Elise M. van der Elst

HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya

Background:The role of homosexuality and anal sex practices in the African HIV -1 epidemic is not well described. We aimed to assess the risk factors for prevalent HIV-1 infection among men who have sex with men (MSM) to guide HIV-1 prevention efforts. Methods:Socio-behavioural characteristics, signs and symptoms of sexually transmitted diseases (STD), and serological evidence of HIV-1 were determined for 285 MSM at enrolment into a vaccine preparedness cohort study. We used multivariate logistic regression to assess risk factors for prevalent HIV-1 infection. Results:HIV-1 prevalence was 43.0% [49/114, 95% confidence interval (CI), 34–52%] for men who reported sex with men exclusively (MSME), and 12.3% (21/171, 95% CI, 7–17%) for men who reported sex with both men and women (MSMW). Eighty-six (75%) MSME and 69 (40%) MSMW reported recent receptive anal sex. Among 174 MSM sexually active in the last week, 44% reported no use of condoms with casual partners. In the previous 3 months, 210 MSM (74%) reported payment for sex, and most clients (93%) were local residents. Prevalent HIV-1 infection was associated with recent receptive anal sex [odds ratio (OR), 6.1; 95% CI, 2.4–16], exclusive sex with men (OR, 6.3; 95% CI, 2.3–17), and increasing age (OR, 1.1 per year; 95% CI, 1.04–1.12). Only four MSM reported injecting drug use. Conclusions:The high prevalence of HIV-1 in Kenyan MSM is probably attributable to unprotected receptive anal sex. There is an urgent need for HIV-1 prevention programmes to deliver targeted risk-reduction interventions and STD services to MSM in Kenya.

Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya

Healthcare workers (HCWs) in Africa typically receive little or no training in the healthcare needs of men who have sex with men (MSM), limiting the effectiveness and reach of population‐based HIV control measures among this group. We assessed the effect of a web‐based, self‐directed sensitivity training on MSM for HCWs (www.marps‐africa.org), combined with facilitated group discussions on knowledge and homophobic attitudes among HCWs in four districts of coastal Kenya.

Experiences of Kenyan healthcare workers providing services to men who have sex with men: qualitative findings from a sensitivity training programme

Men who have sex with men (MSM) in Kenya are at high risk for HIV and may experience prejudiced treatment in health settings due to stigma. An on‐line computer‐facilitated MSM sensitivity programme was conducted to educate healthcare workers (HCWs) about the health issues and needs of MSM patients.

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011–2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities

Although men who have sex with men (MSM) in sub‐Saharan Africa are at high risk for HIV acquisition, access to and quality of health and HIV services within this population are negatively affected by stigma and capacity within the health sector. A recently developed online MSM training programme (www.marps‐africa.org) was shown to contribute to reductions in MSM prejudice among healthcare providers (HCPs) in coastal Kenya. In this study, we used qualitative methods to explore the provision of MSM healthcare services two years post‐training in coastal Kenya.

Cross-sectional survey of treatment practices for urethritis at pharmacies, private clinics and government health facilities in coastal Kenya: many missed opportunities for HIV prevention

Background While bacterial sexually transmitted infections (STIs) are important cofactors for HIV transmission, STI control has received little attention in recent years. The aim of this study was to assess STI treatment and HIV testing referral practices among health providers in Kenya. Methods In 2011 we assessed quality of case management for male urethritis at pharmacies, private clinics and government health facilities in coastal Kenya using simulated visits at pharmacies and interviews at pharmacies and health facilities. Quality was assessed using Ministry of Health guidelines. Results Twenty (77%) of 26 pharmacies, 20 (91%) of 22 private clinics and all four government facilities in the study area took part. The median (IQR) number of adult urethritis cases per week was 5 (2–10) at pharmacies, 3 (1–3) at private clinics and 5 (2–17) at government facilities. During simulated visits, 10% of pharmacies prescribed recommended antibiotics at recommended dosages and durations and, during interviews, 28% of pharmacies and 27% of health facilities prescribed recommended antibiotics at recommended dosages and durations. Most regimens were quinolone-based. HIV testing was recommended during 10% of simulated visits, 20% of pharmacy interviews and 25% of health facility interviews. Conclusions In an area of high STI burden, most men with urethritis seek care at pharmacies and private clinics. Most providers do not comply with national guidelines and very few recommend HIV testing. In order to reduce the STI burden and mitigate HIV transmission, there is an urgent need for innovative dissemination of up-to-date guidelines and inclusion of all health providers in HIV/STI programmes.

Risk of sexual, physical and verbal assaults on men who have sex with men and female sex workers in coastal Kenya.

Background:Violence toward MSM and female sex workers (FSW) is associated with HIV risk, and its prevention is prioritized in international HIV/AIDS policy. Methods:Sociodemographic and behavioural data derived from HIV risk and follow-up cohorts including MSM and FSW in coastal Kenya between 2005 and 2014 was used to estimate the risk of rape, physical assault and verbal abuse, and to assess associations between first occurrence of assault with individual and recent behavioural factors. Results:Incidence of first reported rape was similar for MSM [3.9, confidence interval (CI) 3.1–5.0 per 100 person-years (pyrs)] and FSW (4.8 CI 3.5–6.4 per 100 pyrs), P = 0.22. Incidence of first reported physical and verbal assault was higher for FSW than MSM (21.1 versus 12.9 per 100 pyrs, P = 0.14 and 51.3 versus 30.9 per 100 pyrs, P = 0.03 respectively). Recent alcohol use was associated with reporting of all forms of assault by MSM [adjusted odds ratio (AOR) 1.8, CI 0.9–3.5] and FSW (AOR 4.4, CI 1.41–14.0), as was recent sale of sex for MSM (AOR 2.0, CI 1.1–3.8). Exclusive sex with men, active sex work, and group sex were also specifically associated with reporting rape for MSM. Perpetrators of sexual and verbal assault were usually unknown, whilst perpetrators of physical violence toward FSW were usually regular sexual partners. Conclusion:MSM and FSW experienced a similarly high incidence of sexual assault in coastal Kenya, in addition to physical and verbal assault. Current national policies focus heavily on gender-based violence against women and young girls, but need to be inclusive of MSM and FSW.

How intersectional constructions of sexuality, culture, and masculinity shape identities and sexual decision-making among men who have sex with men in coastal Kenya.

Abstract Men who have sex with men are increasingly recognised as one of the most vulnerable HIV risk groups in Kenya. Sex between men is highly stigmatised in Kenya, and efforts to provide sexual health services to men who have sex with men require a deeper understanding of their lived experiences; this includes how such men in Kenya construct their sexual identities and how these constructions affect sexual decision-making. Adult self-identified men who have sex with men (n = 26) in Malindi, Kenya, participated in individual interviews to examine sociocultural processes influencing sexual identity construction and decision-making. Four key themes were identified: (1) tensions between perceptions of ‘homosexuality’ versus being ‘African’, (2) gender-stereotyped beliefs about sexual positioning, (3) socioeconomic status and limitations to personal agency and (4) objectification and commodification of non-normative sexualities. Findings from this analysis emphasise the need to conceive of same-sex sexuality and HIV risk as context-dependent social phenomena. Multiple sociocultural axes were found to converge and shape sexual identity and sexual decision-making among this population. These axes and their interactive effects should be considered in the design of future interventions and other public health programmes for men who have sex with men in this region.

Strengthening healthcare providers' skills to improve HIV services for MSM in Kenya.

Research on HIV burden and determinants of HIV risks among MSM in sub-Saharan Africa is now considerable [1]. A meta-analysis of 51 surveys conducted between 2005 and 2013 estimated 18.7% HIV prevalence among MSM, a disproportionately large contribution to the HIV epidemic in sub-Saharan Africa [2,3]. Targeted interventions for MSM could significantly decrease HIV transmission, not only among MSM but also on a population level [4,5]. However, anal intercourse in African societies remains highly stigmatized and HIV public health messaging is still unfocused [6]. Compilation of data on testing behaviour among African MSM derives mostly from studies centred among urban and sex worker MSM [7,8] and indicates that legal policy, social inequality, and inadequate training of healthcare providers (HCPs) discourage MSM from seeking HIV prevention and treatment [9–13]. Addressing HIV and other health needs among MSM in this region cannot be met through the healthcare sector alone. Rigorous structural efforts promoting a skilled healthcare labour force, and community sensitization to protect against unfair treatment will improve the provision of effective and ethical health services for African MSM [11,12,14–21]. Efforts to improve access to and healthcare services for Kenyan MSM in the context of HIV research started by our team in coastal Kenya, in 2005. In collaboration with the Kenya Medical Research Institute–Wellcome Trust Research Programme and supported by the International AIDS Vaccine Initiative, Kenyan MSM have been studied in a longitudinal cohort with the aim to prepare populations for HIV-1 vaccine efficacy trials and analyse the immune and viral profiles of individuals who have seroconverted to inform the design of potential HIV-1 vaccines [22]. Although care has been provided in the context of research, this project was the first in Kenya to actively mobilize, test, and link HIV-infected MSM to comprehensive care, including antiretroviral therapy (ART) [3]. HIV-positive men are currently followed in a longitudinal cohort in parallel with the vaccine feasibility study [23–26]. The study clinic initially provided a well tolerated haven wherein MSM study volunteers felt protected and understood by counsellors and clinicians. A major shift took place after an antigay campaign resulted in an attack on the Kenya Medical Research Institute–International AIDS Vaccine Initiative research clinic in Mtwapa in 2010 [14]. In light of HCPs’ potential role to mitigate this societal aggression, we introduced a sensitization programme to provide information on male same-sex behaviour and address the initially deeply held attitudes and beliefs among 74 HCPs in the 49 ART-providing healthcare facilities in the Kenyan Coast [17,27]. This sensitization programme is freely available on www.marps-africa.org. In African communities, HCPs hold strategic positions, not only because of their social legitimacy and robust presence in public institutions, but also because of the critical role they play implementing ethical principles in their communities. Initial evaluation of the MSM sensitization programme suggested short-term improvements in knowledge and reductions in homophobia 3 months postintervention [17]. Rollout of the MSM sensitization training across the HIV health sector in Kenya has resulted in over 1200 trained HCPs to date. Yet, a 2-year follow-up analysis of the initially 74 trained HCPs revealed challenges in sustaining the effects (van der Elst EM, Kombe B, Gixhuru E, Omar A, Musyoki H, Graham SM, et al. The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities, 2015, in preparation). Despite HCPs’ enduring personal commitment, providing fair and appropriate services, retention of new attitudes and practices in the presence of pervasive institutional and societal discrimination remained difficult. Trained HCPs described secondary stigma from their coworkers and managers as pressure to conform to the standards of Kenyan society and their health institutions, which continued to view male same-sex behaviour as immoral and illegal [27]. Experiences of the trained HCPs confirmed that public healthcare is an innately social process. Profession standards and cultural values demonstrated how power within society affects power within healthcare settings. For HCPs to successfully challenge these power structures that prevent change, they need to be self-consciously aware of the way in which their own powerful position either facilitates or inhibits MSM coming forward for HIV healthcare. Interestingly, 10 years after the first MSM enrolled for an HIV-1 vaccine feasibility study in Mtwapa, biomedical research will soon involve approximately 2000 MSM in either ongoing care or research programmes in Kenya. These care and research programmes will enroll 100 MSM in the HPTN 075 multicenter observational study in Kisumu starting in 2015, 700 MSM to the Anza Mapema Test and Treat study in Kisumu, also starting in 2015, and continue to support 1000 MSM currently accessing care and support at the Sex Worker Outreach Programme in Nairobi and close to 200 MSM in Mtwapa. As a result, Kenyan and international researchers have formed an MSM health research consortium in 2014. The aspirations of this consortium include the development of new, innovative biomedical and behavioural research together with the goal of informing and assisting the Kenya Ministry of Health as well as international agencies to inform policy and practice and improve health outcomes for MSM in Kenya and elsewhere. Key epidemiological and social science studies have raised awareness of MSM to policy makers at local and national levels and, together with Kenya’s ‘Mode of Transmission Analysis’ [28], have highlighted MSM as a key population in the national HIV epidemic, resulting in the inclusion of MSM in Kenya’s AIDS Strategic Framework [29]. Another report by the Kenyan National AIDS Control Council proposes a suite of interventions including behaviour modification, early ART, preexposure prophylaxis (PrEP), and male circumcision that can be tailored to different risk groups [30]. Although MSM receive strong prioritization in policy documents and in some research and care settings in Kenya, what is actually urgently needed is a much broader emphasis on sensitization training of a professional cadre of HCPs (both in-service and preservice). Although decriminalization of same-sex behaviour is beyond the Ministry of Health’s mandate, it is feasible that the Ministry could support and advance HCPs’ feelings of empowerment and legitimacy to provide nondiscriminatory services to MSM. Greater inclusion of MSM in health services is also warranted given the role of PrEP as a strategy for HIV prevention. Modelling by WHO estimates that, worldwide, 20–25% reduction in HIV incidence in MSM could be achieved through PrEP, averting up to 1 million new infections over 10 years [31]. PrEP has shown efficacy in several trials and is up to 92% effective against HIV transmission, but if medication adherence is lacking, PrEP effectiveness will steeply drop [32]. Although it is hoped that PrEP will be provided to MSM in Kenya, successful implementation will depend on qualified HCPs whose care for PrEP users will be fundamental to the success to this prevention strategy. In the absence of a free PrEP programme for MSM, how will HIV-1 infections be prevented in this group? Targeting MSM and other key populations for immediate ART will confer individual benefits and will likely reduce onward transmission [33]. HIV and health are not simply biomedical issues but social and political phenomena, which require huge efforts to change in society. In Kenya, adoption of the MSM sensitization training in all medical training colleges and by professional associations, including the Kenya Medical Association, National Nurses Association of Kenya, and Kenya Association of Professional Counsellors, is a first step sending a strong message in the context of health equity. Although inclusion of the MSM sensitization training in health education alone will be insufficient to close the gap in the broader context of cultural, religious, and political anti-MSM sentiment, it may, with careful planning and coordination, achieve a paradigmatic shift in HIV healthcare and become part of a broader social evolution. HCPs across Kenya and beyond have an essential role to play in widely disseminating and discussing human sexualities needs, while enhancing health equity for MSM and other sexual minorities.

“Facing Our Fears”: Using facilitated film viewings to engage communities in HIV research involving MSM in Kenya

Abstract Kenya is a generally homophobic country where homosexuality is criminalised and people who engage in same sex sexuality face stigma and discrimination. In 2013, we developed a 16 min documentary entitled “Facing Our Fears” that aimed at sharing information on how and why men who have sex with men (MSM) are involved in on-going KEMRI HIV prevention research, and associated community engagement. To consider the film’s usefulness as a communication tool, and its perceived security risks in case the film was publicly released, we conducted nine facilitated viewings with 122 individuals representing seven different stakeholder groups. The documentary was seen as a strong visual communication tool with potential to reduce stigma related to homosexuality, and facilitated film viewings were identified as platforms with potential to support open dialogue about HIV research involving MSM. Despite the potential, there were concerns over possible risks to LGBT communities and those working with them following public release. We opted—giving emphasis to the “do no harm” principle—to use the film only in facilitated settings where audience knowledge and attitudes can be carefully considered and discussed. The results highlight the importance of carefully assessing the range of possible impacts when using visuals in community engagement.