Conducting research among key populations in settings with discriminatory laws, policies, and practice: The case of men who have sex with men in Zimbabwe

Dear Editor,

Despite advances in knowledge, key populations remain at substantial risk of HIV infection. In the context of HIV infection, key populations include men who have sex with men (MSM), transgender women, sex workers, intravenous drug users and people in prisons and other closed settings. Key populations remain the most crucial driver of the HIV pandemic, with the majority of incident cases occurring in this population [[1], [2], [3]]. Research has shown that men who have sex with men (MSM) living in sub-Saharan African countries where same-sex sexual conduct is criminalized have a five times higher risk of HIV infection than countries where it is not [4].

Despite the MSM sub-population being at elevated risk of contracting HIV compared to the general population in Zimbabwe, very little information is available about the HIV epidemic within this group, owing mainly to the criminalization of the practices in the country. Criminalization of MSM has partly contributed to very few studies having been done in Zimbabwe, partly for fear, from the researchers' perspective, of being associated with the practice as well as fear of not getting approvals to carry such studies by the bodies that govern the conduct of research in the country. Getting an adequate sample size to be able to make conclusive results from such secretive communities is another challenge that potentially pushes researchers away from studying members of the MSM community in Zimbabwe, as the potential participants are generally suspicious of being trapped in disclosing their sexual orientation to law enforcement agencies, under the banner of research and end up being arrested. In this regard, challenges associated with reaching the sample size will mean the study may take much longer, thus affecting budgets.

Size estimates of key populations and data on how they are affected by HIV, may inform policy that supports prioritization and resource allocation to fund services to meet their specific prevention and treatment needs. Simultaneously, identifying and recruiting MSM in studies can make them visible in ways that place them at risk. Some of the co-authors of this letter were part of a biobehavioural survey that investigated various HIV indicators among men who have sex with men, transgender women, and genderqueer individuals in Zimbabwe [5]. In this letter, we present significant challenges that were faced in the implementation of this study and proffer potential solutions for future researchers to surmount these challenges.

Initially, the local institutional review board was hesitant to review the protocol resulting in a three-year waiting period for ethical approval, for fear of approving a study that involves a criminalized issue according to the law of the land. Secondly, there was a challenge in securing study venues as most building owners were unwilling to use their properties for such a study, for fear of conflicting with the law. The community also wants to be interviewed in safe spaces of their preference. Additionally, during planning, this study group noted that some potential participants would find it challenging to sign written consent, especially if they felt the information required was too intrusive and written documentation of consent was seen as creating a paper trail that could lead to their arrest. Furthermore, due to legal imperatives, the study team failed to disseminate the findings at appropriate HIV conferences and workshops in-country. We also noted that public health sector staff have inadequate training about handling these key populations as there are no comprehensive spread programs on this due to the criminalization of MSM. For security reasons, members of the MSM community can only open up to discuss their sexuality issues with someone they trust or to whom someone within their community introduces them.

We note that the core principles of clinical research ethics, respect for persons, justice, beneficence and non-maleficence must always be respected for research conducted among key populations. The ultimate desirable goal is decriminalizing key populations so that most of the above barriers can fall away. However, the scientific community in countries where criminalization is still in place should foster broader ethics support and policy frameworks that provide a favourable environment for research into studies involving MSM. Information gaps in the HIV epidemics among the MSM, in countries where the practice is criminalized and stigmatized, affect the effectiveness of the HIV response interventions for the sub-group, as decisions will not be based on empirical evidence. Against this background, such countries must promote research within the MSM communities to get reliable data frequently, and ultimately base their HIV response interventions targeting this community on empirical evidence to improve the intended outcomes.

Individuals who desire to conduct research with key populations where they are criminalized should expect significant headwinds and resistance. One key strategy is to continuously make policy makers aware of the utility of this data for the country to achieve epidemic control. This data is increasingly crucial for funding proposals for organizations such as the Global Fund. The data is also helpful for modelling work that produces national and subnational HIV estimates. This vital work can be undertaken provided one is persistent and aware of the sensitivities that require navigation.

Disclaimer

The views expressed in this article are of the authors and do not necessarily represent the official position of the affiliated institutions.