The gay globe

In the last two years, three internet surveys in Europe, the USA and Asia asked over 200,000 gay men and other men who have sex with men (MSM) about sex, safety and stigma. Gus Cairns looks at some of the data, and finds a mix of the expected and unexpected and some challenging findings for HIV prevention.

HIV increasing globally in gay men

In high-income countries, gay men were the first group to start dying from HIV. Now, there are worrying signs that they may also be the last out of the epidemic. The percentage of the general population with HIV is decreasing slowly in most regions of the world but the proportion of gay men who have HIV is increasing in many of the same areas.

UNAIDS estimates that the peak year for new HIV infections was 1997;¹ here in the UK, overall HIV diagnoses per year peaked in 2005 and have since declined by 15%. In gay men, however, they increased by 35% in the same period.² France has seen the same pattern.³ In the US, new diagnoses run at a steady 48,000 a year, but in young gay men they increased by a third in the last four years, and in young, black, gay men by a half.⁴

The percentage of the general population with HIV is decreasing in most regions of the world but the proportion of gay men who have HIV is increasing in many of the same areas.

We are seeing a sequence of increases in HIV in MSM in Asian countries. In 2003, a study found that one in six MSM in Bangkok had HIV. Two years later it was nearly one in four and has stayed at that level. New diagnoses in MSM doubled in Japan and tripled in Taiwan between 2002 and 2007. The Philippines has seen a sevenfold increase in HIV diagnoses amongst MSM under 30 in the last four years. Wherever you look in Asia’s expanding cities, you find high levels of HIV among MSM: one in eight in Chonqing, China (up from one in 50 six years ago), one in six in Mumbai, one in three in Yangon.⁵ There are fewer reliable statistics from Africa, but surveys in high-prevalence countries there find that HIV in MSM is at least as high as it is in the general population, while in low-prevalence countries, such as Senegal, it is ten times higher.⁶

In some places discrimination against MSM is such that we’ve simply had no data. Up to 2009, for instance, only 158 of the estimated 350,000 people with HIV in Ukraine admitted they got it through male-male sex.⁷ HIV prevalence in gay men is now estimated at 8% in Russia and Ukraine, and one survey found that a quarter of MSM in the Ukrainian city of Odessa had HIV.⁸

A dangerous situation

This is, potentially, a dangerous situation if HIV concentrates amongst MSM in countries where to seek testing and treatment is potentially to expose yourself to persecution. The potential for intensifying the oppression both of gay men and of people with HIV is obvious.

Yet the threat of HIV in MSM tends to get downplayed by some of the big global organisations. The Global Forum on MSM & HIV – see www.msmgf.org – was so troubled by the low level of acceptance of papers on MSM submitted to the International AIDS Conference this year, they called for rejected abstracts so they could be featured at the MSMGF pre-conference.

One excuse sometimes given for neglecting MSM is that they are hard to reach, so we don’t know enough to design prevention and treatment programmes to meet their needs. It’s now become a lot harder to make that claim.

In 2010, three regional surveys took place in different parts of the world, utilising a phenomenon that has led to more contact between MSM, more activism, more awareness, more sex and – unfortunately but perhaps inevitably – more HIV:  the internet.

Three surveys

First off the blocks was the Asia Internet MSM Sex Survey (AIMSS), spearheaded by the Singapore-based gay website Fridae, in partnership with the University of Pittsburgh and 40 in-country MSM organisations. This was an expanded, multilingual version of the first survey ever done in Asia, which Aidsmap reported on in 2010.⁹ The new survey was completed by 13,883 men in twelve countries stretching from Thailand to Japan in January and February 2010, asking about their sexual behaviour in the previous six months, drug use, how they met other men, and whether they discussed HIV. It published a preliminary report in July 2010¹⁰ and several papers on its findings have appeared in the last few months.^11,12,13

The Online Buddies Men’s National Sex Study (MNSS) was completed in October 2010, by 24,787 gay men in the US. It was also a collaboration between a commercial gay site and an academic institute, in this case Manhunt and the Center for Sexual Health Promotion at Indiana University. MNSS was a rather different kind of survey. Head researcher Joshua Rosenberger is concerned that an over-emphasis on HIV risk fails to capture the variety of gay men’s sex lives and turns sex between men into a problem. So MNSS asked people what they had actually done the last time they had sex – both in order to widen the discussion beyond conventional ideas of safer sex, and because it’s easier to remember what you did last time than during the last six months. For the same reasons they deliberately excluded HIV status from their published papers about the survey^14,15 and from the entertaining and inventive front-page ‘report’ on some of the findings which came out a year later (see www.mensnationalsexstudy.com).

There are enough data in these studies to keep an army of academics busy for several years.

These two surveys got nearly 40,000 gay men in two parts of the world to talk about their sex lives; two to three times as many as the single largest national survey of sex – gay or straight – ever conducted. Impressive? These were dwarfed by EMIS, the European MSM Internet Survey,¹⁶ which took place from June to August 2010. EMIS collected six times as many responses – a total of 181,490.

EMIS was a large, European Union-funded collaboration co-ordinated by the Robert Koch Institute (RKI) in Germany, in collaboration with other research institutes such as Sigma Research in the UK, commercial websites, academics, and literally hundreds of local partnership organisations. It took place in 38 different European countries and was conducted in 25 languages.

EMIS was helped by the involvement of several commercial internet sites such as Gaydar, Manhunt and Planetromeo, which sent out individual messages to their subscribers urging them to do the survey. Germans completed the largest number of surveys – some 56,000 – but by involving local sites such as Qguys in eastern Europe, useful numbers of responses came from countries like Russia (5263 respondents) and Ukraine (1787) where we’ve known little before. The final report on EMIS has been delayed but the EMIS website features two community reports giving interesting interim data from the survey.¹⁷ National reports, including raw data from the UK,¹⁸ have started to appear.

The findings

There are far too many data to include every interesting finding – the draft report on EMIS alone comes to 248 pages and that only mentions a tiny fraction of what can be gleaned. So what follows is a sample of interesting facts and themes, rather than any systematic review.

We’re going to compare some results across surveys. Researchers hate doing this, because so much depends on who answers the survey and how questions are asked but we’re not scientists here, so here goes.

Age and education

The age of respondents was 38.5 (mean) in the US survey and 34.1 in the European, and the median age in the Asian one was 29. In EMIS, the age of respondents changed smoothly from 35 in the west to 29 in the east, with extremes in the Netherlands (40) and Moldova (25). In the US and western Europe, it’s been getting easier to be out as gay to yourself and others for a long time; in eastern Europe and Asia we are seeing a young, educated new generation coming out for the first time.

This showed in the statistics on education and where people lived. On average, more than half of respondents in all three surveys had a college or university degree. In EMIS, however, this ranged from 34% in the central-west countries (Switzerland, Germany, Austria) to 72% in the former USSR; similarly, while only a quarter of central-west respondents lived in a big city, three-quarters of east Europeans did.

In the UK, the age distribution was interesting: London had half as many men under 20 and a lot fewer men over 50 than the rest of the country, suggesting that gay men may gravitate to the capital city in their 20s but tend to move away as they age.

Sexuality and relationships

At least three-quarters of men defined themselves as ‘gay’ in the surveys; 13% in the US, 15% in Europe and 16.5% in Asia said they were bisexual. Very few used other definitions. In EMIS, a lower proportion defined themselves as exclusively gay in the east.

Only a minority had a primary partner. In Asia, only 33% of men had been in a relationship for more than six months, and in the US 42% had had one for more than three months. In EMIS, the pattern wasn’t necessarily what you’d expect: 41% of people in the western European countries (UK, France, Belgium) had a partner and about a third in the Mediterranean countries and the Balkans: but the highest proportion with a boyfriend was in the former USSR and a higher proportion of them lived with their partner. Western Europe, however, had by far the highest proportion of people in a long-term relationship (over ten years): 22%, compared with just 5% in former eastern-bloc countries.

Sex and condoms

About 85% of gay men in all three surveys had had anal sex during the previous six months or a year, but methodology of the US survey revealed that they certainly didn’t do it every time. Only 37% had anal sex last time they had sex, and other activities were much more common: in MNSS and EMIS, three-quarters of men had given or received oral sex last time they had sex, and oral sex was more popular than mutual masturbation.

Although the condom statistics are stated in many different ways, in MNSS and EMIS at least, ‘[using] a condom every time’ was a minority behaviour. In EMIS 58% of respondents reported at least one episode of unprotected anal intercourse during the last year. In MNSS, only 45.5% of men used a condom the last time they had anal sex and the only age group in which more than half (52%) used condoms last time was the under-25s. There was a steady decline in condom use with age, and the over-50s were, in the US survey, half as likely as the under-25s to use a condom. There were interesting ethnic differences: African-American, Hispanic, and Asian men were all significantly more likely to have used a condom the last time they had anal sex compared to their white counterparts.

In AIMSS, rates of condom use were higher, with only 41% of respondents saying they’d had unprotected anal sex over the last six months. However, it found much lower rates of use amongst its minority of HIV-positive men.

Is condom use the best indicator of risk?

One particularly fascinating finding came from MNSS and somewhat vindicated its taking the focus off condom use. The most common safer-sex strategy in the MNSS respondents was not “Use a condom with me” but “Don’t cum in me”. Semen was seen as highly erotic by MNSS respondents: 84% said it was arousing, 61% said they liked the taste and 51% said they liked it inside them. But when it came to it, relatively few actually let someone ejaculate in them anally or did it to their partner last time they had sex even with a condom – 15.5%, to be exact (12.5% let their partner come in their anus when wearing a condom and 11.3% did it to them while wearing a condom).

Only 20% of those who let their partner come in their anus and only 23% of those who came in their partner’s did not use a condom. This means that anal sex without a condom and with ejaculation only occurred in 2.5% of respondents’ recent encounters. Coming in other places was more popular: 32% in their face or mouth and 25% on their chest.

This may indicate that much more nuanced safer-sex messages are needed. Gay men are attempting to use more ways to protect themselves than are endorsed by standard prevention messages. Some may be very flawed, but others may offer significant protection and should be encouraged. In the ART era, there have been few studies of the per-contact risk of HIV infection in gay men, but one that did look at this found that if withdrawal happened before ejaculation, there was less than half the risk of HIV transmission.¹⁹

HIV prevalence and testing

In Asia, an overall 6% of respondents had been diagnosed HIV positive, ranging from 2% in China to 12% in the Philippines. In Europe, the overall rate was 4.1%, ranging from 15.6% in the Netherlands to zero in the 163 respondents from Bosnia. MNSS in the US didn’t publish HIV rates but in its 2009 survey HIV prevalence was 14.5%.

Seventy per cent of EMIS respondents had ever tested for HIV. About a third (35%) had tested in the last year – exactly the figure for the UK. Testing frequency tended to follow national HIV prevalence with high levels in western Europe, the Mediterranean and former USSR, and lower levels in central Europe, though with several exceptions. France had the highest proportion of men who had taken a test in the last year (47%) and Lithuania the lowest (20%).

One particularly alarming finding in EMIS was that there was no correlation between taking an HIV risk in the last year and having had a test. The proportion of men who’d had unprotected sex with a casual partner of opposite or unknown HIV status in the last year and who had also had a test ranged from 40% in western Europe to 20% in the Baltic states.

Just under 60% of Asian respondents (80% in Thailand, under 50% in the Philippines) had ever tested for HIV and about a quarter in the last six months, ranging from a third in Thailand and South Korea to one in five in the Philippines – a similar frequency to Europe.

HIV incidence

In Europe, the proportion of men who’d taken an HIV test in the last year who had received a positive result was used to give a rough indication of the ‘hotness’ of the epidemic; some worrying signs were found of a sharp increase in HIV in eastern Europe. The proportion of those who tested positive was about a third in Romania and Bulgaria and about a quarter in the other former communist countries, but only one in eight in western Europe and one in 14 in Scandinavia.

The Asian survey did not seek to establish HIV incidence in respondents in the same way, but one of its reports²⁰ mentions that HIV incidence in MSM in recent surveys is particularly high in some cities, especially in what has hitherto been relatively low-prevalence mainland China: last year it was found to be 5.1% a year in Nanjing and 7.6% in Chongqing, the kind of incidence only seen in rapidly expanding epidemics.

HIV treatment and treatment as prevention

The age of the epidemic was related to the proportion of men with HIV on antiretroviral therapy (ART), which ranged from just over 40% in Russia and Ukraine to 87% in Denmark and 78% in France. Older epidemics tended to have more people successfully suppressing their viral load on ART too. In the Netherlands, 88% of people on ART had an undetectable viral load, compared with only 51% in Ukraine. In Romania, Poland and Russia, fewer than 75% of people on ART had an undetectable viral load (also the case, strangely, in Norway). With the exception of Norway, ART success was also correlated with the Human Development Index of the country, i.e. its prosperity.

One really interesting, and strong, correlation was between the proportion of people with HIV who were on ART and the growth rate of the epidemic. To take the extremes, in Denmark 87% of those with HIV were on ART and the annual HIV epidemic growth rate was estimated at 6.5%; in Ukraine just 44% of those with HIV were taking ART and the epidemic growth rate in respondents was estimated at 25%. This may be indirect evidence for the success of treatment as prevention – or it could just be an indicator that in younger epidemics, fewer people are on treatment.

Happiness, disclosure and isolation

Each survey sought to establish emotional indicators of sexual happiness, not just cold facts about viruses, condoms and semen.

EMIS asked its respondents how happy they were with their sex lives and found a wide variation. In France only 28% were unhappy with their sex lives, while in Bosnia – at the other extreme – 60% were unhappy with theirs (Brits were somewhere in the middle). Bosnians, Macedonians, Cypriots and Swedes were more than 30% unhappier with their sex lives than the British; Belgians, Dutch, Spaniards, Portuguese, Swiss and French were more than 40% happier.

One challenging correlation, presented by Ford Hickson of Sigma Research at the European gay men’s prevention conference (FEMP) in Stockholm in November 2011,²¹ is that there is a strong correlation in EMIS between happiness and HIV prevalence: Bosnia, sexually the unhappiest country, was also the one whose small group of respondents reported no HIV infections: conversely, the Netherlands and France reported amongst the highest rates of happiness and the highest HIV prevalence rates.

In many ways this is a no-brainer: more sex is likely to mean more HIV in a situation where condom and other safe-sex usage rates are roughly equal. In the UK, for instance, the one area that stood out for conspicuous sexual dissatisfaction in gay men was the Scottish Highlands, and highlanders also reported a distinctly lower rate of sex generally – for obvious reasons of geographical isolation.

One contrasted finding in the surveys that dealt with HIV was disclosure of HIV status. In EMIS, only 5.6% of respondents who had HIV had never disclosed their HIV status to any sexual partner, with the highest ‘never’ rate found in the Baltic states (13.3%).

In Asia, HIV status disclosure – to any sexual partner – was the exception rather than the rule: 67% of HIV-positive respondents had never discussed their HIV status with a partner, and in mainland China that was 88%. Perhaps as a consequence of this, a much higher proportion of HIV-positive respondents in AIMSS with a main relationship were in one with a partner of unknown or negative status: lack of disclosure makes serosorting impossible. Condom use was no higher in serodiscordant encounters or relationships than in others. In many Asian countries, disclosure of personal issues such as health is in general more taboo than it is in the West and this poses a huge challenge to disclosure-based risk reduction practices.

In Europe, as we said above, the risk was more that men may falsely believe themselves to be HIV-negative, given that recent testing did not correlate with recent risk.

In fact, the HIV-positive minority formed a highly isolated minority in AIMSS, with very different risk patterns from the majority: a far higher proportion had unprotected sex, drank or took drugs, and went to saunas or sex parties, than the majority.

Much more to report

There is a huge amount of data not covered in this article, especially from EMIS: I have missed out, for instance, fascinating findings on STI treatment (showing that the UK has one of the best STI services in Europe); migration (showing that people from minority ethnic groups were almost universally at higher risk of HIV, in whatever country); travel (showing that a high proportion of gay men took their last HIV risk abroad: Germany [probably Berlin] and Spain were the most popular ‘dirty weekend’ destinations); and on a huge number of different ways of measuring anti-gay and HIV stigma and its effects. MNSS also had a number of other findings, including that older men have just as much sex and find it more satisfying than younger ones.

There are enough data in these studies to keep an army of academics busy for several years, and the researchers are not stopping here: the MNSS model is likely to be extended to a South American gay men’s sex survey and both AIMSS and EMIS intend re-runs in the next year or two. Now it’s time to pull all the data together and from them, as Making it Count, the UK’s HIV prevention planning document says, find ways of helping MSM have the best sex with the least harm.

Top ten findings

1. In the US, avoiding ejaculation in a partner was a more popular safer-sex strategy than using condoms.
2. In European countries, the happier people were with their sex lives, the higher the HIV prevalence in their country.
3. In Europe, only 4% of HIV-positive men had never discussed their HIV status with a partner. In Asia, only 33% had ever discussed it.
4. In Europe, the higher the proportion of men with HIV who were on treatment, the lower the growth rate of the HIV epidemic in that country.
5. In the US, only 42% of men had anal sex the last time they had sex. Oral sex was much more popular.
6. In Europe, the highest HIV prevalence was in western Europe but the highest rate of new infections was in eastern Europe.
7. In Asia and Europe, about a third of men had tested for HIV in the last year, though this varied from 20 to 40% according to country.
8. In Europe, higher HIV risk did not mean more testing: men who’d had unprotected casual sex didn’t test any more often.
9. The European survey shows that a high proportion of gay men took their last HIV risk when they travelled abroad: Germany and Spain were the most popular sex destinations.
10. In the US, older gay men had just as much sex as younger ones – and enjoyed it more.

Thanks to Axel J Schmidt and Ford Hickson (EMIS), Joshua Rosenberger and David Novak (MNSS) and Stuart Koe (AIMSS) for their help with this article.