The ability of a sexually active key population community -- whose risk and vulnerability are increased by structural discrimination, social stigma, punitive law, insecurity, economic and political marginalisation, psychological distress, substance abuse and violence – to have non-HIV STIs examined, diagnosed, treated and managed is paramount. Too often, however, the Situational Analysis exercise surfaced experiences from serviceusers who presented to facilities with an active STI, treatment of which was conditional upon being tested for HIV (or was perceived to be conditional) – and subsequently referred for either ART (if positive), or PREP (if negative). Consistently throughout the conversations, service-users reflected how negatively this affected their perception of the availability, accessibility and appropriateness of the service: that HIV-treatment was not the service they were seeking; that they should not be pressured into procedures they have not come for; that entering the HIV-test-and-treat “channel” unnecessarily prolonged the time they needed to spend at the facility; that it deterred them from seeking treatment for the STI. “They tell you you have to test for HIV before they will treat you for STI. So, you end up just going home with your STI.” “If someone comes with an STI it means they are having unprotected sex, so we screen for HIV.” The PSI facilities have no stand-alone STI programme at present, although this was not always the case. Funded through a project, this stand-alone service came to an end in March 2017. Subsequently, STI services are delivered as a value-added service, not as an entry point programme into services in the way that HIV or Family Planning might be; those services are available to clients who come into the programme through other entry points that invariably finance the additional STI- services. “We have no funding for STI services at the moment; we give what we have, and if we don’t have we prescribe. We really need another funder for STI programmes, even if that is just available to the KP programme.” “If clients are part of our HIV cohort, they get our STI services. If they don’t want to be tested for HIV, we can refer them to another centre, although that facility might not be KP-friendly or sensitised.” The availability and accessibility of on-demand, stand-alone STI treatment and management Of the three health facilities, this tension seems most evident in the PSI New Start Centres services for key populations constitute a significant advocacy and programming issue. in both Bulawayo and Harare. As a donor-funded NGO intervention, the PSI Centres are not general hospitals or, in fact, public primary health facilities. They exist as, primarily, HIV Counselling, Testing and Treatment Centres around which a host of complementary services 11. Sensitisation is a multifaceted effect, not an event. are wrapped to provide a continuum of care. HIV is the entry-point through which many “Sensitisation” was referenced in conversations throughout the situational analysis exercise, other services – STI screening and treatment, cervical cancer screening and treatment, family by both service-providers and GALZ programme team members, as having happened planning – might be accessed, and through which such services are subsidized. towards the start of the partnership. Service providers and managers vary in their framing of the conditionality of HIV- services to Unsurprisingly, facility staff being exposed to a sensitisation workshop – a single, isolated STI-treatment, within and between the two Centres: awareness and information activity – does not immediately confer on them empathy, understanding or sensitivity, a fact that is repeatedly borne out in the experiences and “We strongly encourage HIV treatment. If you don’t want to the first time, it’s okay. But you can’t keep coming back without testing.” “Consent is our primary issue here. Even when there is resistance, we try by all means to make people understand. It is important for them to know their status because it helps us in treatment of other issues and conditions. But we don’t coerce them.” PERCEPTIONS, PERSPECTIVES perceptions of the key populations constituency. Nor might that effect, if successfully achieved several months previously, presently remain within the facility. Health facilities are a complex and compound ecology. Sensitisation of this system cannot be achieved – to such effective measure where sensitivity and appropriateness are results within that system, not only an input – through a single, once-off workshop. Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 16