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HIV prevention for MSM in Cape Town, South Africa

The HIV prevalence rate among men-who-have-sex-with-men (MSM) in South Africa has been found to be consistently higher than the general population in a number of research studies. The reasons for this increased vulnerability to HIV infection have not been widely researched. This exploratory research offers a broad overview of the various elements that affect HIV risk among MSM in Cape Town, South Africa and offers recommendations for HIV prevention efforts and further research.

The population of MSM living in Cape Town is highly diverse. The spatial and racial segregation imposed under apartheid continues to shape the social and sexual dynamics of MSM communities. While HIV risk behaviours are similar between ‘white’, ‘black’, and ‘coloured’ communities, the contexts in which they occur, and the social dynamics surrounding them differ. A qualitative approach was used to conduct this research. Sampling was purposive and aimed to recruit MSM with differing backgrounds and sexual identities. Key informant interviews and focus group discussions were conducted. Data were analysed thematically, using a grounded theory style approach.

This report focuses on the drivers of HIV risk among MSM in the previously ‘black’ and ‘coloured’ residential areas of Cape Town. We found that there are multiple factors driving HIV risk in this population, operating at multiple distances from the individual. We adapt a personal, proximal, distal model as a means of discussing our results, noting the combined effects of stressors at these multiple levels in increasing HIV risk. Important factors at a distal level (cultural and structural issues) included homophobic cultural norms and stigma, HIV-related stigma, and poverty.

Proximal factors (interpersonal relationships and the immediate environment) included verbal abuse and violence, lack of safe social and sexual spaces, multiple partnerships, transactional sex, alcohol use, discrimination at health care facilities, and a lack of HIV prevention resources (including condoms and water-based lubricant). Personal factors (within the individual) included self esteem and whether individuals were openly gay or not. Following the identification of these factors we discuss how the interaction between these multiple levels risk affects the risk environments in which MSM live, and in turn how the risk situations in which HIV is transmitted are directly affected by these risk environments. The structural violence inherent in these risk environments is potentially also linked to the increased risk of HIV infection for MSM living here.

The multiple factors that affect HIV risk for MSM in Cape Town necessitate multi-level, multisectoral HIV prevention. This includes standard HIV prevention practices such as condom and water-based lubricant distribution, educational messaging, and workshops on risk-reduction. However, these approaches are likely to have limited effectiveness as they do not address the broader factors that also act to increase HIV risk in this population. It is therefore necessary to broaden the scope of HIV prevention efforts to begin to address the social, cultural, political, and economic factors driving HIV risk.

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