Pioneering HIV Services for and with Men Having Sex with Men in MENA

"Deeply rooted HIV-related stigma and discrimination [in the MENA region], apparent in laws, policies, and programmes, and at all levels of society, pose significant barriers to HIV prevention and care, support and engagement of key populations and people living with HIV. As a result, most remain hidden."

This case study documents experiences and lessons learned from the implementation of a rights-based, community-led programme that sought to create access to quality HIV prevention, care, and support services for men who have sex with men (MSM) in the Middle East and North Africa (MENA) region. Led by the International HIV/AIDS Alliance (the Alliance) and supported by the United States Agency for International Development (USAID), the Responding to Key Populations in the MENA Region project was implemented by 8 partner civil society organisations (CSOs) in Algeria, Lebanon, Morocco, and Tunisia from 2005-2015. The case study is intended for national policy-makers and other decision-makers, civil society programme planners and managers, and funders committed to preventing HIV and improving the lives of MSM, other key populations, and people living with HIV in the MENA region.

The background section of the paper explores the rationale for Responding to Key Populations in the MENA Region, such as the fast-growing HIV epidemic there and the ways in which the HIV response has been neglected in many MENA countries. Amongst populations most at risk for HIV, MSM constitute a particularly vulnerable community in MENA, as elsewhere. A United Nations (UN) global review on discriminatory laws and violence against individuals based on their sexual orientation documented that same-sex practice is illegal in 19 countries in MENA. In the programme's 4 focus countries, decriminalisation of sex between consenting men encounters strong socio-cultural, religious, and political resistance.

When the programme was first introduced in 2005, the Alliance implemented participatory community assessments (PCAs) led by members of MSM communities and CSO partners in each country, which included 6 HIV-thematic organisations, one development organisation, and the only lesbian, gay, bisexual and transgender (LGBT) organisation with legal status in the region when the programme started. The PCA is described as a key defining feature of the programme because it ensured the meaningful engagement of MSM and their insertion into the CSO partners' activities from the programme's inception. (The French- and Arabic-language guide Let's Analyse Our Needs Ourselves is intended for persons conducting a PCA with MSM in MENA or elsewhere.) The Alliance, CSO partners, and MSM community members subsequently developed a package of combination prevention services in accordance with international best practices. The right to health was chosen as a cross-cutting approach to working with populations vulnerable to HIV.

According to the case study, the programme's achievements were evident in 4 main areas, all of which worked together to foster changes at multiple levels:

1. Creating access to MSM-appropriate and friendly HIV prevention, care, and support services through peer outreach - PCAs served as the foundation from which peer-based outreach activities were designed and tailored to diverse MSM sub-communities. Outreach took place in different sites, known for being MSM meeting points, including hotels and brothels, cafes, bars, public baths, parks, university campuses, beaches and festivals. Since meeting points often changed, mapping exercises were conducted on a regular basis to ensure that peer educators could continue reaching MSM communities. A comprehensive combination prevention package of activities was delivered, including behaviour change communications, provision of tailored information, education and communication (IEC) materials (written in Arabic and French using "easy to understand and appealing language"), distribution of free condoms and lubricant sachets, and referrals to HIV and sexually transmitted infection (STI) testing, care, and psychosocial and legal support services. The availability of HIV and STI testing and counselling services was expanded in all countries through mobile, peer-based, and referrals to public and private facilities. The programme also created safe spaces for MSM in the CSO partners' premises. "Such spaces were critically needed and missing in the region." Between August 2013 and September 2015: an estimated 47,991 MSM were reached through outreach-based interpersonal communication activities; 662,111 condoms and 237,593 lubricant sachets were distributed freely to MSM; 8,205 MSM received voluntary counselling and testing (VCT) services for HIV provided by the CSO partners at the CSO reception centres and mobile units; 3,509 MSM were tested, diagnosed or treated for STIs; and 2,106 MSM were provided with psychological support and 388 with legal support. In 2015, the partners of the MENA programme implemented a pilot online peer outreach project to reach more MSM, in partnership with the South East Asian Foundation B-Change Technology. (See text box on pages 15-16 for a description of this sub-project and results of and lessons learned from it.)
2. Mobilising and empowering MSM communities - Many MSM reported having gained confidence; for example, the self-esteem and capacity of MSM volunteers were raised through their participation in PCAs, training, and supportive supervision in tailored peer educational methods and contributions to the design of programmatic activities and communications materials. These provoked profound changes for many, whom having embraced their rights as individuals regardless of their gender or sexual preferences, have now become activists, expertsm and leaders for MSM and LGBT communities in their countries. New MSM and LGBT rights organisations in the region have since been established by former volunteers or staff of this programme. (Examples are provided in text boxes throughout the case study.)
3. Building the capacity of critical providers of services for and supporters of MSM - Transforming the CSOs' organisational culture and strengthening their capacity in HIV thematic areas and project management were part of both the approach and the objectives of the regional programme. "The Alliance put into place a systematic cycle of trainings and continuous one-on-one mentoring to strengthen CSO partners' development in specific areas: programme management, financial management, governance and policy systems, monitoring and evaluation, donor regulations, volunteer management, and thematic HIV and health prevention approaches, including PCA, behaviour change communications and stigma reduction strategies. Drawing on its founding approach for community engagement, fostering participation across CSO partners was an intrinsic part of the organisational development approach. Regional exchanges and peer CSO mentoring were facilitated to ensure mutual sharing, learning and support, and joint ownership of the programme." In 2015, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Alliance, and CSO partners jointly developed a training toolkit on MSM programming in MENA informed by global best practices and this programme's experiences - see Related Summaries below for access. As reported here, "CSO partners have emerged from this experience as credible organisations - recognised nationally and regionally - with rich expertise in tailored, community-based action for HIV prevention, care and support. Today, CSO partners sit alongside National AIDS Programmes (NAPs), UNAIDS and donors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, as valuable partners in the national HIV and AIDS response."
4. Using advocacy to promote a more enabling environment for MSM and CSO partners - In the last 2 years of the programme, 3,020 individuals (health providers, religious leaders, police officers, journalists, and other community representatives) were reached through stigma reduction activities, and 608 decisions-makers were included in advocacy and awareness-raising initiatives. These activities had 3 main objectives. The first was to improve attitudes and acceptance of MSM by reducing stigma and discrimination among some of the most important people among whom MSM live and find support: families, healthcare and social workers, lawyers, police, and religious leaders. (For example, in 2008, the Alliance conducted a training-of-trainers in stigma and discrimination reduction for CSO partners and MSM peer educators from the 4 focus countries.) The second was to generate dialogue and stimulate discussion on MSM-sensitive issues at local, national, and regional levels to influence policies and programmes and promote the inclusion of MSM as a priority in national AIDS strategies. (A significant milestone took place in 2011, when the Alliance and partners were invited to Saudi Arabia to co-facilitate with UNAIDS a regional dialogue with the League of Arab States to develop the Arab AIDS Strategy.) The third objective was to stimulate the adoption of human rights-based language by all stakeholders and at all levels of society. (As an example of the latter, the results from CSO offerings of stigma and discrimination trainings with TV and radio presenters, journalists, and programme producers were particularly noticeable in Lebanon, where HIV and LGBT activists reported a significant positive change in the language used (less offensive) and framing (less scandalous) by media when covering stories related to HIV and/or homosexuality.)

The case study concludes with a section on lessons learned, challenges, and the way forward. Here are just a few:

• "The community engagement approach works and is needed. The Alliance's approach of working with national CSO partners and engaging the communities they serve through participatory processes produced results, despite the hostile environments..."
• Information and communication technologies (ICTs) help to reach hidden communities. Given increasing numbers of police raids and rising homophobia, the ICT virtual prevention project [see above and text box, pages 15-16] offers a promising alternative to traditional outreach activities. Applications, such as Grindr, are frequently accessed by MSM in the MENA region and provide virtual venues for disseminating information on HIV prevention, treatment and support services. A current information gap can be filled by providing information in Arabic on these platforms."
• "Creative methods are needed to coordinate advocacy and anti-stigma campaigns tailored to diverse audiences."
• Working with and for MSM can be expanded to other populations vulnerable to HIV who remain in the shadows in MENA: transgender people, people living with HIV, sex workers, undocumented migrants, and refugees.
• Challenges related to the implementation of the project are related to: quality of sexual healthcare for MSM, referral data, security, rising homophobia, cultural beliefs and taboos, HIV funding in the MENA region, and stability and sustainability (of HIV programmes).
• Areas of action for the future include: scaling up and further rolling out of community-based HIV prevention and testing for gay, other MSM, and transgender communities in MENA; piloting pre-exposure prophylaxis (PrEP); using ICT to increase access to MSM-friendly HIV prevention, testing, and care services; understanding of the health needs of transgender people; and countering social norms that feed enduring stigma and discrimination. With regard to the latter, the Alliance notes that several approaches to changing mentalities and in particular the negative perception of homosexuality should be attempted and combined, including working with the media to produce media coverage of HIV and sexual minorities that is accurate and non-stigmatising. Working with the media could involve sensitising and involving journalists from newspapers, TV, radio, and social media. Furthermore, alliances and partnerships with religious leaders, health institutions, and human rights organisations need to be developed or expanded. Calls to address punitive legal and policy frameworks, including laws and policies that criminalise same-sex behaviour, may become the focus of advocacy efforts, where feasible.

"Men who have sex with men living in MENA need, more than ever, more safe spaces, more empowerment, more MSM-friendly services, increased access to treatment and a more enabling environment. It is of utmost importance to sustain and expand HIV programming for gay and bisexual men, other MSM and biologically male trans-diverse persons across the MENA region."