It’s about doing nice things for at risk people, smiles Dr Kevin Rebe from behind his desk.
An infectious diseases expert, Rebe heads up an unique service that is looking after a population who would otherwise either delay seeking healthcare until it is too late or not go in search of help at all – men who have sex with men and transgender women.
Men who have sex with men (MSM), are not necessarily gay, but are often in long-term heterosexual relationships with a wife, but have sex with men when the opportunity arises. Trans-women are what many describe as a "woman trapped in a man’s body" or, in a few cases, men who have undergone a sex change.
While both groups are viewed as high risk when it comes to HIV infection – both biologically and behaviourally – there is very little is targeted at them in the form of HIV prevention messaging or healthcare services that serve their unique and often complex needs.
Not surprisingly, their more regular or long-term sexual partners are also at high risk.
The transgender community has high rates of HIV infection.
Meanwhile, research has shown that the risk of HIV infection from anal sex is 18 times higher for the receptive partner than vaginal sex.
"There are many cases which illustrate why it is often hard for these groups to seek healthcare at our run-of-the-mill health services – in the public and private sector," says Rebe.
Shaking his head, Rebe recalls one gay couple that went to a community health centre in Cape Town where they were asked, "who is the man and who is the woman".
"They walked out and the one needing the healthcare almost died as he flatly refused to go back to a clinic or hospital. There is lots of discriminatory talk at healthcare institutions and in doctors’ rooms where more than 60% of their clients are women and they feel more comfortable talking about breastfeeding and pap smears than anal warts," says Rebe, who’s fashionable hairstyle and dress sense, already blows the stereotypical white coat, conservative doctor image out the window.
Discriminatory behavior by health providers and the humiliation of being called a male name in front of other patients discourage many transgender women from seeking health services. Outright denial of service by providers is also commonplace.
"Kevin is like a friend. He listens to us and trusts us completely, you can share anything with him and he will not be shocked and think you are weird. I could never do that with any other doctor," said one of the Health4Men patients at the Ivan Toms Centre for Men’s Health in Woodstock.
Health4men is a special interest project of the Anova Health Institute that receives support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR).
Health4men is described as a "holistic project targeting the sexual health care needs of men who have sex with men (MSM). The Ivan Toms Clinic is one of three clinics nationally that deal with the clinical aspects of the programme.
Named after the late activist doctor and former head of health in City of Cape Town, the clinic is focused on making it as easy, simple and painless as possible for these marginalized groups to access lifesaving health care when they are HIV-positive or if they are negative, access all the information and prevention interventions available to keep it that way.
But Rebe is quick to point out that the clinic is not an antiretroviral, HIV or wellness clinic. "We are a clinic with special skills dealing with MSM and sexual health."
These special skills often involve dealing with complex mental health issues, alcohol and drug abuse, which Rebe believes is often driven by the reality of living in a stigmatized society.
"MSMs face enough stigma so in the clinic we make sure that the moment they walk through that door they don’t face double-stigma," he adds.
According to Rebe the most risky groups are those who don’t self identify as gay. "They could have children, a wife in the Eastern Cape and once a week they have sex with a man behind the shebeen. This group is the most vulnerable as they are at high risk of contracting HIV and in turn infecting their wives."
Rebe is scathing of the ABC message that for many years was the backbone of the HIV prevention messaging.
"Abstain? You want to tell this to two testosterone-driven men in a club? They are not hearing this message. It’s useless. Be faithful? It’s stupid, because who must they be faithful to? Condoms? We all know use is inconsistent and low and for transgender women, they don’t have the social capital to negotiate condom use.
"It’s simple, ABC ignores this group," says Rebe.
Rebe believes it is critical to be able to individualise the approach for each patient when it comes to treatment and prevention.
For now, he would like to see more female condoms being made available for use when anal sex is involved, the distribution of "bucket loads" of lubrication (not yet on government’s list) and making these products easily available in shebeens, MSM friendly spaces and other places frequented by these marginalized groups.
"We need the stuff at the front of the clinics and bars, not at the back," says Rebe.
When quizzed about why the HIV incidence is increasing in the gay community, Rebe is quick to reply. "I think for the young generation, the loss of friends and lovers in the 80s is a foreign concept.
For the youngsters, HIV is a treatable disease and they don’t have that consciousness of the illness that the older generation has. I also believe there is message fatigue."
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