Abstract
Key populations (for HIV) face disproportionate levels of stigma, substance use issues and psychological distress. Key populations are individuals who are at a higher risk of contracting HIV than the general population due to their high-risk sexual and substance-use behaviours. They include people who inject drugs (PWIDs), female sex workers (FSWs), transgender and gender diverse (TGD) people and gay, bisexual and other men who have sex with men (GBMSM). The stigma they face includes structural barriers such as lack of access to healthcare and protection services and social barriers such as isolation and victimisation. This study aimed to investigate the co-occurrence of substance use issues and psychological distress (PD) in South African key populations. It also aimed to investigate the types of stigmas experienced, the levels of stigma distress and stigma’s role in substance use issues and PD. Finally, it explored the role of stigma in seeking healthcare for mental health and substance use issues. A mixed methods design was employed, where a quantitative online survey consisting of the Tobacco, Alcohol, Prescription Medications, and Other Substance (TAPS) tool, Depression, Anxiety and Stress Scale (DASS-21), Substance Use Stigma Mechanism Scale (SU-SMS), Sex-Work Related Stigma Scale and the Daily Heterosexist Experiences Questionnaire (DHEQ) was completed online and in person by 240 participants (60 per population group). Follow-up qualitative interviews were conducted with 17 participants (2 PWIDs, 5 FSWs, 5 GBMSMs, and 5 TGD participants) in person or via WhatsApp call. The results showed an overall difference between gender and sexual minorities and those with criminalised behaviours. The results first revealed a co-occurrence of PD and substance use issues across all key populations, with PWIDs having the highest overall substance use and PD scores, followed by FSWs, TGD participants and GBMSMs. Qualitative interviews also revealed this co-occurrence, with participants reporting how they used substances to deal with mental health difficulties. Secondly, the results indicated that specific stigma experiences functioned as risk factors for both PD and substance use issues. PWIDs experienced the most extreme stigma experience and distress, such as being denied access to healthcare, facing violence, lack of support and financial instability. FSWs experienced the second most extreme stigma experience and distress, such as police brutality, client violence, and structural discrimination. TGD participants experienced transphobia, social rejection, and barriers to healthcare, with the third most extreme results. GBMSMs had the least stigma experience and distress, with coping mechanisms acting as a buffer for stigma. Thirdly, qualitative findings revealed that stigma was a core contributor to PD across all population groups, with the highest levels of PD amongst PWIDS, followed by FSWs, TGDs and GBMSMs with the lowest PD levels. Finally, qualitative interviews revealed that stigma hinders key populations seeking healthcare. PWIDs were disproportionately affected by systemic stigma, with no access to healthcare, leading to them being exposed to further health risks. FSWs described
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experiences of discrimination and judgment by healthcare workers, leading to distrust and underutilisation of mainstream services. On the other hand, TGD participants and GBMSMs faced barriers related to healthcare providers’ lack of knowledge in specialised LGBTQ care, leading to them seeking LGBTQ-friendly services. This study revealed the nuanced role of stigma across the key population groups. These findings inform healthcare and community interventions and policies tailored to these populations.