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Building TRUST in an LGBTQ-hostile country

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Science  15 Jun 2018:
Vol. 360, Issue 6394, pp. 1167
DOI: 10.1126/science.360.6394.1167

A bold HIV/AIDS clinic that caters to men who have sex with men.

Davida Anderson poses for friends behind a clinic that doubles as a hangout.

PHOTO: MISHA FRIEDMAN

Five years ago, David Anderson, then 18, knew that he was at high risk of HIV infection. But he had never had a test for the virus because he feared that people at any clinic he visited would make assumptions about his sexuality and status. “I'm a bit feminine,” says Anderson, who now openly identifies as both a gay man and a transgender woman (Davida). But then a friend told him about an unusual community center in Abuja, where he lives. “It was nice and safe for people of my kind to come,” he says. Anderson tested negative and remains uninfected.

The clinic, opened by the Institute of Human Virology, Nigeria, in 2012, was the first in the country to cater to men who have sex with men (MSM) and transgender people, communities so heavily stigmatized that treating them is technically illegal. The clinic nevertheless provides state-of-the-art HIV services and conducts some of the most authoritative research on those communities in Nigeria. “We offer one-stop shopping,” says Man Charurat, an epidemiologist heading a multifaceted research project at the clinic with virologist William Blattner, both of whom are based at the institute's main facility in Baltimore, Maryland.

The study is known as Trusted Community Center to Reduce HIV Infections by Engaging Networks of Friends and Partners to Support Safe Sex, or TRUST—the nickname of the clinic. The study looks at, among other things, the prevalence of HIV, the rate of new infections, and how the virus spreads in networks of sexual partners. Each person who enrolls is given a small incentive to bring five friends. TRUST—which has a second clinic in Lagos run by the U.S. Military HIV Research Program—now has more than 2000 participants, a startling 45% of whom tested positive for HIV.

TRUST also is looking at how antigay laws and other stigmatizing social factors impede care and treatment. In 2014, a new Nigerian law called the Same-Sex Marriage (Prohibition) Act made providing services to MSM a punishable offense. (To avoid legal complications, the TRUST clinic is located out of the way, in a residential neighborhood, and bills itself simply as “MSM friendly.”) Stigma and discrimination against that community were already pervasive the year the law was enacted: According to a survey of 3500 undergraduates in Lagos, nearly 40% thought health care workers should not provide services to MSM, as reported in the August 2017 issue of LGBT Health. Researchers and affected communities alike contend that the law has made things worse.

Charurat, Blattner, and colleagues assessed their clients' attitudes toward seeking health care before and after enactment of the law. Fear of seeking health care jumped from 25% to 38%. Today, only 25% of TRUST participants infected with HIV know their status when they first come in. Of those, fewer than half are on treatment. TRUST encourages all HIV-infected clients to start antiretrovirals, and a new program is offering the drugs to uninfected participants—a proven prevention strategy called pre-exposure prophylaxis.

The TRUST clinic has evolved into a place to hang out as well. Anderson sometimes lets Davida shine, donning a wig, high heels, and an elegant gown. “That's the reason we set this up,” says Charurat as Davida struts around the TRUST clinic grounds, “voguing” with friends. “It's not just a clinic. It's a community.”

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