Gender identity and HIV risk among men who have sex with men in Cape Town, South Africa.

Gender identity plays a potentially important role contributing to HIV risk among MSM in South Africa. Where studies have included a focus on gender identity, MSM reporting gender non-conformity have been found to have a higher risk of being HIV positive than other MSM. This article examines HIV risk among gender non-conforming MSM in a sample of 316 MSM in Cape Town, South Africa. Reporting gender non-conformity was associated with higher HIV prevalence and increased HIV risk behaviour. Gender non-conformity was also associated with a higher likelihood of being unemployed and reporting low household incomes. These findings highlight the importance of gender-identity as a factor affecting access to HIV treatment, care, and prevention in South Africa and this is an issue that needs to be addressed in interventions targeting MSM populations.

HIV risk and prevention among men who have sex with men in rural South Africa.

Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion data, two overarching global themes that encapsulated participants' understandings of HIV risk and the HIV risk environment in their communities were developed. In the first theme, "community experience and the rural social environment", factors affecting HIV risk within the broad risk environment were discussed. These included perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM; and the role of social media as a means of meeting other MSM. The second global theme, "HIV/AIDS knowledge, risk and experience", focused on factors more immediately affecting HIV transmission risk. These included: high levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships; competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context and the specific HIV risk knowledge and behaviours that affect HIV risk in this population.

Efficacy of Tailored Clinic Trainings to Improve Knowledge of Men Who Have Sex with Men Health Needs and Reduce Homoprejudicial Attitudes in South Africa.

PURPOSE: An urgent need exists for training on men who have sex with men (MSM) health needs at public health clinics across Africa. There is also a need to consider the impact of specific training for clinicians and clinic support staff, both of whom come into contact with MSM. Consideration must also be given to the relationship between two key outcomes of such training: increased knowledge regarding MSM and their health and reductions in homoprejudicial attitudes. METHODS: This article explores the impact of training for clinicians and clinic support staff in the Western Cape, South Africa (n = 196), where some training modules were undertaken by both groups and some modules only by clinicians. Participants were evaluated at baseline and post-training on MSM knowledge and homoprejudicial attitudes. RESULTS: After training, both clinicians and clinic support staff showed an increase in knowledge and a reduction in homoprejudicial attitude scores, with similar proportional improvements for both groups. Additional trainings for clinicians also resulted in significant improvements in their knowledge. However, reductions in homoprejudicial attitudes were related to the type of knowledge obtained. A threshold effect in post-training knowledge scores of 9 or greater on sensitivity material significantly increased the likelihood of a reduction in homoprejudicial attitudes. CONCLUSION: These findings show that training for both types of clinic workers is important and effective, but facilitators should be mindful of complex relationships between knowledge and homoprejudicial attitudes.

A Cross Sectional Analysis of Gonococcal and Chlamydial Infections among Men-Who-Have-Sex-with-Men in Cape Town, South Africa.

BACKGROUND: Men-who-have-sex-with-men (MSM) are at high risk of HIV and sexually transmitted infection (STI) transmission. Asymptomatic STIs are common in MSM and remain undiagnosed and untreated where syndromic management is advocated. Untreated STIs could be contributing to high HIV rates. This study investigated symptomatic (SSTI) and asymptomatic STIs (ASTIs) in MSM in Cape Town. METHODS: MSM, 18 years and above, were enrolled into this study. Participants underwent clinical and microbiological screening for STIs. Urine, oro-pharyngeal and anal swab specimens were collected for STI analysis, and blood for HIV and syphilis screening. A psychosocial and sexual questionnaire was completed. STI specimens were analysed for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infection. RESULTS: 200 MSM were recruited with a median age of 32 years (IQR 26-39.5). Their median number of sex partners within the last year was 5 (IQR 2-20). 155/200 (78%) reported only male sex partners while 45/200 (23%) reported sex with men and women. 77/200 (39%) reported transactional sex. At enrolment, 88/200 (44%) were HIV positive and 8/112 (7%) initially HIV-negative participants seroconverted during the study. Overall, 47/200 (24%) screened positive for either NG or CT. There were 32 MSM (16%) infected with NG and 7 (3.5%) of these men had NG infections at two anatomical sites (39 NG positive results in total). Likewise, there were 23 MSM (12%) infected with CT and all these men had infections at only one site. Eight of the 47 men (17%) were infected with both NG and CT. ASTI was more common than SSTI irrespective of anatomical site, 38 /200 (19%) versus 9/200 (5%) respectively (p<0.001). The anus was most commonly affected, followed by the oro-pharynx and then urethra. Asymptomatic infection was associated with transgender identity (OR 4.09 CI 1.60-5.62), ≥5 male sex partners in the last year (OR 2.50 CI 1.16-5.62) and transactional sex (OR 2.33 CI 1.13-4.79) but not with HIV infection. CONCLUSIONS: Asymptomatic STI was common and would not have been detected using a syndromic management approach. Although molecular screening for NG/CT is costly, in our study only four MSM needed to be screened to detect one case. This supports dual NG/CT molecular screening for MSM, which, in the case of confirmed NG infections, may trigger further culture-based investigations to determine gonococcal antimicrobial susceptibility in the current era of multi-drug resistant gonorrhoea.

How do community-based HIV prevention programmes for men who have sex with men 'travel'? Lessons from the Ukwazana/Zwakalani journey in South Africa.

Research reveals how homophobia and stigma link closely to HIV among men who have sex with men in sub-Saharan Africa. This paper considers the varying impact of homophobic stigma on HIV prevention programmes among men who have sex with men in South Africa. It explores how a community-based HIV prevention programme based in the peri-urban townships of Cape Town was 'translated' to peri-urban Johannesburg. Drawing on interviews with volunteers and programme facilitators in Johannesburg, it argues that an altered homophobic environment to that found in Cape Town gave different opportunities to engage both with other men who have sex with men and the broader community. It also argues that programme facilitators should be mindful of how varying degrees of homophobic stigma may relate to broader theoretical debates about sexual binary relationships, which can help us understand why particular programmes choose to focus on certain activities rather than others.

Minority stress in the lives of men who have sex with men in Cape Town, South Africa.

The mental health outcomes of men who have sex with men (MSM) living in sub-Saharan Africa are understudied, despite evidence that discrimination and stigma are widespread. This article examines the occurrence and mental health effects of minority stress in a sample of diverse South African MSM. Twenty-two MSM living in Cape Town took part in exploratory qualitative in-depth interviews and completed mental health questionnaires. Results indicate that the majority of participants experienced minority stress, which affected their sexual relationships and coping strategies. Concealment behaviors and perceived discrimination levels were high and were associated with race, religion, SES, and geographical location.

Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model.

While research now highlights that men who have sex with men (MSM) in places such as South Africa are at particular risk of HIV infection, left relatively unexplored are potential relationships between one of the most pressing social issues affecting peri-urban MSM - namely homophobic stigma - and sexual risk-taking behaviour. Drawing on research from the Ukwazana baseline study of 316 township MSM in Cape Town we examine how homophobic stigma relates to psychosocial factors such as depression and self-efficacy and the risk activity of unprotected anal intercourse (UAI). By deploying cross-sectional association models, we examine a series of relationships between these variables and offer evidence to suggest that HIV prevention programmes aimed at sexual minority groups should be mindful of potentially complex relationships between social stigmas such as homophobia and sexual risk-taking behaviour.

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.

Men who have sex with men (MSM) have a higher prevalence of common mental disorders (CMD), as compared with heterosexual men. HIV infection is independently associated with higher rates of CMD. Given this context, and the high background community prevalence of HIV in South Africa, MSM are at even greater risk of developing CMD. The aim of this research was to investigate neuropsychiatric symptoms and disorders in MSM who were referred for assessment and management of mental health problems, in an MSM Clinic in urban Cape Town, South Africa. Twenty-five men were screened using the MINI, AUDIT, DUDIT, and IPDE Screener. Depression, suicidality, as well as alcohol and drug use disorders were highly prevalent in this group (44, 56, 48, and 56 % respectively). The personality disorder screening was suggestive of a high prevalence of personality disorders. The high prevalence of neuropsychiatric disorders in this sample supports the idea that integrated mental health services are needed to address the complex needs of this population. Adequate input into the mental health needs of this population could reduce the potential for HIV acquisition and transmission, improve adherence to treatment and care, and ensure the provision a comprehensive health service for MSM.

An exploration into the role of depression and self-efficacy on township men who have sex with men's ability to engage in safer sexual practices.

Men who have sex with men (MSM) in South Africa remain at particular risk of HIV infection. The Ukwazana baseline survey is the first to explore this risk in relation to psychological factors associated with unprotected anal intercourse (UAI). A cohort of 316 MSM from township peri-urban Cape Town took part in the survey. The survey found that 55.2% had engaged in UAI over the preceding 6 months. Depression was significantly associated with UAI. Respondents with self-efficacy scores less than two standard deviations above the mean were also more likely to have engaged in UAI. A Sobel test for mediation highlighted that the depression-UAI association was partially mediated by self-efficacy, indicating that most of the effect of depression on UAI was not covarying with self-efficacy. This study, therefore, highlights that both depression and self-efficacy should be considered factors to be addressed in HIV-prevention programmes aimed at peri-urban MSM.

Understanding the needs of township men who have sex with men (MSM) health outreach workers: exploring the interplay between volunteer training, social capital and critical consciousness.

This article considers the complex ways volunteer outreach workers can frame their engagement with a community-based HIV prevention programme for South African township MSM. Drawing on research conducted during the Ukwazana programme in Cape Town it begins by exploring limitations towards MSM participation with programme facilitators (namely previous feelings of mistrust and community homophobia) and strategies developed to offset these concerns. It then considers how great care must also be taken to appreciate how volunteers from marginalised groups can frame training as a key condition for participation. To understand this it is therefore necessary for facilitators to acknowledge a number of additional concerns. These include community status, a lack of bonding social capital between volunteers and a highly developed from of critical consciousness by volunteers regarding HIV prevention possibilities. This article therefore suggests that effort to initially engage marginalised communities must also be met with effort to understand the complex ways volunteers relate to other MSM and to each other.

HIV risk and prevention among men who have sex with men (MSM) in peri-urban townships in Cape Town, South Africa.

Current guidelines on HIV prevention for MSM emphasise the need for 'combination prevention' based on context-specific understandings of HIV risk. MSM in South Africa are a population with a high risk of HIV infection, however there is little research available on the drivers of this risk. In the context of a focus on combination prevention, this paper argues that effective HIV prevention for MSM in South Africa requires an understanding of the factors at multiple 'distances' from individuals that contribute to HIV risk. Based on qualitative research with MSM in Cape Town, South Africa, we situate HIV risk using a socio-ecological framework and identify factors at distal, proximal, and personal, levels that contribute to MSM's high risk of HIV infection. By understanding the interactions and linkages between risk environments and the risk situations in which HIV is transmitted, HIV prevention programmes will be more effectively able to address the multiple drivers of HIV risk in this population.

Sexual lubricants in South Africa may potentially disrupt mucosal surfaces and increase HIV transmission risk among men who have sex with men.

BACKGROUND: Men who have sex with men (MSM) are at high risk for HIV acquisition and transmission. There is a high HIV-transmission potential associated with unprotected anal intercourse (UAI), which requires sexual lubrication for comfortable, non-traumatic anal sex. Lubricant distribution remains poor in many developing nations and MSM have been known to substitute a number of common household or food products to ensure comfortable anal sex. Concern has been raised about the potential toxicity of lubricants used during anal sex. Epithelial injury is related to the osmolality of the lubricant product. OBJECTIVE: To analyse commercially available water-based sexual lubricant products to ascertain their osmolality and potential to cause rectal epithelial damage. METHODS: The osmolality and glycerol concentration was determined for eight of the most frequently purchased water-based sexual lubricants and some commonly used household/food products. RESULTS: Osmolality ranged from 270 - 9 440 mosmol/l (Lubrimaxxx Premium, containing phytosqualane, and JO H(2)O Water Based Lubricant, respectively). Seven (88%) of the commercial lubricants had high osmolalities, with two products approaching 10 000 mosmol/l, far in excess of serum which has an osmolality of ~280 mosmol/l. CONCLUSION: The results of this study show that many of the top-selling brands of water-based sexual lubricants available in SA are hyperosmolar. Given that hyperosmolar products have been shown in vitro and in vivo to cause epithelial injury, they may have the potential to increase HIV acquisition and transmission, if they are used during UAI. Awareness needs to be raised about the mucosal safety of lubricants designed for use during anal sex.

HIV prevention and treatment for South African men who have sex with men.

Men who have sex with men (MSM) are at high risk for HIV acquisition and transmission owing to the high risks associated with unprotected anal sex and barriers to accessing appropriate health services. Globally HIV prevention is failing among MSM, as evidenced by high seroconversion rates. Prevention interventions for MSM are more limited than for heterosexual individuals. Prevention programmes should embrace early their programming. High transmission risk groups such as MSM will benefit from such interventions.