Summary of the impact

Tucker's ethnographic research on the social worlds inhabited by township `Men who have Sex with Men' (MSM), and his quantitative analysis of the associations between social and psycho- social conditions and risky sexual practices for such men, led to the development of the innovative Ukwazana HIV prevention programme — the first of its kind in Africa. Ukwazana, meaning `getting to know each other' in isiXhosa, is based across the central townships of Cape Town, and is unique in fostering partnerships with marginalised township MSM, engaging them collaboratively in HIV prevention initiatives. Based on Tucker's research findings, it is the first scheme to recognise, and tackle, social and psychosocial factors such as homophobia, depression and loss of self- esteem, which often result in risky sexual practices and related illnesses among MSM. This new approach was timely since, despite numerous previous HIV prevention campaigns aimed at township MSM, HIV prevalence for this group was three times the national average.

Underpinning research

The underpinning research, conducted by Dr Andrew Tucker in the Department of Geography, University of Cambridge (ESRC Research Fellow, Sept. 2006 - Oct 2007; University Lecturer, 2008-), involved two main projects: an ESRC Postdoctoral Fellowship (the `Fellowship') and a project funded by the Anova Health Institute of South Africa, 2010-2013 (the `Anova Project'). Both projects broke new ground.

The Fellowship showed how men with same-sex desire, from different `racially-defined' communities in Cape Town (`white', `coloured' and `black African'), encountered distinctive forms of heteronormative regulation within their own social spaces, which shaped how open and safe they could be about their sexuality. The Fellowship, which involved substantial further development of earlier research for a PhD, facilitated new fieldwork in South Africa, produced the novel conceptual frame of `queer visibilities', and led ultimately to the publication of a monograph with the same title (see Section 3.i) and two journal articles (see 3.ii and 3.iii). The new framing attended to the interplay and political significance of varying forms of non-heteronormative visibility in the urban environment. One important conclusion reached by the research was that Western notions of `the closet' as a form of secrecy about sexual identity did not necessarily hold for communities of men historically less rigidly defined by heterosexual/homosexual binaries. This in turn meant that men from different communities often had vastly different sexual and gender identity categories, social networks, community structures and ways of safely negotiating urban space. The research therefore judged Western ideas of sexual political liberation or health service provision as potentially inappropriate for communities with different heteronormative histories. In relation specifically to health and HIV prevention, the research suggested that MSM in black African township communities had historically been poorly served by the Western-centric health organisations tasked to assist them, in part as a result of assumed congruity and affiliation with Western notions of `gay' identity. This had led to feelings of mistrust and disinterest among black African MSM towards health NGOs and their programmes.

The subsequent Anova Project focused on developing and tailoring a new style of HIV prevention programme, based on sustained MSM community engagement, in the former townships of Cape Town. While research elsewhere had highlighted the potential efficacy of deploying community- based HIV prevention programmes (e.g. Campbell 2003), none had been undertaken previously for black African MSM anywhere in Africa. The Anova Project therefore deployed one of the largest quantitative surveys ever undertaken in Africa in order to understand how social and psycho-social factors operating at the community-scale might be associated with riskier sexual behaviour (see 3.v and 3.vi). Though they had not traditionally been seen as important in HIV prevention for MSM, factors such as homophobia, depression and low self-efficacy were found to be central to the successful assistance of MSM in HIV risk reduction. Drawing on the Fellowship, the Anova Project was also able to further explore the specific geographical reach of these unique social and psycho- social pathways to HIV risk. For example, key sites of homophobic stigma (the local `shebeen' or informal tavern) proved to be significant, and particular to township MSM, due to the lack of any form of demarcated social `gay spaces'.

Finally, the research element of this project devoted considerable effort to overcome feelings of mistrust and disinterest on the part of township MSM towards health organisations, highlighted during the Fellowship. Qualitative methods including interviews and focus groups during the Anova Project explored how best to work with MSM volunteers and also how to make them feel valued and protected by the organisation (see 3.iv). The Anova Project coincided with, and fed into, the development of the Ukwazana HIV prevention programme, meeting the need to find ways of maintaining community interest in the Ukwazana programme and hence offsetting the problems of limited or sporadic community engagement highlighted by the Fellowship.

References to the research

Research Grants:

ESRC Research Fellowship — `Male homosexual visibility in Cape Town'; PI: Dr Andrew Tucker; October 2006 — September 2007; £63,854

Anova Health Institute — `MSM Ecosystem'; PI: Dr Andrew Tucker; October 2010 — September 2013; £56,419

Details of the impact

The Ukwazana HIV-prevention scheme was the first programme of its kind in Africa, and the first to commit to long-term engagement with township MSM, whereby the men themselves helped steer the course of HIV community interventions. Tucker's Fellowship and Anova Research Project had direct impact on the ways in which the Anova Health Institute, through their Health4Men subsidiary project in the Cape Town townships, designed, structured and implemented the Ukwazana Programme. Tucker's involvement as a Consultant for the Anova Health Project enabled his research findings to directly shape how the Ukwazana programme developed and functioned. In particular, it was as a result of the projects outlined in Section 2, that Ukwazana focused heavily on MSM community engagement and empowerment, and on the need to address social and psycho- social factors associated with sexual risk-taking behaviour among township MSM. The Ukwazana Programme's interventions, exemplified below, clearly illustrate the impact of Dr Tucker's research:

1. Reflexive engagement. Research during the Fellowship had highlighted the need to move away from more traditional and unsuccessful didactic methods of interfacing with township MSM, which did not consider the specific needs of this group. The Ukwazana programme therefore had to involve continual evaluation of the programme itself by township MSM. As such the programme was focused on a reflexive engagement with those it was tasked to assist. This established a nuanced means of engaging with outreach volunteers and those who attended various activities associated with the programme. In showing how volunteers came to understand their engagement with Ukwazana, research in the Anova Project helped shape the approach of programme facilitators in working with the community. It led directly, for example, to the decision to implement specific training and workshops for volunteers and the wider township community of MSM. Glenn de Swardt, Programme Manager Health4Men writes `the way the program engaged with and developed collaborative working relationships with volunteer outreach workers was impacted upon by the research Dr Tucker undertook' (see 5.1, and Plate 1).

2. Psycho-social intervention. Ukwazana also broke new ground in Africa in attempting to engage directly with the social and psycho-social issues that affected the likelihood of MSM engaging in safer-sexual practices. This approach was adopted as a direct result of Tucker's research for the Fellowship and the Anova Project, which highlighted the under-appreciation of such factors in HIV prevention for black African MSM. As confirmed by the Manager of the Health Project: `the decision to focus on challenging factors such as depression, homoprejudice and a lack of self-efficacy through the programme emerged from Dr Tucker's research' (see 5.1). Ukwazana targeted venues such as township `shebeens' (informal taverns), which, although frequented by township MSM, were also known as spaces of sporadic homophobic violence. Ukwazana identified 30 such shebeens and targeted these to make them more `MSM friendly'. Key activities included Ukwazana `launch events' where outreach workers from Health4Men presented the Ukwazana programme to the community through an evening of engagement activities. The outreach coordinator at Health4Men estimated that approximately 1,700 community members participated in these launches. Additionally, in an attempt to increase MSM community solidarity — a form of social capital - and promote a positive image of MSM to the wider community to help mitigate against homophobia, MSM were involved in a number of `good causes' events termed `Men of Action'. These included cleaning up areas of the townships and distributing food to other disadvantaged groups (see Plate 2). A series of workshops also took place, offering a safe space where township MSM would not simply be informed of the need to engage in safer-sex but would also be able to discuss issues such as homophobia, depression and a lack of self-efficacy in terms of safer-sex. All of this constituted a significant, novel approach, derived directly from the underpinning research.

3. Innovative messaging products. In addition to the community activities outlined above, Ukwazana developed diverse messaging products specifically as a result of the Anova Project. Issues addressed in this context included homophobic discrimination, low self-efficacy (linked for example, to alcohol use and transactional sex) and the need to engage in safer-sex. Eighteen posters were designed in collaboration with volunteer outreach workers and displayed in locations such as shebeens, police stations and clinics across the townships of the city. Similar messaging regarding psycho-social concerns was also designed into drinks coasters, 10,000 of which were disseminated to shebeens and placed on trains. Patrons and passengers were encouraged to take coasters home. Adverts also appeared regularly in the two main community newspapers (Vukani and City Vision — combined distribution 500,000 per week), highlighting forthcoming events such as Men of Action events and workshops, and including a poster from the poster campaign. Posters were also used as the basis for billboards (see Plate 3). Health4Men's paid outreach workers periodically featured on the main local township radio station, Radio Zibonele, highlighting the core aims of the Ukwazana programme (weekly listenership of 50,000).

It is indicative of the efficacy of the programme, and of the significance and reach of the impact of the research, that the Anova Health Institute subsequently duplicated it in four other provinces across South Africa (Gauteng, Mpumalanga, Limpopo and North West), starting in 2011. Given the recent timing of the interventions in Cape Town and other provinces, it is premature to measure the impact of the Ukwazana programme in terms of the number of lives saved or transformed sexual practices, but the very fact that Anova decided to replicate the programme is an indicator of the social receptivity and relevance of the interventions.

In summary, as Helen Struthers, Chief Operating Officer of Anova, observes, `Over several years Dr Tucker, in conjunction with the Health4Men team in Cape Town, helped to create a variety of ways to positively and sustainably impact on the lives of MSM. Dr Tucker's research also influenced the ways in which Health4Men engaged with and worked with volunteer outreach workers' (see 5.2). These interventions, sensitively fashioned through iterative collaborations between a researcher, practitioners, and activists, helped shape the development of an innovative and unique approach to HIV prevention for one of the most at risk groups in Africa.

Sources to corroborate the impact

1. Letter from person 2 (Programme Manager: Health4Men, Anova Health Institute).
2. Letter from person 1 (Chief Operating Officer, Anova Health Institute).
3. Ukwazana's Facebook page detailing many of the impact activities http://www.facebook.com/groups/249253298477550/
4. An article about Ukwazana on Anova's website http://www.anovahealth.co.za/resources/entry/ukwazana_programme/
5. Article from one of the foremost gay news sites in Africa highlighting the unique nature and importance of the Ukwazana programme http://www.mambaonline.com/article.asp?artid=5485
6. A number of advertisements and articles promoting Ukwazana in township newspapers are available in hard copy if requested.

Additional references cited:

Campbell, C., 2003. Letting them die: why HIV prevention programmes fail. James Currey: Oxford