'The Devil has entered you': A qualitative study of Men Who Have Sex With Men (MSM) and the stigma and discrimination they experience from healthcare professionals and the general community in Bosnia and Herzegovina

Barriers to sexual health care for sexually diverse Muslim men: a scoping review

Sexually diverse Muslim men (SDMM) are seen to present later and with more advanced symptoms of HIV and other sexually transmitted infections (STIs). The limited access to sexual healthcare services is attributed to the stigma associated with their multiple intersecting identities. We conducted a scoping review to synthesise research on barriers impeding SDMM's access to sexual health care. We used Arksey and O'Malley's five-stage framework as the methodology for the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses' extension for scoping reviews, was used as a guide for the presentation of the results. Searches conducted in EBSCOhost, Scopus, MEDLINE, Embase, CINAHL, Global Health, and Google Scholar yielded 1382 results, of which 18 studies were deemed eligible for this review. Bronfenbrenner's socioecological model was employed as a framework to analyse the studies. Through analysing the eligible studies, we identified factors operating at three different levels that can impede SDMM's access to sexual health care. Limited awareness and low-perceived risk of HIV/STIs, coupled with the fear of sexual identity disclosure might act as individual-level barriers to sexually diverse Muslim men's access to sexual health care. The experiences of discrimination within clinical settings were presented as a healthcare system-related issue discouraging SDMM from revisiting those services. Heteronormative and religious ideologies, homophobic government programs, and poverty might manifest in the more intimate domains of healthcare delivery, creating hostile spaces for SDMM. Intensive research and advocacy efforts are required to improve SDMM's access to sexual health care, which can reduce their risk of HIV/STIs.

Interventions, Barriers, and Facilitators to Address the Sexual Problems of Gay, Bisexual and Other Men Who Have Sex with Men Living with HIV: A Rapid Scoping Review

Sexual problems are common among gay, bisexual, and other men who have sex with men (GBM) after diagnosis with HIV. However, these are often overlooked in care and research, where sexual risk reduction and biomedical aspects of sexual health tend to dominate. We conducted a rapid scoping review to investigate which sexual problems of GBM living with HIV are addressed by interventions, and the barriers and facilitators to their implementation. Literature from high-income countries published in English since 2010 was reviewed. Medline, Embase, PsycInfo, and Scopus databases were searched on July 4, 2022. Targeted sexual problems were categorized according to the ten dimensions of Robinson's Sexual Health Model, and barriers and facilitators, according to the five domains of the Consolidated Framework for Implementation Research (CFIR). Interventions focused solely on the dimension of Sexual Health Care/Safer Sex were excluded. Relevant information was extracted from the qualifying documents with NVivo 12 software for content analysis. Fifty-two documents were included, referring to 37 interventions which mainly took place in the United States (n = 29/37; 78%), were group-based (n = 16; 41%), and used counselling techniques (n = 23; 62%; e.g., motivational interviewing, cognitive-behavioral therapy). Their settings were mostly primary care (n = 15; 40%) or community-based (n = 16; 43%). On average, interventions addressed three sexual health dimensions (SD = 2; range: 1-10). The most targeted dimension was Sexual Health Care/Safer Sex (n = 26; 70%), which concerned sexual risk reduction. Next, Challenges (n = 23; 62%), included substance use (n = 7; 19%), sexual compulsivity (n = 6; 16%), sexual abuse (n = 6; 16%), and intimate partner violence (n = 4; 11%). Third was Talking About Sex (n = 22; 59%) which mostly concerned HIV disclosure. About a third of interventions addressed Culture/Sexual identity (n = 14; 38%), Intimacy/Relationships (n = 12; 33%), and Positive sexuality (n = 11; 30%). Finally, few targeted Body Image (n = 4; 11%), Spirituality (n = 3; 8%), Sexual Anatomy Functioning (n = 2; 5%) or Masturbation/Fantasy (n = 1; 3%). Forty-one documents (79%) mentioned implementation barriers or facilitators, particularly about the characteristics of the interventions (41% and 78%, respectively; e.g., cost, excessive duration, acceptability, feasibility) and of the individuals involved (37% and 46%; e.g., perceived stigmatization, provider expertise). The other three CFIR dimensions were less common (5%-17%). The search strategy of this review may not have captured all eligible documents, due to its limit to English-language publications. Overall, most interventions incorporated a focus on Sexual Health Care/Safer Sex, at the expenses of other prevalent sexual problems among GBM living with HIV, such as intimate partner violence (Challenges), erectile dysfunction (Sexual Anatomy Functioning), and Body Image dissatisfaction. These findings suggest they could receive more attention within clinical care and at the community level. They also highlight the importance of cost-effective and acceptable interventions conducted in non-stigmatizing environments, where patients' needs can be met by providers who are adequately trained on sexuality-related topics.

Positive views, attitudes, and acceptability toward mHealth applications in addressing queer sexual and reproductive health: Healthcare providers and the queer individuals

Objective

In the age of digital health, mankind has resources to write over the historical narrative of queer individuals' healthcare exclusions. The main purpose of this study was to explore the perspectives of both healthcare providers (HCPs) and queer individuals regarding the use of web-based tools and mobile health applications (mHealth apps) in the context of addressing queer individuals' sexual and reproductive health services and needs (SRHSN).

Methods

An overall study was conducted as an exploratory sequential mixed method. This article provides findings from the performed qualitative cycle. The selection method was led by purposeful sampling, which targeted 33 HCPs delivering SRHSN within the defined study settings. Additionally, respondent-driven sampling was employed to select 22 queer individuals. Throughout the study, semi-structured one-on-one face-to-face interviews were used to collect data.

Results

Four major themes and related sub-themes emerged from HCPs and queer individuals: (a) aid queer individuals with consultations and treatment improvements, (b) drawing parallels with technology in other sectors, (c) enhancing knowledge and education, and (d) positive perception of technological advancements.

Conclusions

In accordance with our findings, HCPs and queer individuals were all positive and sees mHealth apps as a tool to address SRHSN for homosexual people.

"Today one partner, tomorrow another one, and no one is suspicious that you are gay": A Qualitative Study of Understanding HIV Related Risk Behavior Among MSM in Bosnia and Herzegovina

Men who have Sex with Men (MSM) are often exposed to stigma and discrimination, especially in developing countries. Discrimination might have an impact on their sexual behavior. The proportion of MSM among HIV positive persons is rising in Bosnia and Herzegovina (B&H). The aim of this qualitative study was to understand the country context and HIV-related risk behaviors among MSM in B&H. We found that MSM in B&H have a dominant fear of expressing their sexual orientation in the homophobic societal environment, including their own family. Disclosures are often connected with escalated family violence, followed by the silence and ignorance. The fear of being connected to one particular partner and being labeled as a gay lead to the need of "masking" their sexual orientation, and having sexual intercourse with non-steady sexual partners. Although most MSM were aware of the risk of HIV and other STIs, the fear of rejection and remaining alone, shapes their decisions to agree to have sex without condoms.

Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men

Structural stigma shapes men who have sex with men's (MSM's) mental health and sexual behaviours. The aim of this study was to examine how stigmatizing policies interact with downstream anxiety/depression and sexual behaviours to structurally pattern HIV disparities among European MSM. We conducted a secondary data analysis of the European Men-who-have-sex-with-men Internet Survey (EMIS) from 2017. We included a total of 98,600 participants living in 39 European countries. We used the Rainbow Index, a score given to countries based on their sexual and gender minority policies as the predictor of HIV diagnosis. We conducted adjusted random intercept and slope multi-level logistic regressions. In adjusted models, higher Rainbow Index scores was associated with lower predictive probabilities of diagnosed HIV, regardless of the number of condomless intercourse partners. The predictive probability of HIV diagnosis was also lower, regardless of severity of anxiety/depression, where the Rainbow Index score was better. Country-level policies interact with downstream sexual behaviours and anxiety/depression to structurally influence HIV diagnosis among MSM in Europe.

The hepatitis C cascade of care in HIV/hepatitis C virus coinfected individuals in Europe: regional and intra-regional differences

BACKGROUND

Following the introduction of direct-acting antiviral therapy in 2013, WHO launched the first Global Health Sector Strategy on Viral Hepatitis. We describe a hepatitis C virus (HCV) cascade of care in people with HIV (PWH) across Europe in terms of reaching the WHO elimination targets of diagnosing 90% and treating 80% of HCV-infected individuals.

METHODS

HIV/HCV-coinfected participants in the EuroSIDA cohort under prospective follow-up at October 1, 2019, were described using a nine-stage cascade of care. Care cascades were constructed across Europe, on a regional (n = 5) and country (n = 21) level.

RESULTS

Of 4773 anti-HCV positive PWH, 4446 [93.1%, 95% confidence interval (CI) 92.4-93.9)] were ever tested for HCV RNA, and 19.0% (95% CI 16.4-21.6) were currently HCV RNA positive, with the highest prevalence in Eastern and Central-Eastern Europe (33.7 and 29.6%, respectively). In Eastern Europe, 78.1% of the estimated number of chronic infections have been diagnosed, whereas this proportion was above 95% in the other four regions. Overall, 3116 persons have ever started treatment (72.5% of the ever chronically infected, 95% CI 70.9-74.0) and 2404 individuals (55.9% of the ever chronically infected, 95% CI 53.9-57.9) were cured. Cure proportion ranged from 11.2% in Belarus to 87.2% in Austria.

CONCLUSION

In all regions except Eastern Europe, more than 90% of the study participants have been tested for HCV-RNA. In Southern and Central-Western regions, more than 80% ever chronically HCV-infected PWH received treatment. The proportion with cured HCV infection did not exceed 80% in any region, with significant heterogeneity between countries.

SUMMARY

In a pan-European cohort of PWH, all regions except Eastern Europe achieved the WHO target of diagnosing 90% of chronic HCV infections, while the target of treating 80% of eligible persons was achieved in none of the five regions.

Perception of discrimination due to sexual orientation and associated factors among men who have sex with men in 12 Brazilian cities

Discrimination due to sexual orientation (DDSO) has an important association with health outcomes among men who have sex with men (MSM). This study aimed to analyze factors associated with DDSO among MSM in 12 Brazilian cities. This is a cross-sectional study with 4,176 MSM participants recruited in 2016 which used a respondent-driven sampling method in 12 Brazilian cities. DDSO levels were previously identified by a latent class analysis based on 13 variables from the discrimination section. An ordinal logistic regression was used to assess associations with these DDSO levels, and weighted ordinal odds ratios (OR) and their respective 95% confidence intervals (95%CI) were estimated using Gile’s estimator. Most participants were young (< 25 years old) black or of mixed-race (pardo), single individuals who had a religious affiliation, primary or incomplete secondary education, and a high and average socioeconomic status. More than half (65%) reported DDSO in the 12 months prior to this study. We observed an independent association among the four latent DDSO classes and the following variables: age < 25 years old (OR = 1.66; 95%CI: 1.21-2.27), white skin color (OR = 1.43; 95%CI: 1.02-2.01), history of sexual (OR = 2.33; 95%CI: 1.58-3.43) and physical violence (OR = 3.08; 95%CI: 2.11-4.49), disclosure of their sexual orientation as MSM to their fathers (OR = 2.00; 95%CI: 1.47-2.72), experienced suicidal ideation in the two weeks prior to this study (OR = 2.09; 95%CI: 1.46-2.98), and use of any illicit drugs in the last six months (OR = 1.61; 95%CI: 1.19-2.18). Our results indicate that contextual factors may contribute to high DDSO levels among MSM in Brazil. Public health policies toward human rights surveillance and protection among MSM must be urgently addressed.

Positive attitudes towards persons living with HIV in North Kosovo: The university students' perspective

HIV-related stigma could delay the identification and treatment of persons living with HIV (PLHIV), particularly in regions affected by ethnic conflicts. The aims of this study were to assess attitudes towards PLHIV and examine factors associated with stronger positive attitudes towards PLHIV among university students in the Serbian province of Kosovo. A cross-sectional study was conducted at the University of Pristina temporarily settled in Kosovska Mitrovica during the academic year 2013-2014. A total of 1,017 first- and fourth-year students completed an anonymous questionnaire about socio-demographic characteristics, PLHIV, high-risk groups for acquiring HIV and health behaviour. The main outcome measure was the Attitude Score (ATS), calculated as a sum of points awarded for all attitude-related items. The majority of students (84%) expressed positive attitudes towards PLHIV, while others were indecisive. Most students held negative opinions about persons who use drugs (64%), homosexual persons of both genders (50%) and sex workers (42%). Being female (odds ratio [OR] = 1.49, 95% confidence interval [CI] 1.05-2.09) and older (OR = 1.13, 95% CI 1.03-1.24), not doing paid work while studying (OR = 3.35, 95% CI = 1.63-6.84), studying health-related disciplines (β = -0.113, 95% CI = -0.085 to -2.747), having stronger positive attitudes towards homosexual persons of both genders (OR = 0.77, 95% CI = 0.64-0.94) and not using illicit drugs (β = 2.08, 95% CI = 1.03-4.20) were associated with stronger positive attitudes towards PLHIV. Social inclusion of PLHIV and individuals at high risk for acquiring HIV could help reduce the HIV-related stigma.

The push of stigma: a qualitative study on the experiences and consequences of sexuality stigma among same-sex attracted men in Harare, Zimbabwe

This paper describes experiences of sexuality stigma among same-sex attracted men in Zimbabwe and analyses the consequences of such experiences for healthcare seeking. It draws on qualitative research carried out in Harare in 2017, which included in-depth interviews with sixteen gay and bisexual men, and key informant interviews with three representatives of organisations that work with gay men. There were numerous stories about sexuality stigma in the study participants´ social environments, including at home, in local communities and in healthcare facilities. We first offer a description of these and then go on to trace the implications of stigma on the relations between men who have sex with men on the one hand and the healthcare sector on the other. We conceive of stigma as a pushing force that exerts pressure on and in these relations, and identify five types of consequences of this. Stigma works to (1) produce geographical shifts in healthcare, (2) promote private over public care, (3) compartmentalise healthcare (with dedicated providers for queer persons), (4) deprofessionalise care, and (5) block access to appropriate healthcare altogether for some same-sex attracted men. Most of these consequences have negative implications for preventive or treatment-focused HIV programming.

Depression and suicidal behavior in LGB and heterosexual populations in Serbia and their differences: Cross-sectional study

Background

Sexual identity is a significant risk factor for triggering symptoms of depression, as well as for suicide attempts in lesbian, gay and bisexual (LGB) population compared to the heterosexual population. To the best of our knowledge, data on the mental health of LGB persons in Serbia are lacking, and this is the first study to address this problem. The aim of the study was to examine the association between selected determinants and depression, and selected determinants and suicide attempts in LGB and heterosexual populations in the Republic of Serbia, as well as, their differences.

Methods

We conducted a cross-sectional study in 2015 of 264 heterosexual and LGB respondents using the "snowball sampling" method. We used linear regression analyses to investigate the relationship between socio-demographic variables and different sexual identity categories with PHQ-9 scores. We assessed associations between suicide attempts, and socio-demographic characteristics, sexual identity, depression, and suicidal thoughts using logistic regression.

Results

Depression symptoms were higher in female relative to male participants, in participants who were single, divorced or widowed in comparison to currently married, among people with a middle level of education compared to highly educated, and in respondents identified as bisexual or homosexual in comparison to heterosexual. Homosexual and bisexual participants reported suicidal attempts 27 [Odds Ratio (OR) = 27.31] and six times (OR = 6.40) more often than did heterosexual respondents, respectively. Suicide attempts were less frequently reported by single, divorced or widowed participants in comparison to married (OR = 0.25) and those with middle education (OR = 0.38) compared to highly educated.

Conclusions

The present study showed that LGB persons in Serbia have significantly more symptoms of depression and suicide attempts compared to heterosexuals. Public health interventions should focus on the early detection of depression and on overcoming prejudicial and discriminatory attitudes. Also, intervention should emphasize that homosexuality and bisexuality are normal, equal and morally acceptable expressions of human sexuality.

Towards a Framework for Research Ethics Education for Physicians in Serbia

With growing opportunities for medical doctors to work either in academia and industry, research ethics education for health sciences research, meaning research which includes humans and animals and/or their tissues and cells with the goal to understand underlying mechanisms of disease occurrence and disease treatment, is of paramount importance, especially in regions, such as Serbia, where comprehensive research ethics curricula for physician researchers are lacking. This article addresses the spectrum of research ethics topics that were identified through analysis of the existing research ethics curricula in medical schools, international organizations, Serbian legislative codes and the PubMed database applying the key search terms: ethics, research, biomedical, education, curriculum, program, course and their combinations. Selected topics were classified in eight syllabi based on their similarity: #1 Responsible conduct of research, #2 Justice in human subjects research, #3 Research on human subjects, #4 Vulnerable population groups, #5 Conflict of interest, #6 Research on animals, #7 Research on genes, cells and embryos, and #8 Organization of research ethics. Justifications for each syllabus are discussed based on empirical evidence and local context. Higher education authorities could use this framework to strengthen, adjust or refine research ethics education for physician researchers in Serbia.

Interface of Internalized Homophobia and Community Connectedness on Frequency of Doctor's Visits for Rural and Urban MSM in Oklahoma

PURPOSE

Men who have sex with men (MSM) face persistent risk of stigma, with past studies showing unequal treatments of MSM in health care settings. Contextual factors, such as internalized homophobia and connectedness to one's community, have shown to serve as a barrier or facilitator (respectively) with regard to MSM's decisions to seek preventative treatment. These studies, however, predominately feature urban populations, with less consideration given to rural MSM. The current study comparatively investigates these contextual factors between rural and urban MSM to detect differences in the frequency of doctor's visits.

METHODS

A 2-by-2 (rural/urban × doctor visit yes/no) multivariate analysis of variance (MANOVA) was conducted to investigate if significant differences and/or interactions existed for internalized homophobia and community connectedness.

FINDINGS

Results show a significant interaction between rurality and doctor's visits in our sample of predominantly white, self-identified gay men. Higher levels of internalized homophobia and lower levels of community connectedness were seen in rural individuals who had visited a doctor in the past 12 months and in urban individuals who had not seen a doctor in the past 12 months.

CONCLUSIONS

Study findings have implications for future public health research and for health promotion interventions, practices, and policies for MSM in rural areas. Social exclusion reinforces the invisibility of lesbian, gay, bisexual, and transgender (LGBT) populations, particularly in rural areas. Stigma and marginalization of MSM promote structural barriers inhibiting care. Our results give evidentiary support for programs which inform the work of clinicians on mechanisms to create LGBT-inclusive practice settings.

'Until we have laws … everything is useless!': intersectionality, self-identified needs and inequity among sexual and gender minorities in Macedonia

There exists limited understanding about the intersectional nature of needs and inequities among sexual and gender minorities in Macedonia and Eastern Europe. We conducted a qualitative, cross-sectional and national needs assessment among 71 sexual and gender minority community members using semi-structured focus groups and interviews. Thematic analysis was used to better understand their self-identified needs, their concerns about equity and the intersectional nature of their needs. Community members discussed a wide range of health and healthcare needs as well as the social and structural factors that influence those needs, including: cultural norms; victimisation and safety concerns and the role of law, policy and politics; education and democratisation of knowledge; and economic and housing opportunities. Needs were patterned across different sexual and gender minority subgroups such that those experiencing heightened marginalisation (e.g. trans* persons) also experienced compounded forms of inequity. Given that sexual and gender minorities in Macedonia have numerous structurally induced intersectional needs, multilevel and multifaceted strategies are needed to ensure that their rights and needs are respected, protected and fulfilled at structural, community and individual levels.

MSM Behavior Disclosure Networks and HIV Testing: An Egocentric Network Analysis Among MSM in China

Men who have sex with men (MSM) disclose same-sex behaviors with others, creating disclosure networks. This study examined the characteristics of disclosure networks that are associated with HIV testing among MSM in China through an online nationwide survey. Name-generator questions were used to ask each participant ("ego") to nominate up to five social network members ("alters") with whom he had disclosed same-sex behaviors. Among the 806 men, the average disclosure network size was 4.05. MSM who reported larger disclosure networks were more likely to have been tested for HIV (aOR 1.21, 95% CI 1.08-1.34). The most common disclosure network alters were friends (45.1%), followed by sex partners (18.7%) and healthcare professionals (2.5%). Men who disclosed to healthcare professionals were more likely to test for HIV compared to men who disclosed to family members (aOR 5.43, 95% CI 2.11-14.04). Our findings can inform disclosure network-based interventions to promote MSM HIV testing.

Health providers' experiences, perceptions and readiness to provide HIV services to men who have sex with men and female sex workers in Uganda - a qualitative study

Background

Access to HIV services among men who have sex with men (MSM) and female sex workers (FSWs) remains suboptimal globally. While the reasons for this dismal performance have been documented, limited evidence exists on the experiences, perceptions and readiness of health providers to provide HIV services to MSM and FSWs.

Methods

This analysis uses data collected from 48 key informants (health providers in public and private health facilities) as part of a larger study conducted in 12 districts of Uganda between October and December 2013. Data were collected on health providers’ experiences and readiness to provide HIV services to MSM and FSWs and their perceptions on the effect of existing legislation on HIV services provision to MSM and FSWs. Data were captured verbatim, transcribed and analyzed following a thematic framework approach.

Results

All health providers reported that they had ever provided HIV services to FSWs and a majority of them were comfortable serving them. However, no health provider had ever served MSM. When asked if they would be willing to serve MSM, nearly three-quarters of the health providers indicated that they would be bound by the call of duty to serve them. However, some health providers reported that they “would feel very uncomfortable” handling MSM because they engage in “a culture imported into our country”. A majority of the health providers felt that they did not have adequate skills to effectively serve MSM and called for specific training to improve their clinical skills. There were mixed reactions as to whether existing criminal laws would affect MSM or FSWs access to HIV services but there was agreement that access to HIV services, under the existing laws, would be more constrained for MSM than FSWs since society “does not blame FSWs [as much as it does] with MSM”.

Conclusion

A majority of the health providers were generally comfortable serving FSWs but there were strong homophobic tendencies towards MSM. A majority of the health providers lacked skills in how to handle MSM. Interventions aimed at improving health providers’ skills in handling MSM while minimizing the negative attitude towards them are urgently needed.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3713-0) contains supplementary material, which is available to authorized users.