Toronto I-II 1:00 pm

1. Toronto I-II 1:00 pm Towards improving health outcomes for MSM in Africa and African diaspora communities Moderator: Winston HusbandsDirector of Research and Program Development at the AIDS Committee of Toronto and a co-chair of the African and Caribbean Council on HIV/AIDS in Ontario LaRonNelsonAssistant Professor and Assistant Dean for Global and Community Affairs at the University of South Florida College of Nursing

2. Towards Improving Health Outcomes for MSM in African and African DiasporaCommunities LaRon E. Nelson, PhD, RN, NP Assistant Dean of Global & Community Affairs Assistant Professor of Nursing and Pharmacy

3. Background • Men account for approximately 50% of the estimated 240,802 people living with HIV in Ghana • HIV Prevalence among MSM estimated at 25% • MSM account for 25% of HIV cases among most-at-risk populations in Ghana— (includes female sex workers and their patrons) • 20% new HIV infections annually among MSM Ghana National AIDS Control Programme, 2012

4. How to find and connect MSM safely to HIV prevention services?

5. High perceived physical and social risk of same-sex behavior disclosures

6. Would the men be interested?

7. Kwame Nkrumah University of Science & Technology

8. Cultural Leaders

9. Human Rights NGOs Centre for Popular Education & Human Rights, Ghana

10. Government Stakeholders

12. Focused on three communities in Ghana with high HIV prevalence Kumasi Accra Koforidua

17. Self-Administered Survey • Cross-Sectional • Relative Frequency of Condom Use • STD Knowledge • HIV Knowledge • Gender Non Conformity Stigma and HIV Stigma • Gender Equity • Substance Use • Affiliation/Security within the social network

18. Focus Groups and Interviews • Focus Groups with MSM • Conversational Interviews • MSM Peer Leaders • Community/Cultural Leaders • Healthcare Professionals

19. Identified 23 social networks of MSM* * 137 total men

20. Findings from Survey • Overall low condom use (23%) • Highest in Accra • Lowest in Kumasi • High proportion of men with female sex partners (53%) • Higher than proportion of men who reported bisexual attraction • Low non-alcoholic substance use

21. Findings from Survey • Networks were significantly different from one another on all study variables • All psychosocial and knowledge variables were predicted by the network • Measures of network affiliation/security was the biggest predictor of condom use • More affiliated people used condoms more anal and oral sex • More affiliated people use condoms less for vaginal sex

22. Findings from Focus Groups • General Interest in PrEP (22 out of 23 groups) • Concern about efficacy • Guinea Pigs for the West (why no scale up in US) • Costs • Discontinuation of condom use • Gender Norms Inequitable towards women • Most had female partners • Informal underground network of providers that they used to get their sexual health related needs met.

23. Finding from Interviews • Cultural Leaders (n=23) • Mixed on acceptability of targeted care for MSM • Felt that MSM should be able to live in “peace” • No willingness to offer visible political support • Their was resistance to language of “gay-rights” • Believe all MSM are in Accra • Healthcare Providers (n=25) • Believed in fair treatment • Duty to educate clients about morality of behavior (but said they are free to choose) • Only two recalled ever encountering an MSM in clinical practice

24. Implications • Focus on the close social networks as the target of intervention • Versus as a recruitment mechanism • Prevention needs are multifaceted and require a combination approach • Targeting behavioral, social, and biomedical factors for MSM • Needs to accommodate complexity of men’s sexualities • Attention must be directed to MSM outside of urban core • Healthcare Climate needs structural intervention • Nurses and physicians attitudes and behaviors as barriers to scale up efforts

25. Level 1: Structural Intervention • Targeted for change in the healthcare climate • Human Rights Support Training for Healthcare providers

26. Medical Professionalism – A Physician Charter & Biomedical Ethics • Primacy of patient welfare: a dedication to serving patients’ interests • Patient autonomy: to empower patients to make informed decisions • Social justice: to eliminate discrimination ABIM Foundation. Ann Intern Med. 2002;136:243-246 Beauchamp & Childress. Biomedical Ethics 2009. Courtesy of Geoffrey C. Williams, University of Rochester 26

27. Informed Decision Making • 1478 MD-patient encounters audiotaped • 91% of the time, MDs don’t support autonomy • Most frequent error is providing too little structure, not too much Braddock CH 3rd, et al. JAMA. 1999;282:2313-2320 Courtesy of Geoffrey C. Williams, University of Rochester 27

28. Implications • Focus on the close social networks as the target of intervention • Versus as a recruitment mechanism • Prevention needs are multifaceted and require a combination approach • Targeting behavioral, social, and biomedical factors for MSM • Needs to accommodate complexity of men’s sexualities • Attention must be directed to MSM outside of urban core • Healthcare Climate needs structural intervention • Nurses and physicians attitudes and behaviors as barriers to scale up efforts

30. THANK YOU