• the right to consent; • the right to bodily integrity – to decide what happens to your own body. • the right to confidentiality; • the right to dignity; • the right to non-discrimination Health workers should exercise special caution that they do not inadvertently compromise or violate these rights through well-intentioned service provision, often in the pursuit of noble aims or targets. Such violation may be easier to commit than health workers realise amongst populations with lesser power to choose, or to question, or to decline because their available options are limited. For members of Key Populations in social and political contexts such as Zimbabwe, visibility equals vulnerability. In an environment that is not safe, that does not feel safe, that does not feel private, people feel more vulnerable the longer they are exposed to the public. And, in fact, this is more than perception: gay men, trans men and trans women especially report that prolonged exposure and visibility subjects them to a greater sense of self-consciousness and stigma, Under such conditions, there is a fine line between “strongly encouraging HIV testing, even when there is resistance”, between “persuading them convincingly with counselling to do contact-tracing”, and coercion. It may not be acceptable to increase demand for services amongst other potential clients in communities by mobilising their LGBT peers to identify them to a health facility. It may not be appropriate to ask a client for the contact details of sexual partners or family members as part of service delivery without explaining why that information is necessary or how it will be used. Service-users should not have to endure indignity in order to receive services. They should not have to choose between privacy and good health. They should not feel obliged to take an HIV-test before they are eligible for other services to treat the condition with which they first present to a facility. to harassment, to abuse. This principle is a powerful determining factor in the experience of key populations accessing health services through the facilities in Harare and Bulawayo, and plays out in multiple ways throughout the experience: walking from home, waiting at a bus stop or taxi rank, taking public transport, walking through town to the facility, passing security, engaging with the receptionist and identifying the reason for the visit, waiting in a waiting area, standing in line to see a nurse or doctor, moving between departments, personnel and services within the facility, waiting in line to collect medications, and the journey home. Service-users report feeling stared at throughout that experience, feeling judged, being subtly or openly mocked, feeling afraid or threatened. They recount stories of physical harassment en route to a facility. They recall the anxiety of waiting in line expecting to be recognised by And since experience so strongly shapes perception, only a small number of uneasy, distressing, uncomfortable experiences are necessary to dissuade clients from returning to a facility where they have felt compromised – and prompt them to share that perception with others. someone they know from home. This is an important consideration for health facilities that relates directly to how managing patient flow and adapting the physical layout of the facility might reduce wait time, might limit the exposure of key populations to the public, might increase privacy, and increase a Those responsible for delivering services that facilitate access to the right to health do so in the context of a system of other rights – indivisible, interdependent, interrelated. Respecting, upholding and fulfilling those other rights in the course of providing health services ensures a service that is respectful, dignified, appropriate and acceptable, even amongst people whose sexual rights are improperly limited. PERCEPTIONS, PERSPECTIVES 8. Visibility equals vulnerability; and increased vulnerability is a major deterrent to accessing health services for populations already vulnerable and at-risk. sense of safety for insecure populations. Ironically, at the same time, no visibility (as in the case of undisclosed lesbian or bisexual women) leads to low availability of services because that population is thought to be non-existent, or demand seems low, also leading to increased vulnerability. Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 14