AIDS 2016: How Can Clinical Services Engage Men

Who Have Sex With Men in Africa?

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

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

Mainstream health facilities are often perceived by men who have sex with men as being unwelcoming,
judgmental, and unable to deal with their specific needs. As a result, infections remain untreated and
transmissions continue to occur.

The conference did, however, hear of some examples of good practice, in particular the services provided by
the Health4Men program of the Anova Health Institute in South Africa. Health4Men has been able to engage and
retain MSM at its services in Cape Town and Johannesburg; it also provides training and mentoring to healthcare
providers across South Africa.

Kevin Rebe of Anova said that given the low expectations that many MSM have of health services, providers
need to make particular efforts to build trust and engagement. They should make all patients feel welcome,
ensure the confidentiality of discussions between patients and clinicians, and be attentive to the ways in which
individuals define themselves (including the gender pronouns used by transgender individuals).

Rebe stressed that MSM in South Africa do not form a homogenous group. They may share a range of common
behaviors, but these are often clandestine and denied, and the men do not share a social identity. Most "men
who have sex with men" also have sex with women.

It would therefore be unhelpful to have made a "gay identified" clinic space. In fact, as services are branded as
Health4Men, they attract men with a range of needs and behaviors. This diversity in the waiting area avoids
inadvertent disclosure both for MSM and for HIV-positive men, who make up around half of the clinic attendees.

Health4Men has taken a "sex positive" approach -- sexual issues are discussed in a way that encourages
normality and dignity. This facilitates open discussion and counter-balances the way in which much sexual
behavior is treated as abnormal in the wider society.

Clinic staff have received extensive training to help them engage and communicate with a diverse range of
MSM. But awareness and sensitivity are not in themselves enough, Rebe stressed. Staff also need to have
clinical competencies for a clinic to attract and retain MSM in care.

Staff need to be able to take a full sexual history. They should ask all male patients about both female and male
partners and ask very specific questions about sexual behaviors. Developing these skills can be challenging. "It’s
hard for us to get some of our nurses to ask, 'Do you have sex with men, women, or both?' or 'Can I do an anal
exam because you may have been exposed to an STI?'," Rebe said.

Anal examinations were crucial, he said. Without them, problems are likely to go undiagnosed or misdiagnosed.
He stressed that treatment for anal warts -- the most common sexually transmitted infection (STI) he sees -- and
bacterial STIs are actually quite simple to provide once a diagnosis has been made.
Men are most likely to attend a clinic when troubled by symptoms of an STI. These visits should be seen as an
opportunity to build a relationship and to provide other services. In particular, providers should screen for HIV,
substance use, and mental health issues.

More specialized support can be provided based on these assessments. The clinics have identified a need for
harm reduction services for men using recreational drugs and also a number of cases of hepatitis C. Substance
use, depression, and anxiety often appear to be linked to issues of stigma, heteronormativity, and self-esteem.

The clinics also promote evidence-based prevention methods, using informational materials that relate to sex
between men. These include condoms and lubricant, post-exposure prophylaxis (PEP), pre-exposure prophylaxis
(PrEP), and prompt antiretroviral treatment for HIV-positive men. Nonetheless, significant barriers to access for
many of these interventions remain.

In providing HIV treatment to MSM, Rebe said it was helpful for providers to be aware of some specific issues.
Adherence and engagement with care may be affected by men’s experience of social stigma, mental health
issues, or substance use. Providers need to be aware of potential interactions of antiretrovirals with recreational
drugs and anabolic steroids. Antiretrovirals such as lopinavir/ritonavir (Kaletra) can cause diarrhea and flatulence,
potentially resulting in sexual dysfunction for some men.

In addition to the direct services provided by Health4Men, the program has also trained over 2000 staff working in
the public health system. Both administrative and clinical staff receive training on diversity and cultural sensitivity,
with additional modules on clinical skills only provided to relevant staff. An ongoing mentoring program helps
develop and maintain skills. This has allowed many more sites to meet the needs of men who have sex with men.

9/20/16

References

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

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