The healthcare workers who participated in this study provided a range of perspectives and recommendations on how to improve HIV prevention among same-sex attracted men. Below, we summarize their different views, perspectives and recommendations as five distinct models or ideas – five different ways of reasoning – that existed among healthcare providers in Tanzania.
The first may be referred to as a “punitive model” of HIV prevention because it emphasized that there ought to be punishment and restrictions for men who engage in same-sex practices. Interestingly, healthcare providers had two rather different rationales for this proposal. Some considered same-sex sexual practices to be morally wrong, whereas others primarily reasoned that avoidance of same-sex practices would protect men from contracting HIV. To punish same-sex practices between men were thus variously thought of as a strategy to discourage homosexual behaviour and as a strategy to stop the spread of HIV. Among the punitive approaches recommended were to isolate same-sex practicing men who are HIV positive and to limit healthcare services to men who have sex with men. It was argued that actions like these would lead to less HIV transmission, and that they would reduce both the burden of HIV among men who have sex with other men and the resources spent on HIV.
We refer to the second way of reasoning as the “friendly services model” because it emphasized that healthcare workers should receive men who have sex with other men with kindness and friendliness. The key message in this model stood in clear opposition to the punitive model as it emphasized that healthcare workers should accept and have positive attitudes towards same-sex practicing men. Study participants emphasized that healthcare providers need to allow men who have sex with men to freely and unconditionally contact them for consultation whenever they have health problems. To be able to develop more friendly attitudes, some study participants said that healthcare providers need to receive training on how to recognize, relate to, engage with and take care of same-sex loving men.
The third way of reasoning we identified could be referred to as an “educational outreach model” because it emphasized that healthcare workers should reach out to same-sex attracted men to provide education on different relevant topics. In this model, knowledge building was considered vital for the health of men who have sex with men. Among topics that were thought of as salient to focus on in education were the advantages of partner reduction and protected sex as well as early health seeking behaviour.
We refer to the fourth way of reasoning as the “collaboration model” because it highlighted that same-sex attracted men should be invited to take part in the development and delivery of healthcare services. The collaboration model goes beyond the friendly and outreach models in the sense that it does not only promote that men who have sex with men should be welcomed to healthcare (as in the friendly services model) or given targeted education (as in the educational outreach model), but that they should also be given power to take part in the shaping of the health services for their group. As opposed to the previously mentioned models, same-sex practicing men are no longer considered passive recipients of care developed and delivered by others; they are becoming active participants in the production of care. An additional rationale for the collaborative model was that it would lead to improved understanding of men engaging in same-sex sex among healthcare workers and thereby strengthen their competence and capacity as healthcare providers for this group. In other words, collaboration was in a sense regarded as a way of empowering both patients and healthcare workers. Finally, the collaboration model was also thought to make same-sex attracted men feel a sense of belonging to and ownership of healthcare and to have the potential to increase the trust between patients and providers.
The fifth and last idea we identified could be referred to as an “activistic model” because it promoted actions on a system and/or political level that aim to enhance the understanding, acceptance and inclusion of same-sex attracted men in society (including in the healthcare services). Some study participants pointed out that important changes needed to be taken at structural level to create better conditions for men who have sex with men, including changes in laws and policies that negatively affect men who engage in same-sex practises. The activistic model also extended some of the arguments in the previously mentioned models. For example, some of the study participants insisted that not only should friendly sexual healthcare services be available to men loving other men, they should also be offered free of charge (since cost was thought to be a barrier against access to care).
This diversity of perspectives and opinions among the healthcare workers who took part in this study stands in contrast to much reporting that risks giving the impression that practically all healthcare workers in Africa are utterly homophobic (Awondo et al., 2012; Sadgrove et al., 2012). This is clearly not in line with what we found. While on the one extreme of the spectrum we did find healthcare workers who held very disapproving views indeed, all the other four models we describe express varying degrees of understanding of and support for same-sex attracted men.
While punishment and restriction was thought by some study participants to be a strategy that could lessen the impact of HIV on men who have sex with men, Fagan and Meares are among those who argue why and how such approaches may be counter-productive (Fagan & Meares, 2008; Howard, 2008). Instead of achieving any intended benefit, punishment is always accompanied with risks, pertaining not only to the individuals who experience them, but also to their neighbouring members of society (Fagan & Meares, 2008). For example, punishing men who have sex with men with the intention of changing them undoubtedly risks pushing them away from healthcare and from openly mentioning their sexual orientation to healthcare providers. In such a situation, much of what has been achieved through HIV programming could be lost and the consequences might affect entire communities with the result that the HIV pandemic could begin to rise after years of declining. An even more fundamental issue is the obvious conflict between punitive approaches and the clinical-ethical principle of respect for the patient’s autonomy, which promotes the idea that everyone “should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination”(Varkey, 2021a).
However, while some healthcare providers advocated for punishment; many did not. As we will show elsewhere, a recent study among healthcare providers in Dar es Salaam and Tanga, Tanzania (Ishungisa et al, forthcoming) indicate that a majority are supportive of same-sex attracted men who seek healthcare services. There have also been studies elsewhere in Sub-Saharan Africa that have found supportive attitudes to be common among healthcare providers towards same-sex practicing men (Kapanda et al., 2019; M et al., 2020; Micheni et al., 2017; Van Der Elst et al., 2015a). Friendly engagement with, acceptance of, and collaboration with this population not only has the potential to contribute to increased trust in healthcare services, it may also empower patients and give them a feeling of ownership of care (Grimen, 2009; Lee et al., 2002; Nilsen et al., 2006). As pointed out by the World Health Organization (WHO 2017) and Delaney (Jo Delaney, 2018), potential advantages of accepting attitudes and collaboration approaches are that they may enhance the safety of patients and reduce unnecessary harm (Jo Delaney, 2018). Other advantages of accepting and collaborating with patients in delivering care is that collaboration acknowledges patients’ preferences and values, promotes flexibility of care, increases patients’ satisfaction, self-efficacy and autonomy as well as leads to improved health outcomes (Jo Delaney, 2018; Levy et al., 2017; ResearchGate, n.d.; WHO, 2017). In his “Principles of clinical ethics”, Basil Vakey (Varkey, 2021b) pointed out that healthcare providers have a professional obligation to work to the benefit of patients as well as avoid harming them (Varkey, 2021b).
Those subscribing to what we call the activistic model had in mind that laws and policies that prohibit same-sex sexual practices need to be reversed to provide space for provision of healthcare service. This aligns with the guidelines of the World Health Organization (WHO) which stipulate that in countries where anti-homosexuality laws and policies are used to deter access to healthcare and health information, such laws need to be reversed (Khosla et al., 2015), and in circumstances where they are not, healthcare professionals need to follow their obligations and ethics of saving patients’ lives (Khosla et al., 2015).
Lastly, we note the study participants’ views on the so-called comprehensive package of HIV intervention package for key populations (CHIP), which was launched in Tanzania in 2014 (NACP, 2014) and revised in 2017 (NACP, n.d.). Several study participants pointed out that the CHIP remains to be fully implemented. They were of the impression that many of the services outlined in the package are not provided, and the ones offered are not consistently available when needed by men sexing with other men. These reports may seem to indicate that there could be a problem with the implementation of the health authorities’ own strategy for healthcare for key populations in Tanzania. There would therefore seem to be a need for an urgent evaluation of the performance of the CHIP.