Providing prisoners, sex workers, adolescents and men who have sex with men with sexual and reproductive health services has been advocated by the World Health Organisation and the United Nations and several other international bodies. As a result, most national governments have heeded this advice and cater for these groups, known as key populations.
One critical part of accessing quality and effective sexual and reproductive health services is to strengthen HIV prevention and to provide everyone with access to HIV treatment, care and support.
But, in many African countries, knowledge to guide HIV programming for men who have sex with men is only just developing. And when there are guidelines, the services are not always available. This means that many people in these key populations do not get the services they need.
The Malawian National HIV Prevention Strategy specifically acknowledges that these populations must be targeted in its HIV programming. But homosexuality is still a crime in the country. And even though there is a moratorium on criminalising male-male sexual relationships, men who have sex with men have difficulty getting access to health services.
Tanzania also criminalises homosexuality. It has nevertheless started to implement different harm-reduction HIV interventions for key populations, including men who have sex with men. An estimated 15% of men who have sex with men are HIV positive in the country. The figure is double in the country’s capital Dar es Salaam.
The figures are similar in Malawi, where the crude HIV prevalence is 15.4%. Just over 90% of the HIV infections were reported as previously undiagnosed.
Several studies on men who have sex with men have been done in Malawi and Tanzania.
The research shows that there is still a low uptake of HIV prevention and health services among these men. They fear seeking health services and disclosing their sexual orientation because of discrimination. Another study, which corroborates this, shows that only 9% of men who have sex with men in Malawi disclosed their sexual practices to a health care provider.
Our study shows that only 18% of the men who have sex with men that were interviewed said they were exposed to HIV prevention messages that were relevant to them.
While some men are aware of the HIV risks, they believed that within their wider community there is a general lack of HIV information for men who have sex with men, low awareness of the appropriate prevention and low perception of risks related to HIV infection.
Although health workers said they provided services to everyone without regard of sexual orientation, the men interviewed in our study said they experienced constrained access to services.
Health care providers themselves face a number of challenges. One is their concern about adverse repercussions if they provide services to men in same sex sexual relationships.
Another is that they lack awareness. We asked health workers how capable they were at establishing the sexual history of their patients. This would include asking questions about a person’s sexual orientation and sexual practices so that they could better understand the individual’s risk and what clinical care was needed. This was clearly an area of great difficulty.
Our experience as a medical school testifies that our graduates may not be ready to take down the sexual history of their patients in a nonjudgmental way. This clearly will have an impact on their ability to provide sexual reproductive and health services.
This observation is anecdotal and more work is required to quantify the extent to which this a major limitation in clinical management. We will be doing more research into:
- What affects these men from accessing the health system?
- How can the systems and access be improved?
- What interventions exist and how can they be used in the two countries?
- What is the best way to communicate with these men?
Conducting a similar study in Malawi and Tanzania will allow the researchers to cross-fertilise their expertise and share the lessons learnt, which would strengthen the findings.
- Adamson S. Muula is Professor of Epidemiology and Public Health, University of Malawi