Investigating the Role of Sexual Identity/Behavior Stigma and HIV-Related Stigma in HIV Prevention and Care Engagement among Men who have Sex with Men and Transgender Women in South Africa Public
Brown, Carolyn (Summer 2020)
Abstract
HIV remains a leading cause of morbidity and mortality in sub-Saharan Africa. Global achievements in HIV testing, treatment, and retention have not been equally gained and men who have sex with men (MSM) and transgender women (TGW) account for a disproportionately high burden of HIV worldwide. One factor contributing to HIV disparities among MSM and TGW is stigma. MSM and TGW may face multiple layers of stigma, due to sexual orientation and behavior, gender identity, race/ethnicity, HIV, and other identities. This dissertation examines the impact of sexual identity/behavior stigma and HIV-related stigma on HIV prevention and service engagement among MSM and TGW in South Africa.
Aim 1 assessed the association of baseline levels of sexual identity/behavior stigma and HIV-related stigma on HIV prevention uptake among MSM and TGW enrolled in the Sibanye Health Project (SHP). The SHP was a 12-month longitudinal pilot of a package of HIV prevention interventions in Port Elizabeth and Cape Town, South Africa. No measured domains of stigma were found associated with uptake of pre-exposure prophylaxis (PrEP). Increased enacted stigma at baseline was associated with increased number of optional drop-in visits.
Aim 2 investigated the modifiability of sexual identity/behavior stigma through engagement with the care offered by sensitized providers and clinic staff of the SHP. Over the 12-month period, we found decreases enacted stigma, orientation concealment, and healthcare stigma. We did not find any significant change in anticipated or internalized stigma. Changes in stigma were not associated with either PrEP uptake or number of drop-in visits.
Aim 3 was a qualitative assessment of the impact of a sensitized, safe space clinic on HIV prevention engagement and changes in stigma. Emergent themes included the complex factors around engagement with safe spaces (i.e. spaces offering culturally competent, non-stigmatizing care for MSM and TGW) versus community/public clinics, changes in orientation concealment, healthcare stigma, and the personal impact of engagement with safe spaces.
These findings highlight the modifiability of some domains of stigma and the utility of safe space, sensitized clinics in decreasing stigma and increasing HIV prevention engagement among MSM and TGW in South Africa.
Table of Contents
Table of Contents
CHAPTER 1: BACKGROUND AND SIGNIFICANCE
Overview
Measuring Stigma
Research Goal
Sibanye Health Project
CHAPTER 2: DEVELOPING AND VALIDATING THE MULTIDIMENSIONAL SEXUAL IDENTITY STIGMA (MSIS) SCALE
Introduction
Methods
Scale Development
Focus Groups and Cognitive Interviews
Scale Finalization
Coding and Analyses
Results
Discussion
Limitations
Conclusion
CHAPTER 3: ASSESSING THE ASSOCIATION OF BASELINE LEVELS OF STIGMA ON HIV SERVICE AND PREVENTION UPTAKE
Introduction
Methods
Cohort sampling and design
Study Measures
Analytic Methods
Ethics
Results
Sexual Identity Stigma and HIV-related Stigma on PrEP Uptake
Sexual Identity Stigma and HIV-related Stigma on Drop-In Visits Completed
Discussion
CHAPTER 4: ROLE OF ENGAGEMENT WITH CULTURALLY COMPETENT HIV PREVENTION AND CARE SAFE SPACES IN CHANGES IN SEXUAL IDENTITY STIGMA
Introduction
Methods
Study Measures
Analysis
Results
Discussion
CHAPTER 5: CARE PROVIDED IN SENSITIZED CLINIC DECREASES STIGMA AND INCREASES HIV PREVENTION ENGAGEMENT
Introduction
Methods
Study Setting and Population
Data Collection
Analysis
Ethics
Results
Negative experiences in non-sensitized clinics
Safe space engagement increases HIV prevention engagement
Engagement with safe spaces decreasing stigma
Personal impact of safe spaces
Discussion
CHAPTER 6: CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS
APPENDIX A: SHP SEXUAL IDENTITY STIGMA QUESTIONS
APPENDIX B: SHP HIV-RELATED STIGMA QUESTIONS
APPENDIX C: SHP HEALTHCARE STIGMA QUESTIONS
APPENDIX D: QUALITATIVE INTERVIEW QUESTIONS
REFERENCES
About this Dissertation
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