Homophobia as a Barrier to HIV Prevention Service Access for Young Men Who Have Sex With Men

To the Editors: Men who have sex with men (MSM) bear a disproportionate HIV burden across low- and middle-income countries, and there has been a reemergence of HIV among MSM in high-income regions.1–3 Despite this excess burden, it is estimated that only 1.2% of all HIV prevention funding is targeted toward MSM.4 Globally, HIV prevention services only reach an estimated 10% of MSM, demonstrating that coverage of HIV services for MSM is not commensurate with need.5,6 Among MSM, young men who have sex with men (YMSM) face a unique set of challenges that make them particularly vulnerable to HIV infection and poorer HIV-related health outcomes.7 YMSM account for a large proportion of incident and newly diagnosed HIV cases in many parts of the world.8–10 Increased HIV risk among YMSM has been connected with a myriad of risk factors, including disparities in access to health services and structural factors like homophobia (ie, sexual stigma,11 defined as the “shared belief system through which homosexuality is denigrated, discredited, and constructed as invalid relative to heterosexuality11,12(p1)”), which have been associated with increased HIV risk behaviors and decreased rates of HIV testing among MSM.13–22 Despite their heightened vulnerability, there is a paucity of research examining the social and structural determinants of accessibility of HIV prevention services among YMSM, especially outside the United States. Moreover, programmatic data concerning MSM are rarely disaggregated by age, and data on youth are seldom broken out by sexual orientation. Finally, there is an extremely limited amount of data regarding the effects of structural factors on access to evidence-based interventions among YMSM, underscoring a major gap in public health research. We characterized disparities in access to HIV prevention services and structural factors among YMSM relative to older MSM. We also assessed the association between social and structural factors and access to HIV services among YMSM. We conducted a secondary analysis on data from a larger cross-sectional study of MSM and their health providers (n = 5066) on access to HIV services, implemented by the Global Forum on MSM & HIV. The methodology of this study has been previously described.23 In brief, from June to August 2010, participants completed an anonymous online survey administered in Chinese, English, French, Russian, and Spanish. The survey measured 12 psychometric constructs, including scales previously validated on homophobia and internalized homophobia (ie, internalized sexual stigma or internalized homonegativity, broadly defined as the process in which MSM internalize society’s negative attitudes about homosexuality) and an 18-item measure on access to recommended HIV prevention services (eg, condoms, lubricants, and HIV testing).11,24–31 The items in the homophobia measure have Likert scales ranging from 1 to 4; low to high responses correspond with strong disagreement to strong agreement with statements on perceived homophobia. The items in the internalized homophobia measure also have responses ranging from 1 to 4; low to high responses correspond with “never” to “often” endorsing statements that reflect internalized homophobia. The items in the accessibility measures have responses ranging from 1 to 5; low to high responses correspond with low to high accessibility of different HIV services (Table 1).TABLE 1: Disparities in Access to HIV Prevention Strategies, Homophobia, and Internalized Homophobia Between YMSM and Older MSMMale participants who reported having sex with men and provided complete data on the exposures and outcomes of interest were included in this study. This subset did not differ from the overall sample with respect to age, education, income, and region (data not shown). The χ2 and Wilcoxon rank sum tests were used to evaluate differences between YMSM and older MSM. Among YMSM, multivariable linear regression using a stepwise (backward elimination) procedure was used to identify correlates of access to HIV prevention services while controlling for HIV status. The final model used did not show evidence of departure from linearity in qnorm plots. This study was approved by Research Triangle Institute International’s Internal Review Board. Among the 2981 MSM included and eligible, 47% (n = 1402) were YMSM. YMSM respondents were from Asia (73%), Latin America (9%), Australasia (7%), North America (6%), Europe (3%), and Africa (2%). The median age among YMSM was 25 (interquartile range, 22–28). Self-reported HIV prevalence among YMSM was 14%. The majority of YMSM self-identified as gay (86%) and had 2 or more sexual partners in the past year (67%). Over a third (34%) had never been tested for HIV, 30% reported unstable housing, and 3% were homeless. Results revealed that significantly fewer YMSM reported “easy access” to 17 out of the 18 HIV prevention services measured when compared with older MSM (Table 1). For example, compared with older MSM, YMSM reported lower access to HIV testing [36% vs. 52% (P < 0.001)], condoms [35% vs. 46% (P < 0.001)], and lubricants [21% vs. 33% (P < 0.001)]. Furthermore, YMSM had a significantly lower overall mean score for access to HIV prevention services compared with older MSM [3.1 vs. 3.6 (P < 0.001)]. In addition, we found that a greater percentage of YMSM, relative to older MSM, perceived a high degree of social discrimination based on sexual orientation in their country of residence. A greater proportion of YMSM reported that, in the country where they reside, MSM are not treated like everyone else [95% vs. 93% (P = 0.02)], most people have a poor perception of MSM [68% vs. 63% (P = 0.001)], and most people think that MSM are dangerous [65% vs. 48% (P < 0.001)]. YMSM had significantly higher mean homophobia scores than older MSM [2.5 vs. 2.3 (P < 0.001)]. Moreover, we found that a larger proportion of YMSM more frequently endorsed statements that reflect internalized homophobia, relative to older MSM. For example, it was more common for YMSM to wish they were not a sexual minority [40% vs. 29% (P < 0.001)], express desire to get professional help to change their sexual orientation [21% vs. 10% (P < 0.001)], and believe that being a sexual minority is a negative aspect of their identity [26% vs. 19% (P < 0.001)]. The overall mean score for internalized homophobia was significantly higher overall among YMSM compared with older MSM [1.9 vs. 1.6 (P < 0.001)]. Multivariate analyses showed that both homophobia and internalized homophobia were independently and negatively associated with access to HIV prevention among YMSM, controlling for HIV status, relationship status, education, and housing. Increased homophobia was associated with a mean decline of 0.38 points (95% confidence interval: 0.30 to 0.47) in the score for access to HIV prevention services. Increased internalized homophobia was associated with an average decline of 0.27 points (95% confidence interval: 0.17 to 0.37) in the score for access to HIV prevention services among YMSM. In this large online sample, our data suggest that YMSM may be at increased risk for HIV compared with older MSM, due to significant disparities in access to services and social determinants of health. YMSM have considerably lower access to HIV interventions that have been proven effective to prevent HIV infection and transmission. Additionally, YMSM reported higher levels of homophobia and internalized homophobia, which are associated with high-risk sexual behaviors.13,15–17,19–22 Importantly, YMSM who exhibited the greatest levels of homophobia and internalized homophobia had the most compromised access to HIV prevention services, suggesting that higher levels of homophobia adversely impact access to tools that are effective in reducing new HIV infections and forward transmission. This finding is consistent with prior studies that have shown an inverse relationship between higher homophobia and access to HIV services.14,18,32 The combination of these deleterious social factors and the lack of access to services may further exacerbate heightened vulnerability of YMSM to HIV. This study has several limitations. Our study uses a convenience sample and may be subject to selection bias. Although our findings are consistent with other MSM surveys from Asia and Europe, generalizability to all MSM is limited. Moreover, similar to other observational studies, there may be other unmeasured confounders (eg, depression, gender roles) that we did not account for, which may be associated with both our exposures of interest and access to HIV services. In light of the global shifts in funding investments to key populations most affected by HIV (eg, the Global Fund’s emphasis on sexual orientation and gender identity in their investment strategy), the importance of parallel efforts to reduce barriers to accessing HIV-related services can hardly be overstated. Targeted efforts to alleviate this inequity in access to evidence-based HIV prevention interventions for YMSM are urgently needed to successfully curb the HIV epidemic in this population.26–31 For example, community-based social marketing campaigns aimed at YMSM social networks and peer-administered network-based health education strategies have shown promise in expanding HIV testing, treatment, and knowledge among YMSM.33,34 The few evidence-based interventions that are specific to YMSM are far from adequate, and scaling-up existing HIV interventions alone will likely be insufficient, as social factors like homophobia impede uptake of HIV prevention services, especially among YMSM.7 Disparities in HIV incidence and access to HIV prevention services among YMSM will likely persist unless prevention services are tailored to the specific needs of YMSM, strategies promoting resilience are supported, and efforts to reduce barriers to access are developed and funded. As we strive to eradicate HIV, structural interventions addressing homophobia and discrimination—including policies decriminalizing homosexuality—should be implemented and prioritized to ensure that YMSM have an equal opportunity for an AIDS-free generation.