Men who have sex with men (MSM) are categorized as a key population, particularly vulnerable to contracting sexually transmitted infections (STIs) including HIV.1 Ensuring that key populations, who are often marginalized in society, have access to HIV and STI prevention and treatment services is important to an effective public health response. This applies to countries with both concentrated and generalized epidemics, where interventions targeting key populations have been shown to have an effect on HIV incidence in the general population.2 However, although programs targeting MSM are relatively well established in North America and Europe, this is not the case in sub-Saharan Africa.
An acceptably accurate MSM population estimate for South Africa does not exist, but in surveys, as many as 3.1% of men have reported recent sex with a man,3 and 5.4% of men have reported ever having sex with a man.4 These figures do not differ widely from those reported in other African and high-income countries. There is evidence that STIs are highly prevalent in MSM, both in South Africa5 and elsewhere in Africa.6–9 As is the case for other African countries, nationally representative data are not available for South Africa, but estimates of HIV prevalence in MSM range from 13% to 49%, and there is no evidence that the epidemic is waning.10
In South Africa, HIV and STI prevention and treatment services are less accessible to men than to women.11 Reasons for this include that sexual and reproductive health services tend not to actively engage men, and norms around masculinity and health.12 Men may also prefer to interact with other men regarding sexual matters, and fewer men in the health work force limit this possibility.13 In addition, despite explicit constitutional protection in South Africa, MSM experience stigma and discrimination when seeking health services.14 This limits access to sexual health services and leads to reluctance to disclose same-sex sexual behavior,15 limiting appropriateness of care. Services for MSM need to be both sensitive to diversity in gender and sexual orientation and competent in addressing MSM-specific sexual health needs.16 One response to this has been for MSM to seek out services known to maintain confidentiality and be accepting of MSM.14
There are limited data on health programs targeting MSM in sub-Saharan Africa, particularly within public health services. It is important to understand trends in service delivery and utilization, to improve understanding of HIV and STI prevention and treatment needs, and to inform the expansion of service provision. To that end, this study aims to describe the utilization of sexual health services delivered at 2 primary care public sector health facilities that target MSM in Johannesburg, South Africa.
The Health4Men initiative is a multifaceted health program targeting MSM. Embedded in the South African public health sector, it has been provided by Anova Health Institute, a South African–based nongovernmental organization, in partnership with South African provincial Departments of Health, since 2009.16 This program operates at several levels, from community-based outreach and support activities, to sexual health service provision at primary health care facilities within the public health sector. In the latter, facilities are marketed as sexual health clinics for men and have staff that have received extensive training in both sensitivity and competence in MSM sexual health.17
Two Health4Men-supported primary health care facilities located in Johannesburg, South Africa, are described here. One is situated near the city center (Yeoville Health4Men) and the other in Soweto, Johannesburg's largest township (Chiawelo Health4Men), both relatively socioeconomically deprived areas compared with the rest of Johannesburg. They have been operational since early 2012. The clinics are located on the premises of, and work in cooperation with, public sector health facilities and provide free primary care sexual health services.
We retrospectively analyzed routine data from these 2 clinics using multiple data sources and report service utilization over time for STI syndromes, HIV testing, and the antiretroviral therapy (ART) program. Utilization, positive yield of HIV tests, and retention in care in MSM and other men are compared. Data were extracted between 1st January 2014 and 30th June 2016.
Two data sources were used, monthly reports for STI syndrome trends and an electronic patient register for demographic characteristics of service users, HIV testing, and ART services. Monthly reports were generated from data collected daily by clinicians. Because STIs are managed syndromically in the public sector, diagnostic tests are not routinely conducted and microbiological etiology is not generally available.
Ethical approval has been obtained from the University of the Witwatersrand Human Research Ethics Committee (medical), Reference No. M150352.
Definition of Variables
Sexual orientation was self-reported at first visit through a standardized form completed by attendees, but information on sexual behavior was not captured into the register. As such, for the purposes of this analysis, men are identified as MSM based on self-reported gay or bisexual orientation at first visit and other men based on reported straight orientation. Some men identifying as straight may also have had sex with other men. Sexually transmitted infection syndromes were defined based on the national guidelines18 and classified as urethritis (presenting complaint of either urethral discharge or dysuria), genital ulcer (presenting or observed genital sore or ulcer with or without pain), genital warts, anal discharge, or other. Most STIs were managed in accordance with national guidelines, which use a syndromic management approach. Anal discharge, however, is not included in the national guidelines, so specific management guidelines were developed.
Data were collated in Excel and analyzed using Stata 13.0 (Stata Corporation, College Station, TX). Descriptive statistics (medians, interquartile range [IQR], frequencies, and proportions) were used to summarize demographic and service data. Service data were represented graphically per quarter, χ 2 test for trend was used to investigate trends in yield, and linear regression was used to investigate trends in services provided. χ 2 and Fisher exact tests were used, as appropriate, for comparison of proportions between groups, and Mann-Whitney tests were used for continuous variables. Data on STI services were not collected at an individual level and, as a result, could not be disaggregated into MSM and other men.
To determine retention on ART, a cohort of all men starting ART in 2014 and 2015 were followed up until the end of June 2016. Retention was calculated by subtracting those lost to follow-up and those recorded to have died from those starting ART, with transfers out excluded from calculations. Loss to follow-up was defined as occurring when there was no visit 3 months after dispensed medication should have run out. Clients were assigned as lost to follow-up either 3 months after a missed appointment or 6 months after their last appointment when next appointment date was missing. Date of loss to follow-up was defined as the date of the last visit. Kaplan-Meier survival analysis was used to estimate the probability of retention over time, and log-rank tests were used to compare survival curves.
Characteristics of Service Users
Overall, 5796 men attended the 2 clinics during the study period (see Table 1). At first visit, 18.1% of men (1049 unduplicated individuals) identified themselves as gay or bisexual, whereas 76.8% (4452) identified as straight. Some 4.1% of men (257) did not identify as gay, bisexual, or straight: 0.4% (40 men) responded that they were undecided, 1.0% (60 men) declined to state a sexual orientation, and data were missing for 2.7% (157 men). Men at the inner-city site were significantly more likely to identify as gay (P < 0.001), to have a tertiary education (P < 0.001), and to be employed (P < 0.001).
At the end of the study period 58.4% (646) of MSM service users were HIV positive, and of these, 61.8% (399) were receiving ART at the H4M facilities. In service users not classified as MSM, 25.1% (1118) were HIV positive, of whom 59.0% (660) were on ART. At both facilities, MSM were more than twice as likely to be HIV positive as other men; however, ART uptake was similar in both groups.
STI Service Utilization Trends
Seven thousand one hundred eighty-eight STI episodes were managed at both facilities, 4716 (65.6%) of these at the township site (see Table 2). These episodes include individual men returning for repeated complaints and multiple syndromes diagnosed at a single visit. Of all episodes, 4903 (68.2%) were classified as urethritis. The number of STI episodes and number of episodes of urethritis did not change significantly over time (P = 0.85, all STI episodes; P = 0.35, urethritis episodes). The number and proportion of episodes classified as genital ulcers, however, decreased at both sites over time (P < 0.001). Anal discharge made up 1.0% of episodes (24 episodes) at the inner-city site and 0.3% of episodes (13 episodes) at the township site (P < 0.001), with no change over time (P = 0.76, inner-city site; P = 0.15, township site). The category other included scrotal swelling, pubic lice, and scabies. Syndrome data on STI are available as episodes only (including multiple and repeat presentations), but for individual men, of the clients treated of any STI at their first visit, overall 16.9% were MSM (township site, 10.7%; inner-city site, 22.9%; P < 0.001) and 19.3% were HIV infected (township site, 18.3%; inner-city site, 20.4%; P = 0.37).
HIV Test Utilization Trends
A total of 5605 HIV tests were conducted, 13.7% (4631 tests) of which were in MSM (township site, 7.9% [203 tests]; inner-city site, 17.6% [533 tests]; P < 0.001; Fig. 1). The proportion of tests conducted in MSM increased over time at the inner-city site (P < 0.001 whereas it decreased over time at the township site (P < 0.001).
Overall, 27.4% (1538) of tests were repeat tests (individual tested previously at the same clinic); this was similar in MSM (26.8% [736 tests]) and other men (27.6% [4631 tests]). The yield in first tests was 17.4% (676 positive test results); this differed significantly between MSM and other men (MSM, 38.0% [205 positive test results]; other men, 14.1% [471 positive test results]; P < 0.001). The yield for repeat tests was 0.8% (12 positive test results), with no significant difference between MSM (1.5% [3 positive test results]) and other men (0.7% [9 positive test results]; P = 0.21; see Table 3). There was no significant trend over time in positive yield of HIV testing in MSM or other men for either first or repeat tests.
At the end of the study period, there were more than 1090 clients on ART at the 2 clinics combined, 37.8% (400) of whom were MSM. This differed by site: proportion of ART clients that were MSM increased over time at the inner-city site from 37.3% (148 men) at the beginning to 45.3% (286 men) at the end of the study period (P = 0.006), but it did not change significantly at the township site (28.6% [68 men at the beginning] and 26.6% [114 men at the end of the study period], P = 0.99).
Six hundred twenty-eight individuals entered the ART program at the 2 clinics during the period of 2014 and 2015. Of these, 117 (18.6%) were lost to follow-up, 40 (6.4%) were transferred to another facility, and 2 deaths were recorded (Fig. 2). Retention at 1 year was better for those individuals who started treatment in 2015 (90%; 95% confidence interval [CI], 85%–93%) compared with those who started in 2014 (85%; 95% CI, 80%–88%), although this was not statistically significant. Overall, 2-year retention was 81.8% (95% CI, 77.8%–85.1%). There was no significant difference in retention between sites (P = 0.14) or between MSM and other men (P = 0.49). There were significant differences in retention between age groups in MSM (P = 0.05) and in other men (P = 0.04), with those younger than 25 years having the worst retention in both cases. Within age groups, there was no significant difference in retention between MSM and other men.
In this study, we have described the utilization of sexual health services targeting MSM in 2 different locations in South Africa's largest city. These data are unique because they present the first overview of service utilization of MSM in an African public health care setting. We have shown that these services address a need in the community and that men at high risk for HIV access the facilities. The positive yield of HIV testing was 28.3% among men identifying as gay and bisexual compared with 10.4% in those identifying as straight, whereas initiation of ART and retention in care were similarly good in both groups, with 61.8% of MSM and 59.0% of other men known to be HIV positive receiving ART, and an overall 2-year retention of 81.8%. This shows that high-quality sexual health services for MSM can be achieved in an African setting.
We noted important differences between the men attending and the services delivered at the inner-city and township facilities, although both are considered to be relatively socioeconomically disadvantaged compared with other parts of Johannesburg. The inner-city clinic attracted a greater number of MSM, which could, in part, be due to better geographic accessibility for men residing outside the immediate vicinity. The inner-city community is known to have a more mobile population than the township community, and may be perceived to have higher acceptance of MSM and less stigma. Men attending the inner-city clinic were more often employed and tertiary educated, reflecting the different utilization patterns.
A large number of men (4452 individuals) who did not identify as gay or bisexual also attended these facilities. Health services in South Africa are often perceived as being unfriendly toward men in general,16 and it is therefore interesting that straight-identifying men were comfortable using these clinics rather than standard public health services that are located on the same premises. This could be due to a number of factors, including increased feelings of comfort receiving sexual health care from men, who are trained to be nonjudgmental and maintain confidentiality. The Health4Men services target MSM but are marketed inclusively, in an attempt to limit stigma. Signage and branding indicate that services are for men, and no men are excluded from using services, although MSM are targeted through outreach, media campaigns, and online marketing and are directed to Health4Men facilities. It is also likely that being a dedicated service, waiting times would be shorter than those of general services, which could lead to men choosing to use them. It would be useful to explore why straight-identifying men attend these facilities, to inform improved HIV-related services for men in general.
Utilization of STI services was high, particularly at the township clinic, with urethritis as the main presenting syndrome. Eighty percent of individuals who were treated of STIs at their visit were HIV negative, highlighting the importance of STIs as an entry into preventive care. Data on repeat STIs in individuals were not collected, but preliminary data from an ongoing research project conducted at the same facilities show that repeat presentations occur commonly,19 highlighting the need to strengthen prevention. The high utilization of STI services is consistent with data suggesting that the prevalence of STIs in MSM in sub-Saharan Africa is high.6–9
The yield of HIV testing among MSM at the 2 clinics was very high with 28.3% of MSM testing positive. This is more than double the proportion in other men and consistent with estimates of HIV prevalence in MSM in South Africa, which range from 13% to 49%.10 At the inner-city site, the proportion of HIV tests conducted in MSM increased over time, whereas at the township site, it decreased. We think that the decrease is due to an influx of straight-identifying men and that the difference may be due to differences in accessibility of health services to men in general.
Retention remains a crucial challenge for ART programs. Retention at Health4Men clinics was 87% after 1 year and 82% after 2 years. This compares favorably with the findings of a systematic review investigating retention in sub-Saharan Africa, which found a 24-month retention of 70% (range, 66.7%–73.3%) for all individuals.20 The same review found that programs with a higher proportion of men had worse retention.20 There were no statistically significant differences in retention between MSM and other men at our facilities, highlighting that sensitive and appropriate care has been provided for MSM and for other men. The MSM-focused nature of the clinics is likely to be a significant contributing factor to the better retention seen in this study, and the facilities seem to be a conducive space for men. Part of this success could be due to a more patient-centered approach in staff with additional training in sexual health. The services are set up to allow for continuity of care, and relationships between health care providers and clients are developed. Although men were offered ART according to CD4 count, as the national guidelines of the time stipulated, it is likely that men sought out these services specifically, leading to a more motivated client base.
This study has several limitations. First, the data were collected for the purpose of routine monitoring of the program and not specifically for research. Data quality is therefore more difficult to ensure. In addition, misclassification of MSM may have occurred because data on sexual behavior were not collected routinely and ascertainment of MSM relied on self-report of sexual orientation. Although we do not know the extent of this misclassification, it is likely to be substantial. A survey previously conducted in Soweto, where the township facility is situated, found that 16.1% of MSM identified as gay, 33.6% identified as bisexual, and 43.2% identified as straight.21 However, risk was found to vary by sexual identification, with higher HIV prevalence in gay-identifying men.21 Finally, a limitation in the routine monitoring of STI syndromes led to episode numbers being collected rather than individual presentations, and we were therefore unable to report on the distribution of syndrome episodes between MSM and other men.
This type of specially targeted service could not be provided to every community in Johannesburg, and as a result of geographical access barriers, not all MSM could attend Health4Men clinics should they wish to. In an attempt to address this, the Health4Men program uses training and mentoring in public health facilities in all 9 provinces of South Africa to improve understanding of diversity in gender and sexual orientation, and competence in health issues relating to MSM.17
This study has described the routine functioning of a public sector program designed to target MSM in the setting of a generalized epidemic. We show that such services attract high-risk men in general, and MSM in particular, for STI and HIV care. The observed high positive HIV testing yield among MSM illustrates the relevance of such services in the South African public health sector, and the good retention on ART demonstrates that high-quality care can be provided to MSM in Africa.
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