The key findings from SHARP demonstrate that it is possible to reach, engage, link and provide large numbers of men who have sex with men (MSM) with HIV, health, legal and other services by supporting and working with MSM or Lesbian, Gay, Bisexual, and Transsexual (LGBT) community-based organisations (CBOs).
In particular, MSM-led and peer-driven outreach is effective in reaching MSM and linking them to HIV treatment and care and retaining MSM along the entire care cascade. SHARP managed to exceed the target of reaching MSM by 80%: the goal was originally 8,280 but SHARP reached a total of 14,900 MSM. Of these, 5,493 had HIV Testing and Counselling (HTC) and 3,342 were screened for Sexually Transmitted Infections (STIs).
Linking to services
SHARP reached 1,206 health care providers demonstrating that MSM CBOs can successfully engage, sensitise and partner with public health facilities to increase MSM access to quality stigma-free services. Community education and mobilisation are important and 7,927 MSM received HIV and Sexual and Reproductive Health and Rights (SRHR) education. Beyond this, CBOs are also able to effectively contribute to service delivery, reduce loss to follow up and increase retention in care. However, there is a need to improve the availability, compatibility and use of strategic information for MSM.
Advocating for change
MSM continue to be denied access to life-saving healthcare and HIV services because of punitive laws, policies and practices that discriminate on the basis of same-sex relationships, sexual orientation or gender identity. CBOs have the trust of large sections of the MSM community and are well placed to represent the communities’ experiences and needs. Yet deep-rooted homophobia acts as barrier to both the meaningful engagement of MSM in national processes and to addressing legal and structural barriers. Nevertheless MSM CBOs continue to advocate for their recognition and their human rights and SHARP reached 1,031 policy makers. These CBOs are building coalitions to shift perceptions and increase decision-makers’ receptiveness to evidence- and human rights-based interventions.
Safety and security
In such hostile environments the threat of violence is very real. The safety and security of staff, volunteers and clients must always be the first priority and assessed with adequate, budgeted, and flexible plans before any intervention takes place. In hostile environments the safety and security situation can quickly and dramatically change and it is important to have response mechanisms in place and to follow the lead of in-country partners.
Wider holistic needs
MSM CBOs have earned the trust of large sections of the MSM community in part by addressing the wider holistic needs of MSM (including cultural, economic, social, psychological and legal) as a precursor to effectively delivering HIV, SRHR and other health services. An emphasis on sexual health and wellbeing has allowed MSM to engage with their health using a non-judgemental and sex-positive approach. However, mental health remains a significant challenge. In addition, more needs to be done to reach and address the specific needs of MSM living with HIV and other sub-populations such as MSM who sell sex, MSM who use drugs, displaced MSM, MSM under 18, and MSM over 30.
Partnership and training
As MSM CBOs developed partnerships with clinicians and health facilities, they realised that once there was increased willingness to provide services to MSM, many clinicians had never received formal training on MSM health. In order to improve healthcare worker knowledge and competencies around MSM health, the Alliance partnered with Health4Men. They delivered intensive trainings to 63 health care providers covering psychosocial and biomedical needs of MSM (including HIV and STI management), approaches to community engagement and outreach.
MSM CBOs continue to demonstrate considerable resilience and ability to adapt and devise innovative approaches to ensure continued engagement with MSM. They are early adopters of a range of new technologies and numerous opportunities remain untapped in this area. Through SHARP, the Alliance partnered with Health4Men to develop Afya4men.info. This online site provides clearly written sexual health information in Swahili, English and French, targeted to the specific needs of MSM. By January 2016, 5,866 unique users had visited the site with 72% using a mobile device.
Investing in community organisations
Investing in appropriate capacity in community organisations is critical if we are to build strong and robust community systems and to strengthen the long-term programmatic, advocacy and leadership capacity of CBOs. Capacity building is multi-directional; for example, CBOs built the Alliance’s capacity on safety and security and CBOs trained each other to roll-out of Rights Evidence Action (REAct). Capacity building should take into account the absorptive capacity of CBOs and be aligned with their long-term interests as opposed to the needs of a time-bound programme. So for example the Monitoring and Evaluation system (SyrEX) is highly flexible and allows tracking by multiple donors and programmes.
CBOs are an invaluable yet under-used source of expertise, skills and knowledge which can contribute to building resilient and sustainable health systems that meet the needs of MSM. Yet sustainability remains an issue with the reality that many countries are still far away from funding programmes targeting MSM. Greater consideration is needed for how to best support the leadership, interventions and activities of CBOs contributing to an effective HIV response for MSM in hostile environments.
The London School of Hygiene and Tropical Medicine have produced the following appraisal of the programme. It's full of context, case studies, what worked well and reccomendations, making it a useful resource for people designing and delivering similar programmes. Select the thumbnail to download.