The current study is amongst the first investigations focusing on South African HIV-positive MSM and is the first to examine their experiences of stigma and discrimination. In this study we found that HIV-positive men experienced a considerable amount of internalised stigma.
In a study designed to assess the impact of internalised AIDS stigma in the US, Lee, Kochman and Sikkema (2002)
found that 63% of HIV-positive persons sampled in two US cities indicated that they were embarrassed by their HIV infection and 74% stated that it was difficult for them to tell others they are HIV-positive. Lee et al. (2002)
further showed that internalised AIDS stigma was related to depression symptoms over and above demographic characteristics, health status, symptoms of grief and various coping responses. These findings suggest that internalised AIDS stigma may play a crucial role in the emotional reactions and distress experienced by many people who are aware that they are living with HIV/AIDS. Internalised feelings of shame and guilt also have an adverse effect on the health status of the person living with HIV; so too can the level of social support provided also have an impact on their health status.
In our study, even though perceptions of current health were significantly different across the groups of men, HIV-positive MSM and MSW reported considerable levels of social support from their family and friends. In addition, moderate levels of cognitive-affective depression symptoms were found among both MSM and MSW, as with Lee at al. (2002)
in their US study among PLWHA, but no significant differences were reported between the two groups. According to Hall (1999)
, receiving adequate social support, whether it is informational or in terms of a strong social network, was an influence on the psychological well-being of MSM living with HIV/ AIDS.
All HIV-positive men in South Africa, irrespective of sexual orientation, experienced considerable internalised AIDS stigma, emotional distress and discrimination. However, HIV-positive MSM generally experienced more discrimination related to their HIV status than their non-MSM counterparts. It therefore appears that HIV-positive MSM suffer from double or multiple discrimination or super-discrimination.
Results of this study should be interpreted in the light of its methodological limitations. Purposive sampling is subject to selection biases. In order to obtain the sample of HIV-positive MSM, specific locations were targeted where MSM congregate, thus the sample characteristics were biased towards MSM congregating at these specific venues. Another limitation of the study was that there was no procedure in place to ensure that only genuine PLWHA complete the survey.
However, it is unlikely that many HIV-negative participants would have done so, given the considerable stigma still attached to HIV-positive status in the communities surveyed, as well as the fact that participants were not made aware of the very small incentive until after completion of the questionnaire. In addition, the fieldworkers who conducted the survey were mainly from the same residential area and attended the same support groups as participants, so that most participants were known to them. Moreover, many surveys were collected at clinics, which offer closed support groups for people already identified as living with HIV/AIDS. However despite the above limitations, we believe that the current findings contribute new knowledge that could be useful in intervention planning for HIV-positive MSM.
These findings have important implications for services and interventions for all HIV-positive men in South Africa. Interventions are needed that can assist HIV-positive MSM to better adapt and adjust to their condition and the social environment. In particular, coping efficacy training targeted to address managing social stigma and reducing internalised stigma should be developed and tested among them, especially MSM.
In the development of risk-reduction interventions for HIV-positive MSM, a component focusing on reducing the use of injection drug use is also important in tailoring the intervention for HIV-positive MSM. In the US, using injection drugs and MSM are dual risks for HIV infection and contribute to the highest rates of infection among any risk group (CDC, 2000
, cited in Kral et al., 2005
). In an investigation conducted in a US city of HIV-positive gay and self-identified bisexual men injection drug users, Ibanez, Purcell, Stall, Parsons and Gomez, (2005)
showed that this risk group engaged in more unprotected sex than non-injection drug users. They also found that HIV-positive gay and bisexual injection drug users experience more emotional distress than their non-injection drug using counterparts.
HIV-positive MSM may also benefit from interventions designed to broaden and strengthen their social support networks. For example, support groups, which are already common in South Africa, especially among MSM living with HIV/AIDS, may be used as a starting place for the development of social support interventions. However, the ultimate solution to AIDS stigma, especially among MSM, does not lie in the hands of HIV-positive men alone. Structural interventions are needed to change both the social climate of AIDS and sexual politics around sexual practices of MSM. Reducing the combined AIDS and MSM stigmas at the societal level could impact on the internalised stigmas that are clearly magnified in MSM living with HIV/AIDS.