title: The Prevalence of Sexual Behavior Stigma Affecting Gay Men and Other Men Who Have Sex with Men Across Sub-Saharan Africa and in the United States.
abstract: BACKGROUND
  There has been increased attention for the need to reduce stigma related to sexual behaviors among gay men and other men who have sex with men (MSM) as part of comprehensive human immunodeficiency virus (HIV) prevention and treatment programming. However, most studies focused on measuring and mitigating stigma have been in high-income settings, challenging the ability to characterize the transferability of these findings because of lack of consistent metrics across settings.
  
  
  OBJECTIVE
  The objective of these analyses is to describe the prevalence of sexual behavior stigma in the United States, and to compare the prevalence of sexual behavior stigma between MSM in Southern and Western Africa and in the United States using consistent metrics.
  
  
  METHODS
  The same 13 sexual behavior stigma items were administered in face-to-face interviews to 4285 MSM recruited in multiple studies from 2013 to 2016 from 7 Sub-Saharan African countries and to 2590 MSM from the 2015 American Men's Internet Survey (AMIS), an anonymous Web-based behavioral survey. We limited the study sample to men who reported anal sex with a man at least once in the past 12 months and men who were aged 18 years and older. Unadjusted and adjusted prevalence ratios were used to compare the prevalence of stigma between groups.
  
  
  RESULTS
  Within the United States, prevalence of sexual behavior stigma did not vary substantially by race/ethnicity or geographic region except in a few instances. Feeling afraid to seek health care, avoiding health care, feeling like police refused to protect, being blackmailed, and being raped were more commonly reported in rural versus urban settings in the United States (P<.05 for all). In the United States, West Africa, and Southern Africa, MSM reported verbal harassment as the most common form of stigma. Disclosure of same-sex practices to family members increased prevalence of reported stigma from family members within all geographic settings (P<.001 for all). After adjusting for potential confounders and nesting of participants within countries, AMIS-2015 participants reported a higher prevalence of family exclusion (P=.02) and poor health care treatment (P=.009) as compared with participants in West Africa. However, participants in both West Africa (P<.001) and Southern Africa (P<.001) reported a higher prevalence of blackmail. The prevalence of all other types of stigma was not found to be statistically significantly different across settings.
  
  
  CONCLUSIONS
  The prevalence of sexual behavior stigma among MSM in the United States appears to have a high absolute burden and similar pattern as the same forms of stigma reported by MSM in Sub-Saharan Africa, although results may be influenced by differences in sampling methodology across regions. The disproportionate burden of HIV is consistent among MSM across Sub-Saharan Africa and the United States, suggesting the need in all contexts for stigma mitigation interventions to optimize existing evidence-based and human-rights affirming HIV prevention and treatment interventions.
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States. sstahlm1@jhu.edu.
authors.forename: Shauna
authors.identifier: http://orcid.org/0000-0003-2861-7734
authors.initials: S
authors.lastname: Stahlman
authors.forename: Travis Howard
authors.identifier: http://orcid.org/0000-0003-1133-4762
authors.initials: TH
authors.lastname: Sanchez
authors.forename: Patrick Sean
authors.identifier: http://orcid.org/0000-0002-7728-0587
authors.initials: PS
authors.lastname: Sullivan
authors.forename: Sosthenes
authors.identifier: http://orcid.org/0000-0002-6050-605X
authors.initials: S
authors.lastname: Ketende
authors.forename: Carrie
authors.identifier: http://orcid.org/0000-0001-8127-0704
authors.initials: C
authors.lastname: Lyons
authors.forename: Manhattan E
authors.identifier: http://orcid.org/0000-0002-1719-2796
authors.initials: ME
authors.lastname: Charurat
authors.forename: Fatou Maria
authors.identifier: http://orcid.org/0000-0002-7262-8636
authors.initials: FM
authors.lastname: Drame
authors.forename: Daouda
authors.initials: D
authors.lastname: Diouf
authors.forename: Rebecca
authors.identifier: http://orcid.org/0000-0002-8245-0077
authors.initials: R
authors.lastname: Ezouatchi
authors.forename: Seni
authors.initials: S
authors.lastname: Kouanda
authors.forename: Simplice
authors.initials: S
authors.lastname: Anato
authors.forename: Tampose
authors.identifier: http://orcid.org/0000-0002-6854-6339
authors.initials: T
authors.lastname: Mothopeng
authors.forename: Zandile
authors.identifier: http://orcid.org/0000-0001-6479-3773
authors.initials: Z
authors.lastname: Mnisi
authors.forename: Stefan David
authors.identifier: http://orcid.org/0000-0002-5482-2419
authors.initials: SD
authors.lastname: Baral
keywords: HIV; Southern Africa; United States; Western Africa; male homosexuality; mental health; social stigma; stigmatization