AIDS and Behavior

, Volume 17, Supplement 1, pp 51–59 | Cite as

HIV-Untested Men Who Have Sex with Men in South Africa: The Perception of Not Being at Risk and Fear of Being Tested

  • Juan A. Nel
  • Huso Yi
  • Theo G. M. Sandfort
  • Eileen Rich
Original Paper


A community-based needs assessment among men who have sex with men (MSM) in South Africa found that 27 % (n = 280/1,045) of MSM had never been tested for HIV. The most frequently reported reasons for not having been tested were the perception of not being at risk (57 %) and fear of being tested (52 %). This article explores factors associated with these two reasons among the untested MSM. In multiple logistic regressions, the perception of not being at risk of HIV infection was negatively associated with being black, coloured or Indian, being sexually active, knowing people living with HIV, and a history of sexually transmitted infections (STIs) in the past 24 months (adj. OR = .24, .32, .38, and .22, respectively). Fear of being tested for HIV was positively associated with being black, coloured or Indian, preferred gender expression as feminine, being sexually active, a history of STIs, and experience of victimization on the basis of sexual orientation (adj. OR = 2.90, 4.07, 4.62, 5.05, and 2.34, respectively). Results suggest that HIV prevention programs directed at South African MSM will be more effective if testing and treatment of STIs are better integrated into HIV testing systems. Finally, social exclusion on the basis of race and sexual orientation ought to be addressed in order to reach hidden, at-risk, populations of MSM.


HIV testing Prevention programs Reasons for not being tested for HIV Social exclusion Men who have sex with men South Africa 


  1. 1.
    UNAIDS. Global Report UNAIDS Report on the Global AIDS Epidemic; 2010.Google Scholar
  2. 2.
    South Africa. Department of Health. HIV & AIDS and STI National Strategic Plan for South Africa, 2007–2011; 2007.Google Scholar
  3. 3.
    April MD, Walensky R, Chang Y, Pitt J, Freedberg K, Losina E, et al. HIV testing rates and outcomes in a South African community, 2001–2006: implications for expanded screening policies. J Acquir Immune Defic Syndr. 2009;51:310–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Granich RM, Gilks C, Dye C, De Cock K, Williams B. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373(9657):48–57.PubMedCrossRefGoogle Scholar
  5. 5.
    Bennett S, Boerma J, Brugha R. Scaling up HIV/AIDS evaluation. Lancet. 2006;367(9504):79–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Holtgrave D. Evidence-based efforts to prevent HIV infection: an overview of current status and future challenges. Clin Infect Dis. 2007;45(Suppl 4):S293–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Lane T, Raymond H, Dladla S, Rasethe J, Struthers H, McFarland W, et al. High HIV prevalence among men who have sex with men in Soweto, South Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):626–34.PubMedCrossRefGoogle Scholar
  8. 8.
    Mills S, Saidel T, Magnani R, Brown T. Surveillance and modelling of HIV, STI, and risk behaviours in concentrated HIV epidemics. Sex Transm Infect. 2004;80(Suppl 2):ii57–62.PubMedCrossRefGoogle Scholar
  9. 9.
    Mwaluko G, Wringe A, Todd J, Glynn J, Crampin A, Jaffar S, et al. Use of data from HIV counselling and testing services for HIV surveillance in Africa. Lancet. 2007;369(9561):612–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Janssen RS, Holtgrave D, Valdiserri R, Shepherd M, Gayle H, De Cock K. The serostatus approach to fighting the HIV epidemic: prevention strategies for infected individuals. Am J Public Health. 2001;91:1019–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Valdiserri RO. HIV counseling and testing: its evolving role in HIV prevention. AIDS Educ Prev. 1997;9(Suppl 3):2–13.PubMedGoogle Scholar
  12. 12.
    Fenton KA. Changing epidemiology of HIV/AIDS in the United States: implications for enhancing and promoting HIV testing strategies. Clin Infect Dis. 2007;45(Suppl 4):S213–20.PubMedCrossRefGoogle Scholar
  13. 13.
    Girardi E, Sabin C, Monforte A. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr. 2007;46(Suppl 1):S3–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Rotheram-Borus MJ, Newman P, Etzel M. Effective detection of HIV. J Acquir Immune Defic Syndr. 2000;25(Suppl 2):S105–14.PubMedGoogle Scholar
  15. 15.
    Rispel LC, Metcalf C. Breaking the silence: South African HIV policies and the needs of men who have sex with men. Reprod Health Matters. 2009;17(33):133–42.PubMedCrossRefGoogle Scholar
  16. 16.
    Reddy V, Sandfort T, Rispel L, editors. From social silence to social science: same-sex sexuality, HIV/AIDS and gender in South Africa. Cape Town: HSRC Press; 2009.Google Scholar
  17. 17.
    South Africa. Department of Health. HIV, STIs and TB National Strategic Plan for South Africa, 2012–2016; 2011.Google Scholar
  18. 18.
    Cloete A, Simbayi L, Kalichman S, Strebel A, Henda N. Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape Town, South Africa. AIDS Care. 2008;20:1105–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Sandfort TG, Nel J, Rich E, Reddy V, Yi H. HIV testing and self-reported HIV status in South African men who have sex with men: results from a community-based survey. Sex Transm Infect. 2008;84(6):425–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Awad GH, Sagrestano L, Kittleson M, Sarvela P. Development of a measure of barriers to HIV testing among individuals at high risk. AIDS Educ Prev. 2004;16(2):115–25.PubMedCrossRefGoogle Scholar
  21. 21.
    Jacobsen PB, Perry S, Hirsch D. Behavioral and psychological responses to HIV antibody testing. J Consult Clin Psychol. 1990;58:31–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Lyter DW, Valdiserri R, Kingsley L, Amoroso W, Rinaldo C. The HIV antibody test: why gay and bisexual men want or do not want to know their results. Public Health Rep. 1987;102:468–74.PubMedGoogle Scholar
  23. 23.
    Myers T, Orr K, Locker D, Jackson E. Factors affecting gay and bisexual men’s decisions and intentions to seek HIV testing. Am J Public Health. 1993;5:1115–23.Google Scholar
  24. 24.
    Solomon L, Landrigan J, Flynn C, Benjamin G. Barriers to HIV testing and confidentiality: the concerns of HIV-positive and high-risk individuals. AIDS Public Policy J. 1999;14(4):147–56.PubMedGoogle Scholar
  25. 25.
    Kalichman SC, Simbayi L. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect. 2003;79:442–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Meiberg AE, Bos A, Onya H, Schaalma H. Fear of stigmatization as barrier to voluntary HIV counselling and testing in South Africa. East Afr J Public Health. 2008;5:49–54.PubMedGoogle Scholar
  27. 27.
    Peltzer K, Mlambo G, Phaweni K. Factors determining prenatal HIV testing for prevention of mother to child transmission of HIV in Mpumalanga, South Africa. AIDS Behav. 2010;14(5):1115–23.PubMedCrossRefGoogle Scholar
  28. 28.
    van Dyk AC, van Dyk PJ. “To know or not to know”: service-related barriers to voluntary HIV counseling and testing (VCT) in South Africa. Curationis. 2003;26(1):4–10.PubMedGoogle Scholar
  29. 29.
    Lane T, Mogale T, Struthers H, McIntyre J, Kegeles SM. “They see you as a different thing”: the experiences of men who have sex with men with healthcare workers in South African township communities. Sex Transm Infect. 2008;84:430–3.PubMedCrossRefGoogle Scholar
  30. 30.
    South African Advertising Research Foundation (SAARF). Universal Living Standards Measure; 2001.Google Scholar
  31. 31.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.CrossRefGoogle Scholar
  32. 32.
    Bonell C, Weatherburn P, Hickson F. Sexually transmitted infection as a risk factor for homosexual HIV transmission: a systematic review of epidemiological studies. Int J STD AIDS. 2000;11:697–700.PubMedCrossRefGoogle Scholar
  33. 33.
    Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci Med. 2003;57:1–12.PubMedCrossRefGoogle Scholar
  34. 34.
    Baral S, Burrell E, Scheibe A, Brown B, Beyrer C, Bekker L-G. HIV risk and associations of HIV infection among men who have sex with men in peri-urban Cape Town, South Africa. BMC Public Health. 2011;11:766.PubMedCrossRefGoogle Scholar
  35. 35.
    Rispel LC, Metcalf CA, Cloete A, Reddy V, Lombard C. HIV prevalence and risk practices among men who have sex with men in two South African cities. J Acquir Immune Defic Syndr. 2011;57:69–76.PubMedCrossRefGoogle Scholar
  36. 36.
    Rispel LC, Metcalf CA, Cloete A, Moorman J, Reddy V. You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities. J Public Health Policy. 2011;32:S137–51.PubMedCrossRefGoogle Scholar
  37. 37.
    Shefer T, Strebel A, Wilson T, Shabalala N, Simbayi L, Ratele K, et al. The social construction of sexually transmitted infections (STIs) in South African communities. Qual Health Res. 2002;12:1373–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Caceres CF, Aggleton P, Galea J. Sexual diversity, social inclusion and HIV/AIDS. AIDS. 2008;22(Suppl 2):S45–55.PubMedCrossRefGoogle Scholar
  39. 39.
    Smith AD, Tapsoba P, Peshu N, Sanders E, Jaffe H. Men who have sex with men and HIV/AIDS in sub-Saharan Africa. Lancet. 2009;374(9687):416–22.PubMedCrossRefGoogle Scholar
  40. 40.
    Matovu JK, Makumbi F. Expanding access to voluntary HIV counselling and testing in sub-Saharan Africa: alternative approaches for improving uptake, 2001–2007. Trop Med Int Health. 2007;12:1315–22.PubMedCrossRefGoogle Scholar
  41. 41.
    Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. Am J Public Health. 2007;97:1762–74.PubMedCrossRefGoogle Scholar
  42. 42.
    Asante AD. Scaling up HIV prevention: why routine or mandatory testing is not feasible for sub-Saharan Africa. Bull World Health Organ. 2007;85:569–648.CrossRefGoogle Scholar
  43. 43.
    Merson M, Padian N, Coates T, Gupta G, Bertozzi S, Piot P, et al. Combination HIV prevention. Lancet. 2008;372(9652):1805–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Polders L, Wells H. Overall research findings on levels of empowerment among LGBT people in Gauteng, South Africa. Unpublished report. Pretoria: OUT LGBT Well-being; 2004.Google Scholar
  45. 45.
    Rich E. Overall research findings on levels of empowerment among LGBT people in Western Cape, South Africa. Unpublished report. Pretoria: Unisa; 2006.Google Scholar
  46. 46.
    Wells H. Levels of empowerment among lesbian, gay, bisexual and transgender (LGBT) people in KwaZulu-Natal, South Africa. Unpublished report. Pretoria: OUT LGBT Well-being; 2006.Google Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Juan A. Nel
    • 1
  • Huso Yi
    • 2
  • Theo G. M. Sandfort
    • 3
  • Eileen Rich
    • 1
  1. 1.University of South AfricaGroenkloof, PretoriaSouth Africa
  2. 2.School of Public Health and Primary Care, Faculty of MedicineThe Chinese University of Hong KongHong Kong SARChina
  3. 3.HIV Center for Clinical and Behavioral Studies, Department of PsychiatryNew York State Psychiatric Institute, Columbia UniversityNew YorkUSA

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