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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.)

Lesotho has a broadly generalized HIV epidemic with nearly one in three reproductive-aged women living with HIV. Given this context, there has been limited research on specific HIV risks. In response, this study aimed to characterize the burden of HIV and multi-level correlates of HIV infection amongst female sex workers (FSW) in Lesotho. Respondent driven sampling was used to recruit 744 FSW from February to September 2014 in Maseru and Maputsoe, Lesotho. Robust Poisson regression was used to model weighted prevalence ratios (PR) for HIV, leveraging a modified social ecological model. The HIV prevalence among participants was 71.9% (534/743), with a mean age of 26.8 (SD 7.2). Both individual and structural determinants involving stigma were significantly associated with HIV. Women with the highest enacted stigma score (≥ 5) had a 26% higher prevalence of HIV than individuals that did not experience any stigma (PR 1.26, 95% CI 1.01, 1.57). These data reinforce the extraordinarily high burden of HIV borne by FSW even in the context of the generalized HIV epidemic observed in Lesotho and across southern Africa. Moreover, stigma represents a structural determinant that is fundamental to an effective HIV response for FSW in Lesotho.

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.

Purpose: Research on the relationship between sexual orientation-related stigma and risks for HIV among men who have sex with men (MSM) is limited. This study tests a hypothesis that substance use and depressive symptoms mediate the relationship between stigma in the health care system and HIV-related risk practices among MSM in Maseru, Lesotho., Methods: In 2014, we conducted a cross-sectional study among MSM in Lesotho accrued via respondent-driven sampling including a survey and biological testing for HIV. The hypothesis was tested using structural equation modeling., Results: Of the 318 participants, 22.3% had experienced stigma in the health care system. Stigma in the health care system was associated with depression (β = 0.329, P = .018) and alcohol use (β = 1.417, P = .001). Noninjection illicit drug use (β = 0.837, P = .039) and alcohol use (β = 0.282, P = .000) significantly predicted number of sex partners. Stigma was directly associated with condomless anal sex (β = 0.441, P = .036), and no indirect association was found., Conclusions: Alcohol use and depressive symptoms mediate the relationship between MSM stigma in the health care system and reported number of sex partners. The implications are significant with a focus on the need for comprehensive interventions addressing stigma and mental health when aiming to improve more proximal HIV-related risk practices for MSM., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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.)

Men who have sex with men (MSM) face sexual identity stigma in many settings, which can increase risk for HIV by limiting access to care. This paper examines the roles of social support, sexual identity stigma, and sexual identity disclosure among MSM in Lesotho, a lower-middle income country within South Africa. Qualitative data were collected from 23 in-depth interview and six focus group participants and content analysis was performed to extract themes. Four primary themes emerged: 1) Verbal abuse from the broader community is a major challenge faced by MSM in Lesotho, 2) participants who were open about their sexual identity experienced greater stigma but were more self-sufficient and had higher self-confidence, 3) relationships between MSM tend to be conducted in secrecy, which can be associated with unhealthy relationships between male couples and higher risk sexual practices, and 4) MSM community organisations provide significant social and emotional support. Friends and family members from outside the MSM community also offer social support, but this support cannot be utilised by MSM until the risk of disclosing their sexual identity is reduced. Greater acceptance of same-sex practices would likely result in more open, healthy relationships and greater access to social support for MSM., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Social stigma is common among men who have sex with men (MSM) across Sub-Saharan Africa, and may influence risks for HIV and sexually transmitted infections (STIs) via its association with depression. We conducted a cross-sectional study of 530 MSM in Lesotho accrued via respondent-driven sampling. Using generalized structural equation models we examined associations between stigma, social capital, and depression with condom use and testing positive for HIV/STIs. Depression was positively associated with social stigma experienced or perceived as a result of being MSM. In contrast, increasing levels of social cohesion were negatively associated with depression. Social stigma was associated with testing positive for HIV; however, this association did not appear to be mediated by depression or condom use. These data suggest a need for integrated HIV and mental health care that addresses stigma and discrimination and facilitates positive social support for MSM.