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AIDS 2016: How Can Clinical Services Engage Men Who Have Sex With Men in Africa?


Men who have sex with men (MSM) living in African countries have an extremely high burden of HIV, Stefan Baral of Johns Hopkins University reminded delegates at the recent 21st International AIDS Conference (AIDS 2016) in Durban. But in situations often marked by widespread social disapproval of homosexual behavior, health services for MSM are few and far between.

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Across the region, the average prevalence of HIV among men who have sex with men is estimated to be 18%. Studies suggest annual rates of new infections of 6% in South Africa, 7% in Malawi, and 16% in Senegal.

Mainstream health facilities are often perceived by men who have sex with men as being unwelcoming, judgmental, 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 program 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).

Rebe stressed that MSM in South Africa do not form a homogenous group. They may share a range of common behaviors, 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 services are branded as Health4Men, they attract men with a range of needs and behaviors. 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 behavior 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 behaviors. 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 undiagnosed or misdiagnosed. He stressed that treatment for anal warts -- the most common sexually transmitted infection (STI) he sees -- and bacterial STIs 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 an STI. 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 issues.

More specialized 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 informational 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 antiretrovirals with recreational drugs and anabolic steroids. Antiretrovirals such as lopinavir/ritonavir (Kaletra) can cause diarrhea and flatulence, potentially resulting in sexual dysfunction for some men.

In addition to the direct services provided by Health4Men, the program 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 program helps develop and maintain skills. This has allowed many more sites to meet the needs of men who have sex with men.



KB Rebe. Providing clinically competent and affirming health care to MSM/gay and bisexual men. 21st International AIDS Conference. Durban, July 18-22, 2016. Presentation MOSA0102.

Anova Health Institute. From top to bottom: a sex-positive approach for men who have sex with men (a manual for healthcare providers). Fifth edition, 2015.