Integrating Anogenital Health Care Into HIV Programs for Queer Men in Kenya: A Project Ethnography of Lateralizing Community-Led Health Service Delivery

Abstract

Amid shifting political and funding landscapes for HIV prevention, how do we recognize the localized knowledges and skills accumulated at the grassroots, and which undergird community-led health service delivery for “key populations”? Lateralization advances an alternative implementation approach for a new generation of HIV programs that not only meets the global health policy direction of “integrative health” but also centres community insights that ground and move to democratize HIV prevention science. We argue that innovations in community-led HIV care can be leveraged towards addressing other health needs of populations who are often left behind due to criminalization and stigmatization. Gay, bisexual, and other men who have sex with men (“queer men”) have only recently begun to be included in human papillomavirus (HPV) screening and vaccination programs. However, in settings where queer men are criminalized, they continue to be left out of HPV interventions. In Nairobi, Kenya, queer men are presenting for care at extremely late stages of HPV-related anal diseases. In response, Health Options for Young Men Against STIs (HOYMAS), a community-led organization serving queer men including those who sell sex, lateralized lessons learned from their HIV program towards integrating comprehensive HPV care into their services. Beginning in 2022, HOYMAS, in collaboration with the Universities of Manitoba and Maryland and Partners for Health and Development in Africa, worked to: (1) strengthen anogenital health services in their community-run clinic through clinician assessment, treatment, and referral; (2) raise awareness on anogenital health through community discussion groups; (3) share knowledge and experiences with clinicians working in community-led organizations across the country; and (4) develop standard operating procedures and clinical reporting tools. Decades of investment in community-led infrastructure and “know-how” in responding to the HIV epidemic hold valuable lessons towards lateralizing community-led health services to address other health needs of criminalized and marginalized populations.

Keywords

HPV community-led interventions gay bisexual and other men who have sex with men HIV Kenya

In August of 2019, [second author] and [final author] met a peer educator at Health Options for Young Men Against STIs (HOYMAS), a community-led organization serving queer men in Nairobi. HOYMAS, with whom [final author] had been collaborating since 2009, had been financing the surgical removal of human papillomavirus (HPV)-related cases of anal warts for its clients since 2016 and its leadership had requested a meeting to discuss securing grant funding to increase the sustainability of this intervention. Through his health promotion work on social media and hook-up apps, the peer educator was well-positioned to attest to the community’s marked concern about these conditions. “Everyone is asking me about anal warts, about where these things come from, and about how to get rid of them.” He went on to explain that HOYMAS’ Rescue Centre, which had historically housed those with advanced cases of HIV and tuberculosis patients under directly observed treatment, had more recently doubled as temporary housing for post-operative anal warts patients. The facility provided a humanizing and discreet setting for patients’ recovery, where they were attended to by trained clinicians and counselors. Still, he explained, the Centre was also a site of tremendous suffering. “[Post-operative patients] are screaming all night long. They can’t sleep. They’re all crying at night [because of their pain] and you can’t do anything to help them. They can’t sleep.” Their agony had even become a cause of conflict, with many of the patients complaining that the once quiet atmosphere of the two-story home had been disrupted by these post-operative patients. If these patients had sought a diagnosis at HOYMAS earlier, their cases could have been managed with the topical creams regularly applied by the organization’s clinical officer. But they delayed seeking medical attention because, according to the peer educator, they rightfully feared that their condition would “out” them to clinicians in a country where homosexuality is criminalized and discrimination, including in medical settings, is widespread. They “would rather die” than seek care at a public facility and many had already sought the council of “herbalists and witch doctors” before being referred to HOYMAS. “But by then, it’s too late [for topical treatment] for most of them,” the peer educator stated, shaking his head.

Background

Declines in global funding for HIV programs (Kenworthy et al., 2018), changing government priorities towards integrated health care services to achieve universal health coverage (Ministry of Health Kenya, 2020), and rises in laws that criminalize already marginalized populations (Walimbwa et al., 2023) are creating numerous structural challenges for community-driven programs to be able to adapt and respond to the needs of so-called “key populations”—which are marginalized socially excluded groups of people, including sex workers, transgender people, and gay, bisexual, and other men who have sex with men (hereafter referred to as “queer men”, a term that has been taken up by our interlocuters). Resurgences in political homophobia and femmephobia especially create barriers for queer men to be able to access health services tailored to their sexual health needs and free from stigma and judgment (Lorway et al., n d). In March 2023, the Ugandan government passed an extensive anti-homosexuality act that goes to extreme measures to criminalize same-sex sexuality (Jerving, 2023). The legislation criminalizes “promoting homosexuality” and caries the death penalty for acts labeled as “aggravated homosexuality.” Kenyan Parliament Member Peter Kaluma quickly introduced the closely linked “Family Protection Bill” to the Kenyan National Assembly (Jerving, 2023). While the Kenyan bill has not yet passed legislation, similar bills are being introduced across the African continent (Dyer, 2024; Jerving, 2023; Mujugira et al., 2024; Walimbwa et al., 2023).

There is well-documented evidence on how criminalization impacts both health and access to health care services (Platt et al., 2018; Shannon et al., 2015) and additional concerns have been raised about how these new laws will “devastate the HIV response” by linking the provision of HIV prevention to “promoting homosexuality” (Jerving, 2023). There has been growing recognition that UNAIDS’ 95-95-95 targets to “end AIDS” by 2030 cannot be achieved without addressing stigma and discrimination (Joint United Nations Programme on HIV/AIDS, 2015). UNAIDS has called for reaching zero discrimination by 2025, establishing the 10-10-10 targets focused on removing social and legal barriers to accessing HIV care (Joint United Nations Programme on HIV/AIDS, 2023, 2024a; The Lancet HIV, 2021). Furthermore, we have entered an era of growing criticism around global health funding being directed toward specialized “key population” HIV programs that are vertically-oriented—what Orenstein and Seib (2016) define as “disease-specific interventions implemented on a massive scale, usually with restricted funding … and varying degrees of country ownership” (p. 791). Such vertical programs tend to overlook opportunities to deliver a broader menu of health care services in favor of “a singular focus on HIV” (Woensdregt & Nencel, 2022, p. 355). It is increasingly clear that narrowly-focused individual-level biomedical responses alone are falling short (Kenworthy et al., 2018). While reports continue to document significant drops in funding available to address HIV globally (Joint United Nations Programme on HIV/AIDS, 2024b), novel responses that place control into the hands of communities and expand focus beyond a singular disease approach are urgently needed to respond to the complex health and social realities experienced by members of criminalized and marginalized groups more widely.

As we move toward an era of diminished funding support for HIV interventions, how can the knowledge and skills acquired through decades of community-led work be taken up to continue to address the emerging needs of populations? Community-led interventions have been a cornerstone of the HIV response, where ‘communities’ (meaning those groups most affected by HIV, including queer men, transgender people, and sex workers) have drawn on their tacit knowledges (Gerrans, 2005) and lived experiences to respond to the needs of their peers (see for example: Reza-Paul et al., 2008). Below we explore the concept of lateralizing community-led HIV health service delivery—the notion of drawing on the infrastructures for community-led HIV services towards addressing expanded health services for communities who often face barriers to accessing care because of providers’ stigma and laws that criminalize their identities (Lazarus et al., 2024). In this way, we apply the popular concept of integrated health service delivery within accessible community-led health facilities.

Lateralizing Community-Led HIV Health Service Delivery

Community-led HIV interventions have long expanded their focus to respond to the emerging needs of their clients, such as developing violence interventions (Reza-Paul et al., 2012), cervical cancer screenings (Reza-Paul et al., 2019a), and pandemic responses (Kimani et al., 2020; Macharia et al., 2021; Reza-Paul et al., 2020). Ashodaya Samithi, a sex worker-led collective based in Mysore, India, has conceptualized their expanded service model as “lateralizing” health service delivery—moving beyond a narrow focus on HIV prevention and treatment towards applying community technical know-how in program delivery and reach to integrate other community-requested services within community-led clinical spaces (Lazarus et al., 2024). Lateralization does not intend to replace concepts of community-led or community engaged work, rather it builds on these models towards naming the work that communities engage in when applying decades of expertise in HIV care towards addressing the additional needs of their peers. A lateralizing approach leverages existing innovations in HIV prevention and care towards responding to other health concerns, expanding populations served, and updating reporting tools and measurements. This lateralization approach further speaks to calls for models of integrated health care, with community clinics providing an alternative space for integrated services. Lateralizing diseases takes on an intersectional (rather than syndemics) approach, recognizing the intersecting social positions held by marginalized communities and how these socio-political standings affect multiple health outcomes (Sangaramoorthy & Benton, 2022). As stated by Sangaramoorthy and Benton (2022, p. 3), our view of lateralizing diseases seeks to adopt “a set of methodological tools for understanding how individual and collective experiences are shaped by systemic inequalities and a political commitment unequivocally centered on social justice” and is explicitly grounded in the work of feminist legal scholar and critical race theorist, Crenshaw (1989). Lateralizing populations moves programs beyond a narrow focus on “key populations” and expands service access to include the broader social sexual networks of people who may prefer accessing services in community-friendly spaces, meeting the needs of those similarly disadvantaged by discrimination, criminalization, and marginalization who are often those left behind in national public health systems. Finally, lateralizing measurements draws on the innovations in community-led monitoring that happen at the program-level (Baptiste et al., 2020; Brushett, 2009; Lauer et al., 2024; Reza-Paul et al., 2019b) that can be quickly updated and adapted for new program interventions to measure the impacts on disease outcomes far beyond HIV. In the section below, we provide a case study of lateralizing HIV services towards integrating anogenital health care for queer men in Kenya.

A Case Study of Lateralization: Integrating Anogenital Health Care into HIV Programming for Queer Men

Despite high HPV prevalences found in many African countries (Mboumba Bouassa et al., 2018; Müller et al., 2016; Neme et al., 2015; Nowak et al., 2020; Yaya et al., 2021), queer men continue to be left out of HPV interventions. In Nairobi, a study involving 115 participants found that 51.3% had anal HPV infections, with participants living with HIV having a significantly higher prevalence of HPV (84.3% vs. 24.6%) (Oo et al., 2023). A substantial portion of the detected HPV infections were preventable by the current HPV vaccines, which remain freely available to women only in Kenya (Karanja-Chege et al., 2022; Lorway et al., 2022; Oo et al., 2023). This lack of available services, coupled with a homophobic climate, has led to queer men presenting for care at extremely late stages of anal diseases.

HOYMAS, a community-led organization in Nairobi, attempted to respond to its members presenting to their community clinic with complaints of anal conditions, often presenting as large, obstructive warts. HOYMAS was founded in 2009 by a group of male sex workers living with HIV with a focus on providing services for queer men and sex workers. In 2012, they grew interested in leading their own research and the significance of program data for advocacy after becoming exposed to sex worker-driven studies and programs initiated by Ashodaya Samithi in Mysore (Lorway et al., 2009). Beginning in 2016, HOYMAS began to document presentations of anal health concerns (Lorway et al., 2022). Additionally, and despite minimal guidance in Kenya’s cancer and STI guidelines (Anyula Gorigo et al., 2024), HOYMAS’ clinician (the third author), began to develop processes for screening and treating anal warts. However, HOYMAS members saw men presenting with severe and painful anal warts at extremely late stages of diseases and beyond what could be treated at a community clinic. Furthermore, due to a lack of training on anal health care, HOYMAS additionally began receiving referrals from other community organizations across the country, as the only site offering screening and treatment for anal health conditions.

As described in the opening vignette, HOYMAS approached members of this research team to apply for funding to support an anal health research project to better respond to this alarming rise in late presentations of anal diseases and suffering experienced by their community. Beginning in 2022, HOYMAS, in collaboration with the Universities of Manitoba and Maryland and Partners for Health and Development in Africa (PHDA), worked to lateralize lessons learned from their HIV program towards integrating comprehensive HPV care into their healthcare services by: (1) strengthening anogenital health care services in their community clinic; (2) raising awareness on anogenital health through community discussion groups and social media; (3) sharing knowledge and experiences with clinicians working in community-led organizations; and (4) developing standard operating procedures and clinical reporting tools, with government feedback and approval.

A Project Ethnography of the WEMAH Partnership: Wellness and Men’s Anogential Health

Our research approach and longstanding collaborative partnership is guided by community-based participatory action research methodologies that prioritize the tacit and experiential knowledge of communities to create social change, while recognizing and reckoning with the role that power plays in traditional research hierarchies (Cornish et al., 2023). As part of our collaborative community-driven research project, we conducted a project ethnography of HOYMAS’ model of anogenital health services. A community project ethnography, according to Evans and Lambert (2008, p. 467), works to track emergent social phenomena such as ethical tensions and social hierarchies, given its ability to “illuminate the complex and inter-dependent dynamics of context, practice, agency and power that are specific to a project and shape the course of intervention implementation in ways that may be ‘hidden’ in conventional techniques of project reporting”. This approach, which was described by the team as “hanging out with a purpose,” took place between January and August 2022. The second author (an anthropologist) and the fourth author (a community researcher) conducted extensive ethnographic research with clients undergoing surgery and staying at HOYMAS’ Recovery Centre (where men who underwent surgeries received post-operative care) to explore the experiential and health services trajectories of severe anal diseases (Thomann et al., 2025). The second author conducted an average of 20 hours of participant observation per week at field sites including the HOYMAS waiting room and clinic; the waiting room of the surgical site; the HOYMAS Recovery Centre; and travel between these sites. Field notes captured participant interactions with providers and each other; embodied aspects of their condition; and articulations of pain and suffering. Some weeks, additional hours were spent, as the second and fourth author would spend the first two nights post-operation at the Recovery Centre. When there were not active surgeries happening, they spent more time at the HOYMAS clinic as new patients underwent examination to determine whether they should be referred for surgery or whether topical treatment was still viable. At the Recovery Centre, these field notes were supplemented with observations recorded by the second author and three HOYMAS staff working as caregivers. These data enabled us to better understand why queer men in Kenya tend to be reluctant to access services until the late stages of the disease.

Eligible participants (those who were referred to and underwent surgery) were invited to participate in semi-structured interviews. HOYMAS’ clinician informed eligible participants of the study and introduced them to the second and fourth author after completing their pre-operative examination, who then described the study’s main objectives and explained that their participation was completely voluntary and would not impact their ability to receive services. Challenges to recruitment were minimal as the majority of participants were eager to describe their experiences. Because the interviews took place at the Recovery Centre, several days after the surgery, the interviewers had ample time to build rapport with participants. All participants were informed of the study and were told that they could chose not to be involved at all, including in participant observation to take place at the surgery site and the Recovery Centre. All participants included in the manuscript consented to the participant observations. Interviews were structured to capture: (1) onset and physiological unfolding of symptoms; (2) care avoidance and/or experience of self-treatment; (3) experience accessing services in Kenya’s healthcare landscape; and (4) experience of HOYMAS’ services, including surgical procedure and recovery. Thirty-five interviews were conducted and lasted between 60 and 90 minutes. The second and fourth author used an iterative process to analyze transcripts. They individually reviewed five transcripts, identifying emerging themes through memo-ing to create a codebook. Next, they together refined code definitions through iterative discussions, before independently coding the remaining thirty transcripts (15 each) in Dedoose (a qualitative coding software). Interviewing clients who had received surgeries helped to peel back the multiple layers of shame, stigma, fear, and despair that underlay the experience of severe pain and suffering that participants endured prior to receiving care (Thomann et al., 2025). The project ethnography generated crucial information for our case study of lateralization, as further described in the following sections.

Strengthening Anogenital Health Services

The first step of the WEMAH partnership, a Kiswahili word meaning wellness, involved activities aimed at strengthening anogenital health services within HOYMAS’ community clinic. While the clinician (the third author) had already begun screening and responding to requests for care from members, treatment and referral processes were limited. HOYMAS’ clinician provided an initial assessment of anogenital diseases, classifying them as either early or late stages to define the treatment course. Early-stage diseases were treated in the clinic at HOYMAS with podophyllum, a caustic topical solution that destroys the affected tissue. Importantly, clients were asked by the clinician to return to the clinic for podophyllum application, as applying the treatment beyond the surface of the wart is known to cause burning and damage to the skin. Advanced cases were referred for surgical intervention. Given the high cost of surgeries in the private system, HOYMAS and members of the Universities of Manitoba and Maryland team collaborated to set up a cost effective health service for men, which included the following components: (1) an affordable, small, public clinic that was known to be supportive and friendly towards queer people to provide surgeries at a reduced rate; and (2) a community-run recovery centre, located in a discreet, residential home near to where the surgeries took place, provided a space where young men could safely heal, with HOYMAS clinical staff assisting with pain management, wound care, nutrition guidance, counselling, and monitoring for post-operative infections. While people can stay for up to seven days, Recovery Centre staff shared accounts of individuals wanting to stay longer because of the care received (Figure 1).

Figure 1.

Images of Care Provided at the Recovery Centre

Raising Awareness on Anogenital Health

To better understand the knowledge and concerns of the wider queer community, members of HOYMAS conducted informal, peer-led engagement and discussion sessions with community members, peer educators, outreach workers, navigators, and paralegals. These sessions aimed to understand anal health seeking behavior, as well as knowledge, barriers, drivers, and perspectives. We completed six “Creative Spaces” discussion groups, each with 8-10 participants. Creative spaces are based on “a South African model of risk-reduction workshops for sex workers” (see Huschke, 2019). The idea for Creative Spaces came from the fifth author (a community researcher) as a replacement for focus group discussions. The Creative Spaces were led by the fourth and fifth authors (the facilitators), who had been exposed to and received training in research methodologies over the course of HOYMAS’ collaboration with the University of Manitoba. Creative Spaces functioned as larger discussion groups where the facilitators not only posed questions about anal diseases, but also shared information throughout to additionally serve as an educational component. The facilitators developed the discussion guides, which included a PowerPoint presentation with material on HPV-related basic facts about anal diseases, their detection, and treatment. Discussion guides were slightly modified over time, based on the feedback the facilitators received from their peers. The second and last author (medical anthropologists) guided HOYMAS community researchers and clinical and outreach leads on how to analyze the data. This analysis not only drew upon their lived experiences and contextual knowledges but helped the findings to be absorbed immediately by those responsible for utilizing the information in HOYMAS’ ongoing health promotion work. Discussions highlighted how current HIV prevention programs are overly focused on the “usual education” centered on HIV, PrEP, condoms, and lubricants, which overlook the evolving health needs of the community. A more person-centered model towards a comprehensive approach that includes anal health and HPV prevention was identified as urgently needed through these discussions.

Additionally, HOYMAS launched a social media campaign to promote anogenital health services and normalize anal health screenings as a routine part of sexual health check-ups. A social media strategy was developed that focused on reaching young men (between the ages of 18–29 years) and who face barriers to care in public and private health facilities due to stigma and cost of care. A website with information on anal health care services was developed to improve both knowledge and access to anal health care services (https://wemah.notion.site/WEMAH-10842d1eafdd41b4842c83b8af2e8439).

Sharing Knowledge and Experiences with Clinicians

In November 2022, HOYMAS invited 23 clinicians and clinical students from counties across the country working with community organizations providing health services to queer men for a two-day information sharing and knowledge exchange session in Nairobi, to learn from HOYMAS about their anogenital health care model. Discussions focused on the epidemiology of HPV and provided practical information on how staff managed pain, dietary needs, wound care, and post-operative recovery for those receiving surgery. Notably, HOYMAS’ clinician (the third author), with support from the second-to-last author (a global health expert and medical professional) led this workshop, which included tours of HOYMAS for the trainees to inspect their protocols and treatment facilities and observe the program “in action”. Additionally, the third author’s work provided the foundation for these trainings through his clinical work in observing, classifying, tracking, and developing treatment plans for a large number of anal disease cases—speaking to the accumulated wisdom at the grassroots level of community care.

Three individuals who had undergone surgical interventions with the support of HOYMAS and the Recovery Centre team gave testimonials on their experiences, including sharing the emotional suffering they endured at the hands of health care professionals prior to engaging with HOYMAS. The workshop also served as an opportunity to garner knowledge from the participating clinicians about their current practices, as described in the vignette below captured by the second author:

During the tea break, I chatted with a clinical officer about their experience diagnosing and treating anal warts. They said that clinical officers felt undertrained, explaining, “Sure, I can tell [a patient] ‘those are warts,’ but most times I also feel like there is something else going on and I have a hard time distinguishing. Usually they are coming so late so it’s gotten bad.” Later that afternoon, HOYMAS’ clinician facilitated a discussion about anal examinations and the administering of podophyllum. A clinical officer from another organization offered to demonstrate their method. Standing at a whiteboard, they drew a dot to represent the wart before adding a square around it. “You apply it like this, around the wart. I tell [patients] that it’s best to apply it at night.” This indicates that this clinic is sending patients home with the cream, rather than applying it in the clinic. The clinician made note of this as well. “So, they give it out. So do they at [other clinic]. Does anyone else?” Several of the clinical officers raised their hands. The clinician nodded and explained that it’s best to apply it at the facility to avoid drug eruptions and anal ulcers. “Most of the referrals I am getting come with eruptions. [The patient says], ‘I was given Podosol [podophyllum], I applied but this is how I am feeling.’ They come with ulcer or abscess. So, we apply it and have them come weekly. You should not be sending your patients home with Podosol.”

The above exchange offered opportunities for the HOYMAS team to share their learnings on HPV clinical presentation and treatment strategies, such as administering podophyllum in clinic to the hard-to-see anal areas to avoid additional tissue damage. Additional discussions around the importance of taking a detailed history, how to apply podophyllum, and applying Vaseline as a skin protectant prior to podophyllum application took place. Notably, members of other organizations confirmed that they were seeing similar instances of untreated anal warts among their members, with challenges in diagnoses and treatment. Discussions centered the importance of normalizing anal health care, addressing stigma, and improving the capacity of clinicians to manage HPV-related and other anogenital conditions.

Developing Standard Operating Procedures and Clinical Reporting Tools

Kenya National Guidelines for the prevention, management, and control of sexually transmitted infections currently do not include detailed processes for the screening and treatment of advanced anal health diseases for men (Anyula Gorigo et al., 2024). Led by HOYMAS’ clinician, we collaboratively worked to develop standard operating procedures (SOPs) for anogenital health care and clinical reporting tools. The November 2022 workshop served as the first stage of developing the clinical guidelines, by eliciting feedback on needs and practices among community clinical officers across the country. In January 2023, we held a five-day co-creation workshop that brought together members of HOYMAS, the research team, and representatives from the Technical Support Unit (TSU) responsible for providing guidance to the government’s HIV and sexually transmitted and blood-borne infections programs. The workshop provided an opportunity to formally begin drafting the SOPs with technical experts. In June 2023, the draft of these guidelines was shared with the clinicians from the first workshop during a virtual meeting. During the virtual review, the clinicians were guided through the developed tools and given opportunities to provide inputs and suggestions. All the feedback was carefully incorporated into the tools, ensuring that they were refined to better meet the needs of the clinicians and the communities served. Following this review, the next step was to present the tools to the Nairobi County Health Management Team for further input and approval, with a meeting held at the HOYMAS office in August 2023, for further feedback, revisions, and a resharing of the updated documents to ensure that all changes were accurately captured. In January 2024, the documents were also presented and shared with the National Cancer Institute of Kenya. Through these collaborative processes, the SOPs received approval from the National Cancer Institute of Kenya and in June 2024, from the Nairobi County Health Management Team. This approval marked the culmination of a collaborative and multisectoral approach that involved diverse stakeholders throughout the development process, including community leaders, researchers, health care workers, and government representatives. Their input ensured that the developed SOPs were comprehensive in providing person-centered care tailored to the needs of queer men.

Discussion

Lateralization provides a model for HIV programs that not only meets the goal of integrated health care but expands upon the decades of expertise held by communities in leading HIV programs. Innovations in community-led programs hold important insights towards approaches to address other health needs of populations who are often left behind due to criminalization and marginalization, recognizing how socio-political standings affect multiple health outcomes (Sangaramoorthy & Benton, 2022). Our lateralization example attempts to demonstrate a conceptual approach towards community-led interventions that applies existing expertise to respond to communities with intersecting identities and needs beyond HIV care that can be adapted towards the local contextual needs of diverse communities, in varying geographical contexts. The above case study provides a model for expanding existing HIV-focused programming to respond to the health needs of queer men, namely anal health care for HPV-related and other anal conditions—extending services beyond just HOYMAS’ members towards the wider queer community, while also updating existing documentation and monitoring tools to capture uptake of new services. Community knowledges and longstanding relationships between community organizations, their networks, the research team, and technical partners facilitated ‘lateralizing’ HIV care to address emerging and growing needs in anogenital health care, through established channels of trust, communication, decision-making, and support. Lateralization provides a conceptualization for the work already being carried out by community organizations who are experts at responding to the needs of their communities, as especially captured during the COVID-19 pandemic (Kimani et al., 2020; Macharia et al., 2021; Reza-Paul et al., 2020).

However, lateralization is not without its challenges. Over the years, community organizations have faced increased difficulties in sustaining program funding for their activities. At the time of writing, funding needs were further exasperated by stop work orders for organizations receiving US-funding (Callaway, 2025; The Lancet, 2025; The Lancet HIV, 2025). Limited research budgets do not stretch into sustainable program funding and funding can often get redirected towards other emerging priorities or basic operational costs. Additionally, HOYMAS has served as a unique referral centre for the country—an approach that creates hardships on men who must travel long distances by bumpy roads, prolonging experiences of pain, and at times travelling when there are not resources to pay for surgical interventions. While an anal health partnership was requested by the community, starts and stops towards the provision of needed treatment, surgeries, and post-operative care were and remain a constant struggle and highlight ethical concerns around meeting the needs and expectations of community members who are greatly suffering without treatment. Models of community-led anogenital health care must be widely shared so that other organizations can be able to deliver their own anal health programs. Finally, expansion of the HPV vaccination program to freely offering vaccines to queer men and boys remains an urgent priority and the best attempt at curbing a rising pandemic of HPV-related anal health diseases (Karanja-Chege, 2022; Lorway et al., 2022).

While integration has long been a government priority, it is important to stress that integrating health services for key populations into public and private health facilities alone in a climate of criminalization is sure to leave many behind. Government support is required in order to ensure that community-led services can be scaled and maintained. As noted by van Stapele, Nancel, and Sabelis (2019), limiting support from government to a focus solely on health care, while ignoring the harms of criminalization to these same communities creates an impossible reality for effective partnerships. This is especially true for those who face double criminalization as queer men and sex workers. Community-led organizations are uniquely positioned to provide “support, care, acceptance and love” (Moyer & Igonya, 2018, p. 1017; see also Doshi et al., 2022). Our case study highlights the need for sensitive and comprehensive anal health care for queer men in Kenya, as well as a call for funders and governments to “transcend a singular focus on HIV” (Woensdregt & Nencel, 2022, p. 355), towards recognizing and responding to the harms caused by the socio-political environment, while recognizing community’s unique abilities to lead care work. The notion of lateralization—applying decades of community-led expertise in addressing HIV towards responding to other emergent health needs—holds important insights for expanding the type of care that communities can access in trusted, established community-led clinics.

Footnotes

Acknowledgements

We would like to thank the community-based organisation, HOYMAS, as well as their individual members for their leadership on this study.

ORCID iDs

Lisa Lazarus

Robert Lorway

Ethical Consideration

This study was approved by the University of Manitoba Health Research Ethics Board (HS 24029 (H2020:292)) and the AMREF Health Africa Research Ethics Board (AMREF-ESRC P1079/2021).

Consent to Participate

All participants provided written informed consent for the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:The project was supported by the Canadian Institutes for Health Research (179790). Robert Lorway is supported by a Tier 2 Canada Research Chair in Global Intervention Politics and Social Transformation. Matthew Thomann is supported by the Fulbright US Scholar Grant Program, Africa Regional Research Program. Souradet Shaw is supported by a Tier 2 Canada Research Chair in Program Science and Global Public Health. James Blanchard is supported by a Tier 1 Canada Research Chair in Epidemiology and Global Public Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

As the datasets involve sensitive data from criminalised and stigmatised groups, data will not be made publicly available. Some data may be made available from the corresponding author on reasonable request and approval from the community organisation and study team.*

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