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Stoebenau K, Muchanga G, Ahmad SSO, Bwalya C, Mwale M, Toussaint S, Maambo C, Peters CJ, Baumhart C, Mwango LK, Lavoie MCC, Claassen CW. Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis. BMC Public Health 2024; 24:1617. [PMID: 38886691 PMCID: PMC11184712 DOI: 10.1186/s12889-024-19152-y] [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: 12/21/2023] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date. METHODS To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively. RESULTS We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV. CONCLUSION To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.
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Affiliation(s)
- Kirsten Stoebenau
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA.
| | | | - Sacha St-Onge Ahmad
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Chiti Bwalya
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Mwangala Mwale
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Samara Toussaint
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Choolwe Maambo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Carson J Peters
- University of Maryland College Park, 4200 Valley Drive, College Park, MD, 20742-2611, USA
| | - Caitlin Baumhart
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Marie-Claude C Lavoie
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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2
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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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3
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Omosigho PO, John OO, Musa MB, Aboelhassan YMEI, Olabode ON, Bouaddi O, Mengesha DT, Micheal AS, Modber MAKA, Sow AU, Kheir SGM, Shomuyiwa DO, Adebimpe OT, Manirambona E, Lucero-Prisno DE. Stigma and infectious diseases in Africa: examining impact and strategies for reduction. Ann Med Surg (Lond) 2023; 85:6078-6082. [PMID: 38098545 PMCID: PMC10718398 DOI: 10.1097/ms9.0000000000001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/24/2023] [Indexed: 12/17/2023] Open
Abstract
Stigma poses a significant barrier to accessing care, managing, and preventing infectious diseases in Africa. The authors conducted an extensive search across Scopus, PubMed, ScienceDirect, and Google Scholar to identify relevant English-language articles, with no constraints on publication dates, using the keywords "Stigma," and "Infectious Disease," in conjunction with "Africa." This article explores the multifaceted nature of stigma associated with infectious diseases, highlighting its impact on healthcare access and public health outcomes. It delves into the current situation of infectious disease-related stigma in Africa, emphasizing the various diseases and contexts affected. The article identifies drivers of stigma, including negative attitudes, misinformation, and institutional practices, and discusses their role in perpetuating discrimination. Importantly, it provides recommendations for addressing infectious disease stigma in Africa through comprehensive strategies encompassing health education, contact-based interventions, professionalized counselling and peer support services, and community engagement. The article calls for collaboration among governments, healthcare organizations, NGOs, and community leaders to implement holistic strategies that prioritize inclusivity and stigma reduction. Ultimately, it underscores the urgent need to combat stigma to improve healthcare access and outcomes for individuals affected by infectious diseases in Africa.
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Affiliation(s)
| | - Okesanya Olalekan John
- Department of Medical Laboratory Science, Neuropsychiatric Hospital, Aro, Abeokuta
- Global Health Focus Africa, Abuja
| | | | | | | | - Oumnia Bouaddi
- International School of Public Health, Mohammed VI University of Health Sciences, Casablanca
- Mohammed VI Center For Research and Innovation, Rabat, Morocco
| | | | - Abioye Sunday Micheal
- Faculty of Basic Medical Sciences, Department of Public Health, Adeleke University, Ede, Osun State
| | | | - Alhaji Umar Sow
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown
| | | | | | | | - Emery Manirambona
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Research Unit, Global Health Focus, Bujumbura, Burundi
| | - Don Eliseo Lucero-Prisno
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Kigombola A, Lyimo J, Mizinduko M, Mkembela D, Maziku E, Kafura W, Maghimbi A, Musanhu C, Nsubuga P, Yoti Z. Low engagement of key populations in HIV health services in Tanzania: analysis of community, legal and policy factors. Pan Afr Med J 2023; 45:8. [PMID: 37538366 PMCID: PMC10395107 DOI: 10.11604/pamj.supp.2023.45.1.39591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/18/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction key populations (KP) often face legal and social challenges that increase their vulnerability to HIV. These experiences include criminalization, higher levels of stigma and discrimination which negatively affect access to HIV services. This study aims to understand legal, community and policy factors affecting engagement of KP in HIV health interventions. Methods qualitative research key populations design involving a desk review and stakeholder's engagement. We reviewed program data from NACP on how KP access health services and then conducted three stakeholders' engagement meetings. Factors affecting access to health services by KP were documented. Data were organized using socio-ecological model (SEM). Results program data showed only 49% of the estimated KP accessed health services. Barriers to accessing health services at the interpersonal level included lack of social support and high-risk networks linked with risk behaviours. At the community, stigma and discrimination, limited engagement of influential leaders were noted. In health facilities, lack of trained staff to provide KP friendly services affected utilization of health services. At structural level, despite improvements, still various laws negated engagement of KP such criminalizing drug use, same sex, and sex work. Harassments and arrests further marginalize KP and makes access to health intervention harder. Conclusion engagement of key population into HIV health interventions was limited at multiple levels. The study recommends building capacity on KP friendly services for communities, law enforcement and health care providers, further engagement of communities including religious leaders on KP issues and implementing differentiated service delivery models for KP.
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Affiliation(s)
| | | | | | | | | | - William Kafura
- Tanzania Commission for AIDS (TACAIDS), Dodoma, Tanzania
| | | | | | - Peter Nsubuga
- Global Public Health Solutions, Dar es Salaam, Tanzania
| | - Zablon Yoti
- World Health Organization, Dar es Salaam, Tanzania
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5
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Falck F, Bränström R. The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC Public Health 2023; 23:1031. [PMID: 37259082 DOI: 10.1186/s12889-023-15856-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND According to the minority stress theory, stigma affects the health of marginalized populations. Previous stigma research has focused on the health effects of individual and interpersonal stigma, paying less attention to structural factors. Laws on legal gender recognition affect the lives of transgender individuals in unique ways. The fact that these laws and population attitudes vary greatly between European countries, offer a unique opportunity to study the role of structural stigma in the lives of transgender individuals. Little is known about how transgender specific structural stigma relates to individual health determinants. Consequently, the aim of this study was to explore the association between structural stigma and access to gender affirming care, gender identity disclosure in health care, and experiences of discrimination in health care across 28 European countries. METHODS By using multilevel regression, we combined data on health seeking behavior, transgender identity disclosure to health care providers, and experiences of discrimination in health care from 6,771 transgender individuals participating in the 2012 European Union Lesbian, Gay, Bisexual and Transgender survey with a structural stigma measure, consisting of population attitudes towards transgender individuals as well as national legislation on gender recognition. Reasons to refrain from seeking care and discrimination in health care were assessed by categorizing countries as low or high in structural stigma and using Chi-square statistics. RESULTS Country-level structural stigma was negatively associated experiences of seeking gender affirming care and positively associated with concealment of being transgender to health care providers. Identity concealment was associated with a lower likelihood of exposure to discrimination in the health care setting across countries regardless of their level of structural stigma. The most prevalent reasons to forgo gender affirming care were shared between low and high structural stigma country groups and centered around fear. CONCLUSION The results highlight the importance of changing stigmatizing legislation and population attitudes to promote access to gender affirming care as well as openness of being transgender towards providers. Measures to decrease discrimination in the health care setting are warranted in high as well as in low structural stigma countries.
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Affiliation(s)
- Felicitas Falck
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Stockholm, Sweden.
- ANOVA Clinic, Karolinska University Hospital Stockholm, Norra Stationsgatan 69, 171 76, Stockholm, Sweden.
| | - Richard Bränström
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Nobels väg 9, 17177, Stockholm, Sweden
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6
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Mulavu M, Anitha Menon J, Mulubwa C, Matenga TFL, Nguyen H, MacDonell K, Wang B, Mweemba O. Psychosocial challenges and coping strategies among people with minority gender and sexual identities in Zambia: health promotion and human rights implications. Health Psychol Behav Med 2023; 11:2173201. [PMID: 36818391 PMCID: PMC9930791 DOI: 10.1080/21642850.2023.2173201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Background Sexual and gender minorities face high levels of stigma, discrimination, and violence. In many countries, they are often criminalized and are at risk of mental health challenges. In Zambia, little is known about the psychosocial challenges and coping strategies of sexual and gender minorities. This study sought to explore psychosocial challenges and coping strategies among sexual and gender minority populations in Lusaka, Zambia to inform mental health and human rights promotion for this population. Methods The study used a qualitative phenomenological study design. Data were collected through in-depth interviews with 16 sexual and gender minority participants (lesbian, gay, bisexual, and transgender) and four key informants. The sexual minorities included four lesbian, five gay, and three bisexual participants while the gender minorities included two transgender men and two transgender women. Interviews with gender and sexual minorities were mostly focused on the lived experiences of participants, while those of key informants focused on their work with sexual and gender minorities. Snowball strategy was used to recruit participants, while purposive sampling was used to select key informants. All interviews were recorded and transcribed verbatim. Thematic analysis was carried out with the aid of Nvivo 12 software. Results Psychosocial challenges included victimization in the form of threats and physical assault. Stigma and discrimination were experienced in different settings such as healthcare, the workplace, and school. Participants reported having experienced feelings of depression. Rejection from family members was experienced by those who revealed their sexual or gender minority status. Reported coping strategies included social support, self-concealment, listening to music, and substance use. Conclusion This study suggests that sexual and gender minorities in Zambia experience various psychosocial challenges related to their sexuality and gender identity. To assist them cope better with the obstacles they experience, improved psychosocial counseling and mental health services are needed.
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Affiliation(s)
- Mataanana Mulavu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia, Mataanana Mulavu Department of Health Promotion and Education, School Of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
| | - J. Anitha Menon
- Department of Psychology, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Chama Mulubwa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Hoa Nguyen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karen MacDonell
- Department of Behavioral Sciences and Social Medicine, Centre for Translational Behavioral Science, Florida State College of Medicine, FL, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Oliver Mweemba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia
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7
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Knox J, Shiau S, Kutner B, Reddy V, Dolezal C, Sandfort TGM. Information, Motivation and Behavioral Skills as Mediators Between Sexual Minority Stigma and Condomless anal Sex Among Black South African Men Who have Sex with Men. AIDS Behav 2022; 27:1587-1599. [PMID: 36318425 PMCID: PMC10149565 DOI: 10.1007/s10461-022-03892-2] [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: 10/06/2022] [Indexed: 11/06/2022]
Abstract
We assessed pathways between sexual minority stigma and condomless anal intercourse (CAI) among two samples of Black South African men who have sex with other men (MSM). Two cross-sectional surveys were conducted in Tshwane, South Africa; one among 199 Black MSM and another among 480 Black MSM. Men reported on external and internalized experiences of sexual minority stigma, mental health, alcohol use, information-motivation-behavioral skills (IMB) model constructs, and CAI. Structural equation modeling was used to test whether external and internalized stigma were directly and indirectly associated with CAI. In both studies, external stigma and internalized stigma were associated with CAI through IMB model constructs. These results suggest a pathway through which stigma contributes to HIV risk. For HIV prevention efforts to be effective, strengthening safer sex motivation and thus decreasing sexual risk behavior likely requires reducing sexual minority stigma that MSM experience and internalize.
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Affiliation(s)
- Justin Knox
- Department of Psychiatry, Columbia University, New York, US. .,HIV Center for Behavioral Studies, New York State Psychiatric Institute, New York, US. .,Department of Sociomedical Sciences, Columbia University, New York, US. .,, 722 West 168th street, 10032, New York, US.
| | - Stephanie Shiau
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Bryan Kutner
- Department of Psychiatry, Columbia University, New York, US.,HIV Center for Behavioral Studies, New York State Psychiatric Institute, New York, US
| | - Vasu Reddy
- Faculty of Humanities, University of Pretoria, Pretoria, South Africa
| | - Curtis Dolezal
- HIV Center for Behavioral Studies, New York State Psychiatric Institute, New York, US
| | - Theo G M Sandfort
- Department of Psychiatry, Columbia University, New York, US.,HIV Center for Behavioral Studies, New York State Psychiatric Institute, New York, US.,Department of Sociomedical Sciences, Columbia University, New York, US.,Faculty of Humanities, University of Pretoria, Pretoria, South Africa
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8
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Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti. Sci Rep 2022; 12:7511. [PMID: 35525876 PMCID: PMC9079062 DOI: 10.1038/s41598-022-11647-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
Vulnerability to contracting HIV among Men who have Sex with Men and Women (MSMW) was recognized early in the epidemic. However, while global HIV efforts have made tremendous progress for the heterosexually-identified population, the specific needs of MSMW were not directly addressed with tailored and context-adapted interventions. The purpose of this study was to inform this area of research by exploring patterns of stigma through sexual identity developmental history as well as coping mechanisms among MSMW living with HIV in Haiti. A qualitative descriptive study comprised of in-depth interviews with 32 MSMW living with HIV was carried out. Participants were recruited using snowball techniques. An inductive thematic analysis was conducted in NVivo, contextualized by the socio-ecological context of Haiti. MSMW reported struggling with their sexuality since their adolescence, often because of enacted stigma from family members, the community, and cultural conflicts. Most participants described experiencing anxiety, psychological distress, depression, social isolation, suicidal ideation and suicide attempts. Mechanisms for coping with stigma included self-acceptance, social support, hiding their sexual orientation, and tolerance of the voodoo religion. To combat stigma, and improve HIV treatment adherence and retention among MSMW, culturally-tailored multilevel initiatives should be implemented.
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9
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Tan RKJ, Koh WL, Le D, Banerjee S, Chio MTW, Chan RKW, Wong CM, Tai BC, Wong ML, Cook AR, Chen MIC, Wong CS. Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial. J Med Internet Res 2022; 24:e31401. [PMID: 35522470 PMCID: PMC9123545 DOI: 10.2196/31401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 03/09/2022] [Accepted: 04/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series. Objective This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors. Methods The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period. Results Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants’ intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants. Conclusions There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant. Trial Registration ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-033855
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Affiliation(s)
- Rayner Kay Jin Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,University of North Carolina Project-China, Guangzhou, China
| | - Wee Ling Koh
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Daniel Le
- Action for AIDS Singapore, Singapore, Singapore
| | | | - Martin Tze-Wei Chio
- Department of Sexually Transmitted Infections Control Clinic, National Skin Centre, Singapore, Singapore
| | | | - Christina Misa Wong
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, United States
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Mee Lian Wong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | | | - Chen Seong Wong
- National Centre for Infectious Diseases, Singapore, Singapore
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10
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Nakiganda LJ, Bavinton BR, Grulich AE, Serwadda D, Nakubulwa R, Poynten IM, Bell S. Social Influences on Engagement With HIV Testing, Treatment and Care Services Among Men Who Have Sex With Men Living in Rural Uganda. QUALITATIVE HEALTH RESEARCH 2022; 32:635-645. [PMID: 34923882 DOI: 10.1177/10497323211058162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Men who have sex with men in Uganda are a heterogenous, discriminated population, experiencing high HIV burden, limited access to HIV testing, and low treatment adherence. We contribute to the lack of information about men who have sex with men in rural Uganda by using socio-ecological analyses to examine the social influences shaping their engagement with HIV services. Based on in-depth interviews with 16 men, our findings reveal the inhibitive influence of interpersonal relationships with sexual partners, peers and families, and institutional influences within health service and non-governmental organizational settings. Yet men take action to strategize and seek support to enhance engagement with HIV care in heavily criminalized and stigmatized settings. Future HIV prevention, testing, treatment, and care responses could draw on what affected individuals and communities are already doing to enhance access to HIV services and the effective support strategies of some non-governmental organizations and healthcare workers.
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Affiliation(s)
- Lydia J Nakiganda
- Kirby Institute for Infection and Immunity in Society, 7800UNSW Sydney, Sydney, NSW, Australia
| | - Benjamin R Bavinton
- Kirby Institute for Infection and Immunity in Society, 7800UNSW Sydney, Sydney, NSW, Australia
| | - Andrew E Grulich
- Kirby Institute for Infection and Immunity in Society, 7800UNSW Sydney, Sydney, NSW, Australia
| | - David Serwadda
- 561068Rakai Health Sciences Program, Kalisizo, Uganda
- 58589Makerere University School of Public Health, Kampala, Uganda
| | | | - Isobel M Poynten
- Kirby Institute for Infection and Immunity in Society, 7800UNSW Sydney, Sydney, NSW, Australia
| | - Stephen Bell
- UQ Poche Centre for Indigenous Health, 1974The University of Queensland, Saint Lucia, QLD, Australia
- School of Public Health, 1974The University of Queensland, Saint Lucia, QLD, Australia
- Centre for Social Research in Health, 7800UNSW Sydney, Sydney, NSW, Australia
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11
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Nakiganda LJ, Bell S, Grulich AE, Serwadda D, Nakubulwa R, Poynten IM, Bavinton BR. Understanding and managing HIV infection risk among men who have sex with men in rural Uganda: a qualitative study. BMC Public Health 2021; 21:1309. [PMID: 34218799 PMCID: PMC8254907 DOI: 10.1186/s12889-021-11365-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Same-sex sexual relations are criminalised in Uganda, and men who have sex with men (MSM) experience a high burden of HIV infection. In Uganda, health promotion policies focus on equity in healthcare and creating enabling environments. At present there is limited evidence upon which to enhance engagement of MSM in rural settings into effective HIV prevention. To fill this gap, our study explored MSM’s understandings of HIV risk and strategies used to reduce HIV risk in their sexual lives. Methods In-depth interviews were conducted with sixteen MSM in rural communities in Southwestern Uganda. Inductive thematic analysis examined men’s perceptions of HIV risk and strategies of reducing their own HIV risks. Results Understandings of HIV risk and risk practices were framed by lack of access to condoms, challenges negotiating condom and pre-exposure prophylaxis (PrEP) use, and condomless sex being reported as more pleasurable than sex with condoms. Strategies men perceived as enabling them to manage HIV risk included: PrEP use; condom use; knowing partners’ HIV status; avoiding partners associated with HIV risk; oral sex; withdrawal before ejaculation and washing one’s penis after sex. There were several misconceptions arising from poor HIV prevention knowledge. Strategies reliant on communication and negotiation with sexual partners were inhibited by gendered powered imbalances. Conclusions Our findings illustrate that MSM in rural settings in Uganda are making concerted efforts to implement strategies that might reduce risk of HIV transmission and infection within their sexual relationships. Key HIV health promotion and service-related strategies to support MSM with these efforts include an effective condom and lubricant supply chain; a PrEP program in trusted local health units, implemented via discreet community-outreach mechanisms; and same-sex specific HIV-related health promotion.
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Affiliation(s)
| | - Stephen Bell
- UQ Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Australia.,School of Public Health, The University of Queensland, Brisbane, Australia.,Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
| | | | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda.,Makerere University School of Public Health, Kampala, Uganda
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12
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Gioia SA, Russell MA, Zimet GD, Stupiansky NW, Rosenberger JG. The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men. PATIENT EDUCATION AND COUNSELING 2021; 104:1712-1718. [PMID: 33451881 DOI: 10.1016/j.pec.2020.12.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/07/2020] [Accepted: 12/31/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Gay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients' perceptions of their provider's sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients' disclosure of sexual orientation to providers. METHODS Data were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18-26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance. RESULTS Participants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics. CONCLUSIONS Findings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men's health. PRACTICE IMPLICATIONS Dyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients' sexual minority statuses.
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Affiliation(s)
- Sarah A Gioia
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, USA.
| | - Michael A Russell
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, USA.
| | - Gregory D Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA.
| | - Nathan W Stupiansky
- Health Behavior Consultants International, 7575 E Indian Bend Rd, Scottsdale, AZ 85250, USA.
| | - Joshua G Rosenberger
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, USA.
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13
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Nguyen LH, Nguyen HLT, Tran BX, Larsson M, Rocha LEC, Thorson A, Strömdahl S. A qualitative assessment in acceptability and barriers to use pre-exposure prophylaxis (PrEP) among men who have sex with men: implications for service delivery in Vietnam. BMC Infect Dis 2021; 21:472. [PMID: 34030652 PMCID: PMC8147440 DOI: 10.1186/s12879-021-06178-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/12/2021] [Indexed: 11/20/2022] Open
Abstract
Background HIV Pre-exposure prophylaxis (PrEP) is being considered for implementation among MSM nationwide in Vietnam. However, there may be concerns about potential obstacles for PrEP adherence among Vietnamese MSM. This study aims to assess the acceptability to use PrEP, potential barriers and facilitators, and the preferences for PrEP service accessibility and delivery among Vietnamese MSM. Methods Four focus group discussions (FGDs) were conducted with 30 HIV-negative MSM in January 2018 in Hanoi, Vietnam. FGDs explored MSM’s awareness regarding PrEP, perceived benefits and barriers of PrEP use, and willingness to use PrEP. FGDs were audio-recorded and transcribed verbatim. Content analysis was used. Results The mean age of participants was 23.9 years old. Most participants realized the advantages of PrEP given its efficacy in HIV risk reduction and expressed high motivation and interest to use PrEP in the future. PrEP was considered as a supplement alongside condoms. Common concerns about PrEP included side-effects, forgetting to take the pill daily, stigmatization due to using PrEP, negative attitudes toward PrEP from other MSM and accessibility of PrEP. Participants would prefer an injectable PrEP regime if available as it was seen as easier to adhere to. Concerns were also raised that PrEP usage could be interpreted as an indication of engaging in sexual risk behavior for HIV, potentially causing suspicion in love relationships or by family and friends. Participants preferred to receive PrEP in civil business organizations and MSM-friendly clinics, and recommended that pharmacy stores would not be suitable for PrEP implementation due to lack of trust and fear of fake drugs. Conclusion This study indicated a high level of willingness to use PrEP among MSM in Vietnam in combination with condom. Strategies to raise awareness of PrEP, reduce stigma towards PrEP, and improve the accessibility among MSM in Vietnam is needed. Existing MSM-friendly clinics were recommended to implement PrEP programs in Vietnam.
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Affiliation(s)
- Long Hoang Nguyen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden. .,VNU University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.
| | - Huong Lan Thi Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.,Faculty of Nursing, Duy Tan University, Da Nang, Vietnam
| | - Bach Xuan Tran
- Department of Health Economics, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,Department of Health, Behaviours, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Mattias Larsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Luis E C Rocha
- Department of Economics & Department of Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Anna Thorson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Strömdahl
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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14
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Rao A, Rucinski K, Jarrett BA, Ackerman B, Wallach S, Marcus J, Adamson T, Garner A, Santos GM, Beyrer C, Howell S, Baral S. Perceived Interruptions to HIV Prevention and Treatment Services Associated With COVID-19 for Gay, Bisexual, and Other Men Who Have Sex With Men in 20 Countries. J Acquir Immune Defic Syndr 2021; 87:644-651. [PMID: 33443963 PMCID: PMC8276834 DOI: 10.1097/qai.0000000000002620] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The coronavirus pandemic has necessitated a range of population-based measures to stem the spread of infection. These measures may be associated with disruptions to other health services including for gay, bisexual, and other men who have sex with men (MSM) at risk for or living with HIV. Here, we assess the relationship between stringency of COVID-19 control measures and interruptions to HIV prevention and treatment services for MSM. SETTING Data for this study were collected between April 16, 2020, and May 24, 2020, as part of a COVID-19 Disparities Survey implemented by the gay social networking app, Hornet. Pandemic control measures were quantified using the Oxford Government Response Tracker Stringency Index: each country received a score (0-100) based on the number and strictness of 9 indicators related to restrictions, closures, and travel bans. METHODS We used a multilevel mixed-effects generalized linear model with Poisson distribution to assess the association between stringency of pandemic control measures and access to HIV services. RESULTS A total of 10,654 MSM across 20 countries were included. Thirty-eight percent (3992/10,396) reported perceived interruptions to in-person testing, 55% (5178/9335) interruptions to HIV self-testing, 56% (5171/9173) interruptions to pre-exposure prophylaxis, and 10% (990/9542) interruptions to condom access. For every 10-point increase in stringency, there was a 3% reduction in the prevalence of perceived access to in-person testing (aPR: 0·97, 95% CI: [0·96 to 0·98]), a 6% reduction in access to self-testing (aPR: 0·94, 95% CI: [0·93 to 0·95]), and a 5% reduction in access to pre-exposure prophylaxis (aPR: 0·95, 95% CI: [0·95 to 0·97]). Among those living with HIV, 20% (218/1105) were unable to access their provider; 65% (820/1254) reported being unable to refill their treatment prescription remotely. CONCLUSIONS More stringent responses were associated with decreased perceived access to services. These results support the need for increasing emphasis on innovative strategies in HIV-related diagnostic, prevention, and treatment services to minimize service interruptions during this and potential future waves of COVID-19 for gay men and other MSM at risk for HIV acquisition and transmission.
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Affiliation(s)
| | | | | | - Benjamin Ackerman
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Julia Marcus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Fenway Institute, Boston, MA
| | | | | | - Glenn-Milo Santos
- Community Health Systems Department, University of California San Francisco, San Francisco, CA; and
- Center of Public Health Research, San Francisco Department of Public Health, San Francisco, CA
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15
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Rao A, Rucinski K, Jarrett BA, Ackerman B, Wallach S, Marcus J, Adamson T, Garner A, Santos GM, Beyrer C, Howell S, Baral S. Perceived Interruptions to HIV Prevention and Treatment Services Associated With COVID-19 for Gay, Bisexual, and Other Men Who Have Sex With Men in 20 Countries. J Acquir Immune Defic Syndr 2021. [DOI: http://doi.org.10.1097/qai.0000000000002620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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16
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Rao A, Rucinski K, Jarrett BA, Ackerman B, Wallach S, Marcus J, Adamson T, Garner A, Santos GM, Beyrer C, Howell S, Baral S. Perceived Interruptions to HIV Prevention and Treatment Services Associated With COVID-19 for Gay, Bisexual, and Other Men Who Have Sex With Men in 20 Countries. J Acquir Immune Defic Syndr 2021. [DOI: http:/doi.org.10.1097/qai.0000000000002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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17
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Beia T, Kielmann K, Diaconu K. Changing men or changing health systems? A scoping review of interventions, services and programmes targeting men's health in sub-Saharan Africa. Int J Equity Health 2021; 20:87. [PMID: 33789688 PMCID: PMC8011198 DOI: 10.1186/s12939-021-01428-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/17/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sex and gender have been shown to influence health literacy, health seeking behaviour, and health outcomes. However, research examining the links between gender and health has mainly focused on women's health, which is a long-standing global health priority. We examine literature focused on the 'missing men' in global health research, in particular empirical studies that document interventions, programmes, and services targeting men's health issues in Sub-Saharan Africa. Within these studies, we identify dominant conceptualisations of men and men's health and how these have influenced the design of men's health interventions and services. METHODS This is a scoping review of published and grey literature. Following comprehensive searches, we included 56 studies in the review. We conducted a bibliographic analysis of all studies and used inductive methods to analyse textual excerpts referring to conceptualizations of men and service design. An existing framework to categorise services, interventions, or programs according to their gender-responsiveness was adapted and used for the latter analysis. RESULTS From the included studies, we distinguished four principal ways in which men were conceptualized in programs and interventions: men are variously depicted as 'gatekeepers'; 'masculine' men, 'marginal' men and as 'clients. Additionally, we classified the gender-responsiveness of interventions, services or programmes described in the studies within the following categories: gender-neutral, -partnering, -sensitive and -transformative. Interventions described are predominantly gender-neutral or gender-partnering, with limited data available on transformative interventions. Health systems design features - focused mainly on achieving women's access to, and uptake of services - may contribute to the latter gap leading to poor access and engagement of men with health services. CONCLUSION This review highlights the need for transformation in sub-Saharan African health systems towards greater consideration of men's health issues and health-seeking patterns.
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Affiliation(s)
- Thierry Beia
- Health Services Department, Copperbelt University, Jambo Drive, Riverside, Kitwe, Zambia.
| | - Karina Kielmann
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Musselburgh, EH21 6UU, Scotland, UK
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Musselburgh, EH21 6UU, Scotland, UK
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18
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Wang R, Cui N, Long M, Mu L, Zeng H. Barriers to uptake of hepatitis C virus (HCV) health intervention among men who have sex with men in Southwest China: A qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:445-452. [PMID: 32667104 DOI: 10.1111/hsc.13104] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
Men who have sex with men (MSM) are at risk of contracting the hepatitis C virus (HCV). Previous studies have documented low uptake of sexually transmitted disease (STD) prevention and health services among Chinese MSM. We carried out qualitative research among MSM in Southwest China. By taking the Health Brief Model (HBM) as a framework, we aimed to determine the underlying factors related to use of HCV health intervention services among MSM. From May to July 2018, we conducted in-depth interviews in Southwest China with 20 participants. Our research revealed that a lack of knowledge about HCV prevention was the main reason why MSM failed to perceive their susceptibility to HCV and had low motivation to seek preventive services. Poor service accessibility and unpleasant experiences seeing doctors also exerted negative influences on health care-seeking behaviour in MSM. More trust and understanding needs to be built between health providers and MSM. Protection of privacy for MSM should be guaranteed in the delivery of health interventions. In addition, the interviewees showed refusal to engage with health interventions being specifically targeted at MSM, which would create a sense of being 'labelled'. Tailored health interventions may overemphasise their sexuality, segregate them from heterosexuals, and make them feel alienated. Therefore, we speculate that differential treatment may be an obstacle for MSM to become involved in health interventions.
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Affiliation(s)
- Ruoxi Wang
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
- Blood Components Department, Chengdu Blood Center, Chengdu, Sichuan Province, China
| | - Nianqi Cui
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang Province, China
| | - Mengyun Long
- Medical Faculty, Yunnan College of Business Management, Kunming, Yunnan Province, China
| | - Lihong Mu
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
- Research Center for Medicine and Social Governance in Health, Chongqing Medical University, Chongqing, China
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing, China
| | - Huan Zeng
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
- Research Center for Medicine and Social Governance in Health, Chongqing Medical University, Chongqing, China
- The Innovation Center for Social Risk Governance in Health, Chongqing Medical University, Chongqing, China
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19
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Mental Health Services for Men Who Have Sex with Men in China. Community Ment Health J 2021; 57:380-386. [PMID: 32594327 PMCID: PMC7765735 DOI: 10.1007/s10597-020-00660-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Abstract
This study explores the presence of mental health challenges and related service utilization among MSM in China. An online cross-sectional survey recruited 520 MSM in Guangdong, China, to evaluate the participants' psychiatric symptoms, service fulfillment, and challenges. A high proportion of the participants experienced at least one psychiatric symptom in the past year, but less than half of their mental health service needs were fulfilled. The preferred agencies for mental health services were provincial and city-level general hospitals or primary health centers. Lack of knowledge and misconceptions of mental health services were the primary reasons for not receiving necessary services. Mental health service fulfillment was associated with younger age, lower education, higher income, local residency, cohabitation, and disclosure of MSM status. The high rate of mental health issues and gaps in service seeking indicates an urgent need to increase mental health awareness among MSM.
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20
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Bien-Gund CH, Zhao P, Cao B, Tang W, Ong JJ, Baral SD, Bauermeister JA, Yang LG, Luo Z, Tucker JD. Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review. Sex Health 2020; 16:320-331. [PMID: 31213225 DOI: 10.1071/sh18191] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.
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Affiliation(s)
- Cedric H Bien-Gund
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Peipei Zhao
- Shenzhen Nanshan Center for Chronic Disease Control, No. 8 Longyuan Road, Shenzhen 510855, China
| | - Bolin Cao
- School of Media and Communication, Shenzhen University, 3688 Nanhai Avenue, Shenzhen 518060, China
| | - Weiming Tang
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Social Entrepreneurship to Spur Health, No. 2 Lujing Road, Guangzhou 510095, China; and School of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Chapel Hill, NC 27516, USA
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Stefan D Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - José A Bauermeister
- Department of Family and Community Health, School of Nursing, 418 Curie Boulevard, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Li-Gang Yang
- Guangdong Provincial STD Control Center, No. 2 Lujing Road, Guangzhou 510095, China
| | - Zhenzhou Luo
- Shenzhen Nanshan Center for Chronic Disease Control, No. 8 Longyuan Road, Shenzhen 510855, China
| | - Joseph D Tucker
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Social Entrepreneurship to Spur Health, No. 2 Lujing Road, Guangzhou 510095, China; and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; and Institute of Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Road, Chapel Hill, NC 27599, USA; and Corresponding author.
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21
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Gamariel F, Isaakidis P, Tarquino IAP, Beirão JC, O’Connell L, Mulieca N, Gatoma HP, Cumbe VFJ, Venables E. Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study. PLoS One 2020; 15:e0228307. [PMID: 31999760 PMCID: PMC6992190 DOI: 10.1371/journal.pone.0228307] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 01/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Médecins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM- and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care. METHODS In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework. RESULTS Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement, including social media. Interviewees reported experiencing stigma and discrimination because of their gender or sexual identity. HIV-related stigma and health-care setting discrimination, including gossip and breach of confidentiality, were also reported. Although the presence of the peer-educators and their outreach activities were appreciated, they had limited visibility and an over-focus on health and HIV. The face-to-face networks of MSM and transgender women were small and fragmented. Virtual networks such as Facebook were mainly used for flirting, dating and informal communication. Most interviewees were at ease using social media and would consider it as a means of engaging with health messaging. CONCLUSIONS MSM and transgender women have challenges in accessing health services due to being stigmatised because of their gender identity and their sexual behaviour, and often experience stigma at home, in health-care facilities and in their communities. Peer-driven models of engagement were appreciated but have limitations. There is an untapped potential for further expansion and engagement with face-to-face and virtual platforms to reach MSM and transgender women in settings with a high HIV burden, and to provide them with essential information about HIV and their health.
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Affiliation(s)
| | - Petros Isaakidis
- Médecins Sans Frontières, Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | | | | | - Lucy O’Connell
- Médecins Sans Frontières, Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | | | | | | | - Emilie Venables
- Médecins Sans Frontières, Southern Africa Medical Unit (SAMU), Cape Town, South Africa
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine,University of Cape Town, Cape Town, South Africa
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22
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Wirtz AL, Poteat T, Radix A, Althoff KN, Cannon CM, Wawrzyniak AJ, Cooney E, Mayer KH, Beyrer C, Rodriguez AE, Reisner SL. American Cohort to Study HIV Acquisition Among Transgender Women in High-Risk Areas (The LITE Study): Protocol for a Multisite Prospective Cohort Study in the Eastern and Southern United States. JMIR Res Protoc 2019; 8:e14704. [PMID: 31584005 PMCID: PMC6802485 DOI: 10.2196/14704] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In the United States, transgender women (TW) are disproportionately burdened by HIV infection. Cohort studies are needed to evaluate factors driving HIV acquisition among TW over time. These will require implementation strategies that are acceptable to the TW community and feasible to implement. OBJECTIVE This study aims to investigate the rate and correlates of HIV acquisition and other health outcomes among TW in eastern and southern United States. METHODS LITE is a multisite prospective cohort in 6 eastern and southern US cities, which will be followed across 24 months of technology-enhanced biobehavioral follow-up. Adult TW, regardless of HIV status, are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants are enrolled in a baseline study visit, complete a sociobehavioral survey, and test for HIV and sexually transmitted infections. Participants who are not living with HIV at baseline are offered enrollment into the cohort (N=1100); follow-up assessments occur quarterly. RESULTS Cohort assembly was informed by synchronous Web-based focus group discussions with TW (n=41) and by continuing engagement with community advisory board members from each site. Enrollment launched in March 2018. The study is underway in the Atlanta; Baltimore; Boston; Miami; New York City; and Washington, DC, metro areas. As of March 2019, 795 TW completed a baseline visit (mean age 35 years). The majority of the participants are racial/ethnic minorities, with 45% of the TW identifying as black and 28% of the TW identifying as Hispanic/Latinx. More than one-quarter (28%) of the TW are living with HIV infection (laboratory-confirmed). Online recruitment methods support engagement with TW, although peer referral and referral through trusted health facilities and organizations remain most effective. CONCLUSIONS This study is responsive to increasing research interest in technology-enhanced methods for cohort research, particularly for hard-to-reach populations. Importantly, the diversity of literacy, technology use, and overall socioeconomic situations in this sample of TW highlights the need to leverage technology to permit a flexible, adaptive methodology that enhances engagement of potential participants living in marginalized contexts while still ensuring rigorous and sound study design. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14704.
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Affiliation(s)
- Andrea L Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Tonia Poteat
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, NY, United States
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Andrew J Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Erin Cooney
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Allan E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sari L Reisner
- The Fenway Institute, Boston, MA, United States
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States
- Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, United States
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Rao A, Ewing W, Ketende S, Wirtz AL, Jumbe V, Trapence G, Kamba D, Umar E, Beyrer C, Muula AS, Baral S. Correlates of Water-Based Lubricant Use Among Men Who Have Sex with Men in Blantyre, Malawi. AIDS Res Hum Retroviruses 2019; 35:833-841. [PMID: 31204861 DOI: 10.1089/aid.2018.0287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Condom compatible lubricants (CCLs), including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011 to March 2012 using respondent-driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% [95% confidence interval (CI): 20.3-31.4] of MSM (106/329) reported primarily using WBL during anal sex. In multivariable analysis, higher income [adjusted odds ratio (aOR): 5.9; 95% CI: 2.48-14.19], family being aware of their sexual practices (aOR: 2.52; 95% CI: 1.29-4.92), and reporting consistent condom use in the last 6 months (aOR: 1.27; 95% CI: 1.06-1.52) were positively associated with WBL use. Increasing age (per 1 year increase in age; aOR: 0.89; 95% CI: 0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi, especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL, suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggests the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
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Affiliation(s)
- Amrita Rao
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Whitney Ewing
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sosthenes Ketende
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrea L. Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vincent Jumbe
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- Centre for Global Health, Trinity College, Dublin, Ireland
| | - Gift Trapence
- Centre for the Development of People, Blantyre, Malawi
| | - Dunker Kamba
- Centre for the Development of People, Blantyre, Malawi
| | - Eric Umar
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Stefan Baral
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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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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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: 20] [Impact Index Per Article: 4.0] [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: 4.2] [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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Ulanja MB, Lyons C, Ketende S, Stahlman S, Diouf D, Kouamé A, Ezouatchi R, Bamba A, Drame F, Liestman B, Baral S. The relationship between depression and sexual health service utilization among men who have sex with men (MSM) in Côte d'Ivoire, West Africa. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2019; 19:11. [PMID: 30832673 PMCID: PMC6399955 DOI: 10.1186/s12914-019-0186-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/09/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND In Cote D'Ivoire, there has been limited coverage of evidence-based sexual health services specifically supporting men who have sex with men (MSM). To date, there has been limited study of the determinants of engagement in these services including multiple intersecting stigmas and depression. METHODS 1301 MSM aged 18 years and older, were recruited using respondent-driven sampling in Abidjan, Yamoussoukro, Gagnoa and Bouake, Cote d'Ivoire from January 2015 to October 2015. Inclusion criteria included anal sex with another man in the past 12 months were to complete a structured questionnaire including the Patient Health Questionnaire (PHQ)-9 to screen for depression. Chi-Square tests were used to test difference in healthcare utilization across variables, and multiple logistic regression was used to test the association between depression and health care utilization represented by HIV and sexually transmittable infection testing and treatment. RESULTS Depression (aOR:1.40, 95% CI: 1.07-1.84), being aged 25-29 years (aOR:1.84, 95% CI: 1.11-3.03),unemployed (aOR:0.64, 95% CI: 0.42-0.98), being a student (aOR:0.67, 95% CI: 0.48-0.96), being identified as male (aOR:0.44, 95% CI: 0.29-0.67), and identifying as homosexual (aOR:0.74, 95% CI:0.56-0.99) were significantly associated with utilization of sexual health care services in the final multivariable model. Healthcare enacted stigma (aOR: 1.55, 95% CI: 1.03-2.33) was associated with utilizing sexual health care services, but perceived healthcare stigma, social stigma and family stigma were not. CONCLUSION Given higher levels of depressive symptomatology among those engaging in sexual health care services, this engagement represents an opportunity for service integration which may have synergistic benefits for both sexual and mental health. Moreover, MSM in Cote D'Ivoire who had engaged in sexual health services were more likely to report having experienced health-care enacted stigma. Taken together, these results reinforce the need for stigma mitigation interventions to support sustained engagement in HIV prevention, treatment and care services as a means of reducing health disparities among MSM in Cote d'Ivoire.
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Affiliation(s)
- Mark B Ulanja
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Carrie Lyons
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Sosthenes Ketende
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shauna Stahlman
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | | | | | | | | | | | - Ben Liestman
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, E7146, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. .,Programme National de Lutte contre le Sida, Ministère de la Santé et de la Lutte contre le Sida, Abidjan, Côte d'Ivoire.
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Identifying MSM-competent physicians in China: a national online cross-sectional survey among physicians who see male HIV/STI patients. BMC Health Serv Res 2018; 18:964. [PMID: 30545370 PMCID: PMC6293610 DOI: 10.1186/s12913-018-3781-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/29/2018] [Indexed: 11/12/2022] Open
Abstract
Background Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) infection and sexually transmitted infection (STI) in China. Inadequate clinical services and poor clinical competency among physicians are major barriers to improving the sexual health of MSM. This study aims to understand physician clinical competency in providing MSM health services in China. Methods We conducted an online cross-sectional survey among Chinese physicians who have seen male patients for STI complaints in the past year. We obtained information on individual demographics, clinical practice, attitudes toward MSM, and interest in contributing to MSM clinical services. We defined an MSM-competent physician as one who asked male patients about sexual orientation, sexual practices, and recommended HIV/ STI testing during a clinic visit. We conducted multivariable logistic regression to identify factors associated with MSM competency. Results In total, 501 physicians completed the survey. The most common subspecialties were dermatovenereology (33.1%), urology (30.1%), and general medicine (14.4%). Roughly half (n = 267, 53.3%) reported seeing MSM in the past 12 months. Among physicians who saw MSM in the past 12 months, 60.3% (n = 161) met criteria as MSM-competent physicians, and most (n = 234, 87.6%) MSM-competent physicians reported positive or neutral attitudes towards MSM. Over 60% of all physicians were willing to participate in activities for improving MSM services, such as training and being on a list of physicians willing to serve MSM. MSM-competent physicians showed no sociodemographic differences compared with non MSM-competent physicians. MSM-competent physicians were more willing to have their medical institution named on a public clinic list capable of serving MSM (aOR: 1.70, 95%CI: 1.01–2.86) and being on a public physician list capable of serving MSM (aOR: 1.77, 95%CI: 1.03–3.03). Conclusions MSM-competent physicians included a broad range of individuals that practiced in diverse clinical settings. Most physicians were interested in improving and expanding MSM clinical services, despite having neutral attitudes toward same-sex behavior. Future interventions should focus on developing MSM clinical competency and expanding services that meet the needs of MSM.
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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: 22] [Impact Index Per Article: 3.7] [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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Agardh C, Weije F, Agardh A, Nyoni J, Ross MW, Kashiha J, Larsson M. Using pharmacists and drugstore workers as sexual healthcare givers: a qualitative study of men who have sex with men in Dar es Salaam, Tanzania. Glob Health Action 2018; 10:1389181. [PMID: 29072110 PMCID: PMC5678459 DOI: 10.1080/16549716.2017.1389181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Previous research has shown that men who have sex with men (MSM) avoid formal healthcare services because of the fear of discrimination as homosexuality is illegal and stigmatized in Tanzania. Instead, self-treatment by medications obtained directly from pharmacies or drugstores may be common when MSM experience symptoms of suspected sexually transmitted infections (STIs) related to sexual activity with men. Objective: To explore MSM’s perceptions and experiences of seeking treatment and advice from pharmacists and drugstore workers in Dar es Salaam, Tanzania, with regards to their sexual health and STI-related problems. Materials and Methods: 15 in-depth interviews were conducted with MSM with experience of seeking assistance relating to their sexual health at pharmacies and drugstores in Dar es Salaam in 2016. A qualitative manifest and latent content analysis was applied to the collected data. Results: Four themes related to different aspects of MSM’s perceptions and experiences of pharmacy care emerged from the analysis: (1) Balancing threats against need for treatment reflected informants’ struggles concerning risks and benefits of seeking assistance at pharmacies and drugstores; (2) Identifying strategies to access required services described ways of approaching a pharmacist when experiencing a sexual health problem; (3) Seeing pharmacists as a first choice of care focused on informants’ reasons for preferring contact with pharmacies/drugstores rather than formal healthcare services; and (4) Lacking reliable services at pharmacies indicated what challenges existed related to pharmacy care. Conclusions: MSM perceived the barriers for accessing assistance for STI and sexual health problems at pharmacies and drugstores as low, thereby facilitating their access to potential treatment. However, the results further revealed that MSM at times received inadequate drugs and consequently inadequate treatment. Multi-facetted approaches are needed, both among MSM and drugstore, pharmacy, and healthcare workers, to improve knowledge of MSM sexual health, STI treatment, and risks of antibiotic resistance.
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Affiliation(s)
- Charlotte Agardh
- a School of Medicine, Faculty of Medicine , Lund University , Malmö , Sweden
| | - Felicia Weije
- a School of Medicine, Faculty of Medicine , Lund University , Malmö , Sweden
| | - Anette Agardh
- b Division for Social Medicine and Global Health, Department of Clinical Sciences, Malmö , Lund University , Malmö , Sweden
| | - Joyce Nyoni
- c Department of Sociology and Anthropology , University of Dar es Salaam , Dar es Salaam , Tanzania
| | - Michael W Ross
- d Programme in Human Sexuality, Department of Family Medicine and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - John Kashiha
- e Community Health Education Services & Advocacy (CHESA) , Dar es Salaam , Tanzania
| | - Markus Larsson
- b Division for Social Medicine and Global Health, Department of Clinical Sciences, Malmö , Lund University , Malmö , Sweden
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Herce ME, Miller WM, Bula A, Edwards JK, Sapalalo P, Lancaster KE, Mofolo I, Furtado MLM, Weir SS. Achieving the first 90 for key populations in sub-Saharan Africa through venue-based outreach: challenges and opportunities for HIV prevention based on PLACE study findings from Malawi and Angola. J Int AIDS Soc 2018; 21 Suppl 5:e25132. [PMID: 30033589 PMCID: PMC6055127 DOI: 10.1002/jia2.25132] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/18/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Providing outreach HIV prevention services at venues (i.e. "hotspots") where people meet new sex partners can decrease barriers to HIV testing services (HTS) for key populations (KP) in sub-Saharan Africa (SSA). We offered venue-based HTS as part of bio-behavioural surveys conducted in urban Malawi and Angola to generate regional insights into KP programming gaps and identify opportunities to achieve the "first 90" for KP in SSA. METHODS From October 2016 to March 2017, we identified and verified 1054 venues in Luanda and Benguela, Angola and Zomba, Malawi and conducted bio-behavioural surveys at 166 using the PLACE method. PLACE interviews community informants to systematically identify public venues where KP can be reached and conducts bio-behavioural surveys at a stratified random sample of venues. We present survey results using summary statistics and multivariable modified Poisson regression modelling to examine associations between receipt of outreach worker-delivered HIV/AIDS education and HTS uptake. We applied sampling weights to estimate numbers of HIV-positive KP unaware of their status at venues. RESULTS We surveyed 959 female sex workers (FSW), 836 men who have sex with men (MSM), and 129 transgender women (TGW). An estimated 71% of HIV-positive KP surveyed were not previously aware of their HIV status, receiving a new HIV diagnosis through PLACE venue-based HTS. If venue-based HTS were implemented at all venues, 2022 HIV-positive KP (95% CI: 1649 to 2477) who do not know their status could be reached, including 1666 FSW (95% CI: 1397 to 1987), 274 MSM (95% CI: 160 to 374), and 82 TG (95% CI: 20 to 197). In multivariable analyses, FSW, MSM, and TGW who received outreach worker-delivered HIV/AIDS education were 3.15 (95% CI: 1.99 to 5.01), 3.12 (95% CI: 2.17 to 4.48), and 1.80 (95% CI: 0.67 to 4.87) times as likely, respectively, as those who did not to have undergone HTS within the last six months. Among verified venues, <=68% offered any on-site HIV prevention services. CONCLUSIONS Availability of HTS and other HIV prevention services was limited at venues. HIV prevention can be delivered at venues, which can increase HTS uptake and HIV diagnosis among individuals not previously aware of their status. Delivering venue-based HTS may represent an effective strategy to reach the "first 90" for KP in SSA.
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Affiliation(s)
- Michael E Herce
- Department of MedicineUNC Institute for Global Health & Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
- UNC Project—MalawiLilongweMalawi
| | - William M Miller
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Kathryn E Lancaster
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | | | | | - Sharon S Weir
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Mayer KH, de Vries H. HIV and sexually transmitted infections: responding to the "newest normal". J Int AIDS Soc 2018; 21:e25164. [PMID: 29989338 PMCID: PMC6038147 DOI: 10.1002/jia2.25164] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/27/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kenneth H Mayer
- Fenway HealthThe Fenway InstituteBostonMAUSA
- Department of Infectious DiseasesBeth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolHarvard UniversityBostonMAUSA
| | - Henry de Vries
- Department of Infectious DiseasesPublic Health Service of AmsterdamAmsterdamThe Netherlands
- Department of DermatologyAcademic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Infection and Immunity Institute (AI&II)Academic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands
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Qiao S, Zhou G, Li X. Disclosure of Same-Sex Behaviors to Health-care Providers and Uptake of HIV Testing for Men Who Have Sex With Men: A Systematic Review. Am J Mens Health 2018; 12:1197-1214. [PMID: 29947563 PMCID: PMC6142161 DOI: 10.1177/1557988318784149] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
To promote HIV-testing and offer optimal care for men who have sex with men (MSM), health-care providers (HCPs) must first be aware of their patients’ sexual behaviors. Otherwise, HCPs may overlook MSM’s risks for HIV infection and their special health-care needs. For MSM, reporting their same-sex behaviors to HCPs (disclosure to HCPs) may promote their linkage to HIV prevention and treatment cascade and improve their health outcomes. No literature review has been conducted to examine the relationship between disclosure to HCPs and uptake of HIV-testing among MSM. The current study reviewed and synthesized findings from 29 empirical studies published in English by 2016. We summarized the rates of MSM’s disclosure to HCPs, investigated the association between disclosure and HIV-testing among MSM, identified potential facilitators and barriers for disclosure, and discussed the implications of our findings in research and clinical practices. The disclosure rates varied across subgroups and study settings, ranging from 16% to 90% with a median of 61%. Disclosure to HCPs was positively associated with uptake of HIV-testing. African American MSM were less likely to disclose to HCPs. MSM who lived in urban settings with higher education attainment and higher income were more likely to disclose. MSM tended to perceive younger or gay-friendly doctors as safer targets of disclosure. Clinics with LGBT-friendly signs were viewed as safer contexts for disclosure. Having previous communications about substance use, sex, and HIV with HCPs could also facilitate disclosure. The main reasons for nondisclosure included lack of probing from HCPs, concerns on confidentiality breach and stigma, and perceived irrelevance with services. Providing appropriate trainings for HCPs and creating gay-friendly clinical settings can be effective strategies to facilitate disclosures of same-sex behaviors among MSM and meet their specific medical needs. Interventions to promote disclosure should give priorities to MSM from the most marginalized subgroups (e.g., MSM in rural areas, MSM of ethnic minorities).
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Affiliation(s)
- Shan Qiao
- 1 Department of Health Promotion, Education, and Behavior & South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Columbia, SC, USA
| | - Guangyu Zhou
- 1 Department of Health Promotion, Education, and Behavior & South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Columbia, SC, USA.,2 School of Psychological and Cognitive Sciences and Beijing Key Laboratory of Behavior and Mental Health, Peking University, Beijing, China
| | - Xiaoming Li
- 1 Department of Health Promotion, Education, and Behavior & South Carolina SmartState Center for Healthcare Quality (CHQ), University of South Carolina Arnold School of Public Health, Columbia, SC, USA
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Joarder T, George A, Sarker M, Ahmed S, Peters DH. Who are more responsive? Mixed-methods comparison of public and private sector physicians in rural Bangladesh. Health Policy Plan 2018; 32:iii14-iii24. [PMID: 29149312 DOI: 10.1093/heapol/czx111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/12/2022] Open
Abstract
Responsiveness of physicians (ROPs) reflects the social actions by physicians to meet the legitimate expectations of health care users. Responsiveness is important since it improves understanding and care seeking by users, as well as fostering trust in health systems rather than replicating discrimination and entrenching inequality. Given widespread public and private sector health care provision in Bangladesh, we undertook a mixed-methods study comparing responsiveness of public and private physicians in rural Bangladesh. The study included in-depth interviews with physicians (n = 12, seven public, five private) and patients (n = 7, three male, four female); focus group discussions with users (four sessions, two male and two female); and observations in consultation rooms of public and private sector physicians (1 week in each setting). This was followed by structured observation of patient consultations with 195 public and 198 private physicians using the ROPs Scale, consisting of five domains (Friendliness; Respecting; Informing and guiding; Gaining trust; and Financial sensitivity). Qualitative data were analysed by framework analysis and quantitative data were analyzed using two-sample t-test, multiple linear regression, multivariate analysis of variance, and descriptive discriminant analyses. The mean responsiveness score of public sector physicians was statistically different from private sector physicians: -0.29 vs 0.29, i.e. a difference of - 0.58 (P-value < 0.01; 95% CI - 0.77, -0.39) on a normalized scale. Despite relatively higher level of responsiveness of private sector, according to qualitative findings, neither of the sectors performed optimally. Private physicians scored higher in Friendliness, Respecting and Informing and guiding; while public sector physicians scored higher in other domains. 'Respecting' domain was found as the most important. Unlike findings from other studies in Bangladesh, instead of seeing one sector as better than the other, this study identified areas of responsiveness where each sector needs improvements.
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Affiliation(s)
- Taufique Joarder
- Department of International Health (Health Systems) Johns Hopkins Bloomberg School of Public Health, USA.,James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Mohakhali, Dhaka 1212, Bangladesh
| | - Asha George
- Faculty of Community and Health Sciences, SARChI Health Systems, Complexity and Social Change School of Public Health, University of Western Cape, South Arica
| | - Malabika Sarker
- James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Mohakhali, Dhaka 1212, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - David H Peters
- Department of International Health (Health Systems) Johns Hopkins Bloomberg School of Public Health, USA
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Brooks H, Llewellyn CD, Nadarzynski T, Pelloso FC, De Souza Guilherme F, Pollard A, Jones CJ. Sexual orientation disclosure in health care: a systematic review. Br J Gen Pract 2018; 68:e187-e196. [PMID: 29378698 PMCID: PMC5819984 DOI: 10.3399/bjgp18x694841] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/10/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Significant health disparities between sexual minority individuals (that is, lesbian, gay, bisexual, or transgender [LGBT]) and heterosexual individuals have been demonstrated. AIM To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by LGBT adults in healthcare settings. DESIGN AND SETTING Mixed methods systematic review, including qualitative, quantitative, and mixed methods papers following PRISMA guidelines. METHOD Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT) and a qualitative synthesis was performed. Studies were included if their participants were aged ≥18 years who either identified as LGBT, had a same-sex sexual relationship, or were attracted to a member of the same sex. RESULTS The review included 31 studies representing 2442 participants. Four overarching themes were identified as barriers or facilitators to SO disclosure: the moment of disclosure, the expected outcome of disclosure, the healthcare professional, and the environment or setting of disclosure. The most prominent themes were the perceived relevance of SO to care, the communication skills and language used by healthcare professionals, and the fear of poor treatment or reaction to disclosure. CONCLUSION The facilitators and barriers to SO disclosure by LGBT individuals are widespread but most were modifiable and could therefore be targeted to improve healthcare professionals' awareness of their patients' SO. Healthcare professionals should be aware of the broad range of factors that influence SO disclosure and the potential disadvantageous effects of non-disclosure on care. The environment in which patients are seen should be welcoming of different SOs as well as ensuring that healthcare professionals' communication skills, both verbal and non-verbal, are accepting and inclusive.
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Affiliation(s)
| | | | - Tom Nadarzynski
- Department of Psychology, University of Southampton, Southampton, UK
| | | | | | | | - Christina J Jones
- Department of Clinical Medicine, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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Ferguson L, Nicholson A, Henry I, Saha A, Sellers T, Gruskin S. Assessing changes in HIV-related legal and policy environments: Lessons learned from a multi-country evaluation. PLoS One 2018; 13:e0192765. [PMID: 29474486 PMCID: PMC5825062 DOI: 10.1371/journal.pone.0192765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/30/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction There is growing recognition in the health community that the legal environment—including laws, policies, and related procedures—impacts vulnerability to HIV and access to HIV-related services both positively and negatively. Assessing changes in the legal environment and how these affect HIV-related outcomes, however, is challenging, and understanding of appropriate methodologies nascent. Methods We conducted an evaluation of a UNDP project designed to strengthen legal environments to support the human rights of key populations, in particular LGBT populations, women and girls, affected by HIV in sub-Saharan Africa. We analyzed data on activities designed to improve legal environments through a systematic document review and 53 qualitative interviews. Results The project made substantial strides towards legal change in many places, and examples provide broader lessons for work in this area. Two core pillars appear fundamental: a government-led participatory assessment of the legal environment, and building the capacity of those impacted by and engaged in this work. Systematic attention to human rights is vital: it can help open new spaces for dialogue among diverse stakeholders, foster new collaborations, and ensure local ownership, nuanced understanding of the political landscape, attention to marginalized populations, and accountability for (in)action. Entry points for effecting legal change go beyond “HIV laws” to also include other laws, national policies and strategies. Conclusion Conducting legal environment assessments, multi-stakeholder dialogues, action planning and related activities, alongside capacity building, can contribute to changes in knowledge and attitudes directly relevant to reforming laws that are found to be harmful. Shorter-term goals along the causal pathway to legal change (e.g. changes in policy) can constitute interim markers of success, and recognition of these can maintain momentum. Increasing understanding of progress towards changes in the legal environment that can positively affect HIV-related outcomes is important in working to improve the health and lives of people living with HIV.
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Affiliation(s)
- Laura Ferguson
- Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles, California, United States of America
- * E-mail:
| | - Alexandra Nicholson
- Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles, California, United States of America
| | - Ian Henry
- Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles, California, United States of America
| | - Amitrajit Saha
- HIV, Health and Development Team, United Nations Development Program, Istanbul Regional Hub, Istanbul, Turkey
| | - Tilly Sellers
- Health and Development Team, United Nations Development Program, Regional Centre for Africa, Addis Ababa, Ethiopia
| | - Sofia Gruskin
- Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles, California, United States of America
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Das M, Angeli F, Krumeich AJSM, van Schayck OCP. Patterns of illness disclosure among Indian slum dwellers: a qualitative study. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2018; 18:3. [PMID: 29338708 PMCID: PMC5771001 DOI: 10.1186/s12914-018-0142-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Slum dwellers display specific traits when it comes to disclosing their illnesses to professionals. The resulting actions lead to poor health-seeking behaviour and underutilisation of existing formal health facilities. The ways that slum people use to communicate their feelings about illness, the type of confidants that they choose, and the supportive and unsupportive social and cultural interactions to which they are exposed have not yet been studied in the Indian context, which constitutes an important knowledge gap for Indian policymakers and practitioners alike. To that end, this study examines the patterns of illness disclosure in Indian slums and the underpinning factors which shape the slum dwellers' disclosing attitude. METHODS In-depth, semi-structured interviews were conducted among 105 men and 113 women who experienced illness in the year prior to the study period. Respondents were selected from four urban slums in two Indian cities, Bangalore and Kolkata. RESULTS Findings indicate that women have more confidants at different social levels, while men have a limited network of disclosures which is culturally and socially mediated. Gender role limitations, exclusion from peer groups and unsupportive local situations are the major cause of disclosure delay or non-disclosure among men, while the main concerns for women are a lack of proper knowledge about illness, unsupportive responses received from other people on certain occasions, the fear of social stigma, material loss and the burden of the local situation. Prompt sharing of illness among men is linked with prevention intention and coping with biological problems, whereas factors determining disclosure for women relate to ensuring emotional and instrumental safety, preventing collateral damage of illness, and preventing and managing biological complications. CONCLUSIONS The findings reveal that patterns of disclosure are not determined by the acknowledgment of illness but largely depend on the interplay between individual agency, disclosure consequences and the socio cultural environment. The results of this study can contribute significantly to mitigating the pivotal knowledge gap between health policymakers, practitioners and patients, leading to the formulation of policies that maximise the utilisation of health facilities in slums.
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Affiliation(s)
- Moumita Das
- School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
- Institute for Social and Economic Change (ISEC), Bangalore, India
| | - Federica Angeli
- Department of Organization Studies, School of Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands
| | - Anja J. S. M. Krumeich
- Department of Health Ethics and Society, School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
| | - Onno C. P. van Schayck
- Department of General Practice, School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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Joarder T, George A, Ahmed SM, Rashid SF, Sarker M. What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh. PLoS One 2017; 12:e0189962. [PMID: 29253891 PMCID: PMC5734771 DOI: 10.1371/journal.pone.0189962] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022] Open
Abstract
Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research.
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Affiliation(s)
- Taufique Joarder
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Department of International Health (Health Systems), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Asha George
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Syed Masud Ahmed
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Sabina Faiz Rashid
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Joarder T, Mahmud I, Sarker M, George A, Rao KD. Development and validation of a structured observation scale to measure responsiveness of physicians in rural Bangladesh. BMC Health Serv Res 2017; 17:753. [PMID: 29157242 PMCID: PMC5697080 DOI: 10.1186/s12913-017-2722-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Responsiveness of physicians is the social actions that physicians do to meet the legitimate expectations of service seekers. Since there is no such scale, this study aimed at developing one for measuring responsiveness of physicians in rural Bangladesh, by structured observation method. METHODS Data were collected from Khulna division of Bangladesh, through structured observation of 393 patient-consultations with physicians. The structured observation tool consisted of 64 items, with four Likert type response categories, each anchored with a defined scenario. Inter-rater reliability was assessed by same three raters observing 30 consultations. Data were analyzed by exploratory factor analysis (EFA), followed by assessment of internal consistency by ordinal alpha coefficient, inter-rater reliability by intra-class correlation coefficient (ICC), concurrent validity by correlating responsiveness score with waiting time, and known group validity by comparing public and private sector physicians. RESULTS After removing items with more than 50% missing values, 45 items were considered for EFA. Parallel analysis suggested a 5-factor model. Nine items were removed from the list owing to < 0.50 communality, <0.32 loading in un-rotated matrix, and <0.30 on any factor in rotated matrix. Since 34 items (i.e., the number of remaining items after removing nine items by EFA) were loaded neatly under five factors, explained 61.38% of common variance, and demonstrated high internal consistency with coefficient of 0.91, this was adopted as the Responsiveness of Physicians Scale (ROP-Scale). The five factors were named as 1) Friendliness, 2) Respecting, 3) Informing and guiding, 4) Gaining trust, and 5) Financial sensitivity. Inter-rater reliability was high, with an ICC of 0.64 for individual rater's reliability and 0.84 for average reliability scores. Positive correlation with waiting time (0.51), and higher score of private sector by 0.18 point denote concurrent, and known group validity, respectively. CONCLUSIONS The ROP-Scale consists of 34 items grouped under five factors. One can apply this with confidence in comparable settings, as this scale demonstrated high internal consistency and inter-rater reliability. More research is needed to test this scale in other settings and with other types of providers.
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Affiliation(s)
- Taufique Joarder
- BRAC James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Dhaka, Mohakhali 1212 Bangladesh
| | - Ilias Mahmud
- BRAC James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Dhaka, Mohakhali 1212 Bangladesh
- Department of Public Health, College of Public Health and Health Informatics, Qassim University, Bukayriah, Post box: 828, Post code: 51941 Qassim, Saudi Arabia
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Dhaka, Mohakhali 1212 Bangladesh
| | - Asha George
- School of Public Health, University of Western Cape, Cape Town, South Africa
| | - Krishna Dipankar Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Suite E8132, Baltimore, MD 20205 USA
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Shaver J, Sullivan P, Siegler A, de Voux A, Phaswana-Mafuya N, Bekker LG, Baral SD, Wirtz AL, Beyrer C, Brown B, Stephenson R. Comparing Provider and Client Preferences for HIV Prevention Services in South Africa among Men Who Have Sex with Men. J Int Assoc Provid AIDS Care 2017; 16:562-571. [PMID: 29108450 DOI: 10.1177/2325957417736611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Combination prevention efforts are now recommended toward reducing HIV incidence among men who have sex with men (MSM). Understanding the perceptions of both MSM and service providers is critical to informing the development of prevention packages and ultimately improving intervention effectiveness. This study assessed the preferences of MSM and health service providers in the administration of HIV-prevention efforts. Qualitative data were gathered from a series of separate MSM and health care provider focus groups in 2 South African cities. Participants discussed HIV-prevention services and MSM client experiences within South Africa and identified the 3 most important clinic characteristics and 3 most important HIV-prevention services for MSM clients. Priorities indicated by both MSM and health care providers were confidentiality of visit, friendly staff, and condoms, while discrepancies existed between MSM and providers regarding provider consistency and the provision of pre-exposure prophylaxis/post-exposure prophylaxis (PrEP/PEP) and lubricant as prevention methods. Effective interventions must address these discrepancies through the design of intervention and provider training to optimally accommodate MSM.
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Affiliation(s)
- John Shaver
- 1 Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Patrick Sullivan
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Aaron Siegler
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Alex de Voux
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nancy Phaswana-Mafuya
- 3 HIV/AIDS/STI/and TB (HAST), Human Sciences Research Council, Port Elizabeth, South Africa.,4 Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
| | - Linda-Gail Bekker
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,5 Desmond Tutu HIV Foundation, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Stefan D Baral
- 6 Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrea L Wirtz
- 6 Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chris Beyrer
- 6 Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ben Brown
- 4 Nelson Mandela Metropolitan University, Port Elizabeth, South Africa
| | - Rob Stephenson
- 1 Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
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Larsson M, Mohamed Shio J, Ross MW, Agardh A. Acting within an increasingly confined space: A qualitative study of sexual behaviours and healthcare needs among men who have sex with men in a provincial Tanzanian city. PLoS One 2017; 12:e0183265. [PMID: 28817626 PMCID: PMC5560662 DOI: 10.1371/journal.pone.0183265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/01/2017] [Indexed: 12/04/2022] Open
Abstract
Objective To explore risk perceptions, sexual practices and healthcare needs among men who have sex with men in the provincial city of Tanga in northern Tanzania. Previous research suggests that HIV/STIs are increasing problems for this population. Yet, few studies have been conducted outside the urban area of Dar es Salaam, which has limited our knowledge about the HIV/STI risk factors and healthcare needs among men who have sex with men who live outside major metropolitan areas. Method During three months in 2013, 10 in-depth interviews with men who have sex with men were conducted in Tanga. Data were interpreted through qualitative content analysis. Results The theme that emerged was labelled “Acting within an increasingly confined space”. The theme reflects the interference of stigma in men’s lives, and in the face of potential discrimination, men perceived their sexual and healthcare choices as limited. This created obstacles for forming romantic and sexual relationships, insisting on consistent condom use with sexual partners, maintaining open and conducive relationships with family, and accessing healthcare services when required. Conclusions Sexual stigma is a concern as it contributes to HIV/STI risk-related behaviours among men who have sex with men. Priority should be given to programmes that support same-sex practicing men in their efforts to make informed choices regarding their sexual health. Creating safe cyber networks provides an opportunity to reach this population with targeted sexual health education messages. Such programmes might be even more urgent in smaller towns and rural areas where gay specific initiatives are more limited than in urban areas.
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Affiliation(s)
- Markus Larsson
- Division of Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- * E-mail:
| | - Jasmine Mohamed Shio
- Amsterdam Institute for Social Science Research, Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael W. Ross
- Programme in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Anette Agardh
- Division of Social Medicine and Global Health, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Engel N, Davids M, Blankvoort N, Dheda K, Pant Pai N, Pai M. Making HIV testing work at the point of care in South Africa: a qualitative study of diagnostic practices. BMC Health Serv Res 2017. [PMID: 28623923 PMCID: PMC5473989 DOI: 10.1186/s12913-017-2353-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background Point of care testing promises to reduce delays in diagnosing and initiating treatment for infectious diseases such as Human Immuno-deficiency Virus (HIV). In South Africa, decentralized HIV testing with rapid tests offers important lessons for point of care testing programs. Yet, little is known about the strategies of providers and clients to make HIV testing successful in settings short of equipment, human resources and space. We aimed at examining these strategies. Methods This paper is based on a larger qualitative study of diagnostic practices across major diseases and actors in homes, clinics, communities, hospitals and laboratories in South Africa. We conducted 101 semi-structured interviews and 7 focus group discussions with doctors, nurses, community health workers, patients, laboratory technicians, policymakers, hospital managers and manufacturers between September 2012 and June 2013 in Durban, Cape Town and Eastern Cape. The topics explored included diagnostic processes and challenges, understanding of diagnosis, and visions of ideal tests. For this paper, the data on HIV testing processes in clinics, communities and hospitals was used. Results Strategies to make HIV testing work at point of care involve overcoming constraints in equipment, spaces, human resources and workload and actively managing diagnostic processes. We grouped these strategies into subthemes: maintaining relationships, adapting testing guidelines and practices to stock-outs, to physical space, and to different clients, turning the test into a tool to reach another aim and turning the testing process into a tool to enhance adherence. These adaptive strategies are locally negotiated solutions, often ad-hoc, depending on personal commitment, relationships, human resources, physical space and referral systems. In the process, testing is redefined and repurposed. Not all of these repurposing acts are successful in ensuring a timely diagnosis. Some lead to disruptions, unnecessary testing or delays with at times unclear implications for quality of diagnosis. Conclusion Tests shape relationships, professional roles and practices of users at point of care. At the same time, testing processes are dynamic and test results and processes take on new meanings for clients and providers. These insights are crucial for understanding the contexts within which diagnostic devices and policies need to function. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2353-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht University, Postbus 616, NL - 6200, MD, Maastricht, The Netherlands.
| | - Malika Davids
- Lung Infection and Division of pulmonology and UCT lung Institute Department of Medicine, University of Cape Town, Anzio Road, Cape Town, 7925, South Africa
| | - Nadine Blankvoort
- Department of Health, Ethics & Society, Research School for Public Health and Primary Care, Maastricht University, Postbus 616, NL - 6200, MD, Maastricht, The Netherlands
| | - Keertan Dheda
- Lung Infection and Division of pulmonology and UCT lung Institute Department of Medicine, University of Cape Town, Anzio Road, Cape Town, 7925, South Africa
| | - Nitika Pant Pai
- Division of Clinical Epidemiology, Department of Medicine, McGill University and McGill University Health Centre, V Building, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, H3A1A1, Canada
| | - Madhukar Pai
- McGill International TB Centre, Department of Epidemiology & Biostatistics, McGill University, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada
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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: 46] [Impact Index Per Article: 6.6] [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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Geographical disparities in HIV prevalence and care among men who have sex with men in Malawi: results from a multisite cross-sectional survey. Lancet HIV 2017; 4:e260-e269. [PMID: 28256422 DOI: 10.1016/s2352-3018(17)30042-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/01/2016] [Accepted: 12/13/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidemiological assessment of geographical heterogeneity of HIV among men who have sex with men (MSM) is necessary to inform HIV prevention and care strategies in the more generalised HIV epidemics across sub-Saharan Africa, including Malawi. We aimed to measure the HIV prevalence, risks, and access to HIV care among MSM across multiple localities to better inform HIV programming for MSM in Malawi. METHODS Between Aug 1, 2011, and Sept 13, 2014, we recruited MSM into cross-sectional research via respondent-driven sampling (RDS) in seven districts of Malawi. RDS and site weights were used to estimate national HIV prevalence and engagement in care and in multilevel regression models to identify correlates of prevalent HIV infection. The comparative prevalence ratio of HIV among MSM relative to adult men was calculated by use of direct age-stratification. FINDINGS 2453 MSM were enrolled with a population HIV prevalence of 18·2% (95% CI 15·5-21·2), as low as 4·1% (2·2-7·6) in Mzuzu and as high as 24·5% (19·5-30·3) in Mulanje. The comparative HIV prevalence ratio was 2·52 when comparing MSM with the adult male population. Age-stratified HIV prevalence showed early onset of infection with 11·8% (95% CI 7·3-18·4) of MSM aged 18-19 years HIV infected. Factors positively associated with HIV infection included being aged 21-30 years and reporting female or transgender identity. Among HIV infected MSM, less than 1% reported ever being diagnosed with HIV infection (0·9%, 95% CI 0·4-2·5) and initiated antiretroviral treatment (0·2%, 0·2-0·3). INTERPRETATION HIV disproportionately affects MSM in Malawi with disparities sustained across the HIV care continuum. These issues are geographically heterogeneous and begin among young MSM, supporting geographically focused and age-specific approaches to confidential HIV testing with linkage to HIV services. FUNDING Malawi Department of Nutrition, HIV and AIDS (DNHA), UNDP, UNFPA, UNAIDS, and UNICEF.
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45
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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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Ross MW, Larsson M, Nyoni JE, Agardh A. Prevalence of STI symptoms and high levels of stigma in STI healthcare among men who have sex with men in Dar es Salaam, Tanzania: a respondent-driven sampling study. Int J STD AIDS 2016; 28:925-928. [PMID: 27913795 DOI: 10.1177/0956462416683625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Symptoms of sexually transmitted infections (STIs), whether they are presented for treatment or diagnosis, and how they are received by the clinician where they are presented, may be concomitants of stigma associated with homosexuality in homophobic climates. We analyzed respondent-driven sampling data from a study on 200 young men who have sex with men (MSM) in Dar es Salaam, Tanzania to examine sample prevalence, treatment and clinician response to 10 symptoms potentially associated with STIs. Survey measures included 10 self-reported STI symptoms, further specified according to location (genital, anal, oral), further specified according to place of diagnosis, place of, treatment whether there was pharmacy treatment or self-medication, healthcare worker (HCW) inquiries about source of infection and whether the HCW was polite. Most common symptoms reported were genital pain, burning urination, genital itching/burning, penile discharge, and groin swelling. Anal symptoms had the lowest proportion of treatment at public clinics and among the highest proportion of pharmacy treatment; anal sores had the highest proportion of self-medication. HCWs were reported as not being polite in response to 71-90% of the symptoms, (median = 82%). The findings suggest that stigma and negative HCW response are barriers to public clinic treatment for MSM in Tanzania and that these may have implications for both STI treatment and the HIV cascade.
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Affiliation(s)
- Michael W Ross
- 1 Program in Human Sexuality, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Markus Larsson
- 2 Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Joyce E Nyoni
- 3 Department of Anthropology and Sociology, University of Dar es Salaam, Dar es Salaam, Tanzania
| | - Anette Agardh
- 2 Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Risk Factors Associated with HIV Among Men Who Have Sex Only with Men and Men Who Have Sex with Both Men and Women in Three Urban Areas in Mozambique. AIDS Behav 2016; 20:2296-2308. [PMID: 27059491 DOI: 10.1007/s10461-016-1390-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Using respondent-driven sampling (RDS), an integrated biological behavioral survey among men that have sex with men (MSM) enrolled 457 participants in Maputo [63.0 % were MSM who had sex with women (MSMW)], 538 in Beira (36.2 % MSMW) and 330 in Nampula-Nacala (54.8 % MSMW) in 2011. Analysis suggests that MSM who have sex only with men (MSMO) had increased odds of having HIV (aOR 2.7) compared to MSMW. HIV among MSMO associated with age, self-reported STI (aOR 4.2), having a single male anal partner (aOR 3.8) and having transactional sex with a man (aOR 3.5) in the past year. Among MSMW, HIV associated with age, lower education (aOR 32.5), being uncircumcised (aOR 3.1) and having transactional sex with a woman (aOR 6.0) in the past year. Findings confirm that MSMO and MSMW have distinct HIV risks in Mozambique; HIV programs for MSM in Southern Africa should take such differences into consideration.
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Schwartz SR, Nowak RG, Orazulike I, Keshinro B, Ake J, Kennedy S, Njoku O, Blattner WA, Charurat ME, Baral SD. The immediate eff ect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort. Lancet HIV 2016; 2:e299-306. [PMID: 26125047 DOI: 10.1016/s2352-3018(15)00078-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria. METHODS The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with χ2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression. FINDINGS Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0・0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0・001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2・57, 95% CI 1・29–5・10; p=0・007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0・013). INTERPRETATION These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment. FUNDING National Institutes of Health.
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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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Santos GM, Makofane K, Arreola S, Do T, Ayala G. Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men. Sex Transm Infect 2016; 93:62-64. [PMID: 26944344 DOI: 10.1136/sextrans-2015-052386] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 02/10/2016] [Accepted: 02/14/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. METHODS Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, 'how accessible are ____' services) between MSM who responded 'yes'/'no' to: 'have you ever been arrested or convicted for being gay/MSM?' RESULTS Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. CONCLUSIONS Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.
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Affiliation(s)
- Glenn-Milo Santos
- San Francisco Department of Public Health, Center for Public Health Research, San Francisco, California, USA.,Department of Community Health Systems, University of California, San Francisco, San Francisco, California, USA
| | - Keletso Makofane
- The Global Forum on MSM and HIV (MSMGF), Oakland, California, USA
| | - Sonya Arreola
- The Global Forum on MSM and HIV (MSMGF), Oakland, California, USA
| | - Tri Do
- Department of Community Health Systems, University of California, San Francisco, San Francisco, California, USA
| | - George Ayala
- The Global Forum on MSM and HIV (MSMGF), Oakland, California, USA
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