amfAR, The Foundation for AIDS Research

Homophobia and the Spread of HIV in South Africa

By Jeffrey Laurence, M.D.

South Africa has one of the world’s largest HIV/AIDS epidemics, constituting 25 percent of total cases in sub-Saharan Africa and 10 percent of cases worldwide. While heterosexual intercourse as an HIV risk factor has received the most attention in Africa, the epidemic of HIV among men who have sex with men (MSM) has not received an appropriate focus. In two articles this month, amfAR grantee Dr. Waimar Tun and colleagues at the Population Council in Washington, D.C, New York City, and Johannesburg examine the potential impact of internalized homophobia and HIV-related conspiracy beliefs on HIV/AIDS among MSM in South Africa.

South AfricaIn their AIDS and Behavior report, Tun and associates note that MSM in Africa are 3.8 times more likely to be HIV-infected, with homophobia and social discrimination preventing them from accessing prevention and health care services. High levels of stigma and discrimination exist in South Africa despite the fact that homosexuality is constitutionally protected, unlike in many other African countries. MSM are considered “un-African” and are commonly blamed for the spread of AIDS. This leads to an “internalized homophobia,” a self-hatred and shame that MSM incorporate into their belief systems, leading to internal conflicts and devaluation of self. These men “feel different from others,” which sets up barriers to participation in the gay community and access to general health services, thereby increasing their vulnerability to HIV infection.

“I have the feeling that wanting to have sex with other men is a personal shortcoming of mine” is an example of a statement from a nine-item scale that was frequently affirmed by 324 MSM in Tun’s study. Such responses were more common among the 42 percent of participants who self-identified as bisexual as opposed to homosexual. These answers were also more common among participants endorsing HIV-related conspiracy beliefs, such as “people who take HIV medication are human guinea pigs” or “HIV/AIDS is being used to kill black people.” Participants who endorsed at least three of 12 conspiracy beliefs listed in the questionnaire were 2.4 times more likely to hold a high level of internalized homophobia. General misinformation about HIV was also strongly linked with internalized homophobia.

In a second study, published in AIDS Care, Tun found that HIV conspiracy beliefs are associated with inconsistent condom use and lack of testing for HIV. MSM who were never tested were almost twice as likely to hold such beliefs.

What might be done to correct all of this? Tun and colleagues suggest that designing programs to promote self-acceptance around gay identity by helping MSM to build a positive sense of self will be crucial. And HIV educational programs need to better reach MSM who are not “gay-identified.” “Ultimately,” they conclude, “this will lead to improved HIV prevention program access and reduction in HIV transmission.”

Jeffrey Laurence is amfAR’s senior scientific consultant.