"The Nicaraguan experience addressing HIV in MSM through questioning gender inequalities and roles illustrates how supporting community groups that represent sexual diversity and commit to well-planned, implemented, and evaluated projects in a permanent learning process will pay off in terms of overall society benefits."

From the Case Study Series from the United States Agency for International Development (USAID)'s AIDSTAR-One (AIDS Support and Technical Assistance Resources, Sector 1, Task Order 1), this case study describes the work of Nicaragua's Centro para la Prevención y Educación del SIDA (CEPRESI), an organisation working toward HIV prevention for "sexually diverse" populations such as men who have sex with men (MSM). The case study explores the strategies, successes, and challenges associated with CEPRESI's efforts to change perceptions of masculinity among the general population of Nicaragua - where societal norms stigmatise same-sex sexual activity and favour conformity to strict gender roles - and to educate MSM on HIV prevention and treatment.

What has worked well:

• Addressing the social drivers of HIV among MSM: "Extensive research by CEPRESI has shown that masculinity in Nicaragua is traditionally associated with risk taking, power use and abuse, violent reactions, perceptions of sexual might and invulnerability, and the repression of feelings..."
• Combining large- and micro-scale interventions: "CEPRESI simultaneously implemented media and social marketing campaigns to address social determinants of risk and outreach programs that targeted youth as well as communities and settings where data revealed concentrations of men at greatest risk..."
• Recruiting and training sensitive and representative staff: "...All personnel receive intensive training on sexual diversity, human rights, and positive values..."
• Collecting and using data for programme management and advocacy: At the end of the first Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)-funded project, CEPRESI conducted end-of-line data collection and analysis. In 2009, the evaluators interviewed 500 individuals who had participated in CEPRESI's programme activities and organised 6 discussion groups with an additional 90 men. Findings include the following: 98% reported being exposed to HIV prevention information produced by CEPRESI; of those who received a message, 30.4% reported use of condoms and water-based lubricant in all sexual encounters; nearly 55% reported increased measures to prevent HIV and improve their health habits; and 42% reported that they reduced their number of sexual partners.
• Disseminating promising practices in the region: "...CEPRESI has actively engaged in discussions with other MSM and LGBT [lesbian, gay, bisexual, and transgender] groups in Latin America and the Caribbean, advocating for a shift in HIV prevention approaches for MSM. As a result, new regional proposals being submitted to donors for grant consideration increasingly include formative research on social determinants of HIV transmission among men and implementation of innovative programs to promote new models of masculinity."

Recommendations offered include:

• Recognise the plurality of experiences and options of MSM: "...Sexuality is complex and cannot be reduced to social or epidemiological categories, and same-sex activities between men may or may not represent an individual's sexual identity....In Nicaragua and elsewhere, programmers need to recognize the realities of people's sexual activity beyond standard behavioral categories when designing and implementing HIV prevention interventions."
• Clarify the position of transgender (TG) people in MSM support programming: "MSM often have an unclear and at times ambivalent relationship with TG communities....Programmers should be aware that a spectrum of support services - from MSM focus organizations to TG peer-led groups - are needed to cover the diverse range of vulnerable populations highly affected by HIV."
• Draw on "real" peers to promote reduction in risk-taking and safer sex: "...CEPRESI's decision to hire MSM outreach promoters regardless of their sexual orientation resulted in a rich plurality of staff that mirrors the reality of the communities they must work with. Including openly gay men is also critical, as are, for instance, heterosexual men with children and men who do not feel their identity must be primarily based in their sexual preferences, whatever those preferences are."
• Maximise findings from formative research: Monitoring and evaluation (M&E) and data use should be "part of a strategy that is designed from the beginning and comes from a broad range of sources, including epidemiological data, qualitative findings, routine monitoring data, and special studies, including end-of-project assessment. Of equal importance, is the use of data for decision making and program improvement."
• Support emerging leaders: "...Once the public starts to recognize and respect MSM and their health needs, a broader, more participatory grassroots leadership should be encouraged. Program planners have to use sensitivity in managing leadership replacement and continuity, balancing the value of the most experienced with the fresh view of emerging leaders."
• Prepare for donor exit: "...Capacity development should benefit both civil society groups and government institutions, balancing the support of a dynamic and democratic community with the reinforcement of public policies and civil servants..."

The author concludes that "Nicaragua and other countries should integrate a focus on the role of masculinity into a wide range of health issues, including those that have historically focused on women and children. For example, in the central region of Nicaragua, CEPRESI has been asked to participate in maternal and child health programs as a way to engage men in family planning and care." Also, "[b]uilding and strengthening sexual and reproductive health coalitions that can act as social auditors of government actions are fundamental to ensuring long-term national commitment to programming for HIV and related diseases."

Email from Anna Lisi to The Communication Initiative on April 20 2011.