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Download by: [41.160.51.27] Date: 18 April 2017, At: 01:57
African Journal of AIDS Research
ISSN: 1608-5906 (Print) 1727-9445 (Online) Journal homepage: http://www.tandfonline.com/loi/raar20
HIV risk and prevention among men who have sex
with men in rural South Africa
Kabelo Maleke, Nosipho Makhakhe, Remco PH Peters, Geoffrey Jobson,
Glenn De Swardt, Joseph Daniels, Timothy Lane, James A McIntyre, John
Imrie & Helen Struthers
To cite this article: Kabelo Maleke, Nosipho Makhakhe, Remco PH Peters, Geoffrey Jobson,
Glenn De Swardt, Joseph Daniels, Timothy Lane, James A McIntyre, John Imrie & Helen Struthers
(2017) HIV risk and prevention among men who have sex with men in rural South Africa, African
Journal of AIDS Research, 16:1, 31-38, DOI: 10.2989/16085906.2017.1292925
To link to this article: http://dx.doi.org/10.2989/16085906.2017.1292925
Published online: 02 Apr 2017.
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African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Informa UK Limited (trading as Taylor & Francis Group)
African Journal of AIDS Research 2017, 16(1): 31–38 Copyright © NISC (Pty) Ltd
AJAR
ISSN 1608-5906 EISSN 1727-9445
http://dx.doi.org/10.2989/16085906.2017.1292925
Introduction
Men who have sex with men (MSM) in South Africa are a
population at high risk of HIV infection with HIV prevalence
among MSM in various observational studies ranging
between 10.4% and 34.5% (Baral et al., 2011; Lane et
al., 2011; Rispel, Metcalf, Cloete, Reddy, & Lombard,
2011; Sandfort, Nel, Rich, Reddy, & Yi, 2008; Tucker et
al., 2013). However, most research focusing on MSM has
been conducted in urban and peri-urban areas, with minimal
attention being paid to MSM living in rural South Africa
(Imrie, Hoddinott, Fuller, Oliver, & Newell, 2013). Given this
focus on urban and peri-urban MSM, an important need
exists for research focusing on rural MSM to understand
whether these men differ from their urban counterparts in
terms of their specific social, behavioural, and structural
risks for HIV infection.
Several large-scale quantitative studies conducted with
MSM in urban and peri-urban South Africa have identified
demographic, psychosocial, behavioural, and structural
factors associated with HIV risk behaviours and/or risk of
HIV infection. In terms of demographics, South African MSM
older than 25 have consistently been found to have higher
HIV infection rates than other MSM (Baral et al., 2011; Lane
et al., 2011; Sandfort, Knox, Collier, Lane, & Reddy, 2015).
Psychosocial factors contributing to HIV risk include: sexual
self-identity (Lane et al., 2011, 2014; Rispel et al., 2011;
Sandfort, Lane, Dolezal, & Reddy, 2015); experiences of
stigma and homophobia (Arnold, Struthers, McIntyre, &
Lane, 2013; Jobson, De Swardt, Rebe, Struthers, & McIntyre,
2013; Tucker et al., 2014); low self-efficacy for protective
behaviours (Tucker et al., 2014); beliefs about trust and
condom use in relationships (Knox, Yi, Reddy, Maimane, &
Sandfort, 2010); being in a relationship with a regular partner
HIV risk and prevention among men who have sex with men in rural
South Africa
Kabelo Maleke1, Nosipho Makhakhe1, Remco PH Peters1, Geoffrey Jobson1*, Glenn De Swardt1, Joseph Daniels5,
Timothy Lane7, James A McIntyre1,6, John Imrie1,3,4 and Helen Struthers1,2
1Anova Health Institute, Johannesburg, South Africa
2Division of infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
3Centre for Sexual Health and HIV Research, Faculty of Population Health Sciences, University College, London, UK
4Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, KwaZulu-Natal, South Africa
5Program in Global Health, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los
Angeles, USA
6School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
7Center for AIDS Prevention Studies, University of California San Francisco, USA
*Corresponding author, email: jobson@anovahealth.co.za
Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant
healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified
a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV
risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing
perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion
data, two overarching global themes that encapsulated participants’ understandings of HIV risk and the HIV
risk environment in their communities were developed. In the first theme, “community experience and the rural
social environment”, factors affecting HIV risk within the broad risk environment were discussed. These included
perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM;
and the role of social media as a means of meeting other MSM. The second global theme, “HIV/AIDS knowledge,
risk and experience”, focused on factors more immediately affecting HIV transmission risk. These included: high
levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and
lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships;
competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory
results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of
contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context
and the specific HIV risk knowledge and behaviours that affect HIV risk in this population.
Keywords: HIV/AIDS; men who have sex with men; Southern Africa; rural
Maleke, Makhakhe, Peters, Jobson, Swardt, Daniels, Lane, McIntyre, Imrie and Struthers
32
(Arnold et al., 2013; Knox et al., 2010); and experiencing
depression (Tucker et al., 2013). Behavioural risk factors
for HIV infection identified in previous research include:
transactional sex (Lane et al., 2011; Nel, Yi, Sandfort, & Rich,
2013); high numbers of sexual partners (Lane et al., 2011;
Tucker et al., 2014); and alcohol and drug use (Jobson et
al., 2013; Lane, Shade, McIntyre, & Morin, 2008; Parry et al.,
2008; Sandfort, Yi, Knox, & Reddy, 2013). Finally, structural
factors affecting HIV risk include poverty (Dunkle, Jewkes,
Murdock, Sikweyiya, & Morrell, 2013; Jobson et al., 2013;
Lane et al., 2011), unemployment (Baral et al., 2011), and
low levels of formal education (Sandfort et al., 2008).
It is likely that some or all of these factors also contribute
to HIV risk in rural MSM populations, but differences in the
social context of rural South Africa may make particular
factors more important than others. This means that HIV
prevention efforts developed in urban contexts may need to
be adapted based on the relative importance of particular
risk factors. Potentially important features of the rural context
that may affect HIV risk among MSM include: the relative
importance of traditional cultural beliefs and practices (Icard
et al., 2015); high rates of poverty and unemployment
(Neves & du Toit, 2013; Pronyk et al., 2008); high levels of
circular migration between urban and rural areas (Hunter,
2010; Neves & du Toit, 2013; Pronyk et al., 2008); and
lower levels of educational attainment (Lane et al., 2014).
Based on findings among urban and peri-urban MSM, the
relatively higher rates of rural unemployment, and lower
levels of formal education in rural South Africa may have
a disproportionate effect on HIV risk among MSM in these
areas. Circular migration between urban and rural areas may
have both positive and negative effects on HIV risk. While
exposure to MSM-focused HIV prevention interventions in
urban areas may lead rural MSM to adopt less risky sexual
practices, it is also possible that exposure to a wider pool of
sexual partners and a diversity of sexual practices in urban
areas could increase their risk of contracting HIV.
In this article, we discuss the findings of an exploratory
qualitative study conducted with a sample of 23 MSM living
in rural areas of Limpopo province, South Africa, focusing
broadly on describing the rural HIV risk environment (Barnett
& Whiteside, 2002) and identifying factors affecting HIV risk
among rural MSM.
Methodology
The Rural MSM HIV and Sexual Health Study was conducted
in the Mopani district of South Africa’s north-eastern
Limpopo province between April and August 2012. All
procedures and materials were approved by the University
of the Witwatersrand’s Human Research Ethics Committee
and the Limpopo Provincial Department of Health. MSM
from four of Mopani’s five municipal sub-districts — Giyani,
Phalaborwa, Tzaneen, and Letaba — participated in the
study. The area is ethnically heterogeneous, with multiple
languages spoken and a range of cultural traditions being
practised. The primary economic activities in the area are
commercial agriculture, tourism, and mining.
Participants were men aged 18 years and older, resident in
Mopani district, Limpopo, who either self-identified as gay or
reported having male sexual partners. During the preparatory
phase of the study, local healthcare providers introduced
the research team to three gay-identifying key informants.
These men formed the initial part of a snowball sample. All
participants provided signed informed consent for participation
in the study. In total 23 MSM participated in the study: 8
in community mapping sessions (CMSs); 12 in in-depth
interviews (IDIs); and 3 in both. The three key-informants who
assisted with recruitment participated in both activities.
IDIs followed a standard schedule but allowed for the
use of additional open-ended questions and probing.
Interviews were held in a private office at the Anova
Health Institute premises in Mopani district and lasted
approximately one hour. Interviews were conducted in the
language of the participants’ choice. All interviews were
audio recorded, transcribed verbatim, and translated where
necessary. Topics included focused broadly on factors
that have been found to influence HIV risk behaviour in
other South African research, and included: community
life; stigma, discrimination and violence against MSM; sex
and relationships, including intimate partner violence (IPV);
social media; and knowledge of HIV transmission risks.
Three community participatory mapping sessions were
held at the Anova Health Institute premises; the aim was to
engage participants in a process of critical examination of
their local community. Each session lasted approximately
three hours. Participants described and pictorially
represented their perception of their “community”, including
its important physical and social attributes and spaces, both
formal and informal. Specific locations mapped included
healthcare facilities, drinking venues, places for sex, and
places to access HIV prevention resources. Discussions
were conducted in the local language appropriate to the
group’s composition, digitally recorded, and transcribed and
translated for analysis.
Data analysis was based on transcripts of the interviews
and mapping sessions, and did not include an interpretation
of the maps themselves. An adapted thematic analysis
approach was used to analyse data (Attride-Stirling, 2001).
Initial themes were pre-selected based on existing literature,
and additional themes were considered as the analysis
process proceeded. Pre-selected themes included: sex,
condoms and lubricant, relationships, health care, and the
MSM community.
Initial coding was conducted independently by two
authors. During this stage transcripts were carefully read
to identify meaningful units of text, or basic themes, with
relevance to the research topic. Pre-selected themes from
the literature were treated as basic themes. Units of text that
related to the same issue were then grouped into organising
themes and given names describing their content. The same
unit of text could be included in more than one organising
theme. Organising themes were then discussed and further
refined, resulting in a total of nine themes. The nine themes
identified through this process included: perceptions of
rural communities; the MSM community; social media; the
rural healthcare system; condom and lubricant use; sexual
power dynamics; contexts of sexual intercourse; multiple
concurrent partnerships; and transactional sex.
Through continual checking and discussion between
the authors, and other members of the research team,
these organising themes were analysed to develop two
African Journal of AIDS Research 2017, 16(1): 31–38
33
overarching global themes. These global themes broadly
encapsulate the authors’ interpretations of two distinct
spheres of participants’ lives that affect HIV risk among
MSM in their community.
Results
Nearly all participants lived in a village or rural area,
however, most also travelled to larger cities (Pretoria and
Polokwane) to socialise. While most identified as “gay”,
only about half were “out” to friends, and in some instances,
family members. All but one reported ever having had sex
with a man. Two-thirds said they relied on the local public
health system for medical care (Table 1).
The two global themes developed through the analysis
process were labelled “community experience and the rural
social environment”; and “HIV knowledge, awareness and
risk”. These themes and the organising themes they are
comprised of are discussed in more detail below.
Global theme 1: Community experience and the rural
social environment
Perceptions of rural communities
Participants reported that their local communities were
intolerant of homosexuality. While only a few MSM had
experienced physical abuse, most had received dirty looks
and verbal abuse due to their sexual preferences whilst out
in public. The perception of the rural social environment
as homophobic was noted as an important barrier to being
more open about their sexuality by several participants,
with rural villages in particular being noted as places where
openly identifying as gay or MSM was difficult.
Many afternines1 do not want to come out of the
closet because of societal norms and prejudice
(Participant 2, CMS 1).
There are a lot of gay men in the villages who are
in the closet, but the minute you make your sexuality
public, then people start having issues with you…. but
in town it’s a different story as many of us can express
our sexuality publically (Participant 4, CMS 3).
The awareness of the relative acceptability of same-sex
sexuality in different places, and at different community events
led some participants to actively manage their appearance
and social behaviours as a means of avoiding conflict:
One of the challenges that I personally face every
day is what do I wear when I go where, like I have
to decide on how I am going to look for certain types
of people. If for instance I have to go for a family
gathering where my dad is around and there are old
people, then I wouldn’t be dressed up in beads and
everything. I would do the whole attitude thing about
just tone it down a bit, but when I go out with my
friends then I would go all out (Participant 1, CMS 1).
Participants’ experiences within their own families varied
significantly. Some men said their family members were
not accepting or understanding of their sexuality, going so
far as to indicate their expectation that their “gay son” bear
children. Others said their families accepted their sexuality
and supported them:
I’m happy because my family is supportive of me,
even if I get discriminated in the community, I’m glad
that my family supports me (Participant 4, CMS 2).
The MSM community
Participants expressed mixed sentiments about other MSM in
their local communities, and noted that gay-identifying MSM
were more comfortable with the idea of belonging to a local
gay community than bisexually-identifying and “afternine”
MSM. But gay-identifying men also acknowledged that their
“community” was frequently divided by conflict, specifically,
feelings of jealousy and inferiority, which made it more
difficult to create and engage in friendships with other MSM:
Sometimes it’s jealousy because you find that when
you get to a place then some gay guys look at you
and think you have come to take their men. So they
don’t want to socialise with you. They just isolate
themselves and ignore you (Participant 15, IDI).
There is a lot of jealousy in the community, over cars,
over looks, over money, they don’t like each other
because of these issues (Participant 3, CMS 2).
Factors driving the jealousy MSM described included
personal appearance, popularity, sexual attraction and social
status in relation to employment. This jealousy contributed to
tension and disunity within the gay community.
MSM who chose to conceal their sexuality were generally
described by participants as being on the margins of the gay
community. Participants felt that this group tended to socially
distance themselves from other gay men.
Table 1: Sample characteristics
Study participant demographics Number of MSM
Age range
18–25
26–35
14
9
Employed
Unemployed
Training/education
Other
10
6
5
2
Area of residence
Rural
Village
Town
6
16
1
Identification
Gay identified
Non-gay identified
20
3
‘Out’ about their sexuality
Not ‘out’
12
11
Ever had sex with a man
Yes
No
22
1
HIV testing
Ever tested
Never tested
18
5
Healthcare services
Private
Public
8
15
Had heard of MSM-targeted HIV prevention services
Yes
No
2
21
Maleke, Makhakhe, Peters, Jobson, Swardt, Daniels, Lane, McIntyre, Imrie and Struthers
34
Social media
Study participants noted that online social networks had
become an important feature of the rural MSM community,
in part due to the difficulty associated with being open about
their sexuality in their local communities:
Most gay guys in the community live secluded lives,
we all just do our own thing. I think its ‘cause we
don’t really know each other that well, I am only
seeing E for the first time today I’ve only just seen
him on Facebook (Participant 2, CMS 1).
MSM also reported using social media as a means of
meeting sexual partners. Most participants belonged to one
or more online social networks such as Facebook, Mxit,
Mig33, Smiggle and Mamba online:
I meet potential sex partners through an internet
dating service which is discreet, such as Zoosk. I
sometimes get people inviting me on Facebook who
initiate relationships. Other MSM use Mxit and 2go
(Participant 6, CMS 3).
We meet sexual partners on the social network,
or unless you hear from a friend that so and so is
also gay. We meet on Mxit, but on Mxit you have to
investigate if someone is actually gay. … There is
also one called Hook-Ups which is strictly for gay
guys. We don’t meet on Facebook because it’s too
public… (Participant 3, CMS 1).
While using social media to meet sexual partners was
common, it was highlighted as having significant risk. At
times, men would end up making arrangements to meet
partners whom they did not know, at places far away from
home. This put them in vulnerable situations if the person
they met became violent or insisted on unprotected sex:
A lot of guys meet partners on a social network
and most of the time people on those networks
are not honest and so my friend met up with a guy
in Pretoria and got stranded ... I always prefer for
someone to come and meet me … instead of me
going elsewhere (Participant 10, IDI).
In as much as social networks provide a platform and space
to meet other MSM in an otherwise socially constrained
environment, for these men they also appear to pose potential
risk and foster situations that lead to unprotected sex.
MSM and their experiences of the rural healthcare system
The homophobic social context also affected MSM’s access
to health care. For many participants, seeking health care in
the public system was thwarted by the fear of discrimination
on the part of healthcare workers. This discrimination was
most forcefully directed to gay identifying and feminine-
presenting MSM. Participants spoke of being discriminated
against for being gay and of clinic nurses making derogatory
comments towards them when they came into the clinic.
As a result, most of the men avoided public clinics where
possible, especially if they needed treatment for sexually
transmitted infections:
I use private and public clinics, at ‘N’ Clinic MSM are
not very comfortable … because the nurses believe
that this whole MSM thing doesn’t exist…If they
have an STI MSM prefer going to a private doctor
(Participant 12, CMS 3).
For accessing health-care services I go to a public
hospital in Kgapane. I wouldn’t be comfortable going
there for a sexually related illness, I would rather go
to a hospital in another town where nobody knows
me and I would be free and honest (Participant 13,
CMS 3).
Only two participants were aware that MSM-specific health
services were available anywhere in the country (Table
1), and seeing a private doctor was the preferred option for
treatment of any sexually related illness. However, private
care was too expensive and some would seek care in another
town or would leave a condition unattended due to fear of the
discrimination they would encounter at their local clinic:
I experienced something very bad at the hospital
for the last 3 weeks. Even now I didn’t get any help.
I had sex with a guy who didn’t use a condom or
lube … I think something happened to me. When I
went to the toilet I had this discharge … it was so
painful I couldn’t even go to the toilet. When I went
to the hospital to explain to the nurse that I came
for STI testing she wanted to know what happened.
I then told her that I had anal sex, she then asked
me why I did that, don’t I know that the anus is not
for sex. I will get rotten. She was so rude I ended
up leaving without getting any help because I felt so
embarrassed (Participant 2, CMS 2).
Participants also noted the belief that some healthcare
providers intentionally violated patient confidentiality in
casual conversations with community members. The lack of
trust and confidentiality was something they said affected all
community members, heterosexual and homosexual alike.
However, despite these reported difficulties in accessing
health services, most (18 of 23 participants) had tested for
HIV at least once in their lives (Table 1).
Global theme 2: HIV/AIDS knowledge, risk, and
experience
Overall, participants reported knowing about heterosexual
HIV transmission and prevention and the availability of
HIV testing and treatment. Participants shared a similar
range of experiences of HIV: having an HIV test; having
HIV-positive family members and friends currently receiving
or waiting to be eligible for antiretroviral treatment (ARV);
knowing people using different strategies to deal with HIV;
and knowing people who had died. However, the high levels
of HIV-related knowledge in this sample did not appear to
consistently translate into the adoption of less risky sexual
practices. One reason for this was that much of participants’
HIV-related knowledge was concerning heterosexual,
peno-vaginal intercourse. For example, knowledge of the
HIV transmission risks associated with anal intercourse was
inconsistent, and participants reported the perception that
HIV only affected heterosexual people:
We know about it, but have that mind-set that HIV
only infects “males and females”. We don’t think it
happens to us gay men. It’s because of the way in
which we have sex that we don’t think we contract
HIV in that way. I don’t know anything about anal
sex and HIV. I only know that HIV is transmitted
through blood and the lack of protection during sex
(Participant 10, IDI).
African Journal of AIDS Research 2017, 16(1): 31–38
35
Condom and lubricant use
Condom and lubricant use among participants was highly
varied. Free condoms are available in local clinics and some
clubs and taverns. But men preferred to buy their own,
because they disliked “the government condoms”. Most
participants know someone who does not use condoms
because they said “the government condoms” were either
uncomfortable or hurt during sex. Inconsistent condom use
was also perceived to be due to the lack of MSM-specific
HIV prevention information:
Mostly gay guys will not use protection. Only some
of us do. … it’s very rare to find partners here in
Phalaborwa. So there is the pressure of having sex
on the first encounter with a guy, and not thinking of
protection and stuff. Condoms for most gay guys are
not important. It’s about having sex at that moment
in time. I don’t think they find HIV scary (Participant
8, IDI).
A few participants said they used condoms all the time, and
had developed personal condom use strategies. These
included outright refusal to have sex without condoms, and
using condoms with casual partners, but not with those they
loved:
I would never have sex without a condom, because
I’m smart, I would rather not have sex at all than do
it without a condom. But other people don’t think so.
(Participant 4, CMS 2).
Most guys don’t use condoms with the guy they love,
so the more in love they are with a guy then they
don’t use condoms (Participant 2, CMS 1).
The use of condom compatible lubricants also varied
significantly among the men in the sample. Water-based
lubricants could be purchased at local supermarkets and
pharmacies and ranged in price from R48 to R180 (~$5 to
~$16), making them too expensive for many MSM. Men
who could not afford water-based lubricant reported using
Vaseline, body lotions and sometimes saliva as alternatives.
Some men were reluctant to purchase lubricant at the
pharmacy or supermarket because they were self-conscious
and felt that this could effectively “out” them as other people
associate lubricants with anal intercourse. A few participants
had not heard of water-based lubricants. Even among those
who knew about lubricants, a large proportion were unaware
that non-water-based lubricants could break down a latex
condom. Some men also had personal justifications, in
addition to the cost, for not using lubricant when engaging in
anal sex, for example:
Well I use condoms without lube. I have only used
lube twice, ‘cause if he uses lube then I feel like the
person is going to thrust a lot because it’s slippery.
Then the sex will be rough and I don’t like it rough
(Participant 3, CMS 2).
I don’t always have access to water-based lubricants
so I just use whatever is available at the time, and
vaseline is always available. I am not even sure
what water-based lubricant is (Participant 4, CMS 3).
Sexual power dynamics
The power dynamics within relationships between MSM
tended to be heteronormative, based on stereotypes of male
and female sexual relationships, and linked to individuals
preferred sexual roles. Men who preferred the insertive role
in anal intercourse were generally viewed as having more
power than those who preferred to be receptive:
I’m a bottom, and my fiancé is a top, we are not
equal. Sometimes he can make decisions for me
because he is the husband, he is the man. I am the
wife, I can do whatever I want, but he is still the one
above, he makes decisions and I follow (Participant
4, CMS 2).
The power to make decisions lies in the hands of
the one that that is the top the one that penetrates
during sex (Participant 1, CMS 1).
Another factor affecting the power dynamics within
relationships was that most participants stated that they
dated men who were not willing to disclose their sexuality
and for the most part were in simultaneous relationships
with, or married to, women. These relationships in particular
tended to be based on heteronormative stereotypes, and
participants suggested that these stereotypes were also
linked to intimate partner violence:
Violence occurs where one partner is the woman
and one partner is the man… These cases are
not very common though, it doesn’t happen a lot
(Participant 3, CMS 2).
The power dynamics within intimate relationships were
also reportedly affected by whether or not individuals were
employed, with the ability to provide for one’s partner being
seen as being directly linked to one’s power within the
relationship:
In my relationship, my boyfriend has the power
because he is the man of the house he calls me and
pays for everything my accounts, my contract phone
everything. I give him that chance to control me
because I want to get spoiled (Participant 9, CMS 3).
Contexts of sexual intercourse
The men in our sample noted that most sex partners were
found either at taverns and bars, or using online social
networking sites; most sexual encounters between men
occurred at private homes. Participants reported knowing of
people who had sex in the toilets at taverns, but this was
uncommon.
Men also described pressure to have sex on their first
encounter with a man because of the scarcity of sex partners
and the need to establish some kind of connection. This
meant that they often felt compelled to have sex whether
they had the appropriate prevention products or not, as
having sex took priority over one’s safety:
Sometimes you get a guy who is an “afternine”
… and then they want to have sex and they want
to have sex with you there and then, before you
change your mind, so you will get there and use
anything you find. Some use saliva [as lubricant]
(Participant 14, CMS 3).
Maleke, Makhakhe, Peters, Jobson, Swardt, Daniels, Lane, McIntyre, Imrie and Struthers
36
Multiple and concurrent sexual partnerships
Multiple concurrent sexual partnerships (MCP) were
reportedly common. Explanations for this included men
engaging in MCP out of “desperation for sex” because they
were prepared to have sex with anyone who proposed it. In
particular, men who were primarily receptive sometimes felt
compelled to have sex with their regular partners because
if they refused their partner could go and find someone
“desperate to have sex”.
Other participants who were involved in long-term,
long-distance relationships admitted to seeking casual
partners on the basis of what they believed their partners
were doing. Some men openly acknowledged that their MCP
also included engaging in exchange or transactional sex.
Transactional sex
Transactional sex was reported to be relatively common
among local MSM, and participants reported both paying
for and receiving money for sex. One participant claimed
he expected to be given money after a sexual encounter,
because he needed money for rent and credit cards:
Most of the guys I sleep with though usually give me
money after we have sex. I look and analyse you
before I go and have sex with you I see what you
can give me. If someone gives me R500 and says
I should take it and spend it I ask them what they
think I will do with R500. Sometimes the guy gets
furious and says I am selling, I tell them that well its
fine if I am selling to you because at the end of the
day you going home to your wife, so you must pay
me (Participant 6, CMS 2).
Other participants said some “afternines” specifically target
them when they have money to exchange for sex:
Sometimes if you have money then these straight
guys approach you and want you to pay them for
sex (Participant 1, CMS 1).
Alcohol was sometimes also used as a means to get sex, as
one participant stated:
Those that are employed have greater chances of
getting men because the men want to be bought
alcohol (Participant 5, CMS 2).
Transactional sex frequently happened without condoms,
often because the receptive partner, out of desperation to
keep their sexual partner, felt compelled to do as they were
told to keep their partner happy.
Discussion
The MSM who participated in this research, like other South
African MSM, live in a heteronormative and homophobic
social and cultural context (cf. Baral et al., 2009; Tucker et
al., 2014). At an individual level the MSM who participated
in this study described experiencing similar challenges and
constraints to their urban and peri-urban counterparts in
terms of their HIV risk behaviours and being able to be open
about their sexualities. The main differences between these
populations appeared to centre on differences between the
rural and urban/peri-urban social and cultural contexts.
Participants noted that, in contrast to the peri-urban
townships of Johannesburg and Cape Town, where gay
men were able to access social support from each other (cf.
Rudwick, 2011; Tucker et al., 2014) it was difficult to form a
local MSM community because most MSM were unwilling
or unable to be open about their sexualities. In addition to
making it difficult to meet other MSM and sexual partners
this led to high levels of jealousy and competition between
local MSM, which further hindered their ability to support
each other.
The limited opportunities to meet other MSM placed
pressure on MSM to have sex when opportunities arose,
regardless of whether they had condoms and lubricant
available. This also meant that MCPs were common. MCPs
have been noted as an important element facilitating the
rapid spread of HIV, particularly in Southern and Eastern
Africa (Epstein & Morris, 2011; Halperin & Epstein, 2004;
Mah & Shelton, 2011), and for the MSM in this study,
concurrent partnerships combined with difficulties accessing
condom compatible lubricants and an inconsistent ability to
negotiate condom use, mean that this may be an important
factor affecting HIV transmission among rural MSM.
Another consequence of the lack of a local MSM
community was the use of social media as a platform for
meeting partners and other MSM. In terms of HIV risk,
participants noted that meeting sex partners online could
lead to situations in which they were pressured into having
sex without condoms or lubricant. The use of online social
networks among South African MSM has not been widely
examined in research to date, but Stahlman et al. (2015)
found high rates of Internet use for finding sex partners
in their study with MSM in Lesotho and Swaziland. There
may therefore be a need for a greater focus on the role of
social networking websites as potential factors affecting HIV
risk among South African MSM. The popularity of social
networks among rural MSM in this study also suggests that
these might be a useful resource for the implementation of
HIV prevention interventions, particularly in light of the high
levels of hidden MSM behaviour reported by participants.
The relatively high importance of traditional value systems
in the rural context was also reflected in the ways intimate
relationships of MSMs were structured, with a general
consensus among participants suggesting that their
relationships followed heterosexual stereotypes of male
and female roles. These uneven power dynamics meant
that negotiating condom use could be difficult for MSM who
identified as the feminine partner in relationships.
The homophobic social context of their local communities
also affected the ability of MSMs to easily access health
care, with most participants reporting using private doctors
or health facilities outside their communities.
Taken together, these factors suggest the need for more
in-depth research into how these features of the rural context
affect HIV risk among rural MSM, to develop more targeted
and relevant approaches to HIV prevention, treatment, and
care in this population.
Some possible intervention activities suggested by this
exploratory study include a need: to engage in creating
localised support networks for MSM; to address the
misconceptions about MSM-specific HIV transmission risks;
and to facilitate access to condoms and condom compatible
lubricants. It may also be necessary to create spaces in
which MSM can examine and interrogate their beliefs about
African Journal of AIDS Research 2017, 16(1): 31–38
37
power dynamics in their intimate relationships, where these
place them at risk of HIV infection.
This study had several limitations that need to be
discussed. Firstly, the recruitment of the snowball sample
from only three MSMs’ social networks may have limited
the diversity of participants to individuals with similar
backgrounds and social contexts, which in turn may mean
that our findings represent a very specific group of MSM.
Similarly, since most participants self-identified as gay it
was not possible to directly explore variations in HIV risk
behaviours and beliefs across the spectrum of local MSM
identities. A third possible limitation is the fact that the CMSs,
by their nature, could not be guaranteed to be confidential
and participants may have been less open about their own
sexual risks and behaviours as a result of social desirability
bias and the fear of gossip in a community where social
status was clearly highly valued. Despite these limitations,
the findings of our research suggest that rural MSM may
differ in their HIV risks from their urban counterparts,
and as such may require more in-depth research and the
development of more targeted HIV prevention interventions.
Specific issues that could be focused on in future research
include: the role of social media in affecting MSM HIV risk
behaviour; the impact of traditional cultural beliefs and
practices on MSMs’ daily lives and expressions of their
sexuality; the impact of circular migration between rural and
urban areas on HIV risk among rural MSM; how to involve
rural MSM in MSM-specific HIV prevention interventions;
and interventions with healthcare workers focusing on
reducing MSM related stigma and discrimination in public
health facilities.
Conclusion
The findings of this small exploratory study suggest that
meeting the prevention needs of small but highly vulnerable
populations of MSM in rural South Africa will require
knowledge of social dynamics within these communities,
empathy and understanding for MSMs’ lived experiences,
supportive community interventions appropriate to MSM
needs, and capacity building for cultural competence in rural
health services.
Note
1 “Afternines” are men who are either bisexual, experimenting
or gay who are in the closet about their same-sex attraction.
The term was adopted by many South African MSM after a
TV mini-series of the same title was televised by the national
broadcaster. The series brought to light issues around same-sex
male relationships where one partner or both were in the closet.
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