Research has shown that addressing HIV in certain key populations is a priority in order to end the epidemic in the general population.
Key populations are groups identified by the World Health Organisation that warrant specific attention in health programmes because they face a particularly high risk of getting HIV and other sexually transmitted infections. They are also marginalised and do not have good access to health services.
One of these groups is men who have sex with men (MSM). It is critical to ensure that they are able to get access to HIV prevention and treatment services.
But in many parts of sub-Saharan Africa, including South Africa, men who have sex with men encounter stigma and prejudice when they use health services. This often limits their access to healthcare.
Our research shows that it’s possible to provide good quality care in the public sector to men who have sex with men.
We looked at health services specifically designed and provided at a set of South African government clinics. We found that men who accessed these services did well on antiretroviral regimens.
South Africa’s reality
An estimated 7.1 million people in South Africa are living with HIV. That’s about 12.6% of the general population.
Among men who have sex with men, this figure may be as high as 34.6%.
Providing health services to this group is challenging partly because of its diversity. Many men who have sex with men do not see themselves as gay. They may identify as bisexual or straight, or not label themselves in this way at all. This makes it difficult to find ways to reach out to them.
Their sexual practices also vary which can increase their risk of contracting HIV. For example, some men have anal sex without a condom, which is risky. But not all men who have sex with men have anal sex.
So sexual health services for men who have sex with men need to understand and meet the needs of a wide range of men. The challenge is that they usually have to access regular health services where they feel they are not understood and experience discrimination. They often feel unable to explain their sexual history to health workers.
Our study looked at how a health service targeted at men who have sex with men, Health4Men clinics, provided by an NGO in government run, primary care health facilities could help to solve these problems.
There are three Health4Men clinics in Johannesburg and one in Cape Town. They provide comprehensive sexual health services, including preventing and treating HIV and other sexually transmitted infections.
Filling the gaps
Of the gay and bisexual men who were tested for HIV at the clinics close to 40% were HIV positive. The figure was 14% for straight men.
We found that the clinics were very successful in helping men remain on antiretroviral treatment. More than 80% of the men who started antiretroviral treatment at the clinics were still taking their medication two years later. There was no difference in the retention patterns between gay and straight men.
People on antiretroviral therapy must take treatment for the rest of their lives. But keeping people on treatment is a challenge.
In addition, men who have sex with men are often unaware of their sexually transmitted infections because there often aren’t visible symptoms. This often means that they don’t seek treatment. Finding and treating these infections is important because untreated sexually transmitted infections increase the risk of contracting HIV.
Part of the reason that Health4Men services have been successful is the presence of male health care workers. They are specially trained to be sensitive to diversity in gender and sexuality, and to understand the specific needs and health problems affecting men who have sex with men. Their presence seems to make many men feel more comfortable discussing sexual matters.
And based on our research, the clinics attracted men who identified as gay, bisexual and straight, showing that they were considered safe spaces.
Meeting the needs
To stop the spread of HIV, South Africa needs to expand access to specialised health services for men who have sex with men. Services should also be provided in community spaces linked to health facilities.
Implementing these specialised services in rural areas is a bit more challenging due to limited resources. But in these areas health workers should be trained to understand diversity in gender and sexuality. Training health workers about diversity has been shown to reduce prejudicial attitudes toward men who have sex with men.
In the end, what is important is that HIV prevention services – including regular testing, access to condoms and lubricant, treatment of sexually transmitted infections and PrEP (a pill taken daily to prevent HIV infection) – reach HIV-negative men who have sex with men. It’s also crucial for those who are already HIV-positive to have access to antiretroviral therapy to decrease the spread of HIV.