Understanding the sexual and reproductive health barriers and recommendations of men who have sex with men and transgender women in rwanda: the case of Hope and Care (HAC) organization.

Introduction
Men who have sex with men (MSM) and transgender women (TGW) around the globe and in
Rwanda are at higher risk than the general population of being subject to sexual health
disparities, as well as disparities pertaining to the affordability and accessibility of sexual and
reproductive health care services (UNAIDS, 2019). As a result of discrimination and
marginalization, the vulnerability of socially disadvantaged groups such as MSM and TGW is
reinforced; especially, as it relates to sexual and reproductive health (SRH) care. Accordingly,
this study was conducted to explore the perspectives of MSM & TGW populations, highlight the
barriers they experience accessing the SRH services and give rise to community-informed
recommendations for improvements across the SRH care provision spectrum in Rwanda.
Methods
An exploratory sequential mixed-methods study was conducted. Four semi-structured focus
group discussions (FGDs) were conducted with members of the MSM and TGW populations in
Rwanda. Subsequently, a quantitative survey was administered to 134 members of the identified
population to ascertain the magnitude of the barriers and assign weight to the recommendations
that were highlighted in the FGDs.
Results
Four main themes emerged from the focus group discussions. The qualitative results highlighted
the notable disparities experienced in SRH service/care in rural versus urban settings, the
preference for/recommendation of specialized services for these populations and the enabling
impact that NGOs like Hope and Care can have on the acquisition of equitable, accessible SRH
care. Lastly, the focus groups highlighted that despite the harassment and stigma this community
faces at the hands of healthcare providers and society in general, they are highly empowered in
their own sexual and gender identities and serve as active agents in their own SHR care seeking.
The quantitative portion of the study corroborated the results of the focus group discussions,
confirming the challenges faced by these populations while accessing SRH care due to
harassment by healthcare providers, societal stigma, fear of outing and disclosure of identity,
violence, stockouts and lack of knowledge of healthcare providers regarding issues that affect
their communities amongst many others. The recommendations put forth in the focus group
discussions were quantified, each one producing statistical significance across the group; with
very negligible significant differences noted between MSM and TGW and across age groups,
indicating mutual agreement on their collective importance.
Conclusion and Recommendations
The MSM and TGW are self-empowered communities and are acutely aware of their SRH
needs. Hence community recommendations must lead policy change with focused research to fill
existing gaps. Specialized training for healthcare professionals with a holistic approach including
mental health care, strengthening of existing NGOs through government support, provision of
individual insurance, increasing outreach to rural communities, and sensitization of the society
and local leaders emerged as key recommendations. We further suggest an integrated, gender-
transformative approach by strengthening existing medical curricula, training, insurance schemes
and delivery models.