Beyond biomedical and comorbidity approaches: Exploring associations between affinity group membership, health and health seeking behaviour among MSM/MSW in Nairobi, Kenya

ABSTRACT

We explored general health and psychosocial characteristics among male sex workers and other men who have sex with men in Nairobi, Kenya. A total of 595 MSM/MSW were recruited into the study. We assessed group differences among those who self-reported HIV positive (SR-HIVP) and those who self-reported HIV negative (SR-HIVN) and by affinity group membership. Quality of life among SR-HIVP participants was significantly worse compared to SR-HIVN participants. Independent of HIV status and affinity group membership, participants reported high levels of hazardous alcohol use, harmful substance use, recent trauma and childhood abuse. The overall sample exhibited higher prevalence of moderate to severe depressive symptoms compared to the general population. Quality of life among participants who did not report affinity group membership (AGN) was significantly worse compared to participants who reported affinity group membership (AGP). AGN participants also reported significantly lower levels of social support. Membership in affinity groups was found to influence health seeking behaviour. Our findings suggest that we need to expand the mainstay biomedical and comorbidity focused research currently associated with MSM/MSW. Moreover, there are benefits to being part of MSM/MSW organisations and these organisations can potentially play a vital role in the health and well-being of MSM/MSW.

KEYWORDS:

• Men who have sex with men (MSM)
• male sex worker (MSW)
• Kenya, quantitative
• mental health
• affinity groups

Introduction

On 24 May 2019, Kenya’s high court made the decision to uphold sections of the country’s penal code that criminalises same sex relationships between consenting adults, sustaining remnants of European colonialism embodied in antiquated laws that violate human rights and negatively impact health (NPR, 2019). In Kenya, same sex behaviour between consenting adults continues to be a crime punishable by up to 14 years in prison. Evidence from past research has shown criminalisation of same sex relationships to be a barrier to comprehensive HIV prevention, treatment and care programming for gay, bisexual and other men who have sex with men (MSM) – a group that globally bears a disproportionate burden of HIV infections (Baral et al., 2007; Beyrer, 2008; Beyrer et al., 2010; Beyrer et al., 2012; Beyrer et al., 2013; van Griensven et al., 2009). Moreover, researchers have demonstrated that in the face of penalising laws, consequential state-sponsored stigma and discrimination and overt police harassment, MSM are less likely to engage in HIV testing, less likely to have access to prevention technologies, including pre-exposure prophylaxis, and less likely to access needed HIV treatment as well as less likely to remain in HIV care (Beyrer, 2019; Fay et al., 2011; Hagopian et al., 2017; Schwartz et al., 2015; Semugoma et al., 2012; Sullivan et al., 2012). Furthermore, failure by nation states to recognise MSM has resulted in major gaps in adequately understanding and addressing their needs. Moreover, this lack of recognition has contributed to gaps in accurately enumerating this highly vulnerable and marginalised population’s size to effectively inform national HIV prevention strategic planning, allocate resources, and evaluate country-level progress on HIV prevention (Abara & Garba, 2017; Davis et al., 2017; Forsythe et al., 2009; Pachankis et al., 2015; Smith et al., 2009). As in other countries, sodomy laws in Kenya perpetuate human rights violations, continue to fuel the HIV epidemic among MSM, and pose serious public health threats (Beyrer, 2019).

Despite legal proscriptions, Kenya has included MSM as a vulnerable population in their national AIDS strategic framework along with male and female sex workers (MSW and FSW, respectively) and people who inject drugs; together they encompass key populations (NACC, 2016). This inclusion of MSM at the policy level, however, has not fully translated to practice or programmes. That is, beyond indirect interventions (e.g. social mobilisation and community sensitisation) existing programmes do not as purposefully address MSM as they do other key populations, for example female sex workers (NACC, 2016). Supplemented by legal sanctions and penalties largely engendered by and grounded in perpetual institutionalised homophobia, the de-prioritization of MSM is epidemiologically reflected in the unacceptably high HIV incidence and prevalence rates among this population (McKinnon et al., 2014; Price et al., 2012; Sanders et al., 2013). In the absence of political will and structural reform, MSM focused non-governmental (NGOs) and community-based organisations (CBOs) often fill the expanding lacuna created by the government’s lesser commitment and general inaction. Through ebbing partnerships with foreign researchers and diminishing support from multilateral donors, these NGOs/CBOs provide vital and safe spaces for MSM, including MSW, and are often the only viable alternative to protecting their health and human rights.

Our study, A South-to-South collaborative project to understand and address the HIV vulnerability of male sex workers in Nairobi, Kenya (the ‘S2S Study’), was engendered by continued and alarming increases in HIV incidence among male sex workers enrolled in an HIV prevention programme in partnership with a Nairobi-based male sex worker collective, HOYMAS (Health Options for Young Men on HIV/AIDS/STI). Despite the use of proven prevention strategies, such as condoms and lubricants, HIV risk reduction counselling, and HIV prevention education, the seroconversion rate remained extremely high, with an annual HIV incidence of 12 per 100 person-years (McKinnon et al., 2014). The S2S study, which was initiated by HOYMAS and designed and planned in close collaboration with University of Manitoba, sought to understand gaps in existing prevention strategies from the perspectives, knowledge, and experiences of MSM/MSW themselves, a largely understudied population, particularly in low- and middle-income countries including Kenya. This article aims to contribute to extant literature by addressing gaps in our current understanding around general health and psychosocial characteristics of Kenyan MSM and MSW. Moreover, we expand on our initial focus on HIV prevention in the analysis of the findings by considering the following: (1) the potential importance of key populations organisations in a socio-political milieu such as Kenya, (2) the related implications on capacitating these on-the-ground advocacy centres, and (3) the significance and contributions of our findings to the on-going debate in current literature on the investment in and effectiveness of vertical versus horizontal programmes (Atun et al., 2008; Behague & Storeng, 2008; Orenstein & Seib, 2016).

Methods

The S2S study employed a mixed-methods design comprised of a dedicated qualitative phase, which included life histories and key informant in-depth interviews, and a quantitative phase (i.e. questionnaire). Although the study components stood alone as either qualitative or quantitative studies, findings from each preceding phase were used to inform the next phase. One of the most prominent and recurring themes from the qualitative phase, for example, related to unmet needs among MSM and MSW within the context of their mental health wellbeing (Lorway et al., n.d.a). Other themes included stigma in relation to masculinity, as well as cultural expectations, and prevalence of alcohol and other substance use, in particular how addiction shaped sexual risk-taking practices (Lorway et al., n.d.b). Furthermore, findings from qualitative data related to life histories, for example, underscored the central role that HOYMAS played in not only clinical service provision for its members, MSM and MSW, but also in the initiation of social justice initiatives that were more directly tied to civil liberties and global human rights (Lorway et al., n.d.b). These qualitative findings informed the focus of our behavioural and psychosocial quantitative questionnaire and shaped specific questions that helped us to characterise the recurring themes and to explore associations between them quantitatively.

The S2S study focused on communities of MSM and MSW in Nairobi, Kenya. Grounded in a community based participatory approach (Israel et al., 1998; Israel et al., 2001; Lorway et al., 2014), we directly engaged MSM community leaders in partnership with HOYMAS. The local research team, who were identified with the help of community leaders, consisted of 8 community researchers (CRs) and 2 supervisors. Those selected as CRs were well-respected leaders in their communities, were experienced in sexual health research and/or programming and played a central role in the design of data collection tools and in the collection of data.

Prior to data collection, the CRs participated in training workshops led by members of the research team. Training covered quantitative research methods, research ethics, data collection processes specific to our study, and activities that supported the CRs’ familiarisation and comfort with the quantitative questionnaire. The training workshops also focused on cultivating leadership in and building capacity for public health research among CRs.

Study design, sampling and recruitment

This quantitative phase of the cross-sectional study was partially informed by the study’s preceding qualitative research phases, namely life histories of MSM and MSW and key informant interviews among intimate partners of MSM and MSW. In addition to questions that captured socio-demographic characteristics of the participants, the quantitative questionnaire also elicited information around participants’ sexual history (i.e. male and female sexual partners, respectively), health-seeking behaviour, sexual stigma and HIV status disclosure, social support, depression, alcohol and other substance use, recent and childhood trauma, and mobility. The questionnaire, which was made available in English and Kiswahili, was constructed in English with questions translated and back translated in Kiswahili by research staff.

We used a two-pronged approach supported by a group of community mobilisers to recruit participants into the study. First, we used widespread advertisement of the study through social media (e.g. Facebook) and word-of-mouth via community mobilisers to recruit participants. Second, individuals seeking services at our partner sites, HOYMAS and Sex Workers Outreach Programme (SWOP) – clinics serving MSM and MSW communities, were invited to participate. We attempted to engage MSM and MSW who are consistently more difficult to reach by using this multi-faceted recruitment approach. Eligibility for enrolment into the study required that the participants (a) be 18 years of age or older, (b) be a male (assigned at birth) and have sex with men and/or sell sex to men, (c) be either HIV positive or negative, with those in the latter group re-testing if their last HIV test was more than two weeks prior, (d) be enrolled in services at either HOYMAS or SWOP. The latter participant enrolment eligibility criteria fortified the study’s commitment to expanding outreach by serving as a gateway to services for MSM and MSW not engaged in care. Participants completed the questionnaire at the study location where they sought care, with those newly engaged in care participating in the study after their first clinic visit. Community supervisors oversaw survey implementation and ensured minimisation of duplicates.

All participants were 18 years of age or older and provided written consent. A total of 595 MSM/MSW completed the questionnaire. Participants were provided with a travel reimbursement of 400 Kenyan Shilling (KES), approximately 4 USD, for their time and expenses related to their participation.

Data collection

Data were collected directly from the MSM and MSW between September 2015-May 2016 by audio computer-assisted self-interview (ACASI) in English or Kiswahili, depending on the preferred language of the participant. The CRs were responsible for administering the consent process and assisting with technical issues encountered during the ACASI questionnaire, if any. Following the completion of the ACASI questionnaire, participants met with the study site clinician who assessed whether the participant needed to undergo HIV and other clinical assessments. HIV counseling and testing was conducted according to national guidelines among participants who self-reported negative but had not been tested recently (i.e. in the last two weeks).

Measures

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms (Kroenke et al., 2001). The questionnaire has demonstrated high levels of validity and reliability with diverse racial/ethnic groups in the United States (Huang et al., 2006), as well as with populations in East and sub-Saharan Africa (Cholera et al., 2014; Omoro et al., 2006). The questionnaire comprises 9 items rated on a 4-point Likert scale (0-3). Responses are summed with a total score ranging from 0-27. Guided by the scoring guidelines, depressive symptoms severity was categorised as minimal (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27) (Kroenke et al., 2001).

Quality of life

Two questions were drawn from the MOS-HIV questionnaire [SF-36] to assess health-related quality of life (Ware et al., 1993). Translated into several languages, the questionnaire has been used with diverse populations and has shown high levels of reliability and validity (McHorney et al., 1994; Wu et al., 1997). The questions are scored on a 5-point Likert scale (1-5) with a higher score representing poorer health. The two questions were combined as a mean health-related score (Ware et al., 1993).

Service utilisation

Informed by qualitative findings, multiple questions were used to assess need and use of services related to sexually transmitted infections (STI) and mental health. Questions on STI and mental health related need and use of services were framed to account for either lifetime and/or the past one year, as well as to explore preferences with respect to service providers.

Social support

The Medical Outcomes Study Social Support Survey (MOS-SSS) was used to assess perceived social support (Sherbourne & Stewart, 1991). The survey, which has been used with diverse populations in North and South America, Asia, and Africa, has been found to have high reliability and validity (Khuong et al., 2018; Londoño Arredondo, 2012; Margolis et al., 2019; Ncama et al., 2008; Saddki et al., 2017). It consists of 19 questions scored on a 5-point Likert scale (1-5). The measure covers four domains: emotional/information support, tangible support, affectionate support, and positive social interaction. An overall support score was calculated by averaging all 19 questions with higher scores indicating greater perceived social support (Sherbourne & Stewart, 1991).

Sexual stigma

An abridged version of the modified China MSM Stigma Scale (Neilands et al., 2008) was used to measure two dimensions of sexual stigma: perceived stigma and enacted stigma (Logie et al., 2012). The scale has been found to have high reliability with diverse populations in Asia and the United States (Diaz et al., 2001; Logie et al., 2012; Neilands et al., 2008). The modified measure replaced ‘because of your homosexuality’ with ‘because you have sex with men’ to contextualise the terminology to our study’s setting. The eleven questions, each scored on a 4-point Likert scale (0-3), were summed with a higher score representing greater perceived sexual stigma (Logie et al., 2012).

Alcohol use

The Alcohol Use Disorders Identification Test (AUDIT) was used to assess alcohol consumption, drinking behaviours, and alcohol-related problems (Babor et al., 2001; Saunders et al., 1993). The measure has been used in various international community contexts with diverse populations including adults, adolescents and the elderly (Meneses-Gaya et al., 2009). Moreover, numerous studies in those settings have confirmed its validity and reliability (Meneses-Gaya et al., 2009). The AUDIT is a 10-question screening tool scored on a 5-point scale (0-4). Responses are summed for a total score ranging from 0-40. Total scores of ≥8 are indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence (Babor et al., 2001; Saunders et al., 1993).

Other substance use

The Drug Abuse Screening Test (DAST-10), a brief screening tool consisting of 10 ‘Yes/No’ questions, was used to assess substance use excluding alcohol or tobacco (Skinner, 1982). The measure has been found to have good reliability and validity with diverse populations including psychiatric outpatients, non-substance users, and patients being screened for drug/alcohol problems (Yudko et al., 2007). The responses were summed and the recommended cut-off of ≥2 was used to identify ‘harmful substance use’ (Maisto et al., 2000).

Recent trauma

Four key questions were drawn from the USAID HPI Screening Tool to assess four types of recent trauma: forced or coerced sex, physical abuse, emotional abuse and threats or intimidation. Scores range from 0–4 (Betron & Gonzalez-Figueroa, 2009). We defined recent trauma as any positive response on the screening tool.

Childhood abuse

Four questions were drawn from the Childhood Experience of Care and Abuse (CECA) to assess four types of abuse as a child or a teenager: physical abuse at home, unwanted sexual experiences, forced or coerced sexual intercourse and upsetting sexual experiences with a related adult or authority figure (Smith et al., 2002). The measure has been validated with the general and clinical populations (Bifulco et al., 2005; Smith et al., 2002). Scores range from 0-4. We defined childhood abuse as any positive response on the measure.

HIV Status

One question with a binary response (‘Yes/No’) was used to ascertain self-reported HIV status (i.e. positive or negative). Although clinically measured HIV test results were available through clinic records, we relied on self-reported HIV status for two important reasons: (a) approximately 11% of the study participants were newly diagnosed with HIV during their participation in the study; thus, their perspectives and experiences until enrolment into the study were framed within the context of their negative HIV status, and (b) for the remaining participants, self-reports and lab tests were congruent.

Affinity group membership

One question with a binary response (‘Yes/No’) was used to assess affinity group membership (i.e. membership in an organisation that provides support for MSM/MSW).

Data analysis

Data were initially explored in descriptive analyses of all major categorical variables and continuous variables. Group differences between those who self-reported HIV positive and those who self-reported HIV negative were evaluated on the following variables using independent samples t-test or Pearson Chi-Square Test depending on distribution: (a) quality of life, (b) service need and utilisation related to sexually transmitted infections and mental health, respectively, (c) sexual stigma, (d) social support, (e) affinity group membership, (f) depressive symptoms, (g) alcohol and other substance use, and (h) recent trauma and childhood abuse. A similar analytic approach was used to compare differences between those who reported affinity group membership and those who did not report affinity group membership. Analyses were performed with SPSS version 25 (IBM Corp, Armonk NY) and SAS version 9.3 (SAS Institute, Carey NC).

Results

Profile of participants

Sociodemographic characteristics of the participants are presented in Table 1. A total of 595 MSM/MSW participated in the study, with an average age of 27.4 (18-64, SD = 7.4). The vast majority of the participants (97.6%) reported sex at birth to be male, with over two-thirds (69.5%) reporting their current gender as ‘man’ and nearly one-quarter (23.4%) as both ‘man and woman’. When asked about their sexual identity, nearly two-thirds (64.7%) of the participants identified as gay and over one-quarter (29.9%) as bisexual. With respect to religion, over four-fifths of the participants (83.4%) reported practicing Christianity-Protestantism (56.5%) or Catholicism (26.9%). Nearly two-thirds of the participants (63.6%) had completed secondary education or higher. Approximately two-fifths (40.5%) of the participants reported living alone and nearly one-quarter (24.4%) reported living with a male sexual partner. Over a quarter (26.6%) of MSM/MSW reported knowing to ever have fathered a child/children. The vast majority of the participants preferred English (48.1%) or Kiswahili (42.5%) as their spoken language, respectively. Over one-third (36.0%) reported being unemployed. Among those employed, one-third (33.8%) reported sex work as their primary source of income, with 42.2% reporting that they supplemented this income through other work. Of the participants who did not report sex work as their primary income and reported a secondary income, 59.0% reported supplementing their primary income through sex work. Among participants who reported a secondary income, 42.2% reported sex work. Nearly three-quarters of the participants (70.1%) reported exchanging sex for money, food, or other gifts and nearly one-third (32.1%) self-reported as HIV-positive.

Table 1. Sociodemographic characteristics of study participants (N = 595).

Characteristics	Total (%) or Mean (Range, SD)
Age (years)	27.4 (18-64, 7.4)
Sex at birth	595 (100.0)
Male	581 (97.6)
Female	7 (1.2)
Intersex	7 (1.2)
Gender	594 (100.0)
Man	413 (69.5)
Woman	34 (5.7)
Both	139 (23.4)
Neither	8 (1.4)
Sexual identity	595 (100.0)
Gay	385 (64.7)
Bisexual	178 (29.9)
Straight	16 (2.7)
Transgender	16 (2.7)
Religion	595 (100.0)
Protestant	336 (56.5)
Roman Catholic	160 (26.9)
Islam	50 (8.4)
Seventh Day Adventist	19 (3.2)
Traditional African	8 (1.3)
Hinduism	1 (0.2)
No religion	21 (3.5)
Education	594 (100.0)
No formal schooling	11 (1.9)
Primary school (Class 1-8)	94 (15.8)
Secondary school (Form 1-4)	243 (40.9)
Technical/vocational school	111 (18.7)
University	112 (18.9)
Graduate/professional degree	23 (3.8)
Current living situation	595 (100.0)
Live alone	241 (40.5)
Live w/male sexual partner	145 (24.4)
Live w/parents and/or siblings	89 (15.0)
Live w/other family/relatives	36 (6.0)
Live w/female sexual partner/wife & children	32 (5.4)
Live w/female sexual partner/wife	20 (3.4)
Other living situation	11 (1.8)
Live w/male sexual partner & children	10 (1.7)
Live on the streets	6 (1.0)
Live w/children only	5 (0.8)
Fathered children	595 (100.0)
Yes	158 (26.6)
No	437 (73.4)
Most comfortable spoken language	595 (100.0)
English	286 (48.1)
Kiswahili	253 (42.5)
Kikuyu	37 (6.2)
Dholuo/Luo	8 (1.3)
Kamba	3 (0.5)
Meru	3 (0.5)
Kisii	2 (0.3)
Luhya	2 (0.3)
Other	1 (0.2)
Employed	592 (100.0)
Yes	379 (64.0)
No	213 (36.0)
Primary source of income	379 (100.0)
Sex work	128 (33.8)
Other	251 (66.2)
Supplemented income if primary income = sex work	128 (100.0)
Yes	54 (42.2)
No	74 (57.8)
Supplemented income w/sex work if 1^0 ≠ sex work	134 (100.0)
Yes	79 (59.0)
No	55 (41.0)
Secondary source of income	187 (100.0)
Sex work	79 (42.2)
Other	108 (57.8)
Transactional sex	595 (100.0)
Yes	417 (70.1)
No	178 (29.9)
Self-report HIV status	595 (100.0)
HIV-positive	191 (32.1)
HIV-negative	404 (67.9)

General health & other psychosocial characteristics by self-reported HIV status

General health and other psychosocial characteristics by self-reported HIV status are presented in Table 2. Overall, we did not find substantial differences in general health and psychosocial characteristics among participants who self-reported as HIV-positive (SR-HIVP) versus those who self-reported as HIV-negative (SR-HIVN). We have focused our results on findings that were significant between the two groups (i.e. SR-HIVP and SR-HIVN participants) and on other notable findings independent of self-reported HIV status. Quality of life among SR-HIVP participants was found to be significantly worse compared to SR-HIVN participants (2.4 vs 2.2; p = 0.006). Independent of self-reported HIV status, over three-quarters of the participants (76.4%) reported accessing STI related services at least once in the last year and well over four-fifths (83.3%) reported mostly utilising clinics that serve MSM and MSW communities (i.e. key population clinics) for STI-related needs. Among all the participants who responded to whether they had ever sought help for mental health related needs, half (50.2%) reported doing so. Moreover, among all participants who responded to whether they had sought mental health related services in the last 12 months, the vast majority (92.8%) reported seeking care at least once and over half (54.1%) of the participants reported mostly utilising clinics that serve MSM and MSW communities for mental health related needs. The sample’s mean score for sexual stigma was 11.2 (SD = 8.19), indicating moderate levels of perceived and enacted sexual stigma among the study participants independent of self-reported HIV status. In addition, the overall sample reported moderate levels of perceived social support (3.1, SD = 0.928), and mild levels of depressive symptoms (7.6, SD = 5.92). However, 30.0% of the overall sample reported moderate to severe depressive symptoms independent of self-reported HIV status. A greater percentage of SR-HIVN participants reported membership in an affinity organisation (i.e. an organisation that provides support to MSM/MSW) compared to SR-HIVP participants (69.1% vs 60.7%, p = 0.04) and this finding was significant. Over one-third (36.8%) of all participants reported hazardous alcohol use (AUDIT score ≥8) and nearly two-fifths of all participants (39.2%) reported harmful substance use (DAST score ≥2). A significantly greater percentage of SR-HIVN participants reported experiencing trauma in the past one year compared to SR-HIVP participants (48.3% vs 45.5%, p = 0.03). Nearly two-thirds (60.8%) of the total sample reported ever experiencing childhood abuse independent of self-reported HIV status.

Table 2. Health & other psychosocial characteristics by self-reported HIV status.

	SR HIV-Negative	SR HIV-Positive	Total Sample	p-value
Quality of life	2.2 (SD = 0.855)	2.4 (SD = 0.924)	2.3 (SD = 0.888)	0.006
Service Utilisation
STI; 12 months (yes)	75.6% (295/390)	78.1% (139/178)	76.4% (434/568)	0.52
Service provider: Key Pop.	82.6% (333/403)	84.8% (162/191)	83.3% (495/594)	0.50
Mental health; ever (yes)	51.1% (94/184)	48.5% (48/99)	50.2% (142/283)	0.68
Mental health; 12 months (yes)	92.5% (86/93)	93.5% (43/46)	92.8% (129/139)	0.83
Service provider: Key Pop.	50.6% (45/89)	61.4% (27/44)	54.1% (72/133)	0.24
Sexual stigma	11.6 (SD = 8.66)	10.3 (SD = 7.56)	11.2 (SD = 8.19)	0.07
Social Support	3.2 (SD = 0.934)	3.0 (SD = 0.913)	3.1 (SD = 0.928)	0.11
Affinity group member	69.1% (279/404)	60.7% (116/191)	66.4% (395/595)	0.04
Depressive Symptoms	7.3 (SD = 5.95)	8.2 (SD = 5.83)	7.6 (SD = 5.92)	0.11
Minimal (<5)	37.1% (150/404)	27.7% (53/191)	34.1% (203/595)	0.19
Mild (5-9)	34.9% (141/404)	38.2 (73/191)	36.0% (214/595)	0.19
Moderate (10-14)	15.1% (61/404)	19.9% (38/191)	16.6% (99/595)	0.19
Moderately severe (15-19)	8.2% (33/404)	9.9% (19/191)	8.7% (52/595)	0.19
Severe (≥20)	4.7% (19/404)	4.2% (8/191)	4.5% (27/595)	0.19
Substance Use
Hazardous Alcohol Use (AUDIT)	35.6% (144/404)	39.3% (75/191)	36.8% (219/595)	0.39
Harmful Substance Use (DAST)	38.8% (155/399)	39.8% (76/191)	39.2% (231/590)	0.83
Trauma & Abuse
Recent Trauma	48.3% (195/404)	45.5% (87/191)	47.4% (282/595)	0.03
Childhood Abuse	60.1% (243/404)	62.3% (119/191)	60.8% (362/595)	0.62

General health & other psychosocial characteristics by affinity group membership

General health and other psychosocial characteristics by affinity group membership are presented in Table 3. Overall, in contrast to the aforementioned results by self-reported HIV status, we found more significant differences in general health and various psychosocial characteristics among participants who reported membership in an affinity group (AGP) versus those who did not report membership (AGN). We have focused our results on findings that were significant between the two groups (i.e. AGP and AGN participants) and on other notable findings independent of affinity group membership.

Table 3. Health & other psychosocial characteristics by affinity group membership.

	Affinity Group Member: No	Affinity Group Member: Yes	Total Sample	p-value
Quality of life	2.5 (SD = 0.902)	2.2 (SD = 0.868)	2.3 (SD = 0.888)	0.001
Service Utilisation
STI; 12 months (yes)	75.5% (139/184)	76.8% (295/384)	76.4% (434/568)	0.74
Service provider: Key Pop.	76.9% (153/199)	86.6% (342/395)	83.3% (495/594)	0.003
Mental health; ever (yes)	37.0% (34/92)	56.5% (108/191)	50.2% (142/283)	0.002
Mental health; 12 months (yes)	90.6% (29/32)	93.5% (100/107)	92.8% (129/139)	0.59
Service provider: Key Pop.	39.4% (13/33)	59.0% (59/100)	54.1% (72/133)	0.05
Sexual stigma	10.8 (SD = 7.32)	11.4 (SD = 8.60)	11.2 (SD = 8.19)	0.39
Social Support	3.0 (SD = 0.925)	3.2 (SD = 0.926)	3.1 (0.928)	0.02
Depressive Symptoms	7.9 (SD = 5.90)	7.5 (SD = 5.93)	7.6 (5.92)	0.40
Minimal (<5)	31.5% (63/200)	35.4% (140/395)	34.1% (203/595)	0.49
Mild (5-9)	36.0% (72/200)	35.9% (142/395)	36.0% (214/595)	0.49
Moderate (10-14)	17.0% (34/200)	16.5% (65/395)	16.6% (99/595)	0.49
Moderately severe (15-19)	11.5% (23/200)	7.3% (29/395)	8.7% (52/595)	0.49
Severe (≥20)	4.0% (8/200)	4.8% (19/395)	4.5% (27/595)	0.49
Substance Use
Hazardous Alcohol Use (AUDIT)	32.5% (65/200)	39.0% (154/395)	36.8% (219/595)	0.12
Harmful Substance Use (DAST)	41.2% (82/199)	38.1% (149/391)	39.2% (231/590)	0.47
Trauma & Abuse
Recent Trauma	46.5% (93/200)	47.8% (189/395)	47.4% (282/595)	0.60
Childhood Abuse	57.5% (115/200)	62.5% (247/395)	60.8% (362/595)	0.24

Quality of life among AGN participants was found to be significantly worse compared to AGP participants (2.5 vs 2.2, p = 0.001). Independent of affinity group membership, over three-quarters of all participants (76.4%) reported accessing STI related services at least once in the last year with a significantly greater percentage of AGP participants utilising clinics that serve MSM and MSW communities (i.e. key population clinics) for STI-related needs compared to AGN participants (86.6% vs 76.9%, p = 0.003). Among all the participants who responded to whether they had ever sought help for mental health related needs, a significantly greater percentage of AGP participants reported doing so compared to AGN participants (56.5% vs 37.0%, p = 0.002). Moreover, while the vast majority of the overall sample (92.8%) reported seeking mental health services at least once in the last 12 months, a significantly greater percentage of participants with membership to an affinity group (59.0%) reported mostly utilising clinics that serve MSM and MSW communities for mental health related needs compared to those who did not report membership to an affinity group (59.0% vs 39.4%, p = 0.05). Additionally, while the study participants overall reported moderate levels of perceived social support (3.1, SD = 0.928), AGN participants reported significantly lower levels compared to AGP participants (3.0 vs 3.2, p = 0.02). Further, no other significant results were found between AGP and AGN participants in the context of remaining health and psychosocial characteristics (i.e. sexual stigma, depressive symptoms, alcohol and other substance use, recent trauma and childhood abuse) and the overall sample statistics for those characteristics have already been presented in the previous section.

Discussion

In this study, which was engendered by alarming increases in HIV incidence among male sex workers in Nairobi, Kenya, we explored general health and psychosocial characteristics of MSM/MSW by self-reported HIV status and by affinity group membership to better understand gaps in existing prevention strategies. The latter exploration (i.e. affinity group membership), while not intended to be the initial focus of our research, was guided by the aforementioned findings from the qualitative phase of our study which signalled the importance for a closer examination quantitatively (Lorway et al., n.d.a; Lorway et al., n.d.b).

While we did not find substantial meaningful or significant differences in general health and other psychosocial characteristics of MSM and MSW by self-reported HIV status (i.e. positive (SR-HIVP) and negative (SR-HIVN)), we found quality of life among SR-HIVP participants to be significantly worse compared to SR-HIVN participants; a finding corroborated by other studies (Campsmith et al., 2003; Eriksson et al., 2000; Thomas et al., 2017). As reflected in findings from past studies among MSM/MSW (Korhonen et al., 2018; Mimiaga et al., 2011; Secor et al., 2015; Stall et al., 2001), we found high levels of hazardous alcohol use and harmful substance use in the sample of Kenyan MSM/MSW in our study independent of self-reported HIV status, as well as affinity group membership (i.e. membership: AGP; no membership: AGN). Moreover, compared to the national prevalence of alcohol use among Kenyan men in the general population (7.1%), the prevalence of alcohol use in our sample was found to be considerably higher (36.8%) (WHO, 2018). Comparable statistics related to other substance use (i.e. excluding alcohol and tobacco) among Kenyan men at the national level could not be found. Hazardous alcohol use and harmful substance use among MSM/MSW have been associated with a complex set of factors including adverse early life circumstances (e.g. childhood abuse), sexual risk-taking practices, mental health status, trauma, social and sexual practices, and transactional sex (Greenwood et al., 2001; Mimiaga et al., 2011; Ramirez-Valles et al., 2008; Sandfort et al., 2017; Stall et al., 2001).

Underscoring previous findings from MSM/MSW related studies, participants in our study reported high levels of both recent trauma and childhood abuse (Arreola et al., 2005; Fields et al., 2008; Korhonen et al., 2018; Secor et al., 2015) and moderate levels of sexual stigma (Korhonen et al., 2018; Secor et al., 2015; Stall et al., 2001). Furthermore, a significantly greater percentage of SR-HIVN participants reported experiencing trauma in the past year. This finding requires further exploration. Although we did not find significant differences in levels of depressive symptoms between groups delineated by self-reported HIV status or affinity group membership, our overall sample exhibited higher prevalence of moderate to severe depressive symptoms (30.0%) compared to prevalence among the general population in Kenya (4.4%) (WHO, 2017). Researchers from past studies have overwhelmingly evidenced associations between trauma/abuse and (a) depression (Korhonen et al., 2018; Mimiaga et al., 2009; Secor et al., 2015), (b) HIV risk behaviours (Mimiaga et al., 2009; Tomori et al., 2016) and (c) higher rates of HIV incidence (Mimiaga et al., 2009). Further, associations between sexual stigma and depression have also been well documented in extant literature (Choi et al., 2016; Logie et al., 2012; Wohl et al., 2013). In addition, associations between depression and substance use, as well as sexual risk-taking practices have been documented (Ahaneku et al., 2016; Fletcher & Reback, 2015; Reisner et al., 2009).

Our findings, which contribute to a small but growing body of research on Kenyan MSM/MSW, are congruent with research on similar populations in other country contexts. Shifting partially away from the traditional approaches in key populations research, those mainly focused on biomedical and comorbidity related explorations, our study is the first to explore the relationship between affinity group membership and health, including health-seeking behaviour, in the African context and more specifically among Kenyan MSM/MSW. We found quality of life among participants who did not report membership in an affinity group (i.e. AGN) to be significantly worse compared to participants who reported membership in an affinity group (i.e. AGP). Moreover, AGN participants reported significantly lower levels of social support compared to AGP participants. The salubrious effects of social support, whether through moderating, mediating or direct pathways, on physical and psychological well-being generally (Cohen, 2004; Israel & Rounds, 1987; Reblin & Uchino, 2008; Teoh & Hilmert, 2018; Uchino, 2006) and in the context of reducing HIV-related risk behaviours more specifically (Carlos et al., 2010; Fergus et al., 2009; Forney & Miller, 2012; Kapadia et al., 2013; Lauby et al., 2012) have been well-documented in the literature. Moreover, we argue that focus on membership in an affinity group has largely gone unnoticed in key populations research generally and in the African context more specifically. Membership in affinity groups among our study population was also found to potentially influence health seeking behaviour. While needs related to STI services were reported to be high among the overall sample, we found that AGP participants utilised clinics that serve MSM and MSW communities significantly more than AGN participants. Another notable finding linked to membership in affinity groups was related to mental health seeking behaviour. A significantly greater percentage of AGP participants reported ever seeking mental health services compared to AGN participants. Moreover, a significantly greater percentage of AGP participants reported utilising clinics that serve MSM and MSM communities for mental health related needs in the past one year compared to AGN participants. These findings have numerous implications on the central importance of key populations organisations in a socio-political milieu such as Kenya where penalties, legal sanctions, and laws constrain rights, including the right to non-stigmatizing and non-discriminatory health, for MSM/MSW. Moreover, the importance of capacitating these on-the-ground advocacy centres in ways that can maximise real opportunities to improve mental and physical health services for Kenyan MSM/MSW, a population that has largely been excluded from the national AIDS strategic framework, cannot be more urgent.

In an era marked by increasing HIV burden among MSM/MSW (Baral et al., 2007; Beyrer et al., 2012; Lane et al., 2016; Singh et al., 2018; van Griensven et al., 2009), a population that exhibits high levels of (unmet) needs, our findings lend support to the importance for vertical programmes. The on-going debate in current literature on the investment in and effectiveness of vertical versus horizontal programmes often forges compromises, those that focus on integrated or diagonal approaches often aimed to strengthen fragile health systems (Behague & Storeng, 2008; Orenstein & Seib, 2016). Diagonal and horizontal approaches; however, can potentially risk further neglect of highly vulnerable and underserved populations by diverting specifically allocated HIV funds, especially at a time when future funding streams for these populations are uncertain (Grépin, 2011). In addition, cost–benefit analysis of vertical programmes has purported that the costs outweigh the benefits citing that vertical programmes may distort local health priorities and undermine country ownership (Grépin, 2011; Yu et al., 2008). Our findings suggest and we argue that vertical programmes may in fact help strengthen locally based MSM/MSW NGOs and CBOs, organisations that are real resources to those communities, by capacitating (e.g. optimally trained healthcare staff) them to provide vital services and by supporting an infrastructure that can realistically meet on-going demands of MSM/MSW, a disproportionately affected community compared to other groups at greater risk for HIV infection.

Limitations & strengths

This study is not without limitations. First, as a cross-sectional study, inferences about causality cannot be made. Therefore, longitudinal studies will be necessary to determine causal pathways. Second, while our sampling strategy was designed to facilitate inclusion of MSM/MSW who are consistently more difficult to reach and therefore often underrepresented, if at all represented, in research studies, the non-probability sampling method means possibly a less representative sample of the population and limited generalizability of results. In addition, given the Kenyan socio-political context and the sensitive nature of the data collected, there is a likelihood that participants may have been inclined to give socially desirable responses. However, the anonymity and confidentiality associated with the use of ACASI may elicit more frequent reporting of socially sensitive behaviours as well as minimise frequency of missing data (NIMH, 2008). Thus, we believe that the introduction of reporting bias is minimal. Finally, it is important to note that we evaluated these planned comparisons at an unadjusted alpha of 0.05, which we felt appropriate for the exploratory nature of the study.

Conclusions

Findings from our study suggest that we may need to expand the mainstay biomedical and comorbidity focused research currently associated with key populations, specifically MSM/MSW, to better understand and address gaps in existing HIV prevention strategies. Moreover, our findings suggest that there are benefits to being part of MSM/MSW NGOs and CBOs and that further research is urgently needed to better understand the role(s) that these organisations can play in the health and well-being of MSM/MSW. Arguably, as on-the-ground advocacy centres, these affinity group organisations can actively promote and safeguard the health and human rights of MSM/MSW in restrictive and constrained socio-political milieus such as Kenya. Thus, investments must continue to be made in these organisations as they often serve as vital resources for MSM/MSW in the context of their health and human rights. In the presence of institutionalised homophobia and the resulting absence of political will, as well as national level strategic planning and programming, vertical programming through public-private partnerships may be a promising alternative to address HIV risk and other health priorities in MSM/MSW.

Ethics statement

Ethical approval for the study was granted by the University of Manitoba’s Health Research Ethics Board in Winnipeg, Canada, and by the Kenyatta National Hospital/University of Nairobi Ethics & Research Committee in Nairobi, Kenya. Participants provided written informed consent in their preferred language – either Kiswahili or English – after explanation that participation was voluntary, and that anonymity would be respected.

Acknowledgements

We are most grateful to the community participants who generously supported this project by offering their time and insight. We would also like to thank our community partners: Health Options for Young Men on HIV/AIDS/STI and the Sex Worker Outreach Programme. We also acknowledge the help of Brenden Dufault and Robert Balshaw of the Data Science Platform of the George and Fay Yee Centre for Healthcare Innovation and thank them for their services.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets generated during and/or analysed during the current study are not publicly available. Data pertaining to key populations (MSM, MSWs, FSWs) in Kenya are highly sensitive in nature given the political and legal context around sex work and same-sex relationships in the country. Furthermore, the data are detailed, sensitive, and often highly specific to participants’ personal experiences, and as such, may contain potentially identifying information. However, according to UM regulations, permission can be granted to access data sets by an outside analyst only after she/he has completed a learning module certificate and agreement form on UM’s information sharing policies. To achieve access to the data used in this manuscript, interested scientists, clinicians, analysts, and researchers can contact the research programme Principal Investigator, Dr. Robert Lorway ([email protected]), who will then review the application to access data in consultation with the UM Health Research Ethics Board and with HOYMAS community leaders.

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research under the CIHR operating grant number HHP-131557.