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20 October 2025

HIV Treatment Services Among Men Who Have Sex with Men During COVID-19 in Limpopo Province, South Africa

,
,
and
1
South Africa Medical Research Council/University of Johannesburg Pan-African Centre for Epidemics Research Extramural Unit, Faculty of Health Sciences, Johannesburg 2092, South Africa
2
Anova Health Institute, Polokwane 0700, South Africa
*
Author to whom correspondence should be addressed.
COVID2025, 5(10), 180;https://doi.org/10.3390/covid5100180
This article belongs to the Section COVID Public Health and Epidemiology
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Abstract

Men who have sex with men (MSM) are part of the key populations (KPs) that are susceptible to Human Immunodeficiency Virus (HIV) acquisition, transmission, and disruptions to access HIV services. This study aimed to explore and describe the HIV interventions implemented among MSM during the COVID-19 lockdown in the Capricorn District of Limpopo Province in South Africa. This study followed an exploratory qualitative study design with a purposive sample of 16 men who identified as MSM. Data were collected through in-depth interviews which were tape-recorded, transcribed verbatim, and captured on Atlas.ti. Patterns from the created codes were formulated into themes/sub-themes guided by the Consolidated Framework for Implementation Research (CFIR). The MSM had a mean age of 27.9 years. Various constructs and domains of the CFIR showed that during the COVID-19 lockdown, MSM encountered a disruption of HIV services. The response time was elongated, thus increasing the complexity of interventions. Interventions were implemented to ensure continuity of services. These included tailoring the programme through a door-to-door strategy and offering resources to healthcare facilities to enable MSM to access antiretroviral therapy (ART) and related services. The relative advantage of the programme is that it prioritises MSM. Future research should look into COVID-19’s impact on a bigger scale.

1. Introduction

The world experienced the COVID-19 pandemic in the years 2019–2020. Consequently, South Africa, among other countries, implemented lockdown measures to mitigate and curb the spread of the virus [1]. In South Africa, the COVID-19 lockdown was in effect from 26 March 2020. It was divided into five lockdown levels, with level five being the most restrictive and level one being the least restrictive. Lockdown level five started on 26 March 2020, and they transitioned all the way to level one, which was in effect from 1 October 2021 [2]. These included imposing several measures such as curfews, daily and continuous wearing of masks, the use of hand sanitisers, maintenance of physical distance, and bans on meetings and travelling. Only on 5 April 2022 was the national state of disaster lifted in South Africa [1,2]. Notwithstanding that these actions could have helped in controlling the spread of the virus, accessibility to the Human Immunodeficiency Virus (HIV) services was substantially affected by COVID-19 both health-wise and socio-economically, particularly among people living with HIV (PLHIV) as well as key populations (KPs), i.e., men who have sex with men (MSM) [2]. This burden was compounded by the prevailing discrimination, stigma, and marginalisation already experienced by MSM [3].
Key populations are particularly susceptible to HIV acquisition, COVID-19, and interruptions in the delivery of HIV care [4]. Globally, MSM accounted for 23% of new HIV infections [5]. Furthermore, the MSM have a 25-fold greater probability of contracting HIV than other adult men who do not identify as MSM in terms of their sexual orientation [4]. There are several categories of sexual orientations among MSM, including gay and bisexual [6]. To maintain an undetectable viral load and help contain the HIV epidemic, the KPs need to have access to HIV services such as HIV testing, as well as antiretroviral therapy (ART) initiation, retention, and adherence [7].
Fear, isolation, anxiety, and even stigma have all increased as a result of the COVID-19 pandemic. This might negatively impact the health outcomes of MSM who are on ART, in addition to possible connections between HIV and COVID-19 [8]. Therefore, it is crucial to establish how these connections could impact their well-being, particularly those living with HIV, to emphasise the need for pertinent and tailored HIV care services. To understand the challenges faced by MSM during the COVID-19 lockdown, personal experiences and invaluable insights will be explored. This will be achieved through the application of the Consolidated Framework for Implementation Research (CFIR), which is a research tool widely utilised to predict, identify, or elucidate obstacles and enablers to the efficiency of implementations, also referred to as a determinant framework [9]. The five domains that constitute the CFIR include the inner setting, individual characteristics, intervention characteristics, outer setting, and process [10].
By identifying the challenges faced by MSM to access and adhere to HIV treatment during the COVID-19 pandemic using the CFIR, this study explored strategies to mitigate the identified barriers and advise policymakers and other relevant stakeholders on the measures identified by this study to sustain HIV treatment for this population. Consequently, HIV outcomes for MSM might improve while ensuring preparedness for future pandemics. Therefore, this study aims to explore and describe the HIV interventions implemented among MSM during the COVID-19 lockdown in the Capricorn District.

2. Materials and Methods

2.1. Study Design

An exploratory qualitative study design was followed. The design enables the exploration of people’s experiences and seeks to comprehend a phenomenon or concept in greater detail as well as discover new information. Therefore, it enables study participants to add to new knowledge in that particular field [11].

2.2. Study Area

This study was conducted in Limpopo Province’s Capricorn District, South Africa. The study setting is among the five district municipalities in the province. The province’s capital, i.e., Polokwane, which is the province’s economic hub, is under the jurisdiction of the Capricorn District Municipality [12]. Our local municipalities that constitute the district municipality are Blouberg, Molemole, Polokwane, and Lepelle-Nkumpi [12]. With 113 wards and 28 traditional authorities, the district’s 185,222.27 hectares make up 12% of the province’s total surface area. With a total population of 1,372,355 million, Capricorn District municipality accounts for 2.3% of South Africa’s population, and almost 23% of the province’s population [12].

2.3. Men Who Have Sex with Men in Limpopo Province

Limpopo Province is approximately 90% rural [12], with an estimated HIV prevalence of 35.7% among MSM in 2024 [13]. Similarly to MSM in other settings, the MSM in Limpopo Province experience stigma and discrimination, also due to cultural norms [14]. They have limited access to MSM-friendly and specific MSM care, particularly in the rural areas [15]. The MSM’s access to HIV care services in primary health facilities is limited by the insensitisation of public health workers towards MSM’s sexualities, the generalised approach to the provision of HIV-related services which do not cater to their specific needs, and a lack of resources in some facilities [16,17]. Hence, there was an implementation of the MSM programme to cater to their unique needs and reduce HIV transmission. The MSM programme was implemented in the Capricorn District, serving approximately 6000 MSM. There are other similar programmes in other districts within the Limpopo Province; however, the MSM programme in the Capricorn District is the largest one [18].

2.4. Sampling

A purposive sample of the study consisted of 16 MSM, which was determined by data saturation. The minimum sample size required to reach data saturation for qualitative research was reported to be 12 people [19]. However, even when the sample size is compliant, it remains the researcher’s responsibility to ensure that the appropriate sample size is included for adequate response to the study aim.
The recruitment of the interviewees was conducted, assisted by an MSM community gatekeeper who is part of a non-profit organisation (NPO). The NGO in question implemented the largest MSM programme in the Capricorn District Municipalities. They offered HIV services to MSM in the district and supported the South African National Department of Health (NDoH) regarding access to and delivery of HIV services. The MSM community gatekeeper introduced the researcher to the participants and interested MSM were invited to participate in the study.
The criteria for inclusion were men who identified as MSM, were clients of the MSM programme in the Capricorn District municipality during the COVID-19 lockdown, aged 18 years or older, and who gave written informed consent to participate.

2.5. Data Collection

In-depth interviews were carried out to collect data using open- and closed-ended questions from 26 February to 15 March 2024 for a duration of 20–35 min per interview. All 16 MSM were interviewed to completion. The interviews elicited information on the experiences of MSM regarding HIV services accessibility and utilisation amid the COVID-19 lockdown. The questions concentrated on the following: HIV care needs and preferences, challenges and barriers to timely HIV testing, linkage to care, ART refill, ART adherence, viral load tests, attendance of clinic visits, the ability of the programme to adapt to the changes brought by COVID-19 and ensure continuity of services, communication platforms, and recommendations to improve the programme in settings comparable to the COVID-19 lockdown based on their experiences. Open-ended questions were utilised to probe into the detailed experiences of MSM (Appendix A). Verbatim recordings of the interviews were taken and supported by a tape recording for accuracy purposes. Furthermore, field notes were made to supplement the recorded information. No personal or identifiable information about the MSM was disclosed by the organisation whatsoever during this process. It is only the organisation’s management that can access the personal information of the MSM. Furthermore, the MSM who expressed interest gave consent to participate in the interviews. The interviews were held one-on-one in a secluded room at the organisation’s offices where services were rendered.
The CFIR was applied to evaluate the implementation of the MSM programme, and the access and utilisation of HIV treatment services by the programme recipients (i.e., MSM) during the COVID-19 lockdown period, based on the relevant CFIR domains and constructs [9]. The CFIR provides a complete theory-based system which works well for qualitative implementation research. The framework structures influential factors into five domains (as shown in Table 1 below) to provide a systematic approach for qualitative data interpretation. The framework’s adaptability enables researchers to customise it to specific contexts, while maintaining research rigor and improving comparability across studies [9]. Table 1 below shows the domains and constructs that the current study focused on [9].
Table 1. Constructs and domains analysed in this study.

2.6. Data Analysis

Atlas.ti was employed to capture qualitative data [20,21]. A ground-up approach wherein codes result from the research data, referred to as inductive coding, was used [22]. A thorough review of the entire data was conducted to acquaint the researcher with its content. Before analysing the data, the interviews were transcribed verbatim; thereafter, the entire dataset was read to generate codes in alignment with the CFIR constructs. Patterns from the created codes were used to formulate themes and sub-themes where applicable. To analyse open-ended questions, thematic content analysis was used, while close-ended questions were analysed descriptively.
NB: All participants’ responses were included in the thematic analysis, although not all quotes were included in the manuscript. The included quotes were selected based on the best representation of the themes and constructs, while representing a range of MSM perspectives.

2.7. Ethical Considerations

This study has undergone review and approval by the University of Johannesburg’s Research Ethics Committee (REC) (REC-1949-2023) and the MSM community gatekeeper in the Capricorn District, Limpopo Province. All participants were requested to provide written consent to participate in the interviews. All the transcriptions and recordings were secured and coded in protected files with controlled access, while hard copies were locked in cabinets in offices with controlled access. Hesitancy to participate in the study did not affect the programme services received by the participants.

3. Results

Table 2 below shows the general characteristics of the interviewed MSM. Of the 16 MSM interviewed, 13 identified as gay, while three identified as bisexual. The MSM’s ages ranged from 20 to 38 years, with a mean age of 27.9 years. Four of the MSM stayed in semi-urban locations, five in rural locations, six in urban locations, and one in a semi-rural location. Overall, nine of the MSM completed tertiary education, while seven only completed up to Grade 12 (matric) level. Only six of the MSM were employed during the COVID-19 lockdown, including one who was self-employed, while eight were still studying (five at the high school level, and three at the tertiary level), one was in a learnership programme, and one was unemployed. Lastly, all the MSM were black and unmarried or single.
Table 2. General characteristics of the study participants.

3.1. Innovation

Table 3 below shows an assessment of the MSM programme’s innovation during the COVID-19 lockdown.
Table 3. An assessment of the programme’s innovation amid the COVID-19 lockdown.

3.2. Outer Setting

Table 4 below shows an assessment of the MSM programme’s outer setting during the COVID-19 lockdown.
Table 4. An assessment of the programme’s outer setting amid the COVID-19 lockdown.

3.3. Inner Setting

Table 5 below shows an assessment of the inner setting of the MSM programme during the COVID-19 lockdown.
Table 5. An assessment of the programme’s inner setting amid the COVID-19 lockdown.

3.4. Individual Characteristics

Table 6 below shows an assessment of the characteristics of the MSM programme recipients amid the COVID-19 lockdown.
Table 6. An assessment of the characteristics of the programme recipients amid the COVID-19 lockdown.

3.5. Implementation Process

Table 7 below shows an assessment of the MSM programme implementation process during the COVID-19 lockdown.
Table 7. An assessment of the programme’s implementation process amid the COVID-19 lockdown.
Table 8 below summarises the findings of this study by CFIR domains and the associated quotes.
Table 8. Summary of main findings by the consolidated framework for implementation research domains and selected quotes.

4. Discussion

The current study found that the COVID-19 lockdown and associated measures implemented to manage the virus have significantly disrupted the MSM programme in the Capricorn District Municipality, South Africa. Visits to MSM hotspots were prohibited at the beginning of the COVID-19 lockdown. The capability of the programme to reach new clients was limited. During the COVID-19 lockdown onset, the MSM programme had to temporarily close as it was not considered an essential service, although the programme was later resumed due to the provision of travelling permits issued to the MSM programme implementors by the Limpopo Department of Health. This was fostered by the partnership and connection that the programme had built with the department, as reflected in the outer setting domain. The programme has created and sustained formal and informal relationships with different parties across the district, including the Limpopo Department of Social Development, other KPs organisations, and traditional councils in several villages. Additionally, MSM are also essential to maintaining the programme’s viability since they volunteer their time and personal abilities to the programme and other recipients. The programme implementors adapted and tailored aspects of their everyday services to meet the COVID-19 conditions when they were able to operate a few months after the COVID-19 lockdown measures were implemented, thus ensuring the continuity of HIV services to as many MSM as possible.
For the continuation of HIV services provision to MSM, the programme was adapted and tailored accordingly through implementations like the door-to-door strategy to safely provide HIV tests and distribute condoms and lubricants among other services to MSM, at their doorsteps. Additionally, transporting MSM to the designated or nearest public health facility to access their ART further demonstrated the adaptability of the programme. These findings are supported by a qualitative study conducted among programme implementers of the same MSM programme explored in the current study [18]. One of the major factors that enabled the programme to effectively tailor their services and reach more MSM was the interdisciplinary teamwork of the programme implementors. The roles included a programme liaison officer, team leaders, an outreach team, HIV testing services, and retention counsellors, social workers, and nurses [18]. Nonetheless, due to the COVID-19 lockdown, not all clients could be reached through this approach because some of them relocated to other districts and remote areas, with some of those areas being out of bounds for the programme to reach them. Consequently, some MSM were not able to adhere to ART due to challenges accessing it in their local public clinics. Furthermore, barriers included the movement restrictions imposed amid the lockdown, a lack of a transfer letters for the clients of the programme, uncooperative nurses in public health facilities, and the fear of COVID-19 contraction. Fortunately, none of the MSM in the current study were infected with COVID-19; however, some had loved ones who experienced COVID-19 infection during the lockdown. Contrary to the current study, another study conducted in Thailand reported that MSM had appropriate access to ART, thus they were able to sustain ART adherence [3]. Their desire to maintain their immune system in good health enabled them to adhere to ART. Furthermore, the MSM were able to continue receiving HIV care due to the implementation of several strategies for HIV service delivery, including the usage of booths that are accessible by car, fast-tracked ART pick-up services, and home ART delivery [3].
Similarly, another study reported COVID-19 lockdown movement restrictions, including police roadblocks, as the number one barrier to MSM accessing HIV services, with these leading to a fear of invasive questioning by the police [23]. Some MSM would sometimes postpone collection of their ART on a given date due to a fear of police and unplanned HIV status disclosures, as reported in the current study. These may have been evaded if the MSM received letters authorising them to visit HIV centres to receive their treatment and other services; however, securing the permission letters had proven to be difficult [24]. In Zimbabwe and Uganda, public transportation frequently faced delays and took a long time to arrive at treatment centres [23]. In South Africa, similar delays could have been barriers because public transport could only carry very few passengers at a time to maintain social distancing [25]. Possibly, all of the above could have been mitigated by implementing eHealth services to enable MSM to access the required HIV services in the comfort of their own homes, thus promoting ART adherence [2,26].
Moreover, some MSM have lost their jobs or sources of income due to retrenchment or the temporary closure of companies. This led some MSM to relocate from Polokwane city to their homes in villages and townships, where the MSM programme, in most instances, could not easily reach them. Similar findings were reported wherein several KPs lost their jobs, including at gay clubs and informal employment [27]. Some MSM who were forced to return home due to job losses faced homophobic hostility from their families [27,28]. In addition, the COVID-19 lockdown reduced opportunities for MSM to contribute and participate maximally in the programme. For instance, the events that the programme used to host for MSM to share their needs and thoughts on the programme were halted due to restrictions on gatherings. However, the need and motivations of the programme remained significant. The importance of ensuring that programme implementation is centred around the recipients’ needs, and feedback for its success were emphasised [29].
In terms of policies and legislation, same-sex relationships are allowed in South Africa [30]. In 2006, same-sex couples were permitted to engage in civil marriages with the same obligations and outcomes as heterosexual couples entering a marriage. Even though MSM are legally protected, some communities in South Africa still do not accept homosexual relationships [31,32]. Consequently, MSM still experiences stigma, discrimination, and hate crimes, including murder [33].
Despite all the barriers that MSM experienced with access, utilisation, and contribution to the MSM programme services in this study, they were content with the programme implementation in the Capricorn District because it is the first programme of its magnitude in the province. It is a peer-led programme that aims to reduce STIs, particularly HIV, among MSM in a sensitised setting that protects their privacy and confidentiality [34]. It was reported that the MSM in Zimbabwe had received peer support through arranged calls or virtual channels like WhatsApp [23]. Similarly, the peer outreach team in the current study were in constant contact with the MSM to support them during the COVID-19 lockdown, including those who could not be reached physically.
The interventions implemented to mitigate the impact of COVID-19 to ensure continuity of HIV treatment services in the current study are related to the differentiated service delivery (DSD) models that have been proven to be effective in several HIV-burdened, high-stigma, and low-resourced parts of Africa [23,35,36,37]. Hence, these interventions are potentially transferable to similar rural or semi-urban environments where MSM or other KPs face similar structural barriers such as stigma, discrimination, or even poor infrastructure and movement-restricted conditions similar to the COVID-19 lockdown or similar future pandemics. Furthermore, the contextual tailoring of these interventions can greatly support their implementation [38], including engaging local MSM peer educators and leveraging existing community health support structures [37,39]. These may further be adaptable in low- and middle-income countries with marginalised populations experiencing similar health system challenges within and beyond Africa [40].

Strengths and Limitations

This study is focused on MSM, who are a part of the key and vulnerable populations in the world. The findings of this study will add to knowledge and inform policymakers on the barriers impeding access to ART among this population and guide the implementation of interventions, including supporting structures to increase the uptake of ART. This will meaningfully contribute towards meeting the 95-95-95 UNAIDS goals and get us closer to ending HIV as an epidemic by 2030.
The employment of the exploratory qualitative study design facilitated a deeper and more comprehensive analysis of MSM’s experiences during the COVID-19 lockdown. Considering the self-reported structure of this study, the possibility of response bias cannot be excluded. Furthermore, since this study only focused on MSM getting HIV care services from one NGO in one district within Limpopo Province, the findings of this study cannot be generalised to those receiving similar services from different service providers, including governmental health facilities, nor can it be generalised to the entire province. Hence, the possibility of selection bias cannot be excluded from this study. Nonetheless, the information generated from this study can effectively be used to guide the improvement and tailoring of the HIV treatment services provided to MSM.

5. Conclusions

The relative advantage of the MSM programme is its prioritisation of MSM, a group having one of the greatest HIV prevalences and incidences globally. Despite the above, the MSM programme was disrupted by the COVID-19 lockdown restrictions. In spite of the adaptations and tailoring of the programme, access to and use of ART were hampered by the COVID-19 pandemic’s disruption of HIV services and the ensuing lockdown measures, leading to non-adherence among MSM. The COVID-19 pandemic led some MSM to relocate, thus placing them out of the programme’s reach. Hence, the need exists to implement various interventions to improve access to HIV services, including DSD models such as eHealth services, among others, as well as the provision of travel permission letters to MSM who are on ART during movement-restricted conditions. Moreover, investing in and classifying such interventions as essential services will ensure prioritisation and fewer disruptions in situations similar to the COVID-19 lockdown. This study has provided insights into the impact of the COVID-19 pandemic on MSM’s access to HIV treatment services in the Capricorn District of Limpopo Province in South Africa. This is essential for future pandemic preparedness and contributions towards the 95-95-95 UNAIDS goals of ending HIV as a pandemic by 2030. Subsequently, future studies should investigate the impact of COVID-19 and similar pandemics on HIV services among MSM and other KP groups on a larger scale.

Author Contributions

Conceptualization, B.S., R.N.P.-M. and E.P.; methodology, B.S., R.N.P.-M. and E.P.; software, B.S.; validation, B.S., R.N.P.-M. and E.P.; formal analysis, B.S.; investigation, B.S., R.N.P.-M., E.P. and A.B.; resources, B.S., R.N.P.-M. and A.B.; data curation, B.S.; writing—original draft preparation, B.S.; writing—review and editing, R.N.P.-M., E.P. and A.B.; visualization, B.S., R.N.P.-M. and E.P.; supervision, R.N.P.-M. and E.P.; project administration, B.S., R.N.P.-M., E.P. and A.B.; funding acquisition, R.N.P.-M., E.P. and B.S. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the Mid-Career Scientist Program (Grant ref no: HDID14392_GM24). Ms. Sebati was also supported by the Department of Science and Innovation (DSI) through the South African Women in Science Doctoral Fellowship Award. The article processing charges will be supported by the University of Johannesburg.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee at the University of Johannesburg (REC-1949-2023).

Data Availability Statement

The research data collected as part of this study are available upon request from the corresponding author.

Acknowledgments

Funding for this work was awarded by the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the Mid-Career Scientist Program. The award listed above provides funding for the authors, Phaswana-Mafuya Refilwe Nancy, Phalane Edith, and Sebati Betty. The SAMRC/University of Johannesburg PACER Extramural Unit is the organisation that is responsible for this initiative. The writers are solely responsible for the content of this publication, which may not represent the opinions of SAMRC or the University of Johannesburg. The authors have reviewed and edited the output and take full responsibility for the content of this publication. Betty Sebati is also supported by the SAMRC Postgraduate Research Associate Programme.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
MSMMen who have Sex with Men
PLHIVPeople Living with HIV
KPsKey Populations
CFIRConsolidated Framework for Implementation Research
COVID-19Coronavirus Diseases 2019
SAMRCSouth African Medical Research Council
ARTAntiretroviral Therapy
NDoHNational Department of Health
NPONon-Profit Organisation

Appendix A

Table A1. In-Depth Interview Guiding Questions on the Impact of COVID-19 on Access and Utilization of HIV Treatment Services Among Men Who Have Sex with Men in Capricorn District, Limpopo Province, South Africa.
Table A1. In-Depth Interview Guiding Questions on the Impact of COVID-19 on Access and Utilization of HIV Treatment Services Among Men Who Have Sex with Men in Capricorn District, Limpopo Province, South Africa.
Demographics
○
Age (in years), race (black, white, Indian, coloured, other: specify), education (none, primary, high school, tertiary), marital status (single, married, divorced, widowed), location (rural, semi-rural, semi-urban, urban)
Sexual Identity and Orientation
○
Which group of the MSM do you identify with? i.e., gay, bisexual, etc.
Impact of COVID-19 on HIV Care Services
○
Were your healthcare/HIV care needs and preferences met during the COVID-19 lockdown? Provide specific examples of which ones and how they were met.
○
Was the programme able to adapt to the changes brought by COVID-19 and ensure continuity of services during the COVID-19 lockdown?
○
What are the challenges and barriers to timely HIV testing, linkage to Care, ART refill, ART adherence, viral load tests, and making clinic visits during the COVID-19 pandemic? Be specific.
○
Have you ever felt like you needed psychosocial assistance/counselling services due to COVID-19 challenges? If yes, did you get the assistance from the programme?
○
Were you able to communicate with your healthcare providers during the COVID-19 lockdown? How?
○
What improvements would you recommend about HIV care services during the COVID-19 lockdown?
○
Any general comments on your experiences concerning HIV care services and COVID-19?

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