A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi

Abstract

BackgroundIn the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention.MethodsUsing peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM.ResultsResults highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection.ConclusionsQualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.

The immediate effect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort

“…27–30 Moreover, these quantitative results reinforce qualitative findings that criminalisation of same-sex behaviour only adds to the HIV burden by driving MSM away from the benefits of HIV treatment and prevention services. 12,31 Although causality cannot be directly established because of the uniform nature of the experience of the exposure in our population, our individual-level prospective data provide more robust evidence than have previous ecological analyses 21 and cross-sectional data showing reduced uptake of HIV testing in countries criminalising same-sex practices, and have the added benefit of providing more precise estimates for the drivers of this negative outcome. 10 …”

Comparing Provider and Client Preferences for HIV Prevention Services in South Africa among Men Who Have Sex with Men

“…Conversely, high rankings of MSM-specific testing space were present among providers and may be consistent with the findings from another sub-Saharan context, in which providers linked a lack of previous interaction with MSM and decreased willingness to administer HIV-prevention services to this population. 51 As detailed above, a number of providers in our study expressed little or no know experience with MSM clientele, underlying greater favorability of clinic characteristics that would not require increased personal interaction with MSM.…”

“In the Fell Clutch of Circumstance”: HIV and Men Who Have Sex With Men in Sub-Saharan Africa

“…In combination with high levels of homophobia, stigma and discrimination, the illegal nature of same sex sexuality makes it difficult to implement any kind of service targeting MSM, and even where such services exist, MSM may be fearful of accessing them because of the potentially negative repercussions of being identified as MSM. Wirtz et al [34], in Malawi, also noted that criminalisation of same sex behaviour creates fear among health care providers around the potential ramifications of providing care to MSM.…”

“…Studies conducted in Tanzania [7], Malawi [14,34], Swaziland [9,10] and Uganda [35] point to stigma and homophobia as significant factors affecting HIV risk among the MSM in these countries. Fewer recent works from West and Central Africa focused on the roles of homophobia and stigma in exacerbating HIV risk for MSM, but these factors are almost ubiquitously discussed as the background context for MSM research in this region [cf.…”