The Prevalence of Sexual Behavior Stigma Affecting Gay Men and Other Men Who Have Sex with Men Across Sub-Saharan Africa and in the United States

Abstract

BackgroundThere has been increased attention for the need to reduce stigma related to sexual behaviors among gay men and other men who have sex with men (MSM) as part of comprehensive human immunodeficiency virus (HIV) prevention and treatment programming. However, most studies focused on measuring and mitigating stigma have been in high-income settings, challenging the ability to characterize the transferability of these findings because of lack of consistent metrics across settings.ObjectiveThe objective of these analyses is to describe the prevalence of sexual behavior stigma in the United States, and to compare the prevalence of sexual behavior stigma between MSM in Southern and Western Africa and in the United States using consistent metrics.MethodsThe same 13 sexual behavior stigma items were administered in face-to-face interviews to 4285 MSM recruited in multiple studies from 2013 to 2016 from 7 Sub-Saharan African countries and to 2590 MSM from the 2015 American Men’s Internet Survey (AMIS), an anonymous Web-based behavioral survey. We limited the study sample to men who reported anal sex with a man at least once in the past 12 months and men who were aged 18 years and older. Unadjusted and adjusted prevalence ratios were used to compare the prevalence of stigma between groups.ResultsWithin the United States, prevalence of sexual behavior stigma did not vary substantially by race/ethnicity or geographic region except in a few instances. Feeling afraid to seek health care, avoiding health care, feeling like police refused to protect, being blackmailed, and being raped were more commonly reported in rural versus urban settings in the United States (P<.05 for all). In the United States, West Africa, and Southern Africa, MSM reported verbal harassment as the most common form of stigma. Disclosure of same-sex practices to family members increased prevalence of reported stigma from family members within all geographic settings (P<.001 for all). After adjusting for potential confounders and nesting of participants within countries, AMIS-2015 participants reported a higher prevalence of family exclusion (P=.02) and poor health care treatment (P=.009) as compared with participants in West Africa. However, participants in both West Africa (P<.001) and Southern Africa (P<.001) reported a higher prevalence of blackmail. The prevalence of all other types of stigma was not found to be statistically significantly different across settings.ConclusionsThe prevalence of sexual behavior stigma among MSM in the United States appears to have a high absolute burden and similar pattern as the same forms of stigma reported by MSM in Sub-Saharan Africa, although results may be influenced by differences in sampling methodology across regions. The disproportionate burden of HIV is consistent among MSM across Sub-Saharan Africa and the United States, suggesting the need in all contexts for stigma mitigation interventions to optimize existing evidence-based and human-rights affirming HIV prevention and treatment interventions.

Pathways from sexual stigma to incident HIV and sexually transmitted infections among Nigerian MSM

“…Nine sexual stigma indicators were chosen that are representative of stigma prevalent in the US, Western Africa, and Southern Africa,[31] and were utilized to create three latent stigma classes using latent class analysis (LCA). The nine questions asking about stigma as a result of having sex with men included: family made discriminatory remarks, rejection from friends, refusal from police to protect them, verbal harassment, blackmail, physical violence, rape, fear of seeking health care and fear of walking in public.…”

Transactional sex among men who have sex with men participating in the CohMSM prospective cohort study in West Africa

“…This confirms the value of performing more in-depth studies to validate this scale among MSM in West Africa. Social norms and the fear of being stigmatized may constitute barriers to finding regular sex partners, which in turn may push them to engage more in TS [55,7,56]. Although our results do not provide a reason as to why MSM-TS were more likely to be stigmatized than MSM not practising TS, it is possible that practicing TS with other men may lead MSM-TS to reveal their homosexual orientation more often when looking for a client, thereby increasing the risk of being stigmatized by the general public.…”

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“…Many hyper-endemic settings also have similar economic configurations characterized by widespread inequality and poor employment opportunities [31,60,61]. This contributes to high circular male labour migration to cities, mines, farms, on the road and on water for more lucrative work; women, meanwhile, have relatively limited employment and wage income [5,[62][63][64][65][66][67]. Labour migration has been linked to high rates of concurrency, with patterns of reunion and separation providing regular opportunities for HIV transmission, and serving as bridges between sexual networks in different locations [62,63,[65][66][67][68][69].…”