Testing in relationships

A fifth of gay men whose last HIV test was negative and who are in a relationship have not had an HIV test in their present relationship, US researchers have found.

The study recruited 275 HIV-negative male couples via Facebook. It found that 21% tested for HIV every three to six months, 29% had an annual test, 30% tested only when they thought one of them might have taken a risk, and the other 20% had not tested for HIV while in their current relationship.

Men who had not tested for HIV were – not unexpectedly – more likely to be in a new relationship but were also more likely to be younger and less educated. They were less likely to have negotiated an agreement about sex outside the relationship and more likely to say they were faithful and trusted their partner to be. Conversely, men who tested frequently were older, less trusting, more likely to have had recent ‘extramarital’ sex and more likely to have an agreement with their partner about their relationship’s sexual boundaries.

Given that HIV testing rates are still lower in the UK than in the US, especially for frequent testing, the percentage of gay men in a primary relationship who don’t test is likely to be higher here.

Some previous studies have suggested that a majority of HIV infections in gay men are acquired from steady partners, including partners who were believed to be HIV negative.

The researchers recommend interventions to help men in couples with testing, especially in developing and maintaining a plan for repeat HIV testing that accurately reflects the risks taken in their relationship.

Assessing the impact of mass media

A recent evaluation of a Scottish mass media sexual health campaign is instructive, particularly for highlighting the methodological challenges of evaluating such interventions and telling us whether they have had an impact or not.

The Make Your Position Clear campaign was comparable to many other health promotion campaigns for gay men in the UK, with images of attractive men, a somewhat cryptic slogan, a simple health message and a link to a campaign website. It aimed to promote the use of condoms and lubricant, as well as regular sexual health check-ups and HIV tests. The materials were distributed more widely than for many other campaigns, including on the Glasgow Subway, in gay venues and through online dating websites.

Surveys conducted after the campaign was over showed that 60% of HIV-negative gay men could remember seeing it, although very few had visited the campaign website or spoken to an outreach worker about it.

And there was no evidence that the campaign had an impact on condom use and risky sexual behaviour. While the data suggest some associations between having seen the campaign and HIV testing behaviours, they are difficult to interpret – firm conclusions cannot be drawn.

Although campaigns are central to HIV prevention, they are difficult to evaluate reliably. Given problems with funding and pressure to deliver campaigns quickly, research is often subject to compromise from the outset, as was the case here. Data were not collected before the campaign was delivered or in another part of the country where the campaign was not provided.

Partner violence and condom use

A study in South Africa and Zimbabwe has confirmed that women who experience violence from their male partner are less likely to use condoms. In this large study of HIV prevention methods, all 4505 female participants were provided with free male condoms, safer sex counselling and sexual health check-ups.

Many women experienced intimate partner violence – 41% reported fearing violence from their partner, 34% said that their male partner had emotionally abused them, 16% had been physically assaulted and 15% had been forced to have sex.

Over half the women in the trial did not always use condoms, but this was more common amongst those women reporting intimate partner violence, especially those who reported violence more than once. Violence may make it harder for women to suggest using condoms or refuse sex.

The researchers say that programmes to prevent violence and deal with its consequences are needed. For example, health services should ask women about intimate partner violence and refer victims to appropriate services.

Intimate partner violence is also an issue in England – for example, a study of women with diagnosed HIV in east London found that 14% had experienced it in the past year, and 52% in their lifetime.

Sexual roles

An American study has found that HIV-negative men who are ‘versatile’, taking both insertive and receptive roles in anal sex, have considerably more unprotected sex than men who stick to one role.

The study found that 63% of gay men were versatile, 17% exclusively ‘top’ (insertive) and 10% exclusively ‘bottom’ (receptive). The other 10% did not have anal sex. These figures are similar to UK figures from the Gay Men’s Sex Survey of 2008, which found that 56% of respondents were versatile, 18% top, 15% bottom and 11% did not have anal sex.

The researchers comment that versatile men are probably more likely to pass on HIV than single-role men – because they are more likely to acquire HIV through receptive sex and then pass it on through insertive sex. This may be one reason why HIV incidence is so much higher in gay men than in heterosexual people, even more than one would expect from the relatively greater efficiency of anal sex in transmitting HIV.

The study also found, as some others have done, that younger men are more likely to take the receptive role than older men; this is also a pattern that facilitates HIV transmission, as seen in studies of cross-generational sex.

The study did find that many gay men attempt to reduce the risk of HIV transmission by ‘seropositioning’. When the HIV-negative men in the survey had sex with a man they knew to have HIV, they were 2.3 times more likely to be exclusively insertive and 1.5 times more likely when they did not know their partner’s HIV status.

Willingness to take early treatment

Increasing the number of people with HIV who start antiretroviral treatment soon after diagnosis and at higher CD4 cell counts is a key way in which ‘treatment as prevention’ may be implemented. But a recent qualitative study from Kenya suggests a number of barriers to early treatment.

While participants expressed a willingness to consider early treatment, they also expressed concerns about treatment side-effects, the challenge of lifelong adherence and the impact of social stigma. Moreover, starting treatment would mark a transition from a normal life to a terminal illness – antiretrovirals were associated with the idea of people being on their deathbed.

One woman said: “If I am given the ARVs I will think I am nearing the grave.” Others worried about how the attitudes of their partners would change, as the person with HIV was perceived to have reached “the final stage”.

Future research should explore whether these issues are also relevant in UK African communities.

In the Kenyan context, the researchers recommend that counselling messages need to be modified to emphasise the role of HIV treatment in maintaining and preserving health.

Case study: condom campaign

Aiming to reinvigorate condom usage among gay men in Brighton, in 2011 Terrence Higgins Trust developed a project to increase men’s knowledge of the types of condoms available and to increase men’s confidence in choosing a condom that they would enjoy using.

Rather than approaching condom usage from the angle of preventing infections, the project encouraged men to think about condoms in positive terms – men were asked to choose their favourite condom based on attributes such as pleasure, ease of use and comfort.

The campaign, called Brighton’s Next Top Condom, gave men the opportunity to try four ‘advanced’ condoms and report back on which one gave them the best experience – each offered something new in terms of use, sensation or aesthetics. Men could pick up a sampler pack from various locations and participate in an online poll.

As a result, outreach workers now distribute the top rating condom (Mates Ultrathin) as standard. They are also able to offer the second most popular condom (Mates Skyn), sample packs of different brands or a condom size tool during outreach.

Terrence Higgins Trust report that giving service users something practical to use in their sex lives was a powerful intervention tool which generated a substantial amount of interest (the ‘go try it out’ factor). Just over 1000 sample packs were picked up. Many men reported that their knowledge of different condom types was improved.

Other recent news headlines

High rates of anal HPV infection among young gay men

Prevalence and incidence of anal human papillomavirus (HPV) are high among young gay men, according to a recent American study. The investigators believe their research shows the importance of vaccinating young gay men, as has recently been argued by UK sexual health physicians. A recent Australian study has also shown that for older gay men, vaccination could prevent infection with cancer-associated strains.

Intravenous AZT does not provide extra protection against vertical transmission in mothers with undetectable viral load

Intravenous zidovudine (AZT or ZDV) during labour and delivery is effective in reducing mother-to-child transmission among HIV-positive women with virological failure (viral load at or above 1000 copies/ml), even if on antiretroviral therapy during pregnancy, according to French research. However, for women with well-controlled viral load (at or under 400 copies/ml) at delivery and without obstetrical risk factors intravenous zidovudine was not significantly associated with a lower risk of transmission.

South American survey finds rectal microbicide formulated as a douche acceptable

A qualitative study of 140 men who have sex with men and transgender women in three cities in Peru and Ecuador has found that most thought that a rectal microbicide formulated as a douche, rather than as a gel or lubricant, might offer additional safety or efficacy.