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      Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland

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          Abstract

          Introduction

          Same-sex practices and orientation are both stigmatized and criminalized in many countries across sub-Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same-sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio-economic and behavioural determinants.

          Methods

          Three hundred and twenty-three men who reported having had anal sex with a man in the past year were recruited using respondent-driven sampling and administered a structured survey instrument. Asymptotically unbiased estimates of prevalence of stigma and human rights abuses generated using the RDSII estimator are reported with bootstrapped confidence intervals (CIs). Weighted simple and multiple logistic regressions of fear of seeking healthcare and disclosure of same-sex practices to a healthcare provider with demographic, social and behavioural variables are reported.

          Results

          Stigma was common, including 61.7% (95% CI=54.0–69.0%) reporting fear of seeking healthcare, 44.1% (95% CI=36.2–51.3%) any enacted stigma and 73.9% (95% CI=67.7–80.1%) any perceived social stigma (family, friends). Ever disclosing sexual practices with other men to healthcare providers was low (25.6%, 95% CI=19.2–32.1%). In multiple logistic regression, fear of seeking healthcare was significantly associated with: having experienced legal discrimination as a result of sexual orientation or practice (aOR=1.9, 95% CI=1.1–3.4), having felt like you wanted to end your life (aOR=2.0, 95% CI=1.2–3.4), having been raped (aOR=11.0, 95% CI=1.4–84.4), finding it very difficult to insist on condom use when a male partner does not want to use a condom (aOR=2.1, 95% CI=1.0–4.1) and having a non-Swazi nationality at birth (aOR=0.18, 95% CI=0.05–0.68). In multiple logistic regression, disclosure of same-sex practices to a healthcare provider was significantly associated with: having completed secondary education or more (aOR=5.1, 95% CI=2.5–10.3), having used a condom with last casual male sexual partner (aOR=2.4, 95% CI=1.0–5.7) and having felt like you wanted to end your life (aOR=2.1, 95% CI=1.2–3.8).

          Conclusions

          MSM in Swaziland report high levels of stigma and discrimination. The observed associations can inform structural interventions to increase healthcare seeking and disclosure of sexual practices to healthcare workers, facilitating enhanced behavioural and biomedical HIV-prevention approaches among MSM in Swaziland.

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          Most cited references 59

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          Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward.

          Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.
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              From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures.

              Recent analyses suggest that lack of clarity in the conceptualization and measurement of HIV stigma at an individual level is a significant barrier to HIV prevention and treatment efforts. In order to address this concern, we articulate a new framework designed to aid in clarifying the conceptualization and measurement of HIV stigma among individuals. The HIV Stigma Framework explores how the stigma of HIV elicits a series of stigma mechanisms, which in turn lead to deleterious outcomes for HIV uninfected and infected people. We then apply this framework to review measures developed to gauge the effect of HIV stigma since the beginning of the epidemic. Finally, we emphasize the utility of using three questions to guide future HIV stigma research: who is affected by, how are they affected by, and what are the outcomes of HIV stigma?
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                Author and article information

                Journal
                J Int AIDS Soc
                J Int AIDS Soc
                JIAS
                Journal of the International AIDS Society
                International AIDS Society
                1758-2652
                13 November 2013
                2013
                : 16
                : 3Suppl 2
                Affiliations
                [1 ]Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
                [2 ]Rock of Hope, Mbabane, Swaziland
                [3 ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
                [4 ]Swaziland National AIDS Program, Mbabane, Swaziland
                Author notes
                [§ ] Corresponding author: Stefan D Baral, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E 7152, Baltimore, MD 20205, USA. Tel: +1-410-502-0800. Fax: +1-410-614-8371. ( sbaral@ 123456jhsph.edu )
                Article
                18715
                10.7448/IAS.16.3.18715
                3833105
                7eba16a9-9280-4e06-ab11-f010a469b428
                © 2013 Risher K et al; licensee International AIDS Society

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Global action to reduce HIV stigma and discrimination
                Research Article

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