Introduction

The direct risk factors for HIV transmission among men who have sex with men (MSM) in southern Africa are well known, and include: unprotected anal intercourse, concurrency of sexual partnerships with male and female partners, use of oil-based lubricants with condoms, high levels of alcohol consumption, and transactional sex [1–3]. In spite of this knowledge, HIV prevention programmes have failed to adequately address HIV risk in the MSM population in this region. HIV prevalence among MSM remains high, and estimates of HIV prevalence among MSM in South Africa range between 10 and 33 % [1, 2]. In light of current calls for ‘combination prevention’—HIV prevention which addresses both the immediate risks and the underlying causes of vulnerability to HIV infection [4]—it is necessary to examine the social, cultural, and sexual dynamics that influence HIV risk behaviours.

This article discusses the results of an exploratory study which examined HIV risk among MSM living in the peri-urban townships of Cape Town, South Africa. We identify several important factors driving HIV risk in this population, and argue that for HIV prevention interventions focusing on these men to be effective it is necessary for them to address the multiple, interactive effects of these risk factors.

Background

MSM communities in Cape Town are shaped by a range of social and historical influences [5]. Apartheid-era geographical separation of communities based on race is one of the central factors affecting the characteristics and social dynamics of the MSM population. Visser [5] notes that apartheid created distinctive layers of spatial differentiation based on racial, economic, and social difference and that this differentiation created a ‘…clear social structure in which interracial, class, and social contacts were minimised’. The legacy of this segregation for MSM in Cape Town is an ongoing separation in terms of the identities that these men assume, and the social and sexual interactions that they participate in. As a result, it is still possible to identify racially separated MSM identities and social dynamics in the Cape Town metropolitan area [6].

In Coloured communities, for instance, having a gay identity is often understood as assuming a feminine role in one’s daily life; and consequently cross dressing, and adopting more ‘feminine’ mannerisms [6]. These men appear to become accepted as ‘female’ by their communities and are able to express their homosexual identities relatively openly [6]. However, it is important to note that this relative level of acceptance of a cross-dressing, feminine, homosexual identity does not imply the acceptance of other forms of expressing homosexual identity [6].

In contrast, in areas previously designated as Black, many MSM do not openly identify as having sex with men, or as gay [6, 7]. This seems to be related to high levels of homophobic discrimination and stigma in these communities [7]. In contrast to the relatively open and accepting social context of inner city Cape Town, Black township dwelling MSM are often socially hidden and may present themselves as heterosexual to avoid stigmatisation [7].

These differing social contexts in which MSM in Cape Town live have effects on their social interactions, their sexual relationships, and their HIV risk. So while risk behaviours in these populations are similar, the social and sexual dynamics surrounding them may differ.

Methods

Ethics approval for this study was obtained from the University of the Witwatersrand, protocol number M090448. Non-probability, purposive sampling was used to recruit participants with a range of socio-economic and racial backgrounds. Participants were recruited from community-based contacts of Health4Men, an organisation focusing on MSM sexual health in Cape Town. Initial participants were recruited based on their varying racial and social backgrounds, and their knowledge of their local communities. Additional participants were identified by these initial participants and were then invited to take part in the study.

This research used qualitative field research methods. We conducted 10 in-depth, semi-structured interviews and three focus group discussions (FGDs) with 21 men, for a total sample size of 31. Participants included 22 Black MSM, of whom 6 were heterosexually-identifying and 16 openly gay; and 9 Coloured participants all of whom were openly gay. Signed informed consent was obtained from all participants prior to interviews and focus group discussions. Interviews were conducted by the primary researcher using an interview guide developed based on a review of relevant literature and consultation with staff of Health4Men.

Focus group discussions were conducted by the researcher with a Xhosa-speaking research assistant: one with heterosexually-identifying Black MSM, one with openly gay Black MSM, and one with Coloured MSM participants. Both interviews and FGDs were conducted in English. Interviews and FGDs were audio recorded, transcribed verbatim and anonymised by a research assistant. Where participants required clarification of questions the research assistant translated particular words or phrases into Xhosa. However, this did not occur frequently and most participants spoke and understood English. Where translations were done, they were later verified by a second research assistant using the audio recordings. Interviews were conducted prior to FGDs; and the initial findings, but not direct quotes, from the interviews were presented and discussed as part of these discussions as a means of triangulating data.

Inductive thematic analysis was conducted to elicit the themes in the interview and FGD data [8]. Data analysis was ongoing during the interviewing stages of field work and the interview guide was refined based on these initial analyses. Initial codes were assigned to data based on in-depth reading of transcripts. These codes were then categorised into broad thematic areas. After careful consideration of these broad themes, it became apparent that a socio-ecological framework would be a suitable basis for further data analysis, and we decided to adapt the framework used by Eaton et al. [9] in their review of HIV risk among adolescents in South Africa.

At this stage of the analysis we therefore aimed to identify factors influencing HIV risk behaviour ‘…at three levels: within the person, within the proximal context (interpersonal relationships and physical and organisational environment) and within the distal context (cultural and structural factors)’ [9]. We think that this approach is useful in analysing HIV risk, as it supports an understanding of risk as a cumulative process that encompasses factors at multiple levels, and which includes social, economic, cultural, and political forces. In this view the interactions between these factors, and between individuals and communities living in the contexts shaped by these interactions may all be important drivers of HIV transmission.

Results

Distal Level: Cultural and Structural Factors

Poverty, Unemployment and HIV Risk

Poverty and unemployment are important characteristics of the distal level that affect the lives of many residents in the peri-urban townships in which the study was conducted, including MSM. For example, the unemployment rate in Cape Town was 39.7 % for Black communities, and 21.8 % for Coloured communities in 2007 [10]. Most of the participants in this study were unemployed, or had limited access to temporary, casual employment.

Participants in this study associated poverty with HIV in two primary ways. First they noted that poverty might lead MSM to engage in transactional sex as a means of accessing resources:

So they are actually going to do transactional sex because they need money, they need this, and that. There was one person…and he used to go to the hotels around Stellenbosch and make money (In depth interview 8, 21/10/2009)

Second, participants noted that lacking money was an important barrier to accessing MSM friendly health services:

…they are making themselves late (they are dying) because now time to visit the doctors, some of the other gays are not working, they are sick and they haven’t got money to come to town or wherever (FGD 2, 14/10/2009).

…but sometimes it’s so difficult from P--- to come from the township to town, because sometimes money problems (FGD 2, 14/10/2009).

‘…if people they see I’m sick now, I don’t have money to go to come here’ (In depth interview 3, 13/08/2009).

Both of these issues point to the effects of poverty as a driver of social exclusion, and both are likely to contribute to an increased risk of contracting HIV. Delays in accessing health services, for example, can lead to the late detection of sexually transmitted infections (STIs), with consequent increases in the risk of HIV infection [11]. Difficulties in accessing health services may also lead to late detection of HIV infection and subsequent difficulties in treatment and care [11].

Beyond their direct effects on behaviour noted above, poverty and unemployment are likely to influence HIV risk in other multiple, interacting ways. In their study in the Western Cape, for example, Kalichman et al. [12] found that HIV risk was linked to a range of poverty-related stressors in the Black and Coloured communities that they sampled.

In attempting to understand HIV risk for MSM in these communities it is, therefore, essential to understand the socio-economic conditions that influence their social contexts, and to relate these to the broad policy environment in South Africa. Williams [13, pp. 81–82] for example, points out that socio-economic stratification is directly and inversely linked to rates of morbidity and mortality and argues for a policy perspective in which the lifestyle characteristics and living conditions of people in lower socio-economic classes:

…are viewed not as individual characteristics but as the patterned response of social groups to the realities and constraints of the external environment. Such factors include health behaviours, stress in family, residential, and occupational environments, social integration and support, and perceptions of mastery and control. [author’s emphasis]

Addressing the disparities in health status is, in Williams’ view contingent on addressing the inequalities present in the ‘fundamental reward structures of society’. These reward structures are directly shaped by local, national, and international economic and social policy.

In South Africa, the government’s economic policy framework since the advent of democracy in 1994 has focused on encouraging investment through deregulation, privatisation, and fiscal restraint, with poverty alleviation measures seen as separate to economic policy, rather than as integral to the government’s growth strategy [14]. This policy orientation has been argued to have dramatically increased levels of poverty and unemployment in the country over the last 17 years, with low-skilled, Black Africans bearing the brunt of this increase [15]. In 2004, for example, Meth and Dias [16] estimated that the number of South Africans living in poverty between 1999 and 2002, had increased by at least 3.7 million people. A more recent (2010) study of poverty levels in South Africa estimated that between 18 and 24 million people are living in poverty (i.e. almost half of the country’s population), with between 8 and 10 million living in extreme poverty [17]. Such high levels of poverty contribute significantly to the ‘structural violence’ [18] that shapes the contexts in which MSM in the peri-urban townships of Cape Town live. Parker [18] describes structural violence as ‘…the interactive effects of social factors such as poverty, economic exploitation, gender power, sexual oppression, racism, and social exclusion on the social vulnerability of groups and individuals’.

The effects of structural violence are exacerbated for these men because most poor MSM in the study areas are not eligible for government support through social grants, as the grant system does not cover men between the ages of 18 and 65, unless they have a disability [19]. These grants are therefore unlikely to play a direct role in alleviating poverty for most poor MSM in the study areas, although grants may play an indirect role in supporting MSM through other members of their households [19, 20].

In this context of structural violence, individuals may have an increased likelihood of engaging in HIV risk behaviours, and Tenkorang et al. [21] and Kalichman et al. [22] in studies conducted in Cape Town, found significant associations between socio-economic context and HIV risk. Kalichman et al. [22] note that poverty is linked to HIV because of ‘…poor health care infrastructure, greater social density, social isolation leading to closed sexual networks, alcohol and drug abuse, and engaging in sex in exchange for survival resources’. Further, the social environment created by poverty increases individuals’ exposure to psychological stress, which in turn has been linked to an increased likelihood of engaging in HIV risk behaviours [23, 24]. For MSM in Cape Town’s townships social exclusion is a result of a combination of poverty and widespread homophobia and stigmatisation. This combination may be an important contributor to their HIV risk.

Homophobic Social and Cultural Contexts

Cultural and social contexts in which homophobic discrimination is highly prevalent may directly affect individuals’ risk behaviours. In this research, we understood homophobia as the direct and indirect discrimination against, and stigmatisation of, MSM based on their sexual practices and/or sexual orientation. Most directly, by making homosexuality unacceptable, homophobia forces MSM to be secretive in their relationships and sexual interactions with each other. This in turn may contribute to men engaging in sexual intercourse in secret without access to safer sex materials such as water based lubricants, condoms, and relevant HIV prevention information [25]. Equally important in terms of the contexts of HIV risk for MSM is the role of homophobia as a social stressor, with adverse psychological and behavioural effects [26].

Black participants identified ‘culture’ as an important driver of homophobia. Participants did not offer a definition of culture per se, but appeared to view ‘culture’ as an immutable set of beliefs held by people who shared their racial background.

Participants stated that the cultural beliefs held by their communities were strongly homophobic:

…first of all in our culture we are not allowed to be gay. That’s absolutely Satanism (FGD 2, 14/10/2009).

…like our culture we not allowed, or it’s a sin to be gay or whatever, I don’t believe in that, but it’s there, it’s happening (FGD 2, 14/10/2009).

Participants noted that one of the main effects of this social context of homophobia was to lead MSM to keep their sexuality, and their sexual interactions secret:

Because we African people we believe too much in culture, whatever we do it must happen underground, even if we get exposed on that, but it must happen underground because of the culture (FGD 2, 14/10/2009).

One aspect of ‘culture’ discussed was the hetero-normative nature of ‘cultural’ expectations, with particular emphasis placed on the expectation that men should have wives and children as signifiers of masculinity. Dyer et al. [27], and Hunter [28] report a similar view among the men in their samples. In this view, having sex with other men may be perceived to negate the achievement of masculinity, as one participant related:

…we even approached this one man, he was very shy, you know, like “my God, I think, I still think you are a man, and you are getting fucked!” You know? “So it means you are not a man” [author’s emphasis] (In depth interview 2, 09/07/2009).

The negation of masculinity may be a powerful motivator for remaining hidden in a cultural context where masculinity is highly valued. In this view homosexuality presents a threat to traditional masculinities and participants’ awareness of the stigma attached to homosexuality as ‘un-African’ likely contributes to their individual decisions to keep their same-sex behaviours secret.

In contrast, Coloured participants tended to identify religious institutions as the primary sources of intolerance in their communities. Both Christian and Muslim groups were noted to be homophobic, and to influence the attitudes of people in their communities towards homosexuality. For instance, these participants stated:

It’s taboo to be gay and you’re Muslim…you know because they are being stigmatised, or labelled, and they don’t feel comfortable in that institution (In depth interview 7, 19/10/2009).

They are chasing you out of the church if you are gay, they don’t let you come easily (FGD 3, 04/11/2009).

Religious belief is common in the communities in which this study was conducted [29] and this is a potentially important source of homophobic discrimination for MSM.

These multiple sources of homophobia in participants’ local communities may be an important contributor to MSM HIV risk through multiple causal chains [30]. For example, frequent experiences of homophobia may increase the likelihood that individuals will suffer from mental health problems, which in turn have been linked to HIV risk [31]. McDermott et al. [32] similarly found that experiencing homophobia may be strongly linked to self-destructive behaviours, particularly where individuals manage homophobia individually, without expectation of support. A lack of expectation of support was also discussed by participants, one of whom stated:

But there are people I know they are gay that they can’t like cough that out to their family, they are still afraid, some of them they are the children of the priest, utata ufundisi (tr. ‘father is a preacher’), so scared you know and you can’t do anything and your father is preaching like gay is a sin every Sunday and then you come up and then you gay (FGD 2, 14/10/2009).

…but you know what to expose yourself to your family that you are gay, that brings trouble, that’s why nowadays we have tried, kids who are 15 or 16 out of school, out of their family because of exposing (FGD 2, 14/10/2009).

Homophobia in the communities in which MSM in this study live is therefore an important aspect of the structural violence that shapes the risk environmentsFootnote 1 and situations that drive HIV transmission among this population. Other important sources of discrimination that affect the contexts of HIV risk in this population include HIV-related stigma, and the interactions between HIV-related stigma and homophobia.

Stigmatisation of Same-Sex Identities and Practices and HIV-Related Stigma

Cloete et al. [33] found that HIV-positive MSM in Cape Town experienced relatively more HIV-related discrimination than other men, and the authors suggest that HIV-positive MSM suffer from multiple discrimination on the basis of their sexual behaviours and their perceived association with HIV infection. The association between homophobia and HIV-related stigma in the communities in which the participants in this study live found expression in the direct conflation of HIV with homosexuality by community members:

Ja but it’s not a nice idea because if you stay in the township and you are gay and you have HIV they have got this mindset - the people who brought HIV and AIDS are people who are gay you see it’s now even if you go to the clinic (FGD 2, 14/10/2009).

…and in that case even the community we live in like whenever you get sick, you can get any other sickness, not even HIV, but you start losing weight they start calling you “ah you are HIV positive” (FGD 2, 14/10/2009).

You know it’s like people in our township whatever, they just like thinking that HIV comes from gays (FGD 3, 04/11/2009).

It is important to understand how the fear of HIV-related stigmatisation may affect MSM’s health seeking behaviours as an aspect of their HIV risk. For example, participants stated that when someone who is known to be gay attends a clinic it is assumed by people who see him there that he has HIV, regardless of the reason he is attending the health service. This perceived assumption was linked to men’s expressed reluctance towards attending health services.

MSM may also experience HIV-related stigma from within their social groups, which may further contribute to their social exclusion. One participant discussed this as a reason for MSM choosing not to test for HIV:

It’s very stressing especially for gay men, because the problem is … I mean maybe he’s HIV, and then we will just make gossip around this person and we will talk about it in the street and we will laugh…we will point fingers at people who are HIV. Now people they are feeling scared to know their status, if like all the gay people, they feel scared to know their status because of what they were doing to other people, because they were pointing fingers, they were laughing then, making jokes, they were gossiping about people’s status (In depth interview 1, 07/07/2009).

In this context the knowledge of one’s HIV-positive status has potentially wide-ranging consequences. The fear of social exclusion due to HIV infection is therefore an important consideration when attempting to understand the contexts of HIV risk for MSM in Cape Town, particularly in terms of accessing health care services.

Stigmatisation of HIV infection is therefore another aspect of structural violence in these communities which particularly affects MSM. In a context where other forms of social support may be lacking, stigmatisation by other MSM combined with cumulative effects of community level homophobia, poverty, lack of social support and stigmatisation of HIV may directly affect these MSM’s social vulnerability.

Proximal Level

Experiences of Discrimination

The distal level factors affecting HIV risk for MSM in these areas find expression in the daily interactions between MSM, their communities and their immediate social environments—the proximal level of Eaton et al.’s framework [9]. Both Black and Coloured participants reported fairly frequent experiences of discrimination in their local communities, and these experiences may affect HIV risk in several ways.

Daily experiences of discrimination affect the choices MSM make about where, when, and with whom to have sex. Further, they may limit the options available to individuals for socialising and participating in local community activities, and may lead them to socialise in areas or at venues where they are more likely to engage in HIV risk behaviours.

In terms of HIV risk, the most frequently reported risk behaviour was unprotected anal intercourse, and this often occurred while men were under the influence of alcohol. Informal drinking establishments, or ‘shebeens’, were reported to be the main place at which MSM met sex partners. These partners were often ‘straight-identifying’ (heterosexual) men, and negotiating sexual encounters with these men often involved a transactional element—with gay men ‘paying’ straight men for sex. Payment assumed several forms, including giving partners cash, buying gifts, or paying for drinks or drugs.

…because in our townships in shebeens if you want a man you have to buy it. Either you buy three beers, or you give him twenty bucks, they very cheap the guys… (FGD 2, 14/10/2009).

Sometimes they even come back, because they know if they sleep with R--, R-- will give them fifty Rand (In depth interview 2, 09/07/2009).

When sex happened with these partners it was frequently reported to be unprotected, and took place in toilets, dark corners, or open fields. Reasons for not using condoms and water-based lubricants included: being drunk and ‘forgetting’, partners’ refusal to use condoms, and the lack of availability of condoms and water based lubricants.

It is also important to understand the ‘situational specificity’ of erotic desire [34] in these sexual interactions. Situational specificity refers to the specific contexts in which sexual practices take place, and Parker et al. [34] note that these contexts may ‘…make reasonable and acceptable, patterns of behaviour that might in other circumstances be unthinkable and untenable’.

While Parker et al. discuss situational specificity in terms of sexual segregation in prisons, the military, and religious settings, in this study there are also specific situations reported where it appears that sexual interactions between men become ‘reasonable and acceptable’ in spite of the broadly homophobic context in which they occur. For ‘straight’ sexual partners of participants in this study, the consumption of alcohol at shebeens seems to provide this context; the use of alcohol being the factor that makes same-sex sexual behaviour ‘reasonable and acceptable’. For example, this straight-identifying man stated:

…alcohol plays a major role, you pick up someone at the shebeen, you not 100 percent sure that this person is male, you are under the impression that, that it’s a female, you find out at home then it’s too late, then you already busy having sex kind of a thing (FGD 1, 18/08/2009).

This participant appears to use alcohol consumption as a justification for the ‘mistake’ of having sex with a man. Similarly, another participant said that students that he worked with would associate their same-sex sexual behaviours with alcohol consumption:

…he’s the one always getting involved, he gets piss drunk, and then he gets fucked all over the show but ‘nee meneer dis nie ek, dis die wyn (no mister, it’s not me, it’s the wine) (In depth interview 9, 20/11/2010).

Alcohol use is common in South Africa, and Parry et al. [35] found that one-third of all adult drinkers in South Africa reported ‘risky drinking’ over weekends. In this context of high levels of alcohol use the effects of drinking on sexual behaviour are likely to play an important role in HIV transmission [36]. However, while the fact that there is an association between alcohol use and risky sexual behaviour is well established, there is a lack of understanding about the underlying causal relationship between alcohol use and sexual behaviour [36].

Cooper [37] states that there are multiple plausible causal mechanisms that may account for this association. These are classified as ‘third-variable explanations’, ‘reverse causal explanations’, and ‘causal explanations’ [37]. Third-variable explanations include: individual traits (e.g. sensation-seeking needs, avoidant coping styles, and low impulse control); lifestyle traits (e.g. being single, living with alcohol consuming peers); and home environment traits (e.g. living in a conflict-ridden household). Reverse-causal explanations propose that the desire to engage in risky sexual behaviour leads individuals to drink when they perceive a sexual opportunity, while causal explanations revolve around two main theories: alcohol-myopia theory, and expectancy theory [37]. Alcohol-myopia theory posits that when individuals are intoxicated they are more susceptible to momentary pressures and are less able to process complex cues (such as fear of contracting HIV) while maintaining the ability to process ‘simple, salient’ cues (such as sexual arousal)—this is primarily a pharmacological explanation [37]. Expectancy theory proposes that individuals’ behaviour after drinking is driven by their pre-existing beliefs about the effects of alcohol—this is therefore a psychological explanation [37].

To understand the relationship between alcohol consumption and sexually risky behaviour for the men in this study it seems likely that a combination of the above explanations is necessary. The local contexts in which MSM live, discussed above, include a range of stressors that may create an environment in which alcohol use is more likely (‘third-variable explanations’). Morojele et al. [38] also point to the importance of these ‘distal predictors’, noting the importance of unemployment and exposure to social, cultural, community and peer norms around heavy drinking in increasing the likelihood that individuals will engage in risky drinking. The participants in this study mainly discussed alcohol use in terms of how it affected their decision making around safer sex. Importantly in terms of the theories discussed above, they discussed both the expected outcomes and the perceived effects of alcohol consumption:

…when you drunk you don’t focus you just want to do something, but by tomorrow you will regret but by that time it will be late (FGD 2, 14/10/2009).

…in townships alcohol does affect most of the gay people, even straight people, because when you drink you don’t follow whatever you know your goals and whatever you had before you got drunk. As soon as you are drunk someone come touch you, you don’t even look this guys face, is he nice is he right or what, you just going to go and have sex (FGD 2, 14/10/2009)

…alcohol plays a major factor in that, you could meet a person who is gay identifying, or someone who is straight identifying, but the straight identifying one is under the influence of alcohol, regrets for him will follow the next morning when he sees that he has slept with a man (FGD 1, 18/08/2009).

In these contexts MSM may also sometimes consume alcohol with the specific intention of making it easier for themselves to find sex partners. Parsons et al. [39], in a study of alcohol use and MSM sexual scripts in New York City, found that this was the case for many of the men in their sample, and describe this as using alcohol as a ‘social lubricant’ and as a ‘prerequisite for sex’. Other aspects of alcohol use and sexually risky behaviour noted by Parsons et al. [39] include the role of alcohol as increasing sexual spontaneity by increasing sexual arousal, increasing ‘sexual adventurism and assertiveness’, affecting partner selection and sexual behaviour, and affecting sexual compulsivity.

Power Dynamics and Negotiating Safer Sex

The power dynamics within sexual encounters between ‘straight’ men and ‘gay’ men are another important factor affecting HIV risk for MSM. Several authors have argued that for men who self-identify as gay in the communities where this study was conducted, being gay often means adopting a female gender identity [5, 6, 40]. Associated with the assumption of this identity may be individuals’ adoption of stereotypically female traits, such as submissiveness. This may reduce the likelihood that these individuals will insist on the use of condoms and water-based lubricant. Such uneven power dynamics in sexual encounters were alluded to by several participants:

…you think you are going to lose this man, and then I have to do the sex, unprotected sex… (In depth interview 1, 07/07/2009).

You see, and then they [straight men] are “why should I use the lube?”, you know? Because now they are getting involved with the gay people, and then gay people are producing something new to them, and then they will make them to start and then “what is this, why should I use this?” (In depth interview 1, 07/07/2009).

Henderson and Shefer [41] argue that in the context of South Africa’s heteropatriarchal society in which ‘…gay men are stigmatised, “othered”, feminised, and abused’ the power dynamics within the sexual relationships between men may also be characterised by relations of dominance and subordination. The application of gender binarism by heterosexually-identifying MSM in their sexual relationships with other men may lead to their domination of these sexual interactions and limit their partners’ ability to insist on safer sexual practices [41]. Some of the statements made by participants in this study would appear to support this idea, for example:

I know the KY Gel, the KY, but if it’s someone who doesn’t have an understanding of that who says “no, no don’t put that on my penis”, you know, it’s easy for an African man to say “no, no don’t put that. What is that? No don’t put that” [author’s emphasis] (In depth interview 2, 09/07/2009).

Ja it’s really, because people they don’t want the condom, if you just tell them about the condom, yoh you’ll be in trouble! (In depth interview 4, 19/08/2009).

In these instances the drivers of HIV risk are in part related to gender inequality and the power dynamics in these sexual relationships.

Discrimination and Health Care

In addition to increasing the risk that MSM will contract HIV, their frequent experiences of discrimination may prevent them from getting diagnosed, and hence accessing treatment and care. Several of the participants discussed health care facilities as a particularly important source of discrimination, and noted a range of factors that prevented them from attending these facilities.

And one thing I’ve noticed is that most of gay people they can’t reach those facilities because they are afraid they will be discriminated, you know (FGD 2, 14/10/2009).

But in some instances you will find that gay people feel scared to go there, because when they do your test, or you visit, or your STI questions will arise that who do you sleep with (In depth interview 2, 09/07/2009).

A specific concern centred on testing for HIV, and attending clinics for HIV-related care. The stigma associated with HIV in participants’ local communities combined with the generally homophobic environment in these communities produces a ‘double stigma’ for MSM who are known to be HIV positive [33].

…the problem here is every condition has it’s own section, pregnancy here, TB that side, HIV that side. So if you go stand in the HIV queue then everyone will know that you were there and they will tell the rest of the people “oh I saw this one standing at the HIV queue or the STI queue at the clinic” (FGD 1, 17/08/2009).

…most of the nurses there in the township they are our neighbours my mother’s friend…she knows me and she knows my status and she knows that I am gay so she will tell these other nurses “you see that one, he is HIV and he is gay” (FGD 2, 14/10/2009).

Stigmatisation appeared to be a particularly important feature of health services for participants who adopted female gender identities or presented themselves as feminine:

…there’s no privacy-especially for drag queens. For any gay person…It’s like people have to see, and there’s no privacy where, especially if you are on ARVs, and there on the door stand “ARV treatment/HIV treatment”…especially if you have to sit for tablets, people they mock you, you know people they all people like “moffie” (Afrikaans slang meaning ‘gay’) all these things, and really it’s not nice (FGD 3, 04/11/2009).

Similar experiences were reported by Lane et al. [42] among MSM in Soweto, Johannesburg. In the context of HIV risk for MSM in Cape Town, one of the most important consequences of this stigmatisation is possible delay in seeking treatment for sexually transmitted infections (STIs), and the subsequent increase in HIV transmission risk associated with these infections. Other important effects of stigmatisation at health services include receiving poor quality care, possible negligence on the part of health workers [43], and difficulties in medication adherence [44, 45].

Personal Level Factors

Personal level factors occur within individuals and include ‘cognitions and feelings…as well as thoughts about oneself’ [9]. In terms of HIV risk, factors such as self-esteem, self-efficacy, internalised homophobia, and mental health have been associated with HIV risk behaviours [9, 30]. Stein et al. [24] found that among young HIV-positive men sexually risky behaviours were predicted by a range of social and emotional stressors. However, other authors have found limited evidence of a link between emotional distress and HIV risk [46].

Poor mental health and emotional distress are potentially a result of a range of social stressors including low socio-economic status, experiences of homophobic discrimination, and social exclusion. Exposure to such stressors in daily life is also likely to contribute to low self-esteem, and low self-efficacy for protective behaviours [13, 23].

For the men in this study the most frequently discussed personal factor was the effect of homophobic discrimination on self esteem and mental health.

…as a gay person if you go into the government clinics, you going right inside, but you coming out very sick, very sick, you are totally sick.

P4: You are worse.

P5: You are worse, your CD4 count just drops immediately.

P4: And it’s not just the physical illness you know, a lot of- I think people don’t really understand what damages you emotionally, and when you stress, you know, how that also affects your health (FGD 3, 04/11/2009).

…in the township when they start calling you by names you start feeling bad about yourself, as if what you doing is something else that’s what make like most of gay people hide themselves (FGD 2, 14/10/2009).

Participants’ low self-efficacy for protective behaviours was discussed in the context of negotiating the use of condoms and water-based lubricants, and in situations where they had sex after alcohol use.

…so it’s difficult to use condoms when you are interested in a person because all that you are interested in is sex, and if that person doesn’t want to use a condom then you don’t use it because all you are interested in is the sex after all… (FGD 1, 18/08/2009).

…you become careless because you just want to make sure okay lets do this and lets get done now, because if there’s no condom lets do it. And then they just end like that and they end up positive most of the time (FGD 2, 14/10/2009).

Then you just find a guy and you been looking for this guy, he’s drunk, you drunk, whatever, and he has also got a girlfriend around, then you just go quick side-side then you go to the toilet then you just pull finish, without a condom, without protection. Not even lube (FGD 2, 14/10/2009).

Discussion

The implementation of effective HIV ‘combination prevention’ programmes for MSM in Cape Town requires an understanding of both the risk situations in which HIV is transmitted, and the risk environments [47] in which these situations occur. While some aspects of the broader risk environment for HIV transmission are shared across the general population of these areas, the ways in which these aspects interact with the personal experiences and immediate social environments of MSM result in these men having a higher risk of contracting HIV.

In this article we have discussed how these contexts, characterised by structural violence, may affect individual MSM’s HIV risk in the peri-urban townships of Cape Town. This is important because it provides insight into the multiple linkages between risk environments, risk situations, and individuals’ risk behaviours within the risk situations in which HIV is transmitted. Understanding these linkages is essential for the practical implementation of combination prevention strategies. Specifically, an analysis of the distal, proximal, and personal drivers of HIV risk can facilitate the development of HIV prevention strategies that target both individual risk behaviours, and the social contexts that affect these behaviours. For example, in Brazil, in addition to focusing on individual HIV prevention strategies, such as condom promotion and distribution, recognition of the importance of homophobia as a driver of HIV led to the development of programmes aiming to reduce homophobia as a form of HIV prevention [48]. We therefore suggest that it is important for governments, NGOs, and international donor organisations working on HIV prevention targeting MSM (and other key populations), to base their programmes on research which documents these multiple, linked, factors and contexts which affect HIV risk; and to develop HIV prevention programmes that target these various drivers of HIV transmission.

This study was exploratory and hence may reflect a limited perspective of MSM HIV risk in Cape Town. Our use of purposive sampling through Health4Men’s existing community-level contacts also means that we may have restricted our analysis to particular social networks of MSM, who shared the same social and sexual contexts as each other.

In spite of these potentially limited perspectives, the results of this study reveal important areas requiring further attention in HIV prevention campaigns and social research investigating HIV risk for MSM in South Africa.

Conclusion

This research documented some of the risks, and drivers of risk articulated by MSM in peri-urban townships of Cape Town. The risk environment for MSM HIV infection here is characterised by structural violence that includes high levels of poverty and unemployment and an intolerant and homophobic cultural and social context. These broad features of the risk environment translate into daily experiences of homophobia and discrimination, while at a personal level these experiences affect individuals’ self esteem and potentially their self-efficacy for HIV prevention. Ultimately, individuals’ risk behaviours in the risk situations in which HIV is transmitted are shaped by this multiplicity of factors.

While individual behaviour-change strategies remain an important aspect of HIV prevention, their effectiveness is limited when broader structural issues are not addressed [49]. This means that the understanding of what constitutes HIV prevention for MSM in Cape Town, and South Africa more generally, needs to be broadened. As such, advocacy and awareness raising around homophobia and stigmatisation of MSM, both in their communities and at health care facilities, need to be included in HIV prevention strategies. Similarly, an awareness of the effects of socio-economic conditions on HIV risk for MSM necessitates attention to mechanisms of improving access to economic opportunities for these men. Simultaneously, attention needs to be paid to more traditional behaviour change strategies, including communication campaigns, and the supply of condoms, water-based lubricants and relevant HIV prevention information.

Coates et al. [49] argue that for HIV prevention to achieve the ‘radical behaviour change’ necessary for reductions in HIV incidence, countries need to implement combination prevention that combines behaviour change strategies, structural strategies, biomedical strategies, and HIV and STI treatment [49]. Such prevention strategies are imperative if HIV prevention for the MSM population in Cape Town, and South Africa, is to be effective.