HIV infection levels among gay men or men who have sex with men in South Africa and many parts of the continent are generally higher than among heterosexual men. Studies suggest that there is an HIV prevalence of about 20% among men who have sex with men or MSM, while the prevalence among men in the general population is at 14.5%. Similarly, substance abuse is higher among men who have sex with men.

‘€œA young men’€™s survey     showed us that 66% of young MSM reported illicit drug use. Gay men are more likely than their heterosexual counterparts to use alcohol and drugs and initiate these at an earlier age’€, says Dr Greg Jonsson, a psychiatrist at Chris Hani Baragwanath Academic Hospital, south-west of Johannesburg.

Fellow psychiatrist, Dr Kevin Stollof, who works at the Ivan Toms Men’€™s centre in Cape Town, concurs. Between the beginning of 2010 and last month, Dr Stoloff has had over 180 mental health consultations. About 71% of the consultations have been with HIV-positive men. He says the substance abuse, due to HIV infection, is often accompanied by certain mental disorders.  

‘€œGenerally, if you’€™re HIV-positive, you’€™ve got double the chance of having anxiety, depression and substance abuse. And, of course, if you’€™re MSM, that’€™s higher. In addition to seeing those common mental disorders, we see HAND. This is HIV-associated Neuro-cognitive Disorder. These are problems in the brain with thinking, with concentration, with memory and with complex tasks like planning, monitoring one’€™s own social behaviour, abstract thinking, making meals, etc. So, we see a whole range of problems from minor subtle problems ‘€“ forgetting simple facts, forgetting names, slight clumsiness along to the middle of the road cognitive disorder to the severe dementias’€, Dr Stollof says.

Often, these young men are seen to go into a downward spiral. Many are not even aware of their HIV status and invariably continue to be at risk.  

‘€œThere’€™s less fear of HIV. There’€™s lack of awareness about HIV status. About 18% of young MSM know their status. There really is a propensity towards depression and substance abuse, causing lowered self-esteem and various other issues. Young people are more likely to report depressive symptoms and less likely to use counselling or medication for their psychiatric conditions. They are also more likely to report heavy alcohol and also, unprotected insertive and receptive anal intercourse. We know that psychiatrically ill adolescents are more likely to be sexually active, have more partners than those without psychiatric illnesses’€, says Dr Jonsson.

‘€œTherefore, we really need to spend time identifying psychiatric illness and treating them’€, he adds.

Dr Jonsson says two issues cause this. Both are stigma-related. One is stigma as a result of one’€™s sexual orientation and the other stigma induced by HIV infection.  

‘€œInternalised homophobia is very prominent – negative self images, concerns about public attitudes, real fears about disclosing one’€™s status.   Higher levels of HIV stigma are associated with negative outcomes, especially romantic loneliness, poor self-esteem, lack of social support. And then, also, sexual minority stigma associated with emotional and behavioural problems, anxiety, suicide and substance abuse’€.

Chief Executive Officer of Anova Health Institute, Dr James McIntyre, agrees that substance is a problem.

‘€œClearly, we know from experience in the US that what has driven a lot of the almost resurgent HIV infections in some areas is the use of crystal meth or tik. We’€™re seeing in South Africa an increasing use of tik. We’€™re seeing in South Africa an increasing usage of injected drugs. It’€™s a vicious circle of shame and guilt and stigma and discrimination and low self-esteem and then drug use and then back into a circle that, unfortunately, often involves HIV as well. We’€™re aware of it. But this is not something that’€™s only being seen in MSM’€, Dr McIntyre says.

These turn of events may lead to young men engaging in sexual activities prematurely. Often, there is no support network for these youngsters. The health care sector is also ill-prepared to cater to their needs.

‘€œWe need to start looking at the youth that are prone to coercive and unprepared sex. Many health care workers don’€™t know about the diversity of young MSM. And many psychiatrists don’€™t really know. So, what we really have to do is start educating other health care workers. We also need to look at the socio-economic determinants fuelling HIV transmission’€, says Dr Jonsson.