Exploring the use of Healthcare Services and Antiretroviral Therapy among HIV Positive Men Who Have Sex with Men (MSM) in Nigeria: A Qualitative Study

Despite the large body of evidence suggesting that African MSM have poor healthcare seeking behavior, there remains a paucity of research especially qualitative research exploring healthcare seeking practices among Nigerian MSM. This thesis provided a nuanced exploration of the ‘lived’ experiences of HIV positive MSM as they seek to access healthcare services including adhering to antiretroviral treatment (ART) in Nigeria. The central argument of this thesis is that highly valued legal, societal and religious guiding precepts of Nigerian society coupled with the double stigmatizing identities of being both HIV positive and MSM are propagating the everyday stigma, discrimination and extreme violence, which they experience. These stigma, discrimination and violence further act to negatively influence the healthcare seeking practices of HIV positive MSM, especially the extent in which they are able to gain access to healthcare services and adhere to ART. In exploring the lived experience of HIV positive MSM, a qualitative approach using Focus Group Discussions (FGDs) and an Semi-Structured Interview were employed. A total of 4 FGDs and 21 interviews were conducted in both Lagos and Abuja, Nigeria, between January and May 2016. Data were analysed iteratively using both thematic and individual analysis in order to obtain a comprehensive picture of the men’s lived experiences. Findings reveal that HIV positive MSM access sexual and HIV related healthcare services from facilities which are specifically targeted at their population. This is due to the experience of stigma and discrimination as well as the fear of persecution at general healthcare facilities. When they do seek healthcare services from general healthcare services, in a bid to conceal their sexual orientation and avoid stigma or persecution, they falsify symptoms and this leads to misdiagnosis and in some cases death. This thesis reported on a form of stigma ‘Kito’, which is driven by the criminalisation of homosexuality, poverty, social media, religion and norms of the society. This thesis also revealed that HIV positive MSM living in Nigeria lacked knowledge about the transmission of HIV through anal sex and therefore engaged in anal sex as a protective behavior leading to their acquisition of HIV infection. MSM encounter challenges to adhering to ART which fall under patient, ART and social or structural related challenges. The study also highlighted that HIV positive MSM in Nigeria adopt strategies such as setting alarms, repackaging and breaking their ART in smaller easier to swallow pieces, selectively disclose their HIV status and conceal their ART in order to maintain optimal adherence to ART. Findings from this research can inform public health interventions geared at improving engagement with healthcare services including access and adherence to ART among this key population. Additionally, it raises the question of what an effective health education strategy for non-heterosexual men should look like in a context which is highly heteronormative and where same-sex practices and identities are criminalised.