4.2.1.1 Role assumed during penetrative intercourse
The study found that the participants believed that MSM who assume an insertive role “top” were at a much lower risk of contracting HIV than their receptive partners “bottom”. These roles were neither exclusive nor related to sexual orientation for some participants who described themselves as “versatile/verse” since they assume both roles at different times. One participant mentioned that the fact that he is exclusively insertive and circumcised meant that his risk of acquiring HIV was lower. Some of the participants said that they have never adopted the insertive role as a protective measure although they feel safer when they assume this role during intercourse. This is verified in the statement below:
“I have also ensured that I don’t allow any penetration on me………..I read that being penetrated is more dangerous than being on top” (Kwena, 28 years).
“I think you are exposed either way. Some people think that if you are top then you are safer which is kinda true but I have never thought of it as a way to protect myself.” (Star Mor, 24 years).
The exclusively receptive participants believed that their insertive partners feel safe and protected by their sexual role hence they do not usually suggest protective measures which then increases the risk of the receptive partners. For example, one participant stated that: “I expect to be protected by the top guy. Being bottom doesn’t make me responsible for lube [lubricants and condoms. For tops unprotected sex is fine if they are circumcised but for us bottoms it’s riskier. I’m sick of tops not bringing lubes and condoms.” (Thando B, 24 years). The study also found that depending on sexual role there exists a difference in opinions regarding the responsibility to provide condoms and lubes. Some insertive partners argued
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that it was the responsibility of the receptive partner while in another cases; the receptive partner said it is the responsibility of the insertive partner.
“Being top gives me more power because the top controls the relationship and they are usually the decision maker even about condoms. But, when you have sex with a bottom, they always bring condoms with them” (Kabelo, 25 years).
“I expect to be protected by the one who comes to propose. Being bottom doesn’t make me responsible for lubes and condoms” (Kay Bee, 21 years).
4.2.1.2 Socio-economic status of partner
The participants’ perception of risk was evidently influenced by type of sexual partner. Many of the participants expressed reservations about engaging in sexual relations with men from a lower socio-economic status because they are assumed to likely be HIV positive, as they are supposedly less educated and subsequently less aware about HIV. This was expressed in the following statements:
“To be safe [from HIV] I start by getting to know them, particularly where they are going in life, their aspirations. For me, positive, inspirational people are the best” (Lekko Motion, 26 years).
“When you converse what you actually do is measure their wellbeing and sometimes you go home with the one whose well-being is okay with you and sometimes you don’t if his well- being doesn’t sit well with you…By wellbeing I mean the way he presents himself for example his accent, the way he talks or dresses tell you about his lifestyle. That’s perhaps a way of measuring their economic status” (Njabulo, 23 years).
4.2.1.3 Perceived promiscuity and discriminatory dating patterns
The participants made reference to perceived high levels of promiscuity in the MSM community with the belief that it placed them at increased risk of HIV. Some participants believed that promiscuity was high in male-to-male relationships because hormonally men are more sexually active.
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“Because most of them they just do sex anyhow. As you know we are males so we are very sexually active” (Leezy, 23 years).
“You must know the gay community is small, maybe out of 10 gay people 4 of them have slept with each other without knowing” (Njabulo, 23 years).
In addition to this, considering that the MSM community is small, they believe that the risk is further increased when particular members show preference for MSM who possess certain characteristics such as those who are non-effeminate and financially stable. The majority of the participants believed that this kind of behaviour was discriminatory and wrong as it has a negative impact in the sense that it promoted the promiscuity of those individuals who possess these desirable characteristics.
“Most gays select partners based on looks, socio-economic status, accent and all that leads to people narrowing their dating circle because everyone desires partners with the same characteristics. If everyone says no blacks/whites, no feminine, no you know those kind of characteristics then it reduces the number of your potential sexual partners and as you know already we are a minority. So this thing leads to people sleeping with the same people.” (Star Mor, 24 years)
“The gay community is small and people want straight acting partners. People shouldn’t be discriminated or forced to fit into heteronormativity” (Thando B, 24 years).
“Everyone wants a piece of me. Bottoms like me because I am focused, I have published articles, I am from a particular class, and my family is rich. They don’t like girly boys and I am like a real man” (Handsome, 21 years).
4.2.1.4 Preventive measured used
This study also revealed that risk perception is affected by the use of protective methods. The participants who used PrEP or PEP expressed that they felt much more protected than when using a condom. One participant, whose partner is HIV-positive, also stated that he perceived his risk of HIV to be lower because his partner is on anti-retroviral drugs and he is on Truvada (PrEP). Further to this, all participants felt safer when they combined condoms and lubricants.
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“I don’t feel safe with just a condom; I have even abandoned the mission before because of lack of lubes [lubricants]” (Panda, 29 years).
“I am on Truvada since 2016 second semester; trust me PEP, Prep and Truvada it works wonders. If I tell you that I started having unprotected sex with him last year after 1.5 years in a relationship, that’s when he also started his ARV treatment but I knew his viral load and CD4 count so I knew he couldn’t possibly infect me but I still used Truvada on top of that” (Star Mor, 24 years).
4.3. Factors causing inconsistent use of condoms