Public/community engagement in health research with men who have sex with men in sub-Saharan Africa: challenges and opportunities

Abstract Background Community engagement, incorporating elements of the broader concepts of public and stakeholder engagement, is increasingly promoted globally, including for health research conducted in developing countries. In sub-Saharan Africa, community engagement needs and challenges are arguably intensified for studies involving gay, bisexual and other men who have sex with men, where male same-sex sexual interactions are often highly stigmatised and even illegal. This paper contextualises, describes and interprets the discussions and outcomes of an international meeting held at the Kenya Medical Research Institute-Wellcome Trust in Kilifi, Kenya, in November 2013, to critically examine the experiences with community engagement for studies involving men who have sex with men. Discussion We discuss the ethically charged nature of the language used for men who have sex with men, and of working with ‘representatives’ of these communities, as well as the complementarity and tensions between a broadly public health approach to community engagement, and a more rights based approach. We highlight the importance of researchers carefully considering which communities to engage with, and the goals, activities, and indicators of success and potential challenges for each. We suggest that, given the unintended harms that can emerge from community engagement (including through labelling, breaches in confidentiality, increased visibility and stigma, and threats to safety), representatives of same-sex populations should be consulted from the earliest possible stage, and that engagement activities should be continuously revised in response to unfolding realities. Engagement should also include less vocal and visible men who have sex with men, and members of other communities with influence on the research, and on research participants and their families and friends. Broader ethics support, advice and research into studies involving men who have sex with men is needed to ensure that ethical challenges – including but not limited to those related to community engagement – are identified and addressed. Summary Underlying challenges and dilemmas linked to stigma and discrimination of men who have sex with men in Africa raise special responsibilities for researchers. Community engagement is an important way of identifying responses to these challenges and responsibilities but itself presents important ethical challenges

Evaluating Measures of HIV Risk Perception with a Mixed Method Approach Among Adolescent Girls and Young Women Using PrEP in Kenya

Thesis (Master's)--University of Washington, 2020Introduction: Pre-exposure prophylaxis (PrEP) for HIV prevention is a promising HIV prevention option for young African women. The evidence of effective PrEP use in this population group is mixed, and has been tied to poor adherence. Discordance between assessed HIV risk and the actual experience of risk may underlie the dissonance observed between epidemiologic risk, risk perception, uptake of and adherence to prevention measures. We examined the contribution of research methods used in characterising HIV risk to this dissonance by contrasting HIV risk awareness as assessed by standard structured questionnaires and qualitative in-depth interviews. Methods: We conducted secondary analysis of data from a trial of African women aged 18 to 24 years interested in taking PrEP. Enrollment took place at two sites in Thika and Kisumu, Kenya, and participants were followed up for a period of 24 months between 2017 and 2020. We conducted a multi-step mixed methods assessment of HIV risk awareness and related decision-making behaviour. First, a quantitative analysis of survey data with descriptive statistics to characterize the cohort, proportion testing for trend and generalised estimating equations to assess the association between predictors of risk and risk perception. Secondly, an inductive content analysis of interview data for narrative themes; and lastly, joint display methodology to summarise findings from the two analytical methods. Results: We enrolled 350 young women with a median age of 21 years (IQR 19, 22). At baseline, 182 (52%) participants reported feeling at risk for HIV. In multivariable analysis, reporting a lot of HIV worry was significantly associated with higher odds of risk perception (OR 1.95 [CI 1.31, 2.91]), while significantly lower odds were associated with visits at month 12 (OR 0.30 [CI 0.18, 0.48]) and 24 (OR 0.21 [CI 0.09, 0.20]), living with other family or employer (OR 0.56 [CI 0.33, 0.95]) and being single with a steady partner (OR 0.48 [CI 0.33, 0.70]). Qualitative data from 75 serial interviews provided insight into the changes observed over time in report of both risk awareness and sexual behavioural choices. We identified three major themes from the combined qualitative and quantitative analysis: risk dynamism, behavioural risk patterns and the influence of the social environment. HIV risk awareness and decision making was both intentional and contextual; driven primarily by HIV literacy, PrEP use, assessment of a partner’s HIV risk profile and the self-agency to exercise held knowledge. Effective risk mitigation was contingent on intimate partner relationship dynamics and was hindered by the fear of intimate partner violence. Supportive social environments enabled disclosure and promoted the self-agency to effectively mitigate risk. Knowledge of partner status and PrEP use emerged as the primary determinants of risk awareness and related decision making, informing both risk perception and mitigation. Conclusion: We observed complementarity and contrast between the two quantitative and qualitative data in how HIV risk was defined and rationalised, and identified factors at the individual, partnership and societal levels that informed risk awareness and related decision-making. Interview data expounded on the quantitative findings and revealed a more dynamic and rationalised experience of risk than was observed in survey data. The experience of HIV risk by young African women was not haphazard, but rather was rationalised based on HIV and PrEP literacy, current knowledge of partner status and attitudes, and prevailing sexual and economic needs. HIV related decision making was dependent not just on having access to preventive measures, but also on the agency and wherewithal to actualize known mitigation measures. Further work on how knowledge of partner HIV status and PrEP use can be leveraged to support HIV prevention and other sexual reproductive health programs targeting young women is warranted

Uptake and Acceptability of Oral HIV Self-Testing among Community Pharmacy Clients in Kenya: A Feasibility Study

Background While HIV testing and counselling is a key entry point for treatment as prevention, over half of HIV-infected adults in Kenya are unaware they are infected. Offering HIV self-testing (HST) at community pharmacies may enhance detection of undiagnosed infections. We assessed the feasibility of pharmacy-based HST in Coastal Kenya. Methods Staff at five pharmacies, supported by on-site research assistants, recruited adult clients (>= 18 years) seeking services indicative of HIV risk. Participants were offered oral HST kits (OraQuick (R)) at US$1 per test. Within one week of buying a test, participants were contacted for post-test data collection and counselling. The primary outcome was test uptake, defined as the proportion of invited clients who bought tests. Views of participating pharmacy staff were solicited in feedback sessions during and after the study. Results Between November 2015 and April 2016, 463 clients were invited to participate; 174 (38$ 1 per test. Further implementation research is required to assess uptake, yield, and linkage to care on a larger scal

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online trainin

Main advantages and disadvantages of HIV self-testing cited at the pre-test interview, N = 174.

<p>Main advantages and disadvantages of HIV self-testing cited at the pre-test interview, N = 174.</p

Basic characteristics of invited and enrolled clients.

<p>Basic characteristics of invited and enrolled clients.</p

Additional suggestions and concerns regarding pharmacy HIV self-testing.

<p>Additional suggestions and concerns regarding pharmacy HIV self-testing.</p

Previous self-testing experience and HIV test history among enrolled clients, N = 174.

<p>Previous self-testing experience and HIV test history among enrolled clients, N = 174.</p