While other participants from the opposing group of participants attributed the issue of the difficulty to protect oneself from HIV infection to the social pressures that they experience from their partners, which made it difficult for them to negotiate safe sex even though they were re in what is perceived to be common and monogamous relationship:
Yeah, although it isn’t that easy, but communication is vitally important with your partner but at other times your partner will say NO! I don’t want to use a condom because it kills the sensation and I want raw sex [condomless sex] and you are like okay…you want to have raw sex? Because you love the person you end up having to sacrifice and not using protection. (Participant Seven, Gay, Receptive Anal Intercourse Partner)
What’s making it not easy, is that, for example, like recently I didn’t want to have sex with my partner, and he was like, so you are doing it with some other people and all that stuff, so I was like, okay let me just do it. I’m not saying that I just said let me just risk it all and do it for him, but I was like okay let’s just do it because I felt that we were both ready for it, even though I was abstaining at the time.
(Participant Eight, Gay, Receptive Anal Intercourse)
Another group of participants attributed a varied power relation in protecting themselves based on the type of relationship each one had with the partner at the time. The narrative from these comments were based on the view that using protection was easy with a stable partner who you are in a relationship with in comparison to a one-night-stand partner. This was contested by the view that a one-night-stand occurrence gave the individual more power to protect themselves in comparison to a stable relationship which is prone to condom migration over time.
vulnerability of BMSM to HIV infection. Though the consensus in the result of the risk, the risk perspective, the efforts to prevent infection and the assessment of difficulty and simplicity of protecting oneself, it all boils down to the implementation of preventative methods. Although there was a variety of perspectives on the varying methods used, by the interviewees, a common view amongst interviewees was that even with these methods that were available to them, there were inherent risky behaviours that impeded on them using these methods, which subtly links to the impediments to prevention methods. The overarching narrative of promiscuity and alcohol and substance use, including challenges of negotiating safe sex and sustaining safe sex practices emerged subtly across a range of responses. This theme came up in discussions around the effect on HIV and AIDS on the sexual expression of BMSM, the efficacy of preventative methods, the consistent use of preventative methods and how easy BMSM were finding it to protect themselves from infection. The ubiquitous nature of this overarching theme on risky behaviour provides insights for the risk profile of these BMSM and allows for an interrogation of the self-efficacy that they may have to adopt and adhere to a new preventative method that maybe be demanding like PrEP.
According to the Health Belief Model, self-efficacy is defined as an individual’s confidence in their ability to act in a particular way and adopt a particular behaviour (Rosenstock et al., 1988). Self-efficacy is the final construct of the model which was added to the model in the 1980’s. Although it is the least explored construct in this study as highlighted in previous chapters, the findings indicate that it is saliently emerging from discussions that BMSM have about preventative methods. Before the focus is shifted to how these latent sexual behaviours pose concerns for self-efficacy, an exploration of their contextualisation as expressed by the interviewees is needed. In their accounts of the effects that HIV has on their sexual expression, promiscuity emerged as an underscoring factor with the comments below illustrating this:
Because we are promiscuous as MSM, we are very promiscuous, so… (deep breath) being promiscuous as we are, what happens now is that we must restrain ourselves from enjoying our lives in a way that we want to enjoy especially when it comes to sexual plays. Because every time you are with someone you are thinking, ey…HIV is there, it’s out there. So yeah, I won’t lie sex is very nice but then in this day and age you can’t trust anyone. (Participant One, Gay, Receptive Anal Partner)
Another interviewee expressed the notion of promiscuity from a societal perspective highlighting that it is difficult to avoid the effects of promiscuity within the community, placing BMSM at risk:
Sometimes in our gay community, you will find that the community it is very small, and you will find that a person is dating particular person, while at the same time they are dating another person and that is nothing major. (Participant Seven, Gay, Receptive Anal Partner)
Although named by interviewees, in this study from their subjectivity as promiscuity, this finding is not unique to the BMSM community in the Msunduzi Local Municipality. Findings in previous studies on risk behaviors and HIV prevalence among MSM in South Africa (Lane et al., 2011; Rispel et al., 2011b; Arnold et al., 2013) have highlighted the notion of concurrency (having overlapped sexual partners) as a risk factor that heightens risk of HIV transmission in South Africa amongst MSM. This is demonstrated by Arnold et al. (2013) who revealed in their study of Sowetan MSM that there was a higher frequency of sexual partner overlap occurrence in Soweto, over three to four-month period, signalling to a manifestation of what interviewees in this study refer to as promiscuity. To better contextualise this in relation to HIV risk probability, an earlier study of MSM in Soweto conducted by Lane et al. (2011) asserted that the increased odd of infection was related to having many partners, about six to nine sexual partners in the period of 6 months. This assertion also draws attention to not only the frequency of partners in a short space of time but more importantly to the risks associated with this behaviour. Hence, from this vantage point, the concerns of promiscuity as a risk factor that are emergent in this study are applicable to other studies in similar contexts within South Africa.
Reflecting on the role of alcohol and the effects that it has as an inducer of risky behaviours, the views that emerged focused on alcohol-induced disinhibition particularly focusing on the role that alcohol played in making it difficult to consistently use the necessary preventative methods. A recurrent theme in the interviews was a sense that although they were aware of the preventative methods, they needed to use, the concurrent use of alcohol inhibited their use of these methods and influenced their capability to seek multiple and random sexual partners. These discussion points all influence the risk behaviours they identified and their risk towards HIV transmission. This theme, like that of promiscuity, came up for example in discussions around the effect of HIV and AIDS on the sexual expression of BMSM, the efficacy of preventative methods, the consistent use of preventative methods and how easy BMSM were finding it to protect themselves from infection. The
consensus amongst interviewees was that alcohol posed as an impediment to the development and their progress in protecting themselves effectively. One interviewee said:
Because we know, I know that nje you always window shopping and whenever we are drunk, we just want to do our thing. (Participant One, Gay, Receptive Anal Intercourse Partner)
Another interviewee explicitly linked the use of alcohol to impaired decision making, about the use of PrEP or an alternative preventative method. The interviewee commented that:
I just think that for another person it could be an impaired decision due to substance [alcohol] or simply put drug abuse. (Participant Five, Gay, Receptive Anal Intercourse Partner)
The final interviewee drew on the effects that alcohol has even within a relationship setting, devoid of predominately held notions of it being an issue in casual encounters:
Sometimes you will find that when I and my partner go out drinking together when we get back, we don’t bother with protection, we just get back home, jump into bed and the next thing we have had condomless sex. (Participant Seven, Gay, Receptive Anal Intercourse Partner)
The above-varied comments on the concern with alcohol-induced disinhibition reflect the various perspectives from which this concern can be looked at and the varying contexts within which the phenomenon occurs. Taken together, these comments suggest that there is an association between alcohol consumption and elevated risky behaviours, and subtly alludes to concerns of self-efficacy. The present findings seem to be consistent with previous research which found that in township settings across the country, like the ones where the bulk of participants in this study were residing, there was a relationship between increased alcohol consumption and risky sexual behaviours such as unprotected anal intercourse (UAI). In their early study focusing on the relationship between alcohol consumption and risky sexual behaviour in low-income townships in the Gauteng province, Lane et al. (2008b) found that, alcohol was the most commonly consumed substance, with later studies (Lane et al., 2011) developing more specific descriptive compositions of this substance use. With this established, what was emergent amongst these studies was that there was a close
correlation between regularly drinking alcohol and the risk of engaging in UAI, hence significantly increasing the risk profile of these men (Lane et al., 2008b; Lane et al., 2011; Rispel et al., 2011b).
The above correlates to the concerns raised by BMSM in this sample about alcohol use and how being under the influence affects their decision-making capabilities. This reference to this impaired decision-making capability, sub-latently addresses issues of self-efficacy. This is one of the less-researched constructs of the HBM which refers to the individual’s confidence in their ability to act in a way and adopt a behaviour (Rosenstock, 1974b). The model asserts that this will influence an individual’s decision to take behaviour. If the individual has a high perceived self- efficacy, they will be prone to take necessary action or change a behaviour. Through the assertions of the BMSM in the current sample, it is emergent through the concerns about alcohol playing a role in affecting their decisions to consistently use condoms during sex. These comments subtly refer to a lack of self-confidence to maintain their chosen safe-sex behaviour considering their alcohol consumption. These findings raise questions with regards to PrEP and how self-efficient these BMSM will be if they start to use PrEP. The responses to the various questions are discussed in the following section.