Approximately 50% of sexually active gay men in the United Kingdom had unprotected anal sex in the last year, according to the results of the 2005 Gay Men’s Sex Survey, Consuming Passions, which has been published by Sigma Research. The survey also revealed that over 40% of gay men in the UK are unaware of their own HIV status and most sexual encounters occur between men who have not disclosed their HIV infection status.
The study showed in no uncertain terms that a significant amount of sexual activity was taking place that involved a very real risk of HIV transmission. Specifically, it was shown that approximately one-third of HIV-positive men (rising to over 50% of men with large numbers of partners) had had unprotected insertive anal sex with a man who was either HIV-negative or of unknown HIV status; that almost 20% of HIV-negative men had had receptive unprotected anal sex with a man of unknown HIV status, as had approximately a fifth of untested men (rising to 30% of untested men with the greatest numbers of partners).
Some myths about the causes of sexual risk taking were also dispelled by the survey. There has long been an assumption that gay men have low self-esteem, partly related to feelings about their attractiveness, and leading to risky sex. However, few men in the survey reported rating their attractiveness as below average, and HIV-positive men were the most likely to rate their looks as better than the norm.
The ninth Gay Men’s Sex Survey was completed by almost 16,500 men in the summer and early autumn of 2005.
Recent sexual activity
Almost all the men (94%) said that they had had sex with another man in the previous twelve months, with 48% of men said that they had between two and twelve partners over the last year, and 11% reporting 30 or more partners.
Because unprotected anal sex is the sexual activity that involves the greatest risk of HIV transmission, a large part of the survey was devoted to establishing the level of recent condom use by gay men, the reported HIV status of unprotected sex partners, and levels of, and factors associated with, condom failure.
Large numbers remain untested
Large numbers of gay men remain untested for HIV in the UK, with 44% of those completing the survey saying that they had never had an HIV test. Of the men who reported testing negative, 56% had done so in the last year. Although only 7% of the entire sample said they were HIV-positive, this rose to 12% when the investigators restricted their analysis to men who had had a test. Some of the HIV-positive men had been living with the infection for 20 years, but approximately 50% of all men with HIV had had their infection diagnosed within the last five years.
Unsurprisingly, HIV prevalence was highest amongst gay men in London, (12% versus 4% elsewhere in the UK), but the proportion of men recently testing positive was similar across the country at approximately 4%. Although younger gay men have often been viewed as a group particularly vulnerable to HIV infection, the study revealed that the age group with the highest proportion of infections in the last year was 35 – 39.
Unprotected sex with men of different or unknown HIV status
The overwhelming majority of HIV-positive men (79%) said that they had had no unprotected anal sex with men who they knew to be HIV-negative, however, 46% reported having anal sex without a condom with men who were also HIV-positive, and 43% said that they had had unprotected sex with men whose HIV status they did not know.
Only 4% of HIV-negative men said that they had had unprotected sex with a man they knew to be HIV-positive, although approximately a third of HIV-negative men reported risky sex with a man whose HIV status they did not know. Of the untested men, only 1% reported unprotected sex with a man they knew to be HIV-infected, with over a quarter saying that they had anal sex without a condom with a man whose HIV status was unknown to them.
Despite these efforts to minimise the risk from unprotected anal sex, the survey did show that significant numbers of men were engaging in sexual activity that could involve the risk of HIV transmission: 29% of HIV-positive men (rising to over 50% of men with 30 or more sexual partners) reported unprotected insertive anal sex with a man of unknown HIV status in the last year; 19% of negative men reported receptive anal sex with a man of unknown HIV status in the last year; and, 19% (rising to a third of the those with 30 partners or more) of untested men had receptive anal sex without a condom in the previous twelve months with a man whose HIV status they did not know.
Over half of gay men reporting anal sex report inconsistent or no condom use
Insertive anal intercourse was reported by 74% of men. Of these men, 48% said they always used a condom, 39% said they sometimes used a condom, and 13% said they never used a condom. Of the 70% of men who reported receptive anal intercourse, 46% said they always used a condom, 40% said they sometimes used a condom, and 14% reported never using a condom.
When asked directly about their condom use for anal sex, 39% of the entire sample reported inconsistent use for insertive anal sex, and 38% of all men said that they sometimes or never used condoms for receptive anal sex.
Although HIV-positive men were the group most likely to report any condom use, they were also most likely to report inconsistent condom use.
Condom failure
The survey also sought to establish the proportion of men who had experienced condom failure (for example, slippage or breakage) in the last year. Of the men who had used condoms, 13% said that they had failed in some way. Condom failure was significantly associated with inconsistent use. Other factors associated with condom problems were anal sex for 30 minutes or more; the use of either no lubricant or saliva or a non-water based lubricant; using an inappropriately sized condom; younger age; lack of an education post 16; lower annual income; being a practicing Muslim; having sex with men of unknown or different HIV status; having 30 or more sexual partners a year; and drug use
Factors associated with risky sex
Factors significantly associated with HIV-positive men having unprotected insertive sex with men who were either HIV-negative or of unknown HIV status were: being in a serodiscordant or unknown status relationship; having 30 or more sexual partners; rating attractiveness as better than average; and drug use (all p
HIV-negative men having unprotected receptive sex with men who were HIV-positive or unknown HIV status were significantly more likely to: live in southern England or Wales; be aged under 20 or over 50; be black British or white British; have less or no education post-16; to earn less £20,000 a year; to be in a serodiscordant relationship or in a relationship with a man whose HIV status they did not know; to have had 30 or more sexual partners in the last year; and to use drugs (all p
Where now?
The authors recommend that interventions should be targeted at so called ‘naïve risk taking’ – men having unprotected sex with men whose HIV status is unknown. Men with large numbers of sexual partners should be a special focus of such interventions.
Health promotion campaigns should also, the authors recommend, be targeted at men who know that their partners are of a different HIV status, particularly if they have large numbers of partners.
Attractiveness
Low self-esteem has for many years been seen as one of the reasons why gay men take sexual risks. Some health promoters had expressed concern that men who have a poor perception of their attractiveness are likely to engage in HIV risk behaviours.
However, the survey found that most gay men (51%) thought that they were as attractive as men of the same age, and that 37% thought they were either somewhat more attractive than the average or much more attractive than average. Only 12% of men thought they were either less, or somewhat less attractive than average.
The study found that HIV-positive men were more likely than either HIV-negative or untested men to rate their attractiveness as higher than average. Furthermore, HIV-positive men who thought of themselves as attractive were more likely to have unprotected insertive anal sex with men who they knew to be HIV-negative or whose HIV status they did not know. Unsurprisingly, the survey also found that men who rated their attractiveness highly had the greatest number of sexual partners.
Hickson, F et al. Consuming passions: findings of the United Kingdom Gay Men’s Sex Survey 2005. Sigma Research, 2007.