TARGETING SAME SEX ORIENTED PERSONS AS A STRATEGY TO REDUCE NEW STDs/STIs/HIV INFECTIONS IN UGANDA: BY THE NATIONAL STD UNIT’S MOST AT RISK POPULATION INITIATIVE; USING PEER TO PEER (Social/Sexual) NETWORKS TO RAISE AWARENESS ON STDs/STIs/HIV FROM JANUARY TO JULY 2009

KEY WORDS:

IGA: Income Generating Activities

KABPPS: knowledge, attitudes, behaviour, perceptions, practices, sexual behaviour.

LGBTI: lesbian, gay, transgender and intersex

MARPI: most at risk populations’ Initiative

MJAP: Makerere/Mbarara Teaching Hospitals’ Joint AIDS Programme

MSM: men who have sex with men

SWOT: Strength, weakness, opportunities, threats

STD: sexually transmitted diseases

TG: Transgender

INTRODUCTION:

The same sex oriented community is perceived to be trapped in decadence, immorality and promiscuousness. Mention this community and what immediately comes to mind is involvement in a form of sexual intercourse that is abominable. Almost all social interventions that target same sex community, base on presumption of recklessness, decadence, promiscuity and the wrong form of sex (Homonormative relations). This is not helped by fact that the statistical majority of Ugandans are heteronormative, same sex marriage is illegal (Article 31, clause 2a) and a small but significant population is engaged in homonormative relations. HIV-related services in Uganda address effects of unprotected vaginal sex, mother to child, infected blood and psycho-social needs of infected and affected persons who are in a formal setting (hetero-normative). The homonormative-driven mode of infection is criminalised. Studies in sex work activities and social issues highlight existence of anal sex and same sex relations (e.g., MoH/UNFPA Sex work study 2009). But data on same sex characteristics are scanty. It is through understanding same sex orientation in Uganda that a further blow will be dealt against STDs/STIs/HIV. The National objective and Directive principle of state policy in the constitution of the Republic of Uganda number XX provides that the State shall take all practical measures to ensure the provision of basic medical services to the population. In providing medical services the National STD unit pursues this directive diligently and seeks to reach out to all categories of people without discrimination (RIGHTS BASED APPROACHES). This paradigm shift further shows commitment to the fundamental principle of equity of access to effective quality health care. It does this through two settings. The facility based (where beneficiaries walk-in) and outreach services or community based health approach (where phased programmes addressing categories of people are implemented through planned activities by going out to these communities). Outreach programmes are under the MARPs Initiative. MARPs in full is Most-at-risk populations (Sex workers, Long distance truckers, Communities around parking yards, same oriented persons, Couples, School going community, communities around entertainment centers, non-Ugandans in slum areas, slum dwellers, Uniformed folks, in-mates, substance/drug users, IDUs, partners in abusive relations, fisher folks and men). All these categories have specific planned programmes targeting them. That providing for same sex community started the first outreach in January 2009. Other activities the initiative provides are; IEC materials on STDs and training peer leaders who continue reaching out to the sex-workers, uniformed folks, discordant couples, school-going communities and non-school going communities, fisher folk, IDPs, IDUs, Youths and persons in long term relations.

National STD Unit’s Most-at-risk-population Initiative (MARPI) is an indigenous government of Uganda NGO that is promoting reduction of STDs/STIs/HIV/AIDS among same sex oriented persons with unconditional positive regard. Services offered range from quality counselling, guidance, screening for all STDs/STIs including skin infections, HPV and HIV. It offers treatment for all ailments and it is part of the various wards that make up the National referral Hospital of Uganda.

The words MSM/WSW/TGs, homosexual, same sex oriented persons, MSM/Sexual minorities, same sex and lesbian, gay, transgender and bisexual are used interchangeably and mean the same thing. But, for purposes of formality same sex oriented persons is preferred.

Anal sex and same sex marriage is criminalised in Uganda (Penal Code 131, 134, 136, 145, 146, 147, 148). This has created a whole structure and stratification of criminalisation which is not helped by the deep set homophobia and a patriarchal male-domination system. This in turn has defined sexuality, cultural, economical, and social and gender expressions. It has created a gender spectrum of submissive recipient-providers and dominant assertive-demanders.

OBJECTIVES:

GENERATE AN INVENTORY OF SEXUAL AND SOCIAL NETWORKS/ISSUES IN SAME SEX COMMUNITIES TO GUIDE POLICY AND;

1. To establish existence of same sex orientation persons, sexual and social networks in Uganda.
2. To understand the kind of persons, fears, insecurities, incompetence, competences, sexual choices, life choices, vulnerabilities, effects of coming out, effects of visibility, reproductive health issues, sexuality awareness, rights and HIV/AIDS/STIs/STDs status within same sex Community.
3. To establish organisation levels among same sex community and how this can be platforms promoting positive sexual behaviour, improving documentation skills, generating programmatic activities that can cascade into national plans, offer life skills, esteem building and reduction of STDs/STIs/HIV and skin infections.
4. To gauge size, understand characteristics, risks, typology needs, experiences and services specific for same sex oriented persons. Same sex marriage and anal sex are illegal this has driven these communities underground. Because of this, there is no representative sampling frame for same sex oriented people in Uganda. A quasi-sample frame however can be developed.
5. To show best practices  such as; forming viable groups, providing platforms with themes that generate feelings of belongingness, provide HIV information, conduct screening and testing services, conduct outreach and advocacy, create safe spaces, follow up activities at safe spaces, providing IEC materials, providing preventive prophylactics and documenting these activities and experiences in order to build community and political support.
6. To explore determinants of risk behaviour, expression, accessing services, threats to personal life, health, sense of worth, future prospective in form of education, employment, respect that a same sex orientation poses and gender interests arising from social and gender roles as defined in same sex community.
7. Integrate LGBTI issues within the service delivery of various service providers and a funding priority.
8. To inform Ministry of Health policy on need to shift from a sexist to a holistic psycho-social-cultural view towards same sex oriented persons.
9. To show the extent these best practices are providing literacy, psycho-social, legal, capacity for community integration, upliftment, actualising the spirit of the National Constitution Of Uganda, operationalising the National Strategic Plan (2007/8-2011/12) and international plans of action e.g., Maputo Plan of Action, DHR, Millennium Development Goals, UNGASS and WHO.

METHODOLOGY:

The msm/sexual minorities programme (also called the same sex programme) is providing comprehensive health care services for men who have sex with men, women who have sex with women and Transgenders. It aims at creating and strengthening activities geared at self esteem, dignity, development, disease prevention, integration in communities, health seeking behaviour and compliance among LGBTI.

 At the community entry stage, a needs assessment is done with the help of at-least 5 identified leaders. This is what directs future interactions. Initial activity involves identifying viable communities, introductions to community leaders or where there has been prior references done to identify the leaders, their needs and how to intervene. The leader or mobiliser is chosen as first contact person with whom plans to reach out to others are made. Once numbers of beneficiaries, venue (called a safe space) and dates are established arrangements are made and a memorandum of understanding is struck.

 It is important to note that in all the safe spaces we do not discriminate people who seek our services. Hetero-normative and homo-normative people access them equally. However, the mobilisers standing at a vantage point and identify for us those that are willing to come out and declare to us their orientation. This number is combined with those who attend prior sexuality awareness talks held for same sex persons in same areas. During the implementation day also called the outreach day the following are provided; opportunity for same sex persons to do mobilisation work in their areas, health education on sexual reproductive health, counselling, VCT, STD Screening, post-test counselling outreach services and providing results.

Other attendant activities that are on-going once a community has been reached include; making follow-up plans even after an activity has been completed to promote continuity, documenting experiences, providing a hotline number on which beneficiaries call anonymously, home-visits for bed ridden (HIV +ve and other ailments), group counselling, treatment for minor ailments, facilitation for organisations handling same sex communities and training opportunities for other health providers in unconditional positive regard for same sex oriented persons. We are also involved in on-going research work into sex work activities (nature, characteristics, typology and services).

Working hand in hand with established same sex formed group members and providing resources or support where possible is a break through approach. Viable groups formed as a result of continued interaction, support in form of facilitation in rights, sexuality and planning areas and training are a durable solution for the programme. These groups are then modelled after the rights and Health Action Groups concept (adaptation/cross between the Open system Models/ Community Health Models) of MARPI. The idea is to involve MSM/WSW/TGs in efforts to improve on their esteem, dignity, health and worth. While at the same time enabling interventions reach out to as many beneficiaries as possible.

FINDINGS/RESULTS:

There are MSM/WSW/TGs in Uganda and it was not because of Western influence but they have existed even in time immemorial. Those who practice anal sex, be they in hetero-normative or homo-normative relations, are considered immoral. And general perception of public is that same sex relations are decadent and only exist because of permissiveness and anal sex.

Historical same sex organisations were initiated along lines of advocacy modelled after campaigning for freedom. They received money for these causes but due to un-skilled management and poor organisation there was poor accountability and personalising of groups. Some members selfishly used the money, spread information of torture, abuses and evictions. They got funding to address these issues but never shared information with other beneficiaries. This led to dis-integration of organisations. Many organisations have failed to mobilise and hold regular meetings with their members.

There are 15 groups with 25-30 members each that show promise of being sustainable and have so far provided insight into internal assessment using SWOT and KABPPS. The groups are in Kabalagala, Katwe, Bwaise, 2 Universities, Wandegeya, Kampala central, Kitemu, Luweero, Nakawa, Mukono, Namungoona, Jjinja and Mbale. The members have expressed need to be trained in leadership skills, decision-making/problem solving skills, provided with a revolving loan to boost their incomes by investing in identified income generating activities. The income generating activities are; a music and dance troupe for hire, establishing a vocational center, establishing a restaurant to provide 100 meals a day, a secretarial bureau to cater for printing and typesetting needs in a university, a food preparation/catering facility for hire, a dry washing facility and a beauty center. It required US $ 25.000 as a start-up revolving capital which would bring back dividends in 2 years. It is only with these groups that a systematic follow up can be done effectively and cheaply.

There are over 5.000 people who have accessed outreach services under the same sex outreach programme. Of these 1.500 same sex oriented persons who are identifying as MSM/WSW/TGs have been reached (from January-July 2009). 1.000 have identified and lived regularly a same sex oriented normative life for past 3 years (2006-2008). 1200 are not aware that unprotected anal sex is an exposure risk to infections including HIV. 60 are HIV positive, 50 are confirmed lesbians, 700 are TGs (with 596 male to females –MTF, 100 female to males-FTM and 4 are intersexed), 100 are gay men and 150 are bisexual (100 females and 50 males). There are 100 (85 TGs, 10 lesbians and 05 gay men) who have engaged in commercial sex work (buy and sell sex). Most TGs (500) are below 30 years and are in schools ranging from tertiary institutes (18+), secondary (13-17years) down to primary level (5-12 years). The youngest same sex oriented male attending programme was 12 years and has regularly slept with men from age of 09 years. Reported early sexual debut between persons of same sex is common. In this period of study, 950 same sex oriented persons’ responses were to the affirmative about experiences of having had their first sexual debut with a person/s of the same sex (300 admitted to having had first anal sexual debut and repeat experiences from primary through to tertiary and beyond, 650 admitted to having had first anal sexual debut at tertiary level). Most same sex relations are thriving in low cost residences, slum areas, in schools, hostels and high cost residential areas.

This approach has identified only 60 HIV+ve LGBTI persons (30 gay males, 10 lesbians and 20 TGs) who are all below 60 years and are in different stages of need. Only 4 of these 60 are in regular, salaried pensionable professions. The rest rely on irregular means of earning money which include hand-outs from friends and commercial sex work. In the last three months only 20 earned monthly US $ 20 (US $ 1 is equivalent to Ugshs. 2.000). This money was used to cater for house rent, transport and livelihood (clothes, food, socialising and remittances) needs. 10 are critically ill, with wasting syndrome chronic weakness, chronic herpes simplex infection and have been bed-ridden for more than 50% of the day during month of June. 10 are symptomatic, engage in minimal activity, appear malnourished, have recurrent respiratory tract infections and are bed-ridden for less than 50% of day for month of June. 40 are asymptomatic, can afford one meal a day, but enjoy normal activity. 05 have manifested Stevens - Johnson syndrome due to co-trimoxazole.

Many more HIV +ve LGBTI are still not reached because they are out of Kampala, are scared of disclosure, are not part of the sexual and social network that we are using and some are already benefiting from other services.

In 2 Kampala suburb low cost residential areas (Nakulabye and Kisenyi) are different nationalities that mix with Ugandans. There are over 5.000 Horn of Africa and other nationalities. Among these nationalities are same sex persons who need to be reached out to. These areas in question comprise of; Somali, Ethiopian, Eritreans, Congolese, Tanzanians. These are mixing with Ugandans. During 2 needs assessment meetings with 6 leaders it was realised that Somali make up the biggest numbers of non-Ugandans in these two residences. The Somali were distinctly divided as Christians and Moslems. This more than anything else formed basis of their perceptions about HIV/STDs/STIs. There are cases of STDs and HIV cases which require interventions. A number of same sex relations are existing between non-Ugandans and Ugandans.

In most education institutes and communities, same sex sexual relations and intercourse exist. Reasons given by sampled respondents about same sex experiences are: experimenting, peer pressure, identity crisis and one’s normativity. There is need to develop literature that explores reasons, gender issues, normativity and explains same sex relations and intercourse.

Sexual minorities Uganda, Makerere Law Refugee Center, Inter-AID, UNHCR, East/Horn Human Rights Defenders’ Project, are various organisations besides MARPI that have offered counselling, guidance and positive regard towards same sex persons whether Ugandan or non-Ugandan.

A differential diagnosis of 5 established gay, lesbian, transgender, intersex and bisexual groups provides insights in organisation levels of same sex organisations. Most organisations have an internet/virtual community with a membership of almost 100-1.000 each. All have carried out activities in the past 6 months consistently: advocacy for self determination by involving members in good conduct campaigns and Rights awareness sessions; advocacy for self preservation by mobilising members to engage in behaviour change for reduction of STDs, skin infection, HIV-AIDS; they all have faced repercussions of recent sustained spates of hate campaigns and outing by few members who were part of the recent  campaigns to eradicate same sex relations and lifestyles. The vision is the same for all organisations: dignity for all. However, they differ in their missions, objectives and membership composition by virtue of sex, gender, needs and historical effects of women movement campaigns. The lesbian organisations are highly funded than male-based organisations. Lesbian organisations have more funds, compared to others, for travel by members to conferences, safari expeditions, exchange programmes, sports and rapid relief funds. There is poor grass root attachment in all groups. This is because of deliberate lack of reporting of and accountability for funds and omission to serve large numbers of same sex persons, visibility effects, black-mail, extortion and outing as a result of misunderstandings that frequently occur in these groups. In the past 6 months, 3 major break-aways or animosity-driven threats occurred within the community. But, the power to resolve conflicts is so well established and there is respect for authority.

An umbrella organisation has been able to use safe spaces to provide support for MSM through the amfAR fund and it has provided 5000mls of lubricants on top of 15.000mls sourced privately from elsewhere,  has provided promotional materials in form of stickers, T-shirts, MSM info-cards, sponsored activities at 3 safe spaces for 60 LGBTI persons. This is on top of activities by MARPI. This networking has provided opportunities for more LGBTI persons to gain trust in MARPI activities.

2 organised groups by bisexuals have a very large contact base which has networks using match-makers, the telephone and internet. It is still difficult to get this community to form a viable physical group because of the fears that visibility will cause to them, their jobs, their status, hetero-normative families and friends. It therefore remains hard to provide interventions unless more in-depth work, information for behaviour change, incentives that support security and consumables are provided.

CHALLENGES:

The health model in Uganda is a primary health care provision model with moralistic underpinnings. In generating a diagnosis plan it relies mostly on presented cases. These revelations may create un-friendly biases which are grounds for reluctance for same sex communities to seek services. It is only in recent times that due to practical public health models, aggregate communities have had friendly specific interventions (Community Public Health/Right Based Approaches). In Uganda, LGBTI community health interventions have been low key. Most programmes assumed there was so much sexual intercourse among LGBTI community and therefore the need for a classical screening, diagnosis and treatment of STDs/STIs/HIV and primary health care services. However, there are underlying psychological, social, economical and integration issues raised by LGBTI community which if missed may point towards a wrong diagnosis. This requires competent staff to handle this community followed by supplying necessary provisions if this programme is to be effective.

There is no formally existing programme on HIV among LGBTI people. Beyond providing opportunities for HCT and Septrin prophylaxis, ART provision is not regularised and there is no funded psychosocial programme to cater for other needs such as; well-being kits, lubricants, dental dams, IEC materials, rapid relief services, transport, membership-dues to positive clubs and involvement in extra-curricular activities.

There are more issues surrounding HIV and these include: fear of disclosure of HIV status, unprotected sex among the LGBTI community, non-adherence, poor psychosocial support and poor group dynamics among the LGBTI Community. This increases cases of HIV infections, poses counselling challenges, and inadequate LGBTI interventions against HIV.

The LGBTI Community is mostly comprised of people not in formal and regularised jobs (90% of those sampled). They earn very little or nothing and rely mostly on hand-outs. This leaves them vulnerable. Because of this very many are still not in position to negotiate for safer and protected sex. Those in relationships are in multiple concurrent partner relations.

Money committed to LGBTI interventions is little (US $ 100-500) to run 12 activities a month targeting between 300-500 beneficiaries monthly and is influenced by policy makers who have an in-grained moralistic-biased Model. Yet to do quality services one has to use the integrated care approach where the following is done; mobilisation, health education, VCT, Post test counselling, Condom distribution, lubricant supplies, dental dams, follow up of HIV+ve LGBTI persons, providing regular sexuality question and answer sessions, production of IEC materials, networking with other LGBTI organisations, phone counselling, integrated management of illnesses, development of treatment plans, comprehensive HIV care, home -visits, group counselling, guiding in problem solving and decision-making, providing refreshments, follow-up, documenting, transport, airtime for communication, analysis of data, psycho-social support which may include legal and evacuation incidences and processes specific to LGBTI persons. This requires more time, professional and logistical input way beyond the money provided.

Most staff, especially the doctor are working overtime and volunteer more time to do in-depth services provision (which require travelling, communications for directions, facilitating in skills development and providing guidance). Whereas this has provided insight into extent of lived sexuality in Uganda the wear, tear, costs and burn-out is overwhelming.

Over 200 sparsely scattered same sex communities (10-40 members) in and outside of Kampala exist according to gathered intelligence through interconnected networks. The groups thrive from individual membership contributions and are modelled after self-help support group methods. The nearest small community is 8 kms (5 miles) from the National STD unit. The farthest is 150 miles out of Kampala. These communities spread information about services at MARPI.  In the earlier days 45 communities were reached but this number dwindled up to 25 but at least in the past 7 months, 15 have been consistently followed. Groups were served with the following; providing group formation training, awareness sessions on STDs/STIs/HIV, Positive prevention for HIV+ ve same sex persons, ART, Septrin prophylaxis, positive living, Life-planning skills, sexuality/reproductive health education sessions, esteem building, problem solving skills, decision making skills, counselling and guidance sessions for needs that arise with time and Rights awareness. More can be done by consolidating all efforts through empowering formed groups to address lifestyles that reduce STDs/STIs and HIV/AIDS, providing support mechanisms for those living with HIV and acting as platforms for dialogue on life skills such as good conduct.

The other network penetrated is that of Non-Ugandan same sex oriented persons. These ones are divided further into; Western and Non-Western. They use phones and internet as communication means through which they make negotiations, plans and meeting at venues such as hotels, lodges, residences, recreational grounds, green parks, resorts or any other arranged appointments.  The persons include; foreign university students, Ugandans living abroad with their friends, friends of non-Ugandans and expatriate professionals. So far the National STD Unit team has reached Non-Western but African non Ugandans. In reaching out to these communities there is need to identify leaders among them who understand English so that communication is good and peer networks explored. Something that takes longer and requires more funds.

There are biases and misconceptions that the African non-Ugandan persons have expressed through quick appraisal exercises and these need to be investigated further through a well funded study. This needs time and resources.

The myths and biases of non –Ugandan (especially Somali) are;

1. To know one’s status is to mean death.
2. AIDS only gets Christians (said by Moslem Somali).
3. Only certain types of people get AIDS.
4. If one is a good Moslem and prays 5 times a day that person will never get AIDS.
5. It is health providers who infect people with AIDS.
6. HIV testing does not reveal one’s true results.
7. AIDS only gets Moslems (said by Christian Somali).

The myths, attitudes and fears of Ugandans;

1. One cannot get STDs/AIDS by anal sex.
2. Disclosing one’s status makes one a community reject (fears of repercussions of multi-stigma).
3. Male sex workers are highly paid.
4. LGBTI lifestyle is a means to getting money.
5. LGBTI is a transitory life experience, rite of passage and initiation rite.
6. Anal/oral sex is not an exposure risk to infections.

Needs assessment highlighted a range of individual and contextual determinants that influence sexual risk-taking among a sample of LGBTI. A large portion of LGBTI people feel isolated and disconnected from others. Most therefore get into rash relationships as a strategy. Many feel a sense of shame, lack of direction and guilt about their sexual orientation. This makes them avoid formal settings; they therefore seek guidance from older or experienced same sex persons which fuels vulnerability. Many feel pressured to take risks because of negative peer norms that exist in their social and sexual networks.

Making it clear that it is an offence in Uganda to deliberately infect someone with HIV can cause ripple effects for service providers who will be thought of as condescending, it will drive many positive persons in relations underground and many more will fear accessing ARTs.

Criminality in the LGBTI community is visited upon the male sex in a societal context that is homophobic, fuels rumours and falsely accuses persons suspected to engage in same sex relations.

The LGBTI community in seeking out relations is not careful about legal implications (Section 145, Penal Code 1906 AND Section 129, Penal Code 2007) such as; engaging persons who are below 18 years of age which is defilement, detaining with sexual intent (maximum sentence is 7 years), engaging a person who is below 14 years is conspiracy to defile and it is a felony whose minimum sentence is 3 years and maximum sentence is death, sex when HIV+ve is penalised with maximum sentence which is death, same applies to sex with a relative.

The origin of the term ‘against order of nature’ still derives meaning from the Church pronouncement of missionary style sex as being natural and what the Church decides to be natural. This has influenced the thinking of policy makers world-wide.

 Same sex groups receiving funds are addressing same issues and in a very limited catchment area. The needs assessment does not involve a larger LGBTI community and few members know when funds that are addressing their needs have been provided.

15 groups have been followed up regularly; 7 are more organised (GALA, Spectrum, Farug, Frank/Candy, Ice-breakers, Queer Youths and Integrity Spirituals) because they have received funding and support regularly over the past two years. 8 have been formed as a result of MARPI interventions. However, there were 25 which were interfaced with but due to anonymous calls members kept getting as a result of visibility with MARPI they broke ties.

Work among same sex community requires co-activities that strengthen continuity through follow-up. There are new forms of co-activities that are specific to the same sex community and together make sustainable returns. These are however, not budgeted for by the classical approaches of most proposals by policy makers who are blind to homonormative community issues.

Same sex persons report that most of their partners are engaged in transport, motor repair garages, promotional/sales representatives and education sectors. These sectors require specific IEC materials, time and schedules that suit a time when they are not busy which is outside formal working hours.

SOLUTIONS /BEST PRACTICES:

Encourage formation of groups under the Health Action Groups plan of Action (MARPI health action groups). Formed groups under go needs assessment and generate interventions addressing the needs. Then they implement planned activities. These groups can also be used to engage in an income generating activity to address issues of incomes among LGBTI Community and act as safe space for HIV+ve LGBTI to mix with people who understand them. Through these groups, contacts are made and vouchers with directions and phone contact numbers of staff provided.

HIV/AIDS services need funding and should follow these thematic areas even for LGBTI community: Prevention interventions; care/treatment; psycho-social/economic services; gender, sexuality and rights; belongingness; established phased implementation/coordination and management systems that are participatory and uplifting. Primary health services should include HIV testing, STI testing and diagnosis, selected lab work, general physical examinations, PAP smears, referral and follow-up and treatment literacy.

Safe spaces are chosen as outreach provision centres nearer to homes of beneficiaries to avoid long distances which minimises money refunded for transport, refreshments and airtime allowance for making phone calls by mobilisers. This has helped in effectively using provided funds. However, the sustainable way would be to provide funds to groups in which identified members are then trained in viable group formation and leadership skills. The groups are provided with necessary resources to carry out self-assessment and address interventions. All the above activities will require US $ 12.000 per month for 12 activities to provide effective and impacting services among LGBTI community.

More staff members have been trained in Unconditional Positive regard (a team of 11 serve as; lab technologists, a medical doctor/counsellor, pre-test/Guidance counsellor/site manager, Health educator and community based mobilisers/health workers) this has helped in providing confidence support. The other programme staff (entertainment centers, higher institutions of learning, sex workers and couples) share information about different beneficiaries through referrals and this way beneficiaries are provided with appropriate services.

Money as incentives for mobilisers, buying refreshments, IEC materials, follow up support for those screened and found reactive with STDs are provided with medication, follow up for those found HIV positive, provision of hotline number which is used by same sex oriented persons to invite counsellors or the Doctor for specific talks, counselling and guidance.

Support by Director, Coordinator, Assistant Coordinator, Supervisor, Administrator and Staff. These have had exposure, training in unconditional positive regard and client care skills training opportunities. They have also attended most activities, seen LGBTI as attendants and reassured beneficiaries of continued support. This exposure has raised staff awareness about same sex orientation issues.

The annual workplans with budgeted outlines engendering same sex specific interventions have been accepted and are fully funded. However, more needs to be funded in order to realistically address interlinkages between sexuality, miscegenation, relations, sexual health/rights, HIV/AIDS and STIs/STDs among same sex practicing populations (both Ugandan and non-Ugandan).

Providing same sex oriented specific preventives: Provision of lubricants, dental dams and condoms. This is still minimal but at-least through continued support and networking with more established same sex health providers supplies are provided. A more regularised system of provision of consumables, post exposure prophylaxis to LGBTI who may be exposed to HIV, Septrin prophylaxis, ART and treatment for ailments will promote decisions for health seeking behaviour.

Need to regularly and formally pay the staff or at-least provide incentives in form of cash refunds for transport, medication provided, communication in form of airtime and provision of professional fees.

Encouraging continued medical education in courses that keep staff abreast in MSM/WSW/TGs health, rights and social issues. This will reconcile disparities that spring from misunderstanding and misdiagnoses through un-friendly constraining atmospheres for service seekers. Focus is shed on identifying drivers of inequality through lack of expression of sexuality (spiritual, biological, physical and mental). Interconnectedness of barriers to the achievement of full sexual health and rights is realised. Multi vulnerabilities resulting from denial of sexual expression are checked and full quality service provision ensured.

To provide points of change for social and development organisations to include LGBTI issues in their interventions. Such changes include policy reviews that mainstream LGBTI programmes.

Strong collaborative ties with other service providers in areas such as; mental health, sexual health, advocacy, legal, rapid relief, social development and mainstreaming are crucial in providing LGBTI quality comprehensive services. Partnerships with 45 existing self-help groups have been explored. In only 10 of the groups have they been made stronger by providing facilitation in form of skills development to members and supporting the groups to make workplans which can then be merged into a single work plan and supporting the groups during implementation of their activities. These groups will be registered under MARPI Health action groups.

Research funding for studies into same sex nature, typology and characteristics in Uganda will go a long way in informing on emerging and marginalised population groups. This kind of research informs policy, identifies vulnerabilities, and explores critical health, rights and STIs/STDs/HIV/AIDS interventions that can be strengthened. Eventually, mapping of sexuality and rights approaches is done effectively.

Generating funds, logistics, making needs assessment and being able to compose them into proposals, reports and experiential papers. These reports can be presented or disseminated to national and international fora in order to raise awareness, logistics and funds.

MARPI in conjuction with MJAP has enrolled many into HIV care systems, those opting for nearer to home Health centers providing HIV care have been referred there. This entry into HIV care system has enabled many LGBTI HIV+ve persons access services without fear of revelation of their orientation to other health providers.

Through Rights Based Approaches and following Articles 21 clause 1, 2, 3, Articles 29 and Articles 36 of the Constitution of the Republic of Uganda there is an opportunity to provide services indiscriminatively.

Same sex groups that receive funds to address needs should hold pre-implementation meeting to generate a needs assessment for which funds can be used to implement interventions. There should be shared work-plans for target members and within funded groups. This reduces duplication and provides opportunity to spread interventions to those in need.

Working with same sex persons enables exploration of efforts to address specific activities and frequently asked questions’ themes not covered by mainstream organisations and these cover: specific LGBTI I.E.C materials production on a range of thematic topics; HIV-AIDS, safer sex, safer anal sex,  correct condom use, positive prevention, good conduct, black-mail, extortion, corrective rape, paedophilia, drug-use, civic duty/responsibility, relationships, sodomy, spirituality in same sex life, counselling for parents of same sex children,  same  sex sexual debuts in confined communities, repeat same sex relations, counselling for children in same sex relations, bisexuality, transgender life, intersex life and sexuality issues, sexual choices, life choices, vulnerabilities, effects of coming out, effects of visibility, reproductive health issues, sexuality awareness, insecurities, domestic violence, gender-based violence, sexual violence, security and Rights awareness.

Groups can be entry points for strengthening work with LGBTI Community. Groups make it cheaper, sustainable and one gets to meet more LGBTI persons. Through this such indicators like those set by the UNGASS which are relevant to same sex persons can be set and met ( knowing numbers of infected with HIV, those who know their status, correct knowledge of HIV transmission and prevention, promotion of correct consistent condom use, reaching out with HIV Prevention programmes). Through groups care for HIV +ve LGBTI persons can be possible and this has been done in 6 groups where members know others within who are HIV+ve and are provided with social and spiritual encouragement. In 2 groups HIV+ve persons are adhering to ART regimen. In 3 others, HIV+ve persons are adhering to Septrin prophylaxis and are regularly refilling their supply with help from members.

Programmatic thematic (Point-based) activities among same sex communities sampled include; HIV-AIDS/STDs awareness, positive prevention, uptake of VCT, increased screening for STDs, safer sex practices, reduce incidences of abusive relationships, reduce drug/substance use, improve health seeking behaviour, legal/security awareness, work ethics, good conduct ethics, community/social responsibility and involvement skills, rapid relief in case of eviction/expulsion/rejection, behaviour change communications, increased use of internet for positive work, establishing and maintaining social safe spaces, reduction of security, black-mail and extortion incidences, research and documentation.

6 groups have consistently engaged members in pursuing work ethics, reduced drug/alcoholic abuse, providing dialogue on life planning skills, encouraging engagement in IGA’s by members, engage members in pursuing work for cash as opposed to commercial sex work, catering at various events, performing arts and community/social responsibility by engaging in social campaigns.

IMMEDIATE INTERVENTIONS (2009-2013):

OBJECTIVE: Creating and strengthening activities geared at self esteem, dignity, development, disease prevention, integration in communities, health seeking behaviour and compliance among LGBTI.

Mitigating the HIV/AIDS Burden among 60 LGBTI persons; (30 gay males, 10 lesbians and 20 TGs); support the activities of peer educators, support groups in promoting adherence practices, establish/strengthen mobile clinic services, including regular supply of positive prevention kits (Septrin, lubricants, condoms, body lotion, anti-malarials and multi-vitamins) HIV counselling, treatment, generate individual adherence plans, establish care plans, ensure linkages to clinical, psychological, social services and management. 

Scaling up LGBTI HIV/AIDS Intervention; supporting 15 groups; support core personnel costs including management and administrative, facilitate the sexual health work (HIV/STI prevention, counselling, condom and lubricant distribution, dental dams, cancer examination, tetanus toxoid immunisation, RH commodities, free anonymous HIV and STI counselling and testing, and pre/post-exposure prophylaxis, access to follow-up medical care, antiretroviral treatment, psychosocial support, treatment and other services and referrals as needed), support the peer educators’ activities which operate out of identified safe spaces, as well as through outreach to LGBTI populations in communities.

Strengthening the Capacity of 150 Peer Educators to Prevent New HIV Infections Through Provision of Basic Counselling Skills; to train, supervise, and support LGBTI-focused peer educators with continued community-led care and staying negative practices in Kabalagala, Bwaise, Wandegeya, Mukono, Nateete, Makindye, Jjinja and Mbale, working to improve skills associated with HIV/AIDS-related peer counselling, referrals, and social support, and to conduct follow-up monitoring and evaluation to document the outcome of their work.

HIV/Alcohol/Drug Risk Reduction and Violence/Abuses/Discrimination reduction; to engage in strategies that promote; work ethics, incomes among same sex communities, reduction of drug/substance abuse, use of social safe spaces for talent shows and exhibitions, reward/recognition for good work, awareness of legal and security issues, exploration of sexual and social networks and promotion of life planning skills and good conduct for LGBTI persons.

Engaging same sex communities in point-based activities to gain will of larger community; engage members in pursuing work ethics, reduced drug/alcoholic abuse, providing dialogue on life planning skills, encouraging engagement in IGA’s by members, engage members in pursuing work for cash as opposed to commercial sex work, catering at various events, performing arts and community/social responsibility by engaging in social welfare campaigns, creating dialogue opportunities on same sex issues and making courtesy visits to nearest political, cultural and social leaders.

Qualitative Assessment of HIV Risk Behaviours Among LGBTI; conduct in-depth qualitative interviews with 100 LGBTI persons and 10 Key informants in Uganda, documenting social/sexual networks, visibility-related risks, HIV-related risks, risk factors, and programme needs. The findings will be used to develop programme recommendations for future interventions and informed engagement of political, cultural and religious leaders in reducing hate campaigns/sentiments/oppression and giving unconditional positive regard to same sex persons in the fight against HIV-AIDS/STDs.

 Safer life Social marketing drives addressing same sex needs; Packaging positive prevention kits (Septrin, lubricants, condoms, skin lotion and IEC literature), MSM wellness kits (IEC literature, condoms, lubricants), WSW wellness kits (IEC literature/promotionals, Dental dams, lubricants, detergents, sex toys, lotions), TGs wellness kits (IEC literature/promotionals, lubricants, dental dams) and bisexual wellness kits (IEC literature, lubricants, condoms, dental dams)

CONCLUSION:

Involving formed viable groups in addressing community needs (such as community clean up campaigns, encouraging dialogue over certain behaviours, participatory assessment, cleaning school compounds, thematic interests, pursuing local interventions, HIV interventions, sanitation campaigns, good conduct and drama activities) will be more sustainable, provide platforms for legal and social protection, instils valued ethics and is durable. These groups which should meet once a month should be provided with logistical support (US $ 50) to cover venue, rehearsals, costumes and administrative costs for at least the first year, eventually after consolidation these groups will be encouraged to involve hetero-normative persons and take on community responsibilities and requirements cascading into nationally accepted funding inclusion criteria. Activities surrounding good conduct of the beneficiaries should involve (civic responsibility, nuisance-avoidance, good dress codes, abstaining from alcoholic drinks, avoiding recruiting minors, avoid engaging in sex with minors-Paedophile- and other anti-social manners). This will change hetero-normative community and policy-makers perception about same sex oriented communities. Issues that have always eluded policy makers about same sex communities will now be revealed and addressed. With more funding more people will be reached.  Eventually the goal of various policies such as the NSP-to achieve universal access targets for HIV prevention, care and treatment and social support by 2012 will be realised.