Towards ‘men who have sex with men-appropriate' health services in South Africa
K B Rebe,1 MB ChB, FCP (SA), DTM&H,
Dip HIV Man (SA); G De Swardt,1 BA, MW; H Struthers,1 MBA; J
A McIntyre,1,2 MB ChB, FRCOG
1
Anova Health Institute,
Johannesburg and Cape Town, South Africa
2
Centre for Infectious Diseases Epidemiology
and Research, School of Public Health and Family Medicine,
University of Cape Town, South Africa
Corresponding author:
K B Rebe
(rebe@anovahealth.co.za)
Health programming for men who have sex with men (MSM) in South
Africa has been ignored or absent until fairly recently, despite
this population being at high risk for HIV acquisition and
transmission. Anova Health Institute, with support from the US
President's Emergency Plan for AIDS Relief (PEPFAR)/United
States Agency for International Development (USAID) and in
collaboration with the South African National Department of
Health, launched the first state sector MSM-targeted sexual
health clinic in 2010. The clinic has been successful in
attracting and retaining MSM in care, and lessons learned are
described in this article. Components contributing to the
creation of MSM-appropriate healthcare services are discussed.
S Afr J HIV Med
2013;14(2):52-57. DOI:10.7196/SAJHIVMED.841
Until fairly recently, the healthcare needs of men who have
sex with men (MSM) have been under-researched and
under-resourced in South Africa (SA).1
This has occurred despite emerging local evidence confirming
high rates of HIV among this key population. Notwithstanding
inclusion in the country’s previous National Strategic Plan
for HIV and AIDS, STIs and TB (2007 - 2011), services for MSM
were not scaled up nationally, although impressive strides
have been made in some provinces such as the Western Cape and
Gauteng. Evidence from modelling studies shows that in
settings where concentrated HIV epidemics exist among key
populations in countries with generalised heterosexual
epidemics, failure to provide targeted and tailored HIV
prevention and treatment programmes to key populations
negatively affects HIV rates among the general
population.2
MSM in SA comprise of a diverse group of men who share only one behavioural commonality: they have sex with other men.3 Many MSM in SA do not identify with gay culture, which may be viewed as a Eurocentric cultural construct often considered foreign and ‘un-African’.4 The behaviour of MSM has, however, occurred across all cultures and all times, including in SA, and is therefore well described in African oral histories. Colonial oppressors were largely responsible for the criminalisation of sodomy on the continent.5 Homosexual activity in SA therefore often remains clandestine, with MSM identifying as heterosexual and dismissive of Westernised gay culture.3 This has implications for health messaging as non-gay-identifying MSM are not targeted in either mainstream heterosexual or gay media platforms and remain invisible in healthcare settings.
For multi-factorial reasons, MSM are at particular risk for HIV acquisition and transmission.6 Biologically, unprotected receptive anal sexual intercourse is about 16 times more likely to transmit HIV than unprotected vaginal sexual intercourse. 7 This is due to the friable nature of the rectal mucosa, which does not contain mucous-producing cells like the thicker, self-lubricating lining of the vagina.
The vulnerability of MSM is further increased by structural factors such as a lack of funding for MSM-appropriate services, lack of specific skills training of health providers, and institutionalised stigma within the public healthcare sector. MSM patients generally avoid being identified as MSM, culminating in their elevated risk of HIV acquisition, transmission being overlooked, and a lack of counselling about the risks associated with unprotected anal sex.8
Organisations such as the Anova Health Institute, through it’s innovative Health4Men project, and the Desmond Tutu HIV Foundation have been active in addressing these concerns in SA. In 2009 the Anova Health Institute, with support from the US President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), launched the first state sector clinic dedicated to MSM in the country. A further 6 sites have subsequently become operational across multiple provinces. Invaluable lessons have been learned through this process, which will undoubtedly serve as a template for the ongoing expansion of such services.4 , 9-11
MSM experience mainstream state sector healthcare services as unfriendly and prejudiced, which creates a barrier to accessing such services.12 Many local healthcare centres have become friendly to women at the exclusion of men. Women are a captive audience in these clinics, which they attend for antenatal care, childhood vaccinations, completion of children’s road-to-health growth charts and other services. Clinics respond by improving their female-specific skills and services. It is not unusual to find most of the educational materials in HIV clinics focusing on issues such as breastfeeding and female contraception, thereby alienating HIV-positive men. Other barriers to MSM healthcare access include fears about confidentiality related to their HIV status and sexual behaviour. The local catchment area of primary healthcare services is also often problematic; MSM who experience community-based stigma are unlikely to attend a clinic where they are known to other patients or staff members.
For a health provision site to be considered MSM-appropriate, a number of criteria need to be met. Firstly, most MSM require more than a friendly service (often incorrectly referred to as an MSM-sensitised service); they expect competence regarding their specific sexual healthcare needs. Services therefore need to be both sensitive and competent if they are to attract and retain MSM in care.4
The Ivan Toms Centre for Men’s Health (ITCMH), a clinic of the Anova Health Institute in partnership with the Western Cape Department of Health (DoH) and funded by PEPFAR through USAID, was inaugurated in February 2010 in Cape Town. It has since provided care to over 3 800 MSM. There are a few features which have contributed to the success of this clinic. There is buy-in and commitment by the provincial and National DoH.13 The service is marketed as a sexual health clinic for men. It is neither an HIV nor an antiretroviral therapy (ART) clinic, which means that patients in the waiting room cannot be identified as HIV-positive. Approximately half of the clients in the cohort are HIV-positive and half of those are receiving ART. Other MSM attend for HIV and sexually transmitted infection (STI) screening, syndromic STI management, counselling and other mental healthcare services, harm-reduction services for MSM who use drugs, or for research and information purposes. This model assists in providing an enabling space that promotes feelings of anonymity regarding the reason for attendance, and allays fears of being identified as gay or HIV-infected when attending the clinic.
Clinic staff have received extensive sensitivity and competency training and are accepting of the diversity of MSM. They have become accustomed to providing service to MSM with either a feminine or masculine gender-identity, as well as to transgendered individuals. All staff are accustomed to referring to clients by their preferred name and pronoun (as opposed to their legal name).
The scope of practice encompasses holistic sexual health, including STI and HIV prevention, diagnostic and treatment services, as well as in-house access to mental healthcare services provided by staff who have specific experience in providing such care to MSM. Staff have been intensely trained in the specific features of sexual health pertaining to MSM. Medical staff have an expert understanding of how STI presentations, diagnosis and management plans differ in MSM, compared with heterosexual men. A good example is training in physical examination to detect and diagnose anal and pharyngeal presentations of STIs.
A package of care has been developed for the clinic and a
clinical manual is available for guidance both in print format
and online (http://www.anovahealth.co.za).
4 It is
understood that clinics may not be able to provide an optimal
level of MSM healthcare due to resource constraints; therefore,
a package of minimal and optimal services has been developed
(see Tables 1 - 3).
Some specific features of the ITCMH that have worked well
include the provision of MSM-sensitive HIV screening.
Counsellors are trained to ask about male and female partners,
to identify specific sexual behaviours and their risks (e.g.
receptive unprotected anal intercourse), and to avoid adopting a
hetero-normative attitude to counselling (such as asking an MSM
couple which is the man and which is the women in a
relationship). MSM are also encouraged to screen for HIV
together with their partners.14
Since MSM are at an elevated risk of acquiring and transmitting
HIV, prevention technologies assume particular importance.
Condoms, although generally available via the state, are mainly
marketed through heterosexually-targeted campaigns that do not
address the risks of unprotected anal sex. Condom-compatible
lubricant required for comfortable anal sex is largely
unavailable. Medical male circumcision is likely to fail to
protect MSM to the same degree as heterosexual men, which leaves
a deficit of effective prevention interventions.15
Available HIV-prevention resources that are evidence-based –
such as condoms, lubricants, post- and pre-exposure prophylaxis
(PEP and PrEP), and early treatment for positive MSM – should be
prominent at all MSM-targeted sites.
Fig. 1. The Ukwazana (getting to know each
other) campaign. An example of HIV risk-reduction messaging
designed to reach MSM though township taverns/shebeens where
MSM congregate.
Fig. 2. An example of HIV risk-reduction
messaging designed to reach gay-identified MSM through
gay-targeted publications (the pink press).
Marketing MSM-appropriate services is challenging, especially in areas where MSM do not disclose their sexual behaviours and remain hidden to the healthcare system. It has taken time for MSM groups to develop trust in the clinic and the most effective marketing has occurred by word of mouth via clients who have had a positive health-affirming experience at the clinic. Health4Men employs peer educators, and key individuals in MSM communities from specific geographical areas have been recruited as ambassadors for the programme. Marketing and information, education and communication (IEC) materials have been developed through testing with MSM focus groups to ensure that the language is locally understood and contextually correct. Health information, referral links and interactive questions and answers are also available from the Health4Men’s mHealth programme ‘Health4men Connect’ (h4m.mobi) and the programme’s website.
The ITCMH was followed by the launch of the Simon Nkoli
Centre For Men’s Health in Soweto and, more recently, the
Khayelitsha Male Clinic (Cape Town), the Zola and Chiawelo
clinics (both in Soweto) and the Yeoville clinic (central
Johannesburg). These sites have built on the evidence and
experience gained from providing services at the ITCMH.
Guidelines for the management of common MSM health problems
have been developed and packaged into an intensive training
package, which can be delivered at healthcare facility level
to improve staff attitudes and skills and better allow for the
provision of non-judgemental, appropriate MSM-targeted healthcare.
Over time, once enough state clinics have received such
training, it is hoped that MSM-specific healthcare services
can be mainstreamed in standard HIV/ART/STI clinics. Many
resources have been developed locally and abroad to assist
healthcare providers in caring for their MSM clients in a
compassionate and competent manner, even in instances where
the beliefs of healthcare workers do not usually encompass an
understanding of diverse male sexual identities and
behaviours.
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