HIV interventions in a hostile environment

An appraisal of community-led HIV prevention and care interventions for men who have sex with men (MSM) in Kenya, Uganda, Tanzania and Zimbabwe offers key tips for practical success when implementing sexual health and rights programmes in sub-Saharan Africa.

A new report assessing the Men’s Sexual Health and Rights Programme (SHARP), a three-year initiative coordinated by International HIV/AIDS Alliance and funded by the Danish Department for International Development (DANIDA), has been published.

Mapping & appraisal of HIV prevention & care interventions for men who have sex with men (MSM) in Kenya, Tanzania, Uganda & Zimbabwe: A report of the SHARP programme is among one of very few appraisals of HIV interventions for MSM in sub-Saharan African, where the intensely hostile environment for gay men has led not only to difficulties in providing HIV services but also in researching what works and why.

The appraisal, carried out by researchers at the London School of Hygiene and Tropical Medicine (LSHTM), looks in detail at 37 interventions delivered by MSM-led community-based organisations (CBOs). These range from mobile clinical outreach to social networking and from community building to documenting and responding to human rights abuses.

Key findings include:

  • Interventions aimed at MSM are best delivered by organisations led by MSM.
  • MSM CBOS have been successful in forming partnerships to advance the health and social care needs of MSM and to extend their geographical coverage.
  • Mobile technology solutions are a useful means to access hard-to-reach individuals.
  • Investing in MSM CBO organisational development builds stronger community systems to deliver evidence-based interventions to MSM.

Gavin Reid, Regional Advisor Men's Sexual Health and Rights for the Alliance, said: “This appraisal captures the wide range of interventions MSM-led CBOs are delivering in some of the most hostile environments. It demonstrates the pressing need to scale up investment in communities in order for them to fully contribute to meeting their own HIV and health needs, and for them to be able to advocate for their recognition and their human rights.”

HIV testing moonlight clinic, Kenya

An elixir of hope

The LSHTM team found that SHARP exceeded its initial target of reaching 8,280 people, providing HIV prevention and care interventions to more than 14,900 MSM. In addition, its capacity-building achievements were significant. More than 150 healthcare providers were trained under the initiative.

Praise from SHARP participants has been high, and documented in an Alliance video.

Because of SHARP I’ve developed as a human being

- Dennis from Uganda.

I think SHARP has been an elixir of hope to the MSM community

- Jeffrey from Kenya.

While the LSHTM researchers reported great success in reaching younger men, it remained a challenge to reach men over 30 and those living in more rural areas. Overall, they found that the SHARP partners had gained the trust of large sections of MSM communities.

Harassment, violence and discrimination

Importantly, the report’s authors stress that both the successes and limitations of SHARP must be seen in the light of the context in which they operate. Homosexuality remains illegal in all four countries in the programme – as it does in most of sub-Saharan Africa. Lesbian, gay, bisexual and transgender (LGBT) individuals and organisations are under a constant threat and experience widespread harassment, violence and discrimination.

Gays & Lesbians of Zimbabwe (GALZ), like all the SHARP CBOs, had to temporarily close and suspend services – others had to scale down services or even relocate due to serious safety and security threats. In GALZ’s case it was raided by the police and had materials and computers seized.

In this climate, openly public approaches to HIV prevention and care were often not viable for SHARP partners without putting CBO staff and volunteers or their beneficiaries at risk.

However, CBOs have shown remarkable resilience and ability to adapt and innovate including using mobile and new technologies. For example, GALZ turned to Facebook to share experiences and provide health information to specific MSM sub-groups. Elsewhere, WhatsApp was the preferred platform for information delivery.

Partnerships, though difficult and time-consuming to develop, were used to overcome discrimination as well as resource barriers. For example, in Tanzania, Stay Awake Network Activities (SANA) successfully partnered with the international non-governmental organisation Human Rights Watch to report on human rights abuses against vulnerable populations. SANA was subsequently invited to address Parliament on the health needs of key populations in Tanzania.

A dearth of HIV evidence
The authors report that the challenging context is to blame for the dearth of hard evidence to date on HIV and MSM in sub-Saharan Africa. It remains a neglected area in terms of epidemiological and public health research.

However, they stress that it is known that:

  • In Kenya, Tanzania and Uganda there are estimated to be around twice as many MSM living with HIV than the general male population. (While no recent figures are available for Zimbabwe there is no reason to believe the situation there is any better given a similarly limited availability of supportive programming.)
  • Men who have experienced homophobic abuse are more likely to report recent infection with an STI and often struggle to access sexual health services that are sensitive to their sexual practices.
  • While there is some recent progress to include MSM in national strategic planning this has not yet translated into targeted and appropriately resourced programmes led by national governments.

There is also little in the way of published research on what approaches to promoting sexual health among MSM in sub-Saharan Africa are most successful – hence the importance of the LSHTM appraisal.

Appraisal author Dr Adam Bourne of LSHTM said: “An appraisal like this tells you how something is working – in other words, what determines success and what the barriers to success are. That’s really valuable information when trying to develop new interventions and ensuring we reach those most in need.”