The first reports of homosexual behavior in South Africa date back to the days of the Dutch East India Company settlement at the Cape of Good Hope, but address the criminal penalties for the conduct. Oosterhoff describes in ‘‘Sodomy at Sea and in the Cape of Good Hope during the eighteenth century’’ [1], a 1753 trial of a Dutch man and two Indian slaves, who had committed mutual masturbation at the chicken house at Robben Island, off the coast of Cape Town. The court records reflect that ‘‘not satisfied with their devilish frisky stimulation’’ they had also sodomized each other. The consequence, following their confession, was that the three were bound together with chains and thrown overboard into Table Bay. Attitudes towards men who have sex with men (MSM) changed little over the next 250 years. Homosexuality was variously ascribed as a foreign vice, brought in by white settlers, or by migrant workers. Visiting the gold rush town of Johannesburg in 1912, British traveller William Scully noted the occurrence in the predominantly male mining settlement [2, 3]. In his view, though, it was an ‘‘undoubted fact that the Natives from some of the East Coast recruiting areas, as well as from parts of the Tropics, are addicted to those unnatural vices which, according to Holy Writ, occasioned the destruction of the Cities of the Plain’’. The apartheid era brought new controls and legal restrictions, with the ruling National Party viewing homosexuality as a ‘‘threat to white civilization’’ [4] and culminating in the 1960s in a clause in the Immorality Act known as the ‘‘three men at a party clause’’. This criminalized any ‘‘male person who commits with another male person at a party any act which is calculated to stimulate sexual passion or give sexual gratification’’, and defined a ‘‘party’’ as ‘‘any occasion where more than two persons are present’’. Clearly, 250 years of criminalization and repression did nothing to eradicate male same sex behavior, but there was very little research in the biomedical field in this population, until the advent of the first cases of AIDS in South Africa in white gay men in 1983 [5, 6]. Initially seen as a gay disease, HIV in South Africa rapidly developed into a generalized heterosexual epidemic over the next few years. One consequence of this was that government funded awareness and prevention campaigns became increasingly heterosexually focused and silent on MSM issues, and very little specific information or MSM targeted services were available, other than through a few small non-governmental groups. Following the political change in 1994, came the new 1996 South African constitution, which, uniquely in Africa, bans discrimination based on sexual orientation. In 2006, South Africa became the fifth country in the world to legalize same sex marriage. Public opinion, and the expressed views of some politicians and parliamentarians, while currently more accepting of same sex practices than most other African countries, do not fully support this, and stigma still abounds. J. A. McIntyre (&) H. Struthers Anova Health Institute, 12 Sherborne Rd, Parktown, Johannesburg 2193, South Africa e-mail: mcintyre@pixie.co.za