Comparing Client and Provider Preferences for HIV Prevention in South Africa

Background & Significance: Estimates of HIV prevalence among South African MSM range between 10 and 50% and has been estimated to be more than twice that of other reproductive age men. South African MSM experience unique barriers to accessing HIV-prevention services, including the almost exclusive focus on heterosexuals when promoting public health strategies for HIV prevention, and providers’ stigmatizing views of MSM and their lack of understanding regarding the needs or sexual behaviors of MSM. MSM were included for the first time as a target demographic in the South Africa’s 2007-2011 National Strategic Plan for HIV. One emerging approach to HIV prevention is the creation of “combination prevention packages” that conglomerate multiple HIV-prevention measures into a single intervention, designed uniquely for the needs, risks, and preferences of a specific population. In order to maximize the impact of combination prevention packages, it is important to work with both the target population and the community of services providers expected to deliver the interventions, to understand their knowledge, willingness to utilize or provide, and perceived acceptability of the components of the prevention package.

Purpose: An important first step in the development of a combined package of HIV prevention tools for MSM in South Africa is to assess the prevention tools that MSM know, are willing to use, and see as needed to protect themselves from HIV.  Data are required of service providers, to understand how they perceive the HIV prevention needs of MSM and to assess their capacity and willingness to provide HIV prevention services to MSM. Here we present innovative qualitative data collected in focus groups of MSM and health service providers recruited in Cape Town and Port Elizabeth, to examine perceptions of the HIV prevention needs of MSM. The focus is on comparing the perceptions of MSM (the clients) and service providers in order to inform the development of a combined package of HIV prevention tools.

Methods: Focus group data were collected as part of a larger qualitative study assessing health care access, uptake of and structural barriers to using prevention services, sexual behaviors and social networks among men who have sex with men in South Africa. The qualitative data collection efforts represented the first in a three-stage process of developing and testing a combined package of HIV prevention tools for MSM in South Africa. Presented are the results of 11 focus group discussions. Five focus groups were conducted with MSM, of which three were in Cape and two in Port Elizabeth. Six focus group discussions were convened with health care providers, of which three were in Cape Town and three in Port Elizabeth. Participants were shown a list of potential clinic characteristics and HIV prevention services and asked to select the three most desirable and important for MSM. MSM were also asked their experiences of accessing HIV prevention services, while providers were asked their experiences of providing services to MSM.  Prevention tools discussed included: HIV testing (VCT), condoms, lubricants, PrEP/PEP, Couples’ HIV Counseling and Testing (CHTC), home HIV testing, and referral services. Clinic characteristics included: confidentiality, friendly staff, short waiting times, having the same provider at each visit, clean environment, LGBT sensitization, one-stop shop, MSM-specific space, the provider’s ability to ask MSM-specific questions, and incorporation of MSM services into general services.

Data Analysis: Audio recordings from each of the focus groups were translated (when necessary) and transcribed. Data were analyzed using a constant comparative method by comparing similarities and differences between emerging categories. Independent coding across three coders took place, followed by consensus revisions and development of an inductive codebook. During the focus groups, participants raised their hand to indicate their experiences and desires for each of the clinic characteristics and HIV prevention tools; votes were counted and tallied at each focus group. Codes were applied to the text to examine the reasons for the desired clinic characteristics and combined prevention package items. Analysis was conducted using MAXQDA version 10. Key quotes are presented using pseudonyms to protect the privacy of participants. Quotes are presented by participant type, patient or provider, and city of focus group attendance for confidentiality.

Results: The most commonly occurring characteristics at patient’s current clinics in both Cape Town and Port Elizabeth were confidentiality of visit, friendly staff, and same doctor at each visit. Across both locales, patients most commonly selected confidentiality of visit, same doctor at each visit, and friendly staff as ideal clinic characteristics for MSM.

Providers from Cape Town perceived that their clinic of employment most commonly displayed friendly staff, confidentiality of visit, and clean environment. Those providers in Port Elizabeth most frequently believed their places of employment to exhibit confidentiality of visit, same doctor at each visit, short wait time, and clean environment. Providers in Cape Town believed that confidentiality of visit, one-stop shop, and MSM-specific testing space were the most ideal characteristics for MSM clients. Those in Port Elizabeth most commonly listed confidentiality of visit, friendly staff, and LGBT sensitization training as most important for MSM. Overall provider preference was for confidentiality of visit, friendly staff, and MSM-specific testing space, which ranked seventh among MSM.

In the past six months, clients in Cape Town had commonly used condoms, lubricant, and VCT and no members of this group had used CHTC during that period. Among patients from Port Elizabeth, only condoms, VCT, lubricant, and home testing had been utilized during the previous six months. Men from Cape Town selected condoms, PrEP/PEP, and lubricant as ideal prevention services for MSM; those from Port Elizabeth preferred condoms, HIV education, and CHTC. In total, clients’ top preferences were consistent with the views of men from Cape Town, favoring condoms, PrEP/PEP, and lubricant.

In the past six months, providers in Cape Town and Port Elizabeth had most often recommended condoms, VCT, and HIV education to MSM. In Port Elizabeth, providers also commonly recommended CHCT over the past six months. Providers in the Cape Town focus groups most often selected condoms, VCT, and HIV education as ideal prevention services for MSM; providers in Port Elizabeth selected condoms, CHTC, and HIV education. Overall conglomerate provider preference was for condoms, HIV education, and CHTC.

Analysis of transcripts revealed six themes that underlay the selection of clinic characteristics and HIV-prevention services that would be ideal for MSM. These categories are Community Stigma, Healthcare Stigma, Patient Adherence, Personal/Partner Preference, Availability of Care, and Perceived Effectiveness.

Summary: Improving the relationship and establishing positive rapport between MSM clients and HIV-service providers is crucial to reduction of HIV transmission, and this is particularly true in environments characterized by high levels of stigma towards MSM. The qualitative data presented here describe MSM and HIV service provider’s often contradictory understandings of the HIV prevention needs of MSM, and provide information necessary for the development and implementation of efforts to strengthen relationships between MSM and service providers. Among those interviewed, there were both consistencies and discrepancies in the perspectives regarding important factors of a HIV-prevention service environment. Although there were a minority of discriminatory opinions expressed by providers, there existed a general understanding across both groups that specific considerations and efforts needed to be made when providing HIV prevention services to MSM. As illuminated by the qualitative data collected, the discrepancies that exist were in both the selection of ideal clinic characteristics and HIV-prevention services, as well as reasons underlying each selection. The lapses in understanding reveal the manner in which improvement can be made toward greater accessibility by specifying many of the boundaries experienced by MSM and the ways that providers already acknowledge or perpetuate those boundaries. The data also expose differences within groups across cities, emphasizing the importance of tailoring HIV-prevention efforts to the locale, as well as the population.

Conclusions: To our knowledge, this is the first study to provide data comparing the clinical and HIV prevention service preferences of MSM clients and HIV service providers in South Africa. Study findings provide groundwork for the development of a combination prevention package tailored to the needs and preferences of South African MSM. Information is also presented that provides a basis for creating a parallel intervention targeting providers, working to bridge the divergence between them and MSM clients. Future HIV prevention efforts may benefit by utilizing this knowledge to gauge the preferences of sub-Saharan MSM and implementing optimally accessible and relevant HIV-prevention interventions for South African MSM.