Overcoming barriers to health care

Overcoming barriers to health care

Men who have Sex with Men (MSM) are at high risk of acquiring and transmitting HIV and other sexually transmitted infections (STIs) but have historically been neglected in South Africa’s (and, indeed, that of most of the global South’s) response to the epidemic. MSM have been under- researched and underfunded for HIV prevention and treatment interventions. This has occurred despite MSM accounting for a disproportionate number of new HIV infections, which is out of keeping with the size of the MSM population. Local data has confirmed this to be true for South African MSM with the Soweto Men’s Study and the JEMS study showing MSM HIV prevalences of 20 percent and 43 percent, respectively. These high rates indicate a failure of existing HIV and STI prevention services and interventions.

Fortunately the tide is turning and relevant stakeholders are beginning to see the value of MSM-targeted sexual health interventions. As such, MSM in South Africa have been prioritised for services by the South African Department of Health as well as by international donors such as PEPFAR/ USAID and the Global Fund. A clear example of this prioritisation is the evolution in attitude towards MSM by President Jacob Zuma. In 2006 he is quoted as saying, ‘When I was growing up, an unqingili (a gay) would not have stood in front of me, I would knock him out.’ In 2012 he is quoted as saying: ‘Today, we are faced with different challenges.

Challenges of reconciliation and of building a nation that does not discriminate against other people because of their colour or sexual orientation. ‘Today we find MSM services prioritised in the country’s National Strategic Plan for Health Care.

In a 2012 report to the World Bank, authors at Johns Hopkins University School of Public Health modelled the effect of prioritising MSM-targeted HIV interventions in countries that have generalised heterosexually driven HIV epidemics. Such interventions were shown to be of overall benefit in reducing the country’s HIV prevalence and neglecting such interventions impacts negatively on a country’s overall HIV response.

Despite goodwill and good intention, delivering health care to MSM is not always easy because of multiple real and perceived barriers to receiving such care. These barriers may be structural, community based or personal. Examples of structural barriers include a lack of health care access, prejudice and discrimination from health providers, and a skills deficit in meeting the unique health needs of MSM. Community barriers include homoprejudice, stigma, blackmail and extortion. Personal barriers include a lack of self-identification as MSM, incorrect HIV risk determination, low self-esteem, depression and anxiety, and, often, financial considerations.

In order to address these barriers to health care, the Department of Health and Anova Health Institute, with funding and support from PEPFAR/USAID, launched the Health4Men MSM programme at the Ivan Toms Centre for Men’s Health in Cape Town. This represents the first (and now the largest) state sector MSM-targeted sexual health and wellness clinic in Africa, with approximately 8 000 new MSM patient contacts to date.

The Health4Men model has been successfully rolled out across multiple provinces and new funding from the Global Fund will allow for national coverage within the next few months. The model is not clinic based but encompasses three main programatic arms. The first of these is community engagement, aimed at increasing the social captial of MSM living in townships and informal settlements and creating education and demand for MSM-related health services, as well as linking MSM to appropriate healthcare services. The second arm relates to direct clinical services, which will be discussed below. The third, and probably most important, arm of the project relates to institutionalising and mainstreaming MSM sensitivity and skills competency into exisiting HIV and STI state-health structures.

Regarding direct clinical services, the scope of core service that should be offered to MSM has been well defined by the World Health Organisation and was released at the recent International AIDS Soceity Conference in Melbourne as part of a consolidated Key Populations Guidelines document. Core services should be rendered in a non- discriminatory and enabling environment, which promotes human rights and dignity. Core services are otherwise similar to those for all people affected by HIV and STIs and access should be as available and accessible to MSM as for the general heterosexual population. Prevention services should include post-exposure prophylaxis, pre-exposure prophylaxis and early treatment for prevention, among others.

The Health4Men experience has highlighted some specific health care needs that are different from those of heterosexual men. Firstly, STI campaigns have proven more effective than HIV or CD4 campaigns in linking MSM to HIV services and should be used as ‘hook’ or marketing tool.

Image: Oupa Nkosi
Image: Oupa Nkosi

STIs may present differently in MSM compared to other men, including anal presentations of disease or high levels of asymptomatic infections with gonorrhoea or chlamydia. Rates of drug-resistant gonorrhoea are also higher in MSM, which has led to treatment failures being reported among MSM, globally and in South Africa. This exposes a problem in that South Africa’s current STI treatment guidelines are based on empiric and syndromic treatment without direct ascertainment of the cause of infection, or of antibiotic sensitivity. As such, the current guidelines do no meet the needs of MSM in our country as they will fail to detect asymptomatic disease, do not provide enough guidance regarding non-urethral STIs, and will result in treatment failures of cephalosporin-resistant gonorrhoea.

Another specific lesson learned is that mental health and recreational substance use harm-reduction programmes should be integrated into MSM clinical services. It must be stressed that MSM is not a mental health disease. However, MSM may internalise societal homoprejudice, which results in increased levels of anxiety and depression that may be self-medicated with alcohol and recreational drugs. If such services cannot be integrated, then robust referral networks and partnerships are required. The World Health Organisation has produced clear guidelines for working with people who use recreational substances, including needle and syringe exchange programmes and opioid substitution therapy (both of which are currently widely unavailable in our state healthcare sector).

Lastly, the Health4Men programme has generated experience and knowledge in delivering health and risk- reduction messages to key populations of men. Nuanced and clearly directed messages are required and need to be innovative and technology-lead, especially for young MSM.

In summary, the Health4Men programme has been invaluable in providing experiential learning of how to deliver health services to a group of men who are at high risk of HIV and STIs but do not trust or attend healthcare centres. We would encourage the Department of Health to continue to partner with experienced NGOs to deliver targeted and nuanced programmes to MSM. As African countries retract back to conservatism and increased politically-sanctioned homoprejudice, the gap widens between effective programmes in South Africa and the lack of such programmes in the rest of Africa. This provides a unique opportunity for South Africa to lead MSM health care on the continent but also provides an imperative for the country to advocate for universal human rights and non-discrimination based on sexual orientation and gender identity