I’ve been there, and at the end of the day, I fail to say all I want to say because it’s a male.” “We understand the situation we are in in the country. And that organisations can’t be too obvious about supporting our community or they could be deregistered. But, all the posters and information in the facilities are heterosexual. They don’t represent me, or other men who are gay or bisexual. I don’t see myself there.” “The facilities should employ people who are MSM and can understand their peers. If you want to catch a thief, use a thief.” Service users desire identity-affirming attitudes and clinical competence in service providers, so that key populations are not further stigmatised when health workers are unsure how to examine, diagnose or treat them. “Wilkins is okay, they’re doing okay. But at PSI the people who examine you have book knowledge, but it’s not practical for people like us. They expect to see infections in a certain way. But we don’t only get STIs in the front; we also get them at the back.” “The thing is not about acceptance. I don’t need health workers to accept me. The thing is about making people better. To deliver services that make people better. When I come to seek services, but I have to start teaching the nurse before I am helped, I lose confidence. They might be qualified, but they don’t understand the issues of LGBTQ people.” “Nurses and staff need to be better educated to know about us. Last time we had a workshop with them. They were interested in knowing about the STIs that affect gay men. They’ve never actually seen a nicely decorated anus before. The assumption from them is that you can’t do sex with an anus, so they are not sure how to treat it. It’s a mentality they have. When you go there they tell you about the elasticity of the vagina that is not like an anus. They get afraid. But they need to know that the anus has now been upgraded. It’s not only an exit point.” “When I want STI screening only, but not HIV, they tell me it’s not an STI clinic. If we are not there for HIV things, they should still accommodate us.” “I referred someone there but they were told they can’t do STI screening. But if that person goes to another clinic that does offer that service, there are too many questions asked.” First you need to have an HIV test. It’s required. I was told that ‘first you need to be one of our patients before we can give you services. And if you don’t have an HIV test, we can’t register you as a client.’ If you decline, you need to go somewhere else.” “I went for STI screening with my partner. They required that we had to register before we got that service. So we ended up not doing it.” 3. The right to privacy is not academic in this environment. Privacy means security, safety from exposure, protection from potential violence. The absence of privacy increases fear and stigma. In the way that respondents discussed privacy with respect to PSI, this issue is a function of congestion, of facility layout, and of systems-design in the way particular elements of each health service are offered. These may be less significant for a general, heterosexual population, but are of primary importance to a highly stigmatised, highly marginalised population. “There’s no privacy. Everyone is sitting there. You get your pills at the pharmacy in front of everyone. If you want PREP you’re mixed in there with those people on ARVs. So, our people feel afraid to collect drugs.” “They just tell you ‘get in that line’. You fear seeing someone you know. So people avoid the facilities because they’re afraid. Can a Peer Educator not collect the drugs for patients, or have them delivered to our homes or our meeting spaces?” “I don’t want to be seen in that environment, in that line, seen by people that I’m going to get 2. Most specific to PSI, the leveraging of sexual and reproductive health services off of HIV testing and treatment is unacceptable to LGBT service users. In as much as PSI suggests that services – especially STI treatment – are not conditional upon uptake of HIV-services, service users hold a strongly contrary perception. tested.” “Once I went with my boyfriend to test, and we wanted to test as a couple. So I came with my boyfriend, but we got counselled in public, in that group-counselling, together.” “The facility is congested and crowded. We have to move about between one department PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 35