Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland

Abstract

IntroductionSame-sex practices and orientation are both stigmatized and criminalized in many countries across sub-Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same-sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio-economic and behavioural determinants.MethodsThree hundred and twenty-three men who reported having had anal sex with a man in the past year were recruited using respondent-driven sampling and administered a structured survey instrument. Asymptotically unbiased estimates of prevalence of stigma and human rights abuses generated using the RDSII estimator are reported with bootstrapped confidence intervals (CIs). Weighted simple and multiple logistic regressions of fear of seeking healthcare and disclosure of same-sex practices to a healthcare provider with demographic, social and behavioural variables are reported.ResultsStigma was common, including 61.7% (95% CI=54.0–69.0%) reporting fear of seeking healthcare, 44.1% (95% CI=36.2–51.3%) any enacted stigma and 73.9% (95% CI=67.7–80.1%) any perceived social stigma (family, friends). Ever disclosing sexual practices with other men to healthcare providers was low (25.6%, 95% CI=19.2–32.1%). In multiple logistic regression, fear of seeking healthcare was significantly associated with: having experienced legal discrimination as a result of sexual orientation or practice (aOR=1.9, 95% CI=1.1–3.4), having felt like you wanted to end your life (aOR=2.0, 95% CI=1.2–3.4), having been raped (aOR=11.0, 95% CI=1.4–84.4), finding it very difficult to insist on condom use when a male partner does not want to use a condom (aOR=2.1, 95% CI=1.0–4.1) and having a non-Swazi nationality at birth (aOR=0.18, 95% CI=0.05–0.68). In multiple logistic regression, disclosure of same-sex practices to a healthcare provider was significantly associated with: having completed secondary education or more (aOR=5.1, 95% CI=2.5–10.3), having used a condom with last casual male sexual partner (aOR=2.4, 95% CI=1.0–5.7) and having felt like you wanted to end your life (aOR=2.1, 95% CI=1.2–3.8).ConclusionsMSM in Swaziland report high levels of stigma and discrimination. The observed associations can inform structural interventions to increase healthcare seeking and disclosure of sexual practices to healthcare workers, facilitating enhanced behavioural and biomedical HIV-prevention approaches among MSM in Swaziland.

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

“…[77][78][79] Exposure to stigma including culturally insensitive health workers can result in MSM avoiding HIV testing and other prevention services, limiting diagnosis and awareness of status. 78,[80][81][82] Even more acute, men who are aware of living with HIV may avoid HIV treatment altogether. 83 Reduced utilisation of health and HIV services by MSM, due to enacted or perceived discrimination, limits knowledge of the risks of condomless anal intercourse and opportunities for access to prevention services.…”

“…[84][85][86][87][88] However, recent studies demonstrating the high levels of experienced and perceived stigma in countries ranging from Europe to Sub-Saharan Africa suggest that internalised stigma is an outcome of lived stigma and may be a proxy for mental health stressors related to this stigma. 80,[89][90][91][92][93] Indeed, mental health issues appear consistently as outcomes of stigma and as a mediating determinant of HIV risks. [94][95][96] Given the efficient HIV transmission that can take place in sexual networks of MSM if a network member is acutely infected, stigma limiting engagement in services is problematic given that it can contribute to late HIV diagnoses.…”

Is Involvement in Sex Work Associated with Engagement in HIV-Related Medical Care in Latin American Men Who Have Sex with Men? Results of a Large, Multinational Internet Survey

“…Stigma from healthcare providers may limit disclosure of sexual orientation or sexual behaviors among MSM, if they anticipate discrimination following disclosure. 16 Among people living with HIV, HIV and healthcare stigma has been associated with decreased care-seeking behavior.…”

“In the Fell Clutch of Circumstance”: HIV and Men Who Have Sex With Men in Sub-Saharan Africa

“…Additional barriers to implementation include high levels of stigma and homoprejudice across the region [5•, 6-8], a lack of knowledge of the specific needs of MSM in terms of HIV prevention among health care workers and public health officials [9][10][11] and a lack of resources specifically targeted at MSM populations [12]. In spite of these challenges, however, there is an increasing focus on MSM in HIV-related research in SSA, which may, in turn, facilitate the development of appropriate prevention, treatment and care strategies for this population.…”