Strengthening HIV health care services for men who have sex with men in coastal Kenya

This thesis describes work with Kenyan men who have sex with men (MSM) who are highly stigmatized and discriminated against in society, and have not been targeted in HIV prevention programming until recently. Initial work included a size estimation of MSM who sell sex in coastal Kenya in 2006, and a comparison of two methods of risk behaviour assessment (Audio computer-assisted self-interview and face-to-face interview) at cohort enrolment. Subsequent studies included pre- and 3-month post-assessments of MSM-knowledge and homophobic attitudes among 74 health care providers from 49 ART-proving health facilities from four districts in coastal Kenya who had undergone an 8-modular computer-facilitated MSM-sensitivity training, which is also provided freely online (www.marps-africa.org). The MSM-sensitivity training included modules on practical knowledge of the burden of HIV among MSM, sexual behaviour, stigma, and mental health challenges among other topics. Learning was complimented by group discussions, facilitated by MSM. Three months after training, more health care providers had adequate knowledge compared to baseline (49% versus 13%, p<0.001), and homophobic attitudes had decreased significantly, particularly among health care providers with high homophobia scores at baseline. Qualitative assessments among MSM participants in a four-month oral pre-exposure prophylaxis (PrEP) phase I trial underscored the major role health care providers will play in future PrEP implementation. In conclusion, sensitized health care providers in rights constrained environments can strengthen HIV health care services for MSM and have the potential to become ‘agents of change’, striving for and enhancing health equity for MSM and other sexual minorities in sub-Saharan Africa.