1. Reducing HIV STI risk and improving
treatment for Men who have sex with
Men in Mombasa, Kenya
Prepared by
Agnes Rinyiru
(ICRH)

2. Presentation Outline
• Formative Study Background
• Sexual health risks identified
• Issues and barriers to treatment
• Barriers to program response
• Research/Intervention

3. Introduction
• Formative research (2002) by Population Council and ICRH
indicated MSW existed in Mombasa and surrounding areas
• Study defined MSW as ‘any man who regularly receives money
or gift in exchange for sex with other men’
• Increasing in numbers and visibility (study estimated Mombasa
had > 500 MSWs)
• Self identified themselves as either street based, bar/club
based and home based
• Had both male and female sexual partners
• Were at risk of transmitting or getting infected with HIV/STIs

4. Sexual Health Risks Identified
• Low risk perception of HIV/STI infection
• Poor knowledge base of HIV/AIDS
• Multiple sexual partners
• Inconsistent condom use
• Unprotected anal sex
• STI infections were common
• Practiced self-medication for STIs
• Hidden nature of male-male sexual relations -
contributes to high HIV prevalence

5. Issues and Barriers to treatment
• Lack of MSM sensitive health providers and services
• MSM reluctance to use existing health services due
to fear of stigmatization
• Alcohol and Drug use
• Harassment by law enforcement agents
• Sexual abuse and economic exploitation

6. Barriers to program Response
• Denial of MSW existence
• Social marginalization
• Lack of Prevention and care programs directed at men
having sex with men
• The above findings generated rationale for
implementing a program to address HIV/AIDS and
sexual health needs of men who sell sex to men in
Mombasa

7. Intervention Objectives
• To increase knowledge and skills in HIV/AIDS prevention, care
and support, and support behavior change among MSW through
peer education.
• To promote adoption and continued use of safer sex practices
among MSW through condom and lubricant promotion and
distribution.
• To enhance the Health seeking behavior among MSM and reduce
obstacles to obtaining treatment and counseling for STIs and HIV
through Capacity building health personnel to offer MSM friendly
health care services with emphasis on counseling and testing for
HIV and STI treatment.
• Enhance access to CT for HIV and STI treatment through
outreaches and service provision at an MSW friendly drop-in
centre

8. Pre-intervention Activities
• Mapping - 77 MSW hotspots
• Formation of Project Advisory Committee
• MSW enumeration using capture- recapture technique estimated 739
MSWs within Mombasa
• Baseline quantitative and qualitative research to assess sexual risks
behaviour and health seeking behaviour of MSWs
(refer to Geibel et al;2007 in STI journal)

9. Intervention
• Based on formative research and feedback from
baseline assessment intervention activities were
implemented in the following priority sites:
– Mombasa

10. 1. Drop in Centre
To serve the following:
• Friendly Resource centre to receive health related
information
• On-site MSM friendly CT for HIV and STI screening and
treatment at drop-in center
• Drop-in centers serve as triaging centers for referring
sex workers to clinic based services.
• Peer Educators meetings

11. 2. Peer Education Training
Using interpersonal approaches to BCC - 40 MSW
peer leaders were trained in PE to:
• Increase Knowledge on HIV and STI prevention
• Effect behavior change - values, attitude, conduct e.t.c
• Uplift self esteem and empowerment
• Strengthening leadership Skills
• Facilitation Skills
• Stigma Reduction

12. 3. Condom Distribution
• Drop-in centre is distribution point
• Peer educators distribute condoms to peers
• Regular condom distribution to selected MSWs
hotpots – bars, lodgings, nightclubs
• Peer educators select other areas of condom
distribution e.g. guest houses, private massage
parlors, private homes etc

13. 4. Lubricant Promotion
• Baseline study indicated MSWs little knowledge about
water-based lubricants
• Most used oil-based lubricants thus many reported
having experienced condom breakage
Therefore
To promote use water based lubricant among MSW group
• Program has distributed over 12,000 sachets of water-
based lubricant (Assegai) through peer educators

14. 5. Training of Health Providers
• Health providers (n=20) were trained on MSM specific STI related
needs - anal and oral STIs
• Sensitized to offer a MSW-friendly services – non-judgmental,
supportive and sensitive to MSM needs
• Trained on stigma reduction and positive attitude change
• Confidence building meeting held between MSW and service providers

15. 7. Alcohol and drug addiction
training
• The 40 PE were undertaken through intensive
‘Alcohol/Drug/HIV/AIDS Harm Reduction Training
• This was conducted by ‘ Support For Addiction
Prevention and Treatment In Africa (SAPTA) in 2007
• Follow up sessions were held to assess progress
after 5 months

16. 8. Psychosocial Support
• PE (n=40) were trained in basic counseling skills to
provide counseling to peers and host regular
support group meetings
• 6 PE were trained as VCT counselors.
• The 6 are providing VCT/counselling services at the
drop-in centres and other MOH health facilities
• ICRH counselors are providing psycho- social
counseling support to MSW/MSM

17. Project status
Due to successful intervention around Mombasa district
• Program has seen major expansion - Kwale, Malindi and Lamu
• Drop-in centre has been established in Malindi
• A total of 140 PE have been trained with support of APHIA II program
• 6 more MSW have been trained as VCT counsellor – in Malindi and
Kwale
• On-going monitoring and supervision of intervention activities
• Data collection for post intervention evaluation concluded (March to
April 2008)

18. Intervention Sites
Ukunda

19. Lessons Learned
• Collaboration with government (MOH) and stakeholder
engagement contributed to the success of the intervention
• Training health care providers has potential to enhance
provision of friendly MSM specific STI treatment services
• Nurturing and sustaining relationship with target population
reduces the likelihood of resistance to the program.
• Creating ‘safe space’ to discuss personal issues and access to
HIV/STI referrals and CT services enhances uptake of the
services
• Use of interpersonal approach to BCC such as peer education
and easy access to condoms, lubricants and MSM specific
information materials enhances adoption of safer sex practices

20. Challenges
• MSWs are a hidden and highly mobile population thus difficulty
to reach
• High cost and limited availability of water-based lubricants
• Constant threat and hostility from community leaders
• Constant demand for money and personalised attention from
MSW
• Inadequate localised MSM sensitive BCC/IEC materials.

21. Final Thought
• The programs issues raised and lessons learnt from this
study/intervention are not exhaustive. Innovative ideas,
programmes and interventions need to be developed
• More MSM aspects need to be studied and updated
periodically since social- cultural and sexual
environment constantly evolves
• It is hoped that this program supports the process of
learning, sharing and networking in Kenya and the
African region and will continue to inspire MSM
interventions in response to the HIV epidemic

22. Acknowledgement
• MOH
• Population council
• FHI/USAID/APHIA II
• KEMRI
• Support For Addiction Prevention and Treatment In
Africa (SAPTA)
• MSW Peer educators
• Project Steering Committee
• Study participants
• Project Staff/team

23. THANK YOU