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AIDS and Behavior

, Volume 22, Issue 12, pp 3905–3915 | Cite as

The Synergistic Impact of Sexual Stigma and Psychosocial Well-Being on HIV Testing: A Mixed-Methods Study Among Nigerian Men who have Sex with Men

  • Cristina Rodriguez-HartEmail author
  • Cory Bradley
  • Danielle German
  • Rashelle Musci
  • Ifeanyi Orazulike
  • Stefan Baral
  • Hongjie Liu
  • Trevor A. Crowell
  • Man Charurat
  • Rebecca G. Nowak
  • the TRUST/RV368 Study Group
Original Paper

Abstract

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013–February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Keywords

Men who have sex with men Stigma Latent class analysis HIV testing Suicidal ideation Mental health 

Notes

Acknowledgements

We are very grateful to the individuals who participated in this study. Despite the sexual stigma they have experienced and continue to experience, they chose to be a part of this study. We are also very grateful to the study staff who have remained dedicated to the mission of TRUST/RV368 throughout.

Collaborators

The following members of the TRUST/RV368 Study Group were collaborators in this study: Cristina Rodriguez-Hart; Stefan Baral; Trevor A. Crowell; Hongjie Liu; Man Charurat; Rebecca G. Nowak.

Disclaimer

The views expressed are those of the authors and should not be construed to represent the positions of the U.S. Army, the Department of Defense, or the Department of Health and Human Services. The investigators have adhered to the policies for protection of human subjects as prescribed in AR-70.

Funding

This work was supported by a cooperative agreement (W81XWH-11-2-0174) between the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and the U.S. Department of Defense (DoD). This study is also supported by funds from the US National Institutes of Health under Award No. R01MH099001 and R01AI120913 and training grant T32 A1050056-12, the US Military HIV Research Program (Grant No. W81XWH-07-2-0067), Fogarty AITRP (D43TW01041), and the President’s Emergency Plan for AIDS Relief through cooperative agreement U2G IPS000651 from the HHS/Centers for Disease Control and Prevention (CDC), Global AIDS Program with IHVN.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Approval for the study was obtained by the Federal Capital Territory Health Research Ethics Committee, the University of Maryland Baltimore Institutional Review Board (IRB), and the Walter Reed Army Institute of Research IRB.

References

  1. 1.
    Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–50.CrossRefGoogle Scholar
  2. 2.
    Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Data 2017. 2017. http://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf.
  3. 3.
    Wei C, Cheung DH, Yan H, Li J, Shi L, Raymond HF. The impact of homophobia and HIV stigma on HIV testing uptake among Chinese men who have Sex with men: a mediation analysis. J Acquir Immune Defic Syndr. 2016;71:87–93.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Schwartz S, Nowak R, Orazulike I, Keshinro B, Ake J, Kennedy S, et al. The immediate effect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort. Lancet HIV. 2015;2:e299–306.CrossRefGoogle Scholar
  5. 5.
    Rodriguez-Hart C, Liu H, Nowak RG, Orazulike I, Zorowitz S, Crowell TA, et al. Serosorting and sexual risk for HIV infection at the ego-alter dyadic level: an egocentric sexual network study among MSM in Nigeria. AIDS Behav. 2016;20:2762–71.CrossRefGoogle Scholar
  6. 6.
    Keshinro B, Crowell TA, Nowak RG, Adebajo S, Peel S, Gaydos CA, et al. High prevalence of HIV, chlamydia and gonorrhoea among men who have sex with men and transgender women attending trusted community centres in Abuja and Lagos, Nigeria. J Int AIDS Soc. 2016;19:21270.CrossRefGoogle Scholar
  7. 7.
    International Lesbian, Gay, Bisexual, Trans and Intersex Association: Carroll A, Itaborahy L. State Sponsored Homophobia: a world survey of laws: criminalization, protection and recognition of same-sex love. Geneva; 2015.Google Scholar
  8. 8.
    Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363–85.CrossRefGoogle Scholar
  9. 9.
    Herek GM. Confronting sexual stigma and predjudice: theory and practice. J Soc Issues. 2007;63:905–25.CrossRefGoogle Scholar
  10. 10.
    Arreola S, Hebert P, Makofane K, Beck J, Ayala G. Access to HIV prevention and treatment for men who have sex with men: findings from the 2012 Global Men’s Health and Rights Study (GMHR). CA: Oakland; 2012.Google Scholar
  11. 11.
    Arreola S, Santos GM, Beck J, Sundararaj M, Wilson PA, Hebert P, et al. Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide. AIDS Behav. 2015;19:227–34.CrossRefGoogle Scholar
  12. 12.
    Ayala G, Makofane K, Santos G, Beck J, Do TD, Wilson PA, et al. Access to basic HIV-related services and PrEP acceptability among men who have sex with men worldwide: barriers, facilitators, and implications for combination prevention. J Sex Transm Dis. 2013;2013:1–11.CrossRefGoogle Scholar
  13. 13.
    Pachankis JE, Hatzenbuehler ML, Hickson F, Weatherburn P, Berg RC, Marcus U, et al. Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey. Aids. 2015;29:1239–46.CrossRefGoogle Scholar
  14. 14.
    King R, Barker J, Nakayiwa S, Katuntu D, Lubwama G, Bagenda D, et al. Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda. PLoS ONE. 2013;8:e82937.CrossRefGoogle Scholar
  15. 15.
    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(Suppl 1):S137–51.CrossRefGoogle Scholar
  16. 16.
    Niang CI, Tapsoba P, Weiss E, Diagne M, Niang Y, Moreau AM, et al. ‘It’s raining stones’: stigma, violence and HIV vulnerability among men who have sex with men in Dakar, Senegal. Cult Health Sex. 2003;5:499–512.CrossRefGoogle Scholar
  17. 17.
    Cange CW, LeBreton M, Billong S, Saylors K, Tamoufe U, Papworth E, et al. Influence of stigma and homophobia on mental health and on the uptake of HIV/sexually transmissible infection services for Cameroonian men who have sex with men. Sex Health. 2015;12:315–21.PubMedGoogle Scholar
  18. 18.
    Safren SA, Blashill AJ, O’Cleirigh CM. Promoting the sexual health of MSM in the context of comorbid mental health problems. AIDS Behav. 2011;15:S30–4.CrossRefGoogle Scholar
  19. 19.
    Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, et al. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS ONE. 2009;4:e4997.CrossRefGoogle Scholar
  20. 20.
    Risher K, Adams D, Sithole B, Ketende S, Kennedy C, Mnisi Z, et al. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc. 2013;16:1–9.CrossRefGoogle Scholar
  21. 21.
    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.CrossRefGoogle Scholar
  22. 22.
    Hatzenbuehler ML. How does sexual minority stigma “get under the skin”?. A psychological mediation framework. Psychol Bull. 2009;135:707–30.CrossRefGoogle Scholar
  23. 23.
    Herek GM, Berrill KT. Hate crimes: confronting violence against lesbians and gay men. Newbury Park: SAGE Publications Inc; 1992.Google Scholar
  24. 24.
    Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674–97.CrossRefGoogle Scholar
  25. 25.
    Ma W, Raymond HF, Wilson EC, McFarland W, Lu H, Ding X, et al. Participation of HIV prevention programs among men who have sex with men in two cities of China—a mixed method study. BMC Public Health. 2012;12:1–13.CrossRefGoogle Scholar
  26. 26.
    Choi K-H, Lui H, Guo Y, Han L, Mandel JS. Lack of HIV testing and awareness of HIV infection among men who have sex with men, Beijing, China. AIDS Educ Prev. 2006;18:33–43.CrossRefGoogle Scholar
  27. 27.
    World Health Organization. Preventing suicide: a global imperative. Geneva. 2014. http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/.
  28. 28.
    Stoloff K, Joska JA, Feast D, De Swardt G, Hugo J, Struthers H, et al. A description of common mental disorders in men who have sex with men (MSM) referred for assessment and intervention at an MSM clinic in Cape Town, South Africa. AIDS Behav. 2013;17:S77–81.CrossRefGoogle Scholar
  29. 29.
    Hladik W, Sande E, Berry M, Ganafa S, Kiyingi H, Kusiima J, et al. Men who have sex with men in Kampala, Uganda: results from a bio-behavioral respondent driven sampling survey. AIDS Behav. 2016;21:1478–90.CrossRefGoogle Scholar
  30. 30.
    Huen JMY, Ip BYT, Ho SMY, Yip PSF. Hope and hopelessness: the role of hope in buffering the impact of hopelessness on suicidal ideation. PLoS ONE. 2015;10:e0130073.CrossRefGoogle Scholar
  31. 31.
    Dieserud G, Røysamb E, Ekeberg O, Kraft P. Toward an integrative model of suicide attempt: a cognitive psychological approach. Suicide Life Threat Behav. 2001;31:153–68.CrossRefGoogle Scholar
  32. 32.
    Charurat M, Emmanuel B, Akolo C, Keshinro B, Nowak RG, Kennedy S, et al. Uptake of treatment as prevention and continuum of care among HIV-positive men who have sex with men in Nigeria. J Acquir Immune Defic Syndr. 2015;68:114–23.CrossRefGoogle Scholar
  33. 33.
    Rodriguez-Hart C, Musci R, Nowak RG, German D, Orazulike I, Ononaku U, et al. Sexual stigma patterns among Nigerian men who have sex with men and their link to HIV and sexually transmitted infection prevalence. AIDS Behav. 2017;22:1662–70.CrossRefGoogle Scholar
  34. 34.
    Stahlman S, Sanchez TH, Sullivan PS, Ketende S, Lyons C, Charurat ME, et al. The prevalence of sexual behavior stigma affecting gay men and other men who have sex with men across sub-Saharan Africa and in the United States. J Med Internet Res Public Health Surveill. 2016;21:1–19.Google Scholar
  35. 35.
    Vu L, Andrinopoulos K, Tun W, Adebajo S. High levels of unprotected anal intercourse and never testing for HIV among men who have sex with men in Nigeria: evidence from a cross-sectional survey for the need for innovative approaches to HIV prevention. Sex Transm Infect. 2013;89:659–65.CrossRefGoogle Scholar
  36. 36.
    Muthen LK, Muthen B. Mplus User’s guide. 7th ed. Los Angeles: Muthen & Muthen. 2015. https://www.statmodel.com/download/usersguide/MplususerguideVer_7_r3_web.pdf.
  37. 37.
    Kennedy CE, Baral SD, Fielding-Miller R, Adams D, Dludlu P, Sithole B, et al. “They are human beings, they are Swazi”: intersecting stigmas and the positive health, dignity and prevention needs of HIV-positive men who have sex with men in Swaziland. J Int AIDS Soc. 2013;16(Suppl 3):1–7.Google Scholar
  38. 38.
    Olalekan AW, Akintunde AR, Olatunji MV. Perception of societal stigma and discrimination towards people living with HIV/AIDS in Lagos, Nigeria: a qualitative study. Mater Sociomed. 2014;26:191–4.CrossRefGoogle Scholar
  39. 39.
    Nylund K. Latent transition analysis: Modeling extensions and an application to peer victimization[dissertation]. Los Angeles: University of California Los Angeles. 2007. https://www.statmodel.com/download/nylunddis.pdf.
  40. 40.
    Beaujean AA. Mediation, moderation, and the study of individual differences. In: Osborne JW, editor. Quant. methods. Thousand Oaks: Sage Publications; 2008.Google Scholar
  41. 41.
    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.CrossRefGoogle Scholar
  42. 42.
    Gureje O, Kola L, Uwakwe R, Udofia O, Wakil A, Afolabi E. The profile and risks of suicidal behaviours in the Nigerian survey of mental health and well-being. Psychol Med. 2007;37:821–30.CrossRefGoogle Scholar
  43. 43.
    Blashill AJ, Perry N, Safren SA. Mental health: a focus on stress, coping, and mental illness as it relates to treatment retention, adherence, and other health outcomes. Curr HIV/AIDS Rep. 2011;8:215–22.CrossRefGoogle Scholar
  44. 44.
    Stahlman S, Bechtold K, Sweitzer S, Mothopeng T, Taruberekera N, Nkonyana J. Sexual identity stigma and social support among men who have sex with men in Lesotho: a qualitative analysis. Reprod Health Matters. 2015;23:127–35.CrossRefGoogle Scholar
  45. 45.
    Van Der Elst EM, Kombo B, Gichuru E, Omar A, Musyoki H, Graham SM, et al. The green shoots of a novel training programme: progress and identified key actions to providing services to MSM at Kenyan health facilities. J Int AIDS Soc. 2015;18:20226.CrossRefGoogle Scholar
  46. 46.
    Lyons CE, Ketende S, Diouf D, Drame FM, Liestman B, Coly K, et al. Potential impact of integrated stigma mitigation interventions in improving HIV/AIDS service delivery and uptake for key populations in Senegal. J Acquir Immune Defic Syndr. 2017;74:52–9.CrossRefGoogle Scholar
  47. 47.
    Brezing C, Ferrara M, Freudenreich O. The syndemic illness of HIV and trauma: implications for a trauma-informed model of care. Psychosomatics. 2015;56:107–18.CrossRefGoogle Scholar
  48. 48.
    Khanna N, Madoori S. Untangling the intersection of HIV & trauma: Why It matters and what we can do. GMHC Treat. Issues. https://www.poz.com/pdfs/gmhc_treatmentissues_2013_9.pdf.
  49. 49.
    Murray LK, Skavenski S, Kane JC, Mayeya J, Dorsey S, Cohen JA, et al. Effectiveness of trauma-focused cognitive behavioral therapy among trauma-affected children in Lusaka, Zambia. JAMA Pediatr. 2015;169:761–9.CrossRefGoogle Scholar
  50. 50.
    Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83:875–89.CrossRefGoogle Scholar
  51. 51.
    Abas M, Nyamayaro P, Bere T, Saruchera E, Mothobi N, Simms V, et al. Feasibility and acceptability of a task-shifted intervention to enhance adherence to HIV medication and improve depression in people living with HIV in Zimbabwe, a low income country in sub-Saharan Africa. AIDS Behav. 2018;22:86–101.CrossRefGoogle Scholar
  52. 52.
    World Health Organization. Mental Health Atlas-2011 country profiles. 2018. http://www.who.int/mental_health/evidence/atlas/profiles/en/.
  53. 53.
    Pitorak H, Duffy MH, Sharer M. “There is no health without mental health”: Mental health and HIV service integration in Zimbabwe, situational analysis. Arlington. 2012. https://aidsfree.usaid.gov/sites/default/files/aidstar-one_situationanalysis_hiv-mentalhealth_zimbabwe.pdf.
  54. 54.
    Lofgren SM, Nakasujja N, Boulware DR. Systematic review of interventions for depression for people living with HIV in Africa. AIDS Behav. 2018;22:1–8.CrossRefGoogle Scholar
  55. 55.
    Wagner GJ, Ngo V, Glick P, Obuku EA, Musisi S, Akena D. INtegration of DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial. Trials. 2014;15:248.CrossRefGoogle Scholar
  56. 56.
    Geibel S, King’ola N, Temmerman M, Luchters S. The impact of peer outreach on HIV knowledge and prevention behaviours of male sex workers in Mombasa, Kenya. Sex Transm Infect. 2012;88:357–62.CrossRefGoogle Scholar
  57. 57.
    Okall DO, Otieno FO, Nyikuri M, Mills LA, Hardnett F, Odero S, et al. Men who have sex with men in Kisumu, Kenya: support group membership and knowledge of HIV-risk factors. Cult Health Sex. 2013;15:968–80.CrossRefGoogle Scholar
  58. 58.
    Arantxa Colchero M, Bautista-Arredondo S, Cortes-Ortiz MA, Romero-Martinez M, Salas J, Sosa-Rubi SG, et al. Impact and economic evaluations of a combination prevention programme for men who have sex with men in Mexico. Aids. 2016;30:293–300.PubMedGoogle Scholar
  59. 59.
    Batist E, Brown B, Scheibe A, Baral SD, Bekker L. Outcomes of a community-based HIV-prevention pilot programme for township men who have sex with men in Cape Town, South Africa. J Int AIDS Soc. 2013;16:1–7.CrossRefGoogle Scholar
  60. 60.
    Fox MP, Rosen S, Geldsetzer P, Barnighausen T, Negussie E, Beanland R. Review article Interventions to improve the rate or timing of initiation of antiretroviral therapy for HIV in sub-Saharan Africa: meta-analyses of effectiveness. J Int AIDS Soc. 2016;19:20888.CrossRefGoogle Scholar
  61. 61.
    Thomson DR, Rich ML, Kaigamba F, Socci AR, Franke MF. Community-based accompaniment and psychosocial health outcomes in HIV-infected adults in Rwanda: a prospective study. AIDS Behav. 2014;18:368–80.CrossRefGoogle Scholar
  62. 62.
    World Health Organization. Policy brief: WHO recommends HIV self-testing. 2016. http://www.who.int/hiv/pub/vct/who-recommends-hiv-self-testing/en/.
  63. 63.
    Zhang C, Li X, Brecht M, Koniak-griffin D. Can self-testing increase HIV testing among men who have sex with men: a systematic review and meta-analysis. PLoS ONE. 2017;12:e0188890.CrossRefGoogle Scholar
  64. 64.
    Campbell CK, Lippman SA, Moss N, Lightfoot M. Strategies to increase HIV testing among MSM: a synthesis of the literature. AIDS Behav. 2018.  https://doi.org/10.1007/s10461-018-2083-8.CrossRefPubMedGoogle Scholar
  65. 65.
    Stahlman S, Nowak RG, Liu H, Crowell TA, Ketende S, Blattner WA, et al. Online sex-seeking among men who have sex with men in Nigeria: implications for online intervention. AIDS Behav. 2017;21:3068–77.CrossRefGoogle Scholar
  66. 66.
    Adebajo SB, Eluwa GI, Allman D, Myers T, Ahonsi BA. Prevalence of internalized homophobia and HIV associated risks among men who have sex with men in Nigeria. Afr J Reprod Health. 2012;16:21–8.PubMedGoogle Scholar
  67. 67.
    Van der Elst EM, Shally M, Oduor C, Ibrahim O, et al. Peer-led oral HIV self testing finds undiagnosed HIV among GBMSM in Malindi, Kenya. Seattle: CROI; 2017.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Cristina Rodriguez-Hart
    • 1
    • 2
    Email author
  • Cory Bradley
    • 2
  • Danielle German
    • 2
  • Rashelle Musci
    • 3
  • Ifeanyi Orazulike
    • 4
  • Stefan Baral
    • 5
  • Hongjie Liu
    • 6
  • Trevor A. Crowell
    • 7
    • 8
  • Man Charurat
    • 1
  • Rebecca G. Nowak
    • 1
  • the TRUST/RV368 Study Group
  1. 1.Institute of Human VirologyUniversity of Maryland School of MedicineBaltimoreUSA
  2. 2.Department of Health, Behavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  3. 3.Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.International Center on Advocacy and Rights to HealthAbujaNigeria
  5. 5.Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  6. 6.School of Public HealthUniversity of MarylandCollege ParkUSA
  7. 7.U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringUSA
  8. 8.Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaUSA

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