HIV-related stigma among young men who have sex with men in HIV care in Plateau State Nigeria

Introduction

Stigma and discrimination are human rights and global public health problems which constitute serious impediments to optimal HIV treatment outcomes (1–10). Stigma is a damaging social phenomenon which demeans and devalues individuals or a group of people portraying them as undesirable due to attributes or characteristics that are societally adjudged unacceptable (1, 2, 7, 10–18). HIV-related stigma is often expressed as irrational behaviors, negative attitudes, and unfavorable judgments toward people living with or at risk of HIV which remains very common in low and middle income countries including Nigeria. This can negatively affect the health and wellbeing of people living with HIV (PLWH) by acting as an impediment to optimization of HIV prevention, treatment and support services (19–21). This most often become internalized and leads to undesirable affective, cognitive, and mental health outcomes (2). Internalized HIV-related stigma is the conditional acceptance of negative societal perceptions, characterizations, and labeling of PLWH which can be expressed with self-depreciating feelings such as shame, self-blame, low self-esteem, and self-worth (2, 3). Men who have sex with men (MSM) are disproportionately affected by HIV infection which continues to expand worldwide in both developed and developing countries (7, 21). This group is often stigmatized due to their peculiarities, positions, gender identity and sexual orientation which drives discrimination across sectors of society, including in health care, education, workplace as well as within families and in communities (3, 13, 18). Young men who have sex with men (YMSM) living with HIV face a life-long illness associated with numerous health and social challenges that evolve with time thereby impacting on different areas of their lives. They have to cope with the shock, fear, anger, guilt and shame of having HIV infection as well as the attendant stigmatizing responses associated with their sexual identity which impact on their mental health (22). Studies of HIV-related stigma among YLWHA is of relevance since youth are highly vulnerable to stigma and their numbers are on the rise in society. Youth's vulnerability to HIV-related stigma is exacerbated by social and economic marginalization, as well as the rapid physical and psychosocial transitions (8, 12, 15, 19). However, there is still relatively little empirical evidence on HIV-stigma among people living with HIV particularly for the YMSM in HIV care (20). It was against this backdrop that this study was conducted to assess the level of HIV related stigma and its associated factors among YMSM in HIV care in Plateau State, North central Nigeria as a way of generating geo-specific information and evidence for advocacy and policy change.

Methodology Study area

This study was conducted in Jos, Plateau state, North central Nigeria, which has a population of about 3.2 million people (23). There is a viable MSM networks in the state with functional internal systems and coordination structures including HIV support groups. Additionally, The Society for Family Health (SFH) currently operates One Stop Shop (OSS) for HIV services attending to the HIV care needs of the Key Affected Population in the state (KAP) while the APIN (AIDS Prevention Initiatives in Nigeria) Public Health Initiative is the lead implementing partner supporting PEPFAR funded HIV prevention and care programs in the state.

Study population

The study population comprised of all YMSM in HIV care in the state affiliated to the HIV support group or within the MSM network in the state who were between 18–24 years of age.

Study design

This was a cross-sectional study to assess the level of HIV-related stigma and its associated factors among YMSM in HIV care conducted between July 2023 and April 2024 using quantitative method of data collection.

Sample size estimation

The sample size for this study was determined using the sample size estimation formula for a cross-sectional study (24). Where n was the minimum sample size, Z is the standard normal deviate at 95% confidence interval (1.96), q is the complementary probability (1 – p), d is the precision of the study set at 0.05 and p is the prevalence of severe HIV-related stigma among PLHIV from a previous study (6.7%) (6). This gave a minimum sample size of 96.

Criteria for inclusion in the study

All YMSM in HIV care affiliated to the HIV support group or within the MSM network in the state who were 18–24 years were eligible to participate in the study while those who declined to consent for participation in the study were excluded.

Sampling technique

Respondent Driven Sampling (RDS) technique was used in this study to recruit consenting eligible YMSM members of MSM community into the study (18, 23, 25). The Respondent-driven sampling (RDS) is a modified form of snowball sampling which offers several advantages for hard to reach groups. A total of 122 YMSM aged 18–24 years currently in HIV care were identified and recruited for the study following informed consent for participation in the study. The facility appointment diary and the HIV case management registers were used to identify the eligible participants in the one- stop shop (OSS) clinic for the key population while the testing peer navigators, some respected YMSM and the key population MSM coordinator facilitated the recruitment of the YMSM accessing HIV care for the state. The recruitment process ended following a 4-week period of saturation when no eligible participants was found.

Data collection

An interviewer's administration approach to data collection was employed using the Berger's HIV-stigma scale for assessment of HIV related stigma and an adapted tool for demographics as well as social and sexual behaviors of the participants (26, 27). Berger's HIV stigma scale (BHSS) was used for the assessment of perceived HIV stigma among the YMSM in HIV care. Eight trained research assistants who were members of the MSM network carried out the data collection after the completion of the recruitment of the participants into the study. The questionnaires were pretested among MSM in a neighboring state. Prior to the administration of the questionnaire, written informed consent was obtained and documented from all the respondents with the assurance of confidentiality and anonymity of their responses provided.

Grading of response

The HIV stigma scale consisted of 40 items in four different subscales using a 4-point rating scale of strongly disagree = 1, disagree = 2, agree = 3 and strongly agree = 4 giving a maximum attainable overall score of 160 and minimum attainable score of 40. This scale was further subdivided into four subscales namely; Personalized Stigma subscale (PS) having a total of 18 items with a maximum attainable score of 72 using a 4-point rating scale of strongly disagree = 1, disagree = 2, agree = 3 and strongly agree = 4. The Disclosure Concerns (DC) having 10 items with a maximum attainable score of 40 using a 4-point rating scale of strongly disagree = 1, disagree = 2, agree = 3 and strongly agree = 4. Negative Self-Image (NSI) subscale with a total of 13 items and a maximum attainable score of 52 using a 4 point rating scale also and the Public Attitudes (PA) subscale having 20 items with a maximum attainable score of 80. Furthermore, all 40-items on the scale were cumulatively computed to give the Total HIV Stigma Score (TSS). The scores emanating from the elicited responses are scaled in the positive direction indicating that the higher the scores, the higher the level of HIV-related stigma (6, 8, 10, 28). The Total HIV related stigma score was further categorized into low-level stigma, middle-level stigma and High-level stigma using the percentile graph. Scores between 25th percentile and 50th percentile (40–80) was adjudged to be low-level stigma while scores between 50th percentile and 75th percentile (81–120) as middle-level stigma and those >75th percentile (121–160) categorized as high-level stigma (6, 10, 28).

The explanatory variables in this study were classified as demographic characteristics and sexual behaviors of the respondents. The socio-demographic characteristics included age as at last birthday, religion, highest level of education, sexual orientation categorized as bisexual and homosexual, family type assessed as monogamous and polygamous, family history of same sex orientation assessed as present if the respondents had seen or known any family member engaging in sex with another man, engagement in a paid job assessed as engaged and not engaged, disclosure of HIV status as yes or no, duration on HIV treatment in years and disclosure of sexual orientation as yes or no. The sexual behaviors assessment included type of MSM categorized as penetrative, receptive or both, engagement in anal sex within the last 7days as yes or no, use of condoms in the last anal sex assessed as yes or no. Furthermore, number of male sexual partners within the last 3 months was categorized as 1, 2–5, and 6 or more, self-reported lifetime history of STIs as positive or negative and self-reported engagement in transactional sexual practice within the last 6 months prior to the study which wase assessed as engaged or not engaged. Transactional sex was defined as non-marital, non-commercial sexual relationships motivated by an implicit assumption that sex will be exchanged for material support or other benefits e.g. money (29). The primary outcome variable was total HIV-related stigma score while the secondary outcome variables were the HIV-related stigma subscales scores.

Data analysis

All filled questionnaires were reviewed for completeness and thereafter serialized. Data analysis was carried out using SPSSS statistical software version 23. Descriptive statistical analysis was carried out on quantitative variables such age of the respondent, age at same sex sexual debut, total HIV-related stigma scores and the scores of stigma subscales. These quantitative variables were expressed with mean and standard deviation as their summary indices after fulfilling the assumptions of normality while duration on HIV treatment was found to be skewed and median and interquartile range were employed as its summary indices. Other explanatory variables such as age group, marital status, sexual orientation, family history of same sex orientation, and grading of the HIV stigma etc were presented in frequency table expressed in frequencies and percentages. Correlation between the Total HIV-related stigma scores and the scores of the subscales was established using Pearson's correlation. The correlation coefficient (r) for PS subscale was 0.91, DC subscale was 0.75, NSI subscale 0.90 and PA subscale 0.98. The variation in mean total HIV-related stigma score was tested using unpaired students T-test for explanatory variables expressed in two categories while one way analysis of variance was used for those expressed in three or more categories. Mean difference and 95% confidence interval were used as point and interval estimates of the difference in mean scores in the student T-test with a probability value of < 0.05 was considered statistically significant.

Results

The mean age of the study participants was 22.2 ± 2.0 years with 56 (45.6%) being 22 years and below. Fifty-two (42.6%) of the respondents identified as bisexual and 66 (54.1%) debuted sex with a male partner below 16 years of age. Fifty-one (41.8%) of the study participants had completed tertiary education while 73 (59.3%) of them had disclosed their HIV status to at least one person in the past (Table 1).

Table 1. Sociodemographic characteristics of the participants.

With regards to the sexual behaviors of the participants, 31 (25.4%) were penetrative MSM, 18 (14.8%) receptive and 73 (59.8%) both receptive and penetrative in their anal sex sexual preferences. Engagement in transactional sex was self-reported by 41 (33.6%) with 71 (58.2%) reported engagement in anal sex within the last 7 days of the assessment and 33 (46.5%) of those who had engaged in anal sex did not use condoms (Table 2).

Table 2. Sexual behaviors of the participants.

In the assessment of the HIV related stigma, the total HIV-related stigma score for the participants was 121.9 ± 18.8 with 40 (32.8%) being classified as high-level stigma and 75 (61.5%) with middle-level stigma. The mean personalized stigma subscale score of 48.3 ± 11.7 was reported among the participants while average score for stigma associated with disclosure subscale was found to be 30.9 ± 4.2. Mean scores for negative self-image and public attitude stigma subscales were 35.8 ± 6.6 and 57.2 ± 10.4 respectively (Table 3).

Table 3. HIV related stigma assessment scores of the participants.

The variation in the mean overall HIV-related stigma scores across the demographic characteristics and the sexual behaviors of the respondents is shown in Table 4. In this study, age, sexual orientation, age at same sex debut, level of education, employment status, disclosure of sexual orientation and engagement in transactional sex among others did not show any statistically significant variation in the mean total HIV-related sigma scores. However, significant variation in mean total HIV-related stigma score was found with duration on HIV treatment as those who had been on treatment for 3 years and more having a mean score of 117.8 ± 15.2 compared to 110.3 ± 20.1 among those who had been on treatment for 2 years of less (mean difference: −7.50; 95% Confidence interval: −14.45, −5.51; p = 0.035; Table 4). Furthermore, no statistically significant variation was found in the assessment of the mean scores of the personalized stigma and public attitudes subscales across the demographic characteristics and sexual behaviors of the respondents. However, duration on HIV treatment showed statistically significant difference on the disclosure concern subscale with those who had been on treatment for 3 years and more having a mean score of 32.4 ± 3.5 compared to 30.2 ± 4.3 of those who had been on treatment for 2 years of less (mean difference: −2.22; 95% Confidence interval: −3.74, −0.70; p = 0.004). Similarly, respondents who had been on treatment for 3 years and more had a higher mean score of 37.5 ± 4.9 compared to 34.9 ± 7.2 for those who had been on treatment for 2 years of less (mean difference: −2.64; 95% Confidence interval: −5.08, −0.19; p = 0.035) on the negative self-image subscale (Tables 5–8).

Table 4. Variation in mean Total HIV stigma score by characteristics of the participants.

Table 5. Variation in mean personalized stigma subscale score by characteristics of the participants.

Table 6. Variation in mean disclosure concern subscale score by characteristics of the participants.

Table 7. Variation in mean negative self-image subscale score by characteristics of the participants.

Table 8. Variation in mean Public attitude subscale score by characteristics of the participants.

Discussion

HIV-related stigma poses to be an imminent clog in the cascade of HIV treatment and continuum of care thereby potentiating poor adherence, disclosure refusal, self-blame, depression, isolation and treatment failure (6, 30–32). In this study, high level of HIV-related stigma was reported among the YMSM in HIV care as demonstrated by high total HIV stigma scores and also across all the subscales of personalized stigma, disclosure, negative self-image and public attitude. The high total HIV-related stigma scores found in this study are consistent with findings of other studies conducted in India, China and United States of America (7, 18, 20, 33, 34). However, other studies conducted in United States of America reported slightly lower levels of HIV-related stigma in comparison to this study (1, 19). The similarities observed with the findings of this study and others cited ones could be attributable to the use of similar stigma assessment tools, study design and MSM in HIV care as the study participants. However, adults in HIV care who were not members of the MSM community were assessed for HIV related stigma in some of the other referenced studies. It is important to state that the MSM population and particularly YMSM are a vulnerable group perceived to be exhibiting behaviors and sexual identities that contradict social norms, cultures and traditions in most climes (18). This in itself has been the foremost driver of HIV-related stigma among the MSM population and significant contributor to the relegation of this group to the closet. The combination stigmatization and repressive legislations pose serious challenges to HIV care and if not addressed, it will continue to negatively impact the desired HIV/AIDS treatment outcomes and possibly contribute to reversing the gains already achieved in the HIV treatment landscape.

Total HIV-related stigma score was found to increase with duration in HIV care in this study, however, other studies reported abandonment by spouse, isolation by family, exclusion from social activities, bisexual identity, bartering sex, injection drug use, disclosure and depression as factors driving HIV-related stigma (6, 18, 20). It is therefore imperative that development or deployment of innovative and context specify strategies for stigma reduction in HIV care is essential but more importantly such strategies should target the peculiarities of the YMSM in HIV care. The cross-sectional design of this study will not support the establishment of temporal relationship particularly between duration in HIV care and the total HIV-related stigma score which was found to be statistically significant. Additionally, the tool used for the assessment of HIV related stigma focused on perceived stigma making it important that further studies be conducted to examine the lived experience of stigma in this population and its potential environmental drivers as nexus for generating empirical evidence in providing the needed psychological, psychosocial and social support necessary to mitigate the impact of stigma on the YMSM living with HIV.

Conclusion

This study found a high level of HIV- related stigma among the Young Men who Have Sex with Men in HIV care which is significantly influenced by the duration of time in HIV care. The study also found high levels of sub-scales of stigma such as Personalized Stigma, Disclosure Concerns, Negative Self-Image and Public Attitudes.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

This study involving humans was approved by Jos University Teaching Hospital Human Research Ethics Committee. This study was conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

TA: Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. BC: Formal analysis, Writing – original draft, Writing – review & editing. AZ: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. PK: Conceptualization, Supervision, Writing – original draft, Writing – review & editing.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Research reported in this publication was supported by the Fogarty International Center and National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW010543. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

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