Health care in a homophobic climate: the SPEND model for providing sexual health services to men who have sex with men where their health and human rights are compromised

Abstract

We present a model for developing health services for men who have sex with men (MSM) in sub-Saharan Africa and other places where MSM are heavily stigmatized and marginalized. The processes of the SPEND model include Safe treatment for sexually transmissible infections (STIs) and HIV; Pharmacy sites for treatment of STIs in countries where pharmacies and drug stores are the source of medical advice and treatment; Education in sexual health issues for health professionals to reduce discrimination against MSM patients; Navigation for patients who have HIV and are rejected or discriminated against for treatment; and Discrimination reduction through educating potential leaders in tertiary education in issues of human sexuality. Supporting empirical evidence from qualitative and quantitative studies is summarized, and barriers to implementation are discussed. Health care for MSM is one of the casualties of anti-homosexual social and legal climates. There is no amnesty for MSM in health care settings, where the stigma and discrimination that they face in the rest of society is replicated. Such conditions, however, make it necessary to consider ways of providing access to health care for MSM, especially where rates of HIV and STIs in MSM populations are high, and stigma and discrimination encourages high proportions of MSM to marry. This in itself enhances the status of MSM as an important bridge population for STIs including HIV. Where anti-homosexual laws encourage, or are believed to encourage, the reporting of MSM to authorities, health care may be seen as an agent of authority rather than an agency for care.

Social networks of men who have sex with men and their implications for HIV/STI interventions: results from a cross-sectional study using respondent-driven sampling in a large and a small city in Tanzania

“…Baral et al 28 demonstrated in a study from Nigeria that RDS could be used as a method of engaging MSM in antiretroviral therapy services. Models of engagement of MSM such as the SPEND model ((P) Pharmacies as treatment sources; (E) Educate health professionals; (N) Navigation for patients who must access the health system; and (D) Discrimination reduction), which integrates the RDS approach to increase MSM awareness of available services that are trusted, access such networks 29. While these communities are to a large extent ‘underground’ for protection against stigmatisation and victimisation, there is a potential to connect large MSM networks to trusted healthcare workers through RDS or other network-based approaches.…”

Anti-Homosexual Legislation and HIV-Related Stigma in African Nations: What Has Been the Role of PEPFAR?

“…Widely held negative views about gay men and men who have sex with men in Africa, even among health care workers and academics associated with HIV care and research [73], have restricted optimal support and care for African men who have sex with men, or even research on their behalf [74][75][76][77]. Criminalization reinforces those negative views, undermines care and research, and fuels the epidemic.…”

Resilience Factors as a Buffer against the Effects of Syndemic Conditions on HIV Risk and Infection among Tanzanian MSM

“…Thus, in SSA, where gender-based ideas of homosexuality are prevalent, the assumption of a non-gay outward identity by MSM may be an adaptive strategy for protecting themselves against societal homophobic violence. This has been documented as a health-seeking strategy among South African and Tanzanian MSM [24,29,48]. Although the contentious concepts of "coming out" and "social visibility" have also been identified in other studies as protective factors leading to positive health outcomes in Western sample of MSM, they may be, however, counterproductive if adopted by MSM in homophobic cultural settings in SSA [44].…”

“…They are also socially marginalized, systematically excluded from HIV interventions and denied access to health services in a way that threatens the possibility of achieving an AIDS-free generation in Tanzania [48]. This poses a great challenge to HIV researchers and strongly indicates the urgent need for innovative HIVprevention approaches targeting not only Tanzanian MSM but all MSM in SSA.…”

“…For instance, while research advances have suggested that to achieve an AIDS-free generation, inclusion of MSM in HIV research interventions is imperative, the unmet health needs of MSM in this region are currently being heightened by discriminatory laws prohibiting these men from attaining a rights-defined health status [3,48]. Also, despite evidence suggesting that great strides have been made in HIV prevention among behaviorally heterosexual populations, the rates of HIV continue to increase disproportionately among MSM [55].…”