Does anal sex stigma impede engagement of men who have sex with men in HIV services and sexual prevention strategies? A mixed-methods study with structural equation modeling

Abstract

Background: Men who have sex with men (MSM) continue to have the highest rates of HIV infection in the United States. Combinations of biomedical and behavioral interventions could lower incidence, but engagement of MSM has not occurred at the pace necessary to curb the epidemic. HIV primarily infects MSM during anal sex and social factors like stigma toward sexual behavior are likely barriers to healthcare engagement and HIV prevention in general. Objectives: We examined men’s perspectives on stigma toward anal sexuality, and sought to quantify the effects of this devaluation on their sexual concerns and their engagement in HIV services and safer sex practices. We proposed a conceptual model based on theory and literature, and hypothesized that stigma impedes engagement, mediated through elevated concerns. Methods: We conducted online searches and qualitative interviews (N = 35) to develop two new quantitative measures, an Anal Sex Stigma Scale (ASS-S) and an Anal Sex Questions Index (ASQx); refined these in an online sample of MSM (N = 218); then tested our conceptual model of their effects on engagement in a new online sample (N = 1263). Results: The final model accounted for 75% of the variance in engagement, had good fit, and found evidence for the effects of all factors. We did not find evidence of mediation by ASQx, but did find evidence that ASS-S impedes engagement (β = -.28, p < .001), wholly mediated by men’s discomfort talking about sexual orientation and anal sex practices with health workers, after controlling for informational and emotional social support specific to anal sex and socioeconomic status. Conclusions: How MSM cope with stigma and concerns specific to anal sex may not be readily known or easy to disclose and address within healthcare settings, but may inform novel engagement strategies. While interest in specific questions about anal sex are not directly associated with poor engagement, responding to these questions may function as social support, and to some extent encourage greater engagement. Interventions that bolster men’s emotional and informational social support with regard to anal sex may inoculate some men against the concealment effects of anal sex stigma.