Is optimism enough? Gay men's beliefs about HIV and their perspectives on risk and pleasure.

BACKGROUND: Measures of HIV treatments optimism were developed in response to increased risk behavior among gay men, but were limited in their capacity to help understand gay men's risk behavior. METHODS: We explored current beliefs about HIV health and transmission and sexual desire and risk behavior in an online survey of 2306 Australian gay men. The survey included free text components. We conducted 40 qualitative interviews to explore how men's beliefs affected decisions about risk behavior. We conducted a principal components factor analysis on the optimism belief items in the survey, and thematic analysis of the qualitative material was used to interrogate the concepts underpinning these beliefs. RESULTS: We identified two measures of HIV optimism: Health Optimism (α = 0.791) and Transmission Optimism (α = 0.795). In multivariate analysis, unprotected anal intercourse with casual partners was only associated with HIV transmission optimism regardless of HIV serostatus (P < 0.001). Using the qualitative data, we identified 4 themes in how men think about HIV: "concerned," "unconcerned," "fearful," and "irrelevant." Each theme interpellates the 2 optimism measures. CONCLUSION: HIV optimism remains a useful indicator of gay men's likelihood to take risk, but technical knowledge, experience, desire, and attitudes to risk may all affect how people respond and often in multiple, sometimes contradictory, directions. Men's beliefs about HIV transmission risk in particular may reflect willingness to pursue pleasure over risk, or, alternatively, morbid fear of any risk. Measures of HIV optimism should be complemented by analysis of the complexities of individuals' assessments of both risk and pleasure in specific sexual contexts.

Would gay men change their sexual behavior to reduce syphilis rates?

BACKGROUND: The community at which public health strategies for reducing syphilis epidemics are potentially targeted may have different considerations with regards to their sexual and health priorities. We aimed to elicit information on the acceptability of behavior change interventions among gay men for reducing syphilis transmission. METHODS: We conducted an online survey (n = 2306 participants) and focus groups to determine whether further sexual behavior change to reduce syphilis is likely to be acceptable to gay men in Australia. RESULTS: One quarter of survey respondents (26%) indicated that they would be highly likely to reduce partner acquisition rates in order to reduce their chances of syphilis infection. However, among the 475 (21%) men who reported greater than 10 partners in the previous 6 months, only 11% indicated being "highly likely" to reduce partner numbers to avoid syphilis. Among 606 (26%) survey respondents who reported not always using condoms in the previous 6 months, 34% indicated being highly likely to always use condoms with casual partners to avoid syphilis. In the focus groups, men indicated little commitment to sexual behavior change but some willingness to consider short-term changes to reduce community syphilis levels. CONCLUSIONS: Interventions promoting partner reduction or increased condom use are unlikely to be adopted on a long-term basis by men at greatest risk. Behavioral interventions alone are unlikely to materially contribute to syphilis prevention among gay men.

Will changes in gay men's sexual behavior reduce syphilis rates?

BACKGROUND: Reducing rates of partner change and increasing condom usage among gay men are obvious targets for potentially reducing syphilis transmission among gay men. METHODS: We developed an agent-based stochastic model to examine syphilis transmission among a population of gay men, representative of gay men in Australia. This model was used to explore the potential impact of changes in sexual behavior over 1 month, 3 month, and indefinite time frames on syphilis epidemics. RESULTS: Simulations of interventions showed that short-term reductions in rates of partner change and increased condom use would have negligible impact on the long-term trends of syphilis epidemics. If no interventions are introduced, then the model forecasts that the syphilis prevalence in the population could continue to rise, with an increase of 80% in the number of men infected with syphilis during the next decade. However, if changes in sexual behavior are maintained in the long-term, then syphilis epidemics can be mitigated. If condom use is sustained at 80% in partnerships that are HIV discordant or of unknown status, then the prevalence of syphilis is estimated to decrease by 9% over 10 years. Similarly, if partner acquisition rates decrease by 25%, then there will be a 22% reduction in syphilis prevalence. CONCLUSIONS: Interventions promoting partner reduction or increased condom use would be ineffective in the short-term, and would have limited prospects for success in the long-term unless very large changes in behavior are sustained. Complementary social research indicates that such long-term changes in behavior are unlikely to be adopted, and therefore other intervention strategies need to be developed to reduce syphilis among gay men.

Increasing gay men's testing rates and enhancing partner notification can reduce the incidence of syphilis.

BACKGROUND: We sought to determine whether gay men would be willing to increase syphilis testing and partner notification, and assessed the possible epidemiological impact these changes might have in the Australian population. METHODS: We conducted an online survey (n=2306) and focus groups to determine whether interventions to increase testing for syphilis and enhanced partner notification are likely to be acceptable to gay men in Australia. An individual-based mathematical model was developed to estimate the potential population-level impact of changes in these factors. RESULTS: Of all men surveyed, 37.3% felt they should test more frequently for sexually transmissible infections. Men who recent unprotected anal intercourse with casual partners and men who reported a higher number of partners were more likely to indicate a greater willingness to increase testing frequency. HIV-positive men were more likely to indicate that their frequency of syphilis testing was adequate, incorporated as part of their regular HIV monitoring. Lack of convenience was the main barrier reported. Partner notification was broadly acceptable, although perceived stigma presented a potential barrier. The mathematical model indicated that increasing testing rates would have a substantial impact on reducing rates of syphilis infection among gay men and partner notification would further reduce infections. CONCLUSIONS: Interventions promoting testing for syphilis among gay men and increases in partner notification may be acceptable to gay men and are likely to result in decreased infection rates. Rapid testing and modern communication technologies could strengthen these interventions, and have an impact on the syphilis epidemic.