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Background: For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma., Methods: We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data., Results: Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations., Conclusions: Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA., (© 2021. The Author(s).)

Social marginalization harms lesbian, gay, bisexual, and transgender (LGBT) persons' wellbeing in Lesotho. Socio-cultural mechanisms linking LGBT stigma, depression, substance use, and HIV among LGBT persons in Lesotho are understudied. We explore associations between LGBT stigma, mental health stressors, and HIV vulnerabilities among LGBT persons in Lesotho. We conducted in-depth, semi-structured interviews with 46 LGBT persons and six key informants (e.g. healthcare providers). Participants described depression, substance use, and HIV as mutually reinforcing and situated in larger social contexts of stigma. Alcohol use was a stigma coping strategy and a way to build LGBT connections. At the same time, alcohol use elevated HIV vulnerabilities by lowering condom use uptake. Pervasive stigma reinforced barriers to healthcare engagement. Community-led support and services were leveraged to navigate stigma, reduce HIV vulnerabilities, and ultimately improve health. Findings emphasize the key role contexts play in shaping sexual and mental health among LGBT persons in Lesotho.

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2020.)

Lesbian, gay, bisexual, transgender and other sexually and gender diverse persons negotiate for their identities, create communities and advocate for their rights throughout the world. However, there are limited data about the perceptions of social change among sexually and gender diverse persons in contexts where same-sex sexual practices have been recently decriminalised, such as in 2010 in Lesotho. We conducted semi-structured in-depth interviews with sexually and gender diverse persons (n = 46) and six key informants. Findings were analysed using Social Worlds Theory. Participants discussed social constraints and marginalisation across structural (legal systems, employment, education), community (beliefs that sexual and gender diversity are incongruent with Basotho culture; stigma), and familial (tensions with religion and cultural gendered economic traditions) dimensions. The narratives also revealed perceived change across structural (changing norms in legal, employment and education spheres), community (larger community and LGBT community change), familial (negotiating acceptance), and internal (active resistance) domains. The findings reported here can inform multi-faceted programmes to challenge stigma, violence and gender inequity; build social capital; and address the health and human rights priorities of sexually and gender diverse persons in Lesotho.

Stigma and discrimination affecting lesbian, gay, bisexual, and transgender (LGBT) people compromise health and human rights and exacerbate the HIV epidemic. Scant research has explored effective LGBT stigma reduction strategies in low- and middle-income countries. We developed and pilot-tested a participatory theatre intervention (PTI) to reduce LGBT stigma in Swaziland and Lesotho, countries with the world's highest HIV prevalence. We collected preliminary data from in-depth interviews with LGBT people in Lesotho and Swaziland to enhance understanding of LGBT stigma. Local LGBT and theatre groups worked with these data to create a 2-hour PTI composed of three skits on LGBT stigma in health care, family, and community settings in Swaziland (Manzini) and Lesotho (Maseru, Mapoteng). Participants ( n = 106; nursing students, health care providers, educators, community members) completed 12 focus groups following the PTI. We conducted thematic analysis to understand reactions to the PTI. Focus groups revealed the PTI increased understanding of LGBT persons and issues, increased empathy, and fostered self-reflection of personal biases. Increased understanding included enhanced awareness of the negative impacts of LGBT stigma, and of LGBT people's lived experiences and issues. Participants discussed changes in attitude and perspective through self-reflection and learning. The format of the theatre performance was described as conducive to learning and preferred over more conventional educational methods. Findings indicate changed attitudes and awareness toward LGBT persons and issues following a PTI in Swaziland and Lesotho. Stigma reduction interventions may help mitigate barriers to HIV prevention, treatment, and care in these settings with a high burden of HIV.

In recent years, gender and sexual minorities have become increasingly visible across sub-Saharan Africa, marking both the progression and violation of their human rights. Using data from a study with sexual minorities in Lesotho, this analysis leveraged the social ecological model to examine relationships between stigma, human rights, and sexual health among women who have sex with women in Lesotho. A community-based participatory approach was used for the mixed-method, cross-sectional study. A total of 250 women who have sex with women completed a structured questionnaire, of which 21 participated in a total of three focus group discussions. Stigma was common within and outside the health sector. Stigma and human rights abuses were associated with increased risk for HIV and STIs. Interventions to address stigma at the structural, community, and interpersonal levels are essential to ensuring sexual health and rights for women who have sex with women in Lesotho., (Copyright © 2015 Elsevier Inc. All rights reserved.)