2. PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

3. Background and Context Gay men and other men who have sex with men (MSM) around the world face significant challenges to accessing healthcare services Knowledge, skill, and sensitivity needs among healthcare providers inadequately addressed by general medical education curricula

4. The MSMGF-JHU Curriculum for Providers Arms local community groups with the ability to independently implement training programs to build cultural and clinical competency among healthcare providers

5. What are the nine modules? Understanding Gay Men and Other MSM Sexuality and Health Barriers to Health Creating a Friendlier Environment Promoting Mental Health Taking a Sexual History Supporting Gay Men and other MSM Who Use Drugs and Alcohol Interventions for HIV and STI Prevention Clinical Care for HIV and other STIs

6. Are there any accompanying materials? Participant’s guide and deck of PowerPoint slides to accompany each module are available for download from www.msmgf.org/promotinghealth Instruments to evaluate the process and outcomes of the training are also provided. The evaluation tools are designed to assess: Learning needs assessment. Pre- and Post- Assessment Process Evaluation (Overall Satisfaction) Follow-up Surveys Providers Clients

7. Pilot Test with GALZ, Zimbabwe

8. Pilot Training Design Of the nine modules, five of the curriculum’s nine modules were presented over 1.5 days, including: Module 1: Understanding Gay Men and Other MSM. Module 2: Sexuality and Health Module 3: Barriers to Health Module 4: Creating a Friendlier Environment Module 6: Taking a Sexual History

9. Evaluation Results ITEMPRE-TESTPOST-TESTCHANGEP-VALUE Knowledge of MSM issues (mean score)8.09.81.8<0.01 Participants would feel comfortable discussing anal sex with clients 36.8%61.9%25.1%0.1 Participants would feel comfortable providing friendly sexual health services to MSM 31.6%81.0%49.4%0.02 Participants believe they are ethically obliged to maintain confidentiality regarding same-sex behavior, even where it is criminalized 95.2%90.5%4.7%>0.1 Participants believe it is important to develop relationships with LGBT organizations 94.7%90.5%4.2%>0.1 Participants disagree that homosexuals are more likely to commit deviant sexual acts than are heterosexuals 57.9%71.4%13.5%>0.1 Participants disagree that acceptance of homosexuality aids in the deterioration of morals 28.6%76.2%47.6%<0.01 Participants believe it is impossible for a provider who morally objects to homosexuality to provide appropriate services to gay men 52.6%23.8%28.8%0.02

10. Evaluation Results ITEMPRE-TESTPOST-TESTCHANGEP-VALUE Knowledge of MSM issues (mean score)8.09.81.8<0.01 Participants would feel comfortable discussing anal sex with clients 36.8%61.9%25.1%0.1 Participants would feel comfortable providing friendly sexual health services to MSM 31.6%81.0%49.4%0.02 Participants believe they are ethically obliged to maintain confidentiality regarding same-sex behavior, even where it is criminalized 95.2%90.5%4.7%>0.1 Participants believe it is important to develop relationships with LGBT organizations 94.7%90.5%4.2%>0.1 Participants disagree that homosexuals are more likely to commit deviant sexual acts than are heterosexuals 57.9%71.4%13.5%>0.1 Participants disagree that acceptance of homosexuality aids in the deterioration of morals 28.6%76.2%47.6%<0.01 Participants believe it is impossible for a provider who morally objects to homosexuality to provide appropriate services to gay men 52.6%23.8%28.8%0.02

11. Evaluation Results ITEMPRE-TESTPOST-TESTCHANGEP-VALUE Knowledge of MSM issues (mean score)8.09.81.8<0.01 Participants would feel comfortable discussing anal sex with clients 36.8%61.9%25.1%0.1 Participants would feel comfortable providing friendly sexual health services to MSM 31.6%81.0%49.4%0.02 Participants believe they are ethically obliged to maintain confidentiality regarding same-sex behavior, even where it is criminalized 95.2%90.5%4.7%>0.1 Participants believe it is important to develop relationships with LGBT organizations 94.7%90.5%4.2%>0.1 Participants disagree that homosexuals are more likely to commit deviant sexual acts than are heterosexuals 57.9%71.4%13.5%>0.1 Participants disagree that acceptance of homosexuality aids in the deterioration of morals 28.6%76.2%47.6%<0.01 Participants believe it is impossible for a provider who morally objects to homosexuality to provide appropriate services to gay men 52.6%23.8%28.8%0.02

12. Evaluation Results ITEMPRE-TESTPOST-TESTCHANGEP-VALUE Knowledge of MSM issues (mean score)8.09.81.8<0.01 Participants would feel comfortable discussing anal sex with clients 36.8%61.9%25.1%0.1 Participants would feel comfortable providing friendly sexual health services to MSM 31.6%81.0%49.4%0.02 Participants believe they are ethically obliged to maintain confidentiality regarding same-sex behavior, even where it is criminalized 95.2%90.5%4.7%>0.1 Participants believe it is important to develop relationships with LGBT organizations 94.7%90.5%4.2%>0.1 Participants disagree that homosexuals are more likely to commit deviant sexual acts than are heterosexuals 57.9%71.4%13.5%>0.1 Participants disagree that acceptance of homosexuality aids in the deterioration of morals 28.6%76.2%47.6%<0.01 Participants believe it is impossible for a provider who morally objects to homosexuality to provide appropriate services to gay men 52.6%23.8%28.8%0.02

13. Guiding Framework Sexual Health Framework Move away from a disease model Focus on strengths-based approaches and sexual harm reduction Designed for easy adaptation Modular facilitating use of specific modules; Offers flexible training options Complements local training efforts and tools Knowledge, Attitudes, Skills

14. Each Module Robust and detailed technical content: Topline messages around each sub-topic What you need to know about x topic Facilitator’s Tips: To enhance the training process/experience 2 Group Activities: To ensure learning is experiential and to instigate attitudinal change 1 Case Study: To contextualize learning Pre-Assessment Questions To customize the training to learning needs of providers and see where participants are Post-Assessment: To verify if learning has occurred Pre-Reading Assignment: To encourage self-reflection among participants e.g. a media/news piece by Ugandan tabloid Additional Reading: To help interested participants to delve deeper on relevant topics

40. PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

41. Module 1: Understanding Gay Men and Other MSM 41

42. Learning Objectives 42 1 2 3 Define MSM and common sexual practices Identify unique health issues faced by gay men and other MSM Discuss provider roles in addressing the health needs of gay men and other MSM

43. Module Overview 43 1 2 3 4 5 Definition of key terminology including gay men and other MSM Common sexual practices of gay men and other MSM Unique health needs of gay men and other MSM Current global HIV and health trends among gay men and other MSM Sexual health promotion with gay men and other MSM 6 The importance of focusing on gay men and other MSM

44. Introduction 44 1 2 3 Gay men and other MSM: Experience significant barriers to accessing quality healthcare Are disproportionately burdened with HIV and other STIs Health providers: Have knowledge gaps concerning MSM-related health issues Play a crucial role in mitigating health risks Appropriate care is sensitive, responsive, and non-judgmental

45. Who are MSM? Not all MSM identify as ‘gay,’ or bisexual There is great diversity within gay- identifying and non gay-identifying MSM, socially and culturally defined sub-groups and sub-cultures MSM may be married, have children, and have sex with women MSM are often hidden within their communities MSM cannot be identified by clothing, mannerisms, or social roles 45 MSM are men who have sex with other men

46. Same-sex behavior exists globally Evidence of Male-to-male Sex 46 In a recent study in the United States, 3.8% of Americans identified as lesbian, gay, bisexual, or transgender (LGBT), and 8.2% engaged in same-sex behavior Other studies show varied prevalence of MSM in E Asia, S and SE Asia, E Europe, Latin America, and Africa Most study findings are underestimates because of underreporting: o Fear of stigma and discrimination o Criminalization of same-sex behaviors (77 countries) Subsequently, gay men and other MSM can remain invisible in the healthcare system, hindering their healthcare provision

47. Key Terminology Homosexual or same-sex behavior Sexual orientation Sexual identity Gender Gender identity Gender expression Transgender 47

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50. Summary 50 1 2 3 4 5 Exist in all societies and locations Include a variety of sexual orientations and identities Have unique health needs Are at increased risk of HIV and other STIs Face barriers to accessing health services at all levels Providers play a critical role in mitigating barriers to healthcare services. Focusing on gay men and other MSM has many benefits. Gay men and other MSM:

51. www.msmgf.org/promotinghealth

53. Content development Highly iterative, but rigorous Key Ingredients Existing training curricula, tools, guidelines Emerging research concerning gay men Technical Advisory Board Scientists, Frontline Providers, Local Community Members, Trainers Adult Learning Theory Participatory, self-directed, based on existing knowledge, and experiential

54. Technical Advisory Board Eduard Sanders – Kenya (Kenya Medical Research Institute) Kevin Rebe – South Africa (Anova Institute) Paul Semugoma – Uganda (Frank and Candy, AMSHeR, MSMGF) Venkatesan Chakrapani – India (Center for Sexual Health Research and Policy) Frits Van Griensven – Thailand (University of California, San Francisco) Martin Choo – Malaysia (University of Malaya) Igor Toskin – Switzerland (WHO) Carlos Caceres – Peru (Universidad Peruana) Rafael Mazin – USA (PAHO) Billy Pick – USA (USAID) Ken Mayer – USA (Fenway Institute) George Ayala – USA (MSMGF) Chris Beyrer – USA (Johns Hopkins) Rodney Vanderwarker – USA (Fenway Institute) James Robertson – India (Alliance India)

55. Timeline Pilot test in Africa in June In partnership with GALZ PANGAEA-MSMGF consultation in May Launch at AIDS 2014 Workshops with feedback at both MSMGF, Main IAS Conference and the Global Village Implementation Implementation in Costa Rica in Fall 2014 (TBC) Spanish translation, Training, Adaptation Implementation in Senegal in September-October, 2014 (TBC) HIV Prevention 2.0 French translation, Training, Adaptation

56. Acknowledgements Technical Advisory Board Developed by Mohan Sundararaj, MSMGF Ryan Zahn, KPP, CPHHR, JHSPH Krystal Mason, KPP, CPHHR, JHSPH Stefan Baral, KPP, CPHHR, JHSPH George Ayala, MSMGF Ivy Climacosa (Design) and Liesl Messerschmidt (Evaluation Tools)

57. For discussion How do we resource provider-engagement efforts at the country level that are technically robust, culturally relevant and are directed towards sustainability? What is the role of the gay community and gay-led organizations in provider engagement efforts across diverse settings and contexts? Is evaluation of training programs and measuring their impact critical to our understanding around quality improvement of services targeted at gay men and other MSM?

58. www.msmgf.org/promotinghealth