Health Economics

ASSESSING ACCESS TO COMPREHENSIVE HIV PREVENTION

SERVICES FOR MEN WHO HAVE SEX WITH MEN AND FEMALE
SEX IN THE BAMENDA HEALTH DISTRICTASSESSING
ACCESS TO COMPREHENSIVE HIV PREVENTION SERVICES
FOR MEN WHO HAVE SEX WITH MEN AND FEMALE SEX IN
THE BAMENDA HEALTH DISTRICT

Journal: Health Economics

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Manuscript ID Draft

Wiley - Manuscript type: Research Article

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Keywords: Access to HIV/AIDS Services, Key populations

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Page 1 of 27 Health Economics

1 ASSESSING ACCESS TO COMPREHENSIVE HIV PREVENTION SERVICES FOR MEN

2 WHO HAVE SEX WITH MEN AND FEMALE SEX IN THE BAMENDA HEALTH
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DISTRICT
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6 Abstract
7 Having access to quality health and specifically access to comprehensive HIV/AIDS prevention
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9 services is a human right for everyone irrespective of age, sex, gender and sexual orientation. Making
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11 HIV prevention services accessible to key populations with minimal social, legal and behavioral
12 barriers will go a long way to curb the incidence among these groups, improve health outcomes as well
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14 as reduce HIV prevalence in the general population. The main objective of this research was to
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16 investigate the determinants of access to HIV prevention services for Female Sex Workers and Men
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Having sex with Men in the Bamenda Health district. Specifically, the study aimed at investigating the
19 drivers of non-accessibility to HIV prevention services for Men having sex with Men and Female sex
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21 workers and secondly, to scrutinize the drivers of non-accessibility to HIV prevention services for Men
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23 having sex with Men and Female sex workers in the Bamenda Health district. In order to obtain data
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24 for the study, 373 and 199 questionnaires were administered to assess prevention service access to FSW
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26 and MSM respectively. Data was analyzed using descriptive statistics, Chi-square, and the Bivariate
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28 and Multivariate regressions. The descriptive statistics showed that only 29.2% and 55.8% of FSW and
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MSM who participated in the study have access to comprehensive HIV prevention services
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31 respectively. Significant barriers such as, long geographic distance, non-awareness of where to get
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services, un-favorable policy and law as well as inconsistency in condom use were all factors limiting
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35 access to prevention services. Demographic factors like occupation and monthly income also proved
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to be significant in access to prevention services for FSW. Thus for access to be effective, actors should
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38 take these key issues into consideration.
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41 Key words: Access to HIV/AIDS Services; Key populations and Prevention
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43 1. Introduction
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45 Being able to attain an appreciable quality of health is the fundamental right of everyone. The Universal
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47 declaration of human rights in its Article 25(1) spells out that “Everyone has the right to a standard of
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49 living adequate for the health and well-being of himself and of his family, including food, clothing,
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52 housing and medical care and necessary social services, and the right to security in the event of
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54 unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances
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 Health Economics Page 2 of 27

1 beyond his control”(UN General Assembly,1984). It is on this foundation that in 2000, the Millennium
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3 Development Goals(MDGs) goal number 6 was set aside to combat HIV, Malaria and other diseases,
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6 and its target 6B was to ensure that by 2010, there would be universal access to treatment for HIV/AIDS
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8 for all those who need it (MDGs,2002).Building on the successes of the MDGs, the Sustainable
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10 Development Goals were introduced in September 2015 with vision to have a world with equitable
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and universal access to quality education at all levels, health care, social protection, universal respect
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15 for human rights and human dignity, the rule of law, justice, equality and non-discrimination (United
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17 Nations General Assembly, 2015). Under the banner of the Sustainable development goal number 3,
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UNAIDS laid out 10 targets for 2016-2021 strategy. The 6th is that 90% of key populations have access
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22 to combination services, while the 8th is that 90% of people living with HIV, at risk of and affected by
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24 HIV report no discrimination especially in health, education and workplace (Interagency Coalition on
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26 AIDS and Development, 2016).
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29 Key populations are a group of persons who due to their sexual behaviours, are exposed to HIV.
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31 According to the World Health organization (2016), Key populations are groups of persons who due
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33 to some risk behaviors, are at increased risk of HIV irrespective of the epidemic type or local context.
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These persons are faced with legal and social issues the increase their vulnerability. Some groups
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38 considered as key populations are men having sex with men, people injecting drugs, people in prison
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40 and other closed settings, sex workers and transgender people (WHO, 2016). In same light, UNAIDS
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revealed that more than 90% of new infections in central Asia, Europe, North America, the middle East
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45 and north Africa in 2014 were among these persons and their sex partners who accounted for 45% of
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47 new infections worldwide (UNAIDS, 2016). From a meta-analysis carried out between 2007 and 2011
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49 amongst 99,878 female sex workers in 50 countries. The overall prevalence was 11.8%-12% with
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52 variations in regions. This study also showed that, in 26 countries with medium and high background
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54 HIV prevalence, 30.7% of female sex workers were positive. The highest prevalence of HIV was in
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Page 3 of 27 Health Economics

1 sub-Saharan Africa (36.9%), followed by Eastern Europe (10.9%), Latin America and the Caribbean
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3 (6.1%), and Asia (5.2%); the lowest rate was in the Middle East and North Africa (1.7%) (Baral et al.,
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6 2012). For Men having Sex with Men (MSM), 2016 regional estimates indicated that, HIV prevalence
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8 among MSM ranged from 3.0% in the Middle East and North Africa to 25.4% in the Caribeans, Kenya
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10 20%, cote d’ivore 18% while in other countries like china and Thialand the incidence is reported to be
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on a rise (UNAIDS, 2016). MSM accounted for 12% of new infections in 2015 with 6% in Sub-
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15 Saharan Africa and 22 % in regions outside Africa (UNAIDS, 2017).
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17 Cameroon where the study area is located is presently reported to have a mixed generalized and
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concentrated epidemic(Cameroon Country Operational Plan,2016).The first case of HIV was
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22 diagnosed in 1985, and it progressively grew from 0.5% in 1987 to 11.8% in 2000, and only dropped
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24 to 5.5% in 2004(EDS/MICS, 2011).The last Demographic and Health survey found out that in 2011,
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26 the prevalence in general population for ages 15-49 years is 4.3%(EDS/MICS, 2011). Despite this
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29 decrease in general population in 2011, a study in 2011 gave an estimated prevalence among MSM at
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31 25.5% in Douala and 44.4% in Yaounde (Park et al., 2013). According to the Country Operational
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33 Plan (2017), the estimated population size of MSM in Cameroon is 66,842 with HIV prevalence of
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37.2%, In 2012, while adult prevalence was 4.5% HIV prevalence among female sex workers remained
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38 high at 36% (MISANTE, ONUSIDA, 2014; Cameroon Country Operational plan, 2016). Estimated
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40 FSW population size in 2016 was 113,580 with overall prevalence of 36.5% (World Bank, 2016;COP,
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2017).
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45 Though faced with the high burden of HIV as highlighted above, key populations are usually difficult
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48 to reach with prevention services especially for HIV testing. It is based on this that the World Health
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50 Organization (2016) stated that there is clear epidemiological rational for HIV programs to focus on
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52 key populations. WHO(2016) also noted that globally, the rate at which these populations are accessing
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55 safe, effective and quality HIV and AIDS services are extremely low because of behavioral, legal and
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1 social issues like stigma and discrimination, societal discrimination.. Hence HIV services for key
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3 populations remain inadequate leading to increased incidence while that in general population is either
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6 stabilizing or declining (WHO, 2016).
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9 HIV prevention through sensitization, condom use and especially HIV testing is the entry point in the
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11 HIV Continuum of care. According to UNAIDS targets 2020, 90% of positive FSW and MSM
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13 populations should know their status (UNAIDS,2016). The Global Forum on MSM and HIV in 2012,
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conducted an online focus group survey with 5,779 MSM from 165 countries on access to HIV
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18 prevention for MSM. The study revealed a low percentage of respondent reporting access to condoms,
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20 lubricants and HIV testing at about 37%, 20% and 37% respectively. Barriers identified in the study
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22 were homophobia, provider stigma, and negative consequences to out-ness which lead to extortion,
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25 blackmail, and violence. This study also did a comparative analysis between access in low income
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27 countries and high income countries and noted low access across the continuum for low income
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29 countries while high income countries had high access across the continuum (Sonya Arreola et al,
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32 2012). Access to prevention services especially knowledge on HIV has been reported by some studies
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34 to be superficial. A cross sectional study carried out in Takoradi –Ghana with 121 FSW unveiled that
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awareness of HIV, condom use and knowledge of modes of transmission among FSW were highly
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reported. However, comprehensive knowledge on HIV was relatively low at 26.45%. (Helen Habibata
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41 Habib, 2016). A cross sectional surveillance study in 2011 on HIV prevalence and factors associated
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43 with HIV infection with 272 and 239 MSM in Douala and Yaoundé respectively, showed that 64.1%
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45 reported inconsistent condom use with regular male partners and 48.5% with casual male and female
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48 partners as well as inconsistent use of condom-compatible lubricants (26.3%)(Park JN et al,2013). As
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50 concerns FSW, another study also saw that 40.8% FSW reported using male condoms every time they
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52 had sex with clients, while due to more money offered, half reported sex without condoms in the past
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1 HIV vulnerability, HIV services are still limited with only 43% of hotspots reached with HIV
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3 prevention services in Cameroon.
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6 The government of Cameroon through the ministry of public health and other international
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9 organizations(Global Fund for AIDS, Tuberculosis and
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11 malaria(GFATM)PEPFAR/USAID,WHO,UNICEF,WorldBank,CDC,UNESCO,UNDP,GTZ,CARE
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13 Cameroon, Catholic relief services and many others ) have been combating HIV since 1986 through
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the development and implementation of several National Strategic Plans(NSP). The current NSP 2018-
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18 2020 has objectives to; reduce HIV related morbidity and mortality as well as the socio-economic
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20 impact of HIV (NSP-2018-2020).The plan is expected to reduce new HIV infections by 60%,reduce
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22 related deaths by 60%,improve quality of life by 50%,and increase governance on the national
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25 response. Responding to the HIV health needs of key populations in Cameroon started in 2011 with a
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27 project called the HAPP project sponsored by the United States Agency for International Development
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29 (USAID) through Care Cameroon. Key focus of this project was prevention of HIV among Female sex
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32 workers and Men having Sex with Men in 5 regions of Cameroon. Based on need to scale up
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34 interventions with key populations, the second phase of the project known as “Continuum of
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Prevention, Care and Treatment of HIV with most at risk populations in Cameroon”, was extended
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from 2014-2019. The program under the banner of the National strategic plan for HIV response also
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41 aims at reducing HIV/STI infections and related morbidity and mortality, and to ease the impact of
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43 HIV on the socioeconomic development of Cameroon, by improving the Government’s and civil
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45 society technical capacity to implement evidence based prevention, care and treatment for key
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48 populations. The Cameroon Medical Women Association is the implementing partner targeting Female
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50 sex workers, while Affirmative Action Cameroon is the implementing partner targeting Men having
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52 sex with men in the Bamenda health district. Health facilities such the Baptist Health Board provide
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1 HIV prevention, treatment and Care services as well as rehabilitation to female sex workers in
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3 Bamenda.
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6 Despite the considerable efforts to provide interventions that can enhance service uptake by key
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9 populations and reduce the epidemic, the HIV prevalence among key populations in Cameroon still
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11 remains high while access to services is low. Adult HIV prevalence in the general population has fallen
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13 consistently from 7.7% in 1999 to 4.5% in 2012, but has remained high among FSW and MSM from
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25%-36% for FSW and 36% for MSM during the same time period (Cameroon Country operational
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18 Plan, 2017). Bamenda health district where several interventions are being carried out has an estimated
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20 FSW population of 2,842(CMWA mapping, 2017).While the region had an adult prevalence of 6.3%
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22 (EDS/MICS, 2011), FSW had an estimated prevalence of 32.8% and 3.8% for MSM (IBBS,
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25 2016).With this high prevalence of HIV among FSW and MSM, it is unfortunately reported that
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27 coverage of HIV related services for key populations in Cameroon is limited. For instance, only 49.6%
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29 of HIV positive FSW and 29.0% of positive MSM were initiated on Antiretroviral therapy(ART) as
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32 compared to 70% for general population in 2016 (Cameroon Country operational plan, 2017).
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To curb this high prevalence and negative impact of HIV on FSW and MSM as well as bringing an
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37 equilibrium in service uptake for all with no discrimination, HIV services should be made available,
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39 accessible and acceptable for key populations. This should be based on the principles of medical ethics,
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no stigma and discrimination and the right to health (WHO, 2014). Health care workers need to provide
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44 sensitive, appropriate, non-judgmental and non-discriminatory services to key populations (WHO,
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46 2014).To attain the UNAIDS targets for 2020, 90% of HIV positive FSW and MSM are supposed to
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48 know their HIV status which is primary prevention. On the other hand, FSW and MSM are supposed
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51 to understand their risk, acquire knowledge, skills and behavioral interventions to help them reduce
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53 risky behaviours (WHO, 2014). From the stated analysis, one can therefore asked that, what are and
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55 barriers to accessing HIV prevention services in the Bamenda Health district? It will therefore be
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1 imperative to do an Assessment on Access to Comprehensive HIV prevention for Key Populations in

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3 the Bamenda Health district.
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6 Objective of the Study
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9 Main Objective
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12 On the basis of the background and statement of the problem, the major objective of this researh is:
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15 To investigate the determinants of access to HIV prevention for FSW and MSM in the Bamenda Health
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district.
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Specific Objectives
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From the main objective, the specific objectives are:

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26 1. To determine from the perspectives of Men having sex with Men and Female sex workers the
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29 barriers to accessing HIV prevention services.
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31 2. To investigate the drivers of non-accessibility to HIV prevention services for Men having sex
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33 with Men and Female sex workers.

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36 The rest of the paper is arranged in four sections. Section two focuses on literature review while section
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38 3 deals with the methodology of the research. Section four presents the findings and interpretation of
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40 results with section five rounding up with summary of findings, conclusion, and policy implication.
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47 3. Empirical Literature
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49 This part of the literature review focuses on debates, controversies related to two main research
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51 objectives of this work. It will therefore be broken down in various sub sections as per the research
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1 objectives. Within each objective discussed, the variables or factors related to each objectives as
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3 highlighted by recent literature or studies are discussed
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6 Many researchers have over the years attempted to determine the drivers of non- accessibility to HIV
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8 prevention services for key populations. Prominent among these researchers is Baral (2012) where he
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10 looked at the burden of HIV among female sex workers in low income and middle in come countries
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through a systematic review and meta-analysis from January 1, 2007 and June 25th 2011 .He found out
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15 that from 102 articles representing 99,878 female sex workers in 50 countries, HIV prevalence was
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17 11.8%, pooled odds ratio for HIV infection of 13.5%, with wide interregional ranges in the pooled HIV
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prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV
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22 prevalence 30.7% of sex workers were HIV positive with odd ratios of 11.6%. Based on this findings,
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24 the study noted that HIV is disproportionately high among female sex workers and suggested a need to
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26 scale up access to quality HIV prevention considering the legal and policy environment which sex
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29 workers operate, taking actions to address the important role of stigma, discrimination and violence
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31 targeting FSW (Stephan Baral et al, 2012). Similarly, another worldwide online survey supporting
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33 Baral’s study also looked at associations between access to HIV services and individual –level
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perceived sexual stigma, country level crimilization of homosexuality and country level investment in
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38 HIV service for MSM. With 3,340 MSM from 115 countries participants were categorized according
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40 to criminalization of homosexuality policy and investment in HIV services targeting MSM. This study
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showed that Lower access to condoms, lubricants, and HIV testing were each linked with greater
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45 perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in
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47 HIV services (Sonya Arreola, 2015). Though findings from Baral (2012), and Sonya (2015), portrayed
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49 how the policy and legal environment affect access, they failed to look at logistical,economic,
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52 behavioral as well as demographic factors that may affect access to HIV prevention in these global
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1 Shamanesh et al (2003), equally looked at the impact of attempts to abolish sex work in Baina, India
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3 based on a court order in 2003 ,to do away with brothels in a red light district, and the keep sex workers
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6 in mental asylums .They discovered how sex workers were scattered, loss of identity, reduced
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8 negotiating power, increasing competition, leading to a more hostile environment, no community
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10 support, police raids all of which led to limiting access to HIV prevention tools and health care
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(Shahmanesh, et al., 2009).This action and resulting effect proved that, when the environment is not
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15 friendly to key populations their access to basic prevention services is hampered with. Still in support
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17 to the fact that socio cultural factors serve as barriers to access HIV prevention services was a study in
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the small Caribbean nation of Grenada. This study with aim to explore the socio-cultural factors that
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22 influenced vulnerability associated with HIV infection for 47 men who have sex with men aged 16-42
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24 with data regarding homophobia, stigma and discrimination, sexual behaviours, HIV/AIDS and STIs
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26 revealed that, MSM who took part in a formal HIV educational program were more significantly more
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29 likely to get tested for HIV every 10-12 months than non-participants.
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32 While some scholars focused only on socio-cultural factors as highlighted above, other scholars have
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34 seen in Africa that, lack of knowledge of where to get HIV prevention services, long distance to
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services, high cost, as well as negative community attitudes play significant roles in access to HIV
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prevention services. A study was done with the Bridging the Gaps Program partners using qualitative
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41 operational research with 3 key populations in Kenya between October 2014 and August 2015. Results
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43 proved that though HIV prevention services like peer educators for outreach sensitization, HIV testing,
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45 condoms and lubricants exist, there were still a number of constrains like lack of knowledge about
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48 services, distance to services, cost, negative community attitudes. Behavioral barriers like fear of HIV
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50 positive status, fear of disclosure and in accurate self-evaluation of susceptible risk, feeling of
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52 exclusion and fear of trust in MSM led organization still served as barriers to accessing HIV prevention
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55 services. Proximity of services was also a push and constrain factor to some female sex. However,
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1 those who felt stigmatized in nearby centers preferred to overcome long distance and time to visit
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3 centers far off so that they could not be identified. (Bridging the gap research report, 2015). There is
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6 still substantial evidence that distance is a barrier to accessing preventions services. John Ambrose
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8 Sahyo (2016), in his research on the perspective and experiences of young key populations on provision
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10 of services for MSM and FSW in Tanzania also unveiled some significant barriers to access to HIV
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prevention. A Qualitative method was used to explore in-depth information about the community Based
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15 HIV care program for MSM and FSW. Health service providers were purposively sampled .Eligibility
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17 criteria for these interviews included being aged 18 years or older. His participants revealed that
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distance served as major barrier to accessing prevention services as not all districts were reached
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22 compelling them to travel long distances. Another cross sectional descriptive research in Nairobi with
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24 brothel, street and bar based FSW using purposive interviews with a sample size of 382 respondents
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26 revealed that long walking distance from comprehensive health centers influenced the access and
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29 utilization of HIV prevention services (Ruth Njambi, 2014).The findings of Ruth Njambi (2014) and
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31 Ambrose(2016) in regards to walking distance is somehow contradictory to the Bridging the gap
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33 findings where due to stigma and fear of being seen in a clinic participants preferred overcoming
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distance to visit far off services. This shows that, distance still stands as barrier but when issues of
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38 stigma and discrimination come to play, key populations overcome the barrier of long distance in order
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40 to access services from safe, confidential and non-judgmental facilities. This studies gives this research
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work clear barriers to use in measuring access to HIV prevention services for key populations.
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45 A key barrier to accessing HIV prevention services for key populations in Cameroon is stigma and
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48 discrimination fueled by crimilization of sex work and homosexuality as highlighted by a recent
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50 gender analysis in Cameroon by PEPFAR (2016) .Using desk review, field based interviews and focus
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52 group discussion with 16 MSM, 35 FSW, and 45 CBO representatives providers services to MSM and
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55 FSW in Douala, Bamenda and Yaoundé. This analysis revealed that FSW and MSM experience
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1 stigma and discrimination from family, community members and health care providers which greatly
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3 increases their risk of violence, infection and their desire to access health care services and get tested
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6 for HIV (PEPFAR, 2016).This findings also serve as a guide to the type of barriers to use in measuring
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8 access to HIV prevention services for key populations in the Bamenda Health district.
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11 4. Methodology
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14 This section seeks to discuss the model specifications for prevention access, description of variables in
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16 the models, study design, the study population for this work, and inclusion criteria for target population.
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It further presents the sample size for both populations, and sampling techniques of the study, pre-
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21 testing, the data collection instruments, the analytical approach, validation of data for its acceptance as
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25 the study.
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28 Model specification
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30 The model specification for prevention access is the concise description of how the variables relate to
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32 each other. The independent variables for prevention access include behavioral, stigma and
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discrimination, awareness of available services, geographic distance from services, law and policy
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37 environment, with the dependent variable being access to HIV prevention services.
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40 In order to investigates the objectives of this study as highlighted in section one, the following general
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42 notation was used;
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45 𝑃𝐴 = 𝑓(𝐵 + 𝑆 + 𝐴 + 𝐺 + 𝐿)………………………………………………………(1)
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48 Based on this general notation, the econometric specification is as follows:
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51 𝑃𝐴 = 𝛼0 + 𝛼1𝐵 + 𝛼2𝑆𝐷 + 𝛼3𝐴 + 𝛼4𝐺 + 𝛼5𝐿 + 𝜀…………………………………………(2)
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1 Where PA stand for prevention access, B stands for behaviour, SD stands for stigma and discrimination,
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3 A stands for awareness of available services, G stands for geographical distance from services, and L
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6 stands for Law and Policy environment. 𝛼0 and 𝜀 represent the constant and error terms respectively, 𝛼1
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8 , 𝛼2, 𝛼3, 𝛼4, 𝛼5, represents coefficients associated to the variables.
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11 .Description of variables in Model
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14 As concerns prevention access the researcher will describe how the various variables as highlighted
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above will be measured.
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19 This study assumes that when there is no stigma and discrimination there is access to HIV prevention
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22 services and vice versa. The extent to which stigma and discrimination affects HIV prevention services
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24 is rated from 1-5 in line with each source of stigma and discrimination which could be self, peer, family,
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26 authorities, and health care providers. A score between 1 -3 means stigma and discrimination does not
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29 affect access to prevention while a score of 4-5 means stigma and discrimination reduces access to
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31 prevention.
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34 The study also assumes that when there is no awareness about available services, there will be not
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access. On the other hand, when there is awareness there is access to HIV prevention services. If a
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participants responds yes, it means he or she is aware and thus has access to prevention services, while
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41 a no responds indicates that he or she is not aware and thus has no access to HIV prevention services.
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43 Level of awareness is also rated 1-5.A score between 1-3 shows that the level of awareness reduces
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45 access to HIV prevention services while a score of 4-5 means the level of awareness is high and thus
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48 increases access to HIV prevention services.
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51 Geographic distance refers to nearness to HIV prevention services. It is rated from 1-4.A score of 1
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53 means the HIV prevention service is close by, and doesn’t affect access to HIV prevention service
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1 while a score of 2 -4 means the prevention service is either far, very far or too far and thus reduces
2
3 access to HIV prevention services
4
5
6 The researcher assumes that if geographic distance is short, high level of awareness and limited or no
7
8
9 stigma and discrimination against key populations, there will be no barrier to access to HIV prevention
10
11 services while long geographic distance, low awareness and increased stigma and discrimination will
12
13 increase barriers in HIV prevention services for key populations.
14
15
16
17
5. Presentation and Discussion of Empirical Findings
18 The purpose of this study is to understand the determinants of access to HIV prevention for FSW and
19
Fo
20 MSM in the Bamenda Health district. This section focuses on data analysis, interpretation and
21
22
23
presentation. After identifying the problem of study in the introduction, existing literature was
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24
25 reviewed in section two. In section three, the methods that the study used in collecting data was
26
ee

27 explained. This section presents the analysis and findings of the study as highlighted in the research
28
29 methodology. The results are presented on the extent to which behavioral, stigma and discrimination,
rR

30
31
32 awareness of available services, geographic distance, law and policy environment determine
ev

33
34 access to HIV prevention services .The questionnaire which was the research instrument was
35
36
iew

developed following the objectives of the study. Descriptive statistics and regressions were used in
37
38
39 analyzing data on the determinants of access to HIV prevention services for FSW and MSM.
40
41
42 Presentation of demographic findings
43 This section is concerned with outlining the socio demographic characteristics of respondents in terms
44
45 of the distribution of respondent by age, level of education, occupation and average income
46
47
48 Distribution of respondents by age
49 The majority (42.9%) of FSWs were of ages 26-35 years old. For MSM, participants of ages 19-25
50
51 (46.2%) and 26-35 (42.2) respectively were most represented. (Table 1).It shows that the bulk of key
52
53 populations are between the ages 19-35 years that is the youthful population. This is also the age range
54 with high HIV prevalence in Cameroon
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1 Distribution of respondents by educational level

2
Over 55.6% (49.5+6.1) of FSW and 67.9% (43.8+24.1) of MSM had attended secondary and higher
3
4
5 education respectively. This indicates that key populations that participated in the study are educated
6
7 meaning their responses can’t be judged, hence making the result of this study reliable. (Table 1)
8
9
10 Distribution of respondents by occupation
11
12 As concerns occupation, the majority of FSWs (66.6%) were carrying out sex work only whereas for
13
14 MSM, the majority (43.7%) were students. While over two third (68.9%) of FSW were earning
15
16 <50,000F CFA/month, an almost equal proportion of MSM (73.4) were earning zero francs CFA (Table
17
18
19 1).This shows that while some FSW make a living only from sex work as a profession others are
Fo
20
21 engaged in other income generating activities. The result show that MSM practice is not done to earn
22
23
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a living, but rather a sexual orientation.

24
25 Table 1: Socio-demographic characteristics of participants
26
ee

FSW MSM
27 Variables Frequency(373) Percentages (%) Frequency(199) Percentages (%)
28 Age range(years)
29 15-18 03 0.8 11 5.5
rR

30 19-25 129 34.6 92 46.2

31 26-35 160 42.9 84 42.2
32 36-45 72 19.3 12 6.0
46-55 05 2.4 0 0.0
ev

33
Educational Status
34
None/Primary 44 44.4 64 32.1
35 Secondary 49 49.5 87 43.8
36
iew

Tertiary 6 6.1 48 24.1

37 Occupation
38 Farming 5 1.3 8 4.0
39 Housewife 11 2.9 0 0.0
40 Student 30 8.0 87 43.7
Petit trading 39 10.5 47 23.6
41 Hairdresser/Tailor 39 10.5 27 13.6
42 Employed 1 0.3 27 13.6
43 Sex Work only 248 66.5 9 4.5
44 Average
45 income/month
46 Nothing 1 0.3 146 73.4
47 <50000 257 68.9 39 19.6
50-100,000 103 27.6 14 7.0
48 100-200,000 10 2.7 0 0.0
49 >200,000 2 0.5 0 0.0
50
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1 Presentation of other important findings

2
This section presents other important findings related to access to HIV prevention services for FSW
3
4
5 and MSM such as frequency and place of seeking HIV prevention services, and reasons for seeking
6
7 services in such places.
8
9
10 Frequency and place of seeking HIV prevention services
11
12 Over 92.5% of FSW and 80.9% MSM respectively had benefitted from free HIV prevention services,
13
14 with over 43.2% of the participants benefitting all prevention services (HIV prevention education,
15
16 condom/lubricant, HIV/STI testing/screening). The majority of FSW (41.0%) and MSM (47.2%)
17
18
19 respectively have been going for this services occasionally, with the major point of sought of these
Fo
20
21 services are private clinics [56.8% (FSW) and 54.3% (MSM)], followed by drop-in centers [24.2%
22
23
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(FSW) and 31.2% (MSM)]. The major reasons to sought prevention services in these places were;
24
25
26
FSWs [privacy (33.3%)] and MSM [privacy (41.2%) and confidentiality (41.2%)] (Table 2).
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27
Table 2: Frequency and place of seeking HIV prevention services
28
FSWs MSMs
29 Variables Frequency Percentages (%) Frequency (199) Percentage (%)
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30 (373)
31 Benefited free HIV prevention services?
32 Yes 345 92.5 161 80.9
ev

33 No 28 7.5 38 19.1
34 If Yes above, kind of prevention services
35 HIV prevention education 126 33..8 34 17.1
Condoms/Lubricant 39 10.5 25 12.6
36
iew

HIV/STI testing/screening 21 5.6 8 4.0

37 Received more than two of the above 161 43.2 94 47.2
38 Frequency of seeking HIV prevention
39 services?
40 Always 8 2.1 9 4.5
41 Most of the time 85 22.8 43 21.6
42 Occasionally 153 41.0 94 47.2
Rarely 110 29.5 40 20.1
43
Never 17 4.6 13 6.5
44 Place where HIV prevention services are
45 sought
46 Public 25 6.7 29 14.5
47 Private 212 56.8 108 54.3
48 DIC 91 24.4 62 31.2
49 Drug store 45 12.5 0 0.0
Reasons for choice of Health Facility
50
Affordability 35 9.4 24 17.1
51 Nearness 51 13.7 16 8.0
52 Non-discrimination 69 18.5 36 18.1
53 Friendliness 36 9.7 43 21.6
54 Confidentiality 36 9.7 84 41.2
55 Privacy 124 33.3 82 41.2
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1
2
3 Presentation of Findings Based on Research Objective One
4
5 The first objective of this study was to determine from the perspectives of Men having sex with Men
6
7 and Female sex workers the barriers to accessing HIV prevention services in the Bamenda Health
8
9 district. To accomplish this the researcher raised some questions to FSW and MSM related to their
10
11
12
perspective on access to HIV treatment services . Results obtained are presented below following each
13
14 question.
15
16
17 Access to HIV prevention services among FSW/MSM
18
19
Just over a third (29.2%) of FSWs and over half (55.8) of MSM believe they had access to HIV
Fo
20
21
22 prevention services just like anyone in the general population (Figure 1). The major reasons advanced
23
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24 for lack of access were; fear of identification [FSW (16.7%), MSM (6.5%)], discrimination [FSW
25
26
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27 (15.0%), MSM (5.9%)], stigma [FSW (11.3%), MSM (4.5%)] (Figure 2).
28
29 80.00% 70.8%
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30
percentage

55.8%
31 60.00% 44.2%
32
40.00% 29.2%
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33
Lack access
34 20.00%
35 Have access
36
iew

0.00%
37 FSW MSM
38 Access
39
40
41 Figure 1: Have access to HIV prevention
42
43
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1 Reasons for lack of access to HIV prevention services

2
3 16.7%
4 15.0%
5 11.9%
Percentage

11.3% 11.0%
6
7 7.3% FSW
8 5.9% 6.5%
9 4.5% MSM
3.7%
10 2.0% 2.0% 2.3%
11
12
13 Stigma Discrimination Confidentiality Not aware of Identification High cost Distance
Reason for lack of access
services
14
15
16
Figure 2: Reasons for not having access to HIV prevention.
17
18 Stigma/Discrimination on access to HIV prevention services
19 From the Chi-square analysis, self-stigma [FSWs (X2=38.89, P=0.001), MSMs (X2=16.52, P=0.002)],
Fo
20
21
22
stigma from peers [FSWs (X2=14.92, P=0.001), MSMs (X2=13.30, P=0.010)], stigma at family level
23
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24 [FSWs (X2=15.54, P=0.004)], stigma from authorities [FSWs (X2=21.81, P=0.002)], stigma from
25
26 health personnel [FSWs (X2=19.66, P=0.006)] and stigma from other external factors FSWs (X2=38.89,
ee

27
28 P=0.001)] were factors that hinder access to HIV prevention services respectively (Table 3).
29
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30
31
32 Table 3: Stigma on access to HIV prevention services
No Extend Little Extend Moderate Great Extend Very great X2 P-
ev

33 Extend Extend value

34 Yourself 38/77(49.4) 30/72(41.7) 16/85(18.3) 15/73(20.6) 10/66(15.2) 38.89 0.001
35
36
iew

50/89(56.2) 24/35(68.6) 19/31(61.3) 12/17(70.6) 6/27(22.2) 16.52 0.002

37
38 Your Peers 33/50(66.0) 21/98(21.4) 31/105(29.5) 12/56(21.4) 12/64(18.8) 14.92 0.001
39
31/45(68.9) 35/58(60.3) 23/39(58.9) 15/31(48.4) 7/26(26.9) 13.30 0.010
40
41 Family 33/72(45.8) 16/66(24.2) 12/44(27.3) 20/58(34.5) 28/133(21.1) 15.54 0.004
42
43 38/66(63.3) 31/56(55.4) 21/38(55.3) 9/20(45.0) 12/25(48.0) 2.90 0.566
44
45 Authorities 44/98(44.9) 36/114(31.5) 17/90(18.9) 8/48(16.7) 4/23(17.4) 21.81 0.002
46
49/77(63.6) 15/30(50.0) 17/31(54.8) 16/27(59.3) 14/34(41.2) 5.43 0.247
47
48 Health 29/55(52.7) 23/80(28.8) 26/90(28.9) 18/89(20.2) 13/59(22.1) 19.66 0.006
49
50 workers 26/58(44.8) 16/30(53.3) 27/40(67.3) 21/35(60.0) 21/36(58.3) 5.52 0.243
51
52 Others 40/96(41.7) 22/88(25.0) 13/79(16.5) 24/74(32.4) 10/36(27.8) 14.58 0.006
53
49/82(58.5) 28/42(66.7) 9/18(50.0) 10/20(50.0) 16/37(43.2) 5.10 0.273
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1
2
3 Aware of facilities/organisations giving out HIV prevention services?
4
5 Over two third of both FSWs (72.9%) and MSMs (71.9%) were aware of where to seek HIV prevention
6
7 services (Figure 3). Of the two third who were aware, majority [FSW (25.1%), MSM (21.9)] pointed
8
9 out drop-in centers as the main facility offering HIV prevention services (Figure 4).
10
11
12
13 Aware of where to get services Not aware of where to get services
14 80.00% 72.92% 71.86%
15 70.00%
16 60.00%
17
percentage

50.00%
18
19 40.00%
27.08% 28.14%
Fo
20 30.00%
21 20.00%
22 10.00%
23
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0.00%
24
FSW MSM
25
26 Access
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27 Figure 3: Awareness of where to get HIV prevention services?

28
29
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25.1%
30 21.9%
31
percentages

32 15.9%
ev

33 10.8%
10.1% 10.4%
34
35 3.6%
36 2.2%
iew

37
38 CMWA Drug store Faith Base Gov't Private Affirmative Drug store Gov't HF
39 FSW Facilities H.Facilities Clinics MSM
40
Reason for lack of access
41
42
43 Figure 4: Where to get HIV Prevention services
44
45 Geographic Distance from HIV prevention services
46
47 As concerns distance from point of receiving HIV prevention services, over half (58.4%) of FSWs and
48
49
50
a third (26.1%) of MSM lived further away from the point of receiving HIV prevention services. In
51
52 spite of the distance, majority of FSW (86.1%) and over half (58.8%) of MSM accepted to have
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1 received this services through mobile prevention. However, only 16.9% of FSW and 36.2% of MSM
2
3 benefitted from this services any time they want (Table 4).
4
5
6 Table 4: Geographic distance from HIV prevention services
7 FSWs MSM
8 Variables Frequency Percentages Frequency Percentage
9 (373) (%) (199) (%)
10 Distance to prevention services
11 Close by 37 9.9 65 32.7
12 Average distance 118 31.6 80 40.2
Far 165 44.2 39 19.6
13
Very Far 53 14.2 15 7.5
14 Do mobile prevention services reaches
15 you?
16 Yes 321 86.1 117 58.8
17 No 52 13.9 82 41.2
18 Are these services available any time you
19 want?
Yes 63 16.9 72 36.2
Fo
20
No 310 83.1 127 63.8
21
22
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25 Sexual behaviour and HIV prevention services
26
From the Table 2 below, just 24.7% of FSW and a third (35.7%) of MSM have been using condoms
ee

27
28
29 and or lubricants consistently. As regards condom use with major partners, just a quarter (25.5%) of
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30
31 FSW and close to two third (64.8%) of MSM respectively used condoms with their major partners. On
32
ev

33 the other hand, over two third (73.2%) of FSW and just 17.6% of MSM use condoms regularly with
34
35
36 their casual partners (Table 5).
iew

37
38 Table 5: Sexual behaviour and condom use
39 FSWs MSM
40 Variables Frequency Percentages Frequency Percentage
41
(373) (%) (199) (%)
42
Using preservatives consistently in the
43 last three months?
44 Yes 92 24.7 71 35.7
45 No 281 75.3 122 64.3
46 Use condom with your main partner
47 Yes 95 25.5 129 64.8
48 No 252 67.5 57 28.6
49 Use condom with your casual partner
Yes 273 73.2 35 17.6
50 No 70 18.8 140 70.4
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1 Law and Policy

2
Just 3.2% of FSWs and 13.1% of MSMs accepted to know a law in Cameroon that prohibits that sexual
3
4
5 practices/orientation. However, over 56.6% of FSWs and 27.6% of MSM testify to have been penalized
6
7 due to their sexual orientation (Table 6).
8
9 Table 6: Law and policy influencing HIV prevention services
10 FSWs MSM
11 Variables Frequency Percentages Frequency Percentage
12 (373) (%) (199) (%)
13 Know of any law in Cameroon
influencing access?
14
Yes 12 3.2 26 13.1
15 No 361 96.8 173 86.9
16 Ever been penalized due to your
17 sexual orientation?
18 Yes 211 56.6 55 27.6
19 No 162 43.4 144 72.4
Fo
20
21
22 Socio-demographic factors affecting access to HIV prevention services
23
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24
Table 7 and 8 reveals the unadjusted and adjusted logistic regression analysis of socio-demographic
25
26 and access to HIV prevention services among FSWs and MSMs. From the unadjusted logistic
ee

27
28 regression, factors eligible for the multivariate analysis were set at P-values ≤0.2. After controlling for
29
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30
potential confounders two factors were found significant (occupation and monthly income). Thus
31
32
FSWs who carry out sex work plus other activities were 2.7 (1.5-4.9) times more likely to seek HIV
ev

33
34
35 prevention services than those who carried out sex work only. Likewise, FSW with a monthly income
36
iew

37 > 100,000F were 4.7 (1.1-19.7) times more likely to seek prevention services compared to those who
38
39
40 earned <50,000F (Table 7). As concerns socio-demographic characteristics among MSMs, none were
41
42 found significant (Table 8).
43
44 Table 7: Socio-demographic factors (FSW)
45 Barriers to access to HIV services BIVARIATE MULTIVARIATE
46
Socio-demographic factors Prevalence of OR (95CI) P-Value AOR/CI P-Value
47
48 access
49 Occupation
50
Sex work only 51/248(20.6) 1 1
51
52 Sex work + other activities 58/125(46.4) 3.3(2.1-5.3) 0.001 2.7(1.5-4.9) 0.001
53 Education
54
None/Primary 23/72 (31.9) 1
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1 Secondary 36/142 (25.4) 0.7(0.4-1.3) 0.309

2 High school 39/124 (31.5) 0.9(0.5-1.3) 0.943
3 Tertiary 11/35(31.43) 0.9(0.4-2.3) 0.957
4
5 Monthly income
6 <50000Fcfa 70/258(27.1) 1 1
7 50-100,000Fcfa 32/103(31.1) 1.2(0.7-2.0) 0.454 1.2(0.9-2.9) 0.117
8
9 >100,000Fcfa 7/12(58.3) 3.8(1.2-12.2) 0.028 4.7(1.1-19.7) 0.035
10 Age group
11 <25 years 46/132(34.9) 1 1
12
25-34 years 39/160(24.3) 0.6(0.4-1.0) 0.050 1.2(0.6-2.3) 0.594
13
14 35years and above 24/81(29.6) 0.8(0.4-1.4) 0.432 1.5(0.7-3.3) 0.267
15 Table 8: Socio-demographic factors affecting access to HIV prevention services for MSM
16 Barriers to access to HIV services BIVARIATE MULTIVARIATE
17 Socio-demographic factors Prevalence of OR (95CI) P-Value AOR/CI P-Value
18 access
19 Occupation
Fo
20 Employed + MSM 62/112(55.4) 1
21 Student + MSM 49/87(56.3) 1.1(0.6-1.8) 0.892
22 Education
23 None/Primary 19/41 (46.3) 1
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24 Secondary 26/46(56.5) 1.5(0.6-1.8) 0.344

High school 41/64 (60.7) 2.1(0.9-4.6) 0.075
25 Tertiary 25/48(52.1) 1.3(0.5-2.9) 0.589
26 Monthly income
ee

27 Nothing 104/185(56.2) 1
28 ≥ 50,000Fcfa 07/14(50.0) 0.8(0.3-2.3) 0.649
29 Age group
rR

30 <25 years 55/103(53.4) 1

31 25-34 years 51/84(60.7) 1.3(0.8-2.4) 0.316
35years and above 05/12(41.7) 0.6(0.2-2.1) 0.444
32
ev

33
34
35 Social factors hindering access to HIV prevention services
36
iew

37 Table 9 and 10 reveals the unadjusted and adjusted logistic regression analysis of social factors and
38
39
access to HIV prevention services among FSWs and MSMs. From the unadjusted logistic regression,
40
41
42 factors eligible for the multivariate analysis were set at P-values ≤0.2. After controlling for potential
43
44 confounders two factors were found significant (consistent condom use, awareness of where to get
45
46 prevention services, distance and policy). For both FSW and MSM, sex workers with inconsistent use
47
48
49 of condoms were respectively 0.2(0.1-0.5) and 0.4(0.2-0.9) times less likely to have access to HIV
50
51 prevention services compared to their counterparts who uses condoms consistently. More so, FSWs
52
53 who didn’t know where to seek HIV prevention services were 0.5(0.2-0.9) less likely to seek HIV
54
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1 prevention services compared those who knew where to get this services. In addition, MSMs living far
2
3 and very far from the point of distribution of HIV prevention services were respectively 0.4(0.2-0.9)
4
5
6 and 0.3(0.1-0.8) times less likely to have access to the services. The same scenario of distance [0.8(0.3-
7
8 2.0)] was observed among FSWs though not significant. Lastly, FSWs and MSMs who knew no Law
9
10 penalizing their sexual orientation were respectively 3.8(0.7-19.8) and 4.1(1.4-12.1) more likely to seek
11
12
13
HIV prevention services compared to their counter-parts who accepted to know of a Law, though not
14
15 significant (Table 9 and 10).
16
17 Table 9: Social factors hindering access to HIV prevention services (FSW)
18 Behavioural factors
19 Consistent condom use in the last three
months?
Fo
20
Yes 52/92(56.6) 1 1
21 No 57/281(20.3) 0.2(0.1-0.4) 0.001 0.2(0.1-0.5) 0.001
22 Awareness of services
23
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Know where to get HIV prevention

24 services
25 Yes 94/272(34.6) 1 1
26 No 15/101(14.9) 0.3(0.2-0.6) 0.001 0.5(0.2-0.9) 0.037
ee

27 Geographic distance from prevention services

28 Your nearness to HIV prevention services
Close by 16/37(43.2) 1 1
29
Far 47/118(39.8) 0.9(0.4-1.8) 0.712 1.1(0.4-3.7) 0.882
rR

30 Very far 46/218(21.1) 0.4(0.2-0.7) 0.005 0.8(0.3-2.0) 0.628

31 Law and Policy
32 Know any law that affects access to HIV
ev

33 prevention services
34 Yes 2/12(16.7) 1 1
35 No 107/361(29.6) 2.1(0.5-9.8) 0.342 3.8(0.7-19.8) 0.113
Ever been penalized because of your
36
iew

sexual orientation?
37 Yes 52/211(24.6) 1 1
38 No 57/162(35.2) 1.7(1.1-2.6) 0.027 1.5(0.9-2.5) 0.143
39
40
41 Table 10: Social factors hindering access to HIV prevention services (MSM)
42 Behavioural factors
43 Consistent condom use in the last three
44 months?
45 Yes 52/71(73.2) 1 1
46 No 59/128(20.3) 0.3(0.2-0.6) 0.001 0.4(0.2-0.9) 0.019
47
48 Awareness of services
49 Know where to get HIV prevention
50 services
51 Yes 83/143(58.1) 1
52 No 28/56(50.0) 0.7(0.4-1.3) 0.305
53
Geographic distance from prevention services
54
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1 Close by 49/65(58.1) 1 1
2 Far 40/80(50.0) 0.3(0.2-0.7) 0.002 0.4(0.2-0.9) 0.034
3
Very far 22/54(40.7) 0.2(0.1-0.5) 0.001 0.3(0.1-0.8) 0.015
4
5 Law and Policy
6 Know any law that affects access to HIV
7 prevention services
8 Yes 6/26(23.1) 1 1
9 No 105/173(60.7) 5.1(1.9-13.5) 0.001 4.1(1.4-12.1) 0.011
10
Ever been penalized because of your
11 sexual orientation?
12 Yes 24/55(43.6) 1 1
13
No 87/144(60.4) 2.0(1.1-3.7) 0.034 1.4(0.6-2.9) 0.413
14
15
16
17 Limitation of the study
18
19 Financial limitation posed a major limitation to the research. Being a twin research focusing on HIV
Fo
20
21 prevention and treatment for two different populations made the scope of work too broad and the
22
23
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therefore took a lot of time. The cost of producing questionnaires, administering, entering data and
24
25
26 analysing was high. However, with help from my organization and family members, the burden was
ee

27
28 reduced.
29
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30
31 Secondly, this research was done during the socio political crisis in the North West region where the
32
ev

33 research was being done. It greatly affected the completion time as questionnaires could not be
34
35
36
administered in hotspots as planned due to the fact that the study population was scattered and difficult
iew

37
38 to find. However, with the respondent driven sample method used in administering the questionnaires,
39
40 respondent could take time to locate their peers. Well trained data collectors from CMWA and
41
42
Affirmative Action facilitated the process.
43
44
45 Another limitation was that it was conducted within the confines of the Bamenda Health District and
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48 could not to an extent provide enough results that can be generalized in the whole Cameroon. Because
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50 key populations are very mobile, it is necessary that a continuous national research on access be
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52 conducted to support the design and implement national programs targeting key populations.
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5 5. Conclusion and Policy Implication
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7 Key populations play a key role in the dynamics of HIV due to their sexual orientation and behaviours
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9 that exposes them to HIV. Though faced with the high burden of HIV, key populations face unique
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11 barriers to accessing HIV prevention services. And thus, if key populations face access problems, there
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14 is need for more research in this area so as to curb the spread of the pandemic. This research reveals
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16 that key populations in the Bamenda Health district don’t have the expected access to comprehensive
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18 HIV prevention services. Significant barriers such, long geographic distance, limited awareness of
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where to get services, policy and law as well as behavioral factors are limiting access to prevention
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23 services. Demographic factors like occupation and monthly income also proved to be significant for
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25 FSW. The results of this work implies that, for institutions and governments wishing to design HIV
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prevention programs for key populations in the Bamenda health district and in Cameroon in general,
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30 issues like geographic distance, awareness on available services, the law, and consistency in condom
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32 should be prioritized.
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37 REFERENCES
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39 1. Baral, S., et al (2012).Burden of HIV among female sex workers in Low-income and
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48 4. Erin Papworth.,et al (2014) .Examining risk factor for HIV and access to services among
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13 9. John A, (2016).Perceptions and experiences of young key populations on responsive
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