Forty eight (48) district-level key informants were interviewed for this study from 12 districts representing different HIV prevalence zones and known hotspots for MSM and FSWs. Study findings have been grouped by theme, and for each theme, we have presented supporting quotations to illustrate the main findings.
Health providers’ experiences and/or readiness to serve FSWs and MSM
All health providers indicated that they had ever served sex workers; however, virtually no health provider reported that they had ever served MSM. Most of the health providers indicated that they were comfortable serving FSWs although a few of them expressed some level of discomfort nonetheless. We observed that the health providers’ level of comfort with sex workers was largely due to the fact that FSWs can easily open up to them about their sexual practices:
“What worked well was that they [FSWs] are free and open. They freely share information about their sexual habits and most of them are ready to protect themselves. Because I remember during the moonlight tests most turned up for tests and really requested for condoms to use. They are not ashamed to ask for them” (KII, Mbale)
Other key informants indicated that once there is rapport between the health providers and FSWs, FSWs will always be willing to “tell you everything that you desire to hear and because of that kind of interaction, they open up and when they come to the facility they feel very welcome” and this helps them to come for treatment without fear.
“For the sex workers, they are so bold and as long as they have known that they are positive they will always come for their medicines and their adherence rate is far much better than for other people for as long as they have known that they are HIV positive”(KII, Iganga)
However, a few health providers felt that FSWs do not usually open up to them about their sexual habits because they fear that the health providers will “talk about them” or see them as “people who are selling themselves … people who are spreading HIV/AIDS” (KII, Lira). In one case, a key informant in Bushenyi district indicated how she had “personally … called one of my midwives and … told her that ‘please we need to keep confidentiality of these patients [FSWs]’. She is now comfortable with the work and is no longer talking”. We also noted that some health providers tend to rebuke FSWs, especially those that come for antenatal services, and this tends to make them fail to open up, as one key informant from Mbale district intimated: “At times they [FSWs] are marginalized when they come alone for antenatal care. When you ask her about the husband, she will tell you she has no husband. Then someone would say, ‘So you are the harlots, the sex workers? … You are spreading HIV/AIDS’.”
The other reason for failing to open up is due to the fact that sex work is not legalized in Uganda and FSWs feel that if they start to talk about it; they will be arrested and prosecuted (see the Government of Uganda’s position on this issue at:
https://www.mediacentre.go.ug/press-release/arrest-prostitutes). Some health workers seem to think of FSWs as “
spoilt individuals” which creates a distance between them and their sex worker clients. For instance, in Mbale, a key informant said of FSWs: “
To me I believe that even at this health facility some of the staffs may not feel comfortable providing services to FSWs because some of them think that these are spoilt individuals so they may not attend to them … that is why there is a need to have that training that educates them that these people are like other people in the community.”
Since many health providers indicated that they had never served any MSM in their professional life and, therefore, did not have any experience to share, we asked them to imagine what would happen if they were to serve MSM in real life. In response, nearly three-quarters of the health providers indicated that they would be comfortable serving MSM like any other patients. For instance, in Iganga, a key informant indicated that for them, service provision is not dependent on sexual orientation; so, if an MSM were to show up at a facility for HIV services, they would provide him with services in much the same way as they would do for any other patients, reiterating, “the basis of how we offer … HIV services is not because of what you do, we even don’t ask you how you acquired HIV, but for as long as you have HIV, then you deserve to be treated …” (KII, Iganga). This quotation raises two important aspects: first, it reflects on the readiness of health providers to provide non-discriminatory services to all patients regardless of their sexual orientation; but it also implies that health providers might have served MSM (as part of the general clientele that they served) without knowing it. If the latter observation was true, it would imply that the health providers’ submission that they have never served MSM would not be completely true given that MSM may not reveal their sexual identities to them for fear of stigmatization or being denied services. However, as discussed elsewhere in this paper, our study was not able to tease out if these observations were true.
A majority of health providers indicated that, in their capacity as health professionals, they did not have any reservations in serving MSM if they went to tem to obtain HIV services. In Soroti district, a health provider had this to say: “… we respect diversity, we shall not castigate such people, and if they had a need we would embrace such people and help them just like any other person” (KII, Soroti). This informant indicated that while his organization does not have any specialized clinics for MSM, they are willing and ready to serve MSM, as any other patients, and maintain the expected level of confidentiality:
“ … if, for example, you come up with a complication which is directly attributable to homosexuality … for instance, someone comes and the complication needs a surgical intervention, we refer that person to those people whom we know can best help them. We try to maintain confidentiality which that client deserves because everybody has that right to confidentiality and autonomy to choose the type of service to be provided. I wouldn’t want to say that we have something that is specific or specialized for the MSM but we will address them with equal dignity that they deserve as human beings”(KII, Soroti)
Another participant from Mbarara indicated that for him as a health provider, he is obliged to serve all people regardless of the way they present, their sexual practices or sexual orientation, for that matter: “… I am a neutral person, I don’t have feelings for any kind of people regardless of who they are [wheelbarrow pusher, female sex worker or MSM] … if I know that this is the way you want me to help you, I will definitely give you the service.” Collectively, from a professional point of view, health providers reflected on their duty to provide HIV services to MSM without discrimination.
However, when pressed further about their level of comfort as individuals in dealing with MSM, some of the health providers expressed reservations, with some of them stating that they would rather discourage men from continuing with having sex with fellow men: “Honestly, I am a conservative person. I wouldn’t encourage men to have sex with men, so if I had a chance, I would just encourage them to leave the act. I don’t think I need to design strategies for them to continue with their act. But if they are encouraged to seek HIV, syphilis, Hepatitis testing and seeking help from a psychologist or counselor, these will be good strategies for them” (KII, Mbarara). These perceptions show that while health providers feel the obligation to serve MSM as any other patients; in their capacity as individuals, some of them would ideally not be comfortable serving MSM.
In line with the above-mentioned observation, a key informant in Bushenyi indicated that she “would be quite uncomfortable [providing HIV services to MSM] … I don’t see why a man should go with a man when there are women!! Women are there and besides, this is a culture imported into our country … It would be a bit uncomfortable for me to tell a man not to sleep with his fellow man when he is already used to it, I see these things on TV, the homosexuals in Kampala, but not this end”. This participant reported that she would not feel comfortable serving MSM, because “… it [men having sex with men] is not our habit and culture here”. Another informant in Gulu indicated that he would be equally uncomfortable providing HIV services to MSM because “… when I see my fellow man doing that kind of thing [having sex with another man] – I feel very low indeed and, I for one, wouldn’t encourage a man to do that kind of thing”. These sentiments suggest that some health providers will not feel comfortable serving MSM; confirming the high homophobic tendencies towards MSM that continue to hamper access to HIV and other health services in many health facilities in Uganda.
Skills needed by health providers in order to effectively serve MSM and FSWs
Evidence from Kenya suggests that if health providers are trained in how to handle MSM, this can improve their knowledge about MSM needs and reduce their homophobic tendencies towards them [
27,
28]. In following up on these observations, we asked health providers if they had ever received any form of training on how to handle MSM or FSWs; and if not, whether they would be willing to receive such training. In response, most health providers indicated that they did not have any specific skills on how to handle MSM or FSWs in clinical settings, and tended to handle them like any other clients. Some health providers called for a need to be trained in how to communicate with MSM, reasoning that this could help them to serve MSM better: “
I think we are missing a lot because … there could be some kind of communication that can be used to communicate with these people that we could be missing. Thus, I don’t think we have the knowledge to help us identify these populations [or create an environment that makes them feel free to come to us] or know what to do when they come to us” (KII, Gulu).
When asked about whether or not health providers would welcome to be trained in how to handle MSM, an informant from Iganga said such training would be acceptable and would help to “change attitudes of some of our health workers”. The ‘change in attitude’ referred to in the quotation would manifest in health providers’ willingness and openness to serve MSM in a non-discriminatory manner. In Mbarara, another informant suggested a need for revising the curriculum for medical and nursing students to include an emphasis on how to “handle special groups” such as FSWs and MSM:
“ … some of the things I think that need to be improved in the curriculum is HIV medicine. Although HIV medicine is there, what is still missing is how to handle special groups, I am not so sure if it exists in the curriculum. Because for me I get involved in teaching undergraduates but the HIV topics I teach are the basic ones; how to serve anybody who has come for HIV services. So I think as we teach HIV medicine, consideration should also be given on how to serve these most-at-risk populations guided by research and evidence on what they need and the best way we can approach them”(KII, Mbarara)
A few participants called for a need to be trained on gender identification among MSM, reasoning that this is because MSM adopt “
a different gender role depending on the day and circumstances”:
“I think that the medical practitioners should be taught issues relating to gender identification amongst MSM; because some people feel that they are of a different gender depending on the day and circumstances”(Key informant, Kampala)
The call for ‘gender identification’ could be because of a false perception among some health providers that service delivery to MSM would have to be differentiated depending on the role played by men in the relationship or on their sexual identities, which is not true. There is no need for MSM to reveal their sexual identities prior to being served; nor are they expected to indicate what role they play in the relationship. The presence of these sentiments reaffirms the need for health providers to receive gender sensitivity training that should help to address any existing stereotypes around MSM and therefore be able to serve MSM in a non-discriminatory and non-stigmatizing manner.
However, while most of the participants indicated that they would welcome any opportunity to be trained in how to handle FSWs and/or MSM, some of them did not feel the need to be trained in how to handle MSMs: “I feel I am missing that training of handling FSWs who are many in our country. With homosexuals [MSM], I don’t think I would be willing to go for that training” (KII, Bushenyi). This lack of interest in receiving training on how to handle MSM was strongly entrenched in the health providers’ cultural beliefs: “I wouldn’t like [to imagine a] scenario where men are sleeping with men, women are sleeping with women … and some of them taking these drugs like marijuana, you really feel they could maybe benefit from the psychiatric nurses and doctors” (KII, Kampala). Thus, while some participants did not have any objection to being trained in how to handle FSWs, some of them had strong homophobic tendencies towards being trained to serve MSM. Indeed, based on the quotation above, one can infer that these participants equated homosexuality to a mental problem that required the intervention of ‘psychiatric nurses and doctors’.
Effect of existing criminal laws on the provision of HIV services to MSM and FSWs
As noted earlier, this study was implemented before the enactment of the Anti-Homosexuality Act 2014 and the HIV and AIDS Prevention and Control Act 2014. We asked health providers whether or not they thought such Bills, if passed into law, would affect the way MSM and FSWs access HIV and other health services. In response, some health providers thought that if such Bills were passed into law, they would definitely affect the way MSM and FSWs access services: “Yes. It will affect [them] in some way because they [MSM or FSWs] have to keep it a secret for fear that if they open to you, you may take them to the law makers. So they will keep there and keep spreading the virus and other STIs” (KII, Kampala). However, some other health providers did not think that the existence of these Bills – or even if they were passed into law – would affect uptake of HIV or other health services by MSM or FSWs, insisting that the health services are “open to anybody”, and that access to and utilization of health services does not require one to disclose their sexual practices or orientation:
The law may hinder but I don’t think it’s the biggest factor. If you love yourself you go for the services, you don’t have to tell your neighbor that you’re a sex worker or MSM. The only implication the law has is that it keeps them in hiding but if you love yourself then you seek the service. I think services are open to anybody … these populations just need to be talked to and be informed where they can find these services and also be helped out of their stigma, otherwise there’s no discrimination between the populations we serve(KII, Mbarara)
Indeed, when asked if the existence of any FSW- or MSM-specific legislation would affect the way they (health providers) provide health services to MSM or FSWs, majority of the health providers did not think that such legislation would affect them in any way. A key informant in Busia had this to say: “We as service providers … it [the law] will not affect us because we have to treat all people who are sick. But I think that it has scared off the MSM from disclosing when they need services”. Although health providers did not seem to agree on the effect of the existence of the two Bills on access to and uptake of HIV services by MSM and FSWs, there was agreement that the Bills, in their state at the time – or when passed into law – would affect MSM more than FSWs since society “does not blame FSWs [as much as it does] with MSM”. The societal ‘blame’ points to the cultural beliefs around anal sex and other forms of sexual behaviors practiced by MSM. Thus, while being a FSW is frowned upon in society (e.g. women who engage in sex work may be considered to be ‘spoilt’), there is less of stigma around sex work than it is with engaging in anal sex in the Ugandan society. There is a feeling that anal sex and other MSM sexual practices are ‘foreign’ and therefore not part of the Ugandan culture.