How can clinical services engage men who have sex with men in Africa?

Men who have sex with men living in African countries have an extremely high burden of HIV, Stefan Baral of Johns Hopkins University reminded delegates at the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa last month. Across the region, the average prevalence of HIV in men who have sex with men (MSM) is estimated to be 18%. Studies suggest annual rates of new infections of 6% in South Africa, 7% in Malawi and 16% in Senegal.

But in situations often marked by widespread social disapproval of homosexual behaviour, health services for MSM are few and far between. Mainstream health facilities are often perceived by men who have sex with men as being unwelcoming, judgemental 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 programme 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).

He stressed that MSM in South Africa do not form a homogenous group. They may share a range of common behaviours, 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 his services are branded as ‘Health4Men’, they attract men with a range of needs and behaviours. 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 behaviour 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 behaviours. 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 STI he sees) and bacterial sexually transmitted infections 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 a sexually transmitted infection. 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 specialised 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 information 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 ARVs with recreational drugs and anabolic steroids. Antiretrovirals such as lopinavir/ritonavir can cause diarrhoea and flatulence, potentially resulting in sexual dysfunction for some men.

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