Understanding male couples and HIV in Southern Africa

What public health professionals need to know about men in same-sex relationships in Africa

Together Tomorrow is a UK aid supported research project which is shining a light on sexual relationships between men in southern Africa. The study aimed to better understand the nature of male same-sex partnerships with a view to enhancing HIV protection for this marginalised group.

Addressing HIV globally requires us to look not only at individual needs and health systems, but also at ourselves as a society. Along with other marginalised groups, men in same sex relationships are at increased risk of contracting HIV. The Together Tomorrow study, undertaken in collaboration with community based organisations in southern Africa, has revealed some of the factors which make men in same-sex relationships more vulnerable. Among these are the extreme stress experienced by men as a result of living in an intolerant society. The study revealed how this can lead to poor mental health, increases in risky behaviours, and a feeling of being unable to access appropriate healthcare services.

At the International AIDS conference in Durban in July 2016, one message was clear: While we have treatment tools at our disposal, and have made inroads into fighting HIV as a generalised epidemic, the fight is being lost when it comes to the most vulnerable and the marginalised, including men in same-sex relationships. It is in these spaces where the epidemic continues to rage.

“Right to health”, the theme for World AIDS Day 2017, gives pause for reflection on the extent to which marginalised groups are unable to access their right to a healthy life. UK aid’s support for Together Tomorrow’s research reflects its commitment to empower marginalised groups and work for inclusive societies with the goal of ‘building societies where everyone has voice, choice and control over their lives’.

Understanding the needs of men in same-sex relationships

Research in the United States and elsewhere has shown that up to two-thirds of HIV infection in male same-sex relationships occur in the context of a significant relationship — a ‘couple’. This suggests that dynamics within relationships, rather than the behaviour of individuals alone, hold clues for understanding why this group is particularly vulnerable.

Together Tomorrow: Partnerships informing the future, explored the prevention and treatment needs of couples within male same-sex relationships in Africa — in South Africa and Namibia

This study, entitled Together Tomorrow: Partnerships informing the future, explored the prevention and treatment needs of couples within male same-sex relationships in Africa — in South Africa and Namibia. The research was undertaken by the South African Human Sciences Research Council (HSRC) in collaboration with researchers at the University of Michigan and the University of California, San Francisco. The Evidence for HIV Prevention in Southern Africa (EHPSA) programme, which is funded by UK aid, supported the research as part of its work to strengthen HIV prevention in the region.

Partnerships are key

Developing interventions to address complex healthcare challenges such as HIV requires input from the people who experience the problem, or risks failure. For this reason, the Together Tomorrow study team partnered with two local organisations, namely

These non-governmental organisations work within local communities for the inclusion of gay, bi-sexual, transgender and intersex (LGBTI) people. They were involved at every step of the project as the main implementers, while the research teams provided training and support, quality control and data analysis.

Before the research began, community engagement and mobilisation took place and community advisory boards were established to ensure that the voices of stakeholder groups were heard throughout the research process. The advisory boards also played an important role in guiding the implementation teams.

The research process

Zaynab Essack, Study Manager of Together Tomorrow at the HSRC said: “We undertook this study with male same-sex couples to explore dynamics of relationships such as love, trust, commitment. We wanted to find out about risk taking behaviour and the uptake of HIV prevention and treatment options. We wanted to understand how these are impacted by relationships and how they influence minority stress.”

We undertook this study with male same-sex couples to explore dynamics of relationships such as love, trust, commitment. We wanted to find out about risk taking behaviour and the uptake of HIV prevention and treatment options

Minority stress refers to stress experienced by stigmatised minority groups, such as men in same-sex relationships. Members of these groups face stigma, isolation and fear of rejection and victimisation to name a few. The participants from both countries reported similar stressors although the levels of stress appeared higher in the Namibian context where homosexuality is criminalised.

The research was conducted in two phases. The first phase gathered information and insight which then contributed to the development of a questionnaire which was used in the second phase.

Phase 1 — Gathering information to inform the study

Key informants, people working in healthcare settings, government stakeholders and other NGO service providers, were identified and interviewed. The main purpose of these discussions was to determine what services are currently provided, and what challenges exist with providing these services.

Focus group discussions then took place with 27 couples who were currently in same-sex relationships. The researchers asked individuals about their experiences with service provision and about HIV prevention uptake. Finally, interviews took place with 18 couples (although the interviews were held individually). Here discussions centred on the specific nature of their relationships and how these factors could influence HIV prevention and treatment uptake.

Phase 2 — A survey of 220 couples

After this initial phase, there was reflection on the first phase by the researchers and the implementing partners to provide input into the creation of a questionnaire for the next phase. The research questions were largely determined by the researchers while partners played a role in ensuring appropriateness of language and approach for each country context. The survey was then carried out with 220 couples, 150 in South Africa and 70 in Namibia, using mobile devices on which participants completed the questionnaire.

Experiences of the teams

Team members reflected on the challenges faced in recruiting couples, especially in Namibia where homosexuality is criminalised. Despite stakeholders being very engaged, and advanced in their thinking and debates around LGBTI issues, some couples were reluctant to participate in the study. In certain cases, one member of a couple would come forward, but their partner didn’t want to participate, afraid that participating in the study would reveal their sexual preferences with potentially harmful consequences including rejection by family members or even criminal charges.

Seeing the variations of couples was mind-opening for some of the team members, who noticed the extent to which participants differ by age groups as well as gender identities. “Many gay relationships mimic heterosexual ones, and we met men who identify as effeminate or ‘their man’s woman’. Some men however were comfortable with identifying as masculine men, a feature more applicable to the urban regions as opposed to the more rural settings.”

Another spoke about the extent to which being part of the research process had enhanced their organisation’s work. “The most rewarding aspect of the study is the growth in capacity, understanding and skill within the study team. The study was shaped by the voices of the LGBT team members in the study sites and each member within the unit was able to deliver valuable insight into the processes”.

The most rewarding aspect of the study is the growth in capacity, understanding and skill within the study team. The study was shaped by the voices of the LGBT team members in the study sites and each member within the unit was able to deliver valuable insight into the processes

Sharing the results

The results of this research made an important contribution to the conversation at the AIDS Impact conference held in November 2017 in South Africa about the risks, vulnerabilities and challenges same sex couples experience. The outputs were presented at the conference as talks and posters. A media roundtable was held, and social media channels were established to contribute to the global conversation on these topics. Follow @2gether2morrow on twitter using #TogetherTomorrow to keep in touch with the conversation.

The results are explored in greater detail in a series of factsheets with accompanying infographics.

Creating Sexual Agreements

In studies elsewhere, forming and adhering to sexual agreements has been reported to establish higher levels of trust, communication and commitment within relationships. In these two African contexts, the majority of couples had some form of sexual agreement, and the nature of the agreement seemed to impact on HIV risk behaviours. The study team recommended programmes through which couples can gain the necessary skills to discuss and create agreements. Read more about sexual agreements here.

Minority stress contributes to increased risk of HIV

Minority stress leading to poor mental health appears to result in men in same-sex relationships engaging in higher HIV-risk behaviour, including unprotected sex, multiple sexual partners and substance abuse. Good mental health is critical to healthy coping mechanisms and the research established a number of strategies that could help deal with minority stress. These included developing open communication to foster commitment and relationship planning, creating clearly defined sexual agreements which can reduce risks associated with infidelity, and building resilience against stigma and discrimination through the support of a partner. Read more about coping mechanisms here.

Making public health friendlier to men in same-sex relationships

The research team found that men in same-sex relationships struggled when accessing government health facilities, often driving them to hide their sexual identity or seek services at NGOs or elsewhere. Researchers suggested that appropriate training of health workers and civil servants could lead to more accepting, inclusive and professional health-care delivery. Read more about improving healthcare spaces here.

Providing services for couples

Finally, a huge amount was learned from the survey administered to couples. It is clear from the research that for the vast majority of participants, monogamy is an important part of relationship. As with heterosexual couples, it is clear that for men in same-sex relationships there are positive and negative effects of partnerships. Being in a relationship does offer some protection from minority stress, but if you are relying on just one person, and the relationship experiences difficulties or disruption, this can be very difficult. The study team felt that while working with couples is important, attention also needs to be given to the individuals within a couple to help them to be more resilient, whether financially or emotionally. Read more about the study findings here.

Current approaches are not working

The researchers were surprised by the low knowledge and use of HIV prevention options, including condom use and pre-exposure prophylactics (PrEP) as well as the low uptake of testing. It appears that despite an awareness of HIV risk among participants, there is a failure to act upon that risk. Said study manager Essack: “This means that the strategies being employed aren’t working, and we are just starting to get some idea of why.”

One of the implementers spoke about the success of the research and the potential for making appropriate changes to responses. “Real insight into the type of programming and responses that these couples prefer, was also brought to the fore. Systems and programmes can only be responsive, once the voice of those affected are heard and applied within systems extending beyond health into people’s lives”

The road ahead

Partner organisations felt excited by their role in this ground-breaking research. One leader said the most exciting part was the extent to which the male same-sex community had come to trust the organisation and that someone is finally attending to their psychological, physical and emotional well-being. This opens opportunities for further research and conversations.

The research team is looking forward to exploring the research results with study participants and stakeholders in each country as well as exploring the policy implications of this work with representatives from government. Ultimately, the group hopes to move into a next phase in which, with a much stronger understanding of local contexts, interventions can be designed to dismantle the factors which impact on same sex male couples’ ability to stay healthy and safe.

About the authors

Zaynab Essack, PhD, is a research psychologist and social scientist. She is currently employed as a Senior Research Specialist for the Human and Social Development Programme, at the Human Sciences Research Council (HSRC), South Africa. She has experience in conducting multi-method and multinational social science research and ethical-legal analysis, with a focus on vulnerable (key) populations, including men who have sex with men (MSM) and adolescents and young women. Zaynab was project manager for the Together Tomorrow study.

Professor Heidi van Rooyen is the Executive Director of the Human and Social Development Programme at the Human Sciences Research Council in South Africa. Her research has focused on HIV risks and vulnerability as well as the broader contexts and inequalities that shape this risk. Her current focus is on the influence of sexual orientation and gender identity as social determinants of health, and issues of race and identity. Heidi is a certified life coach who balances the demands of leadership, publishing and grant writing with a regular contemplative writing practice and poetry. She is the principal investigator of the Together Tomorrow study.