HIV Innovations and LGBTI Advocacy in Sub-Saharan Africa


In September 2013, UN AIDS reported a dramatic reduction in HIV infections worldwide. While 35 million people throughout the globe are now living with HIV/AIDS, new HIV infections among adults and children were estimated at 2.3 million in 2012, a 33% reduction since 2001. AIDS-related deaths have dropped by 30% since the peak in 2005, as access to lifesaving antiretroviral drugs (ARVs) increases.1
Since two-thirds of the world's HIV+ people (25 million) live in Sub-Saharan Africa, the remarkable improvements in HIV prevention and treatment there are of particular importance. In 2012 an estimated 1.2 million people in the southern and eastern parts of the continent became newly infected and an estimated 1.2 million in the region died of the disease, figures that represent a 50% reduction in HIV incidence in adults in the region.2 New HIV infections per country have been reduced by 30% in many places (Kenya, Mozambique, South Africa, and Swaziland) and by 50% in Botswana, Ethiopia, Malawi, Namibia, Rwanda, Zambia, and Zimbabwe. Since 2005 the number of people in the region receiving ARVs has increased from 625,000 to a staggering 6 million and the number of infants infected decreased by 30% in many nations and by 50% in others. In 2012-2013, South Africa's concerted, strategic policy efforts to battle the disease have led to more than 9 million people being tested and 2.1 million receiving ARVs.3
However, in countries like Lesotho, Tanzania, and Uganda, HIV incidence has begun to plateau or increase. The revised World Health Organization Antiretroviral Treatment (ART) guidelines--to initiate ARVs early and to offer them to all people living with HIV--is predicted to lead to even more substantial decreases.4

Existing mHealth Innovations

Because mobile phones are so prevalent throughout the continent, the most effective means of helping reduce infections in Africa is the use of mobile phone technologies (mHealth) to facilitate improved HIV-related healthcare. There are 650 million mobile subscribers in Africa, and the market expands annually. The website mHealth Africa provides the following graphic that shows the breakdown of subscribers by nation. Two of the four nations with the highest number of subscribers are the Sub-Saharan nations of Nigeria and South Africa.
Mobiles_Africa.jpg

Simultaneously, this map by The New York Times shows that only 16% of Africans have Internet access, with the usage rate at about 1.5% on average in individual African nations. Total smartphone penetration in Africa is estimated to be between 17-19%, though rates vary significantly from country to country. Mobile telecommunications infrastructure throughout much of Africa is not powerful enough or is too expensive to connect to the Internet.5 Since smartphones are not prevalent enought for adequate saturation of HIV+ or at-risk populations in Africa, cheaper models continue to be used in tandem with social media innovations that have greatly expanded HIV healthcare and prevention. Mobile phones are used for drug adherence, sharing prevention and health messages, alerting patients to available services, gathering data, facilitating health workers' monitoring efficiency, and providing remote diagnoses. 86% percent of all NGO employees are using mobile technology for their work.6

Some of the most promising mHealth interventions in Africa include:

Magpi (formerly EpiSurveyor) from DataDyne, is an easy-to-use, free software that allows health workers to efficiently collect data on treatments and clinic supervision via any kind of mobile phone. Users can quickly create an account, design forms and download them to their phones for speedy data collection and analysis. Since 2009, more than 22,000 users have relied on it to upload more than 10 million pieces of data. Fifteen sub-Saharan African nations use EpiSurveyor for HIV healthcare, in conjunction with the World Health Organization.7 This video gives a brief tutorial on how to use Magpi/EpiSurveyor.

EpiSurveyor/Magpi is the product of a $1 million public/private partnership between the UN Foundation and the Vodaphone Foundation.

Ushahidi is a free and open source software that collects, visualizes and maps interactive information. It employs crowdsourcing, in which end users use mobile phones or the Internet to submit pertinent information, such as reports on health clinics and location of HIV+ individuals in need of care. Submitted data points are then aggregated to produce a geospatial, visual map of information.8 The Kenya AIDS NGO’s Consortium (KANCO), in collaboration with the UK's AIDS Portal, conducted a six-month pilot program to map all civil society organizations (CSOs) in Kenya involved with the HIV/AIDS and tuberculosis epidemics.9 This video provides a basic explanation of how Ushahidi works.

What is the Ushahidi Platform? from Ushahidi on Vimeo.



Medic Mobile (formerly Frontline SMS) is another free, open source software used to distribute and collect information via text messages (SMS). The software lets users connect mobile devices to a computer without Internet and then transmit and receive SMS text messages. If internet access is available, Medic Mobile can be used to send bulk SMS text messages to other web or e-mail services. Starting in 2007 as FrontlineSMS, the technology was first tested in rural Malawi, a nation severely impacted by HIV/AIDS. In a region with only 600 volunteer community health workers (CHWs), the software was used to help with tuberculosis treatment, antiretroviral therapy and home-based care. Texting brought home-based care to 130 patients and saved ART monitors over 900 hours of travel time that would have been expended for adherence updates or delivery of medical advice. By 2010, 1,500 end users linked to clinics serving approximately 3.5 million patients in eleven countries worldwide were benefiting from the technology. Medic Mobile is now also used in Uganda, Mali, Kenya, South Africa and Cameroon.10

Young Africa Live is a free mobile phone platform young people in South Africa can use to chat and learn about sex-related issues such as dating, sex, gender stereotypes, and HIV. It reaches more than 30 million South Africans a month and between its launch in December 2009 and the end of 2012, it had 78 million total page views, 2.7 million total comments, and more than 1.3 million unique visitors.11 To promote HIV testing, it provides links to voluntary counseling and testing centers. Its content is graphically dynamic, as evidenced by this animated video based on the results of an annual youth sex survey.


Project Masiluleke was developed by the Praekelt Foundation as a tool to facilitate large numbers of the South African population getting tested for HIV at home and to keep HIV+ patients adherent to ARVs. In South Africa, it is estimated that less than 5% of the population has been tested for HIV yet more than 24% of the population is HIV+. Of the HIV+ individuals, only 10% are currently receiving ART, leaving the remaining 90% infected, untreated and highly infectious. The Project Masiluleke pilot sent over 690 million messages in English and five native languages, resulting in 1.5 million calls to a proscribed AIDS helpline.12

one2one is an integrated digital platform provided by Liverpool VCT in Kenya, offering innovative, peer-led sexual and reproductive-health related interventions for youth. It consists of a mobile SMS-based counseling hotline and a web-based interactive SMS bulk messaging service that addresses the HIV and sexual health needs of high-risk groups like youth and the LGBTI community. The program also uses radio, Facebook, Twitter, YouTube, and WordPress applications, as well as in-person support groups. LVCT is an umbrella organization that provides organizational and technical capacity building services to eleven MSM organizations throughout Kenya.13 No statistics on the program are available but the following graphic, courtesy of one2one, illustrates the program's comprehensive media scope.
ONE2ONE.jpg

Tendai is a specialized medical monitoring software used by citizen journalists working for the Southern African Development Community (SADC). The South African program connected to Tendai is administered by Health-e News Service in the nation's eleven National Health Insurance pilot districts. Citizen journalists file weekly stories on community health issues and report ARV or other drug stock-outs in outlying clinics, according to Kerry Cullinan of Health-e. Each citizen journalist visits their local clinic once a month and uses the Tendai application on their regular mobile phone to record inventories of medicines and to record their presence at the clinic via GPS coordinates. Other data that can be recorded are digital surveys, voice recordings, and photos. The results are sent to a central database program that coordinates the information using customized open-source survey software. The medical supply data is then logged into Excel sheets that are available for all members via the InfoHub site. In August of 2013, clinics outside the capital city of Kampala reported shortages of HIV test kits and ARVs, saying the national government had not been making adequate deliveries. The Tendai-based citizen journalism program allows citizen journalists to report drug shortages such as this one sooner.14

Gene-Radar is a mobile device the size of an iPad created by Cambridge-based nanotech firm Nanobiosym that tests for HIV remotely and provides results, cheaply, in one hour. A health care worker takes a drop of blood, saliva, or other bodily fluid and places it on a nanochip that is then inserted into the device. Gene-RADAR then extracts the DNA and RNA present in the sample and searches its databases for the RNA and DNA of a matching virus.15 Because traditional HIV tests in isolated areas of Africa tend to have low accuracy, and because more reliable tests take up to six weeks for results and cost about $200, Gene-Radar could be extremely useful in the fight to control AIDS on the continent. At $10 per test, the technology could also help drive down the cost of rapid tests worldwide and could track disease outbreaks. Nanobiosym recently received a $250,000 USAID grant to design clinical trials in Rwanda and aims to make the device the size of a smartphone or perhaps something wearable or ingestible.
The following graphic, courtesy of the Boston Globe, demonstrates the technology.
gene-radar.jpg


While no study can quantify how many infections the eight interventions above might prevent, the significant advances in HIV testing and health care delivery they permit, combined with high rates of connectivity, suggest they would advance the use of exciting medical innovations like the use of ARVs as prevention (pre-exposure prophylaxis, or PrEP). PrEP trials have met with notable success in Sub-Saharan nations and healthcare workers and advocates want PrEP, but the prophylaxis is not yet legal there. Pending approval, Medic Mobile could serve as a mechanism for healthcare workers to monitor clients' daily adherence to PrEP and could facilitate counseling when a client is having difficulty with their medication. Gene-Radar could be used for rapid, frequent HIV tests, which are necessary to ensure PrEP's effectiveness. Magpi could be used to collect large amounts of data on adherence and effectiveness for participants so health departments could more easily evaluate PrEP.

PrEP Adherence in Uganda: A Model for Innovation

truvada.JPG
Creative Commons Image

Uganda's government refuses to approve the use of PrEP (a regimen that involves taking the ARV Truvada daily to prevent exposure to HIV), even though 400 Ugandans are infected with HIV every day and 145,000 are infected each year.16 Although the science behind PrEP trials is solid and use of the prophylactic would be cost effective, Uganda's Ministry of Health's AIDS Control Programme bans it on moral grounds, saying that PrEP would encourage "reckless sex." The government also objects to putting HIV- people on ARVs while many HIV+ Ugandans still did not have treatment.

In the 1990's, Uganda espoused a prevention plan called ABC (Abstinence, Be Faithful, and Correct and Consistent Condom Use), and the nation's HIV incidence rate fell from 15% to 6% by 2007. Since then it has risen to 7.3%, most likely due to the messaging of PEPFAR (U.S. Presidents' Emergency Plan for AIDS Relief), which from 2009-2011 channelled almost $900 million in HIV treatment and prevention funds into Uganda through faith-based organizations that teach abstinence and speak out against condoms and homosexuality. Most of the 500,000 HIV+ Ugandans access treatment through PEPFAR.17

A 2013 PrEP study conducted in three Ugandan sites found that out of 1,147 participants from serodiscordant (one positive and one negative) heterosexual couples, 97% drug adherence was obtained, largely due to diligent counseling. Only 14 participants seroconverted and they had all been on placebo. The encouraging results yielded a 100% PrEP efficacy figure with a 95% confidence interval.18 The iPrEx study of MSM (men who have sex with men) in South Africa, South America, Thailand, and the United States from 2007 to 2011 found that out of 2,499 participants, with half taking Truvada and half taking a placebo, 36 HIV infections occurred on Truvada and 64 infections occurred among those taking the placebo. This means that Truvada PrEP provided only 44% additional protection against HIV in this group. One major caveat to this highly contested study is that drug adherence varied drastically among the cohort and blood analysis revealed that if participants took PrEP faithfully seven days a week, HIV acquisition risk was reduced by 92-99% 19

Uganda's large number of serodiscordant heterosexual couples, as well as its MSM and other high-risk populations, would benefit from PrEP, many HIV activists claim. AIDS Vaccine Advocacy Coalition (AVAC) Executive Director Mitchell Warren has said that demonstration projects should be planned in countries like Uganda, where PrEP clinical trials have already taken place. Warren advocates for PrEP because "It is an intervention with the real possibility of preventing infections, especially where other prevention options aren't enough."20 Scientific models have shown that PrEP will be most useful when targeting Most At Risk Populations (Marps). In Uganda and in other nations, Marps include sex workers, IV drug users, and MSM.

HIV, Homophobia, and the Digital Response

Homophobic cultural and political attitudes against the LGBTI (Lesbian, Gay, Bisexual, Transgender, and Intersex) community have led to violence against African MSM in particular and their imprisonment. These biases have also greatly impaired MSM's access to health services. Since homosexuality is illegal in 38 African nations and is commonly viewed as "un-African," denialism and the violence that accompanies it drive MSM's sexual activities underground, so MSM do not receive the vital HIV-related health services other groups do.21 Thus, while HIV is actively targeted in the heterosexual communities of many African nations, it has become a growing problem for MSM and the women that bisexual MSM engage with sexually.22 HIV prevalence among MSM in Sub-Saharan Africa is estimated at 9-25%, although comprehensive government reporting on this phenomenon is extremely low. In South Africa, MSM are twice as likely as heterosexual men to have HIV and MSM constitute an estimated 9.6% of new infections in Kenya and 19.7% in Senegal.23

This graphic from a study published in The Lancet depicts the disproportionate amount of HIV infections in MSM (orange bar) in Sub-Saharan Africa as opposed to all adults there (black bar.)
MSMGF_Epidemic.jpg

In nations such as Cameroon and Uganda, recent events reveal homophobia directly affecting attempts at decreasing the transmission of HIV in MSM. In July 2013, an arson attack destroyed the Alternatives-Cameroun Access Center, which provides services for the LGBTI community, including health care and HIV treatment and prevention for MSM. That same month, gay rights activist and journalist Eric Ohena Lembembe--who was the subject of the documentary film "Born this Way" was murdered in the capital, Yaoundé. The center is being rebuilt, but repeated attacks on human rights defenders and LGBTI groups are common in Cameroon, where homosexual sex is currently punishable by nine years imprisonment and the government denies that anti-gay violence exists.24 Peer educators try to provide more clandestine HIV counseling by surfing popular gay hookup sites like PlanetRomeo (46,000 African subscribers), where they inform men about HIV and direct them to support groups like Alternatives-Cameroun.25Another commercial site, meetmarket.co.za, which claims to reach over 43,000 users in southern Africa a month, acts as a combined gay dating site and as a portal to HIV information sites. Linked-to sites like Health4Men use web pages, Facebook pages, and Twitter accounts for safer sex education, empowerment campaigns, health surveys, and fundraising.

Similarly, in November 2013 prominent gay Ugandan activist Samuel K. Ganafa was arrested along with four others and held without charge or bail for more than two weeks. Ganafa, the executive director of Spectrum Uganda and the chairman of the board for Sexual Minorities Uganda (SMUG), two prominent CSO's that support HIV services along with LGBTI rights in a country with climbing HIV infection rates, was accused of infecting a young man with HIV.26 Accusations of HIV infection frequently arise in an environment that criminalizes homosexuality and stigmatizes HIV, as in Uganda, which has drafted a law with ever harsher penalties against LGBTI people and organizations.27

Thus, LGBTI human rights advocacy is mandatory for building the infrastructure necessary to sustain effective HIV prevention for MSM in Uganda and elsewhere. The film God Loves Uganda documents the negative influence of American religious NGO's on HIV and LGBTI policies in Uganda and it is being shown to communities throughout the continent. Like the videos from the UN's Free & Equal campaign, the film has raised some awareness in Africa and in the United States about equal rights and equal access to health care, but it is uncertain how much these external interventions influence the attitudes of the majority of African publics and governments, since most Africans do not have the technology necessary to view them.

Free & Equal was recently developed by the United Nations' Office of the High Commissioner of Human Rights (OHCHR) as a global public education campaign promoting LGBTI equality. In addition to using articles and fact sheets, the campaign uses social media such as short testimonial videos and other digital content to raise global awareness of homophobic and transphobic violence and discrimination.
This video from the Free & Equal site demonstrates homophobic violence in South Africa.

Free & Equal has its own dedicated website and also engages with Facebook, Twitter, and YouTube to remind member nations and the public that abuse directed at persons for their sexual orientation or gender identity is illegal on the basis of the Universal Declaration of Human Rights. UNFE's September 2013 launch was covered extensively by LGBTI and mainstream television, radio, and print media, according to Tile Wolfe, social media strategist at All Out/Purpose.org, who is handling the campaign's digital arm. As for African impact, "It helps that we launched the entire Free & Equal campaign in South Africa, so we have a media base there in terms of impressions," says Wolfe. (The number of impressions refers to the number of times a piece of digital content is displayed.) "South Africa makes up 2.5% of our fanbase and the campaign is at over 10 million social media impressions," she says. More specific results are difficult to quantify, particularly at this early date.

Endeavors such as the Global Dialogues Project are perhaps easier to access for the average African. Using film as a form of edutainment can empower MSM by addressing relevant issues publicly and encouraging positive debate amongst audiences in an engaging rather than hostile space, according to participating policy organization African Men for Sexual Health and Rights (AMSHER.) AMSHeR, a South Africa-based advocacy alliance of eighteen organizations from Burundi, Cameroon, Cote d'Ivoire, Ghana, Kenya, Malawi, Mozambique, Namibia, Nigeria, South Africa, Tanzania, Togo, Uganda, Zambia and Zimbabwe, claims that the screenings provide opportunities for MSM and non-MSM communities to come together to discuss the issues, especially in rural areas where there is a dearth of visual images and where MSM tend to be invisible.28

Originating in the United Kingdom and the United States, Global Dialogues funds a contest that challenges youths to come up with film concepts concerning HIV/AIDS, LGBTI characters, sexuality, or violence connected to sexual orientation or gender identity. Winning ideas are then produced by professional filmmakers and made available for free for community screenings, television broadcast or internet streaming and download, where they reach 200,000,000 viewers per year.29 A recent film, "Faceoff over homosexuality. Where do YOU stand?" tackled Evangelical homophobia and has received positive feedback at community screenings in Kenya, including from local Christian leaders. "Sadly, the film is not broadcasted on Kenyan TV because of its nature," says Brian Macharia, of Ishtar MSM, a Kenyan CBO advocating for MSM healthcare rights and also a partner in the Global Dialogues Project. "The Global Dialogues outreach mobilizers have to organize (community) screenings themselves when they are invited or during their outreach activities," he said.
"Faceoff over Homosexuality. Where do YOU stand?"


AGACIRO is a web initiative of MOLI (Movement for Individual Freedoms), a Francophone LGBTI and human rights organization based in Bujumbara, Burundi, that establishes an LGBT presence in this nation where same-sex relations have been illegal since 2009. The blog is a community forum that reflects conversations around LGBTI experiences taken from real life meetings and allows individuals to express themselves politically and artistically. Olivier King Sibo, of MOLI, says, "Of course, the contents (of the blog) are not legal because all LGBT-related things are illegal and there is a media commission that regulates all media. Lately that commission voted for a more oppressive law on free expression...but we continue to post until this means of expression is blocked," he said. AGACIRO also uses Facebook and Twitter.

Behind the Mask (BtM) was a South Africa-based NGO/website that covered LGBTI advocacy and AIDS-related issues in 36 African nations and provided information and safe community connections for thousands in unwelcoming environments. According to the Open Society Initiative of Southern Africa, "BtM is acknowledged as the prime source of reliable information on LGBTI affairs in Africa by a growing constituency, locally, regionally, and internationally."30 Although South Africa is the only African nation with a constitutional protection of LGBTI rights, the site folded due to internal differences and lack of funding, according to Davis Mac-Iyalla, a Nigerian LGBTI activist now living in London as a refugee. "Grassroots activism is being killed by big non-governmental organizations and funders," says Mac-Iyalla, as large NGO's have cut back on funding local organizations. "They are turning all activists into professionals," he says. A recent study by amFar (The Foundation for AIDS Research) shows that although PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria have stated goals to reach the LGBTI community, few funding proposals from partner countries outline progams targeting those groups and even fewer get funded. A recent case study found that of a total of 29 proposals submitted, 19 were accepted but 11 made no mention of MSM, and only two contained activity-level data.31

Although international and national NGO's and nonprofits (and sometimes commercial services) are striving to advocate for LGBTI rights and adequate HIV healthcare in African nations via public websites, applications, and videos, the illegality of homosexuality and the criminalization of HIV in such places requires more pragmatic methods of protection and political organization. Kene Esom, Director of Programmes at AMSHeR, says that Ghana's Commission on Human Rights and Administrative Justice is pioneering a system for reporting rights violations by using SMS short code. The commission has been working with the LGBTI community to ensure responses to hate-based violence but, no details are immediately available.

VOJO: A Simpler, Safer Way to Mobilize

One hosted mobile blogging platform, Vojo.co, has the potential to make it easier for average LGBTI Africans to connect clandestinely by posting information and comments in a central space using simple mobile phones and voice, SMS, and MMS messages. Built by a team at the MIT Center for Civic Media and supported by VozMob, Drupal, and Mirabot, the free/open source software does not require a smartphone or Internet access, an important feature for most rural and urban Africans. Accounts are created via SMS, and employ tags, geocoding, maps, groups and group messaging. One limitation is that any new Vojo group receives a U.S. number by default. Although the service Tropo.com can usually connect the U.S. number to a local number, purchasing an MMS gateway is necessary for the full functionality of SMS and MMS, according to Sasha Costanza-Chock, one of Vojo's creators at the MIT Center for Civic Media.

"For Vojo to be a useful tool in Africa, we would need to find resources to set up local numbers and mms gateways, or purchase them from a third party application service provider," says Costanza-Chock. Although financial resources are a challenge for the center right now, Costanza-Chock thinks Vojo would be quite useful in Africa "because it is optimized around the low-cost phones that most people in low income countries (and frankly, millions of working people in any country) depend on," he says. "It also works in situations of low literacy," he adds.

This is an example of a Vojo group dedicated to social justice for gender variant people in Los Angeles. The group's url is nondescript and can even be totally numerical, making it quite discreet and difficult to locate for anyone who is not a member. Signing up for a Vojo group could be limited to word of mouth and that private network could be used as a community alert system in an intolerant environment. The maps application could serve as a secret log of safe spaces for victims of violence or for underground meeting locations.


Sources:

1 UNAIDS Press Release, UNAIDS reports a 52% reduction in new HIV infections. accessed 12/2/13. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2013/september/20130923prunga/
2 amFAR. Statistics Worldwide. Accessed 12/2/13. http://www.amfar.org/about-hiv-and-aids/facts-and-stats/statistics--worldwide/
3 Ibid. http://www.amfar.org/about-hiv-and-aids/facts-and-stats/statistics--worldwide/
4 Africa Focus,The State of the HIV Epidemic in Eastern and Southern Africa, August 20, 2013. Accessed 12/2/13. http://www.africafocus.org/docs13/hiv1308.php
5 eLearning Africa, Africa's Smartphone Revolution, April 4, 2013. Accessed 12/2/13. http://www.elearning-africa.com/eLA_Newsportal/africas-smartphone-revolution/
6 AIDSMAP, Using Mobile Phones in HIV Care and Prevention, May 21, 2009. Accessed 12/2/13. http://www.aidsmap.com/Using-mobile-phones-in-HIV-care-and-prevention/page/1323131/#item1323137
7 M-Health Africa, Epi-Surveyor. Accessed 12/2/13. http://www.mhealthafrica.com/10-best-tools-to-boost-mhealth-initiatives-in-africa-part-12/
8 Ushahidi, The Ushahidi Platform. Accessed 12/2/13. http://www.ushahidi.com/products/ushahidi-platform
9 Ushahidi Blog, KANCO wraps up Ushahidi pilot project with User Trainings. Accessed 12/2/13. http://blog.ushahidi.com/2010/02/18/kanco-wraps-up-ushahidi-pilot-project-with-user-trainings/
10 Frontline SMS: Medic. Accessed 12/2/13. http://medic.frontlinesms.com/
11 Debra Gordon, The AIDS Reader, Tweeting, Posting, Liking: Social Media and the Message About HIV. Accessed 11/8/13. http://www.theaidsreader.com/display/article/1145619/2122916
12Praekelt Foundation, Project Masiluleke. Accessed 12/2/13.http://www.praekeltfoundation.org/projectm.html
13 one2one website. Accessed 12/2/13.http://www.one2onekenya.org/site/index.php?option=com_content&view=article&id=25&Itemid=269
14 Infohub. Tendai. Accessed 12/2/13. http://tendai.medicinesinfohub.net/page/about-tendai/
15Takepart. Dr. Anita Goel's Gene-RADAR Could Revolutionize Virus Detection. Accessed 12/2/13. http://www.takepart.com/article/2012/05/22/dr-anita-goels-gene-radar-could-revolutionize-virus-detection
16IRIN. Uganda rejects HIV prevention tool on moral grounds. Accessed 12/2/13. http://www.irinnews.org/report/98690/uganda-rejects-hiv-prevention-tool-on-moral-grounds
17 Ibid. http://www.irinnews.org/report/98690/uganda-rejects-hiv-prevention-tool-on-moral-grounds
18 PLOS Medicine. Adherence to Antiretroviral Prophylaxis for HIV Prevention: A Substudy Cohort within a Clinical Trial of Serodiscordant Couples in East Africa. Sept. 10, 2013. Accessed 12/2/13. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001511
19 NIH Public Access. Emtricitabine-tenofovir exposure and pre-exposure prophylaxis efficacy in men who have sex with men. iPrEx Study Team. July 24, 2013. Accessed 12/2/13. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721979/
20 IRIN. Uganda rejects HIV prevention tool on moral grounds. Accessed 12/2/13. http://www.irinnews.org/report/98690/uganda-rejects-hiv-prevention-tool-on-moral-grounds
21 PLOS Medicine, Bigotry and Oppressive Laws in Africa Drive HIV in Men Who Have Sex with Men. Jerome Amir Singh. Accessed 12/2/13. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001471
22 IRIN, SOUTH AFRICA: MSM still sidelined in HIV programming. May 27, 2011. Accessed 12/2/13. http://www.irinnews.org/report/92828/south-africa-msm-still-sidelined-in-hiv-programming
23 Exchange. Getting to 'Zero' in Sub-Saharan Africa. Louise Bourchier. Accessed 12/2/13. http://www.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=2048
24 Erasing 76 Crimes, After Attacks, LGBTI defenders in Camroon seek safety. Eric O. Lembembe. July 5, 2013. http://76crimes.com/2013/07/05/after-attacks-lgbti-defenders-in-cameroon-seek-safety/
25 AIDSMAP. Internet proving a key way to reach men who have sex with men in Africa, Asia and beyond. Roger Pebody. Accessed 12/2/13.
http://www.aidsmap.com/Internet-proving-a-key-way-to-reach-men-who-have-sex-with-men-in-Africa-Asia-and-beyond/page/1447379/
26 Advocate. Gay Ugandan Activists Arrested, Detained Without Charge. Sunnivie Brydum. Nov. 14, 2013. Accessed 12/2/13. http://www.advocate.com/news/world-news/2013/11/14/gay-ugandan-activists-arrested-detained-without-charge
27 Human Rights Watch. Africa's Small Steps Toward LGBTI Equality. Neela Ghoshal. July 17, 2013. Accessed 12/2/13. http://www.hrw.org/news/2013/07/17/africas-small-steps-toward-lgbti-equality
28 AMSHER. MSM Issues in African HIV and AIDS Response. Dec. 1-2, 2011. Page 11. Accessed 12/2/13.
http://www.amsher.net/portals/0/resourcedownloads/Workshop%20Report%20MSM%20ISSUES%20IN%20AFRICAN%20HIV%20AND%20AIDS%20RESPONSE_20120911.pdf
29 Global Dialogues. Our History. Accessed 12/2/13. http://globaldialogues.org/about-us/our-history/#.UpvKNWRDtc8
30Open Society Initiative for Southern Africa. Behind the Mask. Accessed 12/2/13. http://www.osisa.org/lgbti/regional/behind-mask-btm
31amFar. Achieving an AIDS-Free Generation for Gay Men and Other MSM in Southern Africa. Executive Summary. Accessed 12/2/13.
http://www.amfar.org/uploadedFiles/_amfarorg/Articles/Around_The_World/GMT/2013/MSM%20Exec%20Summary%20050813_Final(1).pdf