Gay, bisexual and other men who have sex with men in
Scotland rarely talk explicitly about HIV status with their sexual partners,
but make sexual decisions based on their beliefs about their own HIV status and
that of their partners, argue the authors of a recently published needs
assessment. This is a particular issue within long-term relationships,
especially those in which men have sex with casual partners as well.
“There is a need to encourage men to question the safety of
the assumptions they make about open relationships, and to equip them to find
more effective ways of reducing their risks,” they write. “In particular, men
in relationships should be encouraged to view joint HIV testing before ceasing
condom use as cementing trust and commitment.”
The needs assessment was conducted by NHS Lothian and NHS
Greater Glasgow and Clyde, the health boards which cover Scotland’s two largest
cities. It included a case note review, examining the clinical records of men
who have sex with men who were diagnosed with an infection suggestive of
high-risk sexual behaviour; re-analysis of surveys conducted in commercial
gay venues in Scotland in 2005, 2008 and 2010; interviews with 20 sexual health
clinicians; and interviews with 154 men who have sex with men.
As described in another aidsmap.com
article, the case note review showed that a significant proportion of men newly
diagnosed with HIV or a rectal sexually transmitted infection (STI) had complex needs
and overlapping vulnerabilities, such as problematic alcohol use, poor
emotional wellbeing or social deprivation.
The bar surveys show that the proportion of men who have ever
tested for HIV has increased in recent years. But only a minority of men
test as regularly as recommended by public health officials – at least once a
year. Looking specifically at those men in the bar surveys who reported
unprotected anal intercourse with casual partners, multiple partners or
partners of unknown HIV status (and did not have diagnosed HIV), 55.0% had not
tested in the previous year and 35.3% had never tested for HIV.
Similarly, the case note review of men diagnosed with an infection suggestive of high-risk sexual behaviour suggested that a large proportion of these men are taking a
reactive rather than proactive approach to their sexual health. Only a minority came in for testing as a regular check-up, in the absence of
symptoms. Four-in-ten men newly diagnosed with HIV or a rectal STI had the test
because they had symptoms of infection. A quarter did so following partner
Men who have never tested were more likely to be under the
age of 26, live in rural areas and report bisexual behaviour. Men who have
tested but not done so very often tended to be somewhat older, live outside the
big cities and live in areas of social deprivation.
In the absence of recent HIV testing, men made assumptions
about their own HIV status. They also made assumptions about the status of potential
sexual partners and the safety of sex without condoms, often based on a man’s
appearance, character or the simple fact that he hadn’t mentioned having HIV. Men
rarely talked explicitly about HIV status with sexual partners, but still said
that knowing a partner’s HIV status was an important component of sexual
Younger men (under the age of 26) who were included in the
case note review seemed especially likely to report having unprotected sex
based on how well they knew a partner or a desire for intimacy, rather than
knowledge of their own or their partner’s HIV status. The needs assessment
found that young men tended to report high numbers of sexual partners and unprotected
sex, but low perception of HIV risk and relatively poor knowledge of HIV
Serosorting (selecting partners believed to have the same
status as oneself) was widely reported by the men with diagnosed HIV who
subsequently acquired a rectal STI. In the case note review, 32.4% of these men
said that their regular partner was HIV positive and 29.7% reported that all of
their recent casual partners were HIV positive. The report notes that
serosorting can help men living with HIV avoid being involved in HIV transmission,
but often exposes them to sexually transmitted infections.
Moreover, the clinical notes indicated that the underlying
motivations for serosorting were negative, suggestive of poor emotional wellbeing. Men
living with HIV described feeling ‘damaged’ or ‘tainted’ and therefore undesirable
to HIV-negative men, while others harboured anxiety about possible
transmission, criminalisation or disclosure which limited their partner choice
to other men living with HIV.
This was just one example of the stigma, discrimination and
rejection experienced by men living with HIV that was highlighted in the needs
Both the surveys conducted in commercial gay venues and the
case note review found strong evidence of risk behaviour while men were in
relationships. The venue surveys showed that just under half (47.5%) of men
reporting unprotected sex with casual or multiple partners, or partners of unknown or different HIV status, were also in a
relationship. Half of these relationships were long-term (three years or more)
but a third of men did not know their partner’s HIV status.
The case note review found that 39.8% of HIV-negative men
diagnosed with a rectal STI were in a relationship at the time, as were 43.6%
of men newly diagnosed with HIV.
Men in relationships often reported ceasing condom use with
a partner as a symbol of trust, intimacy and commitment. Men tended to see this
as low risk but many had not tested for HIV before making this decision.
Moreover, men in relationships who were included in the case
note review often reported concurrent sexual relationships with other men, either
in the context of an agreed open relationship, during threesomes along with
their partner, or without their partner’s knowledge.
Many men described agreeing risk reduction strategies with
their partners, for example that condoms must always be used with these casual
contacts or that both partners will routinely screen for STIs and HIV. But many
had agreements that were not clear or had not been spoken about since the agreement
was first made; it was apparent that many men struggled to maintain these
The authors say there is a need to encourage men to question
the safety of the assumptions they make about open relationships, and to equip
them to find more effective ways of reducing their risks. In particular, they
recommend that couples test together and share their results, before giving up
condom use. They argue that this could be seen as an accepted stage of gay relationships, in
the same way that testing is sometimes encouraged within heterosexual
relationships. The authors believe that men in open relationships
would be happy to discuss their relationships when attending a sexual health
service, but need to feel confident that staff will understand the context of
their relationships and not be judgemental.
More generally, the authors recommend a continued focus on
regular HIV testing and the benefits of knowledge of HIV status in HIV
prevention interventions. There is a need to support men to be more open in
their conversations about testing, re-testing and HIV status in order to inform
“This requires support and education both for men disclosing
HIV positive status and men hearing such disclosure,” they say.