HIV prevalence among men who have sex with men (MSM) in Senegal is 19%, compared with 0.5% in the general population. Stigma against men who have sex with men (MSM) is high in the majority (96%) Muslim country of Senegal. HIV-related stigma stems from sociocultural and religious beliefs that HIV is a punishment from God or the consequence of sinful behaviors, including sex outside the bounds of marriage and homosexual activity. These stigmas can be major contributors to disengagement from HIV care for fear of scorn and mistreatment. Linkage to and retention in HIV care are critical for improving symptom management and reducing risk of mortality. Isolation and fear resulting from stigma and discriminatory practices can lead to poor treatment seeking behaviors and low adherence to antiretroviral therapy. This in turn may result in increases in HIV symptom distress. Despite the extremely high HIV prevalence in MSM in Senegal, there are gaps in scientific knowledge regarding how intersecting HIV- and homosexuality-related stigmas are associated with HIV care linkage and retention in the MSM population. Further, it is unknown if associations between stigmas and health outcomes are mediated by decreased linkage and retention in HIV care in this underserved population. Our long-term goal is to implement stigma-reduction interventions in order to increase linkage to the continuum of HIV care for MSM in Muslim communities in Senegal. To this end, we will:
(Aim 1) Adapt and assess the validity and reliability of stigma scales for use among MSM in the Muslim context. We will use a community-engaged approach to adapt and test stigma scales among MSM in Senegalese Muslim communities. Testing processes will consist of face validity and psychometric properties (including correlation matrices, split-half reliability, criterion validity, and both exploratory and confirmatory factor analysis). Findings will provide evidence of validated measures for use in future studies.
(Aim 2) Assess the association between the types of and intersectionality between stigmas, and behavioral (treatment seeking behaviors and adherence to treatment) and symptom distress (mental and physical) among 250 MSM LWH in urban and rural Muslim communities in Senegal. We hypothesize that level and type of stigma will be associated with (1) treatment avoidance and low adherence to treatment; and (2) higher HIV physical and psychological symptom distress. We will also examine whether the observed correlations are partially or fully mediated by association with other variables, including disclosure avoidance due to stigma. Findings from this study will lay the groundwork for the design of an intervention to help mitigate the impact of stigmas on treatment related behaviors (linkage and retention in care) and subsequently improve health outcomes of MSM living with HIV in majority Muslim African countries.
Senegal has an HIV prevalence of 19% in MSM, with low treatment coverage and high gaps in treatment access. Although stigma and discrimination against MSM in Senegal is high, it is unknown how these stigmas manifest in this majority Muslim country and how they undermine linkage and retention in HIV care and consequently increase their risk for poor HIV clinical outcomes. The proposed study will address these critical public health issues by (1) adapting and testing HIV and MSM stigma measures for use in Muslim communities; and (2) investigating associations between stigmas, HIV care linkage and retention, and HIV symptom distress. Qualitative methods will provide additional information on challenges that HIV positive MSM experience in the process of being linked to and retained in HIV care, including the ways in which stigmas contribute to these challenges as well as insights into the conditions necessary for their re-engagement in HIV care.