Kolstee J, Holt M, Jin J, et al. Characteristics of gay and bisexual men who rarely use HIV risk reduction strategies during condomless anal intercourse: Results from the FLUX national online cohort study. PLoS One. 2020;15(6):e0233922. Published 2020 Jun 1. doi:10.1371/journal.pone.0233922
Abstract
Purpose: To understand the characteristics of a minority of Australian gay and bisexual men (GBM) who, despite an increase in the number and availability of HIV risk reduction strategies, do not consistently use a strategy to protect themselves from HIV.
Methods: This analysis is based on data from 2,920 participants in a national, online, prospective observational cohort study. GBM who never or rarely used HIV risk reduction strategies (NRR) were compared with two groups using multivariate logistic regression: i) GBM using pre-exposure prophylaxis (PrEP) and ii) GBM frequently using risk reduction strategies (FRR) other than PrEP.
Results: Compared to PrEP users, NRR men were younger (p<0.0001), less socially engaged with gay men (p<0.0001) and less likely to have completed a postgraduate (p<0.05) or undergraduate degree (p<0.05). They were also less likely to have recently used amyl nitrite (p<0.05), erectile dysfunction medication (p<0.05) and cocaine (p<0.05) in the previous 6 months. Compared with FRR men, NRR men were less likely to have completed a postgraduate (p<0.0001) or undergraduate degree (p<0.05), scored higher on the sexual sensation-seeking scale (p<0.0001) and were more likely to identify as versatile (p<0.05), a bottom (p<0.05) or very much a bottom (p<0.05) during anal sex.
Conclusions: NRR men were largely similar to other Australian GBM. However, our analysis suggests it may be appropriate to focus HIV prevention interventions on younger, less socially engaged and less educated GBM, as well as men who prefer receptive anal intercourse to promote the use of effective HIV risk reduction strategies.
Introduction
Sex between men remains the most common way that HIV is transmitted in Australia [1]. In 2017, 70.1% of the 1013 new diagnoses of HIV in Australia were attributed to sex between men [1]. There are a range of strategies to prevent HIV, including condoms, the use of antiretroviral drugs as biomedical prevention, and behavioural risk reduction (such as serosorting and strategic positioning). These strategies differ in their effectiveness [2-5] as well as the length of time over which they have been used by or available to gay and bisexual men (GBM) in Australia.
Data from national behavioural surveillance surveys of Australian GBM in 2013 indicated that most men (98.7%) frequently use at least one strategy to prevent HIV when having anal sex with casual partners [6]. This research was conducted before the widespread promotion of use of undetectable viral load prior to sex or HIV treatment as prevention (TasP), and access to PrEP. In this research, HIV-negative men who had condomless anal intercourse with casual partners most commonly used serosorting (46.9%) followed by condoms (40.5%) [6]. HIV-positive men in Australia most commonly used TasP (58.4%) followed by serosorting (55.4%) [6].
Recent Australian national and state HIV strategies and community-based education campaigns have encouraged the use of effective HIV risk reduction strategies (condoms, PrEP, and TasP) while also reinforcing the importance of communication between partners [7-9]. These strategies and campaigns mirror the understandings of risk and acceptable prevention strategies among GBM [10-11]. They have supported the awareness, acceptability and access to effective HIV risk reduction strategies in Australia.
Effective antiretroviral treatment (ART) for HIV has been available since the mid-1990s and early initiation to achieve viral suppression is highly effective in preventing transmission [5]. Recent data indicated that HIV treatment uptake and viral suppression are high among HIV-positive Australian GBM [12]. The use of antiretroviral medications for prevention (pre-exposure prophylaxis, PrEP) by HIV-negative people has also been shown to be highly effective [13]. First available to GBM in Australia through personal importation (pre-2014), then large research trials (2014-2018) [14-15], PrEP is now widely available and publicly subsidized [16].
Condoms have been the main preventative tool for HIV transmission for GBM since the beginning of the HIV epidemic [17]. Serosorting, restricting sex to partners believed to be the same HIV status, has also been widely used by GBM [17]. Strategic positioning is another strategy which involves partners taking the insertive or receptive position during condomless anal intercourse, depending on the HIV status of one's partner [18]. This strategy is based on the understanding that HIV negative men are less likely to acquire HIV when taking the insertive rather than the receptive position during condomless anal intercourse with an HIV positive man [19]. Receptive condomless anal intercourse is the main route of HIV infection among GBM [19].
Despite a range of effective prevention tools, many GBM recently diagnosed with HIV report receptive condomless anal intercourse with another man prior to their diagnosis, and limited evidence of risk reduction [20]. Inconsistent or infrequent use of HIV risk reduction increases the chance that GBM may have condomless anal intercourse with someone with undiagnosed HIV infection, a key driver of new HIV infections in Australia [21].