MSM and HIV in Ghana
As in many other African Countries, homosexuality is criminalized and considered taboo in Ghana. A Ghanaian BBC Reporter is on record as saying that Ghana is in fact reported to be so inhospitable for gay men that it is near to "impossible to find anyone who will admit to being homosexual, unless you are one of them." 1 This report amply describes the bare reality in planning an intervention and reaching out to MSM in Ghana. This should, however, not hold back the health sector as the price we pay for inaction can be quite high.
Anal intercourse is a well-known mode of transmission of HIV worldwide and is in fact more efficient in this regard than vaginal intercourse. In a study that compared published estimates of the probability of HIV transmission per unprotected sexual act, anal sex among MSM groups was found to carry a higher risk than vaginal sex between heterosexuals.2 In this study, while the probability of HIV transmission per unprotected vaginal sex in Europe ranged from 0.03% to 0.09% for female-to-male transmission and 0.05% to 0.15% for male-to-female transmission, the probability for anal sex in the USA ranged from 0.3% to 3.0% for receptive and 0.01% to 0.18% for insertive anal intercourse.
In Central and South Americas, and parts of Asia, between 40% and over 50% of the cumulative AIDS cases between 1983 and 1994 are believed to have resulted from homosexual transmission.3 Several studies in the developed world since the onset of the HIV/AIDS pandemic, have extensively explored and confirmed the contribution of MSM. There is, however, very little comparable information from many developing countries to guide decision-making, including many parts of Africa.4
Even though heterosexual intercourse is believed to represent the main mode of transmission of HIV in most Developing Countries, some Latin American and Asian countries report that MSM represent a very significant number of reported AIDS cases.5 Studies in Latin America, the Caribbean, India, Senegal and many other places have revealed that a significant number of men who have unprotected sex with men also engage in unprotected vaginal sex and or anal sex with women. This sexual bridging from bisexual men to women is believed to account for a substantial proportion of heterosexual transmission of HIV in those countries.6,7,8
In spite of these facts, many African countries have legal provisions criminalizing homosexual behaviour. This has been shown elsewhere to be a major impediment to research, and in carrying out HIV/AIDS work among MSM groups. In India, it has been reported that an NGO filed a petition with a New Delhi High Court to decriminalise homosexual behaviour because those provisions not only made it difficult to reach the gay community, but were also used by the police to harrass NGOs working with the gay community.9 Such legal provisions also make it difficult to adopt policies that will facilitate the introduction of interventions for MSM. In India, it has been found that condoms officially imported into the country were unsuitable for oral or anal sex.10
Even though the words homosexuality and sodomy do not appear in the Criminal Code of 1960 (Act 29) of Ghana, the Act makes sexual intercourse with a person in an unnatural manner, a crime.11 The Act does not define what "sexual intercourse in an unnatural manner" means but any suspicion of homosexuality is swiftly punished and the culprits incarcerated for a number of years. Some recent developments, which have been given prominence by the vibrant Ghanaian media include:
"CHRAJ wont push for gay rights": In this story the Commissioner for Human Rights and Administrative Justice in Ghana is reported to have "ruled out any idea of advocating for gay rights."12
"Four homosexuals jailed 2 years each": A story of 4 boys who were jailed on their own plea for "indecent exposure" after they were found to be in possession of photographs showing them in compromising homosexual acts.13
"Crowd attacks man in a womans dress" A story of an 18 year-old boy dressed up like a woman, who was taken to bed by a man, and "was subjected to a severe beating by the crowd" when it was found out that he was not a woman.14
These and many other stories showing MSM being stigmatised, and ostracised even by family members, explain how MSM in Ghana have been driven underground, where only the adherents know themselves. Operating undergroun creates a safe haven where MSM have developed their own languages and systems of protecting themselves from exposure. It also makes it difficult to introduce an intervention for MSM as part of the national response to HIV/AIDS.
Though not officially acknowledged, homosexual behaviour is also believed to happen in non-MSM groups, especially in situations where men are kept together for a long time with very limited access to women. These include prison inmates, uniformed personnel on assignments away from home, boarding houses etc. In Ghana, it has been reported that HIV/AIDS is the number two killer of prisoners, and accounts for 17.5% of prisoner deaths in the country after tuberculosis, which accounted for 20.6% of deaths in 2002.15 For this reason, the prisons authorities are adopting measures to check sodomy in prisons. The police themselves have also come under scrutiny in studies in Senegal and India where a significant number of men reported being raped by policemen.16,17
Currently all working documents of Ghana on HIV/AIDS recognise only heterosexual transmission of HIV. The National HIV/AIDS Response Analysis18 and the Ghana HIV/AIDS Strategic Framework 2001-200519 list a number of vulnerable groups, but failed to identify MSM as a potential mode of transmission of HIV. The contribution of MSM to HIV transmission in Ghana is also not highlighted in the AIDS Impact Modules (AIM)20, which are designed as advocacy materials on the epidemic. Facts available at the international level also indicate zero transmission of HIV by homosexual and bisexual groups21 in Ghana.
At the beginning of the HIV/AIDS epidemic in Ghana, the female to male ratio was 6:1. The higher female prevalence was at the time attributed mainly to female sex workers returning from countries with high HIV prevalence. This high female to male ratio declined rapidly to almost 1:1 as the disease began being transmitted locally. This decline was largely explained by heterosexual transmission only, and the contribution of MSM was never investigated.