Acting within an increasingly confined space: A qualitative study of sexual behaviours and healthcare needs among men who have sex with men in a provincial Tanzanian city.

OBJECTIVE: To explore risk perceptions, sexual practices and healthcare needs among men who have sex with men in the provincial city of Tanga in northern Tanzania. Previous research suggests that HIV/STIs are increasing problems for this population. Yet, few studies have been conducted outside the urban area of Dar es Salaam, which has limited our knowledge about the HIV/STI risk factors and healthcare needs among men who have sex with men who live outside major metropolitan areas. METHOD: During three months in 2013, 10 in-depth interviews with men who have sex with men were conducted in Tanga. Data were interpreted through qualitative content analysis. RESULTS: The theme that emerged was labelled "Acting within an increasingly confined space". The theme reflects the interference of stigma in men's lives, and in the face of potential discrimination, men perceived their sexual and healthcare choices as limited. This created obstacles for forming romantic and sexual relationships, insisting on consistent condom use with sexual partners, maintaining open and conducive relationships with family, and accessing healthcare services when required. CONCLUSIONS: Sexual stigma is a concern as it contributes to HIV/STI risk-related behaviours among men who have sex with men. Priority should be given to programmes that support same-sex practicing men in their efforts to make informed choices regarding their sexual health. Creating safe cyber networks provides an opportunity to reach this population with targeted sexual health education messages. Such programmes might be even more urgent in smaller towns and rural areas where gay specific initiatives are more limited than in urban areas.

Public/community engagement in health research with men who have sex with men in sub-Saharan Africa: challenges and opportunities.

BACKGROUND: Community engagement, incorporating elements of the broader concepts of public and stakeholder engagement, is increasingly promoted globally, including for health research conducted in developing countries. In sub-Saharan Africa, community engagement needs and challenges are arguably intensified for studies involving gay, bisexual and other men who have sex with men, where male same-sex sexual interactions are often highly stigmatised and even illegal. This paper contextualises, describes and interprets the discussions and outcomes of an international meeting held at the Kenya Medical Research Institute-Wellcome Trust in Kilifi, Kenya, in November 2013, to critically examine the experiences with community engagement for studies involving men who have sex with men. DISCUSSION: We discuss the ethically charged nature of the language used for men who have sex with men, and of working with 'representatives' of these communities, as well as the complementarity and tensions between a broadly public health approach to community engagement, and a more rights based approach. We highlight the importance of researchers carefully considering which communities to engage with, and the goals, activities, and indicators of success and potential challenges for each. We suggest that, given the unintended harms that can emerge from community engagement (including through labelling, breaches in confidentiality, increased visibility and stigma, and threats to safety), representatives of same-sex populations should be consulted from the earliest possible stage, and that engagement activities should be continuously revised in response to unfolding realities. Engagement should also include less vocal and visible men who have sex with men, and members of other communities with influence on the research, and on research participants and their families and friends. Broader ethics support, advice and research into studies involving men who have sex with men is needed to ensure that ethical challenges - including but not limited to those related to community engagement - are identified and addressed. Underlying challenges and dilemmas linked to stigma and discrimination of men who have sex with men in Africa raise special responsibilities for researchers. Community engagement is an important way of identifying responses to these challenges and responsibilities but itself presents important ethical challenges.

Being forced to become your own Doctor - Men who have Sex with Men's Experiences of Stigma in the Tanzanian Healthcare System.

OBJECTIVE: To acquire a deepened understanding of how stigma in healthcare affects health-seeking behaviours of same-sex practising men in Tanzania. METHODS: In-depth interviews with twelve men were conducted in Dar es Salaam, 2012. Data were interpreted through qualitative content analysis. RESULTS: Narratives revealed that men's healthcare perceptions were shaped by previous encounters, rumours in gay community, norms and legislation around homosexuality. Fears of exposure aggravated men's possibilities of giving full anamnesis and detached them from formal healthcare services. CONCLUSIONS: Stigma in healthcare might lead to severe public health problems due to perceived exclusion from the health system by sexual minorities.