The above quantitative and qualitative analyses revealed several findings that give insight into the attitudes, perceptions and the communicative practices of BMSM in the Msunduzi Local Municipality. Firstly, the results of this investigation show that there is a reported general awareness amongst BMSM. This reported awareness of BMSM in Msunduzi Local Municipality does not support the previous research. Most studies that focused specifically on BMSM in the USA such as Brooks et al. (2015) and Eaton et al. (2015) which
found that awareness levels amongst BMSM in the USA were as low as 36%. What is noteworthy though is the disconnect that exists between the reported awareness and actual awareness. What emerged in the findings is, although there was high awareness reported, there was incongruent knowledge on the actual workings of PrEP and its uses. This is suggestive of a lack of knowledge or understanding of the information available hence, the inconsistencies in knowledge. What was emergent in the interview data was that BMSM were cognisant of a lack of information around and asserted the need for information. Furthermore, this lack of information manifested itself in a lack of awareness and confusions by participants about the difference between PrEP and PEP. The findings indicate that there is, therefore, a need for more PrEP education interventions targeted at MSM, that will address the incongruence in the information.
Stemming from elevated awareness, findings from this study corroborate with earlier African studies, Hugo et al. (2016) and Karuga et al. (2016), which revealed enthusiasm to use PrEP amongst the populations of Kenyan and South African MSM. Quantitative results indicated that BMSM in Msunduzi Local Municipality were willing to use PrEP, with the majority sighting the need to protect themselves against HIV infection.
From the findings that the introduction of PrEP brings new hope for many BMSM to protect themselves, as the responses suggest, the majority were concerned with HIV infection. Data pertaining to the perceived susceptibility of BMSM revealed that a majority perceived themselves to be at high risk of contracting HIV.
When this concern is coupled with findings relating to the efficacy of current preventative methods available to them, an association can be drawn, and suggestions made about the pre-occupation of MSM with the protection against HIV. Results on the adequacy of the currently available preventative method revealed that many BMSM felt that the current methods were not enough. Therefore, if this is considered within the context of a high level of perceived susceptibility to HIV, the enthusiasm with the use of PrEP could be understood as being indicative of a pre-occupation by BMSM within the municipality to maintain a seronegative HIV status.
The need to remain HIV negative was the main motivator for most of the questionnaire respondents, and this foregrounds the previous discussion on the pre-occupation with HIV. Furthermore, findings revealed that the misconception about the uses of PrEP manifests itself in other motivating factors as the results evidenced
that the need to protect oneself from STIs featured prominently as another motivator for PrEP uptake with a small group highlighting the need to engage in condomless sex as a motivator.
Prominent barriers included high cost, and this factor can be contextually understood seeing that most respondents had a low SES, hence costing plays a prominent role in their decision making. These findings provide an opportunity for further insights to be gleaned on how BMSM, the bulk of which have a low SES, envisage the distribution of PrEP that considers their concerns about cost. Other factors which emerged as barriers include the perceived side-effects that would be because of taking PrEP as well as the impact that taking PrEP will have on their daily lives, with the task of having to take a pill daily proving to be too much of a burden for MSM. These findings support those of previous studies that were conducted with BMSM in the USA (Brooks et al., 2015; Lelutiu-Weinberger & Golub, 2016).
An overarching concern that became apparent for BMSM l relates to self-efficacy and was linked to the use of PrEP daily, although, questionnaire results presented an assortment of barriers to adoption this evolved in the interview data collected. Interview data shifted the trajectory of the gusto towards PrEP adoption referred to earlier and BMSM expressed their concern with the effects that daily PrEP use will have on their daily lives.
The main concerns were the regime and concerns about maintaining the regime. These were illuminated in adherence concerns and boiled down to concerns about taking a pill daily. Finally, there were concerns about the feasibility of having to take medication for an illness that you do not have. Participants revealed that they would rather take ARVs for managing an HIV seropositive status than to take medication to prevent a perceived medical condition. They felt that adherence and the required commitment would be forthcoming than in trying to prevent illness they may not have currently.
Although there was enthusiasm triggered by sheer knowledge of the availability of PrEP and intended adoption of PrEP, there was a consensus amongst BMSM that despite PrEP being such a promising innovation, it did not fit a one size fits all approach. Participants were cognisant of its utility in certain situations and but also understood that not all situations were apparent, hence this belief is closely linked to certain concerns (barriers) that BMSM had identified. Therefore, PrEP and its use became a particular decision process that would be based on the particular situation. Its use when in a relationship was identified for its
mitigating opportunities in the face of condom migration that many participants described as characteristic of stable relationships. The overarching intention to protect against HIV also linked to the intent to use PrEP in the backdrop of an eventful and busy sexual life, highlighting its inefficiency in an uneventful sexual life.
Finally, conversations among friends were the most prominent form of inter-personal sexual health communication in the sample. Findings revealed that friends were trusted more than health care workers (HCWs) and family members when it came to the intimate details of previous sexual encounters and sexual health. This is because friends were more trustworthy, were believed to have more experience and were trusted for giving good advice. The results indicated that conversations dealing with the previous sexual encounter, preventative health care and HIV prevention took place frequently amongst BMSM. These conversations were positively positioned to influence the changing sexual health behaviours of MSM. PrEP awareness or information sharing have not been evident in the results suggest that very little conversations may happen amongst BMSM about PrEP. Although they do not explicitly evidence engagement on PrEP related matters these, results suggest being in support of the assertion by Young et al. (2018) on the potential use of social networks to encourage PrEP engagement. By evidencing the potential for changing behaviour, the communication inherent in friendship dyads holds potential for effecting change if PrEP is enlisted.
Dyadic communication between friends was an important way that BMSM expressed, affirmed and experienced their sexuality and hence these conversations had saliency amongst this population. This type of communication also revealed that it had a positive influence on the changing of sexual behaviours and developing sexual norms. Most prevalent to this study is the effect of dyadic communication on the development of perceptions and attitudes towards PrEP. The finding revealed that dyadic communication amongst friends influenced the attitudes and perceptions of BMSM in Msunduzi Local Municipality towards PrEP. Although there was a moderate frequency of these conversations, which suggested to be based on the lack of communication, but conversations about PrEP yielded a developed position amongst the participants about the adoption of PrEP.
Chapter Seven
Lessons on voicing BMSM in the Msunduzi Local Municipality – Hope for PrEP in the age of HIV/AIDS