1. Introduction

This study explores the effectiveness of the HIV and AIDS response within the target population of MSM in Jamaica. It investigates, the views and perspectives of the health workers who carry out or implement these programmes.

Thanks to science, the ability to treat and care for persons living with HIV (PLHIV) and AIDS has grown exponentially. Individuals are defying their prognoses and are living with HIV and AIDS for record number of years than they did when the virus was first discovered. Gay, bisexual, transgendered and other men who have sex with men but may not identify as gay, are disproportionately affected by sexually transmitted infections like HIV (MOH, 2011a). For the purpose of this research the term MSM will be defined and utilized as the public health terminology to capture the target audience of all males who have sex with males.

For the purpose of this research, health workers will be defined as clinical and nonclinical practitioners who are in the work of conducting or implementing different levels of intervention or HIV preventative care. These health workers are the implementers of programmes in which MSM are the primary beneficiaries. They will be programme officers, educators, coordinators, counselors and intervention specialists in NGOs and government.

1.1 Jamaica, MSM and HIV/AIDS

The MSM population in Jamaica has an HIV prevalence of 32.8 percent. (MOH, 2011a). While this information could be seen as reminiscent of international HIV and AIDS statistics, the Jamaican research was conducted among males considered to be especially vulnerable and may not be representative of the already hard to reach population of MSM (MOH, 2011a). The Ministry of Health, in 2005 produced a National HIV/AIDS Policy to renew their mandate of rigorously addressing the health issue. The revised agenda focused largely on vulnerable groups like MSM and sex workers (SW). The document identifies MSM as the group most unlikely to seek sexual health care services or disclose HIV status. They are still among the most vulnerable and hard to reach populations due to stigma and discrimination and there is great need to intensify prevention interventions among this population (MOH, 2012).

1.2 Sexual Health Promotion for Men Who Have Sex with Men

"Men who have sex with men" or "males who have sex with males" (MSM), according to The Joint United Nations Programme on HIV/AIDS, refers to any man who engages in sexual intercourse with another man (UNAIDS 2006). The term, coined by World Health Organization (WHO) epidemiologists, encompasses various identities along the spectrum of human sexual identity. It also includes men who may not classify themselves as homosexual or gay (WHO, 2010). For this study, the public health term, MSM, will refer to men who have sex with men and includes males who are not of adult age.

The term MSM will be used as a public health identifier as opposed to the favoured GMT, GBT or other more self-identifying or socially constructed acronyms. According to research by Peter Figueroa et al, (2011), MSM account for 4.4 percent of Jamaica's adult male population and about 30 percent of new HIV infections in the country.

They also highlight that in 2010 to 2011 NGOs and regional health authorities recorded a renewed cooperative effort to provide workshops focused on the personal empowerment of MSM, SW and Out of School Youth (OSY). The empowerment approach is believed to address individual risk and reduce social vulnerability by encouraging participants of their societal roles (MOH, 2012). This should also counter the stigma and discrimination faced in the wider society. Participants benefitted from HIV/AIDS information, voluntary counselling and testing and prevention tools, therefore building esteem and self-efficacy.

1.3 Rationale

The Ministry of Health (2012) indicate several marks of success and met targets in the national response to HIV and AIDS. The quantitative indicators show some change in behaviour as well as improvements in HIV testing. Despite increased public education campaigns and increased emphasis on this vulnerable group, the HIV prevalence among MSM still remain high and is projected to stable off at 32 percent through the next year (Figueroa, 2011). The research will attempt to explore the views of the health care workers in the hope of looking at the factors impacting or impeding their work as well as possible disparities between national numbers and work on the ground.

While research and reports are available on the topic as well as the programmes currently operating in Jamaica, the perspective of health workers is seldom accounted for in the experiential documentation of HIV/AIDS prevention programmes. This research should provide insight and add an additional perspective to the empirical data surrounding MSM interventions.

1.4 Research Question

What are the perceptions of health workers on the effectiveness of HIV prevention programmes for MSM in Jamaica?

1.5 Aims and Objectives

HIV remains the primary cause of death among Jamaican adults 15-49 years, with over 333 reported deaths due to AIDS in 2010 (MOH 2012b).

This study aims to explore the perceptions of health workers on the efficiency. of programmes working to reduce HIV among Jamaican Men who have Sex with Men.

The objectives of the study include:

? To explore the perceptions of health workers on the effectiveness of HIV reduction programmes for MSM in Jamaica

? To identify the types of HIV prevention interventions/programmes considered most effective in increasing condom usage, access to

services, testing, knowledge, attitude, behaviour, practice

? To investigate the factors contributing to the strength or limitations of these programmes

1.6 Literature Review

The strategic plan published by the Ministry, included findings of the Knowledge, Attitudes, Practices and Behaviour Survey (KAPBS) which stated that in 2011, 14 percent of the estimated MSM population was reached with HIV prevention programmes; 4617 men were reached from an estimate population of 33,000 (MoH 2012).

The same report indicated that 75.52 percent of MSM indicated the use of a condom the last time they had anal sex with a male partner, exceeding the national target of 60 percent by 2012.

Percentage of men who have sex with men that have received HIV testing in the past year and know their results stood at 68 percent. Also meeting national targets. It would seem then that the Jamaican programmes were being successful by these accounts. The prevalence rate among MSM however indicate a disparity in reporting numbers

The study claimed that condom use doubled in 2011. It however provided the limitation that: "levels of condom use may reflect the social desirability of a positive response in this sample of MSM."

In order to account for these global disparities, we should develop research programmes that will address the transferability, the sustainability, as well as the effectiveness of sexual health prevention programmes for MSM (Elford and Hart (2003).

One barrier to the programmes implemented in Jamaica is access to the MSM due to discrimination. Stigmatization and discrimination due to socio-cultural taboos and norms continue to drive MSM underground and some MSM are unaware of or deny their risk factors (Rhodes et al, 2010). The Ministry report also stated that the legislative and policy environment criminalizing anal intercourse serves as a key barrier to providing access to prevention and treatment services and this will likely reduce the impact of HIV on this population (MoH 2012b).

Research conducted by Baral et al, (2009) reflected a systematic review of several HIV prevention programmes across provided the United States. They looked at various demographics and ethnic groups, potentially reminiscent of the Jamaican multicultural population. Their recommendation included a revision of MSM prevention strategy to combine quality biomedical, behavioural and structural interventions, also known as "combination prevention".

The Jamaican strategic plan pointed to this research and stated that newer strategies should include information and communication technology (ICT) such as social media integration, increased access to lubrication and condoms, increased support for MSM living with HIV as well as treatment and care and partnerships with social agencies to decrease social vulnerability while encouraging a supportive environment free of stigma and discrimination (MoH 2012). This national plan is to be implemented with full partnership with civil society and development partners it calls for a multi-sectoral approach in meeting these targets for sexual health promotion for MSM.

Another research using systematic review and meta-analysis and conducted by Johnson et al (2002), was conducted with MSM in the United States and Canada, there work was motivated by a consistent increase in sexual risk behaviour and the incidence of HIV transmission among MSM.

The research examined effectiveness of sexual health programmes according to skills content, motivation, personal and societal responsibility, community basis, length of programmes and number of participants (Johnson et al 2002).

In their findings, they concluded that self-efficacy; esteem, skills training and motivation skills must become critical components of successful interventions for MSM and not just a barrage of information about risky behaviour. This was due in large part to a connection observed between risk behaviour and socioeconomic status (Johnson, et al, 2002). They also added that a lack of research and evidence based processed could be reducing the impact of interventions. They cited the need for "sufficient resources, intensity, and cultural relevance, and a basis in behavioural and social science theory and previous research (Johnson et al, 2002).

The effective sexual health intervention they posit, married interpersonal skills to training in condom negotiation, HIV status disclosure, and communication with partners.

2. Methodology

2.1 Research Design

A qualitative approach is ideal for this study. It seeks to unveil the point of view of health care professionals working with MSM. This qualitative methodology, it is believed, will provide relevant information on the topic by capturing the experiences and realities of the sample. New data will be collected and described, so this will be a primary research study. This technique allows the study to delve deep into the subjective truth of the participants and those they serve and could provide equally substantial if not a more in-depth understanding than a quantitative approach (Burrell and Morgan, 1979).

A descriptive cross-sectional approach will be used to design the study. The participants will be purposively selected in order to capture the expertise and knowledge of those working with the population under research. There is also a small sample of those working with MSM in Jamaica, which limits the propensity for favouritism or bias in selection. Interviews will be used to collect data. One-on-one interviews with programmes leaders and or directors and interviews with workers (implementers/ field workers) will be semi-structured and adapted from previous interviews used in research conducted on similar topic. This systematic process allows for a heightened level of trustworthiness of this qualitative study (Shenton 2004).

The criteria of trustworthiness (credibility, transferability, dependability, con?rmability) constructed by Guba (1981), are still relevant to qualitative study and will be utilized in the framing of the research.

Interviews with field working health care workers will seek to capture similar information but from the perspective of the workers (non-programme leads). This setting will allow for the comfortable sharing of the work they do, much of which is conducted as a team effort. It is expected that they will feed off each other presenting gaps as well as successful perspectives on how they work together for the implementation of their programmes.

2.2 Procedure

The process of qualitatively gathering information includes using data collection tools that may capture personal opinions and views and bring to play different cultural sensitivities, especially as it relates to vulnerable groups such as MSM. It is therefore necessary to gain permissions and ethical approvals from the approved board at the University of Bedfordshire.

Informed consent forms will supply details on the study and capture the approval and willingness of the participants to be engaged in the process. The research will allow for anonymity and withdrawal at any time, which should encourage participation and encourage openness in the interviewing process.

A search of public records, Websites and The Ministry of Health's data have highlighted one government based programme divided into regional groups working with MSM as well as an estimated 10 active non-government entities also doing HIV prevention work with this population across the island. These groups will be formally invited to participate in the research a minimum of 6 companies will be utilized for a minimum of 12 interviews.

2.3 Permissions

The research supervisor will be consulted for all necessary permissions needed to carry out and complete this research. This includes the approval of the Institute for Health Research Ethics Committee before conducting the study. This qualitative study is currently designed to be conducted in the island of Jamaica in order to accurately and comprehensively collect the data from participants. Authorized absence permission will therefore be requested in due process.