Sexual risk and HIV testing disconnect in men who have sex with men (MSM) recruited to an online HIV self-testing trial.

OBJECTIVES: We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)]. METHODS: Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017-2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners. RESULTS: A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26-44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months. CONCLUSIONS: Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales.

OBJECTIVES: SELPHI (HIV Self-Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self-testing (HIVST) in a high-income setting to date, and has recruited 10 000 men who have sex with men (cis- and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self-tests experience HIVST and the implications for further intervention development and scale-up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood-based HIVST. METHODS: Thirty-seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi-structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio-recorded, transcribed and analysed through a framework analysis. RESULTS: Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV-positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage. CONCLUSIONS: Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV-positive results and individuals with minor adverse outcomes.

Association between knowledge, risk behaviours, and testing for sexually transmitted infections among men who have sex with men: findings from a large online survey in the United Kingdom.

OBJECTIVES: In the UK, men who have sex with men (MSM) bear a disproportionate sexually transmitted infection (STI) burden. We investigated MSM's STI knowledge; whether their STI testing behaviour met national guidelines (annually if sexually active; 3-monthly if engaging in STI risk behaviours); and the relationship between STI testing in the last 3 months, STI knowledge and STI risk behaviours by HIV status. METHODS: Sexually active (in the last year) men aged > 15 years who were UK residents and were recruited from gay-orientated online dating platforms completed an anonymous online survey about STI knowledge, STI risk behaviours, and STI testing (March-May 2017). This included 11 true statements about STIs. Respondents scored 1 for each statement they 'knew', with those scoring < 6 overall treated as having 'poor' STI knowledge. Descriptive and multivariable analyses were conducted, separately by HIV status, to test our hypothesis and calculate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). RESULTS: Compared to HIV-positive men (n = 489), the proportion of HIV-negative/unknown-status men (n = 3157) with 'poor' STI knowledge was significantly higher (46.4% versus 22.9% for HIV-positive men) and the proportion with STI testing in the last 12 months was lower (71.6% versus 87.2%, respectively). In the last 3 months, 56.9% of HIV-negative/unknown-status and 74.1% of HIV-positive men reported STI risk behaviours, of whom 45.8% and 55.1%, respectively, had been tested for STIs during this time. Among HIV-negative/unknown-status men, those reporting STI risk behaviours were more likely (AOR 1.52; 95% CI 1.26-1.84) and those with poor STI knowledge less likely (AOR 0.73; 95% CI 0.61-0.89) to have been tested during the last 3 months. However, neither factor was independently associated with 3-monthly testing among HIV-positive men. CONCLUSIONS: Improving STI knowledge, especially among HIV-negative/unknown-status men, and promoting frequent STI testing among men engaging in STI risk behaviours are vital to address the poor sexual health of MSM.

Motivations and values associated with combining sex and illicit drugs ('chemsex') among gay men in South London: findings from a qualitative study.

OBJECTIVES: There is considerable public health concern about the combining of sex and illicit drugs (chemsex) among gay men. With a view to inform supportive therapeutic and clinical interventions, we sought to examine the motivations for engaging in chemsex among gay men living in South London. METHODS: Community advertising recruited 30 gay men for qualitative semi-structured interview. Aged between 21 and 53 years, all lived in South London in the boroughs of Lambeth, Southwark and Lewisham and all had combined crystal methamphetamine, mephedrone and/or γ-hydroxybutyric acid/γ-butyrolactone with sex in the past 12 months. Transcripts were subjected to a thematic analysis. RESULTS: We broadly distinguished two groups of reasons for combining sex and drugs, within which we described eight distinct motivations. The first major group of motivations for combining drugs with sex was that drugs provide the means by which men can have the sex they desire by increasing libido, confidence, disinhibition and stamina. The second major group of motivations for chemsex was that drugs enhance the qualities of the sex that men value. Drugs made other men seem more attractive, increased physical sensations, intensified perceptions of intimacy and facilitated a sense of sexual adventure. CONCLUSION: Analysis revealed that sexualised drug use provides both motivation and capability to engage in the kinds of sex that some gay men value: sex that explores and celebrates adventurism. Those services providing (talking) interventions to men engaging in chemsex should consider these benefits of sexualised drug use alongside the harms arising.

Illicit drug use in sexual settings ('chemsex') and HIV/STI transmission risk behaviour among gay men in South London: findings from a qualitative study.

BACKGROUND: 'Chemsex' is a colloquial term used in the UK that describes sex under the influence of psychoactive substances (typically crystal methamphetamine, mephedrone and gamma-hydroxybutyric acid (GHB)/gamma-butyrolactone (GBL)). Recently, concern has been raised as to the impact of such behaviour on HIV/sexually transmitted infection (STI) transmission risk behaviour, which this qualitative study aimed to explore via semistructured interviews with gay men living in three South London boroughs. METHODS: Interviews were conducted with 30 community-recruited gay men (age range 21-53) who lived in the boroughs of Lambeth, Southwark and Lewisham, and who had used crystal methamphetamine, mephedrone or GHB/GBL either immediately before or during sex with another man during the previous 12 months. Data were subjected to a thematic analysis. RESULTS: Chemsex typically featured more partners and a longer duration than other forms of sex, and the relationship between drug use and HIV/STI transmission risk behaviour was varied. While some men believed that engaging in chemsex had unwittingly led them to take risks, others maintained strict personal rules about having safer sex. Among many participants with diagnosed HIV, there was little evidence that the use of drugs had significantly influenced their engagement in condomless anal intercourse (primarily with other men believed to be HIV positive), but their use had facilitated sex with more men and for longer. CONCLUSIONS: Analysis revealed that, within this sample, chemsex is never less risky than sex without drugs, and is sometimes more so. Targeted clinic-based and community-based harm reduction and sexual health interventions are required to address the prevention needs of gay men combining psychoactive substances with sex.

Community HIV testing for men who have sex with men: results of a pilot project and comparison of service users with those testing in genitourinary medicine clinics.

Results of a community HIV testing pilot (fasTest) targeting men who have sex with men (MSM) in Brighton are reported and service users are compared with those testing in genitourinary medicine (GUM) clinics. FasTest offers rapid HIV testing in a weekly evening drop-in session staffed by GUM professionals in a community organisation. It was prospectively evaluated from November 2004 to March 2006 using a self-completed paper questionnaire assessing demographics, previous use of GUM, HIV testing history and sexual behaviour. Follow-up through GUM/HIV services was monitored. A simplified questionnaire was completed by MSM accessing the GUM clinic over the same time period. Men were included in the analysis if they identified as gay or bisexual or had recent sex with a man, tested for HIV and received a result. In both the fastest and GUM groups, men reported high rates of unprotected anal sex in the last 3 months. fasTest clients were significantly younger and less likely to test positive for HIV. This difference was independent of age and HIV testing history. There was no difference in rates of recent infection between the two. We conclude that community HIV testing is feasible and reaches the target group of high risk MSM.

Sexual partners, penetrative sexual partners and HIV risk.

This paper argues that the notion of sexual partners per se is insufficient for estimating levels of HIV risk behaviour or changes in HIV risk over time, even though it is a crucial element of most epidemiological models of HIV. The concept of a penetrative sexual partner (PSP) is introduced as a considerably more accurate measure of HIV risk. Using data from a longitudinal study of 930 homosexually active men in England and Wales, this paper demonstrates that variation in numbers of PSPs (and thus HIV risk) is not related to variation in the gross numbers of sexual partners.

No aggregate change in homosexual HIV risk behaviour among gay men attending the Gay Pride festivals, United Kingdom, 1993-1995.

OBJECTIVES: To examine aggregate changes in homosexual HIV risk-taking among gay men attending the Gay Pride festival in the United Kingdom over a 3-year period during which HIV prevention activity targeted at this population increased considerably. DESIGN: Three cross-sectional self-completion questionnaires at yearly intervals asking identical questions on sexual behaviour in the preceding year. SETTING: Lesbian and Gay Pride festival held in London, June 1993, 1994 and 1995. PARTICIPANTS: Men attending the festival who were UK resident, had ever had sex with another man and who were willing to fill out a questionnaire (n = 1620, 1753 and 1168 in 1993, 1994 and 1995, respectively). MAIN OUTCOME MEASURES: Self-reported numbers of sexual partners, sexual partners with whom anopenile intercourse occurred and sexual partners with whom anopenile intercourse occurred without a condom. RESULTS: Over the 3-year period there were no changes in the proportion of men engaging in any of the sexual behaviour measures. At each cross-section, one in three men (514 out of 1566, 511 out of 1612, 351 out of 1059 in 1993, 1994 and 1995, respectively) had engaged in anopenile intercourse without a condom with at least one male partner in the preceding year and one in 10 (162 out of 1566, 156 out of 1612, 103 out of 1059 in 1993, 1994 and 1995, respectively) had done so with more than one male partner. CONCLUSION: Despite an increase in prevention work targeted at this population, aggregate levels of sexual risk-taking have remained very stable. A reassessment of the efficacy of current HIV prevention messages and methods with this population is urgently required.

No connection between alcohol use and unsafe sex among gay and bisexual men.

OBJECTIVE: To investigate the relationship between alcohol use and unsafe sexual behaviour. METHODS: The paper discusses data collected from 461 gay and bisexual men interviewed in England and Wales by Project SIGMA during 1991-1992. These data were collected during face-to-face interviews using retrospective weekly diary techniques and include details of all sexual sessions and alcohol use. The 819 reported sexual sessions with other men are divided into those that involved alcohol use (30.6%) and those that did not. RESULTS: Differences in the incidence of HIV risk behaviours between sexual sessions that involved alcohol use and those that did not are small, and none are statistically significant. Furthermore, for those men who engaged in sexual behaviour whilst under the influence of alcohol, the quantity of alcohol consumed had no effect on sexual behaviour. CONCLUSIONS: Among gay and bisexual men, sex under the influence of alcohol is no more likely to be unsafe than sex among men who have not consumed alcohol.

Sex role separation in sexual diaries of homosexual men.

OBJECTIVE: To measure types of sex role prevalence in common and risk-related behaviours among gay men for modelling HIV transmission. DESIGN: Cohort study of 385 homosexually active men recording sexual diaries over 1-month periods. METHODS: Measures of incidence of behavioural sex roles for masturbation, fellatio, anal intercourse and anilingus by relationship type, derived from 1-month sexual diary data. RESULTS: Low behavioural role rigidity for masturbation and fellatio, but higher rigidity for anal intercourse and anilingus. Participants with no regular partner showed a relatively low frequency of anal intercourse, whereas those in closed relationships showed a high frequency. CONCLUSION: Although anal intercourse shows a certain degree of behavioural role rigidity, this rigidity is not large enough to conclude that gay men exclusively engage in either an active or a passive role. Typical rates for exclusive active and passive roles for anal intercourse during the month the diaries were recorded were in the range of 12-15%; the dual role was significantly higher.

The needs of people with HIV in the UK: findings from a national survey.

The aim of this study was to describe the needs of people living with HIV in the UK. A questionnaire addressing 17 areas of need was completed by 1821 people living with HIV in the UK. The core need indicator was a personal assessment of happiness with current state. A quarter of all respondents were happy with their current state across all needs. For each need, the following proportions were unhappy with their current state: sex, 40%; anxiety/depression, 33%; sleep, 32%; self-confidence, 32%; money, 28%; household chores and self-care, 18%; housing, 18%; appetite, eating and drinking, 17%; friendships, 17%; discrimination, 16%; mobility, 15%; dealing with health professionals, 15%; relationships, 14%; drugs and alcohol, 9%; taking treatments regularly, 5%; HIV treatment knowledge, 4%; looking after children, 2%. Although some people with HIV are coping well with minimal unmet need, the overall picture of need is dominated by personal, social and economic issues.

Sexually transmitted infection as a risk factor for homosexual HIV transmission: a systematic review of epidemiological studies.

Existing reviews suggest some sexually transmitted infections (STIs) are risk factors in heterosexual HIV transmission. This may not be so in homosexual HIV transmission, about which reviews make no specific conclusions. This paper reviews published studies which report on the relative risk of STIs in HIV seroconversion in homosexually-active men in order to examine this matter. Papers obtained via various searches were judged adequate if they were prospective cohort or cohort-nested case-control studies; used HIV seroconversion as the outcome; assessed STI exposure objectively; and controlled for potential confounding from age and sexual behaviour. Sixteen papers were obtained, of these 3 were judged adequate. Adequate papers reported little association. Inadequate papers were more likely to report association. Evidence from adequate studies does not suggest STIs are risk factors in homosexual HIV transmission. Some caution is needed in interpreting the results because of the paucity of adequate studies.

Perceptions of superinfection risk among gay men with diagnosed HIV who have unprotected anal intercourse.

This paper explores how men who have sex with men (MSM) with diagnosed HIV who engage in unprotected anal intercourse (UAI) perceive the potential risk of superinfection and how they respond to it. Semistructured interviews were carried out with 42 MSM recruited via community-based agencies throughout England and Wales. The interviews examined sexual risk taking and the ways in which men sought to manage the risks they perceived. All participants had heard of superinfection and one-third considered it a personal risk when they had UAI with men with the same sero-status. The risk of being superinfected with HIV was often situated among a number of other concerns that men felt they needed to manage when having sex. There was significant uncertainty about the likelihood of acquiring an additional strain of HIV, which was exacerbated by competing, and often conflicting, advice from a variety of expert sources. Men frequently drew upon lay and expert understandings of viral load and infectiousness to rationalize engagement in UAI with other diagnosed positive men. HIV health-care providers should seek to find consensus on how to discuss superinfection with MSM, taking account of the array of other physical and social risks associated with sex.

Alcohol, AIDS and immunity.

In order to understand the potential impact of alcohol consumption on the course of the HIV/AIDS pandemic we examine at least 3 very different debates. In an attempt to summarise these debates we assess the impact of alcohol consumption on numerous aspects of HIV infection, including the relationship between alcohol use and likelihood of engagement in 'unsafe' sexual behaviour; the impact of alcohol on immune function and its importance as a co-factor for AIDS-related illness. We argue that, contrary to popular belief, the consumption of alcohol does not appear to make individuals more likely to engage in unsafe sex. Furthermore, while alcohol has clearly been proven to effect immune function in vivo and in vitro there is no clear evidence that it plays any part in individuals' susceptibility to HIV infection or has any effect on disease progression among persons with HIV infection. Clearly some of this research is in its infancy and such conclusions should be treated with caution.

HIV, sexual risk, and ethnicity among men in England who have sex with men.

OBJECTIVES: To examine ethnic group differences in HIV testing history and sexual HIV risk behaviours that may account for such differences, among men in England who have sex with men (MSM), in order to inform HIV prevention planning priorities. METHODS: A self completion survey in the summer of 2001 was carried out in collaboration with community based health promoters. Three recruitment methods were used: "gay pride" festivals, health promoter distributed leaflets, internet version advertised with gay service providers. The leaflet was produced with an alternative cover for targeted recruitment of black men. RESULTS: In a sample of 13,369 MSM living in England, 17.0% were from minority ethnic groups and 5.4% had tested HIV positive. Compared to the white British majority, Asian men were 0.32 times as likely to be living with diagnosed HIV infection, while black men were 2.06 times as likely to be doing so. Among men who had not tested HIV positive, Asian men were less likely to have sex with a known HIV positive partner, while black men were more likely to have insertive unprotected anal intercourse both with a partner they knew to be HIV positive and with a partner whose HIV status they did not know. CONCLUSIONS: Among MSM in England, HIV prevalence is higher among black men and lower among Asian men compared with the white British majority. Increased sexual HIV risk behaviour, especially exposure during insertive anal intercourse, accounts for some of this difference. HIV prevention programmes for MSM and African people should both prioritise black MSM.

Condom use in a large cohort of homosexually active men in England and Wales.

As part of a prospective study of the seroprevalence of HIV, a cohort of 930 men were interviewed regarding their condom use. Of the 270 respondents that engaged in insertive anal intercourse in the month preceding interview 38.9% always used a condom, 49.6% never used one, and 11.5% sometimes used one. Of the 254 respondents that engaged in receptive anal intercourse in the same time period 42.5% always used a condom, 45.7% never used one, and 11.8% sometimes used one. Compared to other research the proportion of respondents who always use a condom for anal intercourse is relatively high, though use is by no means universal. Condom use is more widespread and consistent with casual rather than regular sexual partners, and it is significantly more common within open rather than monogamous relationships. Out of a wide range of other factors only geographical location (London against outside), marital status, perceived HIV status, number of sexual partners, and how seriously respondents take safer sex are correlated with condom use.