¹ Canadian Institutes of Health Research Post-doctoral Fellow, University of Toronto, Toronto, ON, Canada, ²University of Toronto, Toronto, ON, Canada, ³Indian Network for People Living with HIV/AIDS, Chennai, India

Background: Globally, men who have sex with men (MSM) are at elevated risk for HIV infection compared with the general population. MSM are impacted by sexual stigma and HIV-related stigma, which present barriers to HIV prevention. Sexual stigma refers to the devaluing of sexual minorities, negative attitudes and lower levels of power afforded to non-heterosexual behaviors, identities, relationships and communities. HIV-related stigma refers to the devaluing and mistreatment of people who are living, or associated, with HIV. Social support and coping have been posited to moderate the influence of stigma on sexual risk behavior (SRB) among sexual minorities. However, there is a scarcity of information regarding sexual stigma, HIV-related stigma and SRB among MSM in developing countries, which bear the greatest burden of HIV/AIDS; in India, in particular, MSM have HIV infection rates sixteen times higher than the general population. The objective of this study was to examine the associations between sexual stigma, HIV-related stigma and SRB among MSM in South India. The secondary objective was to explore the associations between social support, resilient coping and SRB.

Methods: A collaborative investigation was designed in partnership between the University of Toronto and community-based organizations in South India. Formative research, including community consultations and key informant interviews, was conducted to develop a culturally appropriate cross-sectional survey to examine sexual stigma, HIV-related stigma, SRB, resilient coping and social support. The survey was developed in English, translated into Tamil, and back-translated into English. Peer research assistants administered the survey to a purposive sample of MSM in urban and semi-urban locations in Tamil Nadu, India. Bivariate correlations and hierarchical block regression analyses were conducted using SPSS 17 to measure associations between independent (sexual stigma, HIV-related stigma, resilient coping, social support) and dependent (SRB) variables. Block 1 analyses examined associations between sexual stigma, HIV-related stigma and SRB; block 2 analyses examined associations between social support, resilient coping and SRB.

Results:  The majority (89.0%) of participants (n=200, mean age=30.9) reported experiences of sexual stigma and HIV-related stigma. Sexual stigma and HIV-related stigma were significantly correlated with higher rates of SRB and lower resilient coping and social support scores. In block 1 regression analyses, sexual stigma and HIV-related stigma predicted higher SRB scores, adjusted R2=0.11, F(2, 118)=8.57, p<0.001. In block 2, resilient coping and social support predicted lower SRB scores, adjusted R2=0.27, R2 change=0.16, F(2, 116)=13.41, p<0.001.

Conclusions: Stigma and discrimination were positively associated with SRB among MSM in South India; social support and resilient coping were associated with lower SRB. The influences of sexual stigma and HIV-related stigma on SRB are particularly pronounced outside of urban settings, where MSM have limited access to support services. HIV prevention initiatives in India tailored to urban/rural context and sexual identity should aim to strengthen protective factors, such as coping and social support, and challenge stigma associated with same-sex sexuality and HIVSexual stigma and HIV-related stigma are associated with higher rates of SRB among MSM in South India. Understanding the impact of sexual stigma and HIV-related stigma on SRB informs social work practice by highlighting the importance of multi-level interventions, including micro (e.g. resilient coping skills), meso (e.g. social support) and structural (e.g. challenging sexual/HIV-related stigma) initiatives. Social work research should further explore the influence of HIV-related and sexual stigma on SRB among sexual minorities. An enhanced understanding of the potential roles that resilient coping and social support can play in facilitating healthy sexual behavior can inform interventions to reduce the negative impact of stigma and promote health among sexual minorities. .