Qualitative Study: Counselling MSM in Highly Stigmatized Contexts

This report presents the findings of a qualitative study conducted in Kenya, exploring the challenges faced by counselors and clinicians in providing HIV prevention counseling to men who have sex with men (MSM). The study, based on in-depth interviews, reveals that service providers, despite their experience, require more targeted training to effectively address MSM-specific risk reduction. Key challenges identified include a lack of familiarity with the root causes of MSM risk-taking, such as poverty, sex work, and substance abuse, coupled with frustration over clients' complex issues. The research highlights the need for improved training on questioning techniques, risk reduction strategies, and support supervision. The report underscores the impact of societal stigma on counseling practices and makes practical recommendations for enhancing training and support systems within nascent MSM HIV prevention programs across Africa. The study emphasizes the importance of addressing cognitive and social constructs in developing effective counseling approaches and highlights the need for non-judgmental, informative, and beneficial services to improve access and outcomes for MSM.

Challenges in Providing Counselling to MSM in Highly
Stigmatized Contexts:Results of a Qualitative Study
from Kenya
Miriam Taegtmeyer1,2*, Alun Davies2, Mary Mwangome2, Elisabeth M. van der Elst2, Susan M. Graham2,3,
Matt A. Price4,5, Eduard J. Sanders2,6
1 Department of International Public Health,Liverpool School of Tropical Medicine,Liverpool,United Kingdom,2 Centre for Geographic Medicine Research-Coast,Kenya
Medical Research Institute, Kilifi, Kenya, 3 Department of Global Health, University of Washington, Seattle, Washington, United States of America, 4 Departmen
Affairs,InternationalAIDS Vaccine Initiative,New York,New York,United States of America,5 Department of Epidemiology and Biostatistics,University of California San
Francisco,San Francisco,California,United States of America,6 Nuffield Department of ClinicalMedicine,University of Oxford,Headington,Oxford,United Kingdom
Abstract
The role of men who have sex with men (MSM) in the African HIV epidemic is gaining recognition yet capacity to addres
the HIV prevention needs of this group is limited. HIV testing and counselling is not only a critical entry point for biome
HIV prevention interventions, such as pre-exposure prophylaxis, rectal microbicides and early treatment initiation, but
an opportunity forfocused risk reduction counselling that can support individuals living in difficult circumstances.For
prevention efforts to succeed,however,MSM need to access services and they will only do so if these are non-judgmental,
informative,focused on theirneeds,and of clearbenefit.This study aimed to understand Kenyan providers’attitudes
towards and experiences with counselling MSM in a research clinic targeting this group for HIV prevention.We used in-
depth interviews to explore values, attitudes and cognitive and social constructs of 13 counsellors and 3 clinicians prov
services to MSM at this clinic.Service providers felt that despite their growing experience,more targeted training would
have been helpful to improve their effectiveness in MSM-specific risk reduction counselling. They wanted greater famili
with MSM in Kenya to better understand the root causes ofMSM risk-taking (e.g.,poverty,sex work,substance abuse,
misconceptions about transmission,stigma,and sexual desire) and felt frustrated at the perceived intractability of some of
their clients’issues.In addition,they identified training needs on how to question men about specific risk behaviours,
improved strategies for negotiating risk reduction with counselling clients,and improved support supervision from senior
counsellors.This paperdescribes the themes arising from these interviews and makes practicalrecommendations on
training and support supervision systems for nascent MSM HIV prevention programmes in Africa.
Citation: Taegtmeyer M,Davies A,Mwangome M,van der Elst EM,Graham SM,et al.(2013) Challenges in Providing Counselling to MSM in Highly Stigmatized
Contexts:Results of a Qualitative Study from Kenya.PLoS ONE 8(6):e64527.doi:10.1371/journal.pone.0064527
Editor: Virginia J.Vitzthum,Indiana University,United States of America
Received January 10,2013;Accepted April16,2013;Published June 7,2013
Copyright: ß 2013 Taegtmeyer et al.This is an open-access article distributed under the terms of the Creative Commons Attribution License,which permits
unrestricted use,distribution,and reproduction in any medium,provided the originalauthor and source are credited.
Funding: Financialsupport for this study was provided by the InternationalAIDS Vaccine Initiative,New York,United States of America,and included support
from the United States Agency for International Development (USAID). The contents are the responsibility of the study authors and do not necessarily reflect
views of USAID or the United States Government.Support is also provided by the University of Washington’s Center for AIDS Research (grant AI-27757) and the
NationalInstitutes of Health (grant HD-055864).The funders had no role in study design,data collection and analysis,decision to publish,or preparation of the
manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail:[e-mail]
Introduction
Sex between men in sub-Saharan Africa hasonly recently
gained recognition as a potentialtarget for HIV prevention [1,2],
was the subjectof a recentLancetsupplement[3] and is
increasingly discussed atinternationalconferences.Counsellors
workingin this region facechallengesdue to socialstigma
surrounding men who have sex with men’s (MSM) behaviour and
the fact that homosexual acts remain illegal in 36 African countries
[1,4,5].Research undertaken in Kenya and elsewhere indicates
that MSM have a higherHIV prevalencethan thegeneral
population in Africa [1,6], have high rates of bisexual concurrency
[7], may be activein transactionalsex,and are particularly
vulnerable to HIV acquisition [7–11].Providing counsellors with
skills to effectively provide HIV risk reduction messages tailored
for MSM is an important public health target.
Current counselling, training and service provision through the
voluntary counselling and testing (VCT)modelin Kenya [12]
have focused almost exclusively on heterosexual HIV transmission
Anal sex is rarely discussed even among heterosexual couples, an
little time is given to discussion of sexual orientation or of persona
values relating to homosexuality [13]. Societalattitudes regarding
homosexuality and sex work sometimes conflict with counsellors’
professionalrequirementto provide non-judgementalrisk reduc-
tion counselling.This tension may provide significantstressto
VCT counsellors or clinicians serving MSM. Training of Kenyan
counsellors stresses the importance ofsupportive supervision and
its role in burnout prevention, in refresher training and in tackling
occasions where counsellors have felt their values were challenge
[13]. There is no specific training in recognition of mentalhealth
issues.
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Using the theoreticalframe work ofconstructivism [14],we
investigated attitudestowardsMSM among counsellorson the
Kenyan coast in one of the first MSM cohorts established in Africa
[8,9].Constructivism is derived from the conceptthatreality is
generated by the individualand personalexperience cannotbe
separatedfrom knowledge,attitudesand behaviour[15,16].
Constructivism can be divided into cognitive and sociallevels.
Cognitive constructivism maintains that individuals develop their
own models of reality using a combination of personal experience
and research-baseddata. Social constructivism arguesthat
individualsare membersof a community and thatthisshapes
their modelsof reality [14].Sexuality hasbeen described asa
socialconstruct,with the meanings attached to it reflecting social
and culturalvalues.A socialconstructionistapproach hasbeen
applied to understanding perceptionsof STIs, sexualbehaviour
and sexuality [17–20].We used thistheoreticalframework to
explore counsellors’attitudesand perceptionsof working with
MSM in Kenya and any potentialimpactthese mighthave on
their ability to perform risk reduction counselling for this group.
Methods
Ethics statement
All study participants provided written informed consent.This
studyreceivedapprovalfrom the Kenya MedicalResearch
Institute’s NationalEthicalReview Board.
Participants and setting
The research was conducted in June and July 2008 in a research
clinic enrollingboth HIV-seronegativeand HIV-seropositive
adults as cohort‘volunteers’near Mombasa,Kenya.Individuals
at high risk of HIV based on a history of transactional and/or anal
sex are enrolled into the cohort[8,9,21].The majority ofstudy
cohortvolunteersare MSM and allare offered counselling at
monthly or three-monthly follow-up visits,no cohortvolunteers
were interviewed for this study but data on their behaviours and
attitudesare reported elsewhere [9,22,23].All counsellorsand
clinicians involved in conducting HIV-1 counselling and testing,
risk assessment, screening for or treatment of sexually transmitted
infections were interviewed. All of the counsellors had undertaken
either the certificate in VCT or the additionalhigher diploma in
counselling offered in Kenya.None had any training in mental
health.In this paper counsellors and clinicians are referred to as
‘participants’and cohortenrolees are referred to as ‘volunteers’.
The term ‘‘participant’’wasselected only to distinguish from
cohort volunteers, as all study participation was strictly voluntary.
Data collection
A qualitative approach was chosen,using semi-structured,in-
depth interviews in order to the elicit depth and provide detailed
responses on a range of concepts [24,25]. They were conducted in
English by the first author, who was not affiliated with the site and
staff. Interviewswere audio-tapedand transcribedwithin
24 hours.Participants were assured of confidentiality and written
informed consentobtained.In keeping with similar studies [26],
interviews were structured in such a way that information relating
to homophobiawas not explicitlysolicitedbut open-ended
questions were used to assess personalstrengths,weaknesses,and
challenges related to working with MSM.Topic guides included
questions on length ofexperience,how they feltaboutworking
with MSM, challenges and motivators for working with MSM and
how these might have changed over time and whether and how
working with a group reporting illegal activity (i.e., male-male sex)
has impacted their work or personallife. Specific questions about
risk behaviours,behaviour change and risk reduction counselling
were also asked.Participant responses were double-checked with
the participantduring the interview and compared with hand-
written notes [27]. Findings from the interviews were incorporated
into scenariosand used in a 3-day skills-building training for
counsellors.
Data analysis
Data analysiswas an iterativeprocess[28], allowingfor
inclusion ofthemes emerging from the first few interviews in the
subsequentinterviewsand in the 3-daytraining.Saturation
[29]was reached early in the counsellor interviews with consistent
themesemerging,but interviewscontinued to ensure thatall
participants who worked on the project had a chance to have thei
voicesincluded.It would have been desirable to continue to
interview clinicians untilsaturation ofdata is achieved.However
in this study setting, the interviews were limited to the number of
clinicians working at the clinic. Despite this, on reflection, clinical
stafffelt that their issues had been adequately covered and there
was significant overlap with themes emerging from the counsellor
participants.A ‘framework’approach was used for analysis [30],
and systematically applied to sort the data. Emerging themes wer
sorted and coded by hand by the first author,and a selection of
transcripts were re-read and coded for quality assurance purpose
by an independentexperienced socialscientist.Analyzed data
were reviewed independently by two additionalsocialscientists
and a counsellor participantto ensure thatinterpretationswere
appropriate.After analysisand training,feedbackon study
findingswaspresented to allstaffinvolved in the research for
comment in an open discussion. These discussions and reflections
contributed to the validation of the data.
Results
Three clinician participants who were providing treatment for
sexually transmitted infections and generalmedicalcare and 13
counsellorparticipantswho were providingrisk reduction
counselling were interviewed forthisstudy.In total 7 women
and 9 men were interviewed.Four participantsself-reported as
being from the MSM community in Mombasa.All 16 had first-
hand experience of working with high-risk MSM for at least two
years and had a combined experience ofover 2,400 interactions
with over 480 MSM, as well as experience with female sex worker
and otherpopulationsat risk forHIV acquisition.Participants
represented a variety ofreligious backgrounds including Muslim,
Christian and agnostic. Counsellor participants were trained in the
VCT model of counselling and were conversantwith standard
protocols.Five had a higherdiploma in counselling,8 had a
certificate in counselling, and 3 were clinically qualified. Clinician
participants had not received specific counselling training outside
of their medicaltraining.
What participants knew and learned about working with
MSM (the cognitive construct)
Counsellors’knowledgeand experienceof issuesrelated to
counsellingMSM varied between theserviceproviderswho
identified themselves as MSM and those who did not. Little in the
standard Kenyan VCT training prepared them for the kind of
counselling needsthey faced and the specific challengesof risk
reduction counselling in this setting. On-the-job training and peer-
to-peer supportwas often importantin learning how to provide
appropriate counselling.
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Knowledge and perceptions of sexualroles amongst
MSM
Participantsexpressed an awarenessof the variety ofroles
played by cohort MSM.They describe ‘insertors’(also known as
‘basha’,‘top’ or ‘king’)and ‘receptors’(‘shoga’,‘bottom’or
‘queen’).Six (6/16)of the participants reported thatmost MSM
were taking on both rolesat differenttimesand with different
partners.
Twelve participants noted that among the community at large
there seemed to be a perception that to be an insertor was more
socially acceptable than a receptor:
For someone to feel comfortable that they are accepted in society they just
say thatI am an insertor.(non-MSM participant).
It wassuggested thatthisrole may influence the counselling
provided because some counsellors perceived that insertors would
be able to ‘give up’MSM activity or even be ‘cured’:
It seems like insertors are held at a higher – what do I call it – you are
respected if you are an insertor.It seems like counsellors probably view
insertors as people who can change. ‘He is an insertor. He can change’.
If he is a receptor ‘he can’tchange.He is already used to this habit’.
(MSM participant).
Reported volunteer risk behaviours and triggers for high-
risk behaviour
Participantsreported stresswhen faced with reportsof risk
takingfrom the volunteersand said theyfaced difficultyin
providingeffectiverisk-reduction counselling.One participant
describes the difficulties of counselling and challenges faced by the
MSM cohort volunteers:
As a counsellor I am like:whatI am supposed to be saying? I mean
how do I help in such? (non-MSM participant).
All participants reported thatMSM volunteers used condoms
infrequently and they found this hard to accept as counsellors; two
reported thatclients had flatoutrefused condoms,the other 14
talked ofthem ‘trying butnotliking’condoms or ofonly using
them sometimes.They described how some impoverished cohort
volunteers have unprotected sex regardless of HIV status and how
as counsellors they had mixed feelings, describing empathy felt by
some participants towards the poor predicament ofvolunteer,in
some waysqualifying risk behaviourand low condom use as
understandablefor male sex workersunder pressure.This
counsellor paraphrased the words of a male sex worker:
When I have slepthungry and don’tknow where and when my next
meal will come from and here I have somebody who would want to have
anal sex with me without a condom…. I give in because I am looking
forward to that meal. (MSM counsellor paraphrasing a comment from
a male sex worker volunteer).
Alcoholand drugs were described by allparticipants as being
associated with high-risk volunteer behaviour and that when they
encountered itthey felt unableto work effectivelywith the
volunteers. One counsellor describes alcohol abuse as a trigger for
unsafe behaviour:
We have discovered they mostly have sex when they are drunk
they don’treason.That’s why mostof them seroconverted.(non-MSM
participant).
Participantsidentified common mythsamong volunteersthat
may affect reduced condom use, including that anal sex is less ris
than vaginal sex and that sex with women has a higher risk of HIV
transmission since more women than men in Kenya are HIV
infected.They voiced thatgiving information and debunking
myths was a usefulthing that they could do as counsellors.
Nine (9/16)participantsstated thatthey felthopelesswhen
faced with volunteerswho said thatthey preferred sex without
condoms. They felt that they lacked skills to explore the reasons f
this in the contextof MSM relationships,and to follow through
with appropriate solutions to help reduce risk taking behaviour.
Participants described feeling stressed by attitudes to condoms
among the cohort volunteers and feeling that there was little they
could do to impactlow levelsof condom use.Five (5/16)
participantssaid thatvolunteersreported unprotected sex for
pleasure.The remainderfeltsexualrisk-taking wasan issue of
‘promiscuity’(‘beingfaithfulforthem,it cannotwork’)ratherthan
rooted in love or desire. Themes of attraction,desire and trust as
this relates to condom use were mentioned by three outof four
MSM participants and by one non-MSM participant. Participants
described MSM as generally unlikely to use condoms (‘they do not
like them’or ‘they getmore money without’).The participants reported
that as volunteer trust in their respective sexual partners increase
condom use tended to fall.
You have been using condom but now you are good friends so y
on without.(MSM participant).
Exploration of relationships,and self-esteem during
counselling session
All participants reported thatthey rarely had time to explore
wider life issues with volunteers.Participants found this challeng-
ing asthe need to delve deeper frequently arose in counselling
sessions.Seven participantsmentioned thatvolunteersreported
rejection by their families, feelings of isolation and having low self
esteem.In addition,stressfulvolunteer life events related to the
inabilityto meetbasicneedswere raised.This participant,
paraphrasing the words of a volunteer summed up the limitations
of addressing risky behaviour without addressing the larger conte
of a volunteer’s life:
I imagine sometimes if I want to go to someone for counselling
justaddressed my recentsexualexploits they would notbe helping me.
(MSM participant).
Participants said that low self-esteem amongst volunteers could
be a factordriving risk-taking behaviour,and thatstigma and
shame were factors that may affect MSM self-esteem to a greater
degree than in non-MSM populations. As this participant pointed
out,psychologicaldistress can lead to risk-taking behaviour:
Could these be the issues that are putting them at risk? You do
anywhere. You are living a double life.… When you realize you have
nothing to lose or gain you end up putting yourself at a lot of ris
you think ‘I deserve to die’ you become someone who can take
Drink [and] drive,do a lotofcrazy things.(MSM participant).
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Counsellorsfelt that longercounselling sessionswould give
opportunities for deeper exploration of underlying causes, such as
life circumstances and self-esteem,in order to address risk-taking
behaviour during counselling sessions.
Perceptions of the VCT model in relation to providing risk
reduction counselling for MSM
Despite seeing volunteersquarterly and gaining an increased
awarenessof volunteerlife issuesand risk behaviour,all
participants felt that the risk reduction counselling they provided
was notadequate.Mostparticipants feltthatVCT training had
equipped them well for a heterosexual HIV testing and counselling
session,they often felt ill-prepared to tackle MSM-specific issues.
We didn’tgoto specificsthoughwediscussedaboutstigmaand
accepting all clients and treating them right. That was very inadequate
for the kind ofwork I am doing.(non-MSM participant).
The other problem working with this group is stigmatisation and [their]
feeling ofbeing judged.... The minute they sense a ‘stop [the MSM
behaviour]’ message they will go. That is not our mandate. (non-MSM
participant).
Experienced counsellors acknowledged that sessions were more
focused on probing fordetailsof risk exposure and on telling
people to use condoms than on exploring risk reduction options
from the volunteers’perspectives.Most felt thatcoupled with
providing longer counselling sessions,counselling training should
focusmore on counselling skills(such as reflecting,challenging,
focusing, summarising and addressing loss and grief, rejection and
low self-esteem.)as opposedto information giving(such as
‘‘condoms reduce transmission risk’’;‘‘lubricantreduces the risk
of condoms splitting during analsex’’etc.).
Sometimes they come and their risk is not their issue on that day. I feel
thatallI know is HIV and HIV related risk issues and thatis all.I
wish I had more knowledge and counselling skills in other areas. (non-
MSM participant).
Participantsexpressed frustration with their perceived lack of
skillin risk reduction counselling and felt this most acutely when
seroconversions happened, implying that they felt counselling had
‘failed to protect’the volunteers.
The influence of community values on counselling MSM
(the socialconstruct)
Socialstigma and negative societalperceptions ofhomosexu-
ality in Kenya often challenged participants’ability to deliver
effective,non-judgementalrisk reduction counsellingsessions.
While allparticipants understood the importance of not imposing
one’sown valuesduring counselling sessions,the perception of
homosexualityas deviantor somethingto be ‘‘fixed’’was
common.
The impact of religious values
While all but one participanthad a nominalreligion nine
participants described themselves as having strong religious values,
both Christian and Muslim. Five participants described themselves
as born again Christians.In line with their initialtraining,these
nine participants feltthatthey had been successfulin divorcing
themselves from their religious values about homosexuality for the
duration of the counselling sessions.
Especially on my side I get satisfaction from the fact that I can d
my religious orientation and be able to see this person as a per
values must be respected. A person whose choices must be res
MSM participant).
However,thisdid notalwayscarry over to interactionswith
their colleagues. All of the MSM participants described the stigma
they faced from fellow counsellors:
Stigma was there.A counsellor who was born again would tellus to
stop it(MSM participant).
Some counsellors here they know I am an MSM. They sit me do
tell me to stop [being gay]. I usually ask myself: if they tell me t
do they tellthe clients? (MSM participant).
Homosexuality perceived as a psychologicalproblem
Participants described MSM,including their MSM counsellor
colleagues,as ‘incongruent’.A feature ofthe higher diploma in
counsellingin Kenya is a session on ‘congruency’which is
explainedas having taken a journeythroughone’s own
psychologicalproblems.In brief,a congruentperson hasdealt
with their issuesand an incongruentpersonhas not. An
incongruentperson may therefore be more likely to engage in
risky behaviour than a congruent person. Three participants with
the higher diploma in counselling and two without (none of whom
were themselves MSM)mentioned thatthey did notfeelMSM
should become counsellors for other MSM as they were perceived
as ‘incongruent’:
How can an incongruentperson help another incongruent? …. mostof
them they need to behelped to reach a levelofaccepting themselves.
Beforethey havereached therethey arealready helping someoneelse.
(non-MSM participant).
I feelthatit is quite a challenge for a gay man to be a counsellor t
anothergaymanbecausetheystill practicegay.(non-MSM
participant).
This highlightsa perception among atleastfive participants
who perceived that homosexuality was a psychological ‘‘problem’
and thatfor MSM to achieve ‘‘congruency’’,he mustforgo sex
with other men.As this MSM participant said:
So they (non-MSM-identifying counsellors) think probably being
a disease. You cannot cure someone else when you already hav
disease.(MSM participant).
Not allparticipants felt MSM would make poor counsellors for
other MSM,however.The MSM participantsand two hetero-
sexualparticipants,disagreed and feltthat MSM made good
counsellors for MSM.
Distinguishing sex work from sexualorientation:
understanding gay relationships
Transactionalsex with male clients was very common among
cohortvolunteerswith over two thirds ofparticipantsreporting
being paid for sex [31]. Perhaps as a consequence, only one (8%)
of the participants explicitly distinguished sexualorientation from
sex work. This lack of distinctionin the majorityof the
participants’minds was expressed by this non-MSM participant:
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I look ata gay man as a gay man.They are the same as any other
femalesexworkerwhoprobablyneedscounselling.(non-MSM
participant).
Throughout all but one participant transcript, MSM behaviour
was described as resulting from poverty (‘they started this thing outof
poverty’) and MSM sex was regarded as transactional. The partners
of volunteers were frequently described as their ‘clients’, although
two of the non-MSM participants, and one MSM participant did
note that some MSM did have boyfriends.
Therearesomewho havecomeforward in a relationship buttheir
relationshipsarenotstable.Today they willhavethisrelationship,
tomorrow they willhave another.(non-MSM participant).
Couples counselling for male couples was described as a rare
event and no deliberate attempts at seeing couples were described.
Sexualattraction in the counselling sessions
Frequentreferencesto the issue ofsexualattraction in the
counsellingroom led to a modification ofthe interviewsto
incorporate thisas a question itsown right.All of the male
counsellorsinterviewed had been propositioned atone time or
another by volunteers and some confessed that they had found it
quite hard to resist advances,although they knew that they were
supposed to refer them to another counsellor and stated that was
what they did. A number of second-hand accounts of relationships
between gay counsellors and volunteers were explained. Firstly the
gay counsellorsstemmedfrom the same communitythat
volunteers were recruited from and were previously or currently
enrolled in research cohorts.Secondly they had access to records
and HIV results of people they may have had sexual relationships
with in the past.
But what happened is that some clients came up with some issues. This
counsellor is seducing me. Another is trying to kiss me… It was so hard.
(non-MSM participant).
We have had issues in the counselling rooms where counsellors hiton
clients or the other way around. He is nice, he gives you his number and
you meetup later.(MSM participant).
Also the counsellors lacked skilland professionalism in dealing
with transference.One counsellor identified that there was a lack
of realsupport.
We didn’tequip our counsellors to handle that– for any eventuality.
We justtrain them to do counselling work butwe don’ttrain them on
how to handle themselves professionally.(non-MSM participant).
Thekind ofsupervision wehavehereis quiteartificial.Wego to
supervision, I attend supervision, but we don’t share those issues: for fear
ofcourse.Forfearthatyou willbejudged and forfearthatyour
confidentiality willbe compromised.(MSM participant).
Stigma and criminalisation
Although male-male sex and transactional sex are both illegal in
Kenya,participantsrevealed high levelsof motivation and 11
(85%) mentioned the wider public health benefits of their work as
important or rewarding. They saw no conflict in their work, saying
that it was not illegalto provide services to vulnerable MSM.
In stressing the importance ofpublic health over stigma and
criminalization,one participant referred to her work at a nearby
antenatalclinic:
‘As a nurse if I am in an antenatal clinic I don’t ask ‘How did you
the pregnancy? Is itlegalor not?’(non-MSM participant).
Participantsreported difficulty in gaining the trustof MSM
volunteers,and volunteerrecruitmenteffortswere initially
challengingas well. Eight (8/16) participantsreportedthat
volunteerstold them ofbeing rounded up and arrested.Whilst
describing themselves as ‘strong’and ‘I am OK with it’the four
MSM participants talked of the day-to-day stresses of hiding their
identity from neighbours,continually gauging people’s reactions,
being barred from certain places,and living ‘double lives’.
The positive influence of peers and volunteers on value
systems (changing unhelpfulsocialand cognitive
constructs)
All of the non-MSM participants commented on the way their
attitudes towards MSM had changed over time as they worked
with them both as peers (fellow counsellors)and as persons who
needed HIV testing and counselling:
I have changed a lot.I have to be honest– I used to noteven wantto
work with them.Now we talk.We can go in one bus.I feelwarm.
Thesepeoplearehuman beingsand itis theirchoice.(non-MSM
participant).
We would meet with them every day. It is like flooding. I really h
sortoutmy issues.Coming here really did help me…to work outmy
own confusions atthattime.(non-MSM participant).
They reported enjoying the relationships they had formed and
shedding the stigma they once felt.A generalsense ofshifting
values was also felt by the MSM participants,who reported that
with time they experiencedfewernegativecommentsfrom
colleagues and felt more supported by the team.
Training and supervision needs identified by study
participants
A number of specific needs were identified and are presented in
detailin Table 1. In response to their skillneeds, participants felt
that tailored training was required for MSM counselling to equip
counsellors with skills to support condom negotiation and activitie
that raiseself esteem.Trainingand supervision should also
challenge homophobia and explore personalculturaltraditions
and assumptions.Training recommendationsincluded develop-
ment of tools to deal with self-esteem issues and dispel transmiss
mythscommon among MSM;reinforcingthe importanceof
leaving judgemental values and homophobia at home or better ye
learning why those valuesare harmfuland ultimately shedding
them altogether; and learning to distinguish between men who se
sex to other men and MSM who do not (distinguishing sex work
from sexualorientation)and how to addressthe needsof both
groups.Suggestionsfor supervisorysupportincludedfurther
discussionsof root causesfor risky behaviourin the MSM
communityand to reinforcethe importanceof challenging
negative stereotypes and fostering a safe environmentfor MSM
(including counsellors)to be open and candid abouttheir lives.
Both recommendations touched upon improved outreach to the
local professionalcommunity,includinglawyers,police and
community leaders.
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Table 1. Training and supervision needs identified by study participants.
Theme Key findings Training needs Supervisory support
Inadequate skills for
appropriate risk reduction
counselling
Variety of triggers:financial,drugs and
alcohol,emotional,desire.
Training tailored for counselling MSM and
dispelling myths
Practice skills-building in
supervision sessions
Myths (e.g.analsex and/or
sex between men is less risky)
Develop skills to exploring triggers for
protected and unprotected sex
Set up exchange or counsellor
mentorship programmes
Develop job aide checklist to focus
discussion and challenge client attitudes
Explore linkages to other service
providers in the area
Regular refresher training
Information about available
biomedical interventions (e.g., PreP
and treatment as prevention)
Inability to address client
life issues
Issues specific to MSM included:
Rejection,isolation,low self esteem,
leading a double life.
Provide training and observed skills
practice in generalcounselling
Supervision sessions to explore
underlying root-causes of risk
behaviour
Staff feelhelpless when sero-conversions
occur and ‘express frustration’with clients
Provide skills building to prevent counselling
sessions from becoming ‘stuck’when clients
say they don’t want condoms.
Training to improve understanding
of life issues that affect HIV
prevention
Develop activities to address low
client self-esteem
Personal, cultural and
religious value systems
Challenges in maintaining a
neutralattitude in the counselling process
Reinforce that homophobia has no place in
counselling.Include exercises about
religion and MSM in training.
Encourage counsellors to
challenge their attitudes on an on-
going basis.
Explore personaland culturaltraditions
and assumptions.
Challenge counsellors who may
over-estimate their ability to
divorce their values from practice
Learn to be aware of ‘subtle’language. Develop self and external
assessment exercises for
counsellors
Learn to communicate support through
affirming rather than ‘tolerating’difference
Distinguishing sex work
from sexual orientation
Gay relationships are misunderstood
by some staff
Develop separate HIV-test counselling
protocols tailored to the needs of male sex
workers and gay men who are not
sex workers
Support counsellors in exploring
and understanding sexual
orientation,as unchallenged
assumptions exacerbate
stereotypes.
Continue interaction with high risk
MSM
Unfamiliarity and lack
of exposure
Perception of ‘gayness’as something
that needs to be fixed.
Include training on professionalism Tailor supervision to challenge
stigmatizing values and reinforce
appropriate attitudes and practice.
Continued exposure to male sex workers
and MSM clients and co-workers has
improved professionalism
Use trainers who are themselves openly
MSM in the training so that counsellors are
not only learning on the job
Develop team building exercises to
break down divisions based on
sexualorientation.
Consider peer support groups that
contain a mix of gay and non-gay
identifying counsellors
Conduct training on MSM issues
and create a safe space in the
learning and work settings.
Sexual attraction Sexualadvances by both clients and
counsellors
Exercises on ethics,professionalism and
assertiveness to be included in training
Provide tailored support
supervision
Develop clear staff policies
regarding professionalbehaviour
Stigma and criminalisation Concern about association with MSM Sensitization training required for local
professionalcommunity (hospital,
police,lawyers)
Supervisors liaise with the media
and police
Client legalproblems,imprisonment,
and staff harassment
Train counsellors on legalissues and
dealing with conflict
doi:10.1371/journal.pone.0064527.t001
Providing Counselling to MSM in Kenya
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Discussion
Our findingsreveala numberof distinctthemesincluding
concerns over having inadequate skills for risk reduction counsel-
ling,and challenges in addressing clientlife issues.A number of
counsellorsin this nascentMSM programme described initial
internalstruggles with their personalvalues and unfamiliarity of
working with MSM, such as concerns about being associated with
an MSM project.We uncovered narrativesthatdescribed the
challenges of delivering effective HIV risk reduction counselling to
MSM as part of standard VCT counsellor training in the face of
cognitive and social constructs and we make practical recommen-
dations on training and supportsupervision systems for nascent
MSM HIV prevention programmesin Africa thatcomplement
what is known about current knowledge and future directions for
research [32].
Since VCT counsellor training had not prepared counsellors for
working with MSM,most learned ‘‘on the job’’about risk-taking
behaviours,life events and the triggers for risk-taking behaviour.
Only the four participants from the MSM community initially had
any significantunderstanding ofMSM ‘issues’and thisengage-
ment ofMSM formed the basis ofbuilding trust and ensuring a
safe environment[33].Participants found their values shifted as
they learned more about MSM through their work and through
talking to their colleagues,and this clinic has now evolved into a
safe space seen as a clinic of choice by many MSM in the area.
Few participants felt they were able to link strategies to prevent
risk-taking behaviour with life issues, self worth and stigma. MSM
may have higher rates ofalcoholand drug intake [34],may feel
they are not at risk of HIV or fear testing [35] and avoid services
they perceive as anti-gay [36–38],and may avoid disclosing their
sexualorientationin traditionalVCT sessions [1]. While
participantsknew aboutthe complex issuesfaced by high-risk
MSM in their daily lives, very few described any alteration in their
approach to standard risk-reduction planning.Similarly,while
participants knew that they should be non-judgemental,our data
revealthatdespite changing attitudesovertime,many partici-
pants’strong socialconstructs may have affected their ability to
conduct effective risk reduction counselling.
The impact of counselling
Providinginformationon HIV transmissionand the risk
associated with unprotected receptive analintercourse (RAI)can
lead to reduced risky behaviour among African MSM [39–41].
When we started work with the MSM community at the Kenyan
coast HIV was thought to be a ‘‘vaginaldisease’’ that men would
contractthrough sex with women.We postulatethat correct
knowledge has increased as the result of outreach and prevention
efforts. Our longitudinal cohort has allowed us to collect evidence
of risk reduction during follow-up and revealthatour HIV-
positive cohort participants report significantly less risky behaviour
than our HIV-negativecohort participants(manuscriptin
preparation). It would be difficult to isolate the effect of counselling
versus other components (e.g., education, HIV testing, provision of
condoms and lubricants) included in the package of interventions.
However,it is importantto note thatthe levelof risky sexual
behaviourin our cohortand in otherreported studiesis still
considerable.For example,in the paper by Stromdahlet al[39]
only 11% ofNigerian participantsreported alwaysengaging in
safe sex. In the article by Raymond et al., [41] unprotected RAI in
the past 6 months (reported by 24% of participants) was associated
with having had an HIV test in the past 6 months.The authors
noted that‘‘perceptions oflow risk to acquire or transmitHIV
infection were paradoxically associated with a higher likelihood of
URAI.’’ In our own HIV-1 negative cohort of 449 MSM followed
for variouslengthsof follow up timeduring 2005–2011,on
average, one out of three MSM who reported sex with men only,
and one outof 17 MSM who reported sex with both men and
women acquired HIV-1 per year follow up,suggesting thatrisk
reduction counselling alone was noteffective in reducing HIV-1
acquisition in CoastalKenya [31],and demonstrating a need for
additionalbiomedicalinterventions such as pre-exposure prophy-
laxisand forearly treatmentof HIV positive individualsas a
prevention measure [42,43].
Other authors have noted the significantstigma and discrim-
ination faced by these men [38]. We find that intermittent or on-
going substance abuse,in particular,is a problem thatis linked
with risky behaviour (manuscriptin preparation).We have also
reportedthat HIV-positiveMSM who initiateantiretroviral
therapymay have lower adherenceand poor responseto
treatment,compared to other high-risk adults,including female
sex workers[44].We suspectthatthe stigma,substance abuse,
likely mental health issues, and other problems faced by these me
can be overwhelming to our counsellors.In addition,it is quite
possiblethat non-MSM counsellorsexperiencestressdue to
continuedmale-malesex reportedby participants(whether
protected or not).
The importance of context
There is very little published literatureon the needsand
experiences ofcounsellors working with MSM in Africa and the
culturaland politicaldimensionsof HIV/AIDS are often low
priority [3].What is known isthatwhile the VCT modelis
appropriate for the client-initiated testing that it was designed for
mostVCT training in Africa doesnot addressMSM issues
[13,45]. MSM groups are increasingly acting as advocates and as
service providers [46] and are well placed to face the challenges o
HIV in their communities allowing solutions that are generated to
be contextuallyappropriateto Africa [33,47]and ultimately
allowing integration into generalcounselling services.
Learning from programmes with other marginalised
groups
HIV testing and counselling programmeswith other margin-
alised groups,including female sex workers(FSW),also show
limited or unsustained effectiveness ofbehaviouralinterventions.
Lessonslearnedmay be appropriatefor MSM counselling,
although female sex work is less stigmatized than male-male sex
in mostAfrican settings[48,49].Although many ofthese same
stressfulelements(e.g.,poverty,stigmatization)comprisethe
challenges in providing effective counselling for allmarginalized
groups,the negative socialand cognitive stereotypes surrounding
MSM introduced additionalchallengesin delivering efficacious
counsellingmessages[36]. MSM-specificvulnerabilitiesmay
include psychologicaland cognitive factorsincluding low self-
esteem,being atincreased risk ofdepression,self-stigmatization
and being prone to blackmailand isolation [50,51].Also lack of
knowledge aboutsexuality and misconceptionshow to prevent
transmission (as mentioned above) are different for MSM than for
FSW. Sexual intercourse more often takes place in places that are
more challengingfor providingpreventionservices(parks,
beaches,etc.)and in an environment of criminalization [52].
Training and supervisory needs
The need fora formal,validated training system to better
prepare counsellors to tackle the complex set ofissues specific to
MSM-counselling wasan importantoutcome identified in this
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work and has in part led to the development of standardized tools
for this purpose [53].Training musttherefore define and assess
competencein the contextof MSM counsellingand help
participants to know more about MSM (enhancing the cognitive)
and recognise the impact ofvalue systems.The limited utility of
non-standardized,non-validated‘‘on the job’’ trainingwhile
working with MSM highlight the need for specific VCT training
modules on the MSM behaviours to avoid homophobic language
(both verbaland non-verbal)and to embraceaffirmation as
opposed to ‘tolerance’[26]. Using our constructivist framework we
argue thattraining and supportsupervision can influence the
cognitive and socialconstructs of health workers,nurturing more
positive attitudes towards MSM based on a better understanding
of sexuality.To this end, context-specifictrainingmaterials
covering the areassetoutin Table 1 and newer developments
around pre-exposure prophylaxisand treatmentas prevention
[54] are beginning to be developed and adapted [53],and have
been made freely accessible on the internet(www.marps-africa.
org)[30].
In the absence offormaltraining,the impactof counsellors’
personal values (cognitive constructs) and the values of their peers
and the community(socialconstructs)weighedheavilyon
counsellors’ability to conduct effective risk-reduction counselling.
Bettersupportsystemsand confidentialsupervisory counselling
could assistcounsellorsto develop expertise and dealwith the
issuesof personalvaluescoming into conflictwith their clients’
behaviour,sexualattraction [55],professionalrelationships.
Limitations
One limitation of the study was that responses may have been
influenced by knowledge ofthe interviewer’s experience working
with MSM and her role in initiating VCT counsellor training in
Kenya [56].Conversely,the fact that she was an outsider to the
research project may have enabled more criticaland frank views.
Additionally,since the participantswere working in a research
setting,includedcounsellorsdrawn from the local MSM
community,and had overtwo yearsexperience working with
MSM, our study population may be significantly differentfrom
traditionalVCT counsellors in Africa,where additionalsupport
and mentorship may be required.It may be unwise, therefore,to
generalize these findings to other VCT counsellors who need skills
to serveMSM as well, but are unlikelyto counselMSM
exclusively.
Conclusion
For African MSM early and expandedaccessto non-
judgemental HIV testing and counselling is critical for prevention
efforts.Those who testpositive willthen be able to access early
treatment initiation, lowering onward transmission risk, and those
who test negativecan then accessfocusedrisk reduction
counselling and support.Our findingsrevealthe need fora
tailored training and supervisory approach that is embedded in th
specific contexts of African MSM. Through an analysis of themes
emerging from qualitative interviews with experienced counsellor
and clinicians in Kenya this paper raises specific challenges to the
statusquo and showsthatspecific materialsand training are
required. It sets out areas of training, supervision and support tha
can guide programmessetting outto expand HIV testing and
counselling programmes for MSM in similar contexts.
Acknowledgments
The authors would like to acknowledge the staffat the KEMRI-CGMR-
Coast project in Kilifiand Mtwapa for their input and the stafffor their
time and insights.Sassy Molyneux ofKEMRI-CGMR-Coast in Kilifi,
Kenya,Olivia Tulloch atthe LiverpoolSchoolof TropicalMedicine,
Frances Priddy and SagriSingh of InternationalAIDS Vaccine Initiative
(IAVI) in New York read and critically appraised the documentand the
authorswish to thank them allfor very helpfulcomments.Dr Norbert
Peshu was supportive of the work with MSM. We would also like to thank
the projectadvisory committee and community advisory board for their
efforts in support of our research, and the Kenyan Ministry of Health and
the National AIDS and STD Control Programme for their support of HIV
prevention efforts among MSM. This paper is published with permission of
the Director of KEMRI.
Author Contributions
Analyzed the data:MT MAP. Contributed reagents/materials/analysis
tools:MT AD MM EMvdE SMG MAP EJS. Wrote the paper:MT AD
MM EMvdE SMG MAP EJS.
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