Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape
Town, South Africa
A. Cloetea*, L.C. Simbayia, S.C. Kalichmanb, A. Strebela, and N. Hendaa
aHuman Sciences Research Council of South Africa, Social Aspects of HIV/AIDS and Health, Cape Town, South Africa;
bDepartment of Psychology, University of Connecticut, Storrs, US
(Received 14 December 2006; final version received 4 December 2007)
Since the primary mode of HIV transmission in sub-Saharan Africa is heterosexual, research focusing on the
sexual behaviour of men who have sex with men (MSM) is scant. Currently it is unknown how many people living
with HIV in South Africa are MSM and there is even less known about the stigmatisation and discrimination of
HIV-positive MSM. The current study examined the stigma and discrimination experiences of MSM living with
HIV/AIDS in South Africa. Anonymous venue-based surveys were collected from 92 HIV-positive MSM and 330
HIV-positive men who only reported sex with women (MSW). Internalised stigma was high among all HIV-
positive men who took part in the survey, with 56% of men reporting that they concealed their HIV status from
others. HIV-positive MSM reported experiencing greater social isolation and discrimination resulting from being
HIV-positive, including loss of housing or employment due to their HIV status, however these differences were
not significant. Mental health interventions, as well as structural changes for protection against discrimination,
are needed for HIV-positive South African MSM.
Keywords: South Africa; men who have sex with men (MSM); HIV-positive; AIDS-related stigma;
In the early 1980s in the Apartheid-ruled Republic of
South Africa, the HIV epidemic affected mainly the
1997). Thus, much of the initial research in South Africa
focused on the sexual behaviour of this group in the
context of the HIV epidemic and a considerable amount
of literature on what it means to be gay in the face of the
African AIDS epidemic was published.1
More recent same-sex research, conducted by
Lane, Mcintyre and Morin (2006a), revealed that
South African MSM engage in high-risk sexual
behaviour. The study found that Black African South
African MSM are highly vulnerable to HIV infection.
In addition to this, Lane et al.’s (2006b) investigation
also revealed that stigmatisation as gay and fear of
being HIV-positive present barriers to making use of
the available voluntary HIV testing and counseling
services. Although South African MSM are recog-
nized as at-risk for HIV/AIDS (South African De-
partment of Health, 2000) this population remains
marginalised and to a large extent neglected in current
HIV/AIDS-prevention campaigns and research.
HIV prevalence and incidence among MSM in
South Africa remains undocumented. We are also not
aware of any research on the stigmatisation and
discrimination experiences of MSM living with HIV/
AIDS in South Africa. The current study was thus
conducted to address this void by examining the
stigma and discrimination experiences of MSM living
with HIV/AIDS in Cape Town, South Africa. We
hypothesized that HIV-positive MSM would report
greater stigma and discrimination experiences than
their non-MSM counterparts because of the added
stigmas associated with homosexuality.
Anonymous surveys were completed by 92 MSM and
330 MSW, all of whom were living with HIV/AIDS.
HIV-positive MSW were primarily sampled from
local social service and healthcare providers offering
services to people living with HIV/AIDS (PLWHA)
in Cape Town, South Africa, whereas MSM were
purposefully sampled from venues where gay men
congregate, as identified by HIV-positive MSM key
informants. In preparation for the fieldwork, anti-
retroviral roll out sites, service providers for PLWHA
and established support groups were contacted and
asked for their participation in this phase of the
study. Thus, the sampling method used in this phase
was convenience sampling.
*Corresponding author. Email: email@example.com
Vol. 20, No. 9, October 2008, 1105?1110
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2008 Taylor & Francis
Measures were administered in a seven-page survey
that required approximately 15 minutes to complete.
The questionnaire included demographic and health
characteristics, HIV-risk history, internalised AIDS
stigma, HIV/AIDS discrimination experiences, cog-
nitive and affective depression, social support and
substance use. The surveys were available in the three
languages commonly spoken in Cape Town: Xhosa,
English and Afrikaans.
Eleven fieldworkers were recruited, 10 of whom were
HIV-positive and openly living with their HIV status.
Before the administration of the questionnaire,
participants signed informed consent forms. Respon-
dents were asked not to indicate their names any-
where on the questionnaire. Since the questionnaire
was designed for self-administration, fieldworkers
reported that the respondents generally found it
easy to complete, although there were a few cases
where the fieldworkers administered the question-
naire verbally. Ethical clearance was obtained from
the Human Sciences Research Council’s Research
Ethics Council (REC 3/13/10/04).
For descriptive purposes, the frequencies of responses
to the internalised stigma items and AIDS discrimi-
nation experiences were first examined. Men who
have sex with men and HIV-positive MSW who
endorsed each item were compared using logistic
regression, reporting odds ratios with 95% confi-
dence intervals. Three regression models were con-
ducted that compared
demographic characteristics, health status variables
and stigma and discrimination experiences. The final
model that tested stigma and discrimination experi-
ences included covariates that controlled for differ-
ences on demographic and health characteristics that
were either significant in the previous regressions or
were conceptually relevant (e.g. years since testing
HIV-positive). Statistical significance was defined as
pB.05. Cell sizes vary as participants were included
for all analyses in which they had non-missing values.
The demographic characteristics of the survey sample
consisting of both MSM and MSW are shown in
Table 1. As illustrated in Table 1, MSM were more
likely to describe themselves as Coloured, Indian and
White than of Black African origin. Only 4% of the
MSW described themselves as White, compared to
17% of the MSM. Men who have sex with men were
also less likely to have children (MSM 24%, MSW
65%). No significant differences between MSM and
MSW were found on any of the remaining demo-
graphic characteristics reported on in Table 1.
Health, treatment status and mental health
Controlling for all health status variables in the
model, significantly more MSM reported positive
perceptions of their current health status, than the
MSW (Table 2). However, more MSM (42%) in the
sample reported having two or more hospitalizations,
compared to 28% of the MSW.
The two groups differed significantly on risk
factors such as injection drug use by either themselves
or their sex partners, both of which were more
common among MSM. Other markers for HIV-risk
history included having received money in exchange
for sex (MSM 28%, MSW 6%). Also, as shown in
Table 2, there were no differences between MSM and
MSW on the depression and social support scores.
Stigma and discrimination
We found that internalised AIDS stigma was high
among this sample of HIV-positive men, with 57% of
them reporting that they hid their status from others
(see Table 3). Almost 47% of the sample felt guilty
for being HIV-positive and 43% felt ashamed of
being HIV-positive. Moreover, there were no differ-
ences between MSM and MSW for feelings of
internalised stigma. Contrary to our hypotheses,
therefore, there were no differences between MSM
and MSW on the internalised stigma items.
Men who have sex with men did report experien-
cing greater social discrimination resulting from
being HIV-positive, including loss of job or places
to stay, however, there were no significant differences
found on discrimination experiences between MSM
and MSW. Men who have sex with women seemed to
have more supportive experiences, with 74% of them
having had talked to a friend about AIDS compared
to 58% of their MSM counterparts. There were no
significant difference of being treated differently by
friends and relatives between MSM and MSW.
The current study is amongst the first investigations
focusing on South African HIV-positive MSM and is
the first to examine their experiences of stigma and
1106A. Cloete et al.
men experienced a considerable amount of internalised
In a study designed to assess the impact of
internalised AIDS stigma in the US, Lee, Kochman
and Sikkema (2002) found that 63% of HIV-positive
persons sampled in two US cities indicated that they
were embarrassed by their HIV infection and 74%
stated that it was difficult for them to tell others they
are HIV-positive. Lee et al. (2002) further showed
that internalised AIDS stigma was related to depres-
sion symptoms over and above demographic char-
acteristics, health status, symptoms of grief and
various coping responses. These findings suggest
that internalised AIDS stigma may play a crucial
role in the emotional reactions and distress experi-
enced by many people who are aware that they are
living with HIV/AIDS. Internalised feelings of shame
and guilt also have an adverse effect on the health
status of the person living with HIV; so too can the
level of social support provided also have an impact
on their health status.
In our study, even though perceptions of current
health were significantly different across the groups
of men, HIV-positive MSM and MSW reported
considerable levels of social support from their family
and friends. In addition, moderate levels of cognitive-
affective depression symptoms were found among
both MSM and MSW, as with Lee at al. (2002) in
their US study among PLWHA, but no significant
differences were reported between the two groups.
According to Hall (1999), receiving adequate social
support, whether it is informational or in terms of a
strong social network, was an influence on the
psychological well-being of MSM living with HIV/
All HIV-positive men in South Africa, irrespective
of sexual orientation, experienced considerable inter-
nalised AIDS stigma, emotional distress and discri-
mination. However, HIV-positive MSM generally
experienced more discrimination related to their
HIV status than their non-MSM counterparts. It
therefore appears that HIV-positive MSM suffer
from double or multiple discrimination or super-
Results of this study should be interpreted in the
light of its methodological limitations. Purposive
sampling is subject to selection biases. In order to
obtain the sample of HIV-positive MSM, specific
Table 1. Demographic characteristics of HIV-positive MSM and MSW.
MSM n?92 MSW n?330
46 or older
Years of living in CT
Born in CT
More than 1 year
Less than 1 year
Only visiting CT
Notes: *pB.05; **pB.01.
AIDS Care 1107
locations were targeted where MSM congregate, thus
the sample characteristics were biased towards MSM
congregating at these specific venues. Another limita-
tion of the study was that there was no procedure in
place to ensure that only genuine PLWHA complete
However, it is unlikely that many HIV-negative
participants would have done so, given the consider-
able stigma still attached to HIV-positive status in the
communities surveyed, as well as the fact that
participants were not made aware of the very small
incentive until after completion of the questionnaire.
In addition, the fieldworkers who conducted the
survey were mainly from the same residential area
and attended the same support groups as partici-
pants, so that most participants were known to them.
Moreover, many surveys were collected at clinics,
which offer closed support groups for people already
identified as living with HIV/AIDS. However despite
the above limitations, we believe that the current
findings contribute new knowledge that could be
useful in intervention planning for HIV-positive
These findings have important implications for
services and interventions for all HIV-positive men in
South Africa. Interventions are needed that can assist
HIV-positive MSM to better adapt and adjust to
their condition and the social environment. In
particular, coping efficacy training targeted to ad-
dress managing social stigma and reducing interna-
lised stigma should be developed and tested among
them, especially MSM.
In the development of risk-reduction interven-
tions for HIV-positive MSM, a component focusing
on reducing the use of injection drug use is also
important in tailoring the intervention for HIV-
positive MSM. In the US, using injection drugs and
MSM are dual risks for HIV infection and contribute
to the highest rates of infection among any risk group
(CDC, 2000, cited in Kral et al., 2005). In an
investigation conducted in a US city of HIV-positive
gay and self-identified bisexual men injection drug
users, Ibanez, Purcell, Stall, Parsons and Gomez,
(2005) showed that this risk group engaged in more
unprotected sex than non-injection drug users. They
also found that HIV-positive gay and bisexual injec-
tion drug users experience more emotional distress
than their non-injection drug using counterparts.
HIV-positive MSM may also benefit from inter-
ventions designed to broaden and strengthen their
social support networks. For example, support
groups, which are already common in South Africa,
especially among MSM living with HIV/AIDS, may
be used as a starting place for the development of
Table 2. Health characteristics of HIV-positive MSM and MSW.
MSM n?92 MSW n?330
Characteristicsn%n% AOR 95%CI
Current perception of health
Two or more hospitalisations
Taking ARVs25 27 188 581.02 0.77?1.35
Has had an STI
Given money for sex
Injection drug use
IDU sex partner
Years since HIV-positive diagnosis
Notes: *pB.05; **pB.01.
1108 A. Cloete et al.
social support interventions. However, the ultimate
solution to AIDS stigma, especially among MSM,
does not lie in the hands of HIV-positive men alone.
Structural interventions are needed to change both
the social climate of AIDS and sexual politics around
sexual practices of MSM. Reducing the combined
AIDS and MSM stigmas at the societal level could
impact on the internalised stigmas that are clearly
magnified in MSM living with HIV/AIDS.
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Table 3. Stigma and discrimination of HIV positive MSM and MSW.
MSM n?92MSW n?330
Difficulty of disclosure
Feeling dirty due to HIV-positive status
Feelings of guilt
Ashamed of HIV-positive status
Worthless because of HIV-positive status
Self-blame for HIV-positive status
Hides HIV-positive status
Certainty of disclosing to sex partner
Talked to a friend about AIDS
Treated differently by friends & family
No more visiting after HIV-positive status
Concealment of HIV-positive status
Notes: Model controlling for participant race, having children, perceived health, injection drug use and injection drug using partner histories,
years living with HIV and HIV-related symptoms.
Notes: *pB.06, **pB.01.
AIDS Care 1109
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