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Moyo I, Tshivhase L. Accessing HIV care services by key populations - An Ubuntu philosophy reflection. Curationis 2025; 48:e1-e8. [PMID: 40336377 PMCID: PMC12067027 DOI: 10.4102/curationis.v48i1.2633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 10/20/2024] [Accepted: 10/25/2024] [Indexed: 05/09/2025] Open
Abstract
BACKGROUND Key populations are disproportionately affected by HIV despite the significant decrease in new HIV infections in Africa. They experience challenges like stigma and discrimination as they interface with the healthcare system. This results in reduced access to HIV care services for key populations. Therefore, the attainment of HIV epidemic control may not be easily realised if these gaps are not addressed. OBJECTIVES To explore and synthesise factors associated with accessing HIV care services by key populations, as well as make a reflection of this process using Ubuntu philosophy. METHOD An integrative literature review was conducted on studies published between 2014 and 2024. An electronic search was performed on several databases. Examples of key phrases that were utilised for the search included Africa, HIV care services, key populations and Ubuntu. The studies included were qualitative and quantitative from peer-reviewed journals and restricted to Africa. RESULTS The following themes emerged: non-inclusive healthcare environment, attitudes of healthcare workers and stigma and discrimination. These findings illustrate the challenges and barriers affecting access to HIV care services for key populations. CONCLUSION The insights from this review call for a paradigm shift in the training programmes of healthcare providers in Southern Africa.Contribution: Given the challenges that affect key populations as they access HIV care services, in-service and pre-service training of healthcare providers should incorporate the humane values of Ubuntu.
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Affiliation(s)
- Idah Moyo
- Department of Health Studies, College of Human Sciences, University of South Africa, Pretoria.
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Jadwin-Cakmak L, Harper GW, Ochieng E, Amico KR, Aloo T, Okutah F, Gumbe E, Olango K, Okall DO, Otieno FO, Odero W, Graham SM. Participatory development of the Shauriana program to integrate sexual health and mental health support for young gay and bisexual men and other men who have sex with men in Kenya. ADVANCES IN GLOBAL HEALTH 2025; 4:2442813. [PMID: 40296878 PMCID: PMC12036828 DOI: 10.1525/agh.2025.2442813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2025]
Abstract
Background Gay and bisexual men and other men who have sex with men (GBMSM) are at elevated risk for HIV, especially in rights-constrained settings such as Kenya, where stigma and discrimination have impeded access to HIV prevention. This article describes the development and pilot run of a theory-based and culturally relevant peer-led program called Shauriana ("we counsel each other"), which combines health education and integrated Next Step Counseling (iNSC) to promote sexual and mental health and well-being. Methods Shauriana was developed using participatory methods in collaboration with GBMSM community members using the ADAPT-ITT framework and tested through a pilot run with 10 participants to refine and finalize program materials and procedures. The team monitored attendance and obtained participant feedback through quantitative evaluation and in-depth exit interviews that were thematically analyzed. Results The majority of participants (90%) attended all four core sessions and completed study visits on time. All participants completed an exit interview, providing feedback on program content and format, challenges/barriers, recommendations, impact, and recommending Shauriana to others. We identified key elements for positive engagement with the program, including being peer-led, maintaining privacy and confidentiality, using iNSC to provide guidance while maintaining autonomy, and taking a holistic approach by focusing on mental health and issues affecting GBMSM's lives. We share modifications made in response to feedback and an overview of the final program sessions and structure. Conclusions Pilot participants reported positive experiences engaging in Shauriana, and shared that the program was highly relevant to their lives. Refined intervention procedures and materials are being tested in a subsequent randomized controlled trial. Lessons learned throughout the participatory development process and confirmed in exit interviews center on the importance of community engagement, local GBMSM-leadership, and holistic, autonomy-supporting programming for young GBMSM in Kenya. Trial registration Registered on ClinicalTrials.gov on September 16, 2020 (NCT04550221).
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Affiliation(s)
- Laura Jadwin-Cakmak
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Gary W. Harper
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Elijah Ochieng
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Salina Youth Initiative, Kisumu, Kenya
| | - K Rivet Amico
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Teddy Aloo
- Nyanza Reproductive Health Society, Kisumu, Kenya
| | - Felix Okutah
- Nyanza Reproductive Health Society, Kisumu, Kenya
| | - Edwin Gumbe
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Nafasi Innovations, Tom Mboya, Kisumu 40100, Kenya
| | - Kennedy Olango
- Men Against AIDS Youth Group (MAAYGO), Kisumu 40100, Kenya
| | | | | | - Wilson Odero
- School of Public Health and School of Medicine, Maseno University, Kisumu 40100, Kenya
| | - Susan M. Graham
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
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Aggarwal A, Zhang R, Qiao S, Wang B, Lwatula C, Menon A, Ostermann J, Li X, Harper G. Stigmatizing clinical setting erodes physician-patient interaction quality for sexual minority men through perceived HIV stigma and HIV infection concerns in Zambia. AIDS Care 2024; 36:797-806. [PMID: 38437705 DOI: 10.1080/09540121.2024.2324288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/22/2024] [Indexed: 03/06/2024]
Abstract
This study investigated whether perceived HIV stigma and HIV infection concerns among healthcare providers (HCPs) mediate the association between stigmatizing clinical setting and their interaction quality with sexual minority men (SMM) patients in Zambia. In 2021, a cross-sectional survey was conducted with 91 HCPs offering HIV-related services to SMM in Zambia. Path analysis was conducted to examine the potential mediation effect of "perceived HIV stigma" and "HIV infection concern" among HCPs in the association between "stigmatizing clinical setting" and their "interaction quality with SMM". Mediators i.e., "perceived HIV stigma" and "HIV infection concern" among HCPs, were associated positively with the stigmatizing clinical setting (β = 0.329, p < .01, β = 0.917, p < 0.01), and negatively with physician-patient interaction quality (β = -0.167, p = 0.051; β = -0.126, p < 0.05). Stigmatizing clinical setting had a significant and negative indirect effect on HCPs interaction quality with SMM through increased perceived HIV stigma (z = -1.966, p < 0.05) and increased HIV infection concern (z = -1.958, p = 0.050). To improve physician-patient interaction quality, stigma reduction interventions among HCPs, who serve SMM in Zambia, should target development of development of inclusive policies and the cultivation of cultural norms that are supportive and respectful to SMM, and protection of HCPs from enacted stigma due to offering care to SMM.
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Affiliation(s)
- Abhishek Aggarwal
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Ran Zhang
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Shan Qiao
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Bo Wang
- Population and Quantitative Health Sciences, University of Massachusetts, Boston, USA
| | | | - Anitha Menon
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | - Jan Ostermann
- Department of Health Service Policy and Management, University of South Carolina, Columbia, USA
| | - Xiaoming Li
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Gary Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, USA
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Noor MN, Shaw S, Linton J, Lorway R. Barriers to sexual health care for sexually diverse Muslim men: a scoping review. Sex Health 2024; 21:SH24022. [PMID: 38769681 DOI: 10.1071/sh24022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
Sexually diverse Muslim men (SDMM) are seen to present later and with more advanced symptoms of HIV and other sexually transmitted infections (STIs). The limited access to sexual healthcare services is attributed to the stigma associated with their multiple intersecting identities. We conducted a scoping review to synthesise research on barriers impeding SDMM's access to sexual health care. We used Arksey and O'Malley's five-stage framework as the methodology for the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses' extension for scoping reviews, was used as a guide for the presentation of the results. Searches conducted in EBSCOhost, Scopus, MEDLINE, Embase, CINAHL, Global Health, and Google Scholar yielded 1382 results, of which 18 studies were deemed eligible for this review. Bronfenbrenner's socioecological model was employed as a framework to analyse the studies. Through analysing the eligible studies, we identified factors operating at three different levels that can impede SDMM's access to sexual health care. Limited awareness and low-perceived risk of HIV/STIs, coupled with the fear of sexual identity disclosure might act as individual-level barriers to sexually diverse Muslim men's access to sexual health care. The experiences of discrimination within clinical settings were presented as a healthcare system-related issue discouraging SDMM from revisiting those services. Heteronormative and religious ideologies, homophobic government programs, and poverty might manifest in the more intimate domains of healthcare delivery, creating hostile spaces for SDMM. Intensive research and advocacy efforts are required to improve SDMM's access to sexual health care, which can reduce their risk of HIV/STIs.
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Affiliation(s)
- Muhammad Naveed Noor
- Institute for Global Public Health, Department of Community Health Sciences, Max Rady Faculty of Health Science, University of Manitoba, R065 - 771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada; and Centre for Social Research in Health, University of New South Wales, Kensington, Sydney, NSW 2033, Australia
| | - Souradet Shaw
- Institute for Global Public Health, Department of Community Health Sciences, Max Rady Faculty of Health Science, University of Manitoba, R065 - 771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
| | - Janice Linton
- Neil John Maclean Health Sciences Library, University of Manitoba, Bannatyne Campus, 727 McDermot Avenue, Winnipeg, MB R3E 3P5, Canada
| | - Robert Lorway
- Institute for Global Public Health, Department of Community Health Sciences, Max Rady Faculty of Health Science, University of Manitoba, R065 - 771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
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Aggarwal A, Zhang R, Qiao S, Wang B, Lwatula C, Menon A, Ostermann J, Li X, Harper G. Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia. AIDS Behav 2024; 28:1559-1569. [PMID: 37874436 DOI: 10.1007/s10461-023-04171-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/25/2023]
Abstract
HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (β = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (β = 0.039, z = 5.121, p < 0.001) and current PrEP use (β = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (β = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (β = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.
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Affiliation(s)
- Abhishek Aggarwal
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Ran Zhang
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Shan Qiao
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA.
| | - Bo Wang
- Population and Quantitative Health Sciences, University of Massachusetts, Boston, USA
| | | | - Anitha Menon
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | - Jan Ostermann
- Department of Health Service Policy and Management, University of South Carolina, Columbia, USA
| | - Xiaoming Li
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Gary Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, USA
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Dada D, Abu-Ba'are GR, Turner D, Mashoud IW, Owusu-Dampare F, Apreku A, Ni Z, Djiadeu P, Aidoo-Frimpong G, Zigah EY, Nyhan K, Nyblade L, Nelson LE. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open 2024; 14:e078794. [PMID: 38346887 PMCID: PMC10862343 DOI: 10.1136/bmjopen-2023-078794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations. DESIGN Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. DATA SOURCES Public health and regional databases were searched in 2020 and 2022. ELIGIBILITY CRITERIA Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA. DATA EXTRACTION AND SYNTHESIS Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed. RESULTS Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors. CONCLUSION Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.
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Affiliation(s)
- Debbie Dada
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
| | - Gamji R Abu-Ba'are
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | | | | | | | | | - Zhao Ni
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Pascal Djiadeu
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
- School of Public Health, University of Toronto Dalla Lana, Toronto, Ontario, Canada
| | - Gloria Aidoo-Frimpong
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Edem Yaw Zigah
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | - Kate Nyhan
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Laura Nyblade
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - LaRon E Nelson
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
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Mulenga DM, Rosen JG, Banda L, Musheke M, Mbizvo MT, Raymond HF, Keating R, Witola H, Phiri L, Geibel S, Tun W, Pilgrim N. "I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia. J Assoc Nurses AIDS Care 2024; 35:27-39. [PMID: 38019138 PMCID: PMC10842367 DOI: 10.1097/jnc.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
ABSTRACT Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.
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Affiliation(s)
| | - Joseph G. Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Henry F. Raymond
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - Ryan Keating
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Harold Witola
- National HIV/AIDS/STI/TB Council, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
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Linsenmeyer W, Heiden-Rootes K, Drallmeier T, Rahman R, Buxbaum E, Walcott K, Rosen W, Gombos BE. The power to help or harm: student perceptions of transgender health education using a qualitative approach. BMC MEDICAL EDUCATION 2023; 23:836. [PMID: 37936098 PMCID: PMC10629163 DOI: 10.1186/s12909-023-04761-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Lack of transgender health education among health professional education programs is a limitation to providing gender-affirming care. Educational interventions have advanced in the past decade using a variety of pedagogical approaches. Although evidence supports that educational interventions can significantly improve student knowledge, comfort levels, preparedness, and clinical skills, few studies have addressed student perceptions of or receptiveness towards transgender health education. The study purpose was to explore student perceptions of transgender health education using a qualitative approach. METHODS We utilized a basic qualitative design to explore student perceptions of transgender health education at a Catholic, Jesuit institution. Participants were medical students (n = 182), medical family therapy students (n = 8), speech, language and hearing sciences students (n = 44), and dietetic interns (n = 30) who participated in an Interprofessional Transgender Health Education Day (ITHED) in partnership with transgender educators and activists. Participants completed an online discussion assignment using eight discussion prompts specific to the ITHED sessions. Data were analyzed using the constant comparative method and triangulated across four medical and allied health programs. RESULTS A total of 263 participants provided 362 responses across eight discussion prompts. Three major themes resulted: (1) The Power to Help or Harm, (2) The Responsibility to Provide Health Care, and (3) A Posture of Humility: Listen and Learn. Each theme was supported by three to four subthemes. CONCLUSIONS Health professional students were highly receptive towards transgender health education delivered by transgender community members. First-person accounts from session facilitators of both positive and negative experiences in healthcare were particularly effective at illustrating the power of providers to help or harm transgender patients. Reflection and constructive dialogue offers students an opportunity to better understand the lived experiences of transgender patients and explore their identities as healthcare providers at the intersection of their religious and cultural beliefs.
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Affiliation(s)
- Whitney Linsenmeyer
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA.
| | - Katie Heiden-Rootes
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring Avenue, 3rd Floor, St. Louis, MO, 63110, USA
| | - Theresa Drallmeier
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1008 S. Spring Avenue, 3rd Floor, St. Louis, MO, 63110, USA
| | - Rabia Rahman
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA
| | - Emily Buxbaum
- Department of Speech, Language & Hearing Sciences, Saint Louis University, 3750 Lindell Blvd., Suite 23, St. Louis, MO, 63108, USA
| | - Katherine Walcott
- Department of Nutrition and Dietetics, Saint Louis University, 3437 Caroline Street, Room 3076, St. Louis, MO, 63105, USA
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Mwaniki SW, Kaberia PM, Mugo PM, Palanee-Phillips T. "We must help them despite who they are…": healthcare providers' attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya. BMC Health Serv Res 2023; 23:1055. [PMID: 37789339 PMCID: PMC10546658 DOI: 10.1186/s12913-023-10026-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Compared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM's limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya. METHODS In September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12. RESULTS Analysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs' personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of "treating others as one would want to be treated" as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to "convert" YMSM's perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services. CONCLUSION There is need for interventions to improve HCPs' knowledge of YMSM's health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.
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Affiliation(s)
- Samuel Waweru Mwaniki
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Health Services, Administration and Campus Support Services, University of Nairobi, Nairobi, Kenya.
| | - Peter Mwenda Kaberia
- Department of Mathematics, Faculty of Science and Technology, University of Nairobi, Nairobi, Kenya
| | - Peter Mwangi Mugo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Shaw SY, Leung S, Isac S, Musyoki H, Mugambi M, Kioko J, Musimbi J, Olango K, Kuria S, Ongaro MK, Walimbwa J, Melon M, Emmanuel F, Moses S, Blanchard JF, Pickles M, Lazarus L, Lorway RR, Becker ML, Mishra S, Bhattacharjee P. Assessing awareness and use of HIV self-testing kits after the introduction of a community-based HIV self-testing programme among men who have sex with men in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001547. [PMID: 37594918 PMCID: PMC10437899 DOI: 10.1371/journal.pgph.0001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/18/2023] [Indexed: 08/20/2023]
Abstract
Men who have sex with men (MSM) bear a disproportionate burden of new HIV infections in Kenya, while experiencing discrimination, leading to suboptimal levels of HIV care. HIV self-testing (HIVST) is a tool to increase HIV screening and earlier diagnosis; however, questions remain regarding how best to scale-up HIVST to MSM in Kenya. The main objective of this study was to examine changes in knowledge and use of HIVST after implementation of a community-led HIVST project. Participants were MSM recruited from Kisumu, Mombasa, and Kiambu counties. Data were collected from two rounds (Round 1: 2019; Round 2: 2020) of serial cross-sectional integrated biological and behavioural assessments (IBBA), pre-, and post-project implementation. Two main outcomes were measured: 1) whether the respondent had ever heard of HIVST; and 2) whether they had ever used HIVST kits. Changes in outcomes between IBBA rounds were examined using modified multivariable Poisson regression models; adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) are reported. A total of 2,328 respondents were included in main analyses. The proportion of respondents who had heard of HIVST increased from 75% in Round 1 to 94% in Round 2 (aPR: 1.2, 95% CI: 1.2-1.3), while those reporting using an HIVST kit increased from 20% to 53% (aPR: 2.3, 95% CI: 2.0-2.6). Higher levels of education and HIV programme awareness were associated with both outcomes. Awareness and use of HIVST kits increased after implementation of a community-led HIVST implementation project, demonstrating the importance of integration with existing community groups.
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Affiliation(s)
- Souradet Y. Shaw
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stella Leung
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Helgar Musyoki
- National Syndemic Disease Control Council, Nairobi, Kenya
| | - Mary Mugambi
- National Syndemic Disease Control Council, Nairobi, Kenya
| | - Japheth Kioko
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Janet Musimbi
- Partners for Health and Development in Africa, Nairobi, Kenya
| | | | | | | | | | - Memory Melon
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Faran Emmanuel
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen Moses
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James F. Blanchard
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, England
| | - Lisa Lazarus
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert R. Lorway
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marissa L. Becker
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sharmistha Mishra
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Parinita Bhattacharjee
- Institute for Global Public Health, Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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11
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Poxon A, Leis M, McDermott M, Kariri A, Kaul R, Kimani J. Emergency departments as under-utilized venues to provide HIV prevention services to female sex workers in Nairobi, Kenya. Int J Emerg Med 2023; 16:47. [PMID: 37537558 PMCID: PMC10399019 DOI: 10.1186/s12245-023-00516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/02/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Female sex workers (FSW) in sub-Saharan Africa are disproportionately affected by HIV and remain a key target population for efforts to reduce transmission. While HIV prevention tools such as PEP and PrEP are available through outpatient FSW clinics, these services are underused. Emergency medicine is a rapidly expanding field in Kenya and may provide a novel venue for initiating or optimizing HIV prevention services. This study examined the characteristics of FSW from Nairobi, Kenya, who had utilized an emergency department (ED) during the past year to broaden our understanding of the patient factors related to usage. METHODS An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019. The participants were categorized into those who attended an ED over the past year (acute care users) and clinic-only users (control). A modified version of the WHO Violence Against Women Instrument assessed gender-based violence. Multivariable negative binomial logistic regressions evaluated predictors of health care use among these populations. RESULTS Of the total 220 women (median [IQR] age 32 [27-39]), 101 and 116 were acute care and control populations, respectively. Acute care users had 12.7 ± 8.5 healthcare visits over a 12-month period, and the control population had 9.1 ± 7.0 (p < 0.05). ED attendance did not improve the PrEP usage, with 48.5%, and 51% of acute care and clinic users indicated appropriate PrEP use. Patient factors that correlated with health care utilization among acute care users included client sexual violence (OR 2.2 [1.64-2.94], p < 0.01), PrEP use (OR 1.54 (1.25-1.91), < 0.01), and client HIV status (OR 1.35 (1.02-1.69), p < 0.01). CONCLUSIONS Many FSW at high risk for HIV were not accessing HIV prevention tools despite attending a dedicated FSW clinic offering such services. FSW who had attended an ED over the past year had a higher prevalence of HIV risk factors, demonstrating that emergency departments may be important acute intervention venues to prevent HIV transmission in this population. These results can guide policy design, health care provider training, and facility preparedness to support strategies aimed at improving HIV prevention strategies for FSW in Kenyan ED's.
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Affiliation(s)
- Amanda Poxon
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S1A8, Canada.
| | - Maria Leis
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S1A8, Canada
| | - Miranda McDermott
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S1A8, Canada
| | - Antony Kariri
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Rupert Kaul
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S1A8, Canada
| | - Joshua Kimani
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology, University of Manitoba, Manitoba, Canada
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12
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Sariola S. Mistrust: Community engagement in global health research in coastal Kenya. SOCIAL STUDIES OF SCIENCE 2023; 53:449-471. [PMID: 37002697 PMCID: PMC10240637 DOI: 10.1177/03063127231162082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This article explores a case of mistrust in global health research and community engagement. It uses ethnographic material collected in 2014 and 2016 in Kenya, concerning community engagement by a HIV vaccine research group working with men who have sex with men and transgender women. In 2010, the research group was attacked by members of the wider community. Following the attack, the research group set up an engagement program to reduce mistrust and re-build relationships. Analysis focusing on mistrust shows the dynamics underlying the conflict: Norms around gender and sexuality, political support for LGBTIQ+ rights, and resources disparities were all at stake for those embroiled in the conflict, including researchers, study participants, religious leaders, and LGBTIQ+ activists in the region. Rather than a normative good with liberatory potential, community engagement in this paper is discussed as a relational tool with which mistrust was managed, highlighting the fragility of participation.
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13
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Muwanguzi PA, Nabunya R, Karis VMS, Nabisere A, Nangendo J, Mujugira A. Nurses' reflections on caring for sexual and gender minorities pre-post stigma reduction training in Uganda. BMC Nurs 2023; 22:50. [PMID: 36823533 PMCID: PMC9947888 DOI: 10.1186/s12912-023-01208-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) and transgender women (TGW) have a significant HIV burden worldwide. Data from eight countries across sub-Saharan Africa found a pooled HIV prevalence of 14% among MSM and 25% among TGW. Stigma and discrimination among healthcare providers are barriers to healthcare access by these populations. We sought to explore nurses' attitudes before and after sensitivity training to reduce stigma in HIV prevention and care provision to MSM and transgender persons in Uganda. METHODS An explorative qualitative study comprising in-depth interviews. Nineteen nurses who underwent sensitivity training in caring for the vulnerable, priority and key populations in Uganda participated. We interviewed each participant before and after the stigma reduction training and analyzed the data with NVivo. RESULTS Eight (8) themes emerged from the reflections before the training, namely, 'the definition of MSM and transgender persons', 'legal concerns', 'mental illness', 'attitude in health care provision', 'personal perceptions', 'self-efficacy', 'insufficient training preparation', and 'reasons for gender or sexual orientation preference'. The post-training reflections suggested a change in knowledge and attitude. Five themes emerged for MSM: 'stigma reduction', 'sexual practices and sexuality', 'the need for tailored health approaches', 'MSM and the law' and 'corrected misconceptions'. For transmen, 'reproductive health needs', 'social needs', 'safety needs', 'Gender identity recognition' and 'reduced stigma, discrimination, and barriers to care'. Finally, the reflections on their attitudes towards transwomen were on five topics; Gender affirming care', 'Healthcare provision for transwomen', 'Need for further training', 'New knowledge acquired', and 'Sexual violence'. CONCLUSION Nurses' attitudes and empathy for vulnerable and key populations improved following the training. Nursing training programs should consider incorporating sexual and gender minority (SGM) specific health training into their curricula to decrease negative attitudes. There is a need to identify best practices and conduct implementation research to provide culturally sensitive and affirming healthcare delivery in sub-Saharan Africa. Future studies should evaluate the effect of provider sensitivity training on sexual health and HIV outcomes for SGM. Furthermore, interventions targeting higher-level stigma, such as structural and policy levels, are critical because they influence interpersonal stigma reduction efforts and initiatives.
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Affiliation(s)
- Patience A. Muwanguzi
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Racheal Nabunya
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Victoria M. S. Karis
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Allen Nabisere
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, P. O. Box 7072, Uganda
| | - Joan Nangendo
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala, P.O. BOX 7072, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, P. O Box 22418, Uganda
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14
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Dibble KE, Baral SD, Beymer MR, Stahlman S, Lyons CE, Olawore O, Ndour C, Turpin Nunez G, Toure-Kane C, Leye Diouf N, Diouf D, Drame FM, Mboup S, Murray SM. Stigma and healthcare access among men who have sex with men and transgender women who have sex with men in Senegal. SAGE Open Med 2022; 10:20503121211069276. [PMID: 35517371 PMCID: PMC9066634 DOI: 10.1177/20503121211069276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/07/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: Cisgender gay, bisexual, and other men who have sex with men and transgender women experience HIV incidence disparities in Senegal. These analyses determined how depression and different stigma mechanisms related to sexual behavior are associated with healthcare access, sexually transmitted infection testing, and HIV testing among cisgender gay, bisexual, and other men who have sex with men and transgender women across three cities in western Senegal. Methods: Logistic regression assessed the relationship of three stigma scales (stigma from family and friends, anticipated healthcare stigma, and general social stigma) and depression with these outcomes. Results: Depression and stigma were not associated with healthcare access, sexually transmitted infection testing, or HIV testing. However, individuals who had disclosed their sexual identity to a medical provider were more likely to test for HIV. Conclusions: Sexual behavior stigma experienced by cisgender gay, bisexual, and other men who have sex with men and trans women in Senegal may not limit access to routine healthcare, but may limit disclosure of sexual orientation and practices, limiting access to appropriate HIV prevention services.
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Affiliation(s)
- Kate E Dibble
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan D Baral
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew R Beymer
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Shauna Stahlman
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwasolape Olawore
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cheikh Ndour
- Division de La Lutte Contre Le Sida et Les IST, Ministry of Health, Dakar, Senegal
| | - Gnilane Turpin Nunez
- Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Coumba Toure-Kane
- Molecular Biology Unit, National Reference Center for HIV and STDs, Dakar, Senegal
| | - Nafissatou Leye Diouf
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | | | | | - Souleymane Mboup
- Institut de Recherche en Santé de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | - Sarah M Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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15
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Nduva GM, Otieno F, Kimani J, McKinnon LR, Cholette F, Sandstrom P, Graham SM, Price MA, Smith AD, Bailey RC, Hassan AS, Esbjörnsson J, Sanders EJ. Phylogeographic Assessment Reveals Geographic Sources of HIV-1 Dissemination Among Men Who Have Sex With Men in Kenya. Front Microbiol 2022; 13:843330. [PMID: 35356525 PMCID: PMC8959701 DOI: 10.3389/fmicb.2022.843330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022] Open
Abstract
HIV-1 transmission dynamics involving men who have sex with men (MSM) in Africa are not well understood. We investigated the rates of HIV-1 transmission between MSM across three regions in Kenya: Coast, Nairobi, and Nyanza. We analyzed 372 HIV-1 partial pol sequences sampled during 2006-2019 from MSM in Coast (N = 178, 47.9%), Nairobi (N = 137, 36.8%), and Nyanza (N = 57, 15.3%) provinces in Kenya. Maximum-likelihood (ML) phylogenetics and Bayesian inference were used to determine HIV-1 clusters, evolutionary dynamics, and virus migration rates between geographic regions. HIV-1 sub-subtype A1 (72.0%) was most common followed by subtype D (11.0%), unique recombinant forms (8.9%), subtype C (5.9%), CRF 21A2D (0.8%), subtype G (0.8%), CRF 16A2D (0.3%), and subtype B (0.3%). Forty-six clusters (size range 2-20 sequences) were found-half (50.0%) of which had evidence of extensive HIV-1 mixing among different provinces. Data revealed an exponential increase in infections among MSM during the early-to-mid 2000s and stable or decreasing transmission dynamics in recent years (2017-2019). Phylogeographic inference showed significant (Bayes factor, BF > 3) HIV-1 dissemination from Coast to Nairobi and Nyanza provinces, and from Nairobi to Nyanza province. Strengthening HIV-1 prevention programs to MSM in geographic locations with higher HIV-1 prevalence among MSM (such as Coast and Nairobi) may reduce HIV-1 incidence among MSM in Kenya.
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Affiliation(s)
- George M. Nduva
- Department of Translational Medicine, Lund University, Lund, Sweden
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Joshua Kimani
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| | - Lyle R. McKinnon
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Francois Cholette
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
- National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Paul Sandstrom
- National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Susan M. Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Matt A. Price
- IAVI, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Adrian D. Smith
- Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Robert C. Bailey
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Division of Epidemiology and Biostatistics, University of Illinois Chicago, Chicago, IL, United States
| | - Amin S. Hassan
- Department of Translational Medicine, Lund University, Lund, Sweden
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Joakim Esbjörnsson
- Department of Translational Medicine, Lund University, Lund, Sweden
- Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Eduard J. Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
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16
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Sexual Prejudice and Comfort to Provide Services to Men Who Have Sex with Men Among HIV Healthcare Workers in Western Kenya: Role of Interpersonal Contact. AIDS Behav 2022; 26:805-813. [PMID: 34406550 DOI: 10.1007/s10461-021-03440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
Sexual minority men living in Africa, where many countries criminalize same-sex behavior, are vulnerable to HIV and experience significant barriers to HIV care. Sexual prejudice in healthcare settings is a key contributor to these barriers. Building on social psychological models of prejudice and interpersonal contact at the clinic, we examined the associations between healthcare workers' sexual prejudice and their comfort to provide care to MSM, and assessed the moderating role of workers' prior interpersonal contact with MSM. A cross-sectional survey of 147 healthcare workers varying in level of training and expertise working in HIV care organizations was conducted in western Kenya. Sexual prejudice was negatively associated with comfort to provide care to MSM. Prior interpersonal contact with MSM moderated the association between sexual prejudice and comfort to provide care to MSM among nurses/counselors, such that those with low prior contact and high sexual prejudice were the most uncomfortable providing care to MSM. Interventions are needed to address sexual prejudice and encourage positive forms of interpersonal contact with MSM, especially with nurses and counselors who might have more and varied patient interactions, to improve access to the continuum of HIV prevention and care for MSM in Kenya.
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17
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Mwijage Ishungisa A, Meyrowitsch DW, Mmbaga EJ, Leshabari MT, Moen K. Not a Problem at All or Excluded by Oneself, Doctors and the Law? Healthcare Workers' Perspectives on Access to HIV-Related Healthcare among Same-Sex Attracted Men in Tanzania. J Int Assoc Provid AIDS Care 2022; 21:23259582221121448. [PMID: 35989640 PMCID: PMC9403446 DOI: 10.1177/23259582221121448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: An increasing body of literature focuses on access to
healthcare services for men who engage in sex with other men in Africa, but how
healthcare workers conceive of this topic of healthcare workers’ views on men's
care has not been much studied. Drawing on qualitative research, this article
explores healthcare providers’ perspectives on access to HIV-related healthcare
services among gender and sexuality diverse men in Tanzania.
Methods: A qualitative study was conducted among healthcare
workers in Dar es Salaam and Tanga, Tanzania in 2018/2019. Data collection
entailed qualitative interviewing, focus group discussions and participant
observation. A purposive sampling strategy was used to select study participants
who varied with respect to age, education level, work experience, and the type
and location of the facilities they worked in. A total of 88 participants took
part in the study. Results: This paper describes four different
discourses that were identified among healthcare workers with respect to their
perception of access to healthcare services for men who have sex with men. One
held that access to healthcare was not a major problem, another that some
same-sex attracted men did not utilize healthcare services although they were
available to them, a third that some healthcare workers prevented these men from
gaining access to healthcare and a fourth that healthcare for gender and sexual
minority persons was made difficult by structural barriers.
Conclusion: Although these are four rather different takes on
the prevailing circumstances with respect to healthcare access for same-sex
attracted men (SSAM), we suggest that they may all be “true” in the sense that
they grasp and highlight different aspects of the same realities. More education
is needed to healthcare providers to enable them accept SSAM who seek healthcare
services and hence improve access to healthcare.
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Affiliation(s)
- Alexander Mwijage Ishungisa
- Department of Behavioural Sciences, 92976Department of Epidemiology and Biostatistics of the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, 53139University of Copenhagen, Kobenhavn, Denmark
| | - Elia John Mmbaga
- Department of Behavioural Sciences, 92976Department of Epidemiology and Biostatistics of the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,60504Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Melkizedeck Thomas Leshabari
- Department of Behavioural Sciences, 92976Department of Epidemiology and Biostatistics of the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kåre Moen
- 60504Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
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18
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Shangani S, Genberg B, Harrison A, Pellowski J, Wachira J, Naanyu V, Operario D. Cultural adaptation and validation of a measure of prejudice against men who have sex with men among healthcare providers in western Kenya. Glob Public Health 2022; 17:150-164. [PMID: 33306434 PMCID: PMC8192581 DOI: 10.1080/17441692.2020.1860248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sexual prejudice toward men who have sex with men (MSM) is a pressing concern in sub-Saharan Africa (SSA). Given the high HIV infection risk among this population, sexual prejudice perpetuated by healthcare providers, affects access to and willingness of MSM to seek HIV care services. However, data on healthcare providers' attitudes towards MSM in SSA are limited, and there are no locally-adapted measures of sexual prejudice. We adapted a scale to measure sexual prejudice with a sample of 147 healthcare providers in western Kenya. Results from exploratory factor analysis revealed a single-factor structure. The scale demonstrated high internal consistency with Cronbach's α = 0.91. Healthcare providers who had prior interpersonal contact with MSM, had ever been trained on counselling MSM, and had higher knowledge about MSM health needs reported lower sexual prejudice scores, compared with peers who lacked these experiences (p < 0.001). In contrast, healthcare providers who had experienced secondary stigma (negative judgments from peers and community) for providing care to MSM reported higher scores of sexual prejudice scale (p < 0.001) compared with providers who had not experienced secondary stigma. The scale provides a contextualised tool to assess healthcare providers' attitudes toward MSM in Kenya and countries in SSA with similar cultural norms.
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Affiliation(s)
- Sylvia Shangani
- School of Community & Environmental Health, College of Health Sciences, Old Dominion University, Norfolk, VA, USA
| | - Becky Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Jennifer Pellowski
- Department of Behavioral and Social Sciences, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Juddy Wachira
- Moi University, College of Health Sciences, School of Medicine, Department of Mental Health and Behavioral Social Sciences, Eldoret Kenya
| | - Violet Naanyu
- Moi University, School of Arts and Social Sciences, Eldoret, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University, School of Public Health, Providence, Rhode Island, USA
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19
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Jauregui JC, Mwochi CR, Crawford J, Jadwin-Cakmak L, Okoth C, Onyango DP, Harper GW. Experiences of Violence and Mental Health Concerns Among Sexual and Gender Minority Adults in Western Kenya. LGBT Health 2021; 8:494-501. [PMID: 34463158 DOI: 10.1089/lgbt.2020.0495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose: Sexual and gender minority (SGM) populations throughout Kenya as well as other sub-Saharan African countries face systemic discrimination and substantial human rights violations, yet scant literature documents the potentially harmful mental health effects of these experiences. This study sought to understand the relationship among experiences of violence, social support, and mental health among SGM adults in Kenya. Methods: Members of a local LGBT community-based organization collected survey data in Western Kenya from October 2017 to April 2018, recruiting 527 SGM participants through an array of community outreach methods. Respondents in this cross-sectional study completed a survey regarding their mental health and other psychosocial factors. Multiple linear regression analyses were conducted to assess associations between experiences of violence (SGM violence and intimate partner violence [IPV]) and mental health outcomes (depressive symptoms and post-traumatic stress symptoms [PTSSs]) and to examine the potential moderating effect of social support on these relationships. Results: Relative to those who had never faced violence, participants who experienced IPV and/or violence based on their sexual orientation, gender identity, or gender expression (SGM violence) reported significantly higher levels of depressive symptoms and PTSSs. Emotional support was associated with lower levels of PTSSs. Social support did not moderate the relationship between SGM violence and mental health symptoms. Conclusions: These findings suggest that there may be a relationship between experiences of violence and poor mental health among SGM Kenyans. More studies are needed to better understand SGM-specific risk factors for poor mental well-being among SGM people in Kenya and the types of interventions that may help mitigate these challenges.
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Affiliation(s)
- Juan C Jauregui
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Caroline R Mwochi
- Nyanza, Rift Valley and Western Kenya (NYARWEK) LGBTI Coalition, Kisumu, Kenya.,Western Kenya LBQT Feminist Forum, Kisumu, Kenya
| | - Jessica Crawford
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Cecil Okoth
- Nyanza, Rift Valley and Western Kenya (NYARWEK) LGBTI Coalition, Kisumu, Kenya
| | | | - Gary W Harper
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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20
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Mgopa LR, Rosser BRS, Ross MW, Lukumay GG, Mohammed I, Massae AF, Leshabari S, Mkonyi E, Mushy SE, Mwakawanga DL, Trent M, Wadley J, Bonilla ZE. Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals' experiences and health students' perspectives. BMC Public Health 2021; 21:676. [PMID: 33827508 PMCID: PMC8028207 DOI: 10.1186/s12889-021-10696-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Health care providers across sub-Saharan Africa continue to face challenges while delivering sexual health care services. We explored the experiences, views and challenges of health care professionals and health students across different disciplines in Tanzania, towards delivery of sexual health services to men who have sex with men. METHODS Utilizing a qualitative approach, we recruited 121 health care professionals (providers) and students from the fields of midwifery, nursing and medicine in Dar es Salaam, Tanzania. We conducted 18 focus groups discussions, stratified by profession and experience, to investigate clinical management and challenges while addressing a case of an adult male presenting with rectal gonorrhea. RESULTS Findings indicated this case as extremely sensitive, clinical management involved establishing rapport and consent, medical care from history taking to treatment, and referral to other specialties. However, the illegal status of homosexuality in Tanzania was a primary concern to participants, this triggered the clinical care of this case scenario as challenging. There were uncertainties whether or not that such a case should be reported to the authorities. CONCLUSION Findings from this study revealed a need for training health students in Tanzania to address sexual health issues including accurate information on homosexuality, reporting requirements and clinical management in the legal and socio-cultural context of the African continent.
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Affiliation(s)
- Lucy R Mgopa
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - B R Simon Rosser
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA.
| | - Michael W Ross
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | - Gift Gadiel Lukumay
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Inari Mohammed
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | - Agnes F Massae
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Sebalda Leshabari
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Ever Mkonyi
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
| | | | - Dorkasi L Mwakawanga
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Maria Trent
- Johns Hopkins University, Washington, DC, USA
| | - James Wadley
- Lincoln University, Counseling and Human Services Department, 1570 Baltimore Pike, Philadelphia, PA, 19352, USA
| | - Zobeida E Bonilla
- University of Minnesota, School of Public Health, 1300 S. 2nd St., Minneapolis, MN, 55454, USA
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Öhman J, Larsson M, Kashiha J, Agardh A. 'Fighting an uphill battle': a qualitative study of the challenges encountered by pharmacy workers when providing services to men who have sex with men in Dar es Salaam, Tanzania. Glob Health Action 2020; 13:1770985. [PMID: 32508263 PMCID: PMC7448846 DOI: 10.1080/16549716.2020.1770985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Previous research suggests that Tanzanian MSM might prefer consulting pharmacies and drugstores, rather than public healthcare services, when in need of STI medicines and treatment. Yet, few studies have explored the experiences of providing services to MSM clients among those working at pharmacies and drugstores and examined what challenges they encounter in providing these services. Objective To gain increased knowledge and understanding of the perceived challenges encountered by pharmacists and drugstore workers when providing STI services to MSM clients in Dar es Salaam, Tanzania. Method In early 2016, 16 semi-structured interviews were conducted with persons working at private pharmacies and drugstores in Dar es Salaam. Data were interpreted through qualitative content analysis. Results The overarching theme that emerged was labelled ‘Fighting an uphill battle’, which reflected the challenges pharmacy workers experienced during interactions with MSM clients, and in particular service provision. Pharmacy workers tried to act upon the best of their knowledge to meet the needs of clients, given their understanding of risks and obstacles that MSM faced. Yet, the lack of educational and professional preparedness and insufficient financial and human resources, regarded as necessary to meet the needs of a stigmatised client group, formed barriers for effective service delivery. Conclusions In order to support pharmacists and drug-store workers in Tanzania to address perceived challenges for service delivery to MSM clients, systematic and continuous training on MSM’s sexual health is required. Furthermore, inter-professional cooperation that harnesses provider involvement from all tiers in the healthcare system is essential to offer complementary services to ensure proper STI care and treatment. Thus, interventions that focus on inter-professional communication and interaction between pharmacists and physicians could have a positive impact on timely referrals of suspected STI cases among marginalised populations.
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Affiliation(s)
- Joakim Öhman
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University , Malmö, Sweden
| | - Markus Larsson
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University , Malmö, Sweden
| | - John Kashiha
- Community Health Education Services & Advocacy (CHESA) , Dar es Salaam, Tanzania
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University , Malmö, Sweden
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22
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van der Elst EM, Mudza R, Onguso JM, Kiirika L, Kombo B, Jahangir N, Graham SM, Operario D, Sanders EJ. A more responsive, multi-pronged strategy is needed to strengthen HIV healthcare for men who have sex with men in a decentralized health system: qualitative insights of a case study in the Kenyan coast. J Int AIDS Soc 2020; 23 Suppl 6:e25597. [PMID: 33000906 PMCID: PMC7527756 DOI: 10.1002/jia2.25597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION HIV healthcare services for men who have sex with men (MSM) in Kenya have not been openly provided because of persistent stigma and lack of healthcare capacity within Kenya's decentralized health sector. Building on an evaluation of a developed online MSM sensitivity training programme offered to East and South African healthcare providers, this study assessed views and responses to strengthen HIV healthcare services for MSM in Kenya. METHODS The study was conducted between January and July 2017 in Kilifi County, coastal Kenya. Seventeen policymakers participated in an in-depth interview and 59 stakeholders, who were purposively selected from three key groups (i.e. healthcare providers, implementing partners and members of MSM-led community-based organizations) took part in eight focus group discussions. Discussions aimed to understand gaps in service provision to MSM from different perspectives, to identify potential misconceptions, and to explore opportunities to improve MSM HIV healthcare services. Interviews and focus group discussions were recorded, transcribed verbatim and analysed using Braun and Clarke's thematic analysis. RESULTS Participants' responses revealed that all key groups navigated diverse challenges related to MSM HIV health services. Specific challenges included priority-setting by county government staff; preparedness of leadership and management on MSM HIV issues at the facility level; data reporting at the implementation level and advocacy for MSM health equity. Strong power inequities were observed between policy leadership, healthcare providers and MSM, with MSM feeling blamed for their sexual orientation. MSM agency, as expressed in their actions to access HIV services, was significantly constrained by county context, but can potentially be improved by political will, professional support and a human rights approach. CONCLUSIONS To strengthen HIV healthcare for MSM within a decentralized Kenyan health system, a more responsive, multi-pronged strategy adaptable and relevant to MSM's healthcare needs is required. Continued engagement with policy leadership, collaboration with health facilities, and partnerships with different community stakeholders are critical to improve HIV healthcare services for MSM.
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Affiliation(s)
- Elise M van der Elst
- Kenya Medical Research Institute‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of Global HealthAcademic Medical CentreUniversity of Amsterdamthe Netherlands
| | - Rita Mudza
- Jomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Justus M Onguso
- Institute for Biotechnology ResearchJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Leonard Kiirika
- Department of Horticulture and Food SecuritySchool of Agriculture and Environmental SciencesJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Bernadette Kombo
- Kenya Medical Research Institute‐Wellcome Trust Research ProgrammeKilifiKenya
| | | | - Susan M Graham
- Departments of MedicineGlobal Health, and EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Don Operario
- Department of Behavioral and Social SciencesSchool of Public HealthBrown UniversityProvidenceRIUSA
| | - Eduard J Sanders
- Kenya Medical Research Institute‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of Global HealthAcademic Medical CentreUniversity of Amsterdamthe Netherlands
- Nuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
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23
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Abstract
PURPOSE OF REVIEW HIV prevention and treatment interventions for MSM are not well studied or reported from low-income and middle-income countries (LMIC) in comparison to those targeting gender-conforming populations. Some evidence-based strategies to engage MSM in appropriate healthcare have recently reported on their experiences and impact. Novel recruitment strategies have been developed for treatment and preexposure prophylaxis (PrEP) for MSM, leveraging new community engagement strategies and social media technologies. RECENT FINDINGS Despite publication of several new guidelines, there is little recent evidence available to guide MSM health programs in LMIC, highlighting the need for ongoing research and publication. Some important PrEP pilot study results have recently been published, such as the PrEP Brazil and Princess PrEP programmes, which could guide the scale-up of MSM PrEP. The novel use of technology and online platforms to strengthen MSM health delivery and support is particularly important. SUMMARY Providing healthcare to MSM requires consideration of context, broad stakeholder engagement, implementation of best practice guidelines and ongoing situational assessment and integration of novel community engagement methods that are evidence-based. Implementation of improved antiretroviral programmes and the access to PrEP for MSM are vital.
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24
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Graham SM, Micheni M, Chirro O, Nzioka J, Secor AM, Mugo PM, Kombo B, van der Elst EM, Operario D, Amico KR, Sanders EJ, Simoni JM. A Randomized Controlled Trial of the Shikamana Intervention to Promote Antiretroviral Therapy Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya: Feasibility, Acceptability, Safety and Initial Effect Size. AIDS Behav 2020; 24:2206-2219. [PMID: 31965432 DOI: 10.1007/s10461-020-02786-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV in rights-constrained settings need support for antiretroviral therapy (ART) adherence due to barriers including stigma. The Shikamana intervention combined modified Next Step Counseling by providers with support from trained peers to improve adherence among GBMSM living with HIV in Kenya. A randomized controlled trial with 6-month follow-up was used to determine feasibility, acceptability, safety, and initial intervention effects. Generalized estimating equations examined differences in self-reported adherence and virologic suppression. Sixty men enrolled, with 27 randomly assigned to the intervention and 33 to standard care. Retention did not differ by arm, and no adverse events occurred. Feedback on feasibility and acceptability was positive based on exit interviews. After adjustment for baseline viral suppression and confounding, the intervention group had a sixfold increased odds of viral suppression during follow-up. A larger trial of a scaled-up intervention is needed.
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Affiliation(s)
- Susan M Graham
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, 325 Ninth Avenue, Box 359909, Seattle, WA, 98104, USA.
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya.
| | - Murugi Micheni
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Oscar Chirro
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Joseph Nzioka
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Andrew M Secor
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Peter M Mugo
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | | | - Elise M van der Elst
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - K Rivet Amico
- Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Eduard J Sanders
- Clinical Research, Kenya Medical Research Institute - Wellcome Trust Programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, Oxford, OX3 7BN, UK
| | - Jane M Simoni
- Departments of Psychology; Global Health; and Gender, Women, and Sexuality Studies, University of Washington, Seattle, WA, USA
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25
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Tumwine G, Palmieri J, Larsson M, Gummesson C, Okong P, Östergren PO, Agardh A. 'One-size doesn't fit all': Understanding healthcare practitioners' perceptions, attitudes and behaviours towards sexual and reproductive health and rights in low resource settings: An exploratory qualitative study. PLoS One 2020; 15:e0234658. [PMID: 32584840 PMCID: PMC7316327 DOI: 10.1371/journal.pone.0234658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/30/2020] [Indexed: 11/18/2022] Open
Abstract
Although progress has been made to improve access to sexual and reproductive health services globally in the past two decades, in many low-income countries, improvements have been slow. Discrimination against vulnerable groups and failure to address health inequities openly and comprehensively play a role in this stagnation. Healthcare practitioners are important actors who, often alone, decide who accesses services and how. This study explores how health care practitioners perceive sexual and reproductive health and rights (SRHR) and how background factors influence them during service delivery. Participants were a purposefully selected sample of health practitioners from five low income countries attending a training in at Lund University, Sweden. Semi-structured interviews and qualitative content analysis were used. Three themes emerged. The first theme, "one-size doesn't fit all' in SRHR" reflects health practitioners' perception of SRHR. Although they perceived rights as fundamental to sexual and reproductive health, exercising of these rights was perceived to be context-specific. The second theme, "aligning a pathway to service delivery", illustrates a reflective balancing act between their personal values and societal norms in service delivery, while the third theme, "health practitioners acting as gatekeepers", describes how this balancing act oscillates between enabling and blocking behaviours. The findings suggest that, even though health care practitioners perceive SRHR as fundamental rights, their preparedness to ensure that these rights were upheld in service delivery is influenced by personal values and society norms. This could lead to actions that enable or block service delivery.
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Affiliation(s)
- Gilbert Tumwine
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
- St. Francis Hospital Nsambya, Kampala, Uganda
| | - Jack Palmieri
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Markus Larsson
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Christina Gummesson
- Centre for Teaching and Learning, Faculty of Medicine, Lund University, Lund, Sweden
| | - Pius Okong
- Health Service Commission, Kampala, Uganda
| | - Per-Olof Östergren
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anette Agardh
- Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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26
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Irungu EM, Baeten JM. PrEP rollout in Africa: status and opportunity. Nat Med 2020; 26:655-664. [PMID: 32405065 DOI: 10.1038/s41591-020-0872-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation.
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Affiliation(s)
- Elizabeth M Irungu
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA. .,Department of Medicine, University of Washington, Seattle, WA, USA.
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27
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Wahome E, Graham S, Thiong'o A, Chirro O, Mohamed K, Gichuru E, Mwambi J, Price M, Sanders EJ. Assessment of PrEP eligibility and uptake among at-risk MSM participating in a HIV-1 vaccine feasibility cohort in coastal Kenya. Wellcome Open Res 2020; 4:138. [PMID: 32140565 PMCID: PMC7043115 DOI: 10.12688/wellcomeopenres.15427.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction: Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. We set out to determine PrEP eligibility, uptake and predictors of PrEP uptake among MSM enrolled in an HIV-1 vaccine feasibility cohort in coastal Kenya. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Results: Out of 167 MSM assessed for PrEP eligibility, 118 (70.7%) were identified by both MoH and CDHRS eligibility criteria; 33 (19.8%) by CDHRS alone, 11 (6.6%) by MoH criteria alone, and 5 (3.0%) by neither criterion. Of the men identified by CDHRS alone, the majority (24 or 72.7%) reported receptive anal intercourse (RAI). Of the 162 MSM eligible for PrEP, 113 (69.7%) accepted PrEP at first offer. Acceptance of PrEP was higher for men reporting RAI (adjusted prevalence ratio [aPR], 1.4; 95% confidence interval [CI], 1.0-1.9), having paid for sex (aPR, 1.3; 95% CI, 1.1-1.6) and group sex (aPR, 1.4; 95% CI, 1.1-1.8), after adjustment for sociodemographic factors. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. Approximately 70% of eligible men accepted PrEP at first offer, suggesting that PrEP is acceptable among at-risk MSM. MSM reporting RAI, group sex, or paying for sex were more likely to accept PrEP. Incorporating RAI into MoH PrEP eligibility criteria would enhance the impact of PrEP programming in Kenya.
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Affiliation(s)
- Elizabeth Wahome
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Susan Graham
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Alexander Thiong'o
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Oscar Chirro
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Khamisi Mohamed
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Evans Gichuru
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - John Mwambi
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Matt Price
- International AIDS Vaccine Initiative, New York, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Eduard J Sanders
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya.,Nuffield Department of Medicine, University of Oxford, Headington, UK
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28
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Wahome E, Graham S, Thiong'o A, Chirro O, Mohamed K, Gichuru E, Mwambi J, Price M, Sanders EJ. Assessment of PrEP eligibility and uptake among at-risk MSM participating in a HIV-1 vaccine feasibility cohort in coastal Kenya. Wellcome Open Res 2020; 4:138. [PMID: 32140565 DOI: 10.12688/wellcomeopenres.15427.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2019] [Indexed: 01/22/2023] Open
Abstract
Introduction: Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. We set out to determine PrEP eligibility, uptake and predictors of PrEP uptake among MSM enrolled in an HIV-1 vaccine feasibility cohort in coastal Kenya. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Results: Out of 167 MSM assessed for PrEP eligibility, 118 (70.7%) were identified by both MoH and CDHRS eligibility criteria; 33 (19.8%) by CDHRS alone, 11 (6.6%) by MoH criteria alone, and 5 (3.0%) by neither criterion. Of the men identified by CDHRS alone, the majority (24 or 72.7%) reported receptive anal intercourse (RAI). Of the 162 MSM eligible for PrEP, 113 (69.7%) accepted PrEP at first offer. Acceptance of PrEP was higher for men reporting RAI (adjusted prevalence ratio [aPR], 1.4; 95% confidence interval [CI], 1.0-1.9), having paid for sex (aPR, 1.3; 95% CI, 1.1-1.6) and group sex (aPR, 1.4; 95% CI, 1.1-1.8), after adjustment for sociodemographic factors. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. Approximately 70% of eligible men accepted PrEP at first offer, suggesting that PrEP is acceptable among at-risk MSM. MSM reporting RAI, group sex, or paying for sex were more likely to accept PrEP. Incorporating RAI into MoH PrEP eligibility criteria would enhance the impact of PrEP programming in Kenya.
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Affiliation(s)
- Elizabeth Wahome
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Susan Graham
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Alexander Thiong'o
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Oscar Chirro
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Khamisi Mohamed
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Evans Gichuru
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - John Mwambi
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya
| | - Matt Price
- International AIDS Vaccine Initiative, New York, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Eduard J Sanders
- KEMRI/Wellcome Trust Research Programme Centre for Geographic Medicine Research- Coast, Kilifi, 80108, Kenya.,Nuffield Department of Medicine, University of Oxford, Headington, UK
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29
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Abstract
Kenya has been home to one of the most severe HIV/AIDS epidemics in Sub-Saharan Africa. This persistent epidemic requires interventions tailored to affected populations, particularly men who have sex with men (MSM). Given the resource constraints of many clinics and ecological challenges of Kenya, such as the illegality of sex among MSM, interventions to address HIV must strategically engage this population. This quasi-experimental pilot study of N = 497 sought to explore differences in discovering previously unknown HIV-positive MSM in Nairobi, Kenya. The study used four clinical sites to compare a social and sexual network index testing (SSNIT) strategy compared to traditional HIV screening. Clinics using the SSNIT strategy had significantly higher incidence rates of HIV diagnoses than control clinics (IRR = 3.98, p < 0.001). This study found that building upon the social and sexual networks of MSM may be one promising strategy while discovering critical cases of HIV.
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30
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Van Der Elst EM, Kombo B, Mugo P, Thiong’o A, Kanungi J, Wahome E, Chirro O, Graham SM, Operario D, Sanders EJ. Adjustment to acute or early HIV-1 infection diagnosis to prompt linkage to care and ART initiation: qualitative insights from coastal Kenya. PSYCHOL HEALTH MED 2019; 24:631-641. [PMID: 30468392 PMCID: PMC6425912 DOI: 10.1080/13548506.2018.1549736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 11/13/2018] [Indexed: 01/06/2023]
Abstract
Diagnosing and treating patients with acute or early HIV-1 infection (AEHI) is an important strategy to prevent HIV-1 transmission. We used qualitative methods to understand factors that facilitate adjustment to AEHI diagnosis, prompt linkage to care and initiation of antiretroviral treatment (ART). Twenty-three AEHI patients (12 women, 11 men) included 18 participants identified at health facilities, and 5 participants identified in a sex worker cohort. Of these, 17 participants (9 women, 8 men) participated in qualitative interviews about their AEHI status 2 weeks after diagnosis. Thirteen participants (7 women, 6 men) returned for a second interview 12 weeks after diagnosis. Interviews explored participants' experiences at the time of and following their diagnosis, and examined perceptions about ART initiation and behavior change recommendations, including disclosure and partner notification. A grounded theory framework was used for analysis, eliciting three important needs that should be addressed for AEHI patients: 1) the need to better understand AEHI and accept one's status; 2) the need to develop healthy strategies and adjust to the reality of AEHI status; and 3) the need to protect self and others through ART initiation, adherence, safer sex, and disclosure. A preliminary conceptual framework to guide further intervention and research with AEHI populations is proposed.
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Affiliation(s)
- EM Van Der Elst
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - B Kombo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - P Mugo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - A Thiong’o
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - J Kanungi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - E Wahome
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - O Chirro
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - SM Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - D Operario
- Department of Behaviour and Social Sciences, Brown University School of Public Health, RI, USA
| | - EJ Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Centre for Topical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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31
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Kimani M, van der Elst EM, Chiro O, Oduor C, Wahome E, Kazungu W, Shally M, Rinke de Wit TF, Graham SM, Operario D, Sanders EJ. PrEP interest and HIV-1 incidence among MSM and transgender women in coastal Kenya. J Int AIDS Soc 2019; 22:e25323. [PMID: 31194291 PMCID: PMC6563853 DOI: 10.1002/jia2.25323] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/22/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION There is emerging data on HIV-1 incidence among MSM in sub-Saharan Africa (SSA), but no known estimate of HIV-1 incidence among transgender women (TGW) in the region has yet been reported. We assessed HIV-1 incidence and pre-exposure prophylaxis (PrEP) interest in men who have sex with men exclusively (MSME), men who have sex with men and women (MSMW) and TGW in coastal Kenya. METHODS HIV-1-seronegative individuals who had participated in an HIV testing study in 2016 were traced and retested in 2017 according to Kenyan guidelines. All participants were assigned male sex at birth and had male sex partners; additional data on gender identity and sexual orientation were obtained. We assessed the factors associated with HIV-1 acquisition using Poisson regression and calculated HIV-1 incidence in MSME, MSMW and TGW. PrEP interest was assessed through focus group discussions to characterize subcategories' perceived PrEP needs. RESULTS Of the 168 cohort participants, 42 were classified as MSME, 112 as MSMW and 14 as TGW. Overall, HIV-1 incidence was 5.1 (95% confidence interval (CI): 2.6 to 9.8) per 100 person-years (PY): 4.5 (95% CI: 1.1 to 17.8] per 100 PY among MSME, 3.4 (95% CI: 1.3 to 9.1) per 100 PY among MSMW and 20.6 (95% CI: 6.6 to 63.8] per 100 PY among TGW. HIV-1 acquisition was associated with exclusive receptive anal intercourse (aIRR 13.0, 95% CI 1.9 to 88.6), history of an STI in preceding six months (aIRR 10.3, 95% CI 2.2 to 49.4) and separated/divorced marital status (aIRR 8.2 (95%: 1.1 to 62.2). Almost all (98.8%) participants were interested in initiating PrEP. MSME and TGW felt that PrEP would lead to increases in condomless anal or group sex. CONCLUSIONS TGW had a very high HIV-1 incidence compared with MSME and MSMW. Subcategories of MSM anticipated different PrEP needs and post-PrEP risk behaviour. Further studies should assess if TGW may have been wrongly categorized as MSM in other HIV-1 incidence studies in the region.
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Affiliation(s)
| | - Elise M van der Elst
- KEMRI‐Wellcome Trust Research ProgramKilifiKenya
- Amsterdam Institute for Global Health and Development (AIGHD)Department of Global HealthUniversity of AmsterdamAmsterdamthe Netherlands
| | - Oscar Chiro
- KEMRI‐Wellcome Trust Research ProgramKilifiKenya
| | | | | | | | | | - Tobias F Rinke de Wit
- Amsterdam Institute for Global Health and Development (AIGHD)Department of Global HealthUniversity of AmsterdamAmsterdamthe Netherlands
| | - Susan M Graham
- KEMRI‐Wellcome Trust Research ProgramKilifiKenya
- University of WashingtonSeattleWAUSA
| | | | - Eduard J Sanders
- KEMRI‐Wellcome Trust Research ProgramKilifiKenya
- Amsterdam Institute for Global Health and Development (AIGHD)Department of Global HealthUniversity of AmsterdamAmsterdamthe Netherlands
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Kapanda L, Jumbe V, Izugbara C, Muula AS. Healthcare providers' attitudes towards care for men who have sex with men (MSM) in Malawi. BMC Health Serv Res 2019; 19:316. [PMID: 31101107 PMCID: PMC6525370 DOI: 10.1186/s12913-019-4104-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/16/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Men who have sex with men (MSM) are a priority group in Malawi's national response to Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). There are limited data on service providers' acceptability to deliver appropriate sexual health services in relation to HIV prevention, care and treatment targeting the MSM. We assessed attitudes of healthcare providers already working, health professions students and faculty at health professions training institutions regarding the provision of MSM focused HIV related health services. METHODS We conducted a qualitative study between April and May 2017 in Lilongwe, Malawi. We purposively recruited 15 participants (5 health service providers, 5 health professions students and 5 faculty of tertiary health training institutions) among whom individual in-depth interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically. RESULTS Participants recognized MSM as having health needs and rights. Participants generally expressed willingness to deliver appropriate healthcare because they perceived this as their professional responsibility. Participants suggested that it was the responsibility for MSM to disclose their sexual orientation and or preferences when they access care such that healthcare providers better anticipate their care needs. They suggested a need to increase the availability of MSM-centered and friendly health services as well as trained providers that are non-judgmental, non-discriminatory and have respect for people's right to health care access. CONCLUSION Despite widespread poor attitudes against MSM in Malawi, health service providers and health professions students and faculty accepted and were willing to provide MSM-focused health services. The acceptability and willingness of health service providers, health professions students and faculty to provide health services to MSM offer hope and scope for efforts to strengthen the delivery of health services and quality of care to MSM in Malawi.
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Affiliation(s)
- Lester Kapanda
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine - University of Malawi, Blantyre, Malawi
| | - Vincent Jumbe
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine - University of Malawi, Blantyre, Malawi
- Africa Centre of Excellence in Public Health and Herbal Medicine (ACEPHEM) – College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Mathematical Sciences, Chancellor College, University of Malawi, Zomba, Malawi
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Duby Z, Fong-Jaen F, Nkosi B, Brown B, Scheibe A. 'We must treat them like all the other people': Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa. South Afr J HIV Med 2019; 20:909. [PMID: 31205777 PMCID: PMC6556945 DOI: 10.4102/sajhivmed.v20i1.909] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/20/2019] [Indexed: 12/27/2022] Open
Abstract
Background Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The ‘Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa’ aimed to improve access to appropriate and non-judgemental health services for ‘key populations’, specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers. Objectives The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa. Methods This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex. Results The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes. Conclusion The findings suggest that sensitisation training increases healthcare workers’ knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services.
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Affiliation(s)
- Zoe Duby
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Francisco Fong-Jaen
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Busisiwe Nkosi
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin Brown
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Scheibe
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Matovu JKB, Musinguzi G, Kiguli J, Nuwaha F, Mujisha G, Musinguzi J, Arinaitwe J, Wanyenze RK. Health providers' experiences, perceptions and readiness to provide HIV services to men who have sex with men and female sex workers in Uganda - a qualitative study. BMC Infect Dis 2019; 19:214. [PMID: 30832612 PMCID: PMC6400025 DOI: 10.1186/s12879-019-3713-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Access to HIV services among men who have sex with men (MSM) and female sex workers (FSWs) remains suboptimal globally. While the reasons for this dismal performance have been documented, limited evidence exists on the experiences, perceptions and readiness of health providers to provide HIV services to MSM and FSWs. Methods This analysis uses data collected from 48 key informants (health providers in public and private health facilities) as part of a larger study conducted in 12 districts of Uganda between October and December 2013. Data were collected on health providers’ experiences and readiness to provide HIV services to MSM and FSWs and their perceptions on the effect of existing legislation on HIV services provision to MSM and FSWs. Data were captured verbatim, transcribed and analyzed following a thematic framework approach. Results All health providers reported that they had ever provided HIV services to FSWs and a majority of them were comfortable serving them. However, no health provider had ever served MSM. When asked if they would be willing to serve MSM, nearly three-quarters of the health providers indicated that they would be bound by the call of duty to serve them. However, some health providers reported that they “would feel very uncomfortable” handling MSM because they engage in “a culture imported into our country”. A majority of the health providers felt that they did not have adequate skills to effectively serve MSM and called for specific training to improve their clinical skills. There were mixed reactions as to whether existing criminal laws would affect MSM or FSWs access to HIV services but there was agreement that access to HIV services, under the existing laws, would be more constrained for MSM than FSWs since society “does not blame FSWs [as much as it does] with MSM”. Conclusion A majority of the health providers were generally comfortable serving FSWs but there were strong homophobic tendencies towards MSM. A majority of the health providers lacked skills in how to handle MSM. Interventions aimed at improving health providers’ skills in handling MSM while minimizing the negative attitude towards them are urgently needed. Electronic supplementary material The online version of this article (10.1186/s12879-019-3713-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph K B Matovu
- Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda.
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Juliet Kiguli
- Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Fred Nuwaha
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | | | - Jim Arinaitwe
- AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Shangani S, Naanyu V, Operario D, Genberg B. Stigma and Healthcare-Seeking Practices of Men Who Have Sex with Men in Western Kenya: A Mixed-Methods Approach for Scale Validation. AIDS Patient Care STDS 2018; 32:477-486. [PMID: 30398953 DOI: 10.1089/apc.2018.0101] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In sub-Saharan Africa, men who have sex with men (MSM) experience high HIV prevalence, in part, due to stigma and discrimination creating barriers to engagement in prevention and care services. We examined the reliability and validity of measures of stigma and satisfaction with healthcare providers, as well as explored whether scores on the factors varied across sociodemographic variables among MSM in western Kenya. A mixed-methods design using a sequential triangulation approach was adopted, involving a survey of 89 MSM and 10 key informant interviews. Reliability and correlation analyses, exploratory factor analyses, t-tests, and ANOVAs (analyses of variances) were conducted to test the scale's psychometric properties and examine differences in mean scores by demographics. Thematic analysis with qualitative data was used to validate the meaning of scales and explore how stigma influences and relates to satisfaction with healthcare providers. Of 89 participants, 50% identified as homosexual, 52% had college degree, 45% were above 25 years, and 72% had ever been married. Three subscales measuring enacted stigma, internalized stigma, and mistrust of healthcare providers showed good reliability (α = 0.80, α = 0.90, and α = 0.90). Men who identified as homosexual reported higher mean scores of enacted stigma and distrust of healthcare providers compared to heterosexual/bisexual identified (p < 0.001). Qualitative data revealed perceptions that healthcare providers were not knowledgeable to handle MSM needs. Study provides preliminary evidence for the reliability and validity of measures of stigma and mistrust of healthcare providers in Kenya. Quantitative and qualitative findings highlight the need for interventions to reduce stigma and create a more inclusive health system.
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Affiliation(s)
- Sylvia Shangani
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Violet Naanyu
- Department of Behavioral Social Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Becky Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, Rhode Island
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Wahome E, Thiong’o AN, Mwashigadi G, Chirro O, Mohamed K, Gichuru E, Mwambi J, Price MA, Graham SM, Sanders EJ. An Empiric Risk Score to Guide PrEP Targeting Among MSM in Coastal Kenya. AIDS Behav 2018; 22:35-44. [PMID: 29767324 DOI: 10.1007/s10461-018-2141-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Men who have sex with men (MSM), who have heterogeneous HIV-acquisition risks are not specifically targeted in Kenyan pre-exposure prophylaxis (PrEP) guidelines. We used data from an open cohort, which followed 753 initially HIV-negative MSM participants for more than 1378.5 person-years, to develop an empiric risk score for targeting PrEP delivery. Independent predictors of incident HIV-1 infection in this cohort were an age of 18-24 years, having only male sex partners, having receptive anal intercourse, having any unprotected sex, and having group sex. Poisson model coefficients were used to assign a numeric score to each statistically significant predictor. A risk score of ≥ 1 corresponded to an HIV-1 incidence of ≥ 2.2 [95% confidence interval (CI) 1.2-4.1] and identified 81.3% of the cohort participants as being at high risk for HIV-1 acquisition. The area under the receiver operating characteristic curve was 0.76 (95% CI 0.71-0.80). This empiric risk score may help Kenyan health care providers to assess HIV-1 acquisition risk and encourage PrEP uptake by high-risk MSM.
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Gichuru E, Kombo B, Mumba N, Sariola S, Sanders EJ, van der Elst EM. Engaging religious leaders to support HIV prevention and care for gays, bisexual men, and other men who have sex with men in coastal Kenya. CRITICAL PUBLIC HEALTH 2018; 28:294-305. [PMID: 29770367 PMCID: PMC5935049 DOI: 10.1080/09581596.2018.1447647] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 02/28/2018] [Indexed: 01/18/2023]
Abstract
In Kenyan communities, religious leaders are important gatekeepers in matters of health and public morality. In a context that is generally homophobic, religious leaders may aggravate or reduce stigmatization of sexual minorities such as gay and bisexual men, and other men who have sex with men (GBMSM). Literature indicates mixed results in efforts to encourage religious leaders to work effectively and sensitively with issues regarding HIV and sexuality. This paper describes the implementation of an engagement intervention with religious leaders from different denominations, which took place following a homophobic hate attack that was led by local religious leaders, at an HIV research clinic for GBMSM on the Kenyan coast. After the homophobic attack, tailored engagement activities, including a comprehensive four-day online sensitivity training course took place between June 2015 and October 2016 in the Kenyan coast. HIV researchers, together with trained GBMSM activists, organized the series of engagement activities for religious leaders which unfolded iteratively, with each subsequent activity informed by the results of the previous one. Facilitated conversations were used to explore differences and disagreements in relation to questions of scripture, mission, HIV, and human sexuality. As a result, researchers noted that many religious leaders, who initially expressed exceedingly negative attitudes towards GBMSM, started to express far more accepting and supportive views of sexuality, sexual identities, and same-sex relations. This paper describes the changes in religious leaders’ discourses relating to GBMSM, and highlights the possibility of using engagement interventions to build trust between research institutes, religious leaders, and GBMSM.
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Affiliation(s)
- Evans Gichuru
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bernadette Kombo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Noni Mumba
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Salla Sariola
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.,University of Turku, Turku, Finland
| | - Eduard J Sanders
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elise M van der Elst
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Duby Z, Nkosi B, Scheibe A, Brown B, Bekker LG. 'Scared of going to the clinic': Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities. South Afr J HIV Med 2018; 19:701. [PMID: 29568645 PMCID: PMC5843994 DOI: 10.4102/sajhivmed.v19i1.701] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/30/2017] [Indexed: 11/24/2022] Open
Abstract
Background Men who have sex with men (MSM), sex workers (SW) and people who use drugs (PWUD) are at increased risk for HIV because of multiple socio-structural barriers and do not have adequate access to appropriate HIV prevention, diagnosis and treatment services. Objective To examine the context of access to healthcare experienced by these three ‘Key Populations’, we conducted a qualitative study in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province. Method We carried out in-depth interviews to explore healthcare workers’ perceptions, beliefs and attitudes towards Key Populations. Focus group discussions were also conducted with members of Key Populations exploring their experiences of accessing healthcare. Results Healthcare workers described their own attitudes towards Key Populations and demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing Key Populations. Female SW, MSM and PWUD described their experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. Our findings suggest that the uptake and effectiveness of health services amongst Key Populations in South Africa is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers. Conclusion This research highlights the need to address the broader healthcare provision environment, improving alignment of policies and programming in order to strengthen provision of effective health services that people from Key Populations will be able to access.
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Affiliation(s)
- Zoe Duby
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, South Africa
| | - Busisiwe Nkosi
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, South Africa
| | - Andrew Scheibe
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, South Africa
| | - Ben Brown
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Department of Medicine, University of Cape Town, South Africa
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Sekoni AO, Gale NK, Manga-Atangana B, Bhadhuri A, Jolly K. The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: a mixed-method systematic review. J Int AIDS Soc 2017; 20:21624. [PMID: 28782330 PMCID: PMC5577719 DOI: 10.7448/ias.20.1.21624] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 07/03/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Poor access of lesbian, gay, bisexual and transgender (LGBT) people to healthcare providers with clinical and cultural competency contributes to health inequalities between heterosexual/cisgender and LGBT people. This systematic review assesses the effect of educational curricula and training for healthcare students and professionals on LGBT healthcare issues. METHODS Systematic review; the search terms, strategy and process as well as eligibility criteria were predefined and registered prospectively on PROSPERO. A systematic search of electronic databases was undertaken. Screening for eligible studies and data extraction were done in duplicate. All the eligible studies were assessed for risk of bias. The outcome of interest was a change in participants' knowledge, attitude and or practice. RESULTS Out of 1171 papers identified, 16 publications reporting 15 studies were included in the review. Three were non-randomized controlled studies and 12 had a pre/post-design; two had qualitative components. Bias was reported in the selection of participants and confounding. Risk reported was moderate/mild. Most studies were from the USA, the topics revolved around key terms and terminology, stigma and discrimination, sexuality and sexual dysfunction, sexual history taking, LGBT-specific health and health disparities. Time allotted for training ranged from 1 to 42 hours, the involvement of LGBT people was minimal. The only intervention in sub-Saharan Africa focused exclusively on men who have sex with men. All the studies reported statistically significant improvement in knowledge, attitude and/or practice post-training. Two main themes were identified from the qualitative studies: the process of changing values and attitudes to be more LGBT inclusive, and the constraints to the application of new values in practice. Conclusions Training of healthcare providers will provide information and improve skills of healthcare providers which may lead to improved quality of healthcare for LGBT people. This review reports short-term improvement in knowledge, attitudes and practice of healthcare students and professionals with regards to sexual and LGBT-specific healthcare. However, a unified conceptual model for training in-terms of duration, content and training methodology was lacking.
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Affiliation(s)
- Adekemi Oluwayemisi Sekoni
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nicola K. Gale
- Health services management Centre, University of Birmingham, Birmingham, UK
| | | | - Arjun Bhadhuri
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Wu S, Roychowdhury I, Khan M. Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed. Trop Med Health 2017; 45:16. [PMID: 28680324 PMCID: PMC5493875 DOI: 10.1186/s41182-017-0056-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address. METHODS We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model. FINDINGS Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed. CONCLUSIONS Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.
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Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Imara Roychowdhury
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Mishal Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
- Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT United Kingdom
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'The Devil has entered you': A qualitative study of Men Who Have Sex With Men (MSM) and the stigma and discrimination they experience from healthcare professionals and the general community in Bosnia and Herzegovina. PLoS One 2017; 12:e0179101. [PMID: 28591214 PMCID: PMC5462409 DOI: 10.1371/journal.pone.0179101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Men who have sex with men (MSM) are often exposed to unequal treatment in societies worldwide as well as to various forms of stigma and discrimination in healthcare services. Bosnia and Herzegovina (B&H) is a postconflict developing country located in Southeast Europe and the Western Balkans, where little is known about the experiences of MSM regarding their communities and interactions with healthcare services. The aim of this study was to explore the types of experiences MSM face and to assess the level of stigma and discrimination they are exposed to in this setting. We conducted twelve in-depth face-to-face interviews with MSM who were 16 to 45 years old and residing in B&H. The main findings indicated that they all experienced various levels of stigma, discrimination, prejudice and inequities in treatment and attitudes from different segments of society, including the health care sector, that prevented them from fully developing their human and health potential. Additionally, these experiences were adversely related to opportunities to receive good quality health care services due to the insufficiently educated and old-fashioned health professionals who sometimes believed in black magic practices. The findings present numerous opportunities for educational trainings and structural reform to create a society that provides and guarantees equal opportunities for all.
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Graham SM, Harper GW. Improving HIV prevention and care for African GBMSM. Lancet HIV 2017; 4:e234-e236. [PMID: 28256421 DOI: 10.1016/s2352-3018(17)30020-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
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Sharma M, Barnabas RV, Celum C. Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa. PLoS Med 2017; 14:e1002262. [PMID: 28399122 PMCID: PMC5388461 DOI: 10.1371/journal.pmed.1002262] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.
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Affiliation(s)
- Monisha Sharma
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
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44
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Nyblade L, Reddy A, Mbote D, Kraemer J, Stockton M, Kemunto C, Krotki K, Morla J, Njuguna S, Dutta A, Barker C. The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya. AIDS Care 2017; 29:1364-1372. [PMID: 28325068 DOI: 10.1080/09540121.2017.1307922] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.
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Affiliation(s)
- Laura Nyblade
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | - Aditi Reddy
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | | | - John Kraemer
- a Global Health Division, International Development Group , RTI International , Washington , USA.,c Department of Health Systems Administration , Georgetown University , Washington , USA
| | - Melissa Stockton
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | | | - Karol Krotki
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | - Javier Morla
- a Global Health Division, International Development Group , RTI International , Washington , USA
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45
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Micheni M, Kombo BK, Secor A, Simoni JM, Operario D, van der Elst EM, Mugo P, Kanungi J, Sanders EJ, Graham SM. Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya. AIDS Patient Care STDS 2017; 31:113-121. [PMID: 28282249 PMCID: PMC5359680 DOI: 10.1089/apc.2016.0213] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary.
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Affiliation(s)
- Murugi Micheni
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Bernadette K. Kombo
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | | | - Jane M. Simoni
- Department of Psychology and Global Health, University of Washington, Seattle, Washington
| | - Don Operario
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Elise M. van der Elst
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Peter Mugo
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Jennifer Kanungi
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Eduard J. Sanders
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Susan M. Graham
- Centre for Geographic Medicine and Research, Coast, Kenya Medical Research Institute, Kilifi, Kenya
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, Washington
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46
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Shangani S, Naanyu V, Mwangi A, Vermandere H, Mereish E, Obala A, Broeck DV, Sidle J, Operario D. Factors associated with HIV testing among men who have sex with men in Western Kenya: a cross-sectional study. Int J STD AIDS 2017; 28:179-187. [PMID: 26970651 PMCID: PMC5570462 DOI: 10.1177/0956462416638967] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
HIV diagnosis is an important step in the HIV cascade of prevention and treatment. However, men who have sex with men in low- and middle-income countries have limited access to HIV care services. We examined factors associated with prior HIV testing among men who have sex with men in western Kenya. We recruited 95 men who have sex with men aged 18 years and older, and who reported at least one sexual contact with a man in the past 6 months; however, this analysis is restricted to 89 participants who completed questions on HIV testing. Logistic regression model was used to determine factors associated with HIV testing in the past one year. Results indicate that 23 (26%) had not been tested in the past 12 months. Bivariate analyses demonstrated that condomless anal sex (odds ratio = 3.29, 95% confidence interval = 1.18-9.17) and comfort with healthcare providers (odds ratio = 1.15, 95 % CI = 1.05-1.26) were associated with higher odds of HIV testing in the past 12 months. Experiencing social stigma was associated with lower odds of HIV testing in the last 12 months (odds ratio = 0.91, 95% confidence interval = 0.84-0.94). In multivariable models, social stigma remained significantly associated with lower odds of HIV testing in the last 12 months odds ratio = 0.90, 95% confidence interval = 0.82-0.99) after inclusion of sexual risk and individual level variables. Development of men who have sex with men-sensitive HIV-testing services, addressing stigma, and training healthcare workers to provide culturally sensitive services may assist in effectively engaging men who have sex with men in the HIV treatment cascade.
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Affiliation(s)
- Sylvia Shangani
- Department of Behavioral Social Sciences, School of Public Health, Brown University, Rhoide Island, United States
- School of Public Health, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Violet Naanyu
- Department of Behavioral Science, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ann Mwangi
- Department of Behavioral Science, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Heleen Vermandere
- International Centre for Reproductive Health, University of Ghent, Belgium
| | - Ethan Mereish
- Department of Behavioral Social Sciences, School of Public Health, Brown University, Rhoide Island, United States
| | - Andrew Obala
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Davy Vanden Broeck
- International Centre for Reproductive Health, University of Ghent, Belgium
| | - John Sidle
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, United States
| | - Don Operario
- Department of Behavioral Social Sciences, School of Public Health, Brown University, Rhoide Island, United States
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Brown CA, Grosso AL, Adams D, Sithole B, Ketende S, Greene J, Maziya S, Mnisi Z, Mabuza X, Baral S. Characterizing the Individual, Social, and Structural Determinants of Condom Use Among Men Who Have Sex with Men in Swaziland. AIDS Res Hum Retroviruses 2016; 32:539-46. [PMID: 26651122 DOI: 10.1089/aid.2015.0240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression analyses were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner, respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence of informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.
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Affiliation(s)
| | | | | | | | - Sosthenes Ketende
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | | | | | - Stefan Baral
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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48
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Molyneux S, Sariola S, Allman D, Dijkstra M, Gichuru E, Graham S, Kamuya D, Gakii G, Kayemba B, Kombo B, Maleche A, Mbwambo J, Marsh V, Micheni M, Mumba N, Parker M, Shio J, Yah C, van der Elst E, Sanders E. Public/community engagement in health research with men who have sex with men in sub-Saharan Africa: challenges and opportunities. Health Res Policy Syst 2016; 14:40. [PMID: 27234212 PMCID: PMC4884401 DOI: 10.1186/s12961-016-0106-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 04/19/2016] [Indexed: 11/23/2022] Open
Abstract
Background Community engagement, incorporating elements of the broader concepts of public and stakeholder engagement, is increasingly promoted globally, including for health research conducted in developing countries. In sub-Saharan Africa, community engagement needs and challenges are arguably intensified for studies involving gay, bisexual and other men who have sex with men, where male same-sex sexual interactions are often highly stigmatised and even illegal. This paper contextualises, describes and interprets the discussions and outcomes of an international meeting held at the Kenya Medical Research Institute-Wellcome Trust in Kilifi, Kenya, in November 2013, to critically examine the experiences with community engagement for studies involving men who have sex with men. Discussion We discuss the ethically charged nature of the language used for men who have sex with men, and of working with ‘representatives’ of these communities, as well as the complementarity and tensions between a broadly public health approach to community engagement, and a more rights based approach. We highlight the importance of researchers carefully considering which communities to engage with, and the goals, activities, and indicators of success and potential challenges for each. We suggest that, given the unintended harms that can emerge from community engagement (including through labelling, breaches in confidentiality, increased visibility and stigma, and threats to safety), representatives of same-sex populations should be consulted from the earliest possible stage, and that engagement activities should be continuously revised in response to unfolding realities. Engagement should also include less vocal and visible men who have sex with men, and members of other communities with influence on the research, and on research participants and their families and friends. Broader ethics support, advice and research into studies involving men who have sex with men is needed to ensure that ethical challenges – including but not limited to those related to community engagement – are identified and addressed. Summary Underlying challenges and dilemmas linked to stigma and discrimination of men who have sex with men in Africa raise special responsibilities for researchers. Community engagement is an important way of identifying responses to these challenges and responsibilities but itself presents important ethical challenges.
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Affiliation(s)
- Sassy Molyneux
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya. .,The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK. .,The Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Salla Sariola
- The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK.,Faculty of Social Sciences, University of Torku, Torku, Finland
| | - Dan Allman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Maartje Dijkstra
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Evans Gichuru
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Susan Graham
- Kenya Research Group, University of Washington, Seattle, USA
| | - Dorcas Kamuya
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya.,The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK
| | - Gloria Gakii
- University of Nairobi, Nairobi, Kenya.,University of Manitoba, Manitoba, USA
| | | | - Bernadette Kombo
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Allan Maleche
- KELIN - Reclaiming rights, Rebuilding Live, Nairobi, Kenya
| | - Jessie Mbwambo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Vicki Marsh
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya.,The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK.,The Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Murugi Micheni
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Noni Mumba
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Michael Parker
- The Ethox Centre, Department of Public Health, University of Oxford, Oxford, UK
| | - Jasmine Shio
- Department of Project Management, Deloitte Consulting Ltd, Dar es Salaam, Tanzania
| | - Clarence Yah
- Wits Reproductive Health & HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elise van der Elst
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya.,Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Eduard Sanders
- Department of Health Systems and Research Ethics, KEMRI/Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya.,Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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49
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Wanyenze RK, Musinguzi G, Matovu JKB, Kiguli J, Nuwaha F, Mujisha G, Musinguzi J, Arinaitwe J, Wagner GJ. "If You Tell People That You Had Sex with a Fellow Man, It Is Hard to Be Helped and Treated": Barriers and Opportunities for Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda. PLoS One 2016; 11:e0147714. [PMID: 26808653 PMCID: PMC4726486 DOI: 10.1371/journal.pone.0147714] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the high HIV prevalence among men who have sex with men (MSM) in sub-Saharan Africa, little is known about their access to HIV services. This study assessed barriers and opportunities for expanding access to HIV services among MSM in Uganda. METHODS In October-December 2013, a cross-sectional qualitative study was conducted in 12 districts of Uganda. Semi-structured in-depth interviews were conducted with 85 self-identified MSM by snowball sampling and 61 key informants including HIV service providers and policy makers. Data were analysed using manifest content analysis and Atlas.ti software. RESULTS Three quarters of the MSM (n = 62, 72.9%) were not comfortable disclosing their sexual orientation to providers and 69 (81.1%) felt providers did not respect MSM. Half (n = 44, 51.8%) experienced difficulties in accessing health services. Nine major barriers to access were identified, including: (i) unwelcoming provider behaviours; (ii) limited provider skills and knowledge; (iii) negative community perceptions towards MSM; (iv) fear of being exposed as MSM; (v) limited access to MSM-specific services; (vi) high mobility of MSM, (vii) lack of guidelines on MSM health services; viii) a harsh legal environment; and ix) HIV related stigma. Two-thirds (n = 56, 66%) participated in MSM social networks and 86% of these (48) received support from the networks to overcome barriers to accessing services. CONCLUSIONS Negative perceptions among providers and the community present barriers to service access among MSM. Guidelines, provider skills building and use of social networks for mobilization and service delivery could expand access to HIV services among MSM in Uganda.
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Affiliation(s)
- Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Joseph K. B. Matovu
- Department of Community Health, Makerere University School of Public Health, Kampala, Uganda
| | - Juliet Kiguli
- Department of Community Health, Makerere University School of Public Health, Kampala, Uganda
| | - Fred Nuwaha
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | - Glenn J. Wagner
- RAND Corporation, Santa Monica, CA, United States of America
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50
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Jobson G, Struthers H, McIntyre J. "In the fell clutch of circumstance": HIV and men who have sex with men in sub-Saharan Africa. Curr HIV/AIDS Rep 2016; 12:164-72. [PMID: 25637162 DOI: 10.1007/s11904-014-0249-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Men who have sex with men (MSM) in sub-Saharan Africa (SSA) have been repeatedly found to have high risk of HIV infection, and in spite of the differing nature of the HIV epidemic in the general population between East and Southern Africa, and West and Central Africa, MSM are disproportionately affected by HIV across the entire region. Recent research has examined the drivers of HIV risk, and the dynamics of the MSM HIV epidemic in greater detail. However, this growing knowledge has generally not been translated into effective HIV prevention interventions. In part, this is due to the highly stigmatised and frequently criminalised nature of same-sex sexualities in much of the region. Without human-rights-based advocacy targeting governments and interventions aiming to decrease stigma and homophobia, translating research into effective HIV interventions for MSM in SSA at the scale needed to reduce HIV transmission in this population remains highly unlikely.
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