIV transmission
(Maartens, Celum and Lewin, 2014). While working to develop an efficacious vaccine, other
strategies used to minimize transmission are being explored and implemented. The use of condoms
for example have been employed by many high risk individuals and this has contributed
immensely in reducing the burden of HIV (Ahmed (2001); Pulerwitz, Amaro, Jong,Gortmaker and
Rudd (2002)).

One of the key components in reducing HIV transmission in the long term is to focus on
comprehensive policy in which social and economic level approach is considered instead of the
emergency response to managing infections. This requires social and economic policy that targets
behavioral changes towards attaining an HIV free generation. The Female Sex Worker (FSW),
Men who have Sex with Men (MSM) and people who inject drugs are known to be the key
population with high HIV prevalence and are as well at high risk of infection and must be targeted
during HIV preventive programs. However the life style of people in the key population are
deemed a taboo in many developing countries of Africa with many of the people facing stigma
and others facing jail terms. This has the tendency to reduce the possible impact of any policy that
targets people in the Key population with an aim of reducing transmission (Hagopian, Rao, Katz,
Sanford and Barnhart, 2017). The Global Forum of MSM & HIV conducted its third biannual
study in 2016 and concluded that MSN who have been sexually stigmatized were less likely to
have perceived access to services, virologic suppression and service utilization (Ayala, and Santos,
2016). Pine et al (2016) also corroborated with similar results when they studied MSM in Mexico.
Pine et al (2016) attributed the lack of HIV testing and treatment for MSM to internalized
homophobia caused by cultural machoism and also found that there were HIV positive men who
were sexually active with both men and women but do not associate with LBGT people. The
implication of this suggest that the sexual activities of members in the key population does not
only spread HIV in the MSN, it increase HIV transmission in the general population.

People in the key population remain the engine of HIV epidemics across the globe and their impact
on sustaining the spread of HIV has been studied in the developed world. However, in addition to
the numerous health challenges faced by people in the key population in terms of health service
delivery in Africa is the stigma for being in any of the key population. The stigma faced by
individuals in the key population and in some cases jail sentence makes it difficult for them to
respond to HIV control policy. The impact of stigma or societal acceptance of the life style of
individuals in the key population in Africa on the control of HIV has not been well documented.
It is therefore imperative to fully understand how stigmatization of the life style of people in the
key population of HIV affects the fight for a HIV free generation. The study sought to give more
insight on the stigma faced by people in the key population of HIV transmission and evaluate how
the stigma affects HIV control programs in developing countries of Africa.

Research Objectives
The study sought to explore the dynamics of the key populations in Sub-Saharan Africa and
evaluate the impact of stigma against individuals in the key populations on the fight for an HIV
free generation. Specifically, it sought to;
1) To explore the HIV dynamics of key populations in the Sub-Saharan Africa region.
2) To explore how the societies accept and/or perceive the act of the people in the key
population.
3) Explore the impact of stigma of people in the key population on the fight for a HIV free
generation
Research Methodology
Data on population dynamics of key population for HIV transmission across the Sub-Saharan
African region is almost nonexistent. However, there are independent research that have reported
the HIV prevalence and number of people estimated to be in the key population across the region.
By means of a systematic review of relevant articles, a synthesized data of the HIV transmission
in the key population will be obtained to provide improved knowledge and understanding. Given
that a synthesized information on the dynamics of the key population is obtained through the
systematic review, the study aims at investigating the impact of stigma using statistical and
epidemiological methods to evaluate how the spread of HIV responds to reduced stigma of people
living in the Key population.
Literature Review
Eradication of HIV epidemics in the globe has remained an area of interest for both researchers
and public health providers since the virus was first identified. A lot of scholarly work has been
focused on innovative ways of reducing transmission of the virus whereas some work has been
geared towards improving the life of people living with HIV. This section will focus on few
scholarly works that studies the epidemiology of key population in HIV epidemics and will also
review works that has used mathematical models to elucidate how the epidemics of HIV responds
to intervention.
Public health professionals who are interested in the area of HIV infection and its burden are often
interested in devising ways of reducing transmission of the virus. Mathematical models have been
used to address a lot of questions of interest in the struggle for a HIV free population. As soon as
the first HIV drug was developed, the debate on its impact on transmission also started. Anderson,
, Gupta, and May, (1991) by way of mathematical models argued that using antiviral drugs that
delayed the progression of the infection to disease state without necessarily reducing the infectivity
of the patients will increase HIV transmission and AID’s related deaths. Even though ART reduces
the viral load of an individual and hence reduces the risk of transmission, its use as a transmission
reduction strategy has showed different results. The debate on whether increase in high risk sexual
activities will negate the reduction in HIV transmission provided by treating patients with ART
was investigated by Gray, et al (2003) using a stochastic approach to investigate the impact of
ART on the Ugandan population. Gray, et al (2003) concluded that even though there was a
reduction in HIV related incidence, it was not much significant a reduction. A similar study in
Australian homosexual men population also concluded that large decrease in infectiousness as a
result of mass ART may be counterbalanced as a results of more people engaging in unsafe sex
practice Law, Prestage, Grulich, Van de Ven, and Kippax. (2001). Granich, Gilks, Dye, De Cock,
and Williams (2009) investigated whether a universal voluntary HIV testing with immediate
antiretroviral therapy as a strategy for elimination of HIV transmission will have a positive impact
on HIV transmission. From the study, they concluded that voluntary testing with immediate
antiretroviral therapy if combined with other control methods will help in eradicating HIV/AID’s.
The life style of the Female sex workers across Africa is important in understudying the HIV
epidemics. HIV prevalence among FSW is relatively high compared to the general population and
contribute largely to the spread of HIV Forbi, Entonu, Mwangi and Agwale (2011); Sobéla, et al
(2009); Hladik, et al (2017). There is limiting data on people who inject drugs in West Africa even
though there is growing evidence that they may be at high risk of HIV. The growing epidemics
among people who inject drugs in the southern part of Africa has been documented by (Bowring
et al (2013) Leprêtre, (2015)). Men who have sex with men have been reported in West Africa by
(Merrigan, et al 2011) (Mason et al, 2013) and many of whom do have sexual intercourse with
women (Sheehy, et al. 2014)
The HIV epidemic in the general population is known to depend heavily on the HIV prevalence in
the Key population yet people in the key population are mostly not covered in government
programs such as counseling that aims at reducing HIV infection. The life style of people in the
key population are considered a taboo in Africa with many facing stigmatization. This research
aims at understanding the stigma faced by people in the key population and estimate its impact on
transmission of HIV.
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