Targets miss younger men
The 2012 National Strategic Plan for HIV, STIs, and TB laid an important foundation for improving HIV prevention and treatment for Men who have Sex with Men (MSM) and other key populations that are most affected by HIV in South Africa. Addressing the HIV prevention and treatment needs of these communities, and setting concrete goals for their success, are critical steps to making a lasting impact in our fight against this epidemic.
Many of South Africa’s local organisations, along with our international partners, have already contributed significantly to these goals through innovative programming, expanded services, and continued advocacy efforts. In the past two years, MSM programming has expanded into new provinces, sensitisation training for healthcare workers has been embraced by the National Department of Health, and emphasis on new prevention measures like PrEP has also increased. These much needed initiatives will continue to bolster our prevention and treatment efforts for MSM and continue to make a difference in our epidemic.
A great deal of work is still required, however, to meet the targets set forth in the NSP. In particular, one of the challenges we still face in providing services and support for MSM is the great diversity that exists within this population. Communities of MSM differ immensely across the country and include every race, socio-economic group, religion, and geographic community. This makes designing and implementing a ‘one size fits all’ programme for MSM nearly impossible.
While work has been done across the country to ensure that the most-in-need MSM are gaining access to services, there is one group in particular that is slipping through the cracks: Very few if any programmes are targeting young MSM, particularly those under the age of 18.
Unfortunately, very little research has been conducted with young MSM and therefore local evidence and data for this population is extremely limited. Globally, however, we know that young MSM are a highly vulnerable population that experience higher HIV prevalence than their older MSM peers.
Young MSM are increasingly vulnerable to HIV for a number of reasons. Unlike their heterosexual peers, young MSM face developmental and psychosocial challenges that increase their vulnerability to mental illness, substance abuse, and HIV. Like adult MSM, they may also experience stigma and discrimination because of their sexual orientation.
Not only can this increase their risk of mental illness and experience of violence, but it that can also prevent them from accessing key healthcare services, including HIV and STI testing and treatment. Being unable to disclose their sexual orientation to healthcare workers or other authorities means that young MSM may not be able to access care and support if they experience sexual violence.
Like other adolescents, young MSM continue to be sexually active at younger ages. We know from some samples of MSM in South Africa that the majority report their age of sexual debut to be earlier than 16. Early sexual debut introduces young MSM into a pool of older sexual partners with a high prevalence of HIV. In such situations, safer sex and HIV prevention education, as well as access to prevention supplies like condom and lubrication, are critical to protect young MSM. Unfortunately, young MSM are generally not catered for within prevention programming for adolescents, as most safer sex education is strictly heterosexual. Because of their age, young MSM may also not be targeted by adult MSM programming. Ultimately, despite their increased vulnerability young MSM are being excluded from adolescent- and MSM- specific programming, leaving them entirely unprepared to protect themselves against the HIV epidemic.
In light of the potential risks faced by young MSM, we have to ask ourselves, as a country, what is the best way to protect this highly vulnerable population? This is not the first time in our fight against HIV that we have had to support a vulnerable group with few resources or little knowledge. Years ago, when attention was finally brought to the epidemic raging in South Africa’s MSM community, we had little knowledge of the epidemic, few services, and little policy support. Now, thanks to coordinated advocacy, community-based services, extensive research, and refined policy, we are in a much stronger position. We must follow the same path for young MSM. If we are going to support this vulnerable population then we urgently need additional research, more appropriate education, expanded services, and targeted engagement.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) has released a draft technical brief that can easily guide us in the strategic information and services that we need for young MSM in order to fight this epidemic. Specifically, we need to better understand the young MSM population, their risk behaviours, mental health, and substance use habits. This information will allow us to refine current MSM and adolescent programming to make use of strategic funding and reduce gaps in service provision.
We must not forget that young MSM will have their own opinions about their care and support and these opinions deserve to be heard
We also need to leverage the existing adolescent programmes in our country but invest in making them applicable to all young people, including young MSM. Programmes should include discussions about sexual orientation and provide safer sex information that is applicable to non-heterosexual adolescents. If we are able to leverage our current adolescent programmes and include more sensitised and relevant information, then we will be able to use fewer resources and waste less time than if we create specialised and parallel structures for young MSM.
Like all key populations, we do not need to build specialised healthcare services to support young MSM. Instead, we will only need our current services to be better sensitised to their needs. In addition, it is a useful exercise to think through possible other community-based venues, where young MSM may naturally convene, to offer some of the health and prevention services that are not dependent on health facilities. Healthcare workers and community- based organisations in all HIV prevention programmes that include testing and treatment should be sensitised to provide appropriate counselling, care, and support to young MSM. Furthermore, HIV prevention supplies such as condoms and condom-compatible lubricant, as well as new prevention methods such as PrEP, should be made available and easily accessible to young MSM.
We must not forget that young MSM will have their own opinions about their care and support and these opinions deserve to be heard. As highlighted by UNAIDS, we need to ensure that we are engaging young MSM in our programming and like all other adolescents, provide ways for their voices to be heard and included in the design of future programmes so that they may be more appropriate to their needs.
As long as any one population in our country continues to remain vulnerable to HIV we will never win our fight against this epidemic. Young MSM are uniquely at risk when compared to other heterosexual adolescents and also when compared to adult MSM, and yet we are doing little to support them. We have made great strides in providing services to the MSM community in South Africa but will these efforts and funding continue to make a difference if the next generation of MSM grow up uneducated, stigmatised, bullied, and exposed to STIs and HIV? We urgently must change course before we lose the opportunity to make a difference in the lives of these young people.