SHARP strategies for outreach success in high-risk environments
A sexual and reproductive health and rights (SRHR) programme in Kenya and Uganda exceeded its target reach of men who have sex with men (MSM) by nearly three times thanks to innovative ways of working.
The experience of using non-traditional outreach models to provide sexual health services to MSM is offering valuable lessons.
The models, implemented as part of SHARP (Sexual Health and Rights Programme), saw services tailored to the specific needs of MSM in Kenya and Uganda – countries where same-sex sexual activity is criminalised, and stigma, discrimination, abuse and violence against MSM are rife.
The interventions the models embraced included:
- HIV and STI testing and counselling in nightclubs, hotels and bars frequented by MSM,
- peer-driven behaviour-change communication (BCC) activities mobilised through word of mouth and social media, and
- HIV and SRHR clinical services provided by healthcare workers sensitised on the specific SRHR needs of MSM, through innovative partnerships with health clinics.
Facebook, WhatsApp and other mobile technologies were used to maximise attendance at clinics, and secret passwords used to enable MSM to access specialist services in mobile clinics without fear of ‘discovery’.
SHARP operated in four East and Southern African countries between 2012 and 2015 with the aim of reducing the spread and impact of HIV among MSM, while building healthy MSM communities. It was coordinated by the Alliance, implemented by MSM-led community-based organisations (CBOs) and funded by the Danish International Development Cooperation (DANIDA).
A case study focusing on the experiences of SHARP in Kenya, as implemented by Men Against AIDS Youth Group (MAAYO), and in Uganda, as implemented by Ice Breakers Uganda (IBU), describes the process of setting up interventions as a learning journey. “Despite their different contexts and experiences, a number of critical elements will be relevant to others attempting a similar approach,” say authors Matteo Cassolato and Gavin Reid.
The outreach models adopted comprised both drop-in services at CBO premises and mobile clinical outreach, and were designed in line with World Health Organization (WHO) guidelines on key populations.
Trust and empowerment
Primarily, the authors conclude that, given the high-risk environments in which MSM live in Kenya and Uganda, trust is critical for success. This means services for MSM should be provided by MSM.
“Ultimately, involving communities in the delivery of services to communities translates into ownership and empowerment. In this sense, MSM organisations that provide services for MSM have a distinct advantage, as they are trusted in a way that can’t be replicated by organisations that are not part of the MSM community,” they say.
In the cases examined, trust at times had to be built. This involved lengthy ‘getting to know you’ processes and exchanges of knowledge and experience. “In this way, trust like a currency, moved... enabling personal relationships to grow, partnerships to start and outreach to finally take place,” the authors explain.
Trust, they add, also needs to be extended to the healthcare workers to which MSM are referred. This means instituting training aimed at increasing healthcare worker understanding of the specific needs of MSM is critical.
Safety and security
Other elements singled out as essential for success include the pivotal role of peer educators and attention to safety and security from the start.
Given a reliance on peer educators as gateways to both types of outreach activity, the authors recommend compensating them for their work to ensure consistent commitment. They also recommend that peer educators of different ages and diversity are recruited to maximise the reach of interventions.
Preliminary steps taken to ensure the safety and security of interventions, given the negative attitudes to MSM in Kenya and Uganda, is essential. In the case study this included engaging local communities, training activities with key community stakeholders such as police, sensitising religious and other local leaders on MSM health needs and security assessments of programme partners.
“Taking these measures ahead of programme implementation proved successful because they allowed the programme to have the flexibility it needed to adapt to an environment that could, and did, rapidly change,” the authors state.