Three clinician participants who were providing treatment for sexually transmitted infections and general medical care and 13 counsellor participants who were providing risk reduction counselling were interviewed for this study. In total 7 women and 9 men were interviewed. Four participants self-reported as being from the MSM community in Mombasa. All 16 had first-hand experience of working with high-risk MSM for at least two years and had a combined experience of over 2,400 interactions with over 480 MSM, as well as experience with female sex workers and other populations at risk for HIV acquisition. Participants represented a variety of religious backgrounds including Muslim, Christian and agnostic. Counsellor participants were trained in the VCT model of counselling and were conversant with standard protocols. Five had a higher diploma in counselling, 8 had a certificate in counselling, and 3 were clinically qualified. Clinician participants had not received specific counselling training outside of their medical training.
What participants knew and learned about working with MSM (the cognitive construct)
Counsellors' knowledge and experience of issues related to counselling MSM varied between the service providers who identified themselves as MSM and those who did not. Little in the standard Kenyan VCT training prepared them for the kind of counselling needs they faced and the specific challenges of risk reduction counselling in this setting. On-the-job training and peer-to-peer support was often important in learning how to provide appropriate counselling.
Knowledge and perceptions of sexual roles amongst MSM
Participants expressed an awareness of the variety of roles played by cohort MSM. They describe ‘insertors’ (also known as ‘basha’, ‘top’ or ‘king’) and ‘receptors’ (‘shoga’, ‘bottom’ or ‘queen’). Six (6/16) of the participants reported that most MSM were taking on both roles at different times and with different partners.
Twelve participants noted that among the community at large there seemed to be a perception that to be an insertor was more socially acceptable than a receptor:
For someone to feel comfortable that they are accepted in society they just say that I am an insertor. (non-MSM participant).
It was suggested that this role may influence the counselling provided because some counsellors perceived that insertors would be able to ‘give up’ MSM activity or even be ‘cured’:
It seems like insertors are held at a higher – what do I call it – you are respected if you are an insertor. It seems like counsellors probably view insertors as people who can change. ‘He is an insertor. He can change’. If he is a receptor ‘he can't change. He is already used to this habit’. (MSM participant).
Reported volunteer risk behaviours and triggers for high-risk behaviour
Participants reported stress when faced with reports of risk taking from the volunteers and said they faced difficulty in providing effective risk-reduction counselling. One participant describes the difficulties of counselling and challenges faced by the MSM cohort volunteers:
As a counsellor I am like: what I am supposed to be saying? I mean how do I help in such? (non-MSM participant).
All participants reported that MSM volunteers used condoms infrequently and they found this hard to accept as counsellors; two reported that clients had flat out refused condoms, the other 14 talked of them ‘trying but not liking’ condoms or of only using them sometimes. They described how some impoverished cohort volunteers have unprotected sex regardless of HIV status and how as counsellors they had mixed feelings, describing empathy felt by some participants towards the poor predicament of volunteer, in some ways qualifying risk behaviour and low condom use as understandable for male sex workers under pressure. This counsellor paraphrased the words of a male sex worker:
When I have slept hungry and don't know where and when my next meal will come from and here I have somebody who would want to have anal sex with me without a condom…. I give in because I am looking forward to that meal. (MSM counsellor paraphrasing a comment from a male sex worker volunteer).
Alcohol and drugs were described by all participants as being associated with high-risk volunteer behaviour and that when they encountered it they felt unable to work effectively with the volunteers. One counsellor describes alcohol abuse as a trigger for unsafe behaviour:
We have discovered they mostly have sex when they are drunk… so that they don't reason. That's why most of them seroconverted. (non-MSM participant).
Participants identified common myths among volunteers that may affect reduced condom use, including that anal sex is less risky than vaginal sex and that sex with women has a higher risk of HIV transmission since more women than men in Kenya are HIV infected. They voiced that giving information and debunking myths was a useful thing that they could do as counsellors.
Nine (9/16) participants stated that they felt hopeless when faced with volunteers who said that they preferred sex without condoms. They felt that they lacked skills to explore the reasons for this in the context of MSM relationships, and to follow through with appropriate solutions to help reduce risk taking behaviour.
Participants described feeling stressed by attitudes to condoms among the cohort volunteers and feeling that there was little they could do to impact low levels of condom use. Five (5/16) participants said that volunteers reported unprotected sex for pleasure. The remainder felt sexual risk-taking was an issue of ‘promiscuity’ (‘being faithful for them, it cannot work’) rather than rooted in love or desire. Themes of attraction, desire and trust as this relates to condom use were mentioned by three out of four MSM participants and by one non-MSM participant. Participants described MSM as generally unlikely to use condoms (‘they do not like them’ or ‘they get more money without’). The participants reported that as volunteer trust in their respective sexual partners increased, condom use tended to fall.
You have been using condom but now you are good friends so you just go on without. (MSM participant).
Exploration of relationships, and self-esteem during counselling session
All participants reported that they rarely had time to explore wider life issues with volunteers. Participants found this challenging as the need to delve deeper frequently arose in counselling sessions. Seven participants mentioned that volunteers reported rejection by their families, feelings of isolation and having low self-esteem. In addition, stressful volunteer life events related to the inability to meet basic needs were raised. This participant, paraphrasing the words of a volunteer summed up the limitations of addressing risky behaviour without addressing the larger context of a volunteer's life:
I imagine sometimes if I want to go to someone for counselling and they just addressed my recent sexual exploits they would not be helping me. (MSM participant).
Participants said that low self-esteem amongst volunteers could be a factor driving risk-taking behaviour, and that stigma and shame were factors that may affect MSM self-esteem to a greater degree than in non-MSM populations. As this participant pointed out, psychological distress can lead to risk-taking behaviour:
Could these be the issues that are putting them at risk? You don't belong anywhere. You are living a double life. … When you realize you have nothing to lose or gain you end up putting yourself at a lot of risk. When you think ‘I deserve to die’ you become someone who can take any risk… Drink [and] drive, do a lot of crazy things. (MSM participant).
Counsellors felt that longer counselling sessions would give opportunities for deeper exploration of underlying causes, such as life circumstances and self-esteem, in order to address risk-taking behaviour during counselling sessions.
Perceptions of the VCT model in relation to providing risk reduction counselling for MSM
Despite seeing volunteers quarterly and gaining an increased awareness of volunteer life issues and risk behaviour, all participants felt that the risk reduction counselling they provided was not adequate. Most participants felt that VCT training had equipped them well for a heterosexual HIV testing and counselling session, they often felt ill-prepared to tackle MSM-specific issues.
We didn't go to specifics though we discussed about stigma and accepting all clients and treating them right. That was very inadequate for the kind of work I am doing. (non-MSM participant).
The other problem working with this group is stigmatisation and [their] feeling of being judged. ... The minute they sense a ‘stop [the MSM behaviour]’ message they will go. That is not our mandate. (non-MSM participant).
Experienced counsellors acknowledged that sessions were more focused on probing for details of risk exposure and on telling people to use condoms than on exploring risk reduction options from the volunteers' perspectives. Most felt that coupled with providing longer counselling sessions, counselling training should focus more on counselling skills (such as reflecting, challenging, focusing, summarising and addressing loss and grief, rejection and low self-esteem.) as opposed to information giving (such as “condoms reduce transmission risk”; “lubricant reduces the risk of condoms splitting during anal sex” etc.).
Sometimes they come and their risk is not their issue on that day. I feel that all I know is HIV and HIV related risk issues and that is all. I wish I had more knowledge and counselling skills in other areas. (non-MSM participant).
Participants expressed frustration with their perceived lack of skill in risk reduction counselling and felt this most acutely when seroconversions happened, implying that they felt counselling had ‘failed to protect’ the volunteers.
The influence of community values on counselling MSM (the social construct)
Social stigma and negative societal perceptions of homosexuality in Kenya often challenged participants' ability to deliver effective, non-judgemental risk reduction counselling sessions. While all participants understood the importance of not imposing one's own values during counselling sessions, the perception of homosexuality as deviant or something to be “fixed” was common.
The impact of religious values
While all but one participant had a nominal religion nine participants described themselves as having strong religious values, both Christian and Muslim. Five participants described themselves as born again Christians. In line with their initial training, these nine participants felt that they had been successful in divorcing themselves from their religious values about homosexuality for the duration of the counselling sessions.
Especially on my side I get satisfaction from the fact that I can divorce my religious orientation and be able to see this person as a person whose values must be respected. A person whose choices must be respected (non-MSM participant).
However, this did not always carry over to interactions with their colleagues. All of the MSM participants described the stigma they faced from fellow counsellors:
Stigma was there. A counsellor who was born again would tell us to stop it (MSM participant).
Some counsellors here they know I am an MSM. They sit me down and tell me to stop [being gay]. I usually ask myself: if they tell me that what do they tell the clients? (MSM participant).
Homosexuality perceived as a psychological problem
Participants described MSM, including their MSM counsellor colleagues, as ‘incongruent’. A feature of the higher diploma in counselling in Kenya is a session on ‘congruency’ which is explained as having taken a journey through one's own psychological problems. In brief, a congruent person has dealt with their issues and an incongruent person has not. An incongruent person may therefore be more likely to engage in risky behaviour than a congruent person. Three participants with the higher diploma in counselling and two without (none of whom were themselves MSM) mentioned that they did not feel MSM should become counsellors for other MSM as they were perceived as ‘incongruent’:
How can an incongruent person help another incongruent? …. most of them they need to be helped to reach a level of accepting themselves. Before they have reached there they are already helping someone else. (non-MSM participant).
I feel that it is quite a challenge for a gay man to be a counsellor to another gay man because they still practice gay. (non-MSM participant).
This highlights a perception among at least five participants who perceived that homosexuality was a psychological “problem” and that for MSM to achieve “congruency”, he must forgo sex with other men. As this MSM participant said:
So they (non-MSM-identifying counsellors) think probably being gay is a disease. You cannot cure someone else when you already have the same disease. (MSM participant).
Not all participants felt MSM would make poor counsellors for other MSM, however. The MSM participants and two heterosexual participants, disagreed and felt that MSM made good counsellors for MSM.
Distinguishing sex work from sexual orientation: understanding gay relationships
Transactional sex with male clients was very common among cohort volunteers with over two thirds of participants reporting being paid for sex 
. Perhaps as a consequence, only one (8%) of the participants explicitly distinguished sexual orientation from sex work. This lack of distinction in the majority of the participants' minds was expressed by this non-MSM participant:
I look at a gay man as a gay man. They are the same as any other female sex worker who probably needs counselling. (non-MSM participant).
Throughout all but one participant transcript, MSM behaviour was described as resulting from poverty (‘they started this thing out of poverty’) and MSM sex was regarded as transactional. The partners of volunteers were frequently described as their ‘clients’, although two of the non-MSM participants, and one MSM participant did note that some MSM did have boyfriends.
There are some who have come forward in a relationship but their relationships are not stable. Today they will have this relationship, tomorrow they will have another. (non-MSM participant).
Couples counselling for male couples was described as a rare event and no deliberate attempts at seeing couples were described.
Sexual attraction in the counselling sessions
Frequent references to the issue of sexual attraction in the counselling room led to a modification of the interviews to incorporate this as a question its own right. All of the male counsellors interviewed had been propositioned at one time or another by volunteers and some confessed that they had found it quite hard to resist advances, although they knew that they were supposed to refer them to another counsellor and stated that was what they did. A number of second-hand accounts of relationships between gay counsellors and volunteers were explained. Firstly the gay counsellors stemmed from the same community that volunteers were recruited from and were previously or currently enrolled in research cohorts. Secondly they had access to records and HIV results of people they may have had sexual relationships with in the past.
But what happened is that some clients came up with some issues. This counsellor is seducing me. Another is trying to kiss me… It was so hard. (non-MSM participant).
We have had issues in the counselling rooms where counsellors hit on clients or the other way around. He is nice, he gives you his number and you meet up later. (MSM participant).
Also the counsellors lacked skill and professionalism in dealing with transference. One counsellor identified that there was a lack of real support.
We didn't equip our counsellors to handle that – for any eventuality. We just train them to do counselling work but we don't train them on how to handle themselves professionally. (non-MSM participant).
The kind of supervision we have here is quite artificial. We go to supervision, I attend supervision, but we don't share those issues: for fear of course. For fear that you will be judged and for fear that your confidentiality will be compromised. (MSM participant).
Stigma and criminalisation
Although male-male sex and transactional sex are both illegal in Kenya, participants revealed high levels of motivation and 11 (85%) mentioned the wider public health benefits of their work as important or rewarding. They saw no conflict in their work, saying that it was not illegal to provide services to vulnerable MSM.
In stressing the importance of public health over stigma and criminalization, one participant referred to her work at a nearby antenatal clinic:
‘As a nurse if I am in an antenatal clinic I don’t ask ‘How did you get the pregnancy? Is it legal or not?’ (non-MSM participant).
Participants reported difficulty in gaining the trust of MSM volunteers, and volunteer recruitment efforts were initially challenging as well. Eight (8/16) participants reported that volunteers told them of being rounded up and arrested. Whilst describing themselves as ‘strong’ and ‘I am OK with it’ the four MSM participants talked of the day-to-day stresses of hiding their identity from neighbours, continually gauging people's reactions, being barred from certain places, and living ‘double lives’.
The positive influence of peers and volunteers on value systems (changing unhelpful social and cognitive constructs)
All of the non-MSM participants commented on the way their attitudes towards MSM had changed over time as they worked with them both as peers (fellow counsellors) and as persons who needed HIV testing and counselling:
I have changed a lot. I have to be honest – I used to not even want to work with them. Now we talk. We can go in one bus. I feel warm. These people are human beings and it is their choice. (non-MSM participant).
We would meet with them every day. It is like flooding. I really had to sort out my issues. Coming here really did help me…to work out my own confusions at that time. (non-MSM participant).
They reported enjoying the relationships they had formed and shedding the stigma they once felt. A general sense of shifting values was also felt by the MSM participants, who reported that with time they experienced fewer negative comments from colleagues and felt more supported by the team.
Training and supervision needs identified by study participants
A number of specific needs were identified and are presented in detail in . In response to their skill needs, participants felt that tailored training was required for MSM counselling to equip counsellors with skills to support condom negotiation and activities that raise self esteem. Training and supervision should also challenge homophobia and explore personal cultural traditions and assumptions. Training recommendations included development of tools to deal with self-esteem issues and dispel transmission myths common among MSM; reinforcing the importance of leaving judgemental values and homophobia at home or better yet learning why those values are harmful and ultimately shedding them altogether; and learning to distinguish between men who sell sex to other men and MSM who do not (distinguishing sex work from sexual orientation) and how to address the needs of both groups. Suggestions for supervisory support included further discussions of root causes for risky behaviour in the MSM community and to reinforce the importance of challenging negative stereotypes and fostering a safe environment for MSM (including counsellors) to be open and candid about their lives. Both recommendations touched upon improved outreach to the local professional community, including lawyers, police and community leaders.
Training and supervision needs identified by study participants.