Background: Stigmatization of homosexuality may have important effects on healthcare engagement and disease incidence among men who have sex with men (MSM) in sub-Saharan Africa, but little is known about the relationship between stigma and STIs. This study aims to assess the association between patterns and predictors of stigma and their potential interaction with other risk behaviors on the prevalence and incidence of sexually transmitted infections (STIs).
Methods: Beginning in 2013, the TRUST/RV368 study has recruited 1,480 MSM using respondent driven sampling in Nigeria into a prospective cohort that provides HIV/STI diagnosis and treatment. Participant characteristics, stigma, risk behaviors (transactional sex, receptive anal sex, and binge drinking), and laboratory diagnosed STIs (urethral and rectal gonorrhea and/or chlamydia) from baseline and follow-up were assessed using latent class analysis and latent transition analysis.
Results: Three stigma classes of low (n=605), medium (n=680), and high (n=195) emerged with 59% in the medium or high classes. Participants who were older, more educated, Christian, gay/homosexual, female, and who had disclosed their sexual orientation were significantly more likely to be in the high stigma class. As stigma class increased from low to medium to high, the proportion of each outcome increased (STI prevalence: 14%, 20%, 23%, χ2 p=.043; STI incidence: 8%, 10%, 15%, χ2 p=.110). For STI prevalence, an interaction with stigma was found for transactional sex (OR 1.99 p<.001), receptive anal sex (OR 6.33 p<.001), and binge drinking (OR 2.5 p<.001). For STI incidence, an interaction was found for transactional sex (OR 4.06 p=.003).
Conclusions: There is strong evidence of interconnected epidemics, syndemics, between STI risk and stigma against MSM. Programs to reduce stigma and social vulnerability among MSM are critical to reducing STIs.