London School of Hygiene & Tropical Medicine

Community-led HIV prevention and care initiatives for men who have sex with men (MSM) in Kenya, Uganda, Tanzania and Zimbabwe have been examined in a new report by the London School of Hygiene & Tropical Medicine. The research offers key tips for practical success when implementing sexual health and rights programmes in the region.

The report assesses 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). It is 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 researchers looked 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.
• MSM and the CBOs have been early adopters of mobile technologies and social media to help access hard-to-reach individuals.   
• Investing in MSM CBO organisational development builds stronger community systems to deliver evidence-based interventions to MSM.

The report found that SHARP exceeded its initial target of reaching 8,280 people, providing HIV prevention and care interventions to more than 14,900 MSM by December 2015. More than 150 healthcare providers were also trained under the initiative.

SHARP participants have praised the programme. Jeffrey from Kenya said: "I think SHARP has been an elixir of hope to the MSM community," while Denis from Uganda said: "Because of SHARP I've developed as a human being."

While the researchers found considerable success in reaching younger men, it remained a challenge to reach those living in more rural areas, and men aged over 30 (perhaps due to pressure to marry and have children meaning these men are no longer comfortable engaging with MSM organisations). Overall, they found that the SHARP partners had gained the trust of large sections of MSM communities.

Report lead author, Dr Adam Bourne from the London School of Hygiene & Tropical Medicine, said: "Homosexuality remains illegal in all four countries in the SHARP 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.

"Yet our report shows that some HIV interventions are successfully reaching men who have sex with men in these countries. It looks at how these approaches are 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."

In the hostile 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 resilience and ability to adapt and innovate including using mobile and new technologies like Facebook and WhatsApp to share experiences and provide health information to specific MSM sub-groups.

Gavin Reid, Regional Advisor Men's Sexual Health & 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."

The authors also highlight that due to the challenging environment, there is a lack of evidence on HIV among MSM in sub-Saharan Africa and it remains a neglected area for epidemiological and public health research.

The available evidence suggests that in Kenya, Tanzania and Uganda there are estimated to be around twice as many MSM living with HIV than the general male population, and men who have experienced homophobic abuse are more likely to report a recent STI infection and often struggle to access sexual health services that are sensitive to their sexual practices.

Dr Bourne adds: "While there is some recent progress to include MSM in national strategic planning in sub-Saharan Africa this has not yet translated into targeted programmes led by national governments. We hope this report will raise awareness of what approaches work best to promote sexual health among men that have sex with men in the region."

Publication:

• Adam Bourne, Elizabeth Fearon, Will Nutland, Mapping & appraisal of HIV prevention and care interventions for men who have sex with men (MSM) in Kenya, Tanzania, Uganda and Zimbabwe - a report of the SHARP programme. (2016)

Related links:

• Sigma Research