Links between stigma, suicidal thoughts and less HIV testing in Nigerian men who have sex with men

Contemplating suicide – an indication of poor mental health and a risk factor for committing suicide – is much more common in Nigerian men who have sex with men (MSM) than in the general population and is associated with significantly lower odds of getting tested for HIV. Furthermore, MSM who experience high levels of sexual stigma are more likely to acquire HIV or an STI.

This is according to research recently published by Dr Cristina Rodriguez-Hart of the University of Maryland from a cohort study of Nigerian MSM, exploring the links between sexual stigma, psychological wellbeing and HIV outcomes.

TRUST/RV368 is a prospective cohort study that utilises respondent driven sampling to recruit MSM into HIV prevention, treatment, and care services in Abuja and Lagos, Nigeria. A total of 1480 MSM were enrolled between March 2013 and February 2016. Participants completed questionnaires about their experiences of stigma, sexual behaviour and psychosocial wellbeing.

A mixed methods component of the study focused on the impact of stigma on HIV testing. Quantitative data was used to assess suicidal ideation as a mechanism linking sexual stigma to HIV testing in both Lagos and Abuja. The purpose of the qualitative phase was to gain a better understanding of how sexual stigma impacted health and access to HIV services.

Quantitative data was collected for all 1480 participants. Stigma in relation to having sex with men was measured by considering answers relating to factors such as discriminatory remarks by family members, 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. Participants were then assigned to one of three groups based on their stigma experiences: low, medium or high stigma. The participants were also asked whether they had contemplated suicide (suicidal ideation) and had ever been tested for HIV.

For the qualitative portion, 25 MSM from the Abuja site were interviewed using a semi-structured interview guide. Researchers oversampled participants who were either in the high or medium stigma classes to ensure that they could speak about stigma experiences. The interviews focused on five main topics: treatment of MSM by society, disclosure of same-sex practices, MSM social networks, mental health, HIV testing, and engagement with HIV care for those living with HIV.

The full study sample consisted of participants who were primarily under 25 years of age (60%) and had completed high school or less education (70%). While 82% identified their gender as male, 12% identified as female and 6% identified as both or non-conforming.  

Quantitative findings

All participants reported experiencing some form of stigma (low, 43%; medium, 45% and high, 12%). A large percentage (29%) had experienced suicidal ideation; this is in stark contrast to the prevalence of suicidal ideation in the general Nigerian population at around 3%. Of all participants, 69% had been tested for HIV.

Previously published data from the TRUST/RV368 study considered the impact of stigma on new HIV and STI infections during the trial. It revealed that increasing sexual stigma was associated with an increase in new HIV and/or STI infections in a dose-response association. Of those experiencing low stigma, 10.6% acquired HIV/STI; of those with medium stigma, 14.2% did so; and of those experiencing high stigma 19.0% did so (p = .008).

Suicidal ideation played an important role, partly mediating the relationship between stigma and incident HIV/STI infection. The authors presented the following explanatory pathway: factors such as disclosing sexuality to family led to increased experiences of stigma, which contributes to increases in suicidal ideation and engaging in riskier behaviours such as condomless sex. Overall, this contributes to higher HIV infection rates among the men who experience more stigma. 

In terms of the effects of stigma on HIV testing, the results of the quantitative analysis revealed that the direct effect of stigma class on HIV testing was not statistically significant. However, there was a strong positive association between stigma class and suicidal ideation (17%, 31%, 50% suicidal ideation in low, medium and high stigma classes respectively). Suicidal ideation was associated with a 21% lower odds of having been tested for HIV, irrespective of the stigma class (aOR .79, CI .74-.86).

Elevated stigma in conjunction with suicidal ideation had a combined effect on the reporting of HIV testing. Being in the high stigma class and reporting suicidal ideation appeared to be associated with less HIV testing as compared to being in the low stigma class and reporting suicidal ideation, although this did not reach statistical significance (aOR .65,CI .20-2.11). Being in the medium stigma class and reporting suicidal ideation was associated with a 54% lower odds of HIV testing as compared to being in the low stigma class and reporting suicidal ideation (aOR .46, CI .39-.55).

Thus, for both new HIV infections and HIV testing, suicidal ideation emerged as a pathway via which stigma contributed to either HIV infection or lower levels of testing.

Qualitative findings

The qualitative subsample differed in that they were more likely to be in the medium or high stigma classes, to have experienced suicidal ideation (46%), to have had an HIV test (75%), and were older on average than the quantitative sample.

Qualitative findings revealed that stigma resulted in isolation, emotional distress, avoidant behavior, enduring feelings of trauma and suicidal ideation. In 2014, Nigeria passed a further law criminalising same-sex practices. MSM expressed having no social support and nowhere to turn to for help.

“Anytime I’m alone, I have the trauma in my head, every minute, it comes on and scares me out… I don’t really go out. I hardly go out, even till now, I find it really difficult for me to go places.” (MSM)

“I feel like dying that time because I don’t have money to do anything. I cannot go to my village and tell them, see what happened so that they will help me with another money. You understand, because if you go to the village, ah, see, see, see, they will hear, you understand, so I feel like, in fact, I don’t know, I feel like hanging myself then.” (MSM, after a homophobic attack)

Participants were fearful of getting tested for HIV and disclosing same-sex practices in public health facilities. Many men felt safe seeking HIV/STI testing and treatment services at the MSM-friendly clinic set up as part of the study. They were often referred by fellow MSM who had advised that it was a safe space, highlighting the importance of peer networks.

“Whenever I’m sick, and I need to go to the hospital, I used to be scared. What if this doctor find out that I’m gay? So I wouldn’t go to the hospital. I would just stay at home and be fine.” (MSM)

“Is an MSM that told me that and gave me the courage. He counseled me very well, please go and know your status, and I tell him don’t worry I will go. The next day I went [to the MSM research clinic] and I do my test. He told me that am HIV positive.” (MSM)

Participants found that the research clinic became a site of psychosocial support, a space to meet other MSM and to get educated about HIV. Some participants expressed a desire for these psychosocial services to be expanded to provide more support for MSM in need.

“We have a lot of victims of suicide, we do. We have a lot of victims of depression, people who are depressed and they need to talk to either a psychologist or someone who can provide a psychosocial counseling for people. This would also help build self-esteem, but the issue of support group would also go a long way of helping this.” (MSM)

Conclusions

This prospective cohort study emphasises the ways in which sexual stigma might lead to increased vulnerability to HIV infection through pathways such as emotional distress and suicidal ideation. Suicidal ideation in this study was much higher than the average for Nigerian adults and was associated with significantly lower odds of getting tested for HIV.

MSM who experience high stigma may go on to experience psychological effects that lead to delays or avoidance of HIV testing and treatment. This draws attention to the need for improved mental health services. The study also emphasises the importance of peer-based support networks where men can gain information and support from trusted peers. The authors recommend providing HIV self-testing to Nigerian MSM who may avoid public health settings.