Ethnic minority gay men in UK have very different rates of HIV infection despite similar behaviours

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The largest study to date on ethnic minority gay men and men who have sex with men (MSM) in the UK has found significant variations in rates of HIV infection between ethnic groups despite similar rates of sexual risk behaviour. Professor Jonathan Elford of City University, London presented his findings to the satellite conference on MSM and HIV preceding the International AIDS Conference in Mexico, and his team added more data in posters presented to the main conference.

The MESH Project (Men and Sexual Health) was a joint initiative of City University, Bern University in Switzerland, the Terrence Higgins Trust and Homerton University Hospital in London.

The survey involved four different research questionnaires directed at four different groups:

  • Ethnic minority MSM
  • A comparison group of White British MSM
  • Clinical service providers from sexual health clinics including doctors, nurses, psychologists and others
  • Prevention service providers.

Glossary

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

qualitative

Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

disclosure

In HIV, refers to the act of telling another person that you have HIV. Many people find this term stigmatising as it suggests information which is normally kept secret. The terms ‘telling’ or ‘sharing’ are more neutral.

voluntary male medical circumcision (VMMC)

The surgical removal of the foreskin of the penis (the retractable fold of tissue that covers the head of the penis) to reduce the risk of HIV infection in men.

circumcision

The surgical removal of the foreskin of the penis (the retractable fold of tissue that covers the head of the penis) to reduce the risk of HIV infection in men.

Findings from the latter two surveys will be published later. The ethnic minority and comparison group surveys involved participants completing self-administered internet questionnaires online at gay websites. The large majority of participants was recruited and completed the survey via the Gaydar website. However the survey also appeared on other gay websites targeted at ethnic minority gay men, and participants were also recruited at sexual health clinics and via ethnic minority support and social groups and Pride events, though all questionnaires were completed online. The study took place between August 2007 and April 2008.

The questionnaire contained over one hundred questions but of those who started it, 80% completed all questions. It asked about sociodemographic data, use of sexual health services, sexual behaviour, experiences of discrimination and disclosure of sexuality, and psychological factors.

In addition, the ethnic minority gay men who provided an optional email address (but not the white comparison group) were contacted and asked to participate in qualitative in-depth interviews about their experiences and attitudes, conducted via email exchanges with researchers. Detailed findings from this will also be presented in the future.

Gay men were asked to self-define according to ten different ethnic categories used in the 2001 UK census plus one other. These were Black African, Black Caribbean, African/White mixed, Caribbean/White mixed, Indian, Pakistani, Bangladeshi, Chinese, other Asian, White/Asian mixed, and Arab (the last will be added in the 2011 census).

However researchers identified two significant groups that these categories did not capture: Latin Americans and Eastern Europeans. These two were therefore included as migrant rather than ethnic groups, in other words these two groups could not be born in the UK, whereas members of other groups could be UK-born or immigrants. The White UK comparison group participants had to have been born in the UK.

Altogether there were 1657 ethnic minority respondents; this is the largest survey of ethnic minority MSM ever done in the UK. The White British comparison group comprised 13,717 respondents. Sixty-two participants completed at least two in-depth qualitative email interviews.

The ethnic minority sample consisted of:

  • Black: 399, of whom 140 were Caribbean, 96 African and 141 mixed:
  • South Asian: 379, of whom 199 were Indian, 91 Pakistani, 19 Bangladeshi and 70 mixed:
  • Chinese 166, other Asian 152, Arab 66, and ‘other’ 79.
  • The migrant-only groups comprised 173 Latin American men and 243 Eastern Europeans.

More than half of the Black Caribbeans, Africans and South Asians had been born in the UK (80% of Caribbeans), but only about 20% of Chinese, other Asians and Arabs. Many more lived in London than White British: whereas only 20% of the White British sample lived in London, over 50% of all ethnic groups except Caribbeans and Pakistanis were London residents. The ethnic group was on average much younger than the White British sample with 95% of all Asians and Arabs under 40 compared with 60% of the White British.

About 70% of the sample described themselves as gay, though Black Africans, Indians and Arabs were somewhat more likely to describe themselves as one of the other categories on offer (‘homosexual’, ‘bisexual’ or ‘straight’) compared with ‘gay’ (60%). Ten per cent of the White British men had also had sex with a woman in the past year compared with 20% of the Black Africans and South Asians.

More of the ethnic minority gay men had had an HIV test than the White British men. Two-thirds of the latter had had an HIV test whereas HIV testing rates in the ethnic groups varied from 65% to 80%. Only Pakistanis were less likely to have taken a test (55%), which may reflect the fact that they were also the group least likely to live in London. Highest testing rates were in Londoners (80% tested) and especially in Black and Black/mixed Londoners, 95% of whom had taken a test.

HIV prevalence varied widely between groups:

  • White British and Black African: 8-9%
  • Black Caribbean and Caribbean mixed: 12%
  • South Asian: 3-4% (none of the small group of Bangladeshis had HIV)
  • East Europeans and Chinese 4%, Arabs 7%
  • Latin Americans: 17%.

Elford commented that “we were not expecting to see the higher rates among Latin Americans.” Qualitative interviews revealed that many of them had been diagnosed before coming to the UK.

Sexual risk behaviour did not vary between the ethnic groups. Despite having the lowest rates of HIV, South Asians reported the highest rates of unsafe sex, with 15.5% of the group reporting actually or potentially serodiscordant unprotected sex over the previous three months compared with 14.5% of black men (all categories), 13.7% of White British and 11.2% of men from other groups, though these differences were not statistically significant.

Circumcision rates varied widely, with Eastern Europeans, Chinese, Indians and Black Caribbeans having circumcision rates similar to White British (17%) and other groups, not unexpectedly, having much higher rates. However HIV rates were identical between circumcised and uncircumcised men.

A third of ethnic minority men said they had been racially abused, and one in nine had been physically attacked. About one in 15 men said they had been physically attacked because of their sexuality, and 29% of white men and 24% of ethnic minority men had been verbally abused because of it.

Disclosure of sexuality to family was less common in ethnic minority gay men than white men. Rates of ‘coming out’ to mother, father and siblings were respectively 42%, 38% and 50% in ethnic minority men compared to 65%, 52% and 69% in white men.

The qualitative interviews covered feelings about sexual identity, disclosure, family relations and so on in more depth and will be published in the future.

However Elford commented that they revealed ethnic minority gay men “trying to reconcile a 21st century lifestyle with 1950s family values.” He ended with two quotes, one from a black man commenting on how white men objectified him, and one from an Indian man expressing his difficulty reconciling family values with his sexuality:

“White gay men want to try me because there is some notoriety to having sex with a black man, there are some racist derogatory terms but I never take it to heart!”

“I would make myself straight in a heartbeat because if I were straight I could be open and celebrate my relationship, get married, have children and a family with the support of everyone around me and no one staring. That would satisfy the Indian part of me.”

References

Elford J New research on ethnic minority MSM living in Britain. Workshop R5 from The Invisible Men: Gay Men and Other MSM in the Global HIV/AIDS Epidemic, pre-conference satellite to the Mexico World AIDS Conference 2008.

Elford J et al. HIV risk behaviour among ethnic minority men who have sex with men (MSM) in the UK. XVII International AIDS Conference, Mexico City, abstract TUPE0315, 2008.

McKeown E et al. Stigma and discrimination experienced by men who have sex with men in Britain. XVII International AIDS Conference, Mexico City, abstract TUPE0811, 2008.

Elford J et al. Circumcision status and HIV infection in a diverse sample of MSM living in Britain. XVII International AIDS Conference, Mexico City, abstract LBPE1163, 2008.

McKeown E et al. Identity and sexual health among ethnic minority men who have sex with men (MSM) in Britain: a qualitative study. XVII International AIDS Conference, Mexico City, abstract WEPE0722, 2008