Addressing the Healthcare Needs of African Men who have Sex with Men: Barriers to Healthcare and Promoting HIV and STI Treatment in Sub-Saharan Africa.
Barriers to healthcare for men who have sex with men (MSM) in sub-Saharan Africa (SSA) are rooted in stigma and discrimination against MSM fuelled by the criminalization of homosexuality. These barriers are influenced by factors involving MSM and the healthcare workers (HCWs). MSM are uncomfortable disclosing their identities and conceal symptoms of sexually transmitted infections (STIs), especially those in areas associated with homosexual behaviour to avoid stigmatization. MSM experience ill-treatment and abuse by HCWs and have concerns regarding HCWs maintaining confidentiality and privacy. This forces MSM to seek care from pharmacies/drugstores or resort to self-treatment, which may not be effective. This, coupled with increased HIV- and STI-risk behaviours resulting from depression and internalized homophobia, result in further spread of STIs. Further, barriers in HIV testing lead to exclusion of MSM from treatment cascades. Insufficient sexuality training of HCWs leads to discrimination or denial of treatment for MSM, particularly in government-run clinics. The criminalization of homosexuality deters HCWs from offering treatment to MSM. The prevailing discriminatory environment that accompanies the criminalization of homosexuality forces HCWs to don the role of moral and legal enforcers, making them the perpetrators of forced anal examinations that continue to be prevalent in SSA. Nevertheless, there is evidence to show HCWs in SSA recognize their lack of training in sexuality and have welcomed educational opportunities to better understand the healthcare needs of MSM. Pilot educational interventions for HCWs in SSA have been received enthusiastically, and have resulted in significant changes in HCW knowledge and attitudes and dealing with MSMs with STIs. This work reviews existing literature on barriers to STI-related healthcare for MSM in SSA. By drawing parallels to barriers that were overcome in the HIV epidemic in the 1980s, suitable solutions focusing on HCW education are suggested.
Adam, B. D., Husbands, W., Murray, J., & Maxwell, J. (2005). AIDS optimism, condom fatigue, or self‐esteem? Explaining unsafe sex among gay and bisexual men. Journal of sex research, 42(3), 238- 248. doi: 10.1080/00224490509552278.
Adebajo, S. B., Eluwa, G. I., Ahonsi, B. A., Allman, D., & Myers, T. (2012). Prevalence of internalized homophobia and HIV associated risks among men who have sex with men in Nigeria. African Journal of Reproductive Health, 16(4), 21- 28. https://www.ajol.info/index.php/ajrh/article/view/83669
Adedimeji, A., Sinayobye, J. D., Asiimwe-Kateera, B., Chaudhry, J., Buzinge, L., Gitembagara, A., Murenzi, G., Mugenzi, P., Patel, V. V., Castle, P. E., Mutesa, L., Palefsky, J., & Anastos, K. M. (2019). Social contexts as mediator of risk behaviors in Rwandan men who have sex with men (MSM): Implications for HIV and STI transmission. PLoS ONE, 14(1), Article e0211099. https://doi.org/10.1371/journal.pone.0211099
Agardh, C., Weije, F., Agardh, A., Nyoni, J., Ross, M.W., Kashiha, J., and Larsson, M. (2017). Using pharmacists and drugstore workers as sexual healthcare givers: A qualitative study of men who have sex with men in Dar es Salaam, Tanzania. Global Health Action, 10, 1389181, doi: 10.1080/16549716.2017.1389181
Ahaneku, H., Ross, M. W., Nyoni, J. E., Selwyn, B., Troisi, C., Mbwambo, J., Adeboye, A, and McCurdy, S. (2016). Depression and HIV risk among men who have sex with men in Tanzania. AIDS Care, 28(suppl. 1), 140-147. doi: 10.1080/09540121.2016.1146207
Albuquerque, G. A., de Lima Garcia, C., da Silva Quirino, G., Alves, M. J. H., Belém, J. M., dos Santos Figueiredo, F. W., ... & Adami, F. (2016). Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC International Health and Human Rights, 16(1), 1-10. doi: 10.1186/s12914-015-0072-9.
Anderson, A. M., Ross, M. W., Nyoni, J. E., & McCurdy, S. A. (2015). High prevalence of stigma-related abuse among a sample of men who have sex with men in Tanzania: implications for HIV prevention. AIDS Care, 27(1), 63-70. doi:10.1080/09540121.2014.951597
Baral, S., Adams, D., Lebona, J., Kaibe, B., Letsie, P., Tshehlo, R.,... & Beyrer, C. (2011). A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho. Journal of the International AIDS Society, 14(1), 36. doi:10.1186/1758-2652-14-36
Carrasco, M. A., Arias, R., & Figueroa, M. E. (2017). The multidimensional nature of HIV stigma: evidence from Mozambique. African Journal of AIDS Research, 16(1), 11-18. doi:10.2989/16085906.2016.1264983
Cichowitz, C., Rubenstein, L., & Beyrer, C. (2018). Forced anal examinations to ascertain sexual orientation and sexual behavior: An abusive and medically unsound practice. PLoS medicine, 15(3), e1002536. Doi: 10.1371/journal.pmed.1002536.
Fay, H., Baral, S. D., Trapence, G., Motimedi, F., Umar, E., Iipinge, S.,... & Beyrer, C. (2011). Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana. AIDS and Behaviour, 15(6), 1088-1097. doi:10.1007/s10461-010-9861-2
Hagopian, A., Rao, D., Katz, A., Sanford, S., & Barnhart, S. (2017). Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR?. Global health action, 10(1), 1-10. Doi: 10.1080/16549716.2017.1306391
Harrisberg, K. (2020, March 10). South Africa opens continent’s first queer wellness centre. Reuters. https://www.reuters.com/article/us-safrica-lgbt-health-trfn/south-africa-opens-continents-first-queer-wellness-centre-idUSKBN20X32A
Lane, T., Mogale, T., Struthers, H., McIntyre, J., & Kegeles, S. M. (2008). “They see you as a different thing”: the experiences of men who have sex with men with HCWs in South African township communities. Sexually Transmitted Infections, 84(6), 430-433. doi: 10.1136/sti.2008.031567
Larsson, M., Pettersson, K. O., Kashiha, J., Ross, M. W., & Agardh, A. (2016a). Stretching the boundaries: Tanzanian pharmacy workers’ views and experiences of providing STI services for men who have sex with men. PloS one, 11(11), e0166019. doi: 10.1371/journal.pone.0166019.
Larsson, M., Ross, M. W., Månsson, S. A., Nyoni, J., Shio, J., & Agardh, A. (2016b). Being forced to become your own doctor: men who have sex with men's experiences of stigma in the Tanzanian healthcare system. International Journal of Sexual Health, 28(2), 163-175. doi: 10.1080/19317611.2016.1158763
Larsson, M., Shio, J. M., Ross, M. W., & Agardh, A. (2017). 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, 12(8), e0183265. doi: 10.1371/journal.pone.0183265
Magesa, D. J., Mtui, L. J., Abdul, M., Kayange, A., Chiduo, R., Leshabari, M. T., ... & Tungaraza, D. (2014). Barriers to men who have sex with men attending HIV related health services in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, 16(2), 1-10. doi: 10.4314/thrb.v16i2.8
Maleke, K., Makhakhe, N., Peters, R. P., Jobson, G., De Swardt, G., Daniels, J.,... & Struthers, H. (2017). HIV risk and prevention among men who have sex with men in rural South Africa. African Journal of AIDS Research, 16(1), 31-38. doi:10.2989/16085906.2017.1292925
Meyer, I., & Dean, L. (1998). Internalized homophobia, intimacy and sexual behaviour among gay and bisexual men. In: Herek, G (Ed.), Stigma and Sexual Orientation: Understanding Prejudice against Lesbians, Gay Men, and Bisexuals. Thousand Oaks: Sage.
Mgopa, L. R., Mbwambo, J., Likindikoki, S., & Pallangyo, P. (2017). Violence and depression among men who have sex with men in Tanzania. BMC psychiatry, 17(1), 1-5. Doi: 10.1186/s12888-017-1456-2
Moen, K., Aggleton, P., Leshabari, M. T., & Middelthon, A.-L. (2014). Gays, guys, and mchicha mwiba: same-sex relations and subjectivities in Dar es Salaam. Journal of Homosexuality, 61(4), 511-539. doi:10.1080/00918369.2014.865457
Mpondo, B. C., Gunda, D. W., & Kilonzo, S. B. (2017). HIV epidemic in Tanzania: the possible role of the key populations. AIDS Research and Treatment. doi: 10.1155/2017/7089150
Müller, A. (2016). Health for all? Sexual orientation, gender identity, and the implementation of the right to access to health care in South Africa. Health and human rights, 18(2), 195-208. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395001/pdf/hhr-18-195.pdf
Mwalimu, U. (2016, Oct 27). Statement by the Minster for Health, Community Development, Gender, Elderly and Children, HON. Ummy Mwalimu on key populations HIV services in Tanzania. Ministry of Health, Community Development, Gender, Elderly, and Children, The United Republic of Tanzania. https://m.facebook.com/afyatz/posts/1230922863594845.
Niang, C. I., Tapsoba, P., Weiss, E., Diagne, M., Niang, Y., Moreau, A. M., & Castle, C. (2003). ‘It's raining stones’: stigma, violence and HIV vulnerability among men who have sex with men in Dakar, Senegal. Culture, Health & Sexuality, 5(6), 499-512. doi:10.1080/1369105031000152715
Ogunbajo, A., Kershaw, T., Kushwaha, Boakye, F., Wallace-Atiapah, N.D., & Nelson, L. (2018). Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). AIDS Behav 22, 829–839 (2018). https://doi.org/10.1007/s10461-017-1806-6
Risher, K., Adams, D., Sithole, B., Ketende, S., Kennedy, C., Mnisi, Z.,... & Baral, S. D. (2013). Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. Journal of the International AIDS Society, 16(3S2), 18715. doi:10.7448/IAS.16.3.18715
Ross, M. W., Kajubi, P., Mandel, J. S., McFarland, W., & Raymond, H. F. (2013). Internalized homonegativity/homophobia is associated with HIV-risk behaviours among Ugandan gay and bisexual men. International journal of STD & AIDS, 24(5), 409-413. doi: 10.1177/0956462412472793.
Ross, M. W., Kashiha, J., Nyoni, J., Larsson, M., & Agardh, A. (2018a). Electronic media access and use for sexuality and sexual health education among men who have sex with men in four cities in Tanzania. International Journal of Sexual Health, 30(3), 264-270. Doi: 10.1080/19317611.2018.1491919
Ross, M. W., Larsson, M., Jacobson, J., Nyoni, J., & Agardh, A. (2016). Social networks of men who have sex with men and their implications for HIV/STI interventions: Results from a cross-sectional study using respondent-driven sampling in a large and a small city in Tanzania. BMJ Open, 6(11), e012072. doi:10.1136/bmjopen-2016-012072
Ross, M. W., Larsson, M., Nyoni, J. E., & Agardh, A. (2017). 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. International Journal of STD & AIDS, 28(9), 925-928. doi:10.1177/0956462416683625
Ross, M. W., Nyoni, J., Bowen, A. M., Williams, M. L., & Kashiha, J. J. (2012). Sexual and geographic organisation of men who have sex with men in a large East African city: opportunities for outreach. BMJ open, 2(6), e001813. doi:10.1136/bmjopen-2012-001813
Ross, M. W., Nyoni, J., Larsson, M., Mbwambo, J., Agardh, A., Kashiha, J., & McCurdy, S. A. (2015). Health care in a homophobic climate: the SPEND model for providing sexual health services to men who have sex with men where their health and human rights are compromised. Global health action, 8(1), 26096. Doi: 10.3402/gha.v8.26096.
Ross, M.W., & Anderson, A. M. (2014). Relationships between importance of religious belief, response to anti-gay violence, and mental health in men who have sex with men in East Africa. In Piedmont, R. L. & Village, A. (eds), Research in the Social Scientific Study of Religion, (Vol 25, pp. 160-172). Leiden: Brill.
Ross, M. W., Kashiha, J., & Mgopa, L.R. (2020). Stigmatization of men who have sex with men in health care settings in East Africa is based more on perceived gender role-inappropriate mannerisms than having sex with men. Global health action, 13(1), DOI: 10.1080/16549716.2020.1816526
Ross, M. W., Leshabari, S., Rosser, B. R. S., Trent, M., Mgopa, L., Wadley, J., ... & Agardh, A. (2018b). Evaluation of an assessment instrument for a sexual health curriculum for nurses and midwifery students in Tanzania: The sexual health education for professionals scale (SHEPS). Applied Nursing Research, 40, 152-156. doi: 10.1016/j.apnr.2018.01.005
Ross, M.W., Smolenski, D.J., Kajubi, P., Mandel, J.S., McFarland, W., and Raymond, H.F. (2010). Measurement of internalized homonegativity in gay and bisexual men in Uganda: Cross-cultural properties of the Internalized Homonegativity scale. Psychology, Health and Medicine, 15, 159-165.
Sandfort, T. G., Nel, J., Rich, E., Reddy, V., & Yi, H. (2008). HIV testing and self-reported HIV status in South African men who have sex with men: results from a community-based survey. Sexually transmitted infections, 84(6), 425-429.
Sandfort, T., Bos, H., Knox, J., and Reddy, V. (2016). Gender nonconformity, discrimination, and mental health among black South African men who have Sex with Men: A further exploration of unexpected findings. Archives of Sexual Behaviour, 45, 661-670. Doi 10.1007/s10508-015-0565-6
Sandfort, T., Knox, J., Collier, K.L., Lane, T., & Reddy, V. (2015). HIV testing practices of South African township men who have sex with men in the era of expanded access to ART. AIDS and Behaviour 19, 561-574. Doi 10.1007/s10461-014-0843-7
Tran, H., Ross, M. W., Diamond, P. M., Berg, R. C., Weatherburn, P., & Schmidt, A. J. (2018). Structural validation and multiple group assessment of the Short Internalized Homonegativity Scale in homosexual and bisexual men in 38 European countries: Results from the European MSM Internet Survey. Journal of Sex Research, 55(4-5), 617-629. doi 10.1080/00224499.2017.1380158
Ulanja, M.B., Lyons, C., Ketende, S., Diouf, D., Kouamé, A., Ezauarchi, R., Bamba, A., Drame, F., Liestman, B., & Baral, S. (2019). The relationship between depression and sexual health service utilization among men who have sex with men (MSM) in Côte d'Ivoire, West Africa. BMC Int Health Hum Rights 19. Doi:10.1186/s12914-019-0186-6
Van der Elst, E. M., Smith, A. D., Gichuru, E., Wahome, E., Musyoki, H., Muraguri, N., ... & Sanders, E. J. (2013). Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. Journal of the International AIDS Society, 16, 18748. doi: 10.7448/IAS.16.4.18748
Wanyenze, R. K., Musinguzi, G., Matovu, J. K., Kiguli, J., Nuwaha, F., Mujisha, G.,... & Wagner, G. J. (2016). “If you tell people that you had sex with a fellow man, it is hard to be helped and treated”: barriers and opportunities for increasing access to HIV services among men who have sex with men in Uganda. PloS One, 11(1), e0147714. doi: 10.1371/journal.pone.0147714
Wirtz, A. L., Kamba, D., Jumbe, V., Trapence, G., Gubin, R., Umar, E.,... & Baral, S. D. (2014). A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi. BMC International Health and Human Rights, 14(1), 20. doi:10.1186/1472-698X-14-20
Young, R. M., & Meyer, I. H. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in public health discourse. American journal of public health, 95(7), 1144-1149. doi: 10.2105/AJPH.2004.046714
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