Gay, bisexual and other men who have sex with men in Scotland rarely talk explicitly about HIV status with their sexual partners, but make sexual decisions based on their beliefs about their own HIV status and that of their partners, argue the authors of a recently published needs assessment. This is a particular issue within long-term relationships, especially those in which men have sex with casual partners as well.
“There is a need to encourage men to question the safety of the assumptions they make about open relationships, and to equip them to find more effective ways of reducing their risks,” they write. “In particular, men in relationships should be encouraged to view joint HIV testing before ceasing condom use as cementing trust and commitment.”
The needs assessment was conducted by NHS Lothian and NHS Greater Glasgow and Clyde, the health boards which cover Scotland’s two largest cities. It included a case note review, examining the clinical records of men who have sex with men who were diagnosed with an infection suggestive of high-risk sexual behaviour; re-analysis of surveys conducted in commercial gay venues in Scotland in 2005, 2008 and 2010; interviews with 20 sexual health clinicians; and interviews with 154 men who have sex with men.
As described in another aidsmap.com article, the case note review showed that a significant proportion of men newly diagnosed with HIV or a rectal sexually transmitted infection (STI) had complex needs and overlapping vulnerabilities, such as problematic alcohol use, poor emotional wellbeing or social deprivation.
The bar surveys show that the proportion of men who have ever tested for HIV has increased in recent years. But only a minority of men test as regularly as recommended by public health officials – at least once a year. Looking specifically at those men in the bar surveys who reported unprotected anal intercourse with casual partners, multiple partners or partners of unknown HIV status (and did not have diagnosed HIV), 55.0% had not tested in the previous year and 35.3% had never tested for HIV.
Similarly, the case note review of men diagnosed with an infection suggestive of high-risk sexual behaviour suggested that a large proportion of these men are taking a reactive rather than proactive approach to their sexual health. Only a minority came in for testing as a regular check-up, in the absence of symptoms. Four-in-ten men newly diagnosed with HIV or a rectal STI had the test because they had symptoms of infection. A quarter did so following partner notification.
Men who have never tested were more likely to be under the age of 26, live in rural areas and report bisexual behaviour. Men who have tested but not done so very often tended to be somewhat older, live outside the big cities and live in areas of social deprivation.
In the absence of recent HIV testing, men made assumptions about their own HIV status. They also made assumptions about the status of potential sexual partners and the safety of sex without condoms, often based on a man’s appearance, character or the simple fact that he hadn’t mentioned having HIV. Men rarely talked explicitly about HIV status with sexual partners, but still said that knowing a partner’s HIV status was an important component of sexual decision-making.
Younger men (under the age of 26) who were included in the case note review seemed especially likely to report having unprotected sex based on how well they knew a partner or a desire for intimacy, rather than knowledge of their own or their partner’s HIV status. The needs assessment found that young men tended to report high numbers of sexual partners and unprotected sex, but low perception of HIV risk and relatively poor knowledge of HIV prevention.
Serosorting (selecting partners believed to have the same status as oneself) was widely reported by the men with diagnosed HIV who subsequently acquired a rectal STI. In the case note review, 32.4% of these men said that their regular partner was HIV positive and 29.7% reported that all of their recent casual partners were HIV positive. The report notes that serosorting can help men living with HIV avoid being involved in HIV transmission, but often exposes them to sexually transmitted infections.
Moreover, the clinical notes indicated that the underlying motivations for serosorting were negative, suggestive of poor emotional wellbeing. Men living with HIV described feeling ‘damaged’ or ‘tainted’ and therefore undesirable to HIV-negative men, while others harboured anxiety about possible transmission, criminalisation or disclosure which limited their partner choice to other men living with HIV.
This was just one example of the stigma, discrimination and rejection experienced by men living with HIV that was highlighted in the needs assessment.
Both the surveys conducted in commercial gay venues and the case note review found strong evidence of risk behaviour while men were in relationships. The venue surveys showed that just under half (47.5%) of men reporting unprotected sex with casual or multiple partners, or partners of unknown or different HIV status, were also in a relationship. Half of these relationships were long-term (three years or more) but a third of men did not know their partner’s HIV status.
The case note review found that 39.8% of HIV-negative men diagnosed with a rectal STI were in a relationship at the time, as were 43.6% of men newly diagnosed with HIV.
Men in relationships often reported ceasing condom use with a partner as a symbol of trust, intimacy and commitment. Men tended to see this as low risk but many had not tested for HIV before making this decision.
Moreover, men in relationships who were included in the case note review often reported concurrent sexual relationships with other men, either in the context of an agreed open relationship, during threesomes along with their partner, or without their partner’s knowledge.
Many men described agreeing risk reduction strategies with their partners, for example that condoms must always be used with these casual contacts or that both partners will routinely screen for STIs and HIV. But many had agreements that were not clear or had not been spoken about since the agreement was first made; it was apparent that many men struggled to maintain these strategies.
The authors say there is a need to encourage men to question the safety of the assumptions they make about open relationships, and to equip them to find more effective ways of reducing their risks. In particular, they recommend that couples test together and share their results, before giving up condom use. They argue that this could be seen as an accepted stage of gay relationships, in the same way that testing is sometimes encouraged within heterosexual relationships. The authors believe that men in open relationships would be happy to discuss their relationships when attending a sexual health service, but need to feel confident that staff will understand the context of their relationships and not be judgemental.
More generally, the authors recommend a continued focus on regular HIV testing and the benefits of knowledge of HIV status in HIV prevention interventions. There is a need to support men to be more open in their conversations about testing, re-testing and HIV status in order to inform sexual decision-making.
“This requires support and education both for men disclosing HIV positive status and men hearing such disclosure,” they say.
Coia N et al. HIV Prevention Needs Assessment of Men Who Have Sex with Men, Scottish Government, 2014.