"What if I get sick, where shall I go?": a qualitative investigation of healthcare engagement among young gay and bisexual men in Nairobi, Kenya.

BACKGROUND: Globally, young gay, bisexual and other men who have sex with men (YMSM) experience a disproportionate burden of disease compared to young heterosexual men and older MSM. However, YMSM experience major inequities in access and use of health services. We sought to gain a detailed understanding of YMSM's healthcare engagement experiences across public, private, tertiary institution-based and MSM-friendly health facilities in Nairobi, Kenya, to inform development of interventions to improve access and use of health services by YMSM. METHODS: In September 2021, in-person qualitative in-depths interviews were conducted among 22 YMSM purposively sampled from 248 YMSM who had previously participated in a respondent-driven sampling integrated bio-behavioral survey. Interviews were done in English, transcribed verbatim and analyzed descriptively using NVivo version 12. RESULTS: Participants were 18-24 years old, all identified as cisgender male, three-quarters as gay and a quarter as bisexual. Themes that were defined from the analysis included: YMSM's experiences during healthcare seeking in various clinical settings, priority health needs, desired healthcare provider (HCP) characteristics, and the potential role of digital health interventions in improving access and use of health services. Participants relayed experiences of prejudice, stigma and discrimination when seeking services in public and institution-based health facilities, unlike in community pharmacies, private and MSM-friendly health facilities where they felt they were handled with dignity. Health needs prioritized by YMSM centered on prevention and control of HIV, sexually transmitted infections (STIs), depression and substance abuse. Participants desired HCPs who were empathetic, non-judgmental and knowledgeable about their unique health needs such as management of anorectal STIs. Participants highlighted the usefulness of digital media in offering telehealth consultations and health education on subjects such as HIV/STIs prevention. CONCLUSION: During engagement with healthcare, YMSM experience various barriers that may cause them to postpone or avoid seeking care hence resulting in poor health outcomes. There is need to equip HCPs with knowledge, skills and cultural competencies to enable them offer equitable services to YMSM. Considerations should also be made for use of digital health interventions that may help YMSM circumvent some of the aforementioned barriers to service access and use.

"We must help them despite who they are ": healthcare providers' attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya.

BACKGROUND: Compared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM's limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya. METHODS: In September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12. RESULTS: Analysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs' personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of "treating others as one would want to be treated" as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to "convert" YMSM's perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services. CONCLUSION: There is need for interventions to improve HCPs' knowledge of YMSM's health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.

Prevalence of five curable sexually transmitted infections and associated risk factors among tertiary student men who have sex with men in Nairobi, Kenya: a respondent-driven sampling survey†.

BACKGROUND: Young men who have sex with men (MSM) are a key population at high risk of sexually transmitted infections (STIs). We conducted a respondent-driven sampling (RDS) bio-behavioural survey to estimate the prevalence of five curable STIs: chlamydia, gonorrhoea, syphilis, trichomoniasis and Mycoplasma genitalium infection, and associated risk factors among tertiary student MSM (TSMSM) in Nairobi, Kenya. METHODS: Between February and March 2021, we recruited 248 TSMSM aged ≥18years who self-reported engaging in anal and/or oral sex with another man in the past year. Samples collected included urine, anorectal and oropharyngeal swabs for pooled Chlamydia trachomatis , Mycoplasma genitalium , Neisseria gonorrhoeae and Trichomonas vaginalis testing using multiplex nucleic acid amplification tests, and venous blood for serological Treponema pallidum screening and confirmation of current infection. Participants self-completed a behavioural survey on a REDCap digital platform. Data analysis was done using RDS-Analyst (v0.72) and Stata (v15). Differences in proportions were examined using the chi-squared (χ 2 ) test, and unweighted multivariate logistic regression was used to assess factors associated with STI prevalence. RESULTS: RDS-adjusted prevalence rates of at least one of the five STIs, chlamydia, gonorrhoea, Mycoplasma genitalium infection, trichomoniasis and latent syphilis were 58.8%, 51.0%, 11.3%, 6.0%, 1.5% and 0.7%, respectively. Factors independently associated with STI prevalence were inconsistent condom use (adjusted odds ratio (AOR)=1.89, 95% confidence interval (CI): 1.03-3.47, P =0.038) and the last sex partner being a regular partner (AOR=2.35, 95% CI: 1.12-4.92, P =0.023). CONCLUSION: STI prevalence among TSMSM in Nairobi, Kenya, is disturbingly high, demonstrating urgent need for tailored testing, treatment and prevention interventions for this population.

HIV prevalence and associated risk factors among young tertiary student men who have sex with men (MSM) in Nairobi, Kenya: a respondent-driven sampling survey.

BACKGROUND: Young men who have sex with men (MSM), are a key population at higher risk of HIV infection yet they are underrepresented in research. We conducted a bio-behavioral survey to estimate HIV prevalence and associated risk factors among tertiary student MSM (TSMSM) in Nairobi, Kenya. METHODS: Between February and March 2021, 248 TSMSM aged ≥ 18 years who reported sex with another man in the past year participated in a respondent-driven sampling (RDS) based cross-sectional survey. Participants completed an electronically self-administered behavioral survey and provided a blood sample for HIV antibody testing, alongside urine, anorectal and oropharyngeal swabs for pooled testing of sexually transmitted infections using a multiplex nucleic acid amplification test. RDS-Analyst v.0.72 and Stata v.15 software were used for data analysis. Differences in proportions were examined using chi-square (χ2) test, and unweighted multivariate logistic regression was used to assess factors associated with HIV infection. RESULTS: HIV prevalence among study participants was 8.3%, whereas the weighted prevalence was 3.6% (95% CI: 1.3-6.0%). Median ages of participants, and at self-reported first anal sex with a man were 21(interquartile range [IQR] 20-22) and 18 (IQR 17-19) years, respectively. A majority (89.3%) of TSMSM owned a smart phone, 46.5% had ever used a geosocial networking app for MSM such as Grindr ® to find a sex partner, and a third (33.6%) met their last sex partner online.  Almost three-quarters (71.3%) had > 1 male sex partner in the year before the survey. A third (34.3%) did not use condoms with their last sex partner, 21.2% received money from their last sex partner and 40.9% had taken alcohol/another drug during their last sexual encounter. HIV infection was associated with studying in private institutions (adjusted odds ratio[AOR] = 6.0; 95% confidence intervals [CI] : 1.2-30.0, p = 0.027), preferring a sex partner of any age-younger, same or older (AOR = 5.2; 95 CI: 1.1-25.2, p = 0.041), last sex partner being > 25 years (AOR = 6.4; 95% CI: 1.2-34.6, p = 0.030), meeting the last sex partner online (AOR = 4.2; 95% CI; 1.1-17.0, p = 0.043) and testing positive for Neisseria gonorrhea (AOR = 7.8; 95% CI: 2.0-29.9, p = 0.003). CONCLUSIONS: HIV prevalence among TSMSM in Nairobi is alarmingly high, demonstrating a need for tailored prevention and control interventions for this young key population.

"My Friends Would Believe My Word": Appropriateness and Acceptability of Respondent-Driven Sampling in Recruiting Young Tertiary Student Men Who Have Sex with Men for HIV/STI Research in Nairobi, Kenya.

(1) Background: We conducted formative research to assess the appropriateness and acceptability of respondent-driven sampling (RDS) in recruiting tertiary student men who have sex with men (TSMSM) into a prospective human immunodeficiency virus/sexually transmitted infection (HIV/STI) biobehavioral survey in Nairobi, Kenya. (2) Methods: Between September and October 2020, semi-structured qualitative interviews were held with service providers from organizations that serve MSM (n = 3), and TSMSM (n = 13). Interviews were conducted in English, audio-recorded and transcribed, then thematically analyzed using NVivo version 11. (3) Results: Service providers reflected that RDS was appropriate due to the large though concealed networks of TSMSM. TSMSM perceived RDS to be acceptable based on their large social network sizes and the trust that existed amongst themselves. TSMSM were concerned about participating due to the risk of being outed as MSM and hence emphasized that researchers needed to assure them of their confidentiality and include MSM as part of the study team to encourage participation. (4) Conclusions: RDS was perceived as both an appropriate and acceptable sampling method. Use of RDS should be considered as a strategy for recruiting young, marginalized populations for HIV/STI research.