Exploring the multi-dimensional and intersectional inequalities in healthcare utilisation among openly identifying and non-identifying MSM in KwaZulu-Natal, South Africa

BACKGROUND: Significant inequities in health care utilization exist among men who have sex with men (MSM) who balance multiple, intersecting social groups and identities. This is especially true for non-identifying MSM, who despite their disproportionately high risk, remain under-served by existing HIV programs.
METHODS: In-depth interviews were conducted with MSM in KwaZulu-Natal, South Africa using a human centred design approaches that sought to learn more about participant's beliefs, relationships, interactions, and practices. Interviews were cconducted in isiZulu and/or English. Participants were sampled using snowball sampling, and purposively screened to ensure both openly identifying and non-identifying MSM were sampled. Research activities were approved by the Foundation for Professional Development Research Ethics Committee (FPDREC) [Reference 01/2021]. Data were analysed thematically using an integrative inductive-deductive framework approach. Healthcare utilization and healthcare needs were explored across intersectional categories, such as, identifying, and non-identifying MSM.
RESULTS: Between May and August 2021, 41 IDIs were conducted, participants had a mean age of 29 years (min: 20 and max: 48), 83% African, 54% rural and 45% urban, 59% engaged in sex with men but did not identify as MSM or gay. MSM are not a homogenous group and constantly navigate multiple and sometimes-contradictory religious and cultural expectations. Participants reported experiences of vulnerability, a sense of alienation and discrimination from family, friends, community members. Additionally, non-identifying MSM expressed persistent feelings of guilt, shame, and fear. Resulting in infrequent testing for HIV, little to no STI service access and sparse awareness of oral PrEP. Key disparities in awareness and access emerged along indicators of inequality, namely, younger men, those with few financial means, non-identifying men, men with multiple partners. Fewer opportunities for testing as well as social and system-wide barriers such as harmful gender norms, inaccessible or unfriendly services contributed to a lower uptake of HIV services.
CONCLUSIONS: The intersection of race with age, sexuality, and identity (identifying vs non-identifying), can negatively affect ones vulnerable mens' risk of HIV. These findings highlight the importance of multi-dimensional and cross-cutting healthcare access interventions to address the intersectional barriers experienced by MSM. MSM need to be involved as co-designers of interventions.

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