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Prevention Research

Pathways From Sexual Stigma to Inconsistent Condom Use and Condom Breakage and Slippage Among MSM in Jamaica

Logie, Carmen H. PhD*,†; Wang, Ying MSW*; Marcus, Natania L. MA; Levermore, Kandasi MPH§; Jones, Nicolette MA§; Ellis, Tyrone BA§; Marshall, Annecka PhD; Newman, Peter A. PhD*

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: August 15, 2018 - Volume 78 - Issue 5 - p 513-521
doi: 10.1097/QAI.0000000000001712
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Abstract

INTRODUCTION

Men who have sex with men (MSM) are overrepresented in the global HIV pandemic, including in the Caribbean.1–3 In Jamaica, HIV prevalence is 1.7% [95% confidence interval (CI): 1.4 to 2.0] among reproductive-aged adults,4,5 yet MSM report HIV rates between 28% and 32%—among the highest in the Caribbean.6,7 HIV vulnerabilities are elevated by contextual factors, such as the criminalization of consensual same sex sexual practices in Jamaica, and subsequent lack of human rights protections across employment, education, and health care systems.8 Pervasive stigma, family rejection, and socially sanctioned violence from community and the police targeting lesbian, gay, bisexual, and transgender (LGBT) persons are also reported in Jamaica.9–11

Sexual stigma—social and structural processes of devaluation, mistreatment, and constrained power and opportunities of sexual minorities12—may elevate HIV vulnerabilities13 through complex pathways. Stigma may operate as a distal driver of HIV by exacerbating mental health issues, such as depression, which in turn might reduce uptake of condoms and other preventive methods.14 Stigma also limits access and uptake across the HIV prevention cascade,15 including preventive information, condom use, and routine HIV testing and care.13,16,17 Qualitative and cross-sectional studies in Jamaica, Barbados, and the Bahamas have highlighted negative and stigmatizing attitudes toward MSM among health care providers and students.18–22 Findings from a qualitative study with LGBT young persons in Kingston, Jamaica, indicated multiple types of violence experienced across social ecological sites (eg, family, employment, and health care)23 contributed to social isolation and poor mental health, and health care provider stigma was associated with reduced HIV testing uptake.9–11,24

Sexual stigma has been associated with increased condomless anal sex among MSM. A 2015 cross-sectional study of 38 European countries found that MSM living in countries with discriminatory laws and higher negative attitudes toward LGBT persons had higher odds of no condom use at last sexual encounter.25 A 2015 survey of MSM from 115 countries, including the Caribbean region, reported that criminalization of consensual same sex practices was associated with greater perceived sexual stigma and lower self-reported access to condoms, lubricants, and HIV testing.26

Perceived stigma, the awareness and fear of negative attitudes and norms, and enacted stigma, acts of violence, mistreatment, or discrimination, can become internalized, whereby negative beliefs about same sex practices are accepted by LGBT people themselves.27 Internalized stigma is also associated with sexual risk; a 2011 meta-analysis of 16 studies reported a significant correlation between internalized stigma and condomless sex in MSM.28 Stress resulting from sexual stigma contributes to mental health disparities among LGBT populations,29–31 which in turn can contribute to sexual risk. Cross-sectional studies with MSM in Vietnam,32 Lesotho,33 South Africa,14 and rural United States34 have found that the relationship between sexual stigma and frequency of condom use32,34 and condomless anal sex14 is mediated by mental health variables such as depression.

Interpersonal factors such as sexual abuse may also play a mediating role in the relationship between sexual stigma and sexual risk. A 2012 systematic review of 12 studies found that MSM with sexual abuse histories were more likely to be HIV positive and to report engaging in recent condomless anal intercourse [odds ratio (OR) = 1.85, 95% CI: 1.36 to 2.51].35 A cross-sectional study with MSM in Jamaica found that HIV prevalence increased with the number of adverse life events, such as sexual abuse or experiencing violence.7

Condom use self-efficacy may facilitate condom use among MSM. Condom use self-efficacy refers to one's level of confidence in their ability to have safe sex and is comprised of the ability to obtain condoms, knowledge of proper condom use, and ability to use negotiation skills regarding condom use during sex.36 Longitudinal and cross-sectional research in the United States, South Africa, and Hong Kong reported that condom use self-efficacy is associated with reduced sexual risk practices in MSM.36–40 A longitudinal study of MSM living with HIV in Canada reported that condom use self-efficacy predicted condom use and moderated the relationship between the intention to use condoms and condom use.39 Tucker et al's37 cross-sectional study of MSM in Cape Town's townships found that self-efficacy partially mediated the relationship between depression and sexual risk practices, highlighting the associations between condom use self-efficacy, mental health, and sexual risks among MSM. Moreover, Tucker et al14 found that stigma can compromise condom use self-efficacy; condom use self-efficacy and depression fully mediated the relationship between sexual stigma and condomless anal sex. The authors also conducted a qualitative study that corroborated their findings; MSM in Cape Town's townships reported that homophobic stigma can lead to decreased safer sex practices by lowering self-efficacy and increasing negative affect (such as depression).41

Most research on sexual risk among MSM, broadly14,32,34 and in Jamaica, specifically7,42–44 has used condom use as the key outcome variable, yet HIV may be transmitted during episodes of condom use. Probability modeling based on population-wide census data in Ontario, Canada, indicated that over half of new HIV infections among MSM may occur during anal sex with a condom, indicating high levels of condom failure and breakage.45 A cross-sectional study with MSM in India revealed that 20% of the sample reported at least one instance of condom breakage in the month before the survey.46

Condoms frequently break because of incorrect use,47 and a major component of condom use self-efficacy is the knowledge of proper condom use,36 yet scant research has examined the connection between condom use self-efficacy and condom breakage. A study of heterosexual men recruited from US sexually transmitted infections (STI) clinics found that, for each unit decrease in condom use self-efficacy, the odds of experiencing condom breakage increased by 1.07.48 Additional research on condom use self-efficacy and condom breakage in MSM is needed to clarify the relationship. We located no studies to date that examined pathways from distal correlates, such as sexual stigma, to condom breakage.

Previous studies with MSM in Jamaica identified interpersonal-level (physical abuse) and structural-level (poverty) correlates of HIV infection,7,42 including associations between sexual stigma and HIV infection,9 yet pathways between sexual stigma and condom outcomes are underexplored with MSM in Jamaica. The criminalization of consensual same sex practices may reduce access to condoms, lubricant, and relevant HIV-preventive information for MSM,7,26 underscoring the salience of understanding barriers and facilitators of condom use in contexts of criminalization. Although we located one study with MSM in South Africa that reported depression and condom use self-efficacy mediated the relationship between sexual stigma and condomless anal sex,14 scant studies have examined pathways to condom breakage or slippage among MSM. We located no studies that examined pathways from sexual stigma to condom breakage/slippage and inconsistent condom use in MSM in Jamaica. Social ecological perspectives explore the interplay between multiple life domains, including intrapersonal, interpersonal, and structural factors,49 that shape behavior, health outcomes, and well-being. We apply a social ecological approach to examine the interrelationships between intrapersonal-level (depression and condom use self-efficacy), interpersonal-level (sexual abuse history), and structural-level (sexual stigma) factors that influence condom use and condom breakage and slippage among MSM in Jamaica.

METHODS

Study Design and Population

We conducted a cross-sectional structured survey with MSM in Kingston, Montego Bay, Ocho Rios, and surrounding areas. We collaborated with Jamaica AIDS Support for Life (JASL) a community-based AIDS Service Organization in Jamaica that identified the need for the research and initiated the relationship with the primary investigator (CHL). JASL remained an active collaborator throughout the process of study design, data collection, data analysis and interpretation, and manuscript preparation. From March–November 2015, 556 MSM enrolled in the study. Peer research assistants (PRAs) who identified as MSM were recruited, contributed to the survey design, and underwent a series of research trainings. After these, they conducted participant recruitment and implemented the surveys. The survey was pilot tested with PRAs to enhance clarity and relevance of items. PRAs were trained in conducting surveys and signed confidentiality agreements. The tablet-based PRA-administered survey took approximately 35–40 minutes to complete. Respondents received an of $1000 Jamaica dollars (approximately $8 USD) honorarium for completing the survey.

We used chain-referral sampling, a technique to access marginalized populations including sexually and gender diverse persons.50 Chain-referral sampling relies on a series of participant referrals to others from the same population and differs from snowball sampling as it strategically seeks multiple networks to expand beyond one social network.51 This produces a sample, although nonrandom, more representative of the study group than snowball sampling.51 Respondent-driven sampling (RDS) is a refinement of the chain-referral methodology that uses several waves of recruitment in a chain-referral sample and collects data on participants' social network size to allow for adjustment for nonrandom recruitment and for proportional population estimates of characteristics and behaviors.50 A study that compared RDS with chain-referral sampling in recruiting people who inject drugs in Russia found no significant difference between these methods in recruiting higher risk population.50 Future research with MSM in Jamaica could use RDS, building on the chain-referral methods used in this study by collecting network size information to explore associations between social network size and outcomes.

Survey participants were issued a coupon with a unique participant identification (ID) number and were invited to refer a maximum of 5 other MSM in their social networks to participate in the study. Respondents in turn were given up to 5 coupons to recruit other MSM and received $500 Jamaican dollars (∼$4 USD) for each participant that they recruited (eg, when a coupon ID was presented that corresponded to a participant's unique ID number), up to a maximum of 5 persons. Research ethics approval was granted from the University of Toronto, Canada, and the University of the West Indies, Mona Campus, Jamaica. All PRAs signed confidentiality agreements.

Measures

Inconsistent Condom Use and Condom Breakage and Slippage

Inconsistent condom use in the last 4 weeks was measured by 2 items: (1) “How many times did you have receptive anal intercourse (bottom) or insertive anal intercourse (top) in last 1 month: never; 1–2 times; 3–4 times; 5–6 times; 7–8 times; 9+ times?” and (2) “When you had receptive/insertive anal intercourse in the last month, how many times did your partner/you use a condom: never; 1–2 times; 3–4 times; 5–6 times; 7–8 times; 9+ times?” Participants who answered “never” to the first question were excluded from the multivariate and SEM analysis. Participants were coded as “yes” if there was a disparity between these 2 questions, and participants were coded as “no” otherwise. Condom breakage and slippage was assessed with the item: “When you had receptive or insertive anal intercourse in the last month and you or your partner wore a condom, how many of these times did a condom slip, tear, break, or not work?” Participants' answers were coded as “yes” if any incident occurred and were coded as “no” if they reported “never.”

Sexual Stigma

Sexual stigma was the main predictor, assessed using a homophobia scale developed by Diaz et al,49 which addressed awareness of negative social norms, community acts of discrimination, violence, and mistreatment (continuous, range 13–52, Cronbach's α = 0.89). This scale includes 13 items [eg, “On a scale of 1 (never) to 4 (many times), how often have you heard that gay/bisexual men are not normal?”].

Mediators

Potential mediators included depression, sexual abuse history, and condom use self-efficacy. Depressive symptoms in the last 2 weeks were measured continuously using the Patient Health Questionnaire-2 (PHQ-2) (range: 2–8) and found in previous studies to have a sensitivity of 83% and a specificity of 92% for screening for major depression.52 Sexual abuse history was measured with the item: “In your life have you ever experienced sexual abuse?” (yes = 1, no = 0). We assessed condom use self-efficacy using Kalichman et al's40 scale for negotiating safer sex (continuous, range: 5–20, Cronbach's alpha: 0.75). This scale includes 5 items (eg, “I am confident about suggesting using condoms with new sex partners”).

We also included several sociodemographic factors as covariates: age (continuous); monthly income in US dollars (continuous); city of residence (categories: Kingston, Montego Bay, Ochos Rios, and other); food insecurity (continuous, range 1–4); unstable housing in last month (no/yes; participants were coded as having unstable housing if they usually slept outside, in a shelter, or at a friend or relative's house vs. their own room or shared apartment); current unemployment (unemployed vs. employed or studying); and education level (less than high school vs. completed high school).

Statistical Analyses

We first conducted descriptive analyses of all variables for the entire sample (N = 556). Participants who reported having had insertive/receptive anal sex were included in the following analyses. Unadjusted and adjusted logistic regressions were used to estimate the odds ratio (OR) of inconsistent condom use (N = 422) and condom breakage/slippage (N = 410) among MSM with complete data. Structural equation modeling (N = 410) was then conducted using weighted least squares estimation methods to test the direct effects of sexual stigma on inconsistent condom use and condom breakage/slippage, and the indirect effects through depression, sexual abuse, and condom use self-efficacy, adjusting for sociodemographic factors. Model fit was assessed by using χ2, root mean square error of approximation (RMSEA) and the Comparative Fit Index (CFI). A significance level of >0.04 for χ2, a score of <0.08 for RMSEA, and a score greater than 0.90 for CFI indicate an acceptable fit.53 Statistical significance was set at the P < 0.05 level. Missing responses were excluded from the analyses. All statistical analyses were performed using STATA (version 14.0) and Mplus (version 1.40).

RESULTS

Participant Characteristics

Tables 1 and 2 display sociodemographic characteristics for the entire sample (N = 556). The average age for the sample is approximately 26 years old (SD = 5.78, range 16–55), and the mean monthly income was US $197.09 (SD = 334.86, range 0 = 3850). Nearly one-third of the sample (32.83%, n = 175) reported having unstable housing. More than one-third (35.97%; n = 200) reported a lifetime history of sexual abuse. More than one-fifth (21.33%, 90/422) reported inconsistent condom use, and 37.80% (155/410) reported condom slippage or breakage.

TABLE 1.
TABLE 1.:
Demographics and Correlates of Condom Use Among MSM in Jamaica (n = 566)
TABLE 2.
TABLE 2.:
Demographics and Correlates of Condom Breakage and Slippage Among MSM in Jamaica (n = 556)

Bivariate analysis revealed no significant differences in sociodemographic characteristics between participants who consistently vs. inconsistently used condoms (Table 1). However, participants, who had lower education levels, who had more food insecurity, and who lived in Ocho Rios vs. Kingston, were more likely to report condom breakage/slippage (Table 2).

Multivariate Logistic Regression on Inconsistent Condom Use and Condom Breakage/Slippage

Table 3 illustrates the unadjusted and adjusted OR for inconsistent condom use and condom breakage and slippage. Results were adjusted for age, monthly income, education, relationship status, food insecurity, housing insecurity, and number of coital acts (for inconsistent condom use)/number of times condoms used (for condom breakage/slippage). Condom use self-efficacy [adjusted odds ratio (AOR): 0.78, 95% CI: 0.70 to 0.87, P < 0.001] was associated with lower odds, and sexual abuse history (AOR: 1.86, 95% CI: 1.02 to 3.40, P < 0.05) with higher odds, of inconsistent condom use. Higher sexual stigma (AOR: 1.02, 95% CI: 1.00 to 1.06, P < 0.05) and lower condom use self-efficacy (AOR: 0.88, 95% CI: 0.79 to 0.98, P < 0.01) were associated with increased odds of condom breakage and slippage.

TABLE 3.
TABLE 3.:
Multivariate Logistic Analysis on Correlates of Inconsistent Condom Use and Condom Breakage and Slippage Among MSM in Jamaica

Structural Equation Modeling

Structural equation modeling was conducted to examine the direct and indirect effects of sexual stigma on inconsistent condom use and condom breakage and slippage. The direct effect is the part of the exposure effect that is not mediated by other variables, whereas the indirect effect is the part of the exposure effect mediated by other factors. Table 4 displays the results of the final model. Figure 1 illustrates the model with standard coefficients and the significance levels of each pathway. The standardized coefficient indicates that, with an SD of increase of the independent variable, the dependent variable would increase by × SD, holding all other variables constant in the model.54 Standard errors are included in parentheses. In the final model, the direct paths from sexual stigma to inconsistent condom use and to condom breakage/slippage were no longer significant, indicating these paths were mediated by other variables. Specifically, sexual stigma had a significant indirect effect on inconsistent condom use (ß = 0.144, P < 0.05), suggesting that the combination effect of sexual abuse history (ß = 0.110, P < 0.05), condom use self-efficacy and sexual abuse history (ß = 0.032, P < 0.01), and condom use self-efficacy and depression (ß = 0.008, P < 0.05), partially mediated the relationship between sexual stigma and inconsistent condom use. Sexual abuse history accounted for 76.3%, the combination of condom use self-efficacy and sexual abuse history accounted for 22.2%, and the combination of condom use self-efficacy and depression accounted for 1%, of the indirect effect of sexual stigma on inconsistent condom use.

TABLE 4.
TABLE 4.:
Final Path Model of Inconsistent Condom Use and Condom Breakage and Slippage Among MSM in Jamaica (N = 410)
FIGURE 1.
FIGURE 1.:
Final path analysis results for sexual stigma on inconsistent condom use and condom breakage and slippage. Standard coefficients are reported with the standard errors in parentheses. Statistical significance is noted with the following notations: *P < 0.05, **P < 0.01, ***P < 0.001. Covariates include age, monthly income, education level, relationship status, food insecurity, and unstable housing.

There were no significant direct or indirect effects of sexual stigma on condom breakage and slippage. The combination effect of condom use self-efficacy and sexual abuse history (ß = 0.023, P < 0.05) fully mediated the relationship between sexual stigma and condom breakage and slippage, accounting 57.50% of the total effect. Sexual stigma had a significant indirect effect on condom use self-efficacy (ß = −0.169, P < 0.001), suggesting that a sexual abuse history (ß = −0.135, P < 0.001) and depressive symptoms (ß = −0.035, P < 0.01) partially mediated the relationship between sexual stigma and condom use self-efficacy. Sexual abuse history accounted for 79.8% of the total effect on condom use self-efficacy, and depressive symptoms accounted for 20.7% of the total effect. Final model fit indices suggested that the model fits the data well [χ2(2) = 9.150, P = 0.01; CFI = 0.969; RMSEA = 0.080; weighted root mean square residual (WRMR) = 0.555].

DISCUSSION

In this study of community recruited MSM in 3 Jamaican cities, we identified high levels of condom breakage and slippage and, to a lesser extent, inconsistent condom use. Our findings highlight the relationship between sexual stigma and condom outcomes and advance our understanding of mechanisms through which sexual stigma can lead to reduced odds of condom use and increased odds of condom breakage and slippage among MSM.

The association between stigma and sexual risk behavior in MSM is well established globally25,26,55,56 and in Jamaica.9,42 Our findings indicate that sexual stigma indirectly influenced condom outcomes and safer sex self-efficacy through intrapersonal-level (depression) and interpersonal-level (sexual abuse history) factors.57 The relationship between sexual stigma and inconsistent condom use was mediated by the combination effect of sexual abuse history, condom use self-efficacy, and depression. The relationship between sexual stigma and condom breakage and slippage was mediated by the combination effect of condom use self-efficacy and sexual abuse history.

We found that depression and sexual abuse history mediated the relationship between sexual stigma and condom use self-efficacy. These findings build on previous work with MSM in Cape Town14 that revealed sexual stigma was indirectly related to reduced condom use using factors such as depression and self-efficacy. Depression may compromise self-efficacy, or the belief that one can influence their own motives, behavior and social environment,58 because of maladaptive beliefs about the self and the future.59 The present findings also corroborate Klein's36 finding that childhood maltreatment, including sexual abuse, may be associated with compromised condom use self-efficacy in MSM. A systematic review of 75 US studies reported that MSM reported lifetime sexual assault rates between 11.8% and 54%, significantly higher than the national average for men.60 More than one-third (35.97%) of our sample of Jamaican MSM reported a sexual abuse history, and this was associated with reduced condom use and increased condom breakage and slippage. Although previous studies in the US demonstrated a connection between sexual abuse histories and increased condomless sex among MSM,61–63 this is the first study to our knowledge to connect a history of sexual abuse to condom breakage and slippage. Our findings highlight the necessity of assessing for a history of sexual abuse when conducting HIV preventive interventions with MSM.

Condom breakage and slippage was common in our study; 38% of MSM reported condom breakage or slippage during receptive/insertive anal intercourse in the past month, in line with rates of condom breakage ranging from 18% to 50% reported in global research on MSM45,46,64,65 and with Jamaican men, where 18.5% reported breakage in the 7 days before a screening (sexual orientation information not specified).66 Our study highlights a complex relationship between sexual stigma and condom breakage and slippage, a previously unexplored association. Our findings suggest that exploring only individual-level factors may overlook important social ecological correlates of condom breakage and slippage. We also found that the association between stigma and condom breakage and slippage relationship was mediated by a sexual abuse history and condom use self-efficacy, confirming previous research with US heterosexual men,48 which found that condom use self-efficacy was associated with decreased odds of condom breakage. A study of men at an STI clinic in Kingston, Jamaica, found that rates of condom breakage decreased significantly after an intervention that provided condom counseling.66 Yet, this study did not specify participants' sexual orientation; condom use interventions specifically tailored to MSM in Jamaica that focus on increasing condom use self-efficacy and decreasing sexual stigma are needed.

Our study has several actionable implications. Multilevel interventions may target individual, social, community, and population levels of vulnerability and provide strategies to challenge stigma with LGBT individuals in Jamaica.67 At the individual level, counseling focused on reducing internalized sexual stigma67 and trauma-informed, skills-focused, cognitive behavioral therapy that targets depressive symptoms, histories of abuse, and condom use self-efficacy can help MSM build the adaptive coping skills necessary to negotiate condom use with partners.68 At the social and sexual network level, community empowerment, such as peer-based, group interventions focusing on condom use skills, and the effects of sexual stigma on mental health, can connect MSM who may be socially isolated67 in a supportive, educational environment.66 Mobile outreach services that provide HIV prevention services, such as condoms, lubricant, and HIV and STI testing,67 may also increase accessibility for MSM, particularly in contexts of criminalization such as Jamaica. At the systemic level, LGBT sensitization trainings conducted by community organizations for health care professionals and policy makers are needed to combat structural stigma that prevents MSM from accessing appropriate health care services.57,67 Finally, higher order social and structural policies can provide a framework for reducing HIV risks by increasing access to the HIV prevention and care continuums with marginalized populations69,70; policy may have downstream impacts at the network, community, and individual levels.57

This study has limitations. Nonrandom sampling limits the generalizability of our findings to all MSM in Jamaica, and the cross-sectional design limits attributions of causality. Common to studies of condom use, these data were self-reported and may be influenced by recall bias or social desirability. In addition, we did not assess partner characteristics (history of HIV testing and monogamous partner) in our measure of inconsistent condom use. Future research on sexual risk should assess partner characteristics to more accurately determine level of risk. Although recruitment through a community-based organization may have biased our sample toward those more likely to be engaged in care, we successfully recruited more than 500 MSM using PRAs and their networks in the context of stigma and criminalization of MSM in Jamaica. In addition, PRAs recruited participants through their own networks, with the potential to include participants who do not regularly access care. Our use of chain-referral sampling, which uses network recruitment to expand coverage of the population, reduces volunteer bias and includes more isolated respondents.50 Future studies may use RDS to explore social network factors and HIV vulnerabilities and to increase the representativeness of the sample.

Despite these limitations, our study has a number of strengths. First, we build on the scarce literature on condom breakage and slippage as a condom outcome among MSM; our study is the first to our knowledge to confirm social ecological correlates of condom breakage and slippage. Second, we found that approximately one-third of MSM participants reported histories of sexual abuse, which has notable prevention implications and is underexplored with MSM in the Jamaican context. Third, we found that the relationship between stigma and condom use was mediated by social ecological factors—depression, condom use efficacy, and sexual abuse history; this underscores the need to consider how to conceptualize effective condom use interventions among MSM in contexts of high sexual stigma and criminalization. Tailored interventions at the individual, interpersonal, community, and structural levels are needed to reduce sexual stigma, address psychosocial vulnerabilities, and increase engagement in the HIV prevention cascade among MSM in Jamaica.

ACKNOWLEDGMENTS

The authors thank all the participants, peer research assistants, and collaborators: Jamaica AIDS Support for Life, JFLAG: Jamaica Forum for Lesbians, All-Sexuals and Gays, Caribbean Vulnerable Communities (CVC), Aphrodite's Pride.

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Keywords:

MSM; Jamaica; stigma; condom use; condom efficacy; condom breakage

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