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.

'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.