Men who have sex with men (MSM) in Sub-Saharan Africa are subjected to high levels of sexual identity-related stigma, which may affect mental health and sexual risk behaviors. MSM who are open about their sexual identity appear to be most affected by stigma. Characterizing the mechanism of action of stigma in potentiating HIV-risks among MSM is important to support the development of interventions.
MSM were recruited across 5 cities/towns in Swaziland through snowball sampling ending in December 2014. Participants (N=532) completed a survey that included questions about demographics, stigma, and mental and sexual health. Latent class analysis was used to identify classes based on self-reported measures of sexual identity stigma and whether the sexual identity of the participant was known to his family or healthcare workers. Logistic regression was used to identify demographic characteristics, sexual risk behaviors, and mental health characteristics (i.e., depression – PHQ9) associated with latent class membership.
A three-latent-class model was selected. The first class consistent of MSM who demonstrated overall low probabilities of sexual identity stigma (55%). MSM in the second class exhibited high probabilities of physical violence and fear/avoidance of healthcare, and were less likely to have their sexual identities known (10%). Members of the third class demonstrated high probabilities of verbal harassment, stigma from family and friends, and were more likely to have their sexual identities known (34%). Relative to the “low stigma” class, participants who were sampled from an urban area (Adjusted Odds Ratio [aOR]=2.78, 95% Confidence Interval [CI]=1.53, 5.07) and who engaged in condomless anal sex (aOR=1.85, 95% CI=1.17, 2.91) were more likely to belong to the “high stigma, ‘out’” class. In contrast, participants who had a concurrent partner (including female partners) were more likely to belong to the “high stigma, not ‘out’” class (aOR=2.73, 95% CI=1.05, 7.07). Depression was associated with membership in both high-stigma classes (aOR=2.42, 95% CI=1.51, 3.87 “out” and aOR=3.14, 95% CI=1.50, 6.55 not “out”).
Community-level sexual identity stigma is associated with individual-level risk behaviors among MSM and these associations vary by level of sexual identity openness. Comprehensive HIV interventions should aim to reduce stigma and encourage community-level support.