Switching on After Nine: Black gay-identified men's perceptions of sexual identities and partnerships in South African towns

Bisexuality among Men who have Sex with Men in Sub-Saharan Africa: Findings from the HPTN 075 Study

Studies among men who have sex with men (MSM) in sub-Saharan Africa (SSA) focus mainly on HIV epidemiology, revealing little about the diversity within this population. We utilized data from the HIV Prevention Trials Network (HPTN) 075 study, to explore demographic and psychosexual characteristics of MSM in SSA who also have sex with women. Persons included in the analyses were aged 18-44 years and assigned male sex at birth and identified as male, reported anal sex with a man in the past 3 months, and had enrolled at one of four study sites (Kisumu, Kenya; Blantyre, Malawi; Cape Town and Soweto, South Africa). Nearly a quarter of the participants had recently engaged in sex with both men and women (MSMW). These men differed in terms of demographic and psychosexual characteristics, and sexual behavior from men who only had had sex with men (MSME). Compared to the latter, MSMW were more likely to prefer the insertive sexual role, reported more sexual partners in the past three months, and had more instances of condomless insertive anal intercourse with a man. These findings suggest that men who have sex with both men and women have specific characteristics and need tailored interventions that take their specific needs into account.

Marriage and Steady Relationships with Women in Men Who Have Sex with Men in Sub-Saharan Africa: A Mixed-Method Systematic Review and Meta-analyses

High HIV prevalence in Sub-Saharan African (SSA) in men who have sex with men (MSM) leads to greater risk for their wives and other steady female partners because of prolonged exposure. To provide insights into the context possibly contributing to the risk of HIV transmission from MSM to women, our mixed-method synthesis about MSM' marriage and steady relationships with cisgender women aimed to: (i) assess the extent of engagement in steady relationships with women and in risky behaviors with these women across SSA's four regions; (ii) explore the underlying dynamics within these relationships by gathering qualitative information. We used quantitative and qualitative data specifically pertaining to related to marriage or other steady relationships with women from a systematic review on men who have sex with both men and women (MSMW) in SSA (PROSPERO-CRD42021237836). Meta-analyses were performed on quantitative data for each region. Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using thematic synthesis. Data were selected from 125 studies. For Southern, East and West Africa, the estimated pooled proportions of married MSM were 4% (95% CI 2-8%; n = 10 studies; 4183 MSM), 8% (6-11%; 19; 7070), and 7% (6-9%; 13; 4705). In Southern Africa, 29% (11-56%; 5; 1667) of MSM had steady female partners. In East Africa, 34% (14-61%; 5; 2003) were currently or previously married to women. Motives to marry women included a desire to have children, and to conform to heteronormative social norms and family pressure. Marriage was seen as a means to discontinue homosexual behaviors or, conversely, a way to secretly continue same-sex behaviors more freely. Procreative intentions and a desire for secrecy often deterred MSM from using HIV prevention methods with their wives. For some MSM, steady relationships with women provided them with mutual support. However, these relationships could also lead to stressful and conflict-ridden situations, potentially resulting in psychosocial and HIV-related risks for the MSM as well as their male and steady female partners. Steady relationships with women are common in MSM in SSA. Sexuality concealment strategies with steady female partners depend on the circumstances that lead MSM to enter into these relationships, and have various implications on sexual behaviors with both male and female partners. Community-based support, HIV research, prevention, and care programs should be adapted to MSM's different life situations to reduce direct HIV transmission risk to steady female partners.

HIV and gender identity expression among transfeminine people in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial

INTRODUCTION

Transfeminine people in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine people and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming.

METHODS

A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine people (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We used a combination of thematic analysis and case study descriptions to explore gender identification among participants.

RESULTS

Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members. Among peers, they expressed their identity through typically more effeminate gender characteristics, for example self-identifying as "femgay". With partners they often also took on a feminine identity role, for example identifying as women in sexual and romantic relationships (meaning they viewed and expressed themselves as the feminine partner in the relationship).

CONCLUSIONS

Our findings are amongst the first exploratory and descriptive data of transfeminine people in South Africa. We show how transfeminine people navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.

HIV and gender identity expression among transfeminine women in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial

Introduction

Transfeminine women in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine women and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming.

Methods

A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine women (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We discuss gender identification presented in participants' daily lives and in relation to HIV service access.

Results

Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members, but amongst peers, they expressed a more effeminate identity and with partners they took on a feminine identity.

Conclusions

Our findings are amongst the first exploratory and descriptive data of transfeminine women in South Africa. We show how transfeminine women navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.

Factors influencing HIV-risk perception among MSM students at a university in Durban, South Africa

Risk perception is embedded in attitudes and beliefs that determine how one ultimately behaves. In relation to HIV-risk behaviours, risk perception is a key dimension in most health behaviour models used to construct health promotion campaigns. This study aimed to understand HIV-risk perception and associated factors among men who have sex with men (MSM). The qualitative data used in this study came from 15 in-depth interviews with MSM studying at the University of KwaZulu-Natal in Durban, South Africa. The findings show that MSM perceive themselves to be at risk for HIV due to their awareness of the main routes of infection. This perception exists because HIV has affected them through the loss of close family members. With each sexual encounter, risk perception changed based on factors such as the sexual role being assumed (insertive versus receptive), the socio-economic status of the partner, perceived level of discriminatory dating patterns, and the use of preventive measures. High levels of risk perception among the men did not translate into positive attitudes towards condoms as many of them preferred to have unprotected sex with trusted partners. Despite perceiving their risk of HIV infection to be high, MSM continue to engage in multiple sexual partnerships and high partner turnover. However, the men in this study were keen to protect their health; with time, they have developed more positive attitudes towards HIV and they understand that it is possible to protect oneself before and after infection.

Stigma and HIV service access among transfeminine and gender diverse women in South Africa - a narrative analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial

BACKGROUND

Transgender women have a disproportionately high HIV prevalence compared to cisgender women and men who have sex with men, which puts them at risk of HIV-related stigma (Baral SD et al., Lancet Infect Dis, 13;3, 2013). People whose gender identities are in tension with dominant social norms (including transgender women) often also experience gender identity-related stigma. There has been increasing attention to transgender people in HIV research and interventions. However, very little research has been done in sub-Saharan African countries.

METHODS

We conducted a qualitative cohort study which included eight transfeminine and/or gender diverse women (four living with HIV) in Western Cape, South Africa, for a follow-up period of 12-18 months. Using a narrative analysis approach, we set out to understand how transfeminine and gender diverse participants in the cohort anticipated, experienced and internalised HIV stigma and gender identity stigma, and how these stigmas affected HIV service access.

RESULT

We found that participants reported anticipated, experienced, and internalised stigma relating both to their gender identity and to living with HIV. Participants reported inconsistent uptake of antiretroviral therapy (ART) services (including ART initiation and adherence) that they linked to stigma. We also found that gender diverse women and transfeminine women are challenged with other stigmatising social identities, like being a sex worker, drug user and/or a man (or assigned male sex at birth) who have sex with men (MSM). We use the terms 'transfeminine' and 'gender diverse' as terms that are inclusive of gender variant people who were all assigned male sex at birth and identify as women in some or all aspects of their lives. The persons in our study also showed gender identifications that were fluid and sometimes varied in different contexts and situations, therefore gender identity and sexual identity were often conflated for these individuals. Participants managed high levels of reported stigma by drawing on social support networks like families, friends and peers.

CONCLUSION

Our study provides exploratory work on how stigma may affect HIV services uptake amongst gender diverse women and transfeminine women in South Africa. We recommend future studies to further explore the unique HIV risks of gender diverse individuals.

TRIAL REGISTRATION

DOH-27-0513-4253 .

Social contexts as mediator of risk behaviors in Rwandan men who have sex with men (MSM): Implications for HIV and STI transmission

INTRODUCTION

Men who have sex with men (MSM) are disproportionately impacted by HIV/AIDS resulting from risky sexual behaviors. Social and contextual factors are known to mediate risk behaviors, but there is limited information about the prevalence of risky sexual practices of Rwandan MSM and the concomitant socio-contextual determinants making it difficult to assess implications for preventing HIV/STI transmission in this key population.

METHODS

Using exploratory qualitative design, we obtained socio-contextual information regarding prevalence of risky sexual behavior and assessed implications for HIV/ STIs transmission and preventive measures taken by MSM to improve sexual health and wellbeing. Thirty MSM were recruited to participate in in-depth interviews using respondent-driven sampling from LGBT associations in Kigali. Data were analyzed using standard qualitative data analysis procedures.

RESULTS

Respondents' were between 18-40 years old; all completed primary education and are mostly low-socioeconomic status. Risky sexual practices were common, but differed by peculiar individual and contextual factors. Older MSM often reported occasional sexual relations with women to avoid suspicion and social stigma. Younger MSM's risky sexual practices are mostly transactional and mediated by the need for social acceptance and support. Knowledge of STIs was poor, but prevalence, especially of HPV was high. The options for improving sexual wellbeing are limited and mostly clandestine.

CONCLUSION

Risky sexual behavior of Rwandan MSM has major implications for HIV/STI transmission. An environment of intense social stigma and social isolation makes it difficult to obtain information or services to improve sexual health. Effective interventions that address individual and contextual determinants of risk and access to health services are urgently needed to limit the consequence of MSM as a bridge for HIV transmission to the general population.

"Booze is the main factor that got me where I am today": alcohol use and HIV risk for MSM in rural South Africa

Excessive alcohol consumption has been shown to increase HIV risk for men who have sex with men (MSM) and compromise HIV prevention behaviors. However, there is limited contextual understanding of alcohol use for MSM in rural sub-Saharan African settings, which can inform and direct HIV interventions. Applying an adaptation of PhotoVoice, we worked with 35 HIV-positive MSM who created photo-essays about alcohol and HIV in Mpumalanga. A semi-structured protocol was used in focus group discussions that were audio-recorded, translated and transcribed. Transcript data and visual data of 24 photo-essays were analyzed using a constant comparison approach. We found that participants used alcohol to build and sustain social networks, meet sexual partners, and enhance sexual experience. Excessive alcohol use was common, which was associated with increased HIV risk behaviors within a community of MSM who maintained multiple partnerships. Our study suggests that HIV interventions need to address excessive alcohol use to mitigate the associated HIV risk at both the individual and community levels.

Opportunities for Enhanced Strategic Use of Surveys, Medical Records, and Program Data for HIV Surveillance of Key Populations: Scoping Review

BACKGROUND

Normative guidelines from the World Health Organization recommend tracking strategic information indicators among key populations. Monitoring progress in the global response to the HIV epidemic uses indicators put forward by the Joint United Nations Programme on HIV/AIDS. These include the 90-90-90 targets that require a realignment of surveillance data, routinely collected program data, and medical record data, which historically have developed separately.

OBJECTIVE

The aim of this study was to describe current challenges for monitoring HIV-related strategic information indicators among key populations ((men who have sex with men [MSM], people in prisons and other closed settings, people who inject drugs, sex workers, and transgender people) and identify future opportunities to enhance the use of surveillance data, programmatic data, and medical record data to describe the HIV epidemic among key populations and measure the coverage of HIV prevention, care, and treatment programs.

METHODS

To provide a historical perspective, we completed a scoping review of the expansion of HIV surveillance among key populations over the past three decades. To describe current efforts, we conducted a review of the literature to identify published examples of SI indicator estimates among key populations. To describe anticipated challenges and future opportunities to improve measurement of strategic information indicators, particularly from routine program and health data, we consulted participants of the Third Global HIV Surveillance Meeting in Bangkok, where the 2015 World Health Organization strategic information guidelines were launched.

RESULTS

There remains suboptimal alignment of surveillance and programmatic data, as well as routinely collected medical records to facilitate the reporting of the 90-90-90 indicators for HIV among key populations. Studies (n=3) with estimates of all three 90-90-90 indicators rely on cross-sectional survey data. Programmatic data and medical record data continue to be insufficiently robust to provide estimates of the 90-90-90 targets for key populations.

CONCLUSIONS

Current reliance on more active data collection processes, including key population-specific surveys, remains warranted until the quality and validity of passively collected routine program and medical record data for key populations is optimized.

How social stigma sustains the HIV treatment gap for MSM in Mpumalanga, South Africa

There are gaps in HIV care for men who have sex with men (MSM) in African settings, and HIV social stigma plays a significant role in sustaining these gaps. We conducted a three-year research project with 49 HIV-positive MSM in two districts in Mpumalanga Province, South Africa, to understand the factors that inform HIV care seeking behaviors. Semi-structured focus group discussions and interviews were conducted in IsiZulu, SiSwati, and some code-switching into English, and these were audio-recorded, transcribed, and translated into English. We used a constant comparison approach to analyze these data. HIV social stigma centered around gossip that sustained self-diagnosis and delayed clinical care with decisions to use traditional healers to mitigate the impact of gossip on their lives. More collaboration models are needed between traditional healers and health professionals to support the global goals for HIV testing and treatment.

Breakage is the norm: use of condoms and lubrication in anal sex among Black South African men who have sex with men

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men's subjectivities - their perceptions of and preferences for specific brands, types and flavours of condoms and lubricants - influenced engagement with such safer-sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer-sex supplies, health services and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa

Background

Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access.

Objectives

To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa).

Methods

A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training.

Results

Fourteen per cent of trainees had received previous training to counsel clients around penile-anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% - 87%, p < 0.0001), specifically around penile-anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training.

Conclusion

MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs.

Learning to Live With HIV in the Rural Townships: A Photovoice Study of Men Who Have Sex With Men Living With HIV in Mpumalanga, South Africa

There is limited understanding about the health and well-being of men who have sex with men (MSM) with HIV infection living in rural African areas. We present the results of an adapted photovoice project with 35 MSM with HIV infection who live in townships in Mpumalanga, South Africa. The project was designed to explore the social factors that influenced HIV care. Twenty-four photo essays were developed by participants in focus group discussions that were audio-recorded and transcribed for analysis. Transcripts and photo essays were coded using a constant comparison approach combining researcher observation notes and reflection on participant-identified themes. Participants identified (a) a shared experience of illness and coming to terms with having HIV infection and (b) family and taverns as necessary support systems. The findings suggested that family- and tavern-based interventions might improve health outcomes for MSM newly diagnosed with HIV infection living in rural and semi-rural African communities.