Self-identified bisexual men and implications for research, prevention and care in men who have sex with men: a mixed-method systematic review and meta-analysis in Southern Africa
Résumé
ntroduction In Southern Africa, men who have sex with men (MSM) face high levels of stigma and heteronormative pressure. Bisexual men constitute an MSM subgroup that should not be neglected in MSM studies or HIV programmes, especially because of the risk of HIV bridging to female partners. We aimed to provide a multi-level synthesis of bisexual men in Southern Africa and to explore the psychosocial, political and health context of male bisexuality there. Methods In compliance with the PRISMA guidelines, we conducted a mixed-method systematic review of published peer-reviewed articles studying self-identified bisexual men (SIBM) in Southern Africa. We performed a meta-analysis on the proportions of SIBM in cross-sectional quantitative studies on MSM. Pooled proportions were calculated using a random-effects model. Subgroup analyses were performed to estimate the effect of the country (South Africa vs. other) and of the study design (respondent-driven sampling and inference approach (RDS) vs. other) on SIBM proportions. Qualitative data were analysed with the three-step thematic synthesis methodology used for qualitative research in systematic reviews. Results Meta-analysis The pooled proportion of SIBM was 22%(95% CI [16;29]) (n=25 studies, Fig 1). Subgroup analysis showed significantly lower SIBM proportions in South Africa compared to other countries (15%[9-24] vs. 35%[28-43], p<0.001), and in studies not using RDS compared to those using it (11%[7-18] vs. 37%[32 43], p<0.001). Qualitative synthesis Two analytical themes emerged (n=37 studies): i) the perception of bisexual men (self, other MSM, healthcare workers), and ii) barriers to research, prevention, and care in bisexual men. Bisexual men often express strong internalized stigma and a desire to stay hidden. Other MSM (gay men) can either stigmatize bisexual men (by blaming them for HIV transmission from/to women) or, conversely, seek them out as sexual partners, because of the latter’s perceived discreteness and lower HIV risk. The lack of knowledge about bisexuality, its invisibilization in healthcare workers, the fear of being identified as an MSM, and a lower sense of community belonging compared to other MSM, were all important barriers to reaching bisexual men in healthcare facilities and in MSM community-based settings, in order to provide adapted prevention and care. Conclusion In the articles analysed, one fifth of MSM self-identified as bisexual in Southern Africa. Bisexuality may be a strategy to cope with social or internalized heteronormative pressure; this pressure is probably less present in South Africa where same-sex marriage is legal. Our quantitative and qualitative data show that bisexual men are a particularly hidden and hard-to-reach population because of various psychosocial factors. Adapted recruitment strategies are therefore needed in MSM research studies and HIV programmes to improve the representativeness of MSM subgroups, to enhance prevention and care for bisexual men, and to reduce the HIV/STI bridging risk to female partners. The present review reflects previous findings that protective laws and policies effectively reduce self-stigma in stigmatized populations, something which could have implications for public health.
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