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.
