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

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

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.

Examining HIV Knowledge and Sexually Risky Behaviors among Female Sex Workers in Kampala, Uganda

HIV incidence remains alarmingly high among female sex workers (FSWs) in Uganda, necessitating targeted interventions. This study aimed to identify individual and provider-level barriers and facilitators to primary HIV prevention among FSWs in an urban setting. Focus groups involving FSWs and healthcare providers (HCPs) were conducted to inform the development of tailored prevention interventions. Results revealed that all participants had mobile phones, recent sexual activity, and a history of HIV testing, with high rates of sexually transmitted infections and varying HIV test results. FSWs displayed a well-informed awareness of HIV transmission risks, emphasizing the threat for those not testing positive. They unanimously recognized the crucial role of HIV testing in informing, mitigating risks, promoting ART use, and endorsing consistent condom usage. Despite heightened awareness, HCPs noted potential underestimation of vulnerability. Various challenges, including inadequate condom usage, substance abuse, and client dynamics, underscored the complexity of safeguarding against HIV transmission among FSWs. Widespread alcohol and drug use, including marijuana, kuber, and khat, served as coping mechanisms and social facilitators. Some FSWs successfully reduced alcohol intake, highlighting challenges in addressing substance use. FSWs preferred group discussions in health education programs, emphasizing peer interactions and the effectiveness of visual aids in HIV prevention education. This study provides comprehensive insights to guide the development of targeted interventions addressing the multi-faceted challenges FSWs face in HIV prevention.

"We must help them despite who they are…": healthcare providers' attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya

BACKGROUND

Compared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM's limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya.

METHODS

In September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12.

RESULTS

Analysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs' personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of "treating others as one would want to be treated" as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to "convert" YMSM's perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services.

CONCLUSION

There is need for interventions to improve HCPs' knowledge of YMSM's health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.

"For my safety and wellbeing, I always travel to seek health care in a distant facility"-the role of place and stigma in HIV testing decisions among GBMSM - BSGH 002

Gays, bisexuals, and all other men who have sex with men (GBMSM) are heavily impacted by HIV in Ghana compared to the general population. In addition to HIV and same-sex intercourse stigma, barriers such as reduced privacy, lower-income status and limited health care facilities (HCF) affect HIV testing decisions among GBMSM. We employed a phenomenological research design to understand the role of place and stigma in HIV testing among GBMSM in slums. GBMSM (n = 12) from slums in Accra and Kumasi, Ghana, were recruited and engaged in face-to-face interviews. We used a multiple reviewer summative content analysis to analyze and organize our key findings. The HIV testing options we identified include 1. Government HCF, 2. NGO and community outreach 3. Peer-educated services. Factors influencing GBMSM to test for HIV at HCF outside their areas included 1. The location of HCF 2. HIV and sexual stigma from slum areas 3. Positive HCW attitudes at distant HCF. 4. Negative Healthcare worker (HCW) attitudes towards GBMSM. These findings highlighted how stigma from slums and HCW influence HIV testing decisions and the need for place-based interventions to address stigma among HCW in slums to improve testing among GBMSM.

Low engagement of key populations in HIV health services in Tanzania: analysis of community, legal and policy factors

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.

Stigma and discrimination against people living with HIV by health care providers in Egypt

OBJECTIVE

HIV/AIDS has been recently increasingly observed in developing countries including Egypt. This study aimed to explore stigma and discrimination attitudes of health care providers (HCPs) in Egypt, as elimination of stigma in healthcare settings is a priority to improve case detection and management.

METHODS

A Google form questionnaire using the validated Arabic version of Health Care Provider HIV/AIDS Stigma Scale (HPASS) was sent to physicians and nurses of Ministry of health (MOH) hospitals and University hospitals in 10 randomly selected Governorates in Egypt. Data was collected from July to August, 2022 from 1577 physicians and 787 nurses. Bivariate and multivariable linear regression analyses were used to identify the predictors of the stigmatizing attitude of HCPs towards People living with HIV (PLHIV).

RESULTS

The majority of HCPs had worries about contracting HIV infection from their patients (75.8% of physicians and 77% of nurses). They believed that protective measures are not good enough to protect them from getting infected (73.9% of physicians and 74.7% of nurses). About half of the participants had worries about the safety of performing blood investigations to PLHIV (54% of physicians and 59.9% of nurses). Less than half of HCPs believed they have the right to refuse providing care to patients to protect themselves (44.6% of physicians and 50.1% of nurses). Only 10.5% of physicians and 11.9% of nurses have previously refused to provide health care to PLHIV. There was a significantly higher mean score of prejudice and stereotype among nurses compared to physicians (prejudice; 27.34 ± 7.88 vs 26.17 ± 7.5, stereotype; 18.54 ± 4.61 vs 16.43 ± 5.21, for nurses and physicians, respectively). Less years of physicians' experience (B = -0.10, p < 0.01) and rural residence (B = 1.48, p < 0.05) were significantly associated with higher prejudice score while having lower qualification (B = -1.47, p < 0.001) was significantly associated with higher stereotype score.

CONCLUSION

Standards of practice should be developed to adjust the services and prepare HCPs to provide medical care free from stigma and discrimination against PLHIV. Improving knowledge of HCPs regarding the methods of transmission of HIV, the use of infection control measures and the emotional factors shaping lives of PLHIV should be targeted through updated training programs. More concern should be directed to young providers in the training programs.

"I decided in my heart I have to complete the sessions": A qualitative study on the acceptability of an evidence-based HIV risk reduction intervention among women engaged in sex work in Uganda

BACKGROUND

The HIV burden remains a critical public health concern and women engaged in sex work [WESW] are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high rates of HIV prevalence among WESW. Yet, they have not been targeted by theory-informed HIV prevention intervention approaches.

METHODS

We conducted semi-structured in-depth interviews with 20 WESW upon intervention completion to explore their experiences with an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda (2018-2023. Specifically, we explored their initial motivations and concerns for participating in the intervention, barriers and facilitators to attendance, and their feedback on specific intervention characteristics.

RESULTS

The main expectations revolved around access to health-related information, including information on STIs, HIV, and PrEP as well as on how one can protect themselves while engaging in sex work. Initial concerns were around potential breach of confidentiality and fear of arrest. The main facilitators for session attendance were the motivation to learn health-related information, the attitude of facilitators, and the incentives received for participation, whereas main challenges were related to family commitments and work schedules. WESW appreciated the group format of the intervention and found the location and times of the intervention delivery acceptable.

DISCUSSION AND CONCLUSIONS

Overall, our findings suggest that the HIV risk reduction intervention was appropriate and acceptable to WESW. Yet, WESW experience unique concerns and barriers that need to be accounted for when designing interventions targeting this population, especially in resource-limited settings where sex work is illegal and highly stigmatized.

CLINICAL TRIAL REGISTRATION

NCT03583541.

Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020

INTRODUCTION

Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement.

METHODS

Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020.

RESULTS

Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility.

CONCLUSIONS

Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.

Classroom Instruction: Medical Students' Attitudes Toward LGBTQI+ Patients

The Association of American Medical Colleges declared it essential that medical students receive instruction on the health needs of lesbian, gay, bisexual, transgender, questioning, and intersex (LGBTQI⁺) individuals. The integration of LGBTQI⁺ health and instruction in medical curricula, however, is scant. A pre-post confidential survey study was completed by first-year medical students (N = 103; 85% response rate) in the context of classroom instruction. The California State University Northbridge instrument assessed students' perspectives on LGBTQI⁺ Patient-Care, Comfort with LGBTQI⁺ Patient Interactions, Gender and Sexuality, Civil Rights, and LGBTQI⁺ Education. Post-instruction, students reported a significant increase in understanding of bisexuality (p = .02), being transgender (p = .006), and LGBTQI⁺ couples' adoption rights (p = .003). The findings support the incorporation of LGBTQI⁺ instruction into medical curricula and suggest that educators may consider consulting pre-intervention data before teaching LGBTQI⁺ health content, which would allow material to be tailored toward learner-specific needs.

Sexual Prejudice and Comfort to Provide Services to Men Who Have Sex with Men Among HIV Healthcare Workers in Western Kenya: Role of Interpersonal Contact

Sexual minority men living in Africa, where many countries criminalize same-sex behavior, are vulnerable to HIV and experience significant barriers to HIV care. Sexual prejudice in healthcare settings is a key contributor to these barriers. Building on social psychological models of prejudice and interpersonal contact at the clinic, we examined the associations between healthcare workers' sexual prejudice and their comfort to provide care to MSM, and assessed the moderating role of workers' prior interpersonal contact with MSM. A cross-sectional survey of 147 healthcare workers varying in level of training and expertise working in HIV care organizations was conducted in western Kenya. Sexual prejudice was negatively associated with comfort to provide care to MSM. Prior interpersonal contact with MSM moderated the association between sexual prejudice and comfort to provide care to MSM among nurses/counselors, such that those with low prior contact and high sexual prejudice were the most uncomfortable providing care to MSM. Interventions are needed to address sexual prejudice and encourage positive forms of interpersonal contact with MSM, especially with nurses and counselors who might have more and varied patient interactions, to improve access to the continuum of HIV prevention and care for MSM in Kenya.

Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa

Background

A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant.

Methods

We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model.

Results

After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory.

Conclusions

Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

Health services we can trust: how same-sex attracted men in Dar Es Salaam, Tanzania would like their HIV healthcare to be organised

Drawing on qualitative research in Dar es Salaam, Tanzania, this article explores how men who engage in sex with other men perceive their interactions with healthcare providers, and how they would prefer healthcare services to be organised and delivered. The paper describes the strengths and weaknesses men associate with private and public healthcare; the advantages and disadvantages they associate with dedicated clinics for sexual minority persons; what they conceive of as good healthcare services; and how they would characterise a good healthcare worker. The paper also presents recommendations made by study participants. These include the view that health services for same-sex attracted men should be developed and delivered in collaboration with such men themselves; that health workers should receive training on the medical needs as well as the overall circumstances of same-sex attracted men; and that there should be mechanisms that make healthcare available to poorer community members. We analyse men's views and recommendations in the light of theoretical work on trust and discuss the ways in which same sex attracted men look for signs that healthcare workers and healthcare services are trustworthy.

Factors Associated with Utilization of HIV Testing Services among Adolescents Aged 10-19 Years in Lira District, Northern Uganda: A Cross-Sectional Study

Background

HIV testing remains a problem among adolescents in low- and middle-income countries, and yet, HIV testing is a cornerstone in the fight against HIV. However, there is scanty literature on the utilization of HIV testing services by adolescents especially in rural settings. This study is aimed at determining the uptake of HIV testing services and associated factors among adolescents aged 10-19 years in Lira District, Northern Uganda.

Methods

This was a cross-sectional study done among 277 randomly selected adolescents aged 10-19 years attending outpatient clinics in Pentecostal Assembly of God (PAG) Mission Hospital, Ngetta Health Center III, and Boroboro Health Center III. Data were collected using an interviewer-administered structured questionnaire. Data collected included sociodemographic characteristics, history of test and receipt of HIV results in the last three months, and facility-related factors affecting uptake of HIV testing services. Data analysis consisted of descriptive statistics, cross-tabulations, and logistic regression at a 95% level of significance in SPSS version 25.

Results

The uptake of HIV testing services was 43% (119/277) among the study participants. Adolescents who had completed primary education (aOR: 5.47; 95% CI: 1.07-28.15; p = 0.042), are employed (aOR: 2.77; 95% CI: 1.16-6.60; p = 0.022), had used a condom in the last sexual intercourse (aOR: 4.46; 95% CI: 1.78-11.15; p = 0.001), and are involved in HIV testing outreaches (cOR: 10.86; 95% CI: 3.81-30.93; p ≤ 0.001) were more likely to uptake HIV testing services compared to those who had tertiary education, are unemployed, had never used a condom, and are not involved in HIV testing outreaches.

Conclusion

Utilization of HIV testing services by adolescents aged 10-19 in Lira District, Northern Uganda, is generally low. The Ministry of Health should strengthen HIV testing services targeting adolescents to increase uptake of HIV testing services.

Sexual rights and sexual pleasure: Sustainable Development Goals and the omitted dimensions of the leave no one behind sexual health agenda

This commentary explores the missing discourse of sexual rights and sexual pleasure in the Sustainable Development Goals (SDG) that purport to leave no one behind. The SDG propose a welcome focus on sexual health and human rights for all, expanding beyond the Millennium Development Goals. While promising in many ways for advancing global sexual and reproductive health, and reproductive rights, the omission of sexual rights is troubling. So too is the erasure of lesbian, gay, bisexual, transgender and queer (LGBTQ) persons, and sex workers, from the SDG discussions of social inequities. Illustrative examples are provided to demonstrate how a sexual rights focus could advance SDG 3 focused on healthy lives and well-being for all. First, sexual rights are presented as integral to realizing Target 3.3's focus on ending the HIV pandemic among LGBTQ persons and sex workers (and LGBTQ sex workers). Second, sexual pleasure is introduced as an integral component of sexual health and sexual rights that could facilitate the realization of Target 3.7's aim to provide universal access to sexual and reproductive health information and education. To truly leave no one behind and realize sexual health for all, the SDG need to begin from a foundation of sexual rights.

Understanding and managing HIV infection risk among men who have sex with men in rural Uganda: a qualitative study

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.

Healthcare worker training to improve quality of care for sexual and gender minority people in sub-Saharan Africa: learning from efforts in Uganda

INTRODUCTION

Training in care for sexual and gender minority (SGM) populations is critical for ending the HIV epidemic. SGM people, particularly men who have sex with men (MSM) and transgender women, experience disproportionate HIV infection across the globe. The objective of this commentary was to synthesize facilitators of and barriers to SGM health training efforts for healthcare workers in Uganda, in order to help inform potential priorities, strategies and next steps to advance culturally responsive HIV-related care for SGM communities across Uganda and sub-Saharan Africa.

DISCUSSION

SGM health training often includes education on: foundational concepts and language; stigma, discrimination and SGM health disparities; understanding and addressing implicit bias; sensitive and effective communication and building SGM-inclusive and welcoming healthcare environments. Clinicians' education includes sexual and gender histories, sex-positive HIV counselling, sexually transmitted infections, HIV pre-exposure prophylaxis and gender-affirming hormone therapy. SGM communities in sub-Saharan Africa have often experienced discrimination, persecution, incarceration and physical violence, and they encounter unique barriers to engagement in sexual health services and HIV prevention and treatment. SGM health training efforts in Uganda reveal challenges to and opportunities for advancing equity for SGM communities in sexual health and HIV medical care across the region. In Uganda, SGM community advocacy, as well as policies and programmes of the Ministry of Health and US President's Emergency Plan for AIDS Relief, have increased readiness and need for scaling up training and skills-sharing in SGM-focused HIV and sexual healthcare, including Ugandan-led and international initiatives.

CONCLUSIONS

Numerous challenges exist to widespread culturally responsive HIV and sexual healthcare for SGM communities in sub-Saharan Africa. Lessons learned from healthcare worker training efforts in Uganda may inform future replication, adaptation and dissemination initiatives to meet the needs of more SGM communities in the region. Evaluation of SGM health training programmes to determine the impact on HIV virological suppression and sexual health outcomes will be critical for identifying best practices and strategies that may support advancing HIV epidemic control for SGM communities in Uganda and across sub-Saharan Africa.

Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals' experiences and health students' perspectives

BACKGROUND

Health care providers across sub-Saharan Africa continue to face challenges while delivering sexual health care services. We explored the experiences, views and challenges of health care professionals and health students across different disciplines in Tanzania, towards delivery of sexual health services to men who have sex with men.

METHODS

Utilizing a qualitative approach, we recruited 121 health care professionals (providers) and students from the fields of midwifery, nursing and medicine in Dar es Salaam, Tanzania. We conducted 18 focus groups discussions, stratified by profession and experience, to investigate clinical management and challenges while addressing a case of an adult male presenting with rectal gonorrhea.

RESULTS

Findings indicated this case as extremely sensitive, clinical management involved establishing rapport and consent, medical care from history taking to treatment, and referral to other specialties. However, the illegal status of homosexuality in Tanzania was a primary concern to participants, this triggered the clinical care of this case scenario as challenging. There were uncertainties whether or not that such a case should be reported to the authorities.

CONCLUSION

Findings from this study revealed a need for training health students in Tanzania to address sexual health issues including accurate information on homosexuality, reporting requirements and clinical management in the legal and socio-cultural context of the African continent.

Attitudes of medical students towards men who have sex with men living with HIV: implications for social accountability

OBJECTIVES

To explore the attitudes that medical students in Haiti harbour toward Men who have Sex with Men living with HIV in order to better understand how stigma and other factors may impair healthcare, and to explore suggestions of opportunities in line with the values of social accountability.

METHODS

This study employed a qualitative design by using a grounded theory approach regarding the context of Haiti. We used purposive sampling to select the 22 research participants. In-depth interviews were conducted, audio-recorded, transcribed and analyzed using an inductive content analysis approach.

RESULTS

Although stigmatizing attitudes emerged through the findings, medical students expressed willingness to provide Men who have Sex with Men with adequate health services in relation to HIV care. Their expressions were based on the Men who have Sex with Men's comprehensive right to receive equitable care, the moral responsibility of healthcare professionals, their perception of health disparities and the HIV global risk reduction. Participants pointed out that the medical education curriculum did not consider sexual health and specificities of sexual minorities and suggested a more inclusive and socially accountable training based on equity and quality.

CONCLUSIONS

The students expressed favourable attitudes regarding health services to Men who have Sex with Men even though some layered stigmatizing attitudes emerged through the discussions. They all lacked skills on how to handle health specificities of sexual minorities. These findings recommend a revision of the medical education curriculum in regard to social accountability principles.

Peer distribution of HIV self-test kits to men who have sex with men to identify undiagnosed HIV infection in Uganda: A pilot study

Introduction

One-in-three men who have sex with men (MSM) in Uganda have never tested for HIV. Peer-driven HIV testing strategies could increase testing coverage among non-testers. We evaluated the yield of peer distributed HIV self-test kits compared with standard-of-care testing approaches in identifying undiagnosed HIV infection.

Methods

From June to August 2018, we conducted a pilot study of secondary distribution of HIV self-testing (HIVST) through MSM peer networks at The AIDS Support Organization (TASO) centres in Entebbe and Masaka. Peers were trained in HIVST use and basic HIV counselling. Each peer distributed 10 HIVST kits in one wave to MSM who had not tested in the previous six months. Participants who tested positive were linked by peers to HIV care. The primary outcome was the proportion of undiagnosed HIV infections. Data were analysed descriptively.

Results

A total of 297 participants were included in the analysis, of whom 150 received HIVST (intervention). The median age of HIVST recipients was 25 years (interquartile range [IQR], 22–28) compared to 28 years IQR (25–35) for 147 MSM tested using standard-of-care (SOC) strategies. One hundred forty-three MSM (95%) completed HIVST, of which 32% had never tested for HIV. A total of 12 participants were newly diagnosed with HIV infection: 8 in the peer HIVST group and 4 in the SOC group [5.6% vs 2.7%, respectively; P = 0.02]. All participants newly diagnosed with HIV infection received confirmatory HIV testing and were initiated on antiretroviral therapy.

Conclusion

Peer distribution of HIVST through MSM networks is feasible and effective and could diagnose more new HIV infections than SOC approaches. Public health programs should consider scaling up peer-delivered HIVST for MSM.

Effectiveness of health care workers and peer engagement in promoting access to health services among population at higher risk for HIV in Tanzania (KPHEALTH): study protocol for a quasi experimental trial

Background

While there are indications of declining HIV infection rates in the general population globally, Tanzania included, men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID), now called Key Populations (KP) for HIV epidemic have 2–20 times higher infections rates and contributes up to 30% of new HIV infection. Tanzania have developed a Comprehensive Guideline for HIV prevention among key population (CHIP) to address the epidemic among KPs. However, these populations are stigmatized and discriminated calling for innovative approaches to improve access to CHIP. This project seeks to test the effectiveness of healthcare workers and peer-to-peer engagement in promoting access to CHIP among HIV at risk populations in Tanzania.

Methods

A quasi-experimental design involving Dar es Salaam City as an intervention region and Tanga as a control region will be done. Using respondent driven sampling, 1800 at risk population (900 from Intervention site and 900 from control site) will be recruited at baseline to identify pull and push factors for health services access. Stakeholder’s consultation will be done to improve training contents for CHIP among health care workers and peers. Effectiveness of healthcare workers training and peer engagement will be tested using a quasi-experimental design.

Discussion

The results are expected to co-create service provision and improve access to services among KPs as a human right, reverse HIV infection rates among KPs and the general population, and improve social and economic wellbeing of Tanzanian.

Trial registration

Retrospectively registered on 28th August, 2019 with International Standard Randomized Clinical Trial Number (ISRCTN11126469).