“Health” Issues commonly raised by Sex-workers, women-who-sex-with-women, Trans-persons, Intersex and men who have sex with men in Uganda: 2008-2011 (Calibrating Uganda’s Sensitivity and Competence towards Key Populations)

MARPS IN UGANDA[1] 

Context:

Women-who-sex-with-women[2] (WSW), Trans-persons[3] (Trans), Intersex[4] (I), men who have sex with men[5] (MSM), sex-workers[6] and Substance users[7] do exist in Uganda. They continuously present unique morbidity causes and stress related complaints at various health service points that require quick responses done with expediency, specificity and sensitivity[8].  Health is a: state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It may also mean: general condition of a person's mind, body and spirit, usually meaning to be free from illness, injury or pain (as in “good health” or “healthy”). Health is not just a state, but also "a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Using these definitions to calibrate a minimum standard calls for broad and sweeping approaches. In addressing their issues one needs to embrace combination prevention which recognizes three broad categories of interventions: biomedical, behavioral, and structural[9]. Once HIV-related illnesses have been diagnosed the follow up care and management should maximize the preventive benefits of treatment[10].  Providing spaces where complaints are attended will improve on evidence-generation to justify investment and prioritized budgeting[11]. As noted from most of the reports, the underlying issue of protection[12] is high up on the minds of beneficiaries even as they present other illnesses. Any health care practitioner should have this in mind and it will influence adherence. Stigma and discrimination follow after protection issues[13] . A gender and dignity affirming space will influence proper diagnosis[14]. Unconditional positive regard[15] based on informed readiness to serve will make the service provider understand needs of say, Transgender persons[16]. This openness in turn enables one embrace “beyond business as usual” approaches as they are targeting sexual minorities[17]. As service providers position themselves to address sexual minorities’ issues they should be conversant with pressures from: stigma, discrimination, poverty, violation of human rights, homophobia, and heterosexism[18]. Doing no harm calls for non-discrimination and due diligence accorded to all. Sexual minorities living with HIV continue presenting at service provision points. They need to be given the same care and management accorded to the rest[19]. Sexual minorities should be involved in short trainings to equip them with skills to improve adherence and compliance practices[20].  A service provider should endeavour to improve the cultural grasp, sensitivity and competence using various means and guidelines[21]. A checklist of complaints and needs that influence appropriateness of services[22] range from: bruises, wounds, cuts, acid burns, burns, scalds, battering, blows, foreign bodies in orifices (anal/vaginal), STIs, HIV, post abortion care, malaria, TB, URTIs, UTIs, Anal discharge, anal inflammation, oral inflammation,  targeted information, education and communication on sexuality, orientation, gender, identity and keeping relationships. Issues of visibility ranged from those who are openly gay, TG, lesbians, intersex, MSM, WSW, bisexual MSM, bisexual lesbians, female to male (FTM) and male to female (MTF) transgender. Some FTM and MTF demand surgical correction as well as hormonal supplements to enable them achieve a peak gender of choice. The follow-up affirmation counselling and refilling hormonal supplies may require to travel out-side Uganda. Intersex need to have sexuality support counselling and referral for surgical correction (CORSU[23]- Hospital is one such facility). Some MSM engage in sex-work. A few others are MSM living with HIV and whereas they may be attached to ART accredited health facilities they need psychosocial support follow-up. Reports and experiences of evictions are common. Some are victims of domestic-violence and yet another big number are victims of black-mail, extortion and are outed without their own consent. The health worker to handle such cases needs to be so many things at one and also be in position to use a very comprehensive referral system including legal, credit extension and psychosocial support.

INITIATING TARGETED INTERVENTIONS:

The goal of targeted interventions is three-phase: improves demand, attendance and provision. It improves the practice of evidence-based medicine, improves the ability of the health sector to respond to the specific needs of beneficiaries and addresses structural mechanisms that may fuel discrimination and stigma if left un attended to. Health care provision based on evidence and ethical principles rather than beliefs, religious values, or moral authority is what is needed in Uganda. The health sector interventions that build capacity of health workers to initiate targeted interventions are focused on two primary determinants increasing clinical capacity of health care providers as well as increasing cultural competence of health care providers in managing the needs of minorities. This experience forms basis for addressing needs of other sexual minorities. Men who have sex with men (MSM) are a population group that flagged off sexual minority health care initiatives. There is need for targets, shared lessons as we spread the most effective interventions, roll out to cover re-attendances, bigger numbers, issues of chronic care continuum and eventually cover the rest of sexual minorities. Why start with MSM? Well, MSM have consistently been found to be at elevated risk for adverse health outcomes in both high and low income settings.  There is emerging evidence of disproportionate burden of sexually transmitted infections among MSM across the African continent and this risk co-exists in many countries with laws criminalizing same-sex practices.  Moreover, there is pervasive stigma and consequently human rights violations have been documented in every country of Africa where MSM have been studied.  Moving forward from this dire situation requires  a comprehensive effort including better understanding individual level and structural risk factors and developing multimodal combination HIV prevention interventions (CHPI) addressing these levels of risk. Domestic community-based organizations (CBO) serving the needs of MSM in nearly every country on the continent with their domestic allies are a starting point. In this relation, health care providers should be targeted as primary allies, along with legal, academic and social-workers, for nascent and emerging CBO serving the needs of MSM and consequently other categories of minorities in Africa. Systematic review of risk of infectious diseases including HIV have consistently demonstrated that MSM carry elevated risk above that faced by their heterosexual male counterparts even in the generalized epidemics of Southern Africa.  Similarly, health care educational institutions are increasing the amount of attention focused on guiding ethical values for health care.  There are numerous guiding frameworks for ethical principles in health care yet analyzing these issues with any of these frameworks result in the same conclusion: health care workers should be willing to provide care for people in need of those services.  All health care consumers, MSM or not, should have the freedom to decide on treatment for themselves unless that decision were to cause serious harm to the general public.  In the absence of infectious diseases, sex between men is not inherently dangerous and poses no risk to the health of the general public.  Health care providers should also respect the autonomy of competent men who have sex with men to make decisions.  As any mention of same-sex practices has been removed from the DSM-IV, the argument that men having sex with other men is evidence of a lack of corpus mente bears no weight.  The provision of health care should be completed confidentially and MSM should not fear that disclosure of their sexual practices to health care workers will result in breach of privacy.  Health care workers are also mandated to afford their services with dignity and justice to their clients, whether their sexual practices include same-sex practices or not.   And most importantly, health care workers are to always provide beneficent care focused on helping the person seeking their services. In addressing these it will make the goal of health sector interventions improved and able to respond to the specific needs of MSM. Changing physician and ancillary health provider’s behaviors is complicated and active strategies such as knowledge translation tend to be more effective than passive methods[24].   The most well established model for a structured training program for health care providers is the Guide to Lesbian, Gay, Bisexual and Transgender Health developed by Fenway Health and published by the American College of Physicians[25].    There has also been a model collaboratively proposed by the Desmond Tutu HIV Foundation in Cape Town, South Africa and the Kenyan Medical Research Institute for intervention with health care providers in the African context.  Preliminary studies by these two groups have shown that these interventions are both feasible and effective in the African context.

We know that providing individual level interventions is not going to significantly mitigate the adverse health outcomes of MSM in stigmatizing and criminalizing contexts.  Even with the advent of effective biomedical interventions such as pre-exposure prophylaxis and rectal microbicides, coverage and uptake of these interventions will be limited in the absence of meaningful social and structural change.   As healers, health care workers are given a special status in society.  Their opinions count.   In an ideal setting, opinions of health care workers on issues related to the provision of health care should not be swayed by political implications or religious beliefs.  And as we now have evidence of a disproportionate burden of disease among MSM in the African context as well as that each of the guiding ethical principles of the provision of health care is consistent with providing just, private, and beneficent care with dignity to MSM, we believe that health care workers should be prioritized for intervention. 

Targets:

-Health Sector interventions to position themselves as environment within which discrimination and stigma due to one’s sexuality, orientation, gender and identity are not basis for delay or denial to access services.

-Health sector to inform policy and programme and be part of the machinery targeting elimination of discrimination and stigma of all kinds.

-The health sector interventions to focus on two primary determinants including increasing clinical capacity of health care providers as well as increasing cultural competence of health care providers in managing the needs of minorities.

Forward looking Suggestions:

The health sector interventions are focused on two primary determinants including increasing clinical capacity of health care providers as well as increasing cultural competence of health care providers in managing needs. The ground-breaking training starts with understanding needs of MSM.  A structured training programme for health care providers will be implemented based on the Guide to Lesbian, Gay, Bisexual and Transgender Health developed by Fenway Health and The Healthcare Worker Training Intervention.  The training program can be delivered to a maximum of 10 participants per session and will include 6 modules.  These sessions will be delivered at a central site to key health care personnel who are have been involved in service provision, willing and interested to take part.  The first module provides background on the epidemiology of HIV and STIs among MSM in Sub-Saharan Africa with a focus on Southern and Eastern Africa and countries with HIV epidemic patterns similar to Uganda.  The second module will focus on describing the relationship between stigmatizing health services and high risk sexual practices.  The third module will focus on taking sexual histories in a non-judgmental way.  The fourth module will focus on clinical skills including physical examination techniques including pharyngeal and anal examinations, and collection of clinical samples including pharyngeal swabs.  The fifth module will focus on describing effective individual level HIV prevention interventions for MSM including the use of condoms and water and silicone based lubricants.  The sixth module will focus on describing effective risk reduction counseling methods for MSM.  The training program consists of both didactic teaching as well as facilitated   discussion with participants.  The piloting[26] of this programme has indicated that the full workshop will take approximately 16 hours over two days including a one hour lunch break assuming the participants have prepared by reading materials that will be distributed ahead of time.  The proposed health sector interventions will be implemented with a team approach including co-facilitators from Makerere University’s College of Health Science-School of Public Health, physicians who provide services targeting MSM and MARPI Initiative (National STD/Skin Unit, MoH, ACP/STD Programme) which  was the first health provision point for MSM community in Uganda, Johns Hopkins, and the Fenway Health team and will be done for key health provision organizations that have been identified through formative work by MARPS IN UGANDA and Johns Hopkins as willing to receive this training.  These organizations include MARPS IN UGANDA (focal point), Makerere University School of Law’s HURIPEC, St. Paul Reconciliation and Equality Center (SPREC), Civil Society Coalition on Human Rights and Constitutional Law (CSCHRCL) across Uganda as well as the Johns Hopkins Uganda STI treatment facility that provides STI and HIV treatment in Kampala.  Over 5 days, we anticipate reaching 12 physicians and over 17 nurses, 15 behavioral health providers and 55 community health workers.  These targets are consistent with the emphasis on task shifting and referral, as well 5 participants will be lawyers who have helped in working on mobilisation of MSM to seek health services and in turn will train others.  Outcomes of these trainings will be assessed from the perspective of MSM in terms of access, more culturally competent services in Uganda and as part of a prospective evaluation of risk status and disease burden among MSM in Uganda.  Additionally pre and post test assessments will be used to measure changes in knowledge, attitudes and beliefs on MSM health needs and confidence in ones ability to provide these services.  Special break-out sessions will be offered to nurses, behavioral health counselors and community health workers.  The focus of these sessions will be around cultural competency, creating a supportive environment for MSM and community engagement with NGOs serving MSM.  An important outcome of this training will be that it is intended to serve as a model for the implementation of health care interventions for other countries where same-sex practices remain heavily stigmatized and even criminalized. 

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[1] www.marpsinuganda.org

[2] FEM Alliance, Empowered at Dusk, Tusitukirewamu Group, WONETHA, Lady Mermaid, MARPS IN UGANDA, Mpondwe Women Health Effort  reports

[3] FEM Alliance, Blue Initiative,  Empowered at Dusk, WONETHA, Lady Mermaid, Mbale Health Action Group, Kawempe Health Action Group, RADO, MARPS IN UGANDA reports

[4] Support Initiative for People with Atypical Sex Development (SIPD) , MARPS IN UGANDA reports

[5]  MARPI, MARPs Network, MARPS IN UGANDA reports

[6] FEM Alliance, Tusitukirewamu Group, Empowered at Dusk, WONETHA, Lady Mermaid, MARPS IN UGANDA, Mpondwe Women Health Effort  reports

[7] Uganda Harm Reduction Network, WONETHA, MARPS IN UGANDA, UYDEL reports

[8] Key Global Policy Developments concerning MSM and HIV.

[9]  Guidance for the prevention of Sexually Transmitted Infections-PEPFAR, 2011, MARPS IN UGANDA, GALA Reports.

[10] The Treatment 2.0 Framework for Action: Catalyzing the next phase of Treatment, care and support -WHO, 2011.

[11] Achieving an AIDS-Free Generation for Gay and other MSM-amfAR and Johns Hopkins School of Public Health Report, 2011

[12] Protecting Vulnerable LGBTI Populations: An opportunity for US Global Leadership-2011, SPREC, FARUG, and SMUG reports.

[13] Stigma and MSM: Barrier to Prevention-The Body, 2010/11, MARPS IN UGANDA Reports.

[14] Anova Health Institute (2010) from top to bottom: a sex-positive approach for men who have sex with men – a manual for healthcare providers.

[15] Principles on the application of international human rights law in relation to sexual orientation and gender identity

[16]Toolkit- HIV and Gender Based Violence Prevention for LGBTI persons-safaids

[17] UNAIDS Action Framework: Universal access for MSM/TG-2009

[18] GENDER IDENTITY AND VIOLENCE IN MSM AND TRANSGENDERS:  Policy Implications for HIV Services  JULY 2009

[19] Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people. WHO Recommendations for a public health approach 2011

[20] A guide for gay men with HIV Your sexual health-Terrence Higgins Trust

[21] 10 Essential Steps for “Getting to Zero”: Principles and Recommendations for Addressing Key Populations at the UN 2011 High Level Meeting on AIDS

[22] MARPS IN UGANDA with other facilities provide health care-related, psycho-social services and refer legal-related issues.

[23] A private, non-profit and non-governmental organisation, whose acronym in full is: Comprehensive Rehabilitation Services in Uganda. It offers preventive, curative and rehabilitation services.

[24] Grimshaw, J.M., et al., Changing provider behavior: an overview of systematic reviews of interventions. Med Care, 2001. 39(8 Suppl 2): p. II2-45.

[25]Makadon, H.M., Mayer, K., Potter, J.,Goldhammer, H., Fenway Guide to Lesbian, Gay, Bisexual & Transgender Health [2007, Boston: American College of Physicians. 544.

[26] Thanks to Stefan Baral MD MPH CCFP FRCPC Associate Director, Public Health, Human Rights and Marginalized Populations Center for Public Health and Human Rights, Department of Epidemiology Johns Hopkins School of Public Health