Mitchell, a gay man, found out he was HIV-positive two years ago. Thoughts of making frequent visits to hospital frightened him, he says.
The last time he had been to hospital, a doctor had called a group of his colleagues and they examined him without touching him. Mitchell had anal warts. Some of the doctors made rude remarks.
“I felt really humiliated. I vowed never to step my foot in a hospital again,” says Mitchell, who did not want his second name published for fear of stigma.
It was not until a year later when he discovered a gay-friendly clinic in Nairobi that Mitchell started HIV treatment.
HIV prevalence is high among men who have sex with men (MSMs) in Kenya. The prevalence rate was at 18.2 per cent in 2015, almost three times that in the general population.
Stigma and discrimination, however, force most HIV-positive gay men not to seek health services. Many of them do not adhere to ARV treatment because they are afraid of going to hospital.
Despite criminalisation of same sex acts, the Health ministry partners with community-based organisations to set up gay-friendly clinics where MSMs can get health services without fear of discrimination and judgement.
The ministry also trains peer educators to follow up and ensure patients adhere to HIV treatment. The exact number of MSMs is unknown. National Aids Control Council estimates show that there were 22,000 MSMs in Kenya by 2015.
Peter Njane, the director of Ishtar-MSM (an organisation that provides free health services for MSMs) says an informal survey in Nairobi showed that more than 10,000 men practise same-gender sex. People classified as MSMs include gay men, bisexual men and heterosexual men who have sex with fellow men for whatever reason.
INFECTION RATE CAUSES
A number of factors contribute to high rates of HIV infection among MSMS. Lack of information about safe sex is the biggest of all, Njane says. Since homosexuality is illegal in Kenya, same sex relationships happen in secrecy, and so even accessing information that could help someone protect himself is difficult, he says.
“You have a situation where small kids are coming here and saying they never knew that having sex with another man would put them at risk of contracting HIV. They think it is a safer way of having sex because the information out there is that HIV infection occurs between men and women,” Njane says.
Talking about a health problem related to one’s sexual orientation is even harder, and so most MSMs don’t know where to get help.
“How do you for example tell a doctor that you have anal gonorrhoea,” Njane says. “In Kenya, we don’t talk about sex, so it is even harder to talk about sex between people of the same gender.”
Njane says it is difficult to pass information about HIV among MSM without being accused of promoting homosexuality, so the organisation uses the snowballing method to reach this population.
Mary Mugambi, the acting programme manager for key populations at Nascop, says it is difficult to pass information on safe sex to MSMs when they are still in the closet.
“The fact that you don’t come out clearly about your sexual orientation makes it difficult for you to get the right information,” Mugambi says. “Unless they accept themselves and come out, they might not get the right information.”
HIV transmission during anal intercourse is 18 times greater than during vaginal intercourse and this explains why there’s high HIV prevalence among MSMs. There’s no lubrication during anal sex, unlike in vaginal intercourse and so there occurs a lot of bruises which could increase chances of infection, Mugambi explains.
“That’s why we advocate for 100 per cent condom use among MSMs,” Mugambi says. “Condoms also have to be used with lubricants because without lubricants, we may have condom bursts due to that dryness.”
Condom use among MSMs is not very common but it is improving, Mugambi says. In 2013, an estimated 69 per cent of MSMs reported using a condom the last time they had anal sex, up from 55 per cent in 2011, according to Avert, an HIV news website.
Abuse of drugs and alcohol is common in this community, and this puts them at double risk of HIV infection. HIV prevalence among people who inject with drugs was at 18.3 per cent in 2011, according to 2014 data from the National Aids Control Council. Many MSMs engage in alcohol and substance abuse in efforts to deal with stigma and discrimination.
“The fact that you are not accepted in the community, you look different and you feel different, brings a lot of stress within you,” Mugambi says. “So you need to be high to operate. Drugs give you relief from pain. Some of them use alcohol to try and block those issues.”
Mugambi says Nascop offers psychosocial support, screen and refer those who have an alcohol abuse problem, but the department does not have the optimum capacity to deal with the problem.
The fact that some MSMs are sex workers and the small size of the potential pool of sex partners also increases chances of infection. Infections spread quickly within the group.
“Sometimes you find that almost everyone is having warts. In other times, it is a different infection,” said an administrator of an MSM clinic who sought anonymity.
The penal code criminalises homosexual acts and spells out a jail term of up to 14 years as punishment. The Health ministry, however, advocates the health rights of everyone regardless of their sexual orientation.
“Health and legal issues are separate,” Mugambi, the Nascop official says. “They [MSMs] come to the facilities and when you examine them, you find that they are having anal sex and all that. Some of them have STIs and others have HIV, so we work with them from that level.”
Mugambi says Nascop does not encourage people to engage in anal sex but encourages those who are already practising it to come out so they can get the right information and prevent infections.
“It is illegal to have same sex relations but if we arrest them, it is not like we are helping them. They will go under and have unprotected sex and also infect people who are in the general population,” Mugambi says.
The Health ministry runs an elaborate HIV prevention programme for MSMs in partnership with groups such as Ishtar-MSMs and HOYMAS, an organisation for male sex workers.
It also facilitates the establishment of gay-friendly clinics, where MSMs can easily get health services. Such clinics are situated in major towns in the country and along the transport corridor from Mombasa to Busia and Malaba border points.
Ishtar runs one such clinic in Nairobi. It attends to at least 10 people every day. The Health ministry offers technical support and provides condoms and lubricants, which are distributed to members. Njane says plans are under way to expand the clinic so it can provide all the necessary services, including provision of ARVs.
Daniel, who first came to Ishtar as a client at the clinic says he was relieved to find health workers who understood him.
“They are able to understand you better because you are not the first client of your kind that they are seeing,” he says. “It is not like other hospitals where people start pointing fingers at you the moment you leave the doctor’s room.”
Daniel says most men in his cohort fear going to general hospitals, and especially being attended to by female doctors.
“Some of the doctors will tell you that you have the condition because you are immoral. Others ask you why you cannot be like other men,” he says.