Towards ' men who have sex with men-appropriate ' health services in South Africa

JUNE 2013, Vol. 14, No. 2 SAJHIVMED 52 Health programming for men who have sex with men (MSM) in South Africa has been ignored or absent until fairly recently, despite this population being at high risk for HIV acquisition and transmission. Anova Health Institute, with support from the US President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID) and in collaboration with the South African National Department of Health, launched the first state sector MSM-targeted sexual health clinic in 2010. The clinic has been successful in attracting and retaining MSM in care, and lessons learned are described in this article. Components contributing to the creation of MSM-appropriate healthcare services are discussed.

Until fairly recently, the healthcare needs of men who have sex with men (MSM) have been under-researched and under-resourced in South Africa (SA). [1]This has occurred despite emerging local evidence confirming high rates of HIV among this key population.Notwithstanding inclusion in the country's previous National Strategic Plan for HIV and AIDS, STIs and TB (2007 -2011), services for MSM were not scaled up nationally, although impressive strides have been made in some provinces such as the Western Cape and Gauteng.Evidence from modelling studies shows that in settings where concentrated HIV epidemics exist among key populations in countries with generalised heterosexual epidemics, failure to provide targeted and tailored HIV prevention and treatment programmes to key populations negatively affects HIV rates among the general population. [2]SM in SA comprise of a diverse group of men who share only one behavioural commonality: they have sex with other men. [3]Many MSM in SA do not identify with gay culture, which may be viewed as a Eurocentric cultural construct often considered foreign and 'un-African' . [4]The behaviour of MSM has, however, occurred across all cultures and all times, including in SA, and is therefore well described in African oral histories.Colonial oppressors were largely responsible for the criminalisation of sodomy on the continent. [5]Homosexual activity in SA therefore often remains clandestine, with MSM identifying as heterosexual and dismissive of Westernised gay culture. [3]This has implications for health messaging as nongay-identifying MSM are not targeted in either mainstream heterosexual or gay media platforms and remain invisible in healthcare settings.
For multi-factorial reasons, MSM are at particular risk for HIV acquisition and transmission. [6]Biologically, unprotected receptive anal sexual intercourse is about 16 times more likely to transmit HIV than unprotected vaginal sexual intercourse. [7]his is due to the friable nature of the rectal mucosa, which does not contain mucous-producing cells like the thicker, selflubricating lining of the vagina.
The vulnerability of MSM is further increased by structural factors such as a lack of funding for MSM-appropriate services, lack of specific skills training of health providers, and institutionalised stigma within the public healthcare sector.MSM patients generally avoid being identified as MSM, culminating in their elevated risk of HIV acquisition, transmission being overlooked, and a lack of counselling about the risks associated with unprotected anal sex. [8]rganisations such as the Anova Health Institute, through it's innovative Health4Men project, and the Desmond Tutu HIV Foundation have been active in addressing these concerns in SA.In 2009 the Anova Health Institute, with support from the US President's Emergency Plan for AIDS Relief (PEPFAR)/ United States Agency for International Development (USAID), launched the first state sector clinic dedicated to MSM in the country.A further 6 sites have subsequently become operational across multiple provinces.[11] MSM experience mainstream state sector healthcare services as unfriendly and prejudiced, which creates a barrier to accessing such services. [12]Many local healthcare centres have become friendly to women at the exclusion of men.Women are a captive audience in these clinics, which FORUM they attend for antenatal care, childhood vaccinations, completion of children's roadto-health growth charts and other services.Clinics respond by improving their femalespecific skills and services.It is not unusual to find most of the educational materials in HIV clinics focusing on issues such as breastfeeding and female contraception, thereby alienating HIV-positive men.Other barriers to MSM healthcare access include fears about confidentiality related to their HIV status and sexual behaviour.The local catchment area of primary healthcare services is also often problematic; MSM who experience community-based stigma are unlikely to attend a clinic where they are known to other patients or staff members.
For a health provision site to be considered MSM-appropriate, a number of criteria need to be met.Firstly, most MSM require more than a friendly service (often incorrectly referred to as an MSM-sensitised service); they expect competence regarding their specific sexual healthcare needs.Services therefore need to be both sensitive and competent if they are to attract and retain MSM in care. [4]he Ivan Toms Centre for Men's Health (ITCMH), a clinic of the Anova Health Institute in partnership with the Western Cape Department of Health (DoH) and funded by PEPFAR through USAID, was inaugurated in February 2010 in Cape Town.It has since provided care to over 3 800 MSM.There are a few features which have contributed to the success of this clinic.There is buy-in and commitment by the provincial and National DoH. [13]The service is marketed as a sexual health clinic for men.It is neither an HIV nor an antiretroviral therapy (ART) clinic, which means that patients in the waiting room cannot be identified as HIV-positive.Approximately half of the clients in the cohort are HIV-positive and half of those are receiving ART.Other MSM attend for HIV and sexually transmitted infection (STI) screening, syndromic STI management, counselling and other mental healthcare services, harmreduction services for MSM who use drugs, or for research and information purposes.This model assists in providing an enabling space that promotes feelings of anonymity regarding the reason for attendance, and allays fears of being identified as gay or HIV-infected when attending the clinic.
Clinic staff have received extensive sensitivity and competency training and are accepting of the diversity of MSM.They have become accustomed to providing service to MSM with either a feminine or masculine gender-identity, as well as to transgendered individuals.All staff are accustomed to referring to clients by their preferred name and pronoun (as opposed to their legal name).A package of care has been developed for the clinic and a clinical manual is available for guidance both in print format and online (http://www.anovahealth.co.za). [4]It is understood that clinics may not be able to provide an optimal level of MSM healthcare due to resource constraints; therefore, a package of minimal and optimal services has been developed (see Tables 1 -3).

Table 1. Recommended service package for addressing the sexual health of MSM: HIV/AIDS
Some specific features of the ITCMH that have worked well include the provision of MSM-sensitive HIV screening.Counsellors are trained to ask about male and female partners, to identify specific sexual behaviours and their risks (e.g.receptive unprotected anal intercourse), and to avoid adopting a hetero-normative attitude to counselling (such as asking an MSM couple which is the man and which is the women in a relationship).MSM are also encouraged to screen for HIV together with their partners. [14]ince MSM are at an elevated risk of acquiring and transmitting HIV, prevention technologies assume particular importance.Condoms, although generally available via the state, are mainly marketed through heterosexually-targeted campaigns that do not address the risks of unprotected anal sex.Condom-compatible lubricant required for comfortable anal sex is largely unavailable.Medical male circumcision is likely to fail to protect MSM to the same degree as heterosexual men, which leaves a deficit of effective prevention interventions. [15]Available HIV-prevention resources that are evidence-based -such as condoms, lubricants, post-and pre-exposure prophylaxis (PEP and PrEP), and early treatment for positive MSM -should be prominent at all MSM-targeted sites.
Marketing MSM-appropriate services is challenging, especially in areas where MSM do not disclose their sexual behaviours and remain hidden to the healthcare system.It has taken time for MSM groups to develop trust in the clinic and the most effective marketing has occurred by word of mouth via clients who have had a positive health-affirming experience at the clinic.Health4Men employs peer educators, and key individuals in MSM communities from specific geographical areas have been recruited as ambassadors for the programme.Marketing and information, education and communication (IEC) materials

FORUM
have been developed through testing with MSM focus groups to ensure that the language is locally understood and contextually correct.Health information, referral links and interactive questions and answers are also available from the Health4Men's mHealth programme 'Health4men Connect' (h4m.mobi) and the programme's website.
The ITCMH was followed by the launch of the Simon Nkoli Centre For Men's Health in Soweto and, more recently, the Khayelitsha Male Clinic (Cape Town), the Zola and Chiawelo clinics (both in Soweto) and the Yeoville clinic (central Johannesburg).These sites have built on the evidence and experience gained from providing services at the ITCMH.Guidelines for the management of common MSM health problems have been developed and packaged into an intensive training package, which can be delivered at healthcare facility level to improve staff attitudes and skills and better allow for the provision of non-judgemental, appropriate MSM-targeted healthcare.Over time, once enough state clinics have received such training, it is hoped that MSM-specific healthcare services can be mainstreamed in standard HIV/ART/STI clinics.Many resources have been developed locally and abroad to assist healthcare providers in caring for their MSM clients in a compassionate and competent manner, even in instances where the beliefs of healthcare workers do not usually encompass an understanding of diverse male sexual identities and behaviours.

STIs = sexually transmittedTable 3 .
infections; MSM = men who have sex with men; NAATs = nucleic acid amplification tests; RPR = rapid plasma reagin; TPHA = treponema pallidum haemaglutination assay; LGV = lymphgranuloma venereum; IgG = immunoglobulin G; HPV = human papilloma virus; TDF = tenofovir; 3TC = lamivudine.Examples of interventions for preventing HIV among MSM* Psychosocial Biomedical Reducing number of sex partners Increased HCT and early detection of positives Reducing alcohol and recreational drug use Male and female condoms Increasing condom use for risky sexual behaviours Condom-compatible sexual lubricant Increasing the use of condom-compatible lubricant Early ART Sero-sorting PEP Sero-positioning STI screening and treatment Motivational counselling PrEP (refer to SA guidelines) Couples' services including targeted counselling Microbicides (undergoing research) Combating societal homoprejudice and increasing access to non-judgemental healthcare services HIV vaccines (undergoing research) Screening and management of depression and other mental health disorders Harm-reduction programmes for drug users includes safe injection technique, clean injecting equipment (needles), treatment of soft-tissue abscesses, IEC materials, education about overdoses and linkage to rehabilitation programmes for those who want to stop drug use Development and dissemination of appropriate healthcare and risk-reduction messages that address the specific sexual health needs of MSM Medical male circumcision; does not provide the same risk reduction as for heterosexual men but might protect bisexual men and those who exclusively adopt the penetrative role in anal sex MSM = men who have sex with men; HCT = HIV counselling and testing; ART = antiretroviral therapy; PEP = post-exposure prophylaxix; SA = South Africa; STI = sexually transmitted infection; PrEP = pre-exposure prophylaxic; IEC = information, education and communication.*Source:De Swardt and Rebe.[4]

FORUM
The scope of practice encompasses holistic sexual health, including STI and HIV prevention, diagnostic and treatment services, as well as in-house access to mental healthcare services provided by staff who have specific experience in providing such care to MSM.Staff have been intensely trained in the specific features of sexual health pertaining to MSM.Medical staff have an expert understanding of how STI presentations, diagnosis and management plans differ in MSM, compared with heterosexual men.A good example is training in physical examination to detect and diagnose anal and pharyngeal presentations of STIs.

Fig. 1 .
Fig. 1.The Ukwazana (getting to know each other) campaign.An example of HIV riskreduction messaging designed to reach MSM though township taverns/shebeens where MSM congregate.

Fig. 2 .
Fig. 2.An example of HIV risk-reduction messaging designed to reach gay-identified MSM through gaytargeted publications (the pink press).