Understanding and managing HIV infection risk among men who have sex with men in rural Uganda: a qualitative study

Background

Same-sex sexual relations are criminalised in Uganda, and men who have sex with men (MSM) experience a high burden of HIV infection. In Uganda, health promotion policies focus on equity in healthcare and creating enabling environments. At present there is limited evidence upon which to enhance engagement of MSM in rural settings into effective HIV prevention. To fill this gap, our study explored MSM’s understandings of HIV risk and strategies used to reduce HIV risk in their sexual lives.

Methods

In-depth interviews were conducted with sixteen MSM in rural communities in Southwestern Uganda. Inductive thematic analysis examined men’s perceptions of HIV risk and strategies of reducing their own HIV risks.

Results

Understandings of HIV risk and risk practices were framed by lack of access to condoms, challenges negotiating condom and pre-exposure prophylaxis (PrEP) use, and condomless sex being reported as more pleasurable than sex with condoms. Strategies men perceived as enabling them to manage HIV risk included: PrEP use; condom use; knowing partners’ HIV status; avoiding partners associated with HIV risk; oral sex; withdrawal before ejaculation and washing one’s penis after sex. There were several misconceptions arising from poor HIV prevention knowledge. Strategies reliant on communication and negotiation with sexual partners were inhibited by gendered powered imbalances.

Conclusions

Our findings illustrate that MSM in rural settings in Uganda are making concerted efforts to implement strategies that might reduce risk of HIV transmission and infection within their sexual relationships. Key HIV health promotion and service-related strategies to support MSM with these efforts include an effective condom and lubricant supply chain; a PrEP program in trusted local health units, implemented via discreet community-outreach mechanisms; and same-sex specific HIV-related health promotion.

Power relations in sexual agreements among male couples in Southern Africa

Sexual agreements between same-sex practising men facilitate communication about health promotion activities, including HIV prevention. In African contexts, male couples negotiate their sexual agreements in relation to rigid cultural prescriptions about male power and privilege, intense hostility towards same-sex sexualities and persistent heterogendered socio-cultural norms. Yet the impact of such norms on relationship practices and HIV risk among male couples remains inadequately explored. This qualitative study examined the role of gendered power disparities in establishing sexual agreements among male couples in two Southern African contexts. Eighteen male couples completed in-depth interviews focused on relationship practices, including sexual agreements. The research employed critical social theory to analyse power relations and socio-cultural norms shaping male couples' explicit and implicit sexual agreements, with a focus on implications for HIV risk. The findings outline different types of and motivations for sexual agreements among male couples, including qualified non-monogamy with female partners only. The study illustrates how Southern African male-male sexual practices remain embedded in a cultural context favouring the replication of heteronormative sexual behaviours and relationship practices. These heterogendered norms impact negatively on the process of establishing explicit, mutually agreed-upon sexual agreements, and thus place male couples at increased risk for HIV.

Development and Validation of the Power Imbalance in Couples Scale

Few researchers have quantitatively explored the relationship power-HIV risk nexus in same-sex male couples. We developed and validated the Power Imbalance in Couples Scale (PICS) to measure relationship power among men in same-sex, committed relationships and its association with sexual risk behaviors. We recruited three independent and diverse samples of male couples in the greater San Francisco and New York City metropolitan areas and conducted qualitative interviews (N1 = 96) to inform item development, followed by two quantitative surveys (N2 = 341; N3 = 434) to assess the construct, predictive, convergent, and discriminant validity of the PICS. Exploratory factor analysis of the first survey's data yielded four factors-overtly controlling partner, supportive partner, conflict avoidant actor, and overtly controlling actor-that accounted for more than 50% of the shared variance among the PICS items. Confirmatory factor analysis (CFA) of the second survey's data supported these four factors: χ²(1823) = 2493.40, p < .001; CFI = .96, RMSEA = .03 and WRMR = 1.33. Strong interfactor correlations suggested the presence of a higher-order general perception of power imbalance factor; a higher-order factor CFA model was comparable in fit to the correlated lower-order factors' CFA: χ²(2) = 2.00, p = .37. Internal reliability of the PICS scale was strong: α = .94. Men perceiving greater power imbalances in their relationships had higher odds of engaging in condomless anal intercourse with outside partners of discordant or unknown HIV status (OR 1.27; 95% CI 1.01-1.60; p = .04). The PICS is an important contribution to measuring relationship power imbalance and its sequelae among male couples; it is applicable to research on relationships, sexuality, couples, and HIV prevention.

'You have to bow right here': heteronormative scripts and intimate partner violence in women's same-sex relationships

Intimate partner violence is increasingly recognised as occurring not only between heterosexual partners but also in same-sex relationships. Heterogendered relationship norms have been identified as intersecting with other social inequalities to create and sustain power differentials between partners - and fuel violence - yet remain largely unexplored in relation to women's same-sex relationships. Building on existing feminist research we explore the use of gendered scripts in South African lesbian and bisexual women's accounts of relationship norms and practices. We apply a feminist poststructuralist lens to focus-group discussion data to investigate how such scripts are drawn on to either uphold or challenge violent and coercive relationship practices. The findings illustrate the salience of heterogendered norms and demonstrate how violent practices become possible in contexts of deepening socioeconomic impoverishment - such as in post-apartheid South Africa - where race, space, gender and sexuality are tied to attempts at reclaiming respectable personhood. Efforts to dismantle inequitable gendered power relations and attendant violent practices require both macro-interventions aimed at shifting structural constraints on lesbian and bisexual women's agency, as well as micro-processes aimed at scripting equal power relations between partners as desirable.

Relationship Power Among Same-Sex Male Couples in New York and San Francisco: Laying the Groundwork for Sexual Risk Reduction Interventions Focused on Interpersonal Power

Research is clear that power differentials between women and men shape women's human immunodeficiency virus (HIV) risks; however, little research has attempted to examine power differentials within same-sex male (SSM) couples and whether these influence sexual risk outcomes. To produce the first quantitative scale that measures power in SSM relationships, the current work was a Phase 1 qualitative study that sought to understand domains of relationship power and how power operated in the relationship among 48 Black, White, and interracial (Black-White) SSM couples recruited from San Francisco and New York. Interview domains were focused on definitions of power and perceptions of how power operated in the relationship. Findings revealed that couples described power in three key ways: as power exerted over a partner through decision-making dominance and relationship control; as power to accomplish goals through personal agency; and as couple-level power. In addition, men described ways that decision-making dominance and relationship control could be enacted in the relationship-through structural resources, emotional and sexual influence, and gender norm expectations. We discuss the implications of these findings for sexual risks and HIV care and treatment with SSM couples that are focused on closing gaps in power.

Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa

Background

Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access.

Objectives

To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa).

Methods

A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training.

Results

Fourteen per cent of trainees had received previous training to counsel clients around penile-anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% - 87%, p < 0.0001), specifically around penile-anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training.

Conclusion

MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs.

'We go to the bush to prove that we are also men': traditional circumcision and masculinity in the accounts of men who have sex with men in township communities in South Africa

In predominantly isiXhosa-speaking township communities in South Africa, men who have sex with men negotiate their identities and sexual practices alongside heteronormative cultural scripts of what it means to be a man. Such idealised notions of masculinity are predicated on the selective appropriation of cultural practices that preserve (heterosexual) male privilege and power. In this paper, we explore the identity work done by men who have sex with men, with particular reference to male circumcision as a cultural practice widely drawn on to inform and regulate normative masculinity. Through a narrative-discursive analysis of the accounts provided by men who have sex with men from township communities, we highlight how participants' dissident sexualities are constructed as compromising their masculine identities. Participating in cultural practices such as traditional circumcision aligns participants to the idealised forms of masculinity that afford men full citizenship in their communities. Study findings suggest that sexual dissidence is less troubling to participants than deviating from gendered markers of hegemonic masculinity, and point to ways in which marginalised men might have an interest in maintaining the dominant gendered order. We conclude with implications for research and programmatic work with gay, bisexual and other men who have sex with men.

Gay Xhosa men's experiences of ulwaluko (traditional male initiation)

This paper explores the lives of gay men undergoing traditional initiation in the Eastern Cape. Nine participants aged between 18 and 26 reported their reasons for becoming traditionally circumcised, which included personal validation of cultural manhood, the desire to conform to societal norms and expectations, and pressure from family members to 'convert' them to heterosexuality. While homosexuality remains a target for vilification and abuse both in Southern Africa and across the African continent, practices such as ulwaluko (traditional male initiation) must surely be among the most threatening to a young gay Xhosa man's self-esteem.

Exploring the Health Belief Model and first-year students' responses to HIV/AIDS and VCT at a South African university

The Health Belief Model (HBM) is a psychosocial framework that attempts to explain health behaviour. It is determined by an individual's personal beliefs or perceptions about a disease and the options available to decrease its occurrence. In the context of sexual risk behaviours, literature reveals that knowledge about HIV/AIDS and Voluntary Counselling and Testing (VCT) are key strategies in the management and prevention of HIV. This study was conducted in 2011, the same year the First Things First campaign was implemented in universities across South Africa to maximise opportunities for HIV testing among youth. It aimed to identify first-year students' responses to HIV/AIDS and VCT at the University of the Witwatersrand (WITS). The mixed research methods consisted of self-administered structured questionnaires with a sample population of 195 first-year students and 2 in-depth interviews with experts in the field of HIV/AIDS. Descriptive statistical analyses (frequencies and cross-tabulations) and thematic content analysis was carried out. The findings indicate that students are willing to know their status. The positive influence of peers is a motivation for those accessing VCT. However, some students do not access VCT due to personal fears while other students do not access VCT because of their low individual risk perception for HIV due to sexual abstinence. It concludes that university students' self-efficacy and cues to action might bring about a positive change in the future of the epidemic within a university context.

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.

Narratives of Power and Abuse in Gay Relationships in the Cape Metropole

This qualitative study, which employed a semi-structured guide with in-depth interviews, examines how gay men construct a gay identity and have relationships within a heteronormative society in the Cape Metropole, South Africa. Data were collected via an MP3 player and each interview was transcribed and analysed using content analysis. The sample distribution included 15 gay men aged between 20 to 46 years. Of these, 12 participants were black (six coloured, three Indian, three African) and three were white. The study examined to what extent unequal power relations and forms of abuse are reported in current practices of gay male relationships. In this article, I will unpack how the intersection of class, age, and other forms of social inequality facilitate abuse before examining how abusive experiences reported emerged out of heteronormative stereotypes, where the ‘masculine’1 partner dominated decision-making and where the ‘feminine’ partner was expected to engage in traditionally ‘feminine roles’. Participants reported surveillance and/or punishment to ensure compliance. In sexual practices, psychological and sexual abuse occurred where normative gender power relations were in operation, leading to experiences of unwanted sexual practices and being infected with HIV. There were further examples where abuse was linked to homophobic and traditional cultural practices. Some of the gay men experiencing abuse in their relationships appeared to resist normative gender power relations, in that the majority of participants found agency to end their relationships in different ways — suggesting that power relations can be interrogated.