Getting services to MSM living in hostile environments

A three year programme aimed at effectively reducing the spread and impact of HIV among men who have sex with men in East Africa ends this month. What lessons can be learnt by others doing similar work?

Last week at the International Conference on AIDS and STIs in Africa (ICASA) in Zimbabwe, representatives of African key population groups were stopped at the airport on arrival and divested of their materials which were intended for distribution at the conference.

Understandably there was outrage.  What should have been a safe space to share experiences about how best to reach communities who are more susceptible to acquiring HIV and other sexually transmitted infections (STIs) became instead a clear example of the daily safety and security risks faced by individual activists and the community based organisations that do this difficult work. Community organisations like Gay and Lesbians of Zimbabwe (GALZ), Men Against AIDS Youth Group Organisation (MAAYGO) in Kenya, Icebreakers Uganda (IBU) and Community Health Education Services and Advocacy (CHESA) in Tanzania, all of whom have been involved in delivering the SHARP (Men’s Sexual Health and Rights) Programme.

Tailored services to reach MSM

In Africa, as well as elsewhere, MSM have a higher risk of contracting HIV compared to the population as whole. It is extremely difficult for gay men or other MSM to access safe, non-discriminatory sexual health information and services.  That’s where SHARP came in. Funded by the Danish government, work started in 2012 on a multi-tiered approach focusing on both individuals and communities.

The project divided its efforts between improving access to and uptake of clinical services specifically tailored to the needs of men who have sex with men, and  influencing the restrictive laws, policies and cultural beliefs that make it more difficult for them to access quality services.

The service delivery model in SHARP adopted two complementary approaches: outreach in community drop-in centres, usually held at the premises of the community based organisation, and day/night mobile clinical outreach at pre-arranged locations (bars, hotels as well as other MSM ‘hotspot’ locations). Although it varies in different locations, both approaches involved the provision of a basic package of sexual health services (ie condoms and lubricants, HIV testing and counselling, SRHR counselling and referral for HIV treatment).

Proving services across Uganda

At the Icebreakers drop-in centre in Kampala, clinical services were provided in partnership with the government sponsored Most at Risk Population Initiative (MARPI), in addition to the services provided by MARPI at Mulago Hospital, where doctors offer services tailored for the MSM community and other key populations.  Peer educators from Icebreakers used their networks, including social media, to encourage men to access the services not only in the capital but in across West, South, East and North of Uganda through regular outreaches across the country.   Throughout Uganda, 2,803 unique MSM have received two or more services in the SHARP service package.

Reaching MSM in Western Kenya

MAAYGO have been running mobile outreach clinics in Kisumu Town and six neighbouring districts, working in partnership with the Kisumu District Hospital and local clinics. Tents were set up outside strategic locations such as nightclubs and bars known to be frequented by MSM. 

<p>A nurse performs testing and counselling inside a tent at the Moonlight outreach in Kisumu nightclub district. The outreach is run by MAAYGO twice a month for MSM to access condoms, lubes, testing and other services. MAAYGO, Kisumu, Kenya.</p>
<p>MAAYGO&nbsp;is an implementing partner of the Alliance&rsquo;s&nbsp;<a href="/our-priorities/current-projects/173-sharp" title="Regional Men&rsquo;s Sexual Health and Rights Programme (SHARP)">Regional Men&rsquo;s Sexual Health and Rights Programme (SHARP)</a>, which is improving the sexual health and rights of MSM in Kenya, Uganda,&nbsp;Tanzania and Zimbabwe.</p>From inside, HIV testing and counselling services were offered as well as STI screening. MAAYGO peer educators used their own networks to promote the clinics which took place at different times in order to ensure wide availability and, to date, 3,093 unique MSM have been reached.

Safety and security

For the outreach to work, efforts to maintain the safety and security of both service providers and users have been prioritised. Hotspots have been carefully mapped and a practical checklist developed for each organisation, including nominating a security contact point in the organisation, developing a ‘phone tree’ in order to cascade information to outreach workers, and training provided on the careful use of social media (tagging, use of locations). 

Over the course of the project, several SHARP partners experienced difficulties operating in environments where MSM are directly criminalised.  In Kenya, a group of people working for MAAYGO were arrested for ‘illegally promoting homosexuality’ whilst conducting a survey for the National AIDS Control of Kenya.  In response, MAAYGO had to move their office and initiated sensitisation forums with the police, local chiefs and community leaders.  Following months of work, MAAYGO staff met with the Police Provincial Officer to present them with evidence on how the police were harassing community members and the organisations supporting them. 

Now relations have dramatically improved.  Since February 2015, MAAYGO has been facilitating a support group for police officers living with HIV and offering workshops to fellow officers to raise their awareness.  The police are now providing security for MAAYGO outreach services in the Nyaza Province.

Monitoring human rights

Once logged, this information is used to set up a local crisis response to individual emergencies. These emergencies are mostly for temporary shelter (30%), transport (20%) and access to medicines (15%).  In addition, the data is being used as evidence for national and global advocacy efforts.

Sharing the SHARP experience

As the programme closes, efforts to sustain the work in Uganda, Kenya, Zimbabwe and Tanzania are ongoing.  Trained and competent staff exist in each country, the community based organisations have grown in strength, with strong financial and M&E systems, and durable partnerships formed with health providers, law enforcement agencies and with local community leaders.  Over the course of the programme, SHARP has reached over 15,000 MSM (80% higher than target). Efforts are ongoing to document the programmatic approach including:

  • A short film (see above) documenting the impact of SHARP was previewed at ICASA during a packed satellite meeting on strategies for working with MSM in hostile environments last week. 
  • Programmatic country case studies will be released on the Alliance website in early 2016, along with short video interviews with a selection of some of the inspiring community outreach workers and activists involved in all four countries. They tell their own stories of ‘what works’. 
  • Finally, a quick reference guide on a wide range of topics relevant to rights-based, effective, sustainable and integrated community-led and public health responses to men who have sex with men (MSM) has been published.  This is currently being piloted in the four SHARP countries and an updated version will be released in 2016.