Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland

Introduction: Same-sex practices and orientation are both stigmatized and criminalized in many countries across sub-Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same-sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio-economic and behavioural determinants.

Methods: Three hundred and twenty-three men who reported having had anal sex with a man in the past year were recruited using respondent-driven sampling and administered a structured survey instrument. Asymptotically unbiased estimates of prevalence of stigma and human rights abuses generated using the RDSII estimator are reported with bootstrapped confidence intervals (CIs). Weighted simple and multiple logistic regressions of fear of seeking healthcare and disclosure of same-sex practices to a healthcare provider with demographic, social and behavioural variables are reported.

Results: Stigma was common, including 61.7% (95% CI=54.0-69.0%) reporting fear of seeking healthcare, 44.1% (95% CI=36.2-51.3%) any enacted stigma and 73.9% (95% CI=67.7-80.1%) any perceived social stigma (family, friends). Ever disclosing sexual practices with other men to healthcare providers was low (25.6%, 95% CI=19.2-32.1%). In multiple logistic regression, fear of seeking healthcare was significantly associated with: having experienced legal discrimination as a result of sexual orientation or practice (aOR=1.9, 95% CI=1.1-3.4), having felt like you wanted to end your life (aOR=2.0, 95% CI=1.2-3.4), having been raped (aOR=11.0, 95% CI=1.4-84.4), finding it very difficult to insist on condom use when a male partner does not want to use a condom (aOR=2.1, 95% CI=1.0-4.1) and having a non-Swazi nationality at birth (aOR=0.18, 95% CI=0.05-0.68). In multiple logistic regression, disclosure of same-sex practices to a healthcare provider was significantly associated with: having completed secondary education or more (aOR=5.1, 95% CI=2.5-10.3), having used a condom with last casual male sexual partner (aOR=2.4, 95% CI=1.0-5.7) and having felt like you wanted to end your life (aOR=2.1, 95% CI=1.2-3.8).

Conclusions: MSM in Swaziland report high levels of stigma and discrimination. The observed associations can inform structural interventions to increase healthcare seeking and disclosure of sexual practices to healthcare workers, facilitating enhanced behavioural and biomedical HIV-prevention approaches among MSM in Swaziland.