What was done?
The Alliance understands that communities are capable of far more than community mobilisation and believes that communities remain an invaluable yet under-used source of expertise, skill and knowledge. Men who have sex with men (MSM)-led and peer-driven service delivery is a critical component of effective prevention and treatment services for MSM along the entire care cascade.
The SHARP programme has increased access and uptake of HIV, health, legal and other services by supporting community-based organisations to strengthen community systems and build links to health systems.
The service delivery model in SHARP adopted two complementary approaches:
- outreach in community drop-in centres, usually held at the premises of the community based organisations; and
- day/night mobile clinical outreach at pre-arranged locations (bars, hotels as well as other MSM ‘hotspot’ locations).
Although varying in different locations, both approaches involved providing a basic package of sexual health services; for example, information and small group discussions, condoms and lubricants, HIV testing and counselling, sexual and reproductive health and rights (SRHR) counselling and referral for HIV treatment.
The SHARP service package included:
- One-to-One peer HIV and SRHR education and psychosocial support
- Small group HIV and SRHR education
- Targeted HIV and SRHR information, education and communication (IEC) materials
- HIV testing and counselling (HTC)
- STI diagnosis and treatment
- Referrals for HIV anti-retroviral treatment (ART)
- Distribution of condoms and condom-compatible lubricants
- Referrals for sexual violence and post-exposure prophylaxis
- Referrals for harm reduction services for MSM using drugs
- Referrals to legal services
- Referrals for crisis and emergency response
In Africa, as well as elsewhere, MSM have a higher vulnerability to contracting HIV compared to the population as whole yet it is extremely difficult for gay men or other MSM to access safe, non-discriminatory sexual health information and services.
Many factors contribute to the increasing the vulnerability of MSM to HIV including laws and policies that criminalise MSM; homophobic stigma and discrimination which can lead to depression and other mental health issues; social and economic exclusion; physical violence, and a lack of access to quality services. Living with HIV as an MSM intensifies their health and psychosocial needs, and exposes MSM to HIV-related stigma, further isolating them from their own communities and services.
Challenges faced and limitations of our approach
Recognising extensive needs and limited resources, the SHARP partners – which were MSM CBOs – established partnerships with a number of health facilities, primarily within the health system, to ensure access to a comprehensive package of health. Given the challenging contexts in which the programme was implemented this required significant investment of time to sensitise, build and strengthen relationships.
In addition, while most of the SHARP partners were based in capital cities or regional centres, substantial effort was directed into expanding the availability of services resulting in a substantial increase in geographical reach of services. The provision of a wider package of services required the establishment of referral pathways, especially for MSM diagnosed with HIV and those requiring specific services such as treatment for severe STI cases.
Onward referrals are also typically made to other social care and legal support organisations, although further partnerships are needed in order to respond to wider issues such as housing, poverty, employment and nutrition. These partnerships however are often vulnerable to changes in the volatile political context and require ongoing investments of time.
In SHARP programme countries – like elsewhere in Africa – MSM often face considerable risks in their daily lives. Being disproportionately vulnerable to HIV and STIs they are severely underserved. MSM CBOs provide a variety of services that help to address the holistic individual and group social, economic, legal, and psychological and health needs of MSM. By doing this, MSM-led and MSM-run CBOs have earned the trust of large sections of the MSM community and are well suited to reaching and providing a range of HIV, SRH and other health services.
The SHARP partners established relationships with health facilities and adopted two approaches to delivering services:
- Static Services provided in:
- Community drop-in centres within the premises of the CBOs (with clinical staff from either the CBO and identifying as MSM or from public health facility)
- Public health care facilities staffed by clinicians sensitised by the MSM CBOs
- Mobile clinical outreaches implemented both during the day and at night at pre-arranged locations with MSM CBO peer educators and clinical staff from public health facilities.
As partnerships were developed with clinicians and health facilities the SHARP partners realised that there was increased willingness to provide services to MSM yet many had never received formal training on MSM health. In order to improve healthcare worker knowledge and abilities around MSM health, the Alliance partnered with Health4Men, an innovative good-practice project of the Anova Health Institute. The intensive trainings covered providing information about psychosocial and biomedical needs of MSM; approaches to community engagement and outreach; and organisational factors. The participants’ clinical knowledge increased on average from 64% to 88% and homophobic stigma decreasing by a third.
As the SHARP partners developed partnerships with health facilities, they realised that while there was increased willingness from some health care workers to provide services to men who have sex with men (MSM), many clinicians had never received formal training on MSM health.
Alliance partnered with Health4Men, an initiative of the Anova Health Institute, to provide a series of trainings in Cape Town, Nairobi and Kisumu to clinicians and peer educators. This meant they would be able to offer competent and non-discriminatory healthcare and support to MSM.
The three-day intensive trainings were context-specific and designed to cover social, biomedical, community-based and organisational elements relevant to holistic MSM health, including HIV and Sexually-Transmitted Infections (STI) management and treatment.
Due to the range of epidemics, policies and dynamics in different countries the training was not based on a generic model. Rather, each training session was specifically tailored to the unique situations found in the participants’ countries and drew on the many years of expertise and experience of Health4Men’s biomedical and social scientists who deliver the training. For example, consideration was given to particular local issues such as the best options for STI diagnosis and treatment in resource-constrained environments. They also looked at adapting outreach and community mobilisation models for reaching diverse MSM in hostile environments.
Data analysis showed that trainees increased their ‘total knowledge’ (a combination of basic psychosocial and more advanced biomedical knowledge) on average from 64% to 88%. Further, homophobic stigma decreased among participants (from over 18 points to 12 points, a reduction of a third (measured using an adapted scale taken from van der Elst et al 2013).
Trust in services by MSM for MSM
In contexts where being identified as MSM can mean being arrested, a model that empowers MSM organisations to offer a basic package of HIV and sexual health services to other MSM is first and foremost a model that MSM can trust. In such contexts MSM cannot and should not simply be recipients of care, but agents of care identifying, reaching, linking and ensuring MSM access to and uptake of services. Ultimately involving communities in the delivery of services to communities translates into ownership and empowerment. In this sense, MSM organisations providing services to MSM have a distinct advantage, being the recipients of a trust that cannot be replicated by other non-MSM organisations.
Another key aspect of the model was the CBOs ability to develop efficient formal and informal partnerships with public health clinics and other larger providers of sexual health services. A symbiotic relationship between two separate entities, the partnerships between CBOs and clinical services’ providers were mutually beneficial and found a natural balance. Through the partnerships, clinical providers gained access to groups of MSM that they would not have known how to reach otherwise. CBOs extended their geographic reach, while making the models more sustainable in the longer term. In Uganda the partnership between the ‘Ministry of Health-supported’ Most at Risk Populations Initiatives (MARPI) and Icebreakers Uganda (IBU), provided IBU with legitimacy for their work with MSM groups and were able to argue in communities that all Ugandans are entitled to healthcare.
IBU, based in Kampala, have expanded their outreach from just being centred on the capital to working throughout the West, South and East of Uganda (with plans to go to the North in 2015). Services are now available to MSM in Jinja, Mukono, Mbarara, Ntungamo, Masaka, Tororo, Fortportal, Kasese, Wakiso, Hoima, Mbale and Entebbe as well as Kampala.
This tremendous expansion of geographical reach happened in the immediate aftermath of the passing of the Anti-Homosexuality Act. This intervention is made possible by a strong partnership with MARPI, a KP clinic and NGO working under the auspices of the Ugandan Ministry of Health. An agreement was reached between IBU and MARPI to integrate the IBU services and staff with those provided by MARPI. IBU covers the cost of all staff, travel, medicines and commodities. A comprehensive outreach team of clinicians, laboratory workers, counsellors, M&E staff, driver and outreach co-ordinator travel to the outreach location to connect with local MSM CBOs and IBU affiliated volunteers.
IBU uses its network of MSM CBOS and locally-based peer educators to mobilise the local MSM population. By doing the outreach with MARPI and by also targeting general population and sex workers at the same time IBU are able to effectively reach and connect MSM with services operate ‘invisibly and in plain sight’.
IBU and MARPI staff provide HIV counselling, testing and diagnosis on-site, as well as syndromic STI screening and distribution of prevention commodities, information and education on HIV and SRHR. Referrals are made to local state-run hospitals for treatment when necessary. To date, IBU have not been able to keep pace with demand for this service, perhaps due to limited availability of MSM friendly sexual health clinics outside of Kampala.
Lessons learnt include:
- Peer-led outreach is effective in reaching MSM and linking them to HIV treatment and care
- Lesbian, Gay, Bisexual and Transgender (LGBT) organisations can successfully engage, sensitise and partner with public health facilities to increase MSM access to friendly services
- Many MSM are lost to follow up between referral, HIV testing and linkage to care which will require strengthening of continuum of care for individual MSM
- There is a need to improve availability and use of strategic information on MSM access to services and retention in care.