Community-based organizing against HIV and for rights among same-sex attracted men in Dar es Salaam, Tanzania

There was very little focus on same-sex attracted men (SSAM) and transgender women (TGW) in HIV programming and research in sub-Saharan Africa the first two decades of the HIV epidemic. This project was developed against the backdrop of the knowledge gap that had resulted from this, and has had as its main objective to generate new knowledge related to HIV among SSAM and TGW in Tanzania, and to contribute to the development of HIV programming for and in these groups. Research topics have included community-based organizing against HIV as well as the status and dynamics of the HIV epidemic among SSAM, TGW and other key populations (KP) in the HIV epidemic. This is a short summary of key findings. GRASSROOTS ORGANIZING Considerable grassroots organising against HIV has emerged among SSAM in Tanzania over the past few years. A striking feature is that this is not primarily brought about by men of money, education and position, but to a large extent by men from lower socio-economic backgrounds. This has shaped an HIV activism at the intersections between economic poverty and social marginality. Associated with the organizing, a range of global queer identities have gained ground among HBM in Tanzania. While some identity labels are borrowed from the English language, their meanings have often been changed or transformed as they have been taken up locally. Several global actors (e.g. INGOs and bilateral agencies) have also entered the field of HIV and HBM, and several have been seeking collaboration with the local grassroots movement. While the funding offered by these actors is highly welcome, it is also associated with challenges and critique. Local actors often find that the support is provided within a framework where grassroots actors are represented more in terms of what they are lacking than in terms of what they are possessing, as entities that need to be developed and shaped more than joined and supported, and as groups that should be trained and taught more than learnt from. There are several structural obstacles that community-based organisations have to negotiate, including (a) the legal situation; (b) criticism of HBM from within religious circles and in the political discourse; and (c) widely shared cultural values that consider explicit engagement with the sexual as ill-suited in formal discourse. The most basic enabler is a widely shared Tanzanian culture of flexibility and tolerance. THE CIRCUMSTANCES OF TGW Recently, organising has also emerged among TGW. The TGW community experiences that it is in a more difficult situation than the SSAM community, with regards to general acceptance, knowledge and understanding among health care providers, and inclusion in HIV programming. Based on qualitative research, we have explored the lives and circumstances of TGW, their health care experiences, and their HIV-related challenges. One one hand, there is a considerable degree of understanding of TGW in Dar, but TGW also experience hars discrimination, exclsuion and violence. Gender transition-related health care is not available, but a few are using hormonal treatment prescribed abroad. HIV, STI AND RELATED RISKS AMONG KP HIV prevalence among KP has declined significantly in the project period. Among SSAM as well as among FSW and PWID, prevalence rates have dropped by more than 50% in this period. However, the current rates are still far above that in the general population (where it is now 4.7%). Among SSAM 8.3% are HIV positive (95%CI: 6.3-10.9), among FSW 15.3%, and among PWID 8.7% (95%CI: 6.4-11.8). The prevalence of other STI is also high in all three groups. Among SSAM, the prevalence of hepatitis B is 6.8% (95%CI: 4.8-9.4), hepatitis C 6.2% (95%CI: 4.4-8.5) and syphilis 0.3% (95%CI: 0.08-0.9). Among FSW, the prevalence of hepatitis B is 2.9% (95%CI: 1.9 ? 4.4), hepatitis C 2.6% (95%CI: 1.6-4.0) and syphilis 0.3% (95%CI: 0.05-1.7). Among PWID, the prevalence of hepatitis B is 6.3% (95%CI: 4.4-8.9), hepatitis C 16.2% (95%CI: 13.0-20.1) and syphilis 0.3% (95%CI: 0.04-2.1). Significant risk practices among SSAM include low condom use, and frequent engagement in transactional sex and group sex. Many report to have experienced police arrest (30.1%), physical violence (21.1%) and forced sex (24.1%). Risk factors among FSW include a high number of clients, low condom use, and considerable alcohol use during commercial sex. On the other hand, three quarters (76%) have had an HIV test and received the test result in the last year, and 91% of those who are HIV positive are enrolled in care. A third (30.3% 95%CI: 25.4-35.2) of PWID say they have difficulties accessing clean needles, and 40% (95%CI: 35.2-45.8) have ever shared a needle. Among the latter, 72.0% (95%CI: 65.2-79.1) had done so during the last month. Knowledge of pre-exposure prophylaxis (PrEP) is still very low in all KPs, but the willingness to use it is high among those who are aware of PrEP.

Despite the disproportionate burden of HIV being carried by same-sex practising men in many African countries, HIV prevention programming targeting such men is still scant. However, in Dar es Salaam a nascent grassroots organizing against HIV and for heal th and rights is currently emerging. If successful, this kind of organizing may have the potential to play a significant role for HIV prevention. Building on previous research among MSM in Dar es Salaam and using a set of complementary qualitative researc h methods, this project will endeavour to generate new knowledge about the ongoing evolvement of community-based HIV- and rights-related work among MSM. The study will focus on how community-based groups strategize and work, the ways in which they manage to engage and involve a diverse population of MSM in HIV prevention, the ways in which they may achieve contact and collaboration with the 'mainstream HIV establishment', and the ways in which the ongoing work may lead to adjustment or adoption of practic es that provide added protection or harm reduction with respect to HIV. The postdoctoral candidate will join one or more of the mentioned groups as a particpant, and at the same time, with group members as co-investigators, study the processes community-b ased actors go through as they debate, formulate, implement and evaluate community-based activities. The study will also employ dialogical interviews (with MSM, 'mainstream' HIV actors and other key informants), group discussions, and media monitoring. Th e project will be carried out in collaboration between the University of Oslo and the Muhimbili University. It will thus contribute to a strengthening of research capacity and competence both in a Norwegian and a Tanzanian university. A third institution with an exceptional international standing will also join the collaboration: the National Centre in HIV Social Research in Sydney, where the postdoctoral candidat will be a visting researcher for 6 months.