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

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          Abstract

          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 training.

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          Most cited references37

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          Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana.

          Same-sex practices are stigmatized in much of sub-Saharan Africa. Cross-sectional relationships between discrimination, access to and use of health care services, and HIV knowledge among men who have sex with men (MSM) were assessed in Malawi, Namibia, and Botswana. A survey and HIV screening were used to explore these variables and the prevalence of HIV. Overall, 19% of men screened positive for HIV infection. Ninety-three percent knew HIV is transmitted through anal sex with men, however, only 67% had ever received information of how to prevent this transmission. Few (17%) reported ever disclosing same sex practices to a health professional and 19% reported ever being afraid to seek health care. Men reported ever been denied health care services (5%) and 21% had ever been blackmailed because of their sexuality. Strong associations were observed between experiences of discrimination and fear of seeking health care services. Characterizing the relationship between stigma and health care seeking practices and attitudes can inform the development and implementation of HIV interventions for African MSM.
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            High acceptability of HIV pre-exposure prophylaxis but challenges in adherence and use: qualitative insights from a phase I trial of intermittent and daily PrEP in at-risk populations in Kenya.

            This paper used qualitative methods to explore experiences of men who have sex with men and female sex workers in Nairobi and Mtwapa, Kenya, who used oral pre-exposure prophylaxis (PrEP) for HIV prevention as part of a four-month trial of safety, acceptability and adherence. Fifty-one of 72 volunteers who took part in a randomized, placebo-controlled, blinded trial that compared daily and intermittent dosage of PrEP underwent qualitative assessments after completing the trial. Analyses identified three themes: (i) acceptability of PrEP was high, i.e. side effects were experienced early in the study but diminished over time, however characteristics of pills could improve comfort and use; (ii) social impacts such as stigma, rumors, and relationship difficulties due to being perceived as HIV positive were prevalent; (iii) adherence was challenged by complexities of daily life, in particular post-coital dosing adherence suffered from alcohol use around time of sex, mobile populations, and transactional sex work. These themes resonated across dosing regimens and gender, and while most participants favored the intermittent dosing schedule, those in the intermittent group noted particular challenges in adhering to the post-coital dose. Culturally appropriate and consistent counseling addressing these issues may be critical for PrEP effectiveness.
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              A call to action for comprehensive HIV services for men who have sex with men.

              Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Journal
                Int Health
                Int Health
                inthealth
                inthealth
                International Health
                Oxford University Press
                1876-3413
                1876-3405
                May 2015
                16 January 2015
                16 January 2015
                : 7
                : 3
                : 151-162
                Affiliations
                [a ]Kenya Medical Research Institute, Centre for Geographic Medicine Research–Coast, P.O. Box 230, Kilifi, Kenya
                [b ]National AIDS and STI Control Programme, P.O. Box 19361–00202, Nairobi, Kenya
                [c ]Desmond Tutu HIV Foundation, Anzio Road, Observatory 7705, Cape Town, South Africa
                [d ]Amsterdam Institute for Global Health Development, University of Amsterdam, P.O. Box 22700 1100 DE, Amsterdam, The Netherlands
                [e ]Department of Global Health, Academic Medical Centre, University of Amsterdam, P.O. Box 22700 1100 DE, Amsterdam, The Netherlands
                [f ]University of Washington, Seattle, WA 98195, USA
                [g ]Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX3 7BN, UK
                Author notes
                [* ]Corresponding author: Tel: +31 625087466; E-mail: maartje.dijkstra@ 123456amc.nl
                [†]

                Deceased

                Article
                ihu101
                10.1093/inthealth/ihu101
                4427535
                25596188
                a6ffbb2a-eaf3-46ab-b933-4da08fbbd1b3
                © The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 19 August 2014
                : 27 October 2014
                : 28 October 2014
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                Medicine
                art adherence,community engagement,healthcare worker,msm sensitivity training,sub-saharan africa

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