Sexual stigma is the cooccurrence of the following four components within a power imbalance: labeling, stereotyping, separation, and status loss and discrimination specific to sexual minorities because of same-sex practices . Although sexual stigma has been found to be associated with HIV prevalence and with avoidance of seeking health care [2,3], it remains unknown whether sexual stigma drives onward transmission of HIV and sexually transmitted infections (STIs) among Nigerian MSM. Psychological processes resulting from sexual stigma may maintain or exacerbate poor mental health, ultimately influencing behaviors that put MSM at risk of new infections [4–6]. Understanding the mental health processes in these pathways may allow an intervention point to prevent further transmission.
A number of studies have shown a direct relationship between sexual stigma and suicidal ideation [4–7] and there is growing evidence that suicidal ideation is a significant problem for MSM across Sub-Saharan Africa [8–10]. Suicidal ideation is often associated with cognitive processes including hopelessness, pessimism, negative self-perceptions, and poor problem-solving skills that may hinder protective health behavior [11,12].
Sexual stigma has also been found to be associated with condomless sex among MSM across a variety of settings outside of Nigeria [13–16]. This relationship may be mediated by psychological processes that include distress, anxiety, depressive symptoms, and suicidality [4,15,17]. Individuals experiencing poor mental health as a result of sexual stigma may use condoms less frequently because of lowered self-esteem [18,19], feelings of hopelessness, or fatalism [20,21], a need for validation or emotional contact [22,23], and sexual sensation seeking . Each of these may become barriers to the development of positive attitudes and intentions that foster protective behavior.
Very few studies have linked sexual stigma to HIV/STIs by way of both mental health and sexual risk behavior and studies assessing sexual stigma's association with HIV and STIs have used prevalence [24–26]. Studies assessing mental health as a mediator of the stigma-HIV/STI association have not assessed suicidal ideation as an indicator of mental health. Therefore, the objectives of this study were to assess: if sexual stigma toward Nigerian MSM is associated with incident HIV/STI infection and if the sexual stigma HIV/STI acquisition association is mediated by suicidal ideation and condomless sex.
The Network-Based Recruitment of MSM into HCT, Care, Treatment and Prevention Services at Trusted Community-based Venues (TRUST/RV368) study utilizes respondent-driven sampling to recruit MSM into a prospective cohort at two sites in Nigeria as previously described [27,28]. Eligibility criteria included male sex assigned at birth and at least 16 years of age in Abuja or 18 years in Lagos. All participants provide written informed consent and approval for the study was obtained by the Federal Capital Territory Health Research Ethics Committee, the University of Maryland Baltimore Institutional Review Board, and the Walter Reed Army Institute of Research Institutional Review Board.
From March 2013 to February 2016, 1480 participants completed a baseline questionnaire and were provided with HIV testing and counselling using a parallel algorithm of Determine (Alere, Waltham, Massachusetts, USA) and Uni-gold (Trinity Biotech, County Wicklow, Ireland), with STAT-PAK (Chembio, New York, New York, USA) as the tiebreaker, upon enrollment and every 3 months thereafter. Urine and rectal swab specimens were tested for Chlamydia tachomatis and Neisseria gonorrhoea using the Aptima Combo 2 assay (Hologic, Bedford, Massachusetts, USA) every 3 months. Incident infections were defined by a first positive diagnosis after a previously negative diagnosis. The proportion of individuals with an incident HIV and/or STI infection were pooled as a composite measure for the outcome variable. Variables other than HIV and STIs included in the analysis were assessed only at study enrollment: ever experienced sexual stigma, ever disclosed same-sex practices to family, ever experienced suicidal ideation, condomless sex with casual sex partners in the past 12 months (versus inconsistent condom use or no sexual acts with casual sex partners). Analyses were conducted using STATA Version 13 (Statacorp, College Station, Texas, USA) and MPlus Version 7.4 .
Creation of three stigma subgroups
Nine sexual stigma indicators were chosen that are representative of stigma prevalent in the United States, Western Africa, and Southern Africa , and were utilized to create three latent stigma classes using latent class analysis. The nine questions asking about stigma as a result of having sex with men included: family made discriminatory remarks, rejection from friends, refusal from police to protect them, verbal harassment, blackmail, physical violence, rape, fear of seeking health care, and fear of walking in public. The analyses were conducted using modal class . Thus, the latent stigma class variable was converted into a manifest variable with three categories of low (n = 633), medium (n = 663), and high (n = 184) stigma.
Chi-square goodness of fit testing was used to determine if the proportions of the following variables differed by stigma subgroup: disclosure of same-sex practices, suicidal ideation, condomless sex, and incident HIV/STI infection.
Path analysis is a form of structural equation modeling that is recommended when researchers have hypotheses regarding causal associations between measured variables. A strength of this analysis is that it allows the inclusion of multiple mediators and outcomes, testing direct and indirect effects, and assessing model fit . We tested whether a sexual stigma-HIV/STI incidence association was partially mediated by suicidal ideation and condomless sex, adjusting for disclosure of same-sex practices, age, education, having had a female sex partners in the past 12 months, and sex position (insertive, receptive, both). A test of whether a larger model (with the direct association between stigma and HIV/STI acquisition included) was a better fit than a smaller model (without the direct association) was conducted using a robust χ2 model difference test . The path analysis produced standardized probit regression estimates. A positive coefficient means that an increase in the predictor leads to an increase in the predicted probability. A negative coefficient means that an increase in the predictor leads to a decrease in the predicted probability. The model was clustered by city using a sandwich procedure that calculates robust errors . Model fit was assessed using the following standard criteria: χ2 goodness of fit test P value more than 0.05, root mean square error of approximation less than 0.05, comparative fit index more than 0.90, and Tucker-Lewis Index more than 0.90.
The sample consisted of participants who were primarily under 25 years of age (60%), had completed high school or less education (70%), identified their sex as male (82%), had never disclosed their same-sex practices to a family member (83%), engaged in both insertive and receptive anal sex with male partners in the past 12 months (53%), and approximately half had a female sex partner in the past 12 months. Bivariate analysis revealed that increasing sexual stigma was associated with increasing incident HIV and/or STI infections in a dose–response association (low: 10.6%, medium: 14.2%, high 19.0%, P = 0.008; Fig. 1).
The larger model with a direct relationship between stigma and HIV/STI acquisition in addition to the indirect associations had a better fit than the smaller model (P < 0.001). Figure 2 presents the final path model. The model had good fit across all fit statistics (χ2P = 0.387, root mean square error of approximation = 0.007, comparative fit index = 0.998, and Tucker-Lewis Index = 0.996). There was a significant total effect of stigma on HIV/STI acquisition (standardized estimate 0.159, standard error (SE) 0.047, P-value = 0.001), consisting of a significant direct effect (standardized estimate of direct effect 0.152, SE 0.047, P-value = 0.001) and a significant indirect effect (standardized estimate of indirect effect 0.006, SE 0.001, P-value < 0.001).
The path analysis model revealed that MSM who were in higher stigma classes at baseline were more likely to contract HIV/STIs over the course of the study, and this was partially explained by stigma's association with suicidal ideation, suicidal ideation's association with condomless sex with casual sex partners, and condomless sex's association with HIV/STI acquisition. The current study extends the literature by assessing newly acquired infections rather than existing infections (i.e. prevalence) and identifies mediating processes that partially help to explain the association between stigma and HIV/STI acquisition. The direct association between stigma and incident HIV/STI infection remained significant in the model, suggesting the existence of other unmeasured factors that need further exploration.
The levels of suicidal ideation found in this sample were much higher for all stigma classes as compared with the prevalence estimates in a nationally representative sample of Nigerian adults (3.2% with a third subsequently attempting suicide) . The proportion reporting suicidal ideation among the low stigma class alone was 5.3 times that of the nationally representative sample. Suicidal ideation is predictive of suicide, one of the leading causes of death worldwide . Therefore, our findings highlight the need to incorporate mental health issues of MSM in HIV and STI programming in Nigeria. One option would be to adopt WHO's Mental Health Gap Action Programme intervention, that addresses mental, neurological, and substance use disorders with trauma-informed care approaches, within nonstigmatizing venues that serve MSM .
Addressing poor mental health is also important for preventing sexual behavior that increases the risk of HIV and STIs. Hatzenbuehler et al.'s  psychological mediation framework posits that sexual stigma causes or exacerbates poor mental health through psychological processes, such as hopelessness. Intervention strategies that counteract psychological processes associated with suicidal ideation could include: improving problem solving skills and appraisal to bolster feelings of control and self-worth ; organizing peer support groups that are available to counsel MSM clients to alleviate feelings of social isolation and loneliness ; and adapting cognitive behavioral therapy interventions successful in high-income settings at reducing condomless sex among MSM to the Nigerian context [39–42].
There are several limitations with these analyses. The latent class analysis that produced the three stigma classes had moderate entropy, which means that some people may have been misclassified . The analyses could have been strengthened by indicators of internalized stigma and other measures of mental health, such as depressive and anxiety symptoms, but which were not collected in the cohort. Our sample size for incident HIV infection was small, limiting our ability to assess the model for HIV and STI separately. Several variables in the model were asked as lifetime experiences, making the temporal ordering unclear and causality difficult to establish. It is possible that stigma did not precede suicidal ideation or condomless sex for some participants. Lastly, the methodology precluded accounting for variation in observation time for different participants and for potential variability in the model variables following enrollment.
Rarely have studies included robust measures of new infections collected from an MSM cohort and explicated a pathway by which to understand how sexual stigma may promote onward transmission of HIV/STIs. These findings call for a meaningful integration of stigma mitigation strategies, mental health services, and psychosocial support as a standard of care, as well as including resiliency-based strategies to build self-efficacy. Together these strategies will minimize deficits in problem-solving skills and overcome feelings of hopelessness among Nigerian MSM.
We are grateful to the individuals who participated in this study, despite the sexual stigma they have experienced, as well as to the study staff who have remained dedicated to the mission of TRUST/RV368 throughout.
M.C., S.B., and I.O. designed the study. R.G.N. and B.K. collected and managed data. C.R-H., R.G.N., M.C. and D.G. conceived the analyses. C.R-H. analyzed data with input from R.M., R.G.N., D.G., M.C., and S.B. C.R-H., D.G., R.G.N., S.B., and M.C. drafted the manuscript and R.M., T.A.C., H.L., and O.G. provided critical review and editing. All authors have seen and approved the article.
The TRUST/RV368 Study Group is constituted as follows: Principal investigator: Man Charurat (IHV, University of Maryland, Baltimore, Maryland, USA).
Co-investigators: Alash’le Abimiku, Sylvia Adebajo, Julie Ake, Senate Amusu, S.B., T.A.C., Charlotte Gaydos, H.L., Jennifer Malia, Nelson Michael, R.G.N, Helen Omuh, I.O., Sheila Peel, Merlin Robb, C.R-H., Sheree Schwartz.
The work was supported by a cooperative agreement (W81XWH-11-2-0174) between the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and the U.S. Department of Defense (DoD). This study is also supported by funds from the US National Institutes of Health under Award No. R01MH099001 and R01AI120913 and training grant T32 A1050056-12, the US Military HIV Research Program (Grant No. W81XWH-07-2-0067), Fogarty AITRP (D43TW01041), and the President's Emergency Plan for AIDS Relief through cooperative agreement U2G IPS000651 from the HHS/Centers for Disease Control and Prevention (CDC), Global AIDS Program with IHVN.
The views expressed are those of the authors and should not be construed to represent the positions of the U.S. Army or the Department of Defense or the Department of Health and Human Services.
Conflicts of interest
There are no conflicts of interest.
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