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Parinita Bhattacharjee, an Assistant Professor and Director for Programme Delivery in the Institute of Global Public Health, University of Manitoba, Canada, is working on HIV prevention and structural drivers of HIV in Kenya. In this interview, Bhattacharjee talks about the stigma and discrimination experienced by men who have sex in men (MSM) in Kenya. Covid-19 has exacerbated the difficulties faced by MSM, as well as hindered the delivery of HIV care and services.

In an Open Letter, Bhattacharjee and a group of researchers including community researchers, document the innovative steps made by MSM led organisations to adapt to the challenges created by Covid-19. Find out about the efforts taken to provide necessary clinical, social and mental health support to the community.

What difficulties do highly marginalized groups in Kenya, like MSM face?

MSM in Kenya experience very high violence, stigma and discrimination. Same sex relationship is criminalized by law and is considered immoral by the Kenyan society. As a result, MSM in Kenya sometimes lead a “dual life” where they have to hide their sexual orientation. This situation makes them easy victims to harassment by law enforcement, as well as blackmail and violence by other members of society. When MSM disclose their orientation to families, they risk losing support and respect of the family. There have been instances where they have been thrown out of family homes. MSM can be discriminated against at school and workplaces.

HIV prevalence among MSM is high at 18%, which is at least 3-4 times higher than the HIV prevalence among adult general population males in Kenya. In addition to HIV, MSM in Kenya experience other health issues related to anal health, STI, HPV, TB and so on. MSM experience stigma and discrimination in existing health services and that acts as a barrier to access services. Though there have been services established by civil society organizations and MSM led organizations in Kenya, there is still a sub group of MSM who fear accessing services. Low self-esteem and confidence, fear of stigma, low perception of risk, drug and alcohol use also discourage MSM from accessing health services.

How has Covid-19 exacerbated the difficulties faced by the community?

During Covid-19, MSM suffered job losses and unpaid leave like many other working-class Kenyans. Many of the industries where MSM were employed, like the hospitality industry, bars, barber shops and salons, and massage parlors closed for several months soon after the first cases of Covid-19 were identified in Kenya. Many MSM who depended on formal and informal modes of sex work, experienced loss of income as the sex industry collapsed with the closure of hotspots and other public spaces and venues where they would normally gather to meet clients.

Loss of jobs and income had dire financial consequences and led to food insecurity among MSM. Financial insecurity forced some MSM to stay with friends to save on rent, thereby increasing the conditions of overcrowding and Covid-19 related exposure risks. Being unable to afford rent, some MSM were forced to vacate rented homes and live on the streets. Some even had to leave the cities where they were living with friends, to go and stay with their parents. A number of MSM who lived with one of their sexual partners reported experiences of intimate partner violence. Along with coping with fears related to Covid-19, many MSM are also experiencing anxiety, stress and hopelessness with regards to an unpredictable future.

How has the pandemic impeded the delivery of HIV services to MSM?

MSM, like other highly HIV vulnerable “key populations”, are expected to undergo health check-ups and HIV testing every three months as per national guidelines. This health strategy relies upon regular and intensive peer outreach work. However, access to health services and social support provided through MSM led organisations and other civil society organisations reduced considerably during the months of March through to May 2020. Covid-19 related restrictions on travel, social gathering, and closure of clinics and drop-in centres, limited MSM’s access to vital services. Most HIV prevention activities for MSM, rely on face-to-face outreach and interactions between peers. Many of those activities were suspended following the announcement of COVID-19 response measures.

Furthermore, both service providers and users were fearful of coming to the clinics, as Covid-19 worried them about interacting with staff and providing or obtaining services. Initial rumours of COVID-19 transmission also stirred fears in their communities. Loss of income meant that most MSM could not afford sanitizers or face masks to protect themselves and others.

Who is trying to help?

All the organisations providing services to MSM played their part and helped them. The most critical role may have been played by the MSM led organisations as they mobilized resources to buy food, sanitizers and masks for MSM and distributed them free of cost. Food provision was critical during the onset of Covid-19 as people lost jobs/ income, many experienced food insecurity.

The donors provided resources to educate the service providers and peer outreach workers on the causes and prevention of Covid19. Service providers were given personal protection equipment. In addition, most donors provided support for hand washing or sanitization for clients who visited the clinics. The Ministry of Health through NASCOP also provided guidance to provide services following all safety protocols including multi month dispensing of ART.

What novel services did organisations develop? Are they proving successful to fill the gap in HIV testing?

The organisations adopted novel ways to provide services. The peer educators started WhatsApp groups to stay in touch with the MSM in their cohort. The clinics started inviting clients by appointment so that social distancing can be maintained. The CBOs and NGOs also started partnering with public health facilities to provide services for MSM as the public health clinics are expected to follow safety protocols.

For HIV testing, to avoid overcrowding of the clinics, the organisations started distributing HIV self-testing kits. The testing kits, condoms and lubricants were delivered at home or a place chosen by the MSM clients to ensure that the clients do not have to travel. Virtual outreach by peer educators also increased reach to MSM who were using virtual spaces, as the hotspots had closed. Many KP led organisations also started providing mental health support, including counselling to those who needed it, as many MSM complained of anxiety and depression. These innovative ways of providing services successfully filled the gap. In the months of March and April 2020, data from Kenya shows that MSM seeking HIV testing reduced. However, the situation was normalized by May 2020 and maintained usual activity from then.

What do you recommend for continuing support to the HIV community?

The MSM community and the organisations providing services were not prepared for this crisis. Nor were the donors and the government. However, all stakeholders showed tremendous resilience. In future, preparedness to manage these shocks should be built within the community and the organisations.

Donors should be flexible to provide resources to address the immediate consequences of such shocks but also to fund innovations. Some of the innovations which helped reach MSM should be continued. Mental health interventions are critical during a crisis, as stress, anxiety and depression tend to increase in this situation.

As a researcher, what does open research mean to you?

Open research means higher and quicker accessibility and visibility of new knowledge or information and thus more use of the information. Open peer review platforms encourage transparency.

Read the Open Letter and the peer review reports on Gates Open Research for more on HIV testing amid COVID-19 and how organisations are adapting their services to provide for communities against emerging challenges.