“They are human beings, they are Swazi”: intersecting stigmas and the positive health, dignity and prevention needs of HIV‐positive men who have sex with men in Swaziland

Abstract

IntroductionDespite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across settings, there has been little investigation of the experiences of MSM who are living with HIV in sub-Saharan Africa. Using the framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment needs of MSM who are living with HIV in Swaziland.MethodsWe conducted 40 in-depth interviews with 20 HIV-positive MSM, 16 interviews with key informants and three focus groups with MSM community members. Qualitative analysis was iterative and included debriefing sessions with a study staff, a stakeholders’ workshop and coding for key themes using Atlas.ti.ResultsThe predominant theme was the significant and multiple forms of stigma and discrimination faced by MSM living with HIV in this setting due to both their sexual identity and HIV status. Dual stigma led to selective disclosure or lack of disclosure of both identities, and consequently a lack of social support for care-seeking and medication adherence. Perceived and experienced stigma from healthcare settings, particularly around sexual identity, also led to delayed care-seeking, travel to more distant clinics and missed opportunities for appropriate services. Participants described experiences of violence and lack of police protection as well as mental health challenges. Key informants, however, reflected on their duty to provide non-discriminatory services to all Swazis regardless of personal beliefs.ConclusionsIntersectionality provides a framework for understanding the experiences of dual stigma and discrimination faced by MSM living with HIV in Swaziland and highlights how programmes and policies should consider the specific needs of this population when designing HIV prevention, care and treatment services. In Swaziland, the health sector should consider providing specialized training for healthcare providers, distributing condoms and lubricants and engaging MSM as peer outreach workers or expert clients. Interventions to reduce stigma, discrimination and violence against MSM and people living with HIV are also needed for both healthcare workers and the general population. Finally, research on experiences and needs of MSM living with HIV globally can help inform comprehensive HIV services for this population.

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

“…Studies conducted in Tanzania [7], Malawi [14,34], Swaziland [9,10] and Uganda [35] point to stigma and homophobia as significant factors affecting HIV risk among the MSM in these countries. Fewer recent works from West and Central Africa focused on the roles of homophobia and stigma in exacerbating HIV risk for MSM, but these factors are almost ubiquitously discussed as the background context for MSM research in this region [cf.…”

“…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.…”

Advancing the strategic use of HIV operations research to strengthen local policies and programmes: the Research to Prevention Project

“…The 2009–2014 Swaziland National Multi-Sectoral Strategic Framework for HIV and AIDS [39] noted that “Quality and reliable data are largely lacking for most of the key populations,” and attributed this gap to “lack of prioritization of such populations in prevention programmes.” R2P collaborated with the Swaziland Ministry of Health and other NGOs to conduct a quantitative survey using respondent-driven sampling to estimate population-level prevalence of HIV and risk factors among MSM and FSW in Swaziland [40–46]. The project also included complementary qualitative research including in-depth interviews and focus group discussions among MSM and FSW living with HIV to understand their experiences and unique needs in prevention, care and treatment services [47, 48]. In this study, HIV prevalence was estimated at 60.5% among FSW and 12.6% for MSM [40, 49].…”

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men

“…Where homosexuality is criminalised, studies have shown that MSM avoid accessing HIV prevention services due to fear of being persecuted, extorted or blackmailed 6 7 . W4 Dramatic reductions in access to HIV services have also been observed immediately after laws criminalising homosexuality were put into place 8 .…”