Application of Findings in the HIVST Intervention
The research team’s findings on how to implement a community-led delivery of HIVST for MSM informed the intervention such that the CBOs included HIVST into their ongoing HIV prevention and treatment programs (for further details on the findings see Thomann et al., forthcoming). The data analysis process concluded with an agreement that individual site teams would come together at their respective organizational level, while considering their respective contexts, to review findings and to assess what could be integrated into the HIVST intervention for MSM. For instance, in the analysis, participants from across the sites had suggested MSM-specific social events, alongside a need for sensitization and networking at physical hotspots and virtual platforms, as a means to increasing uptake of HIVST kits. Emmanuel, a 37-year-old gay man from Kisumu, explained how MSM can be reached in groups and sensitized about HIVST.
…they can have theme activities that they partake like they have movie Mondays where people come to watch a movie, that is. .. a movie that you know has a gay-related theme or health-related or HIV health-related theme; so, they can bring their clients in those themed days, and they can be educated on that [HIVST].
The CBOs put in place mechanisms for holding MSM-themed social events that were designed to fit their specific contexts. For instance, in Kisumu, MAAYGO held what they referred to as an “HIVST Party” targeting their community members in a hotel and integrated themed activities such as singing, poetry, spoken word and run-way modelling. In Kiambu, MPEG held their MSM-themed event to promote HIVST at local entertainment clubs known to be frequented by MSM in the area. Similarly, mobilizations for the uptake of the kits occurred at physical spots frequented by MSM, as well as through varied social and dating virtual platforms such as Facebook pages, WhatsApp groups, Planet Romeo, Badoo and Grindr, among others.
The site-level analysis of the data by the different site teams provided instrumental findings that informed programs on the specific considerations they needed to make in the design of the intervention. The team from Mombasa, for instance, concluded from the analysis process that reaching some MSM in their region with HIVST kits would be deterred by the strong religious ties in the area and high levels of HIV-related stigma from religious leaders and the local community. During his interview, Bruce, a 21-year-old gay man from Mombasa, explained the deep-rooted HIV-related stigma within religious communities.
In Mombasa, because of churches, mosques, you cannot go just anywhere distribute [HIVST kits], they will look at you … and at the streets when you just say we are here to teach you about HIVST kit, when you just name, the word HIV, people will be like looking at you, they will be surprised to hear the name, because HIV to some is like they believe that when I am infected with HIV that’s the end of me.
In order to pro-actively address these stigma-related concerns, the Mombasa team engaged key religious leaders and other community opinion leaders from the area for a sensitization session on HIVST among MSM, ahead of distributing the HIVST kits. This provided a platform to initiate a partnership that would begin to address HIV-related stigma directed toward the MSM community.
Another area considered for HIVST interventions was the integration of MSM-targeted health services within government health facilities. Most participants interviewed who were not members of any of the MSM programs reported they would not want to be identified as an MSM or be associated with the MSM-led organisations and preferred a distribution approach that would allow them to get the kits from government health facilities. Evans, a 35-year-old gay man from Kisumu, justified why he would prefer a government facility:
I have never had a problem taking services at the government hospital, yeah only if it’s a sensitive issue like maybe anal STIs, that one I cannot go to the government hospital but when it’s just the, the normal health routine like maybe I want to go for HIV testing and counselling or maybe I need to get some condoms, that one I don’t have a problem, because usually when I go to access health in any health institution, I go as a Kenyan who has a right to access health. I don’t go as MSM.
Based on this, all three sites worked on context-specific approaches that would allow them to collaborate with select government health facilities within their respective counties. In Kisumu for instance, apart from their clinic operating within the CBO premises, the organisation negotiated and was assigned space at one of the government facilities in order to offer HIV prevention and treatment services including HIVST kits to their members.
Alongside the integration of study findings to ongoing interventions, it is important to note the implementation of the intervention was equally an iterative process which involved several revisions being made to the intervention strategies as findings emerged. For instance, as captured in the ethnographic field notes, in Mombasa, because of COVID-19, they engaged a motorbike rider to ensure continuity of distribution of the HIV self-testing kits to the MSM community within the target area. Also, in all the sites, demand creation through the social media and other virtual spaces was intensified.