An 'elephant in the room'? Stigma and hepatitis C transmission among HIV-positive 'serosorting' gay men

Recent research has highlighted concerns about sexually transmitted infection with hepatitis C virus (HCV) in populations of HIV-positive men who have sex with men. This paper presents results from a qualitative pilot study exploring the experience of stigma in HIV/HCV co-infected men. The preliminary findings suggest that HCV infection can be experienced as more stigmatising than HIV among gay and other men who have sex with men. This hierarchical stigmatisation complicates the disclosure of HCV infection, threatening the 'safety' of HIV serosorted unprotected sexual practice. Further research is required to explore the effect of stigma on HIV/HCV co-infected men, but these preliminary findings suggest that heath promotion initiatives are needed to counter hepatitis C stigma by raising awareness and facilitating greater empathetic ownership of hepatitis C as a gay community issue.     

‘It's like the treasure’: beliefs associated with semen among young HIV‐positive and HIV‐negative gay men

This paper examines cultural and social meanings associated with semen, along with related issues of unprotected receptive anal intercourse, HIV seroconversion, treatment optimism and viraemia. The findings are derived from qualitative interviews conducted with 12 HIV‐positive young gay men and 12 HIV‐negative counterparts who participated in a prospective cohort study in Vancouver, Canada. Focussing on the narratives of young gay men, the analysis reveals a diverse range of knowledge, values and functions of semen, especially in relation to its exchange. Beliefs about semen appeared to differ by HIV serostatus and were linked with intimacy, identity and pleasure, particularly among the HIV‐positive men. Against dominant representations of semen in relation to issues of loss, anxiety and infertility, this unique study sheds much needed light on its role within the cultural construction of sexuality among gay men. As such, these narratives are of direct importance to primary and secondary HIV prevention, including condom promotion and the development of rectal microbicides.     

Race,social support,and coping strategies among HIV‐positive gay and bisexual men

Few studies have examined the relation between race, social support, and coping, particularly among HIV‐infected individuals. We examined the relation of race and social support to coping with HIV infection in a sample of 121 gay and bisexual men (64 African American, 57 White). Compared to White participants, African Americans reported higher use of multiple coping strategies. High levels of perceived social support were related to greater use of positive coping and seeking support; lower levels of social support were related to greater use of self‐destructive coping. There were no race‐related differences in social support, and no race by social support interactions. Possible explanations for observed cultural differences and coping challenges of African American gay and bisexual men with HIV are discussed.     

Between ‘0’ and ‘1’: safer sex and condom use among young gay men in Hong Kong

Young men who have sex with men are becoming the most at-risk subgroup for HIV incidence in Hong Kong. To understand how young gay men in Hong Kong interpret and implement safer sex and condom use, focus-group discussions and individual in-depth interviews were held. The 74 participants were nearly all ethnic Chinese gay men aged between 18 and 25 years. Findings indicate that the challenge for health intervention lies in young gay men’s inconsistent condom use despite their high level of HIV-related knowledge. Participants described using condoms, testing for HIV and abstaining from anal sex as measures undertaken to prevent HIV infection. However, sociocultural norms and expectations pertaining to ‘0’ (docile, bottom) and ‘1’ (assertive, top) roles and trust between partners complicate the consistent implementation of risk-reduction measures. Influenced by heteronormative and romantic beliefs, sexual behaviours such as condomless anal sex and internal ejaculation hold symbolic meanings – exclusivity, commitment, intimacy, possession – for young gay men in Hong Kong, which override health concerns. These findings support more empowerment-driven HIV programming for young gay men.     

‘I’m more aware of my HIV risk than anything else’: syndemics of syphilis and HIV among gay men in Winnipeg

Despite decreased rates of HIV infection in Winnipeg, syphilis incidence continues to rise. Communities of men who have sex with men shoulder much of this burden of illness. This qualitative study aimed to better understand the co-evolution of HIV and syphilis in Winnipeg through a series of interviews with gay men. Eighteen individuals were recruited through advertising in sexual health centres and through subsequent snowball sampling. Thematic interpretive analysis and inductive reasoning were used to find individual and shared group meanings. We found that HIV formed the contextual ground on which sexual decision-making was made, with three main themes emerging during interviews: 1) bacterial STI transience being contrasted against HIV permanence; 2) syphilis being ‘dirty’ versus HIV carrying significant stigma, though being spared the label of uncleanliness; and 3) the role of pleasure and intimacy in sexual health decision-making. Based on these findings, we recommend further exploration to develop more effective strategies around syphilis prevention, in particular with regards to the longer-term illness ramifications and its relationship to HIV transmission.     

‘Risk’ and sexual coercion among gay and bisexual men in Aotearoa/New Zealand–key informant accounts

Research over the past decade on rape and sexual coercion among gay and bisexual men has shown that significant numbers of men report some form of unwanted or coerced sexual experience. Most studies have investigated the prevalence and impact of sexual assault, with little exploration of the nature and meanings of sexual coercion. This paper contributes to understandings of the latter, analysing the notion of ‘risk’ as it appeared in the talk of 23 key informants interviewed. These informants offered expert perspectives on the issue of sexual coercion and unwanted sex among gay and bisexual men, based on their professional and community experience. Thematic analysis led us to identify two predominant patterns of talk around risk: a focus on sociocultural contexts as risky for sexual coercion and a focus on certain types of individuals as vulnerable and ‘at risk’ of sexual coercion. Accounts of individual risk fit with currently dominant prevention models, which work to strengthen individuals' abilities to avoid or resist coercion. The accounts that emphasised context fit with recent theorising which suggests broader interventions are also necessary to prevent sexual coercion, ones that challenge normative constructions of sexuality and sexual practice.     

‘Church hurt can be the worst hurt’: community stakeholder perceptions of the role of Black churches in HIV prevention among young Black gay and bisexual men

Black gay and bisexual men aged 15–29 are disproportionately represented among new cases of HIV in the USA. Researchers have argued that community-based prevention cannot succeed without the participation of faith-based organisations, particularly given the salience of religion and spirituality in the lives of young Black gay and bisexual men. Yet some Black churches may be hesitant to engage in HIV prevention efforts given their beliefs about same-sex behaviour. It is less clear, however, whether and how public health practitioners in the field of HIV prevention have approached church inclusion. We therefore explored how community stakeholders describe the involvement of Black churches with the HIV continuum of care. We draw on a qualitative dataset of 50 in-depth semi-structured interviews conducted in Detroit, USA. Participants offered multiple perspectives on the response of Black churches to the HIV epidemic, from overt stigma to gradual acceptance and action. Nevertheless, participants agreed that when stigma was present in the pews and the pulpit, young Black gay and bisexual men were at potential risk of social isolation. Furthermore, tensions may exist between Black churches and secular community-based organisations that are attributable to histories of mistrust. These findings have important implications for future community-based intervention strategies among young Black gay and bisexual men.     

‘Mobile men with money’: the socio‐cultural and politico‐economic context of ‘high‐risk’ behaviour among wealthy businessmen and government officials in urban China

China's transition from an injection drug‐driven HIV epidemic to one primarily transmitted through sexual contact has triggered concern over the potential for HIV to move into the non‐drug‐injecting population. Much discussion has focused on the migrant men of China's vast ‘floating population’ who are considered a high‐risk group. As a result, many men who frequently engage in high‐risk behaviour but are not included in this especially vulnerable group are evading HIV prevention messages. This paper highlights the socio‐cultural and politico‐economic factors that motivate many of China's wealthy businessmen and government officials, sometimes referred to as ‘mobile men with money’, to engage in such behaviour. Examination of the activities related to the work of these men reveals a situation where the confluence of a market‐oriented economy operating within a socialist‐style political system under the influence of traditional networking practices has engendered a unique mode of patron‐clientelism that brings them together over shared social rituals including feasting, drinking and female‐centered entertainment that is often coupled with sexual services. As a result, consideration of the socio‐cultural factors influencing these men's sexual practices is important for responding to the newly emerging stage of China's HIV epidemic.     

HIV prevention and men who have sex with women and men in México: Findings from a qualitative study with HIV‐positive men

Unprotected sex between men is the major risk factor for HIV infection in México and many other Latin American countries. There is a substantial body of literature demonstrating that the relationship between sexual identity and sexual practice is not binary or causal — men who have sex with other men do not necessarily perceive themselves as gay — and there is increasing interest in HIV prevention with men who have sex with both men and women. In México, HIV prevention with men who have sex with women and men and who are not socially affiliated or identified with gay men is lacking. This paper explores the sexual histories and HIV‐risk perception of HIV‐positive Mexican men who indicated that they have sex with women in a screening interview and then in the context of an in‐depth interview also reported having had sex with men. We consider the sexual practices and sexual and social identities of these men, examining their explanations for having sex with other men, the strategies used to affirm their masculinity, the management of their sexual identity in their social networks, HIV‐risk perception before diagnosis and sexual practices after diagnosis. Recommendations are made to improve HIV prevention for men who have sex with men as well as women and who do not assume a gay or bisexual identity.     

Heteronormativity and ‘troubled’ masculinities among men who have sex with men in Addis Ababa

In most societies, heterosexuality is the dominant way of expressing sexuality and masculinity and those men outside of it are stigmatised and discriminated against. This paper explores the sexual lives of men who have sex with men and the personal and social conflicts that arise as they attempt to both live up to societal expectations and manage their sexual desires. It critically explores how an overriding heteronormativity structures and influences men's perception and understanding of sexuality and masculinity/femininity. The paper draws on data from 24 in-depth/life history interviews, one focus group discussion and ethnographic observation conducted between July 2006 and June 2007. The study reveals that powerful and dominating beliefs about heteronormativity and masculinity result in men who have sex with men dealing with a number of issues of personal conflict and contradiction resulting in uncertainty, resentment, ambivalence, worry and discomfort. Heteronormativity or the expectations of parents, community and society at large is far more influential on the sexuality of men who have sex with men than their own individual desires and needs. The paper concludes that there is little room for individuality for Ethiopian men who have sex with men with their sexual bodies ‘belonging’ to parents, families and to society at large.     

Is HIV prevention creating new biosocialities among gay men? Treatment as prevention and pre‐exposure prophylaxis in Canada

The advancements of “treatment as prevention” (TasP), “undetectable viral load” (UVL) and “pre‐exposure prophylaxis” (PrEP) are redefining HIV prevention standards. Relying on the concept of biosociality, this article explores how gay men rally around, debate, and sometimes disagree about these emerging HIV prevention technologies. This article is based on data from the Resonance Project, a Canadian community‐based research project. Twelve focus groups (totalling 86 gay and bisexual men) were held in three Canadian cities (Montreal, Toronto, Vancouver) in 2013–2014. Respondents view UVL and PrEP through the prism of their generational experience of HIV prevention. In this respect, biosocialities highlight an experiential dimension that is tied to the context of the HIV epidemic. The biosocialities of HIV prevention are also built around serological identities. However, our study shows the diversity of these positions. Analysis grounded in biosocialities is useful for better understanding how scientific information circulates, is made sense of, and generates debate among gay men.     

When ‘raw sex’ turns to a ‘raw deal’ … taking the opportunity to think about sex? Interviews with HIV-positive gay men diagnosed with acute hepatitis C

Since 2001, cases of hepatitis C virus (HCV) sexual transmission have been reported in France, among HIV-positive gay men who do not inject drugs. An earlier study focused on the incidence of acute hepatitis C and risk factors associated with HCV transmission. The present study, based on in-depth interviews, aimed to highlight the biography, the sexual practices and the experiences of gay men infected with HCV. Beyond an apparent uniformity, the group of interviewees illustrates a variety of situations, life stories and health pathways, depending on their age. These well-adjusted gay men were used to engaging in unprotected sexual practices, but before their diagnosis they largely ignored HCV-transmission risk, which was associated in their mind with a pejorative drug addict image. Once diagnosed with acute hepatitis C, they experienced a critical and emotional period during which they were open to discuss their sexual practices and reconsider risk-reduction procedures, without being willing to give up on their satisfying sex life. Health educators should consider labelling hepatitis C as an STI in order to disrupt its negative image and to help HIV-positive gay man raise their awareness of HCV-transmission risks and implement better risk-reduction strategies.     

‘HIV and work don't go together’: Employment as a social determinant of HIV outcomes among men who have sex with men and transgender women in the Dominican Republic

Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV in the Dominican Republic. Little is known about their experiences living with HIV as a chronic condition. We explored employment as a social determinant of well-being with HIV. We conducted 42 qualitative in-depth interviews with MSM (n?=?16) and transgender women (n?=?5) living with HIV; each participant completed 2 interviews to facilitate depth and iterative analysis. We used narrative analysis and systematic coding to identify salient themes related to employment and the HIV experience and developed a conceptual model of the pathways between HIV stigma, unemployment, and HIV outcomes. Early life experiences, including rejection from families and school, resulted in limited work opportunities, especially among transgender women. Following HIV diagnosis, participants across all socio-economic levels lost jobs and/or were unable to get jobs due to illegal HIV testing and HIV stigma and discrimination. Not being able to work impacted mental health, engagement in HIV care, and overall well-being. We conclude that lack of employment is a salient concern among MSM and transgender women living with HIV. Holistic, multi-level programmes that address illegal HIV testing and discriminatory hiring practices are urgently needed to facilitate engagement in care and long-term well-being.     

HIV generations? Generational discourse in interviews with Australian general practitioners and their HIV positive gay male patients

The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of ‘HIV generations’ was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms – ‘a different time’ and ‘difference today’ – suggesting that concepts of time and inequity are deeply embedded in these men’s understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and ‘lay’ understandings of changes and patterns in the HIV epidemic.     

Understanding why gay men seek HIV‐seroconcordant partners: Intimacy and risk reduction motivations

Our goal was to situate the interest of some gay men in having HIV‐seroconcordant partners within the psychosocial context of concurrent motivations for intimacy and sexual risk reduction. Data were obtained from semi‐structured qualitative interviews with a racially/ethnically diverse sample of 32 gay men (16 HIV‐positive and 16 HIV‐negative) living in New York City who sought HIV‐seroconcordant partners. Thematic analysis indicated that seroconcordant partner selection was strongly motivated by a desire to reduce sexual risk as well as the pursuit of multiple forms of intimacy. Affirmative experiences in seroconcordant relationships and goals for future long‐term relationships also informed men's current partner selection practices. When seeking seroconcordant partners, men reported key junctures and disjunctures between motivations for intimacy and interests in risk reduction. Our findings suggest that HIV prevention efforts will have greater relevance if they address broader motivational concerns for partner selection and serosorting, including the pursuit of intimacy.     

‘It's raining stones’: stigma,violence and HIV vulnerability among men who have sex with men in Dakar,Senegal

Research in many countries has highlighted the vulnerability of men who have sex with men to HIV and other sexually transmitted infections (STIs). Yet in Africa, such men have received little attention in HIV/AIDS programming and service delivery because of the widespread denial and stigmatization of male homosexual behaviour. In Dakar, Senegal, a study conducted by researchers from Cheikh Anta Diop University, the Senegal National Council Against AIDS, and the Horizons Program elicited quantitative and qualitative data about the needs, behaviours, knowledge, and attitudes of men who have sex with men. Findings reveal that respondents have distinct identities and social roles that go beyond sexual practices, that sex with men is driven by many reasons, including love, pleasure, and economic exchange, and that respondents' lives are often characterized by stigma, violence and rejection. The data also highlight that many men are at risk of HIV because of unprotected sex with other men, a history of STI symptoms, and poor knowledge of STIs. The study underscores the need for non‐stigmatizing, sexual health information and services.     

‘I am like a woman’: constructions of sexuality among gay men in a low-income South African community

South African research on same-sex sexuality is sparse. Black men living in rural areas, and particularly coloured men, have often been neglected in same-sex sexuality research. This paper describes the findings from a study that explored the sexuality constructions of a group of young, coloured, self-identified gay men who live in a semi-rural, low-income, South African community. Social constructionist grounded theory was used to analyse interviews conducted with 12 men between the ages of 20 and 31. It was found that these men construct their sexuality as being ‘like a woman’. In our exploration of this core category, we show how men use notions of femininity to construct their sexuality. We conclude by considering how this group of gay men's performance of femininity could be viewed as reproducing mainstream ideas of gender within their community, while at the same time functioning as acts of subversion.     

After the fall from grace: negotiation of new identities among HIV‐positive women in Peru

Despite increasing rates of HIV infection among heterosexual women in Peru, married women remain virtually invisible as a group at risk of HIV or requiring treatment. This study analyzed the intersections of HIV with machismo and marianismo, the dominant discourses in Latin America that prescribe gender roles for men and women. Data sources include recent literature on machismo and marianismo and interviews conducted with 14 HIV‐positive women in Lima, Peru. Findings indicate how the stigma associated with HIV constructs a discourse that restricts the identities of HIV‐positive women to those of ‘fallen women’ whether or not they adhere to social codes that shape and inform their identities as faithful wives and devoted mothers. Lack of public discourse concerning HIV‐positive marianas silences women as wives and disenfranchises them as mothers, leaving them little room to negotiate identities that allow them to maintain their respected social positions. Efforts must be aimed at expanding the discourse of acceptable gender roles and behaviour for both men and women within the context of machismo and marianismo so that there can be better recognition of all persons at risk of, and living with, HIV infection.