Sexual behaviours that are most likely to result in acquiring HIV are most common in teenagers, while those behaviours most likely to pass on HIV are most common among men in their thirties. These are some of the results of the 2008 United Kingdom Gay Men’s Sex Survey, released last month.
The survey also suggests that more men than ever have tested for HIV (including one in ten at a GP's surgery) but that less than half had done so in the previous year. There is also some evidence of ‘strategic positioning’ during oral sex and information about behaviours which lead to condoms splitting or coming off.
At the same time, researchers have issued preliminary data from a similar survey conducted across Europe in 2010. With over 180,000 men completing the questionnaire, it is the largest sexual health survey ever conducted with gay and bisexual men.
UK Gay Men’s Sex Survey
The Gay Men’s Sex Survey uses a self-completion questionnaire that is available in a booklet form (distributed by health promotion organisations) and in an online version (promoted by a number of commercial gay, health promotion and gay community websites). For the 2008 edition 7,461 valid responses were received from gay or bisexual men living in the UK.
The researchers analysed how engaging in specific sexual risk behaviours varied by age. They identified certain behaviours which might result in a participant acquiring HIV, and other behaviours which might result in him passing on HIV.
Looking first at behaviours which could lead to HIV acquisition, this analysis is limited to men who reported that they had tested HIV-negative or who had never tested at all.
- Taking ejaculate in the mouth during oral sex with a partner of unknown or HIV-positive status. 40% of men under the age of 20 reported this - higher than any other age group.
- Receptive unprotected anal intercourse with a partner of unknown or HIV-positive status. 23% of men under the age of 20 reported this - again higher than any other age group.
- Using poppers during receptive unprotected anal intercourse with a partner of unknown or HIV-positive status. 5% of under-20s reported this, but the numbers did not vary by age group.
Now turning to behaviours which could lead to HIV transmission, this analysis is limited to men who were diagnosed HIV positive or who had never tested at all.
- Ejaculating in the mouth of a partner of unknown or HIV-negative status. 46% of men in their thirties reported this - higher than any other age group.
- Insertive unprotected anal intercourse with a partner of unknown or HIV-negative status. 28% of men in their thirties reported this - again higher than any other age group.
The researchers say that “these findings are consistent with a picture whereby MSM on average pass HIV to men younger than themselves”.
However for all of these sexual risk behaviours, the age group least likely to report them was the oldest, those over the age of 50.
‘Strategic positioning’ refers to men choosing their sexual role with some consideration of what they believe to be their own HIV status and that of their partner. These decisions generally assume that HIV transmission occurs more frequently from the insertive to the receptive partner than the other way round.
As has been reported in previous surveys, men who had tested negative or who had never tested were much less likely to take the receptive role in unprotected anal intercourse if they knew their partner was HIV positive. Similarly, when men with diagnosed HIV were with a partner who they knew also had HIV, they were equally likely to have receptive or insertive unprotected sex. If they thought their partner was HIV-negative, they were much more likely to take the receptive role themselves.
But the survey also asked about positioning in relation to oral sex and ejaculation in the mouth, a previously unexplored area. Of all men who had had sex in the past year, 99.2% had had oral sex and 77% had had oral sex involving ejaculation in the mouth. But some men are giving attention to the HIV status of their partners in relation to this practice. For example, among HIV-positive men, ejaculation in a negative man’s mouth was much less common (13%) than having a negative man ejaculate in their mouth (26%).
Thirteen per cent of men who had used condoms in the past year had experienced a condom splitting or coming off during sex. The researchers asked about eight behaviours which are thought to increase the risk of this happening.
- 17% of condom users had used saliva as a lubricant. These men were somewhat more likely than other men to experience condom failure (odds ratio 1.32; 95% confidence interval 1.02 - 1.71).
- 15% of condom users reported having intercourse for over 30 minutes without changing the condom. Men who did so were twice as likely as other men to experience condom failure (2.34; confidence interval 1.85 - 2.95).
- 11% did not use any lubricant at all. These men were almost twice as likely to experience condom failure (1.86; confidence interval 1.40 - 2.48).
Moreover men reporting three other behaviours also had a statistically significant increased risk of experiencing condom failure. These behaviours were using oil-based lubricant, using a condom that is too small, and unrolling the condom before putting it on.
However, contrary to received wisdom, two of the behaviours asked about were not significantly associated with condom failure. Men who reported putting lubricant inside the condom and men who reported not using ‘lots of’ lubricant were no more likely to experience condom failure than other men.
Younger men, and men who had sex with both men and women, were more likely to experience condom failure than other men.
Continuing the rising trend seen in recent years, 72% of men completing the survey had ever been tested for HIV. However, excluding those who had been diagnosed with HIV over a year ago, only 46% of men had been tested for HIV in the last 12 months. However the Health Protection Agency and other organisations recommend that gay men should test annually.
Whereas over three-quarters of men who had tested had done so most recently at a sexual health or genito-urinary medicine (GUM) clinic, relatively high numbers had done so at less traditional settings. Nine per cent had tested at a GP surgery, 5% at a private health care clinic and 4% at an HIV organisation. On the other hand, less than 1% had tested at hospital or by using a home testing kit.
As in previous surveys, living with diagnosed HIV was more common among men in London and in the North West of England, men with lower educational qualifications, men with higher numbers of male sexual partners (especially those with 30 or more a year) and black men and men of white ‘non-British’ ethnicities.
Also released last month are preliminary results from the largest ever international study of the sexual health of gay and bisexual men. When the Gay Men’s Sex Survey was conducted in the UK in 2010, the same internet-based questionnaire was made available in 25 languages across Europe.
The researchers were taken aback by the high level of response, with a total of 180,988 men completing the survey. The response rate was particularly high in Germany, Switzerland, Luxembourg, Ireland, Portugal, Slovenia and Austria. It was lowest in Turkey, Moldova and Russia.
Levels of basic HIV knowledge were generally very high, with 93% already knowing five key facts about HIV.
Overall, around 35% had taken an HIV test in the previous twelve months. Testing for HIV in the last year was most common in Spain, Portugal, Belgium and France. It was least common in Lithuania, Finland, Slovenia, Croatia and Turkey. The researchers say that in some countries, such as Poland and Russia, the proportion of gay and bisexual men who are HIV-positive is considerably higher than in previous estimates.
Full results will be published in the autumn of 2011.
Hickson F et al. Tactical dangers: Findings from the United Kingdom Gay Men’s Sex Survey 2008. Sigma Research, 2010.
The European MSM Internet Survey (EMIS) Community Report 1. Robert Koch Institute and partners, 2010.