Ignoring men who have sex with men and excluding them from prevention programs has enormous health implications. Photo credit: Scott Geibel (Original photo)

For HIV prevention efforts to make gains in halting the AIDS pandemic, access to information and services, such as voluntary counseling and testing (VCT) and treatment for sexually transmitted infections (STIs), must become a reality for everyone, particularly those most affected by the disease. However, the fact remains that some populations are difficult to reach through conventional health programs. According to the Office of the United States Global AIDS Coordinator, men who have sex with men are “among those who are most marginalized in society and have the least access to basic health care.”¹

Stigma and discrimination often play an insidious role in inhibiting vulnerable populations, including men who have sex with men, from gaining access to vital information and critical prevention and treatment services. This is evident in much of the developing world—and in Africa in particular—where the stigmatization of homosexual behavior and the denial of the existence of men who have sex with men persists.

Unfortunately, the health implications of ignoring men who have sex with men and excluding them from prevention programs are far reaching. A Horizons study of men who have sex with men in Senegal found that many engage in high-risk sexual behaviors, such as having multiple partners and unprotected sex, in the absence of counseling and prevention services geared toward them. Add to this poor knowledge of STIs and a high rate of symptoms, and the situation is ripe for the widespread transmission of HIV.²

Despite increasing awareness of the role men who have sex with men may play in the dynamics of HIV transmission in Africa, research that can help policymakers and program managers address the issue has been limited. To better understand the HIV/STI risks and prevention needs of men who have sex with men in Kenya, researchers from the Institute of African Studies at the University of Nairobi and the Horizons and FRONTIERS programs of the Population Council conducted a study from 2003 to 2004 in Nairobi. The study is groundbreaking because it collected quantitative and qualitative information on stigma, health-seeking behavior, sexual behavior, condom use, STI symptoms, and HIV testing from an unacknowledged, yet vulnerable population in order to develop appropriate interventions to meet serious health needs.

The study included a survey of 500 men who have sex with men; in-depth interviews with a sample of these men, gatekeepers, and service providers; and observations. Researchers used the snowball method of sampling for the survey, in which two “mobilizers” were identified and asked to recruit respondents, who subsequently recruited others.

Stigma, Discrimination, and Health-seeking Behavior

Most of the survey respondents, who ranged in age from 18 to 55 and represented a wide variety of occupations, felt that stigma and discrimination were major problems in their lives, with many feeling rejected and hated by the general society. A third experienced humiliation, harassment, or discrimination in the past 12 months, while one in five respondents were victims of some form of violence (see Table 1).

In-depth interview informants noted that stigma, discrimination, and violence often lead men who have sex with men to go to great lengths to hide their sexual identities from the public. In some cases they have relationships with women, including marriage, which helps conceal the fact that they are sexually active with men. Over a third of the men surveyed had not discussed their sexual orientation with another person, including family members. A majority (68 percent) of the men stated that they were uncomfortable discussing their sexual practices with anyone other than a male sexual partner.

This caution carries over to health care-seeking behavior—only 5 percent of survey respondents reported discussing their sexual conduct with health care personnel. Instead, the men in the study largely turn to each other and develop strong personal networks for emotional, social, and professional support and health information, including discussions related to stigma and HIV/STI prevention.

Sexual Risk Behavior and Condoms

Sex with multiple partners among men in the study is common. Almost half of survey respondents reported having two or more partners within the past month, while 79 percent reported the same within the past year. Although the average number of partners in the past year was three, this does not account for the 30 percent of the sample that could not remember the actual number of partners they had. However, there was a substantial subgroup (21 percent) that reported having only one partner in the previous year.

Condoms are widely available in Nairobi, and their use is high among the study sample. Three out of four men surveyed reported using a condom at last anal sex and 58 percent indicated “always” using condoms. Eleven percent cited never using a condom. But survey respondents also reported widespread use of oil-based lubricants, primarily Vaseline, which can make condoms vulnerable to breakage. Only one out of five men in the survey knew that only water-based lubricants should be used with latex condoms.

Further analysis of the survey data revealed that having only one sexual partner in the past year was significantly associated with having unprotected sex. About half of the sample who did not use a condom at last anal sex said it was because they trusted their partner. In addition, victims of some form of violence over the past year were found to be more than twice as likely not to use a condom at last sex. This finding may reflect that these individuals, because of experiences of abuse, feel less empowered to negotiate condom use than other men.

STI Symptoms and HIV Testing

Even though condom use is reportedly high, the study sample described a higher level of STI symptoms than found among men in the general population of Nairobi. For example, 6 percent of men in the study reported that they had experienced genital or anal discharge in the past 12 months, compared to one percent of all males surveyed in Nairobi, according to the 2003 Kenya Demographic Health Survey.³

Eight out of ten men surveyed with STI symptoms in the past 12 months sought treatment, with the majority choosing to go to private clinics. In-depth interviews revealed privacy and confidentiality as primary reasons why private clinics were chosen over other available health facilities.

More than half of the men surveyed (57 percent) had been tested for HIV. This is more than twice the proportion of the general male population in Nairobi Province who had been tested.⁴ Almost all (98 percent) of those who underwent HIV testing received their results, and 70 percent were tested within the last year. Of those not tested for HIV, 95 percent knew where they could go for VCT.

The high utilization of testing services by men who have sex with men is a missed opportunity to impart HIV prevention messages geared toward them. The researchers found that the curriculum used to train VCT counselors in Nairobi does not include specialized advice for men who have sex with men or address particular issues of partner notification and couples’ testing for this population. Most providers assume that all clients are heterosexual, and therefore do not offer information that may be of particular interest to men who have sex with men, such as which lubricants should be used with condoms for HIV prevention.

Health Services

Men in the study both desire and seek professional health care from the variety of medical facilities available throughout Nairobi. Still, they cite difficulty finding providers trained to meet their specific sexual health needs. As indicated earlier, respondents report confidentiality as a chief concern in selecting a health facility for STI treatment, fearing the reaction of the health provider to their sexual practices as well as possible legal action since homosexual behavior is illegal in Kenya.

In-depth interviews with service providers revealed that the issue of male-to-male sexual behavior is rarely discussed among providers, or with their patients. This is despite the fact that providers are aware of symptoms that indicate a male patient is having sex with other men, such as anal sores or ulcers in the throat. Since such patients usually do not ask for specific advice, or discuss their symptoms, providers in turn offer treatment without question or inquiry, creating another missed opportunity for HIV prevention counseling.

“The results of this study will go a long way in challenging local notions of sexuality and sexual practices in the era of HIV/AIDS, particularly among health providers, and hopefully lead to more comprehensive counseling” said W. Onyango-Ouma of the Institute of African Studies/University of Nairobi, one of the study’s principal investigators.

References

³Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.

⁴Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC Macro. 2004. Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro.