title: Depressive symptoms and substance use as mediators of stigma affecting men who have sex with men in Lesotho: a structural equation modeling approach.
abstract: Research on the relationship between sexual orientation-related stigma and risks for HIV among men who have sex with men (MSM) is limited. This study tests a hypothesis that substance use and depressive symptoms mediate the relationship between stigma in the health care system and HIV-related risk practices among MSM in Maseru, Lesotho.
  
  
  
  In 2014, we conducted a cross-sectional study among MSM in Lesotho accrued via respondent-driven sampling including a survey and biological testing for HIV. The hypothesis was tested using structural equation modeling.
  
  
  
  Of the 318 participants, 22.3% had experienced stigma in the health care system. Stigma in the health care system was associated with depression (β = 0.329, P = .018) and alcohol use (β = 1.417, P = .001). Noninjection illicit drug use (β = 0.837, P = .039) and alcohol use (β = 0.282, P = .000) significantly predicted number of sex partners. Stigma was directly associated with condomless anal sex (β = 0.441, P = .036), and no indirect association was found.
  
  
  
  Alcohol use and depressive symptoms mediate the relationship between MSM stigma in the health care system and reported number of sex partners. The implications are significant with a focus on the need for comprehensive interventions addressing stigma and mental health when aiming to improve more proximal HIV-related risk practices for MSM.
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Electronic address: wda2@jhu.edu.
authors.forename: Da
authors.initials: D
authors.lastname: Wendi
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Shauna
authors.initials: S
authors.lastname: Stahlman
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Ashley
authors.initials: A
authors.lastname: Grosso
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Sweitzer
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Sosthenes
authors.initials: S
authors.lastname: Ketende
authors.affiliation: Population Services International, Johannesburg, South Africa.
authors.forename: Noah
authors.initials: N
authors.lastname: Taruberekera
authors.affiliation: Ministry of Health, Maseru, Lesotho.
authors.forename: John
authors.initials: J
authors.lastname: Nkonyana
authors.affiliation: Matrix Support Group, Maseru, Lesotho.
authors.forename: Tampose
authors.initials: T
authors.lastname: Mothopeng
authors.affiliation: Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Stefan
authors.initials: S
authors.lastname: Baral
mesh_terms: D000328:Adult; D000367:Age Factors; D003430:Cross-Sectional Studies; D003906:Developing Countries; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control / Q000523:psychology*; D018451:Homosexuality, Male / Q000523:psychology* / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007927:Lesotho; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012309:Risk-Taking; D012747:Sexual Partners / Q000523:psychology*; D057545:Social Stigma; D019966:Substance-Related Disorders / Q000453:epidemiology* / Q000523:psychology; D055815:Young Adult
keywords: Depressive symptoms; HIV-related risk practices; MSM; SEM; Stigma; Substance use