HIV health care services for men who have sex with men (MSM) in Sub-Saharan Africa (SSA) are still
severely lacking [1]. Especially in Africa, the existence of MSM has largely been denied traditionally,
and high rates of HIV infection among this population have invariably been ignored [2]. As a result,
the high prevalence of HIV among men, and their risky sexual practices have not been considered
until recently. As a consequence, an operational response to include HIV-prevention messages
addressing MSM in SSA has been largely missing [1, 3-5]. Yet, documentation of homosexuality on
the East African coast exists from the nineteenth century onward [6-9], and detailed local
anthropological descriptions of MSM groups and behaviours in SSA predate the emergence of HIV
[10]. Strong sociocultural beliefs, stigma and cultural intolerance of same-sex relationships, coupled
with misconceptions about HIV and unclear legislation on same-sex behaviour, have created
confusion and distrust among government officials, health care providers (HCP) and the
communities at large in many African countries [11-13]. The predominantly heteronormative
attitudes reflected in health care providers may increase MSMs’ fear of seeking health care and
further isolate and deprive MSM of access to effective health care and safe treatment [14].
However, some African societies and governments have recently begun taking steps to include MSM
in HIV prevention and care programming. This has been based on recognition of civil rights
organizations, sizes of MSM populations and emerging reports of elevated HIV-1 incidence and
prevalence estimates among MSM in SSA [5, 15-18]. Kenya is one of these countries, and although
Kenya lacks laws prohibiting discrimination against MSM, it is at the frontline in addressing the
health care needs of MSM.
This thesis describes how Kenyan MSM1
have been engaged by the Kenya Medical Research Institute
in operational research on HIV service delivery in coastal Kenya since 2005. This has been a uniqueendeavour in a highly stigmatizing and homophobic environment that has nonetheless provided
services for MSM on a regular basis. The thesis subsequently focuses on access to health care for
MSM outside the context of research, framing health care providers’ attitudes as crucial to the
pursuit of the implementation of MSM HIV services.