have sex with women (WSW). In fact, in at least two facilities, a different understanding are not homogenous. And that in the absence of transparent, inclusive, accountable was expressed between management and service-providers within the same facility. There engagement between service-users and service-providers, differences in perception lead to is consistent ambiguity across the health facilities about whether this group is recognised as lower demand, delivery and uptake of services. a Key Population target group at all and, in fact, uncertainty about whether the population even exists in substantive numbers to require specific services. It is clear from the Situational The uncertainty and ambiguity about women who have sex with women, evident in Analysis exercise that health workers perceive women who have sex with women as exotic; responses from health workers, is consistent with the experience of the populations they are an unfamiliar population around whom health workers have very little exposure or themselves. A remarkably stark difference exists in user-experience and perception of health experience. services between men who have sex with men (MSM) and other populations: trans people and women who have sex with women. “We’ve not seen that community. They’re not really much there. Like they’re invisible to us.” “Women who have sex with women can come to access the services, but when they do, they don’t come out as lesbians. They live a double life, so they present to us at the facility as heterosexual women. We don’t have those protective barriers available for WSW because it’s not seen as a felt need. At least from a facility level, we don’t think we’ve felt that need from them.” “They need to come out of the closet and say what they need.” “We don’t get a lot of them, or they don’t own up. We don’t have experience in serving them. They should also access cervical cancer screening, but it may be that it is uncomfortable or painful for them.” “When we think of GALZ, people associate them with gays or bisexual men. Women who have sex with women have been very silent. I wish they could engage us more; we might need to have a sensitisation so we understand them more.” “We’re not really attending to all the groups of KPs. We see that we’re favouring gays and bisexuals. We have lubricants and condoms for males, but not for women who have sex with women.” Whilst all key population groups agree that their user-experience and quality of care and service could be markedly better, men who have sex with men have a significantly better experience with service-providers than do women and trans people, and consistently so across facilities and cities. And arguably, in some ways, cis-gendered lesbian and bisexual women are even less catered for than trans people. This marked disparity can be attributed to a number of reasons: • From a public health perspective where HIV is being managed and controlled through a determined “Test and Treat | Treat All” strategy, men who have sex with men are a popular and promoted target group for services, as may be trans people in certain environments. These perceived high-risk groups are sought out for services, and receive priority attention and access to protective barrier methods, testing, counselling, treatment and other interventions such as PREP. From that HIV- management perspective, however, women who have sex with women are – inaccurately – perceived by health programmers to be at significantly lesser risk of transmission of HIV. • Women who have sex with women are exotic to service providers; little is known about them. The situational analysis suggests that the visibility of populations is proportional to service-provider perception of need/demand: in other words, seeing the population is evidence they exist, and a foundation on which to build clinical experience; not seeing them 4. Perceptions about service-delivery and service-quality vary significantly between (a) populations of service-users and (b) service-users and service-providers. suggests they aren’t there. Naturally, there is something problematic about that logic: there are a number of complex social reasons why women who have sex with women As a perception survey, the Situational Analysis reinforces the fact that Key Populations PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 11