Healthcare worker training to improve quality of care for sexual and gender minority people in sub‐Saharan Africa: learning from efforts in Uganda

Abstract

Introduction Training in care for sexual and gender minority (SGM) populations is critical for ending the HIV epidemic. SGM people, particularly men who have sex with men (MSM) and transgender women, experience disproportionate HIV infection across the globe. The objective of this commentary was to synthesize facilitators of and barriers to SGM health training efforts for healthcare workers in Uganda, in order to help inform potential priorities, strategies and next steps to advance culturally responsive HIV‐related care for SGM communities across Uganda and sub‐Saharan Africa. Discussion SGM health training often includes education on: foundational concepts and language; stigma, discrimination and SGM health disparities; understanding and addressing implicit bias; sensitive and effective communication and building SGM‐inclusive and welcoming healthcare environments. Clinicians’ education includes sexual and gender histories, sex‐positive HIV counselling, sexually transmitted infections, HIV pre‐exposure prophylaxis and gender‐affirming hormone therapy. SGM communities in sub‐Saharan Africa have often experienced discrimination, persecution, incarceration and physical violence, and they encounter unique barriers to engagement in sexual health services and HIV prevention and treatment. SGM health training efforts in Uganda reveal challenges to and opportunities for advancing equity for SGM communities in sexual health and HIV medical care across the region. In Uganda, SGM community advocacy, as well as policies and programmes of the Ministry of Health and US President’s Emergency Plan for AIDS Relief, have increased readiness and need for scaling up training and skills‐sharing in SGM‐focused HIV and sexual healthcare, including Ugandan‐led and international initiatives. Conclusions Numerous challenges exist to widespread culturally responsive HIV and sexual healthcare for SGM communities in sub‐Saharan Africa. Lessons learned from healthcare worker training efforts in Uganda may inform future replication, adaptation and dissemination initiatives to meet the needs of more SGM communities in the region. Evaluation of SGM health training programmes to determine the impact on HIV virological suppression and sexual health outcomes will be critical for identifying best practices and strategies that may support advancing HIV epidemic control for SGM communities in Uganda and across sub‐Saharan Africa.

“You are not a man”: a multi‐method study of trans stigma and risk of HIV and sexually transmitted infections among trans men in Uganda

“…The research team utilizes a trans‐inclusive approach incorporating community engagement, provider sensitivity training, peer support, inclusion of trans people in research design and implementation, and as co‐investigators and members of the community advisory group, plus quarterly consultative meetings for trans people, peers and research staff. Sexual and gender minorities report that the research clinic is inclusive and welcoming, and that they feel safe while there [ 25 ].…”

Nurses’ reflections on caring for sexual and gender minorities pre-post stigma reduction training in Uganda

“…Several types of stigma exist among these populations. Enacted stigma - the experience of unfair treatment by others - is common in healthcare settings in sub-Saharan Africa [ 5 ], where lack of provider knowledge about culturally sensitive care is a significant barrier to healthcare access by SGM. This situation is not any different in several parts of the world, as highlighted by studies done in several countries [ 6 – 12 ].…”

“…Several stigma-reduction interventions for SGM exist in Sub-Saharan Africa. These include training health workers in cultural responsiveness and involvement of SGM peer educators in Uganda [ 21 ], and addressing structural stigma through Advocacy and Other Community Tactics in Burundi, Cameroon, Côte d’Ivoire, Ghana, and Zimbabwe [ 22 ]. Other interventions include the reduction of interpersonal stigma in Ghana through participatory stigma-reduction training for all staff levels with delivery by staff and clients from the facilities who were trained as stigma-reduction facilitators [ 23 ] and a participatory theatre intervention in Eswatini and Lesotho [ 24 ].…”

A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria

“…In recent years, the number of programmes addressing the needs of transgender populations (primarily HIV services) implemented in SSA countries has increased [25,26], including the provision of gender-sensitive and stigma reduction trainings for healthcare providers [27][28][29]. As HIV programmes attempt to expand their services to the transgender population, there is a need to better understand how stigma influences existing services in specific contexts like Nigeria.…”