As a peer educator for the Jhpiego-supported Gateway Project in Malawi, John Banda* spends nights and weekends scouting Ngabu area bars, sports fields and other community venues, looking to help men in need of HIV prevention or treatment services.
Drawing on his own experience as a gay person living with HIV who, since 2017, has benefited from antiretroviral therapy (ART), the 34-year-old is publicly open and insistent about knowing one’s serostatus and seeking lifesaving care. With homosexuality against the law in his country, John’s work is sensitive.
The aim of this work is preventing and reducing the transmission of HIV, particularly in key populations at great risk for HIV infection, including men who have sex with men, people who inject drugs and sex workers; and ultimately meeting the UNAIDS target 95-95-95: that by 2030, 95 percent of all people living with HIV know their HIV status; 95 percent of all people who know their status receive ART; and 95 percent of all people receiving ART will have viral suppression so their immune systems remain strong and the likelihood of their infections being passed on is greatly reduced.
Men who have sex with men often face stigma, discrimination and interpersonal violence. Where health services are available, challenges remain in accessing them. At the same time, this population is at increased risk of sexually transmitted diseases including HIV, which is 25 times higher among gay men and other men who have sex with men, compared to the general population.
This is why the Gateway Project, in partnership with the Government of Malawi and Ministry of Health, sensitizes health care workers to provide HIV testing, counseling, care and treatment services to key populations. Key population-friendly health care workers are trained to counteract stigma in HIV service delivery and to conduct “know your provider” sessions. These meetings are opportunities for clients to become familiar with service providers in an informal setting before meeting them in the clinic or hospital. They also provide a platform for all to discuss and solve their challenges in accessing services.
Jhpiego is implementing the Gateway Project–Key Populations program in Chikwawa, Mzimba, Chiradzulu and Mwanza districts, with funding from the U.S. President’s Emergency Plan for AIDS Relief through the U.S. Centers for Disease Control and Prevention.
“At first I was very skeptical when John asked me about my sexual orientation,” says Gilbert,* a 24-year-old gay male sex worker who met John at an area bar. “I looked at him in doubt as to whether to trust him with my secret or not.”
John’s candor and offer of support convinced the young man to disclose not only his sexual orientation, but also that he had never been tested for HIV.
I took this as an opportunity to learn about my HIV status and was interested in seeking medical attention at Bangula District Hospital where doctors are trained to provide health services to men [such as myself].”Gilbert
Trained by Jhpiego as a peer educator, John provided counseling to the young man and offered him an HIV self-test kit. When Gilbert reported positive results, John referred him to a clinic for a confirmatory test and treatment.
He assured Gilbert he would continue to follow up with him. In fact, for six months after a man tests positive and starts ART, John continues to provide support. Long-term continuity of treatment is necessary for achieving and maintaining viral suppression and good health. Among John’s many goals is raising awareness about U=U or “undetectable equals untransmissible,” by explaining that people living with HIV with an undetectable viral load cannot transmit the virus to sexual partners.
From October 2020 to March 2021, the Gateway Key Populations program has reached out to 1,743 gay men and other men who have sex with men with quality health care services. Of these, 1,569 (88%) have received HIV testing services with 118 (8%) learning of a positive HIV status and 117 (99%) starting ART. Five men who have sex with men who tested HIV-negative and self-reported activities that increase their risk of exposure to HIV were provided HIV-prevention services, including pre-exposure prophylaxis in March 2021.
“At the clinic, I was pleasantly surprised at how quickly I was helped when I presented a referral slip,” Gilbert recalls. “The doctor was quite pleasant and respectful to me. I felt comfortable talking about my health.”
When his second test confirmed the positive result of the HIV self-test, he was surprised all over again, admitting, “I always assumed I was immune to HIV infection.” He immediately enrolled to receive ART, and now visits Ngabu Health Center to get a month’s worth of the pills, which he takes daily.
Even as he follows up with Gilbert, John is back at work, on sports fields and in bars, striking up conversations about HIV with others in his community who may be unaware of their status and their risk of acquiring HIV.
When I identify [myself as a gay man], I ask him to tell me [who] he has been sexually involved with,” says John, who leads by example to show peers how knowing your HIV status is the first step to preserving good health.
“And the next man I meet; I encourage him to do the same.”
*The names of the peer educator and his client have been changed to protect their safety.
Sarah Sakanda is a knowledge and communication specialist for Jhpiego in Malawi.
Maryalice Yakutchik is Jhpiego’s communications manager.