I work as a senior programme officer for the Networking HIV, AIDS and TB Network of South Africa (NACOSA). NACOSA is a non-profit organisation seeking to reduce the impact of HIV, AIDS and TB through building capacity, networking and strengthening the multi-sectoral response to HIV, AIDS and TB in Southern Africa. I work mostly in the training unit which forms part of our capacity building programme. Our training topics vary from organisational development themes such as Financial Management, Successful Planning and Governance to more programme specific topics such as Strengthening Orphan and Vulnerable Child Support and Sensitising Front-line Health Workers on working with Men who have Sex with Men.
Whilst HIV infection amongst Men who Have Sex with Men (MSM) was a focus in the early days of the epidemic in South Africa, there is little currently known about the HIV epidemic amongst MSM in the country. Although MSM has been identified as a vulnerable group they have not been considered to any great extent in national HIV and AIDS interventions.
The NSP of South Africa (HIV and AIDS and STI National Strategic Plan 2007-2011) highlights the following guiding principle: “Ensuring Equality and Non-discrimination against marginalized group.” All these groups, including MSM, have a right to equal access to interventions for HIV prevention, treatment and support. The Top to Bottom Prevention, Treatment and Care MSM Symposium really highlighted the many barriers MSM face when accessing health care. The following could be viewed as some:
•A lack of understanding, prejudice and judgement by health providers and among MSM themselves
•A perception that health services cater mostly for heterosexual people
The Importance of a Welcoming Environment
The need to create more welcoming and sensitive services to Gay-identified or other men who engage in sex with men is critical to the overall response to HIV prevention in the Western Cape Province and South Africa as a whole. It is a focus of concern due to the infection rates that may be attributed to same sex among men and the impact this can also have on women who may also be partners of some of these men. It is also a concern due to the fact the men who have sex with both men and women may also be transmitting HIV to gay-identified men. A health care worker may not be knowledgeable or be comfortable in asking or responding to the sexual health needs of men who have sex with men. This can create challenges in giving education, supporting behaviour and motivating men to continue seeking services.
PEPFAR in its Technical Guidance on Combination HIV prevention for MSM defines the core elements of a comprehensive package of HIV-prevention services for MSM and their partners to be:
•Distribution of condoms and condom-compatible lubricants;
•HIV counselling and testing;
•Active linkage to health care and antiretroviral treatment (ART);
•Targeted information, education and communication (IEC); and
•Sexually transmitted infection (STI) prevention, screening and treatment.
The sensitizing of Health Workers is key in the proposed package of preventive measures. Asking the correct questions to assess risk through the HIV counselling and testing process and providing the correct information is crucial.
A Look at MSM Couples Testing
Rob Stephenson an Assistant Professor of Global Health in the Rollins School of Public Health, Emory University, Atlanta, USA, provided valuable insight in the benefit of MSM couples testing together through Couples Voluntary Counselling and Testing (CVCT). I personally liked the different perspective of this type of counselling as a more forward looking approach than a possibly more retrospective view on sexual history in a normal VCT setting. To elaborate on this further, couples receive pre and post-test counselling as well as test results together and this allows them to adopt a prevention plan.
In the study done by Rob, many MSM felt that CVCT would strengthen a relationship and would lead to stronger communication between partners. It could also provide a way to understand how to deal with HIV in a relationship and provides a forum for the disclosure of sero-status, development of protection plans, and future planning behaviors. The study also concluded that CVCT may also provide a mechanism for validating male same sex relationships:
•Internally by promoting communication, responsibility and trust
•Externally by promoting the male couple as a unit of intervention
When there is a non-stigmatised testing site there is higher HIV Counselling and Testing (HCT) uptake. This would of course be true for CVCT too. Apart from the CVCT approach that was unique to me I also felt that there is still a lot that we can do in terms of the use of technology in prevention messages for MSM.
Using Technology to Reach MSM
Dr Patrick Sullivan from Emory University in his session on Using technology in working with MSM highlighted the benefits technology can have when used in prevention programmes for hard to reach individuals. Where MSM are so highly stigmatised, more MSM can be reached because of the scalability and low cost of, for example, cell phone messaging and/or the internet. Both the Internet and cell phones are integrated with the men’s lives; they are acceptable and meet men where they are and where they are taking risks. Information can be provided and men can ask information and receive it instantly. Interactive data collection and internet based surveys are also made possible. This could be used in online interventions. In his summary Dr Patrick Sullivan said that new technologies are a way to:
•Distribute good content
•Improve data collections efficiency
•Reach (potentially younger) users
MSM first need to feel comfortable and safe enough to access health care for any prevention programme or intervention whether biomedical or behavioural to be successful. In order to reach this often hard to reach population, non-judgemental MSM-friendly health facilities and staff must be in place.
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