When designing HIV outreach programs, it is important to have a deep understanding of your target audience. When it comes to designing HIV services for men who love men, it is not enough to follow the epidemiological term 'men who have sex with men' and design and deliver the service as if all these men are exactly the same, and have the same needs.
There is a need to distinguish different segments of the target population and rank them based on their level of HIV risk. It is essential to involve MSM from different segments in this exercise as key informants. A starting point for segmentation could be their age or the life phase in which they are; both will harbour important consequences for their vulnerability or risk behaviour towards HIV, as well as their existing knowledge and attitudes and the tone/approach outreach workers need to take.
Examples of age/life phase-based segments for which different approaches may be applied are:
High-school based adolescents;
Adolescents engaged in sex work (possible to segment further, i.e. street-based, internet-based, venue-based);
Young men engaged in sex work (possible to segment further, i.e. street-based, internet-based, venue-based);
‘Twinks’/university students based with family;
University students from outside QC, staying in dormitories;
Young (18-35) urban professionals;
Young men (18-35) working in construction sites, as taxi drivers or other lower-class professions;
Bisexual men who are married / have families.
One big difference across these categories will be the extent to which men will feel connected to a ‘gay community’ or not. For example, married or bisexual men often do not see themselves as part of the gay community and they may be hesitant to access HIV services that are delivered under a community-banner.
Another important difference across the categories is their attitude towards sex. Men may see sex with other men as a) a way to earn money, b) an expression of love to an actual or potential lover, or c) as fleeting recreation and enjoyment. It has been shown in other countries that men who regard sex as part of a love relationship are less likely to use condoms than those in the other two categories. It should be noted that attitudes can be linked to a person's lifestyle and life phase, in other words, attitudes may change over time.
Experience from other countries shows that the easiest-to-reach segments of MSM will often be the most motivated, educated, wealthiest, or healthiest segment of that group. If the more challenging and needy members of the target audience are to be reached, extra effort and often different approaches and strategies will be required. It is important for the programme to make a concentrated effort to reach those most in need of HIV services, even if that means extra effort.
It is important to conduct further qualitative / ethnographic research on each segment of the target audience to understand the contexts of their lives. This can help identify their broader needs and to discover the most appropriate modalities for reaching and recruiting clients into HIV your services. Many of the listed segments may not be attracted to messages about HIV or safer sex, but would, for example, be interested to learn about healthy lifestyles, how to be fashionable or ‘cool’, how to find a suitable long-term boyfriend, or, for male sex workers, how to avoid violence and abuse by clients. In other words, understanding what makes your target audience ‘tick’ will provide knowledge about how HIV prevention messages and promotion of HIV testing and other HIV services can best be approached, marketed and packaged--and solid qualitative research is essential for this understanding.
Another important question to answer is whether it is more effective to have ‘peers’ conduct outreach work, or whether there should be a difference in age between the bringer and the receiver of outreach education. In other words, is communication most effectively performed ‘horizontally’ or ‘vertically’? In countries where communication is structured hierarchically, such as Thailand and China, young outreach workers often find it socially awkward to ‘teach’ clients who are the same age or older than them, and the aim is to recruit outreach workers who are at least a year older than the target audience.
Especially if there is no funding for a proper assessment, it can be an idea to conduct a literature review of studies and assessments that have already been conducted by other agencies or researchers about the population segment you are interested in, in your own city/country as well as in other countries in the region.
A cheap alternative to a full-fledged research study is to conduct a ‘rapid assessment’; in such an exercise, a small number of individual interviews is conducted with key informants who have special, in-depth knowledge of the target audience. This can be followed by the conduct of a few focus group discussions with representatives of the target audience to validate initial findings and insights from the key informant interviews.