Increasing Reach and Engagement of MSM
What was done?
The SHARP Implementing Partners (IPs) started by looking at their service package and identifying what components they could provide and what components they would need to refer to health providers. With a defined service package in place (see Improving Services) the IPs then employed a wide range of interlinked approaches to identify, reach and connect with MSM.
Though there were country-specific variations of approaches, common features to the model in each country include, for instance:
- Mapping of MSM to identify areas with existing potential demand
- Community-led and peer-driven targeted engagements to build trust with MSM communities
- A holistic human rights-based approach which prioritises safety and security and takes into account the broader needs and interests of MSM and with a clear service package
- Integration of HIV with sexual and reproductive health and rights (SRHR) in service delivery
- Sex positive messaging focusing on holistic sexual health and well-being, as opposed to disease prevention and treatment
- A family-centred approach and the engagement of regular sexual partners and family members of MSM
- The use of ICT and social media
- Bi-directional community to health facility referral systems (though the degree of formalisation varies) so MSM are able to access services along the continuum of care
- Using unique identifier codes (UIC) to both ensure client confidentiality and for the safety of those reached [continued below]
- Strengthening of active linkages between the community and public health systems with integrated outreaches
- Scheduling outreaches on a frequent and predictable basis creating supply-driven demand
- Significant geographical expansion of outreach and linking to local service providers
- Addressing broader issues including access to safe spaces, emergency response, family reconciliation, and referral to legal services
CHESA and SANA primarily engage new clients through reaching out to them at physical venues in the neighborhoods they serve around the city. In order to do this, they have a map of locations where MSM are known to meet, including bars, music halls, beaches and private addresses. This ‘hotspot map’ – a large physical display on the wall – therefore underpins many of SANA and CHESA’s activities and is updated yearly.
Because of the repressive political and social environment, venues for where MSM live or meet shift quite rapidly. For the most part, no venues are stable enough to consistently cater to the MSM population. An area where men congregate one year might no longer be a meeting point the next year. In order to update the map, SANA and CHESA first identify and then approach individuals at each location who can serve as ‘gateways’ to the community of MSM there.
Peer educators arrange a time to visit these gateway individuals to ascertain whether there are still MSM present at the location. New hotpots are also identified through social networks and from enquiring at each identified hotspot. CBOs engage with local authorities to make them aware of their mapping activity, which helps to prevent problems. More informally, throughout the year peer educators might become aware of new locations to visit or locations that become inactive, and these changes are recorded. The map then forms the basis on which peer educator work is organised and the means by which a mobile caravan intervention is planned. Given the changing nature of the MSM physical venues, and where men feel safe to meet, it is necessary to update these maps on a regular basis, ideally at least every two years.
To date CHESA and SANA have conducted mappings in Ilala and Kinondoni in Dar Es Salaam and they plan to do mappings in Pwani and Tanga in 2015.
The infographic below summarizes some of the overall key strategies and specific approaches to extending reach and access to services in each country.
Evidence shows that outreach-based and targeted community HIV prevention and treatment interventions are effective in reaching MSM and other key populations. We know that effective interventions cannot have an impact on the epidemic of HIV and STIs among MSM unless they are scaled up and expanded to reach all MSM at risk. All four SHARP countries officially or unofficially acknowledge KPs as a target group in their national HIV or health strategies and plans. Yet, much more needs to be done to turn the words in strategies and plans into actual resourced programmes that are implemented for and by MSM. This is compounded by lack of adequate data on population size and HIV outcomes among MSM, which makes it difficult to advocate for improvements in access to care and health outcomes.
It can be hard and potentially dangerous to reach MSM due to laws and policies that criminalise MSM, homophobic stigma, etc. Some MSM fail to access or maintain contact with health services as a result of experiencing, or the fear of experiencing, stigmatising attitudes and discrimination from healthcare providers.
MSM also face challenges from within their own communities especially after a positive HIV diagnosis, exacerbating difficulties with disclosure and lack of psychosocial-support and leading to poor adherence and retention in care.
Challenges faced and limitations of our approach
Most of the SHARP partners are based in the capital cities or regional centres and many IPs initially provided undefined and/or inconsistent service packages with one-way referrals to health care providers. In addition health care providers did not always recognise nor value the many roles that the partners are best placed to deliver.
MSM CBOs in all countries encountered security threats and had to temporarily close, relocate or temporarily scale down or suspend services as a result of hostile social or political environments. In all cases programming resumed as soon as the implementing partners deemed it safe and feasible. The impact of this situation on reaching and maintaining contact with MSM cannot be overestimated and there is a unmet need to address trauma experienced by the community and those who experience vicarious trauma by providing services.
Having solid security plans as well building relationships with (and sensitising) health facilities allowed for the creation of networks committed to providing health and HIV services to MSM. With defined service packages and referral pathways in place, effort was then directed into expanding geographical reach and the times that services are available through intensive peer-educator led community daylight and moonlight outreach and the use of social media.
GALZ uses Facebook to achieve a variety of specific objectives and to reach different sections of the Zimbabwean MSM community. Reported objectives include sharing experiences, creating a forum for mutual support, providing health information, sharing information about the LGBTI community elsewhere in the world, sharing research findings and discussing fashion. In order to do it, they have developed several different Facebook groups, in some cases seeding them from the beginning, and in other cases participating in existing groups. The various GALZ-run pages vary from 208 to 1,869 members and one of the closed groups they contribute to has 8,422 members.
Health information is mixed into a wider range of topics felt to be appealing to the target population, and a range of professionals have been invited to participate, including fashion designers, gardeners, artists and chefs. A range of other Facebook groups that GALZ staff monitor and post targeted information to, include those aimed more at sexual hook-ups, and those that provide sexual health information. These pages are all kept separate from the GALZ organisational Facebook pages. As Sylvester from GALZ explains below, the organisation now makes initial contact with many of its new members via social media.
While their strategy appears to have been successful, it has required a large investment of time. Initially, the seeded groups took a lot of effort on the part of GALZ staff, who tended to be the only people posting. As the groups became more popular and discussion over comments grew, others began to post. While this somewhat reduced the demands on staff time, the overall volume of personal messages is high. This is the means by which many men have been making first contact and they need to be dealt with on a regular basis. Additionally, there are tensions around privacy and security. It is likely that some of GALZ’s work on Facebook has benefitted from the profile and status that named staff involved in the groups have among the MSM community in Zimbabwe. Using personal profiles might not, however, be an acceptable strategy for all staff members or volunteers at SHARP. Nonetheless, the targeting of groups, seeding of discussion, mix of different types of information and separation from organisational pages could be useful strategies for other CBOs.
The outreaches facilitated access to condoms and lubricants and provided HIV testing and counselling (HTC) and STI diagnosis to consenting MSM.
In addition to outreaches in the community all SHARP partners also provide safe spaces at their premises where social events, small group HIV and SRH education (including life skills, safety issues, relationship skills, family planning) and where a varied range of other services are also available.
At the same time ICT was used to:
- contact and connect with MSM
- inform MSM about up-coming social and health events
- warn MSM of potential security risks
- inform MSM about available services
- communicate MSM-specific sexual health messages
- support MSM in assessing their individual STI and HIV risk
- have informed discussions on wider topics of interest to MSM such as violence and relationships
Lessons learnt include:
- Safety and security of staff, volunteers and clients should be assessed before any intervention
- MSM CBOs have the trust of large sections of the MSM community
- MSM CBOs demonstrate considerable resilience and ability to adapt and devised innovative approaches to ensure continued engagement with MSM
- Wider needs and issues in the lives of MSM need to be recognised and addressed in order to effectively deliver HIV, SRHR and other health services
- MSM CBOs are overstretched trying to meet the needs and expectations of the MSM community with limited funding and partners willing to work with them
- More needs to be done to reach and address the needs of MSM living with HIV and other sub-populations (MSM who sell sex, MSM who use drugs, displaced MSM, MSM under 18, MSM over 34) and to support to the mental health and holistic health of MSM