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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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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: 1.5] [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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Criminalization of Sexual and Gender Minorities and Its Consequences for the HIV Epidemic in Zambia: A Critical Review and Recommendations. J Assoc Nurses AIDS Care 2021; 32:423-441. [PMID: 34115722 DOI: 10.1097/jnc.0000000000000281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT To elaborate the negative impacts of sexual and gender minority (SGM)-related legislation for the HIV epidemic in Zambia, we reviewed Zambian legislation that restricts the rights of SGM people and synthesized its consequences. We retrieved legal documents through the National Assembly of Zambia and the Zambia Legal Information Institute and conducted a critical review based on four academic databases following thematic synthesis methodology. Eighteen literature records and six Zambian laws were included in the review. Existing laws criminalize same-sex sexual behavior and restrict same-sex marriage and the adoption of children. Anti-SGM legislation has limited legal protections for SGM people and increased vulnerability of criminal prosecution and HIV exposure, persistent stigma/discrimination, insufficient public health resources, and lessened access to HIV-related services. We recommend enacting legal protections for SGM people, decriminalizing anti-SGM laws, rectifying misinformation to destigmatize SGM people, targeting health care for SGM people, and including SGM people in the national HIV strategy.
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Daniels J, Struthers H, Soler J, Ricco E, Blackmon J, Teklehaimanot S, McIntyre J, Coates T. Building self-advocacy in HIV care: the use of role-play to examine healthcare access for HIV-positive MSM in rural South Africa. Glob Health Promot 2020; 28:32-40. [PMID: 33300432 DOI: 10.1177/1757975920974008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is high HIV prevalence and low rates of viral suppression for men who have sex with men (MSM) in South Africa, with few MSM-centered interventions to address these outcomes along the HIV treatment cascade. Participatory interventions may support community building among HIV-positive MSM through which they can share approaches of self-advocacy that are contextually grounded. We conducted a pilot study to assess the use of role-plays in influencing social isolation while also updating our understanding of MSM healthcare experiences in Mpumalanga, South Africa. The study was conducted with 21 MSM leaders who were HIV-positive. There were three groups of seven participants each who created and performed role-plays based on their healthcare experiences, with a focus group discussion (FGD) conducted afterward. Audio-recordings were transcribed, translated, and analyzed using a constant comparison approach. We found that MSM described role-play as cathartic and a future HIV care educational tool for other MSM, and that they outlined points of self-advocacy during HIV care in clinics. Our study suggests that future research should utilize role-play so to integrate contextual factors influencing HIV treatment, especially in high HIV prevalence settings.
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Affiliation(s)
- Joseph Daniels
- Department of Psychiatry and Human Behaviors, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Helen Struthers
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joshua Soler
- Department of Psychiatry and Human Behaviors, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Emilio Ricco
- Department of Psychiatry and Human Behaviors, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Joshaun Blackmon
- Department of Psychiatry and Human Behaviors, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - Senait Teklehaimanot
- Department of Psychiatry and Human Behaviors, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
| | - James McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thomas Coates
- Center for World Health, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
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Macharia GN, Yue L, Staller E, Dilernia D, Wilkins D, Song H, McGowan E, King D, Fast P, Imami N, Price MA, Sanders EJ, Hunter E, Gilmour J. Infection with multiple HIV-1 founder variants is associated with lower viral replicative capacity, faster CD4+ T cell decline and increased immune activation during acute infection. PLoS Pathog 2020; 16:e1008853. [PMID: 32886726 PMCID: PMC7498102 DOI: 10.1371/journal.ppat.1008853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/17/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
HIV-1 transmission is associated with a severe bottleneck in which a limited number of variants from a pool of genetically diverse quasispecies establishes infection. The IAVI protocol C cohort of discordant couples, female sex workers, other heterosexuals and men who have sex with men (MSM) present varying risks of HIV infection, diverse HIV-1 subtypes and represent a unique opportunity to characterize transmitted/founder viruses (TF) where disease outcome is known. To identify the TF, the HIV-1 repertoire of 38 MSM participants' samples was sequenced close to transmission (median 21 days post infection, IQR 18-41) and assessment of multivariant infection done. Patient derived gag genes were cloned into an NL4.3 provirus to generate chimeric viruses which were characterized for replicative capacity (RC). Finally, an evaluation of how the TF virus predicted disease progression and modified the immune response at both acute and chronic HIV-1 infection was done. There was higher prevalence of multivariant infection compared with previously described heterosexual cohorts. A link was identified between multivariant infection and replicative capacity conferred by gag, whereby TF gag tended to be of lower replicative capacity in multivariant infection (p = 0.02) suggesting an overall lowering of fitness requirements during infection with multiple variants. Notwithstanding, multivariant infection was associated with rapid CD4+ T cell decline and perturbances in the CD4+ T cell and B cell compartments compared to single variant infection, which were reversible upon control of viremia. Strategies aimed at identifying and mitigating multivariant infection could contribute toward improving HIV-1 prognosis and this may involve strategies that tighten the stringency of the transmission bottleneck such as treatment of STI. Furthermore, the sequences and chimeric viruses help with TF based experimental vaccine immunogen design and can be used in functional assays to probe effective immune responses against TF.
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Affiliation(s)
- Gladys N. Macharia
- Department of Medicine, Imperial College London, London, United Kingdom
- IAVI Human Immunology Laboratory, London, United Kingdom
| | - Ling Yue
- Emory Vaccine Centre, Yerkes National Primate Research Centre, Emory University, Atlanta, GA, United States of America
| | - Ecco Staller
- Department of Medicine, Imperial College London, London, United Kingdom
- IAVI Human Immunology Laboratory, London, United Kingdom
| | - Dario Dilernia
- Emory Vaccine Centre, Yerkes National Primate Research Centre, Emory University, Atlanta, GA, United States of America
| | - Daniel Wilkins
- Emory Vaccine Centre, Yerkes National Primate Research Centre, Emory University, Atlanta, GA, United States of America
| | - Heeyah Song
- Emory Vaccine Centre, Yerkes National Primate Research Centre, Emory University, Atlanta, GA, United States of America
| | - Edward McGowan
- Department of Medicine, Imperial College London, London, United Kingdom
- IAVI Human Immunology Laboratory, London, United Kingdom
| | - Deborah King
- Department of Medicine, Imperial College London, London, United Kingdom
- IAVI Human Immunology Laboratory, London, United Kingdom
| | - Pat Fast
- IAVI, New York, NY, United States of America
| | - Nesrina Imami
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Matthew A. Price
- IAVI, New York, NY, United States of America
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, United States of America
| | - Eduard J. Sanders
- Kenya Medical Research Institute-Wellcome Trust, Kilifi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Headington, United Kingdom
| | - Eric Hunter
- Emory Vaccine Centre, Yerkes National Primate Research Centre, Emory University, Atlanta, GA, United States of America
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States of America
| | - Jill Gilmour
- Department of Medicine, Imperial College London, London, United Kingdom
- IAVI Human Immunology Laboratory, London, United Kingdom
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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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Kutner BA, Wu Y, Balán IC, Meyers K. "Talking About it Publicly Made Me Feel Both Curious and Embarrassed": Acceptability, Feasibility, and Appropriateness of a Stigma-Mitigation Training to Increase Health Worker Comfort Discussing Anal Sexuality in HIV Services. AIDS Behav 2020; 24:1951-1965. [PMID: 31858301 DOI: 10.1007/s10461-019-02758-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Health workers report challenges to broaching sexual behavior with gay and bisexual men (MSM). We conducted a stigma-mitigation training to increase provider-initiated conversation about anal sexuality among Chinese health workers. The two-day workshop, titled Smarter Sex is the New Safer Sex: Anal Pleasure and Health, coupled information about anal physiology and sexual response with gradual exposure to trainees' emotional and cognitive responses. We analyzed surveys and one-time interviews. Acceptability (satisfaction with training activities and recommended practices), feasibility (compatibility with participants' current practices), and appropriateness (perceived fit with participants' work mission and goals) were high, reaching 84-95% of the scale range, though with variable ratings for trainee comfort during participation. Qualitative data confirm health workers' motivation to discuss anal sexuality and the value of learning about anal physiology and sexual response, but revealed continued uncertainty about how to broach and navigate discussion with clients. Refinement of the training to align with health worker recommendations and to augment communication options and skills is warranted, as is involvement of MSM clientele themselves.
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Affiliation(s)
- Bryan A Kutner
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, USA
| | - Yumeng Wu
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, USA
| | - Ivan C Balán
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, USA.
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Barriers to Accessing Sexual Health Services for Transgender and Male Sex Workers: A Systematic Qualitative Meta-summary. AIDS Behav 2020; 24:682-696. [PMID: 30868447 DOI: 10.1007/s10461-019-02453-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Access to safe and effective sexual healthcare services for transgender and male sex workers (TMSW) is a human right. Globally, TMSW experience a higher prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections than the general population or other sex workers, suggesting the existence of unique challenges for this group when accessing healthcare. A systematic database search identified 22 qualitative papers addressing barriers to accessing sexual healthcare services for TMSW. These papers were critically evaluated for adherence to best practice standards for qualitative research and research with sex workers. A coding process identified five themes. Stigma was the predominant barrier, and was divided into stigma related to sexuality, gender identity, HIV status, sex worker status, and internalised stigma. Other barriers were confidentiality concerns, sexual health literacy, fatalism, and structural barriers. Each of these themes were informed by the wider context of stigma. The literature presents a complex syndemic of social disadvantage and exclusion acting to produce and reinforce health disparities related to sexual health and access to screening and treatment for TMSW.
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Daniels J, Struthers H, Maleke K, Lane T, McIntyre J, Coates T. 'My Tablets are on Top of the Fridge': The Roles of Relationship Desire and Medical Mistrust in ART Adherence for HIV-Positive MSM and Transgender Women Living in Rural South Africa. AIDS Behav 2019; 23:2849-2858. [PMID: 31402416 DOI: 10.1007/s10461-019-02628-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Given the high HIV prevalence for men who have sex with men (MSM) and transgender women in South Africa, there is limited understanding of social determinants that influence antiretroviral treatment (ART) adherence. Although universal testing and treatment (UTT) is available, ART adherence remains suboptimal. We conducted focus groups with MSM and transgender women in order to understand factors influencing their ART adherence in Mpumalanga, South Africa. All focus groups were audio-recorded, transcribed and translated for analysis using a constant comparison approach, guided by the concept of Therapeutic Citizenship. We found there is medical mistrust of ART based on differing interpretations of HIV cure that may influence treatment adherence behaviors within social networks, and relationship desire had a significant influence on optimal ART adherence. Our findings suggest that clinics must provide interventions that integrate HIV disclosure and relationship skill-building to support optimal ART adherence for MSM and transgender women under UTT.
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Affiliation(s)
- Joseph Daniels
- Department of Psychiatry and Human Behavior, Charles R. Drew University of Medicine and Science, 1731 E. 120th St, Los Angeles, CA, USA.
| | - Helen Struthers
- Anova Health Institute, Johannesburg, South Africa
- University of Cape Town, Cape Town, South Africa
| | | | - Tim Lane
- Equal International, San Francisco, CA, USA
| | - James McIntyre
- Anova Health Institute, Johannesburg, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Tom Coates
- UCLA Center for World Health at the David Geffen School of Medicine, Los Angeles, CA, USA
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10
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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: 16] [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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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: 2.7] [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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12
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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: 45] [Impact Index Per Article: 7.5] [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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Hassan NR, Swartz L, Kagee A, De Wet A, Lesch A, Kafaar Z, Newman PA. "There is not a safe space where they can find themselves to be free": (Un)safe spaces and the promotion of queer visibilities among township males who have sex with males (MSM) in Cape Town, South Africa. Health Place 2017; 49:93-100. [PMID: 29227887 DOI: 10.1016/j.healthplace.2017.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/30/2017] [Accepted: 11/30/2017] [Indexed: 11/28/2022]
Abstract
Males who have sex with males (MSM) are prioritised in the global fight against HIV/AIDS, as a key affected population to receive HIV prevention, treatment, and HIV-related care and support (WHO, 2016). There is, however, limited empirical research conducted on how to engage communities of South African MSM in clinical HIV prevention research programs. The development of LGBTIQ safe spaces may potentially be a viable option to promote community-based engagement by bridging the divides between HIV-prevention researchers, marginalised queer populations, and other HIV-prevention stakeholders located in heteronormative spaces (Molyneux et al., 2016). We conducted ten in-depth, qualitative interviews with MSM safe space members who have been involved in HIV prevention research programs. Data were analysed using a thematic analytic strategy (Braun and Clarke, 2006). Our results indicate that the "safe spaces" currently operational in Cape Town are not stable spaces nor are they always safe, but they form part of a broader and much more long-term political and geographical strategy of inclusion and emancipation.
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Affiliation(s)
- N R Hassan
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - L Swartz
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - A Kagee
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - A De Wet
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - A Lesch
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - Z Kafaar
- Department of Psychology, Stellenbosch University, Private Bag ×1, Matieland 7602, South Africa.
| | - P A Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1V4.
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14
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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: 154] [Impact Index Per Article: 22.0] [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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15
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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: 144] [Impact Index Per Article: 20.6] [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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16
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Scheibe AP, Duby Z, Brown B, Sanders EJ, Bekker LG. Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa. South Afr J HIV Med 2017; 18:673. [PMID: 29568621 PMCID: PMC5843261 DOI: 10.4102/sajhivmed.v18i1.673] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/05/2017] [Indexed: 11/01/2022] Open
Abstract
Background Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access. Objectives To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa). Methods A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training. Results Fourteen per cent of trainees had received previous training to counsel clients around penile-anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% - 87%, p < 0.0001), specifically around penile-anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training. Conclusion MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs.
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Affiliation(s)
- Andrew P Scheibe
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Zoe Duby
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Ben Brown
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Eduard J Sanders
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
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17
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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: 5.3] [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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18
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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: 17] [Impact Index Per Article: 2.4] [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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19
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Tucker A, Liht J, de Swardt G, Arendse C, McIntyre J, Struthers H. Efficacy of Tailored Clinic Trainings to Improve Knowledge of Men Who Have Sex with Men Health Needs and Reduce Homoprejudicial Attitudes in South Africa. LGBT Health 2016; 3:443-450. [PMID: 27835058 DOI: 10.1089/lgbt.2016.0055] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE An urgent need exists for training on men who have sex with men (MSM) health needs at public health clinics across Africa. There is also a need to consider the impact of specific training for clinicians and clinic support staff, both of whom come into contact with MSM. Consideration must also be given to the relationship between two key outcomes of such training: increased knowledge regarding MSM and their health and reductions in homoprejudicial attitudes. METHODS This article explores the impact of training for clinicians and clinic support staff in the Western Cape, South Africa (n = 196), where some training modules were undertaken by both groups and some modules only by clinicians. Participants were evaluated at baseline and post-training on MSM knowledge and homoprejudicial attitudes. RESULTS After training, both clinicians and clinic support staff showed an increase in knowledge and a reduction in homoprejudicial attitude scores, with similar proportional improvements for both groups. Additional trainings for clinicians also resulted in significant improvements in their knowledge. However, reductions in homoprejudicial attitudes were related to the type of knowledge obtained. A threshold effect in post-training knowledge scores of 9 or greater on sensitivity material significantly increased the likelihood of a reduction in homoprejudicial attitudes. CONCLUSION These findings show that training for both types of clinic workers is important and effective, but facilitators should be mindful of complex relationships between knowledge and homoprejudicial attitudes.
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Affiliation(s)
- Andrew Tucker
- 1 Anova Health Institute , Johannesburg, South Africa .,2 Department of Environmental and Geographical Sciences, University of Cape Town , Cape Town, South Africa
| | - Jose Liht
- 3 Independent Researcher , Cambridge, United Kingdom
| | | | | | - James McIntyre
- 1 Anova Health Institute , Johannesburg, South Africa .,4 School of Public Health and Family Medicine, University of Cape Town , Cape Town, South Africa
| | - Helen Struthers
- 1 Anova Health Institute , Johannesburg, South Africa .,5 Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town , Cape Town, South Africa
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20
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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: 2.0] [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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21
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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: 46] [Impact Index Per Article: 5.8] [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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22
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van der Elst EM, Gichuru E, Muraguri N, Musyoki H, Micheni M, Kombo B, Smith AD, Graham SM, Sanders EJ, Operario D. Strengthening healthcare providers' skills to improve HIV services for MSM in Kenya. AIDS 2015; 29 Suppl 3:S237-40. [PMID: 26372492 PMCID: PMC4706371 DOI: 10.1097/qad.0000000000000882] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- 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
| | - Evans Gichuru
- Kenya Medical Research Institute – Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Murugi Micheni
- Kenya Medical Research Institute – Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bernadette Kombo
- Kenya Medical Research Institute – Wellcome Trust Research Programme, Kilifi, Kenya
| | - Adrian D. Smith
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Susan M. Graham
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - 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
| | - Don Operario
- School of Public Health, Brown University, Providence, Rhode Island, USA
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23
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Resilience among gay/bisexual young men in Western Kenya: psychosocial and sexual health outcomes. AIDS 2015; 29 Suppl 3:S261-9. [PMID: 26562815 DOI: 10.1097/qad.0000000000000905] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore associations between intrapersonal and interpersonal factors and both sexual and psychosocial resilient outcomes among young gay, bisexual, and other men who have sex with men (GBMSM) in Western Kenya. DESIGN Cross-sectional observational study. METHODS Five hundred and eleven GBMSM ages 18-29 were recruited from nine communities in Western Kenya using community-based mobilization strategies. Participants completed an audio computer-assisted self-interview survey in English or Duhluo. We estimated four three-step hierarchical linear regression models to examine associations between predictors (intrapersonal and interpersonal factors) and four resilient outcomes (psychological well-being, self-esteem, condom use, HIV testing). RESULTS Psychosocial well-being model (modeled conversely as depression/anxiety) was significant (F(13,424) = 106.41, P < 0.001, R = 0.765) with loneliness, lesbian/gay/bisexual (LGB) difficult process, LGB identity superiority, and reactions to trauma as predictors. Self-esteem model was significant (F(12,425) = 6.40, P < 0.001, R = 0.153) with known HIV-seropositivity, perceived social support, internalized homonegativity, and LGB difficult process as predictors. Condom use model was significant (F(13,379) = 4.30, P < 0.001, R = 0.128) with perceived social support, self-esteem, and reactions to trauma as predictors. HIV testing model was significant (F(12,377) = 4.75, P < 0.001, R = 0.131) with loneliness, LGB identity uncertainty, LGB difficult process, and LGB identity superiority as predictors. CONCLUSION This study demonstrates the variety of ways in which intrapersonal and interpersonal factors are associated with HIV-related resilient outcomes for young GBMSM in Western Kenya. HIV prevention programs for this population should be developed in collaboration with GBMSM and include intervention components that promote resilience.
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Abstract
Objectives Mental health conditions can erode quality of life and interfere with health-related behaviours such as medication adherence. We aimed to determine the prevalence and correlates of depression and other psychosocial factors among self-identified men who have sex with men (MSM) in coastal Kenya. Design A cross-sectional survey. Methods Psychosocial and mental health characteristics were assessed in an audio computer-assisted self-interview (ACASI) survey among 112 MSM participating in two ongoing HIV-positive and HIV-negative cohorts in Mtwapa, Kenya. Results One-third of participants met criteria for major depressive disorder [16.1%, 95% confidence interval (95% CI) 9.8–24.2] or other depressive disorder (15.2%, 95% CI 9.1–23.2). Alcohol abuse was reported by 45% of respondents (95% CI 35.2–54.3) and other substance abuse by 59.8% (95% CI 50.1–69.0). Sexual and HIV stigma were moderate, with median scores of 11 [interquartile range (IQR) 6–17, potential range 0–33] and 25 (IQR 23–29, potential range 11–44), respectively. There were significant bivariate correlations between alcohol abuse, other substance abuse, sexual stigma and childhood and recent abuse. In a multivariable linear regression model, sexual stigma (beta = 0.17, 95% CI 0.03–0.32) and marriage to a woman (beta = −2.41 95% CI −4.74 to −0.09) were each associated with depression score. Conclusion We found moderate to high levels of depression and substance abuse, and moderate levels of sexual stigma. These variables were highly inter-correlated and associated with an experience of trauma or abuse. Comprehensive mental health services are needed in this population to address these issues.
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The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities. J Int AIDS Soc 2015; 18:20226. [PMID: 26493863 PMCID: PMC4615801 DOI: 10.7448/ias.18.1.20226] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 09/13/2015] [Accepted: 09/20/2015] [Indexed: 12/12/2022] Open
Abstract
Introduction Although men who have sex with men (MSM) in sub-Saharan Africa are at high risk for HIV acquisition, access to and quality of health and HIV services within this population are negatively affected by stigma and capacity within the health sector. A recently developed online MSM training programme (www.marps-africa.org) was shown to contribute to reductions in MSM prejudice among healthcare providers (HCPs) in coastal Kenya. In this study, we used qualitative methods to explore the provision of MSM healthcare services two years post-training in coastal Kenya. Methods From February to July 2014, we held 10 focus group discussions (FGD) with 63 participants, including HCP from 25 facilities, county AIDS coordinators and MSM from local support groups. Participants discussed availability, acceptability and accessibility of HIV healthcare for MSM. HCP also discussed changes in their health service practices after completing the training. FGD were recorded, transcribed verbatim and analyzed using Ritchie and Spencer's “framework approach” for qualitative data. Results HCPs described continued improvements in their ability to provide service in a non-stigmatizing way to MSM patients since completing the training programme and expressed comfort engaging MSM patients in care. Four additional recommendations for improving MSM healthcare services were identified: 1) expanding the reach of MSM sensitivity training across the medical education continuum; 2) establishing guidelines to manage sexually transmitted anal infections; 3) promoting legal and policy reforms to support integration of MSM-appropriate services into healthcare; and 4) including MSM information in national reporting tools for HIV services. Conclusions Positive impacts of this sensitivity and skills training programme were reflected in HCP attitudes two years post-intervention. Scaling-up of efforts will rely on continued policies to include MSM in healthcare programmes to reduce stigma in health settings and guidelines for MSM STI service delivery.
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