via sahivsoc.org, by Rebe K, De Swardt G, Struthers H, McIntyre JA

Until fairly recently, the healthcare needs of men who have sex with men (MSM) have been under-researched and under-resourced in South Africa.1 This has occurred despite emerging local evidence confirming high rates of HIV among this most at risk or key population (MARP). Notwithstanding inclusion in the country’s previous National Strategic Plan for HIV and AIDS, STIs and TB (2007 – 2011), services for MSM were not scaled up nationally although impressive strides have been made in some provinces such as the Western Cape and Gauteng. Evidence shows that in settings where concentrated HIV epidemics exist among MARPS in countries with generalised heterosexual epidemics, failure to provide targeted and tailored HIV prevention and treatment programs to MARPS negatively impacts on that country’s HIV rates among the general population. 
MSM in South Africa comprise a diverse group of men who share only one behavioural commonality: they have sex with other men. 3 Many South African MSM do not identify with gay culture which may be viewed as a Eurocentric cultural construct which is often considered foreign and un-African.4 The behaviour of men having sex with men has however occurred across all cultures and all times, including South Africa, and is therefore well described in African oral histories. Colonial oppressors were largely responsible for the criminalisation of sodomy on the continent.5 Homosexual activity in South Africa therefore often remains clandestine with MSM identifying as heterosexual and dismissive of Westernised gay culture.3 This has implications for health messaging as non-gay-identifying MSM are not targeted in either mainstream heterosexual or gay media platforms and remain invisible in health settings.

MSM are at particular risk for HIV acquisition and transmission for multi-factorial reasons.6 Biologically, unprotected receptive anal sex is about sixteen times more likely to transmit HIV than unprotected vaginal sex.7 This is due to the friable nature of the rectal mucosa which does not contain mucous-producing cells as compared to the thicker, self-lubricating lining of the vagina.

The vulnerability of MSM is further increased by structural factors such as a lack of funding for MSM-appropriate services, lack of specific skills training of health providers and institutionalised stigma within the public health sector. MSM patients generally avoid being identified as MSM, culminating in their elevated risk of HIV acquisition or transmission being overlooked and no counselling about the risks associated with unprotected anal sex.

Organisations such as the Anova Health Institute, through it’s innovative Health4Men project, and the Desmond Tutu HIV Foundation have been active in addressing these concerns in South Africa. In 2009 the Anova Health Institute, with support from PEPFAR/USAID, launched the first state sector clinic dedicated to MSM in the country. A further six sites have subsequently become operational across multiple provinces. Invaluable lessons have been learned through this process which will undoubtedly serve as a template for ongoing expansion of such services
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