Gay men’s HIV prevention in UK must focus on men under 30 and those with large numbers of sexual partners, says Sigma Research

HIV prevention activities in the UK need to prioritise men under the age of 30 so that interventions reach men before they are infected, say the authors of this year's report on the Gay Men's Sex Survey, an annual survey that was completed by more than 12,000 men in 2006.

Moreover, as men with large numbers of sexual partners are more likely than other men to be become HIV-positive and engage in risky sex, prevention must also target this group.

Most prevention activities with gay and bisexual men in the UK are carried out by organisations that have endorsed the collaborative planning framework Making it Count, published in 2003. The framework recommends that the priority populations for prevention activities should be men with diagnosed HIV, and among those without HIV, the following groups: younger men, men with larger numbers of sexual partners, men in sexual relationships with men with HIV, men with lower rather than higher levels of education, and black men.

However there are doubts over the extent to which current prevention activities effectively target these groups.

The annual Gay Men’s Sex Survey uses a self-completion questionnaire that is available in a booklet form (distributed by health promotion organisations) and in an online version (promoted by a number of commercial gay, health promotion and gay community websites). In 2006 12,155 valid responses were received from gay or bisexual men living in the UK.

Age

The mean age of participants was 35.2. The sample included 7% under the age of 20, 30% in their twenties, 29% in their thirties, 21% in the forties, and 13% aged 50 and above.

The questionnaire asked both about having ever tested positive for HIV, and having done so in the last year. The prevalence of diagnosed HIV was lowest in those under 20 and rose as men got older (rising to 13.4% for men in their forties), before declining as men got older.

There was a similar pattern for new diagnoses in the last year (incidence). This was lowest for men under 20 (0.2%), rose in those in their twenties (1.1%), peaked in men in their thirties (2.1%), before declining in those in their forties (1.1%) and in older men (0.6%).

The mean age at diagnosis was 35. Moreover, using CD4 counts at diagnosis, the Health Protection Agency has estimated that, for gay and bisexual men, the average time between HIV infection and diagnosis is five years. This suggests that the average age at infection was 30.

The researchers argue that prevention interventions must aim to reach men before they are infected with HIV, so they must be targeted towards younger men. In order to see whether this is taking place, health promoters will need to collect information on the age of men coming into contact with an intervention, and check that the average age is 30 or under.

Nonetheless, it is important to note that an additional priority group for HIV prevention programmes are men who already have HIV (as HIV transmission always involves an HIV-positive person), and this group tends to be older.

Other information was provided on age. Firstly, men in the survey who had had either any anal sex or unprotected anal intercourse (UAI) in the previous year were younger than those who had not. Whereas 61% of men in their twenties had UAI, this figure was 53% and 47% for men in their thirties and forties respectively.

Moreover in response to a number of knowledge and awareness statements that are used to indicate HIV prevention needs, the younger men showed more unmet need. Men under 20 were most likely to hold a naive belief about the likelihood of HIV-positive men disclosing their status before sex, and were more likely to report knowledge deficits. Men in their twenties were also most likely to disagree with the statement “The sex I have is always as safe as I want it to be”.

Men with higher numbers of sexual partners

Respondents were asked to state the total number of men they had had sex with in the previous year. Overall, almost a quarter (22%) had sex with only one man in the last year and half (50%) had four male partners or less. A quarter (25%) had 13 or more partners and one-in-8 (12%) had more than thirty partners in the last year.

Having tested HIV-positive was much more common among men who had more sexual partners. Whereas less than 5% of men with four or less partners had tested positive, 12% of those with 13-29 partners and 20% of those with 30+ partners were diagnosed with HIV. There was a similar pattern for testing positive in the past twelve months.

In terms of risky sex, whereas 45% of men with between two and four partners had had unprotected anal intercourse (UAI) in the last year, 57% of those with more than 13 partners had UAI, and 64% of those with 30+ partners had UAI.

Moreover, the survey asked questions about the use of the recreational drug poppers during sex. These questions were asked because previous research has identified using poppers during receptive UAI with an HIV-positive partner to be a significant factor facilitating HIV transmission.

Using poppers during receptive anal sex was strongly associated with number of partners (use of poppers increased step-wise with numbers of partners). For example, compared to men with only one partner in the last year, those with 30+ partners were almost six times (OR 5.7) more likely to have used poppers during any receptive anal sex and 21 times (OR 20.8) more likely to have used them during receptive UAI with a partner not known to be HIV-negative. The last finding means that many of the men with most partners are also having one of the types of sex that is thought to be most risky.

Although men with many partners tended to have relatively high levels of knowledge about HIV transmission, they were much more likely to report that the sex they had was not always as safe as they wanted it to be. Whereas 2.5% of men with just one partner reported this, 15% of those with 30+ partners did so.

Finally the survey provides information about which demographic groups are more likely to have higher numbers of sexual partners. Having large numbers of sexual partners was very strongly associated with living with diagnosed HIV infection. Among men not diagnosed with HIV, having higher numbers of partners was more common among men in their 40s rather than older or younger men, and among men of Asian or White other ethnicity. However, men with very large numbers of partners were found among all sub-groups.