As discussed much earlier in this dissertation, there is a relationship between MSM and the HIV epidemic.
Furthermore, there is a high prevalence and incidence of HIV and AIDS among BMSM across affected regions, from high, middle to low-income countries.Research with South African MSM has found that their risk of HIV infection is driven by multiple personal, interpersonal, and structural factors (Lane et al., 2011;
Tun, Kellerman, Maimane, Fipaza, Sheehy, Vu and Nel, 2012; Arnold et al., 2013). McIntyre et al. (2013) further assert that there is a mix of factors that combine to increase MSM’s HIV risk. These include a myriad of issues such as social exclusion, direct experiences of homoprejudice, lack of access to power and resources and lack of access to income-earning opportunities.It is crucial to understand these various factors which influence MSM and increase their vulnerability to HIV, especially in a study of this nature. Exploring the perceptions and attitudes of these BMSM towards preventative methods such as PrEP against the contextual backdrop upon which MSM negotiate their existence and make decisions on prevention and care, is fundamental.
The structural factors that drive the risk of South African BMSM transmitting HIV, include high levels of stigma and discrimination from multiple sources (Lane et al., 2008a; Rispel et al., 2011; Vu, Tun, Nel and Nel, 2011);
cultural and religious beliefs about the unacceptability of homosexuality (McIntyre et al., 2013); and lack of
access to appropriate HIV prevention, treatment and care (Lane et al.,2008a; Rispel., 2011). Scheibe, Kanyemba, Syvertsen, Adebajo, and Baral (2014) note the importance of considering both poverty and increasing levels of inequity as drivers of HIV risk among MSM in Cape Town. In contrast, Arnold et al. (2013) note an increase in HIV risk associated with higher income levels among BMSM in Soweto, which may point to the dual role of poverty and local level income inequality as interacting factors affecting HIV risk. Firstly, a deeply rooted stigmatisation of homosexuality has been shown to obstruct this population’s access to proper counselling, treatment and care for several mental and physical health risks, including HIV (Meyer et al., 2010; Wilson and Peggy, 2016). This is supported by Chris Beyrer (2007) who best contextualises this by arguing that when MSM remain hidden and their behaviour remains illegal, HIV infection epidemics among this group are bound to continue.
More so, gay men and other BMSM, often due to homophobic environments and social contexts, have limited access to the necessary HIV education and support for sexual risk reduction as well as important prevention material, such as condoms and water-based lubricants (Millett, Jeffries, Peterson, Malebranche, Lane, Flores, Fenton, Wilson, Steiner and Heilig, 2012; Jeffries et al., 2013). This is mainly due to many not accessing healthcare facilities for fear of stigmatisation and discrimination by healthcare providers at mainstream health services (Lane et al., 2008a; Rispel et al., 2011a; Arnold et al., 2013; Rebe et al., 2013).
An important aspect within this structural factor that was described by Rebe et al. (2013) is the lack of appropriate skills training of health professionals to deal with MSM, which signposts structural marginalisation as highlighted in the above section and the erasure of MSM from mainstream healthcare. Discrimination and its effect can be manifested in community engagement and how these affect MSM’s risk. Baral et al. (2011) found that human rights violations were common among MSM in Cape Town and that being blackmailed was significantly associated with HIV infection, highlighting the multimodal way through which discrimination increases the risk of HIV transmission.
Secondly, behavioural and interpersonal factors which directly affect MSM’s risk of HIV infection include the intimate relationships they sustain. In their discussion of contextual factors associated with condomless anal sex in a sample of BMSM from Soweto, Arnold et al. (2013) found that rates of condomless anal intercourse were significantly higher with partners described as ‘regular’, and the authors suggested that a focus on trust, love and the regularity of anal intercourse in HIV prevention interventions for MSM may be a useful
complement to other HIV prevention initiatives.Some studies have found that general correct knowledge about HIV and other sexually transmitted infections (STIs) was lower than desirable amongst MSM.
Perceptions that anal sex poses no risk of HIV transmission, and that such behaviours might be actively sought after because of this misconception has also been documented (Muraguri, Temmerman and Geibel, 2012).
Further, the contexts in which MSM live are important in understanding their vulnerability to HIV. In a review of BMSM research in Sub-Saharan Africa,Muraguri et al. (2012)suggested that the existence of multiple concurrent male sexual partnerships in lieu of inconsistent or no condom increases the risk of HIV transmission among BMSM.
The living conditions of basically educated, unemployed and disenfranchised BMSM, such as the picture painted about them in Chapter One, cannot be divorced from their HIV risk profile. Hence, it is important to study BMSM in non-metropole areas like Msunduzi Local Municipality. This view was supported by Karuga, Njenga, Mulwa, Kilonzo, Bahati, O'Reilley, Gelmon, Mbaabu, Wachihi, Githuka, and Kiragu (2016), who argued that the community in which MSM live has been documented as key in driving the HIV epidemic due to concurrent heterosexual relationships with the general population. These factors and their effects can be assumed to be as a primary result of the biological factors that disproportionately position BMSM at risk.
Condomless receptive anal intercourse (URAI) is the main risk factor for sexual transmission of HIV among BMSM (Merrigan, Azeez, Afolabi, Chabikuli, Onyekwena, Eluwa, Aiyenigba, Kawu, Ogungbemi and Hamelmann, 2011). The high concentration of rectal cells vulnerable to HIV-1 infection (macrophages, T- cells and dendritic cells) and the single-cell layer of rectal mucosa, results in a per-act risk for HIV transmission that is 10 - 20 times greater than condomless vaginal intercourse, thus biological susceptibility (efficiency of rectal HIV transmission) influences this vulnerability (Bekker et al., 2012).
The socio-economic and the cultural aspects of the lives of MSM may also increase their vulnerability to HIV transmission. Cultural and religious contexts that include intolerance of homosexuality by the community may contribute to HIV risk directly and indirectly through various causal paths. Indirectly, these contextual factors may result in internalised homophobia.
Vu et al. (2012) reported high levels of internalised homophobia in their sample of MSM from Tshwane (Pretoria) and noted an association between internalised homophobia and HIV related misinformation, which in turn affects the individuals' likelihood to engage in risky behaviours. Importantly, these personal factors are also affected by MSM's relationships with each other and with the communities they live in may contribute to depression and lower self-esteem, which have been linked to increased rates of condomless anal intercourse.
Economic and political factors also, directly and indirectly, affect individual risks of acquiring HIV through multiple causal pathways (Gupta, Parkhurst, Ogden, Aggleton and Mahal, 2008). There are great disparities in access to HIV services and commodities among gay men and other MSM within the country based on their economic standing (Masvawure, Sandfort, Reddy, Collier and Lane, 2015). This is evident from the fact that MSM with higher incomes are several times more likely to access lubricants and antiretroviral therapy compared to those with the lowest income levels. This systematically leaves MSM with lower socio-economic status (SES) at risk of not getting access to the necessary materials, not seeking medical attention in mainstream health facilities and thus finding themselves in interpersonal relationships where they are unable to negotiate safe sex with their partners who may be in a concurrent heterosexual relationship with a woman (Mantell et al., 2016).
The final structural factor which is of central importance to the vulnerability of MSM to HIV transmission is the policy context of the countries in which they live. National commitments to respond to the HIV epidemic among MSM lags behind those for other populations, even though, MSM typically share a disproportionate burden of HIV infection.It is important that governments recognise this bias and set it aside in the interest of national public health. As Scheibe et al. (2014) note, while the broad policy context in South Africa is supportive of MSM rights, the ability to enjoy the freedoms enshrined in the Constitution is still linked to individuals’ power and resources. Further, the degree to which the constitutional enshrinement of individuals’
rights is reflected in the policies and programmes implemented by government departments at national, provincial and local level varies and consequently affect MSM’s vulnerability to HIV transmission.