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How can clinical services engage men who have sex with men in Africa?
Roger Pebody, 2016-08-19 09:40:00
Men who have sex with men living in African countries have
an extremely high burden of HIV, Stefan Baral of Johns Hopkins University
reminded delegates at the 21st
International AIDS Conference (AIDS 2016) in Durban, South Africa last month. Across the region, the average prevalence of HIV in men who have
sex with men (MSM) is estimated to be 18%. Studies suggest annual rates of new
infections of 6% in South Africa, 7% in Malawi and 16% in Senegal.
But in situations often marked by widespread social
disapproval of homosexual behaviour, health services for MSM are few and far
between. Mainstream health facilities are often perceived by men who have sex
with men as being unwelcoming, judgemental and unable to deal with their
specific needs. As a result, infections remain untreated and transmissions
continue to occur.
The conference did however hear of some examples of good
practice, in particular the services provided by the Health4Men programme of
the Anova Health Institute in South Africa. Health4Men has been able to engage
and retain MSM at its services in Cape Town and Johannesburg; it also provides
training and mentoring to healthcare providers across South Africa.
Kevin Rebe of Anova said that given the low expectations
that many MSM have of health services, providers need to make particular efforts
to build trust and engagement. They should make all patients feel welcome, ensure
the confidentiality of discussions between patients and clinicians, and be attentive
to the ways in which individuals define themselves (including the gender
pronouns used by transgender individuals).
He stressed that MSM in South Africa do not form a
homogenous group. They may share
a range of common behaviours, but
these are often clandestine and denied, and the men do not share a social
identity. Most ‘men who have sex with men’ also have sex with women.
It would therefore be unhelpful to have made a ‘gay
identified’ clinic space. In fact, as his services are branded as ‘Health4Men’,
they attract men with a range of needs and behaviours. This diversity in the
waiting area avoids inadvertent disclosure both for MSM and for HIV-positive
men (who make up around half of the clinic attendees).
Health4Men has taken a ‘sex positive’ approach – sexual issues are discussed in a way that encourages normality and dignity. This facilitates open discussion and counter-balances the way in which much
sexual behaviour is treated as abnormal in the wider society.
Clinic staff have received extensive training to help them engage
and communicate with a diverse range of MSM. But ‘awareness’ and ‘sensitivity’
are not in themselves enough, Rebe stressed. Staff also need to have clinical
competencies for a clinic to attract and retain MSM in care.
Staff need to be able to take a full sexual history. They
should ask all male patients about both female and male partners and ask very
specific questions about sexual behaviours. Developing these skills can be
challenging. “It’s hard for us to get some of our nurses to ask, ‘Do you have
sex with men, women or both?’ or ‘Can I do an anal exam because you may have
been exposed to an STI?’,” Rebe said.
Anal examinations were crucial, he said. Without them,
problems are likely to go un-diagnosed or mis-diagnosed. He stressed that
treatment for anal warts (the most common STI he sees) and bacterial sexually
transmitted infections are actually quite simple to provide once a diagnosis
has been made.
Men are most likely to attend a clinic when troubled by symptoms
of a sexually transmitted infection. These visits should be seen as an
opportunity to build a relationship and to provide other services. In
particular, providers should screen for HIV, substance use and mental health
More specialised support can be provided based on these
assessments. The clinics have identified a need for harm reduction services for
men using recreational drugs and also a number of cases of hepatitis C.
Substance use, depression and anxiety often appear to be linked to issues of
stigma, heteronormativity and self-esteem.
The clinics also promote evidence-based prevention methods, using
information materials that relate to sex between men. These include condoms and
lubricant, post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP) and
prompt antiretroviral treatment for HIV-positive men. Nonetheless, significant
barriers to access for many of these interventions remain.
In providing HIV treatment to MSM, Rebe said it was helpful
for providers to be aware of some specific issues. Adherence and engagement
with care may be affected by men’s experience of social stigma, mental health
issues or substance use. Providers need to be aware of potential interactions
of ARVs with recreational drugs and anabolic steroids. Antiretrovirals such as lopinavir/ritonavir
can cause diarrhoea and flatulence, potentially resulting in sexual dysfunction
for some men.
In addition to the direct services provided by Health4Men,
the programme has also trained over 2000 staff working in the public
health system. Both administrative and clinical staff receive training on diversity
and cultural sensitivity, with additional modules on clinical skills only
provided to relevant staff. An ongoing mentoring programme helps develop and
maintain skills. This has allowed many more sites to meet the needs of men who
have sex with men.