Dealing with minority stress: Male couples and HIV in Southern Africa

Along with many other marginalised groups, men in same sex relationships are at increased risk of contracting HIV. A study conducted by the HSRC and partner organisations, showed the extreme stress of living in an intolerant society contributes to poor mental health, risky sexual behaviour and reluctance to access healthcare services among male couples.

The HIV prevalence among men who have sex with men (MSM) in South Africa and Namibia is disproportionately high relative to other men. However, in African contexts there is a lack of information regarding primary MSM partnerships, including their sexual agreements regarding sex with outside partners, and their engagement in HIV prevention.

For this reason, researchers in the Together Tomorrow study conducted focus group discussions, in-depth interviews and surveys with over 600 males in same-sex partnerships in South Africa and Namibia. The aim was to learn more about their relationship functioning, sexual behaviour, the stress they experience as a minority group, as well as their HIV prevention and treatment needs and services uptake.

The HSRC collaborated with investigators from the University of California and the University of Michigan and worked with local community support organisations, the Gay and Lesbian Network in South Africa and Positive Vibes in Namibia to conduct the study. They presented the findings of the study to the media and stakeholders at the Aids Impact Conference in Cape Town in November 2017.

The research was carried out in phases. In the first phase, partner organisations conducted community engagement and mobilisation activities. A key component was gender sensitisation training of communities, including tribal authorities in KwaZulu-Natal. Individual interviews were conducted with key informants, including service providers and civil society. Focus group discussions were conducted with 64 partnered MSM in South Africa and 45 partnered MSM in Namibia. In addition, 27 couples in-depth interviews were conducted. In the second phase, the researchers used mobile technology to conduct interviews with 220 MSM couples who were recruited from communities in Pietermaritzburg and outlying areas of KwaZulu-Natal, as well as Keetmanshoop, Swakopmund, Walvis Bay and Windhoek in Namibia.

“We wanted to explore the dynamics of relationships such as love, trust and commitment. We also wanted to find out about risk-taking behaviour and the uptake of HIV prevention and treatment options, and to understand how these are impacted by relationships and how they influence minority stress,” says Dr Zaynab Essack, a senior research specialist in the HSRC’s Human and Social Development (HSD) research programme, who managed the study.

Coping with minority stress
Minority stress refers to the chronic stress experienced by a stigmatised minority group. Members of the MSM community often live in hostile and homophobic social environments and this can be linked to adverse mental health outcomes. Poor mental health among MSM in other countries has been associated with risk behaviours, including unprotected sex, multiple sex partners and substance abuse. This may increase their HIV vulnerability. A significant proportion of participants (59%) reported having sex while high on substances and 17.6% reported symptoms of depression. 

The researchers found that the participants in this study use several coping mechanisms in attempts to reduce this stress. Some developed defence mechanisms such as denial that people’s negativity towards homosexuality caused them distress. Others learned to conform by acting straight or maintaining a concurrent heterosexual relationship. Some MSM have children in an effort to feel safe in a society where heterosexual relationships are seen as the norm. Several men reported using alcohol and drugs to lessen their inhibitions while exploring their sexuality.

Creating sexual agreements
A sexual agreement refers to an explicit and mutually agreed understanding between partners on what sexual behaviours they agree to engage in and with whom. Most participants described having sexual agreements in place, and most were monogamous. Only 15% of participants described having open relationships. The in-depth interviews revealed that when relationships were open, these were restricted to female outside partners. Some men reported that the more dominant partner was more likely to seek outside partners. In a few cases, the researchers detected discrepancies where one partner assumed monogamy and the other believed there was an explicit agreement in place.

The formation of and adherence to sexual agreements have been reported to establish higher levels of trust, communication and commitment in relationships, which may reduce HIV risk behaviours. Many participants found it difficult to communicate about these agreements. Therefore researchers recommend that couples should be supported with skills to discuss and create sexual agreements.

Relying on their partners
The researchers found that MSM couples experience many of the same challenges as opposite sex couples, including communication difficulties, infidelity and abuse. However, the anxiety and experiences of being discriminated against by family, friends and others mean that they are often socially isolated and tend to rely heavily on their partners for emotional support.

Most of the men in the survey identified as gay and reported high levels of both experienced and anticipated stigma around HIV and their sexuality. The researchers found low levels of uptake of HIV prevention interventions and high levels of risk behaviour. For example, almost 60% reported having sex while drunk in the previous month. Only 21% of men had tested for HIV in the previous year and 12% self-reported that they were HIV positive. Couples in which both members reported high levels of stigma, frequent substance use, and poor communication skills displayed significantly lower knowledge of HIV prevention and were less likely to use condoms with each other or outside partners.

The researchers identified a need for MSM-focused couples services to support men who have sex with men in their relationships and stressed the importance of identifying safe spaces in society where they can express themselves freely, and demonstrate their love for one another, without fear of discrimination or aggression.

Queering public healthcare spaces
Many participants reported experiencing several forms of homophobic stigma and discrimination when accessing public healthcare, including healthcare workers’ negative attitudes toward same-sex desire and behaviour. Some participants perceived public health facilities as “straight spaces” and felt that it was necessary for them to “act straight” through the ways they dressed and presented themselves when entering these facilities. They are reluctant to disclose their sexuality to healthcare workers and many preferred to access services at NGOs that provided targeted MSM-friendly services.

The researchers recommend that public healthcare services need to be more gender inclusive. A reluctance to disclose same sex practices to healthcare workers, limits access to HIV-related prevention options, such as pre-exposure prophylaxis (taking medication to avoid HIV-infection), and screening for other sexually transmitted infections.

This research was the first with male-male couples in southern Africa and provides important insights into the relationship dynamics of these couples. The researchers hope to leverage this understanding of couple dynamics to develop dyadic interventions for male-male couples that address their mental health, social and HIV prevention needs.

Prof. Heidi van Rooyen, executive director of the HSRC’s Human and Social Development Programme and principal investigator on this study, Dr Zaynab Essack, senior research specialist in the same programme, and HSRC science writer Antoinette Oosthuizen.

The Together Tomorrow study is funded by Evidence for HIV Prevention in Southern Africa (EHPSA), a UK aid programme managed by Mott MacDonald.