Knowledge gaps, problems accessing services for MSM in several countries of eastern and south-eastern Europe

Knowledge of PEP poor across Europe
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A substantial minority of men who have sex with men (MSM) in countries such as Cyprus, Serbia, Lithuania, Ukraine and Hungary are not being reached by HIV prevention programmes and have gaps in their factual understanding of HIV and its prevention, according to a report from the European MSM Internet Survey.

Although residents of countries with a higher level of social and economic development generally had better access and knowledge, there were notable exceptions ­– respondents in Ireland had poorer knowledge and worse access to HIV testing than in neighbouring countries. Men found it hard to get hold of condoms in Spain.

In 2010, the European MSM Internet Survey (EMIS) surveyed around 180,000 gay or other men who have sex with men from all parts of the continent. The study’s report was released last month and a series of Aidsmap articles have described other findings from this unique survey.


One part of the online survey assessed respondent’s factual knowledge of HIV testing, HIV transmission, sexually transmitted infections (STIs) and post-exposure prophylaxis (PEP).


odds ratio (OR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

post-exposure prophylaxis (PEP)

A month-long course of antiretroviral medicines taken after exposure or possible exposure to HIV, to reduce the risk of acquiring HIV.

multivariable analysis

Statistical technique often used to reduce the impact of confounding factors, in order to attempt to identify the real association between a factor of interest and an outcome. 

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 

Questions were formulated not only to assess respondents’ knowledge but also to educate them – they were presented with a series of true statements, and asked whether they already had this information. The results may somewhat over-estimate participants’ knowledge, but this bias should be consistent across all questions and populations.

Some statements were quite basic, and most would be seen by health educators as essential information for men who have sex with men to possess (e.g. “You cannot be confident about whether someone has HIV or not from their appearance”, “Most sexually transmitted infections can be passed on more easily than HIV”.) A few were a little more specific (e.g. “PEP should be started as soon as possible after exposure, preferably within hours”).

Respondents across Europe were more knowledgeable about HIV testing than other topics – on average, they were already aware of 93% of the statements on testing. In general, knowledge of HIV transmission was greater (81%) than knowledge of sexually transmitted infections (65%). Knowledge of PEP was low in every country, with an average of 30% already having the information provided.

Taking all 16 questions together, mean national scores ranged from 62 to 81%. There appeared to be a west-east divide, with the countries that scored highest being the Netherlands, the United Kingdom, Switzerland, France and Denmark (all 78% or above).

Turkey, where virtually no prevention programmes for MSM exist, had particularly low scores in all of the knowledge areas (62%). Also scoring low were Romania (67%), Cyprus (65%), Latvia (66%) and Lithuania (63%).

But there were exceptions to these regional trends. Poland, Croatia and Bosnia & Herzegovina had higher scores than neighbouring or culturally similar countries. Ireland, Finland and Greece had poorer scores than comparable countries.

Younger and less educated men had somewhat poorer knowledge than others.

More significantly, differences in overall knowledge were strongly correlated with HIV status – respondents diagnosed with HIV had a mean knowledge score of 87%, those who last tested negative scored 77% and those who had never been tested for HIV scored 67%.

Access to services

Respondents were asked a series of questions about their access to HIV testing, condoms and prevention information.

Overall, 91% were confident of their ability to get tested for HIV if they wished to. Scores were generally higher in western Europe (e.g. 97% in France), but less so in Ireland (88%), Portugal (91%) and Germany (91%). The poorest scores were in Turkey (73%), Cyprus (80%) and Serbia (80%).

In relation to condoms, men were asked if they had had unprotected anal intercourse in the past year solely because they did not have a condom to hand.

This was the case for 14% of respondents (i.e. 86% did not have a problem with condom availability). Again, the most encouraging results came from countries in western Europe or Scandinavia.

However 30% and 20% of Norwegian and Spanish respondents respectively had had unprotected sex because condoms were not available, suggesting that condom availability is as serious a problem in these countries as it is in Turkey (32%), Macedonia (28%), Moldova (25%), Serbia (23%), Cyprus (23%) or Romania (20%).

Slovenia, the Czech Republic and Hungary had good scores for condom availability.

Finally, the questionnaire asked about either calling a telephone helpline or having received sexual health information that was specifically for men who have sex with men. Overall, 79% had done so, with the best scores again in the west of the continent, and poorer scores in countries of south-eastern Europe and the ex-Soviet Union.

Whereas information provision was poor in Russia, access to HIV testing and condoms was relatively good there.

The researchers found that there was a strong correlation between the average score for access to services in a country, and the average prevention knowledge score that had been recorded in that country (R2=0.70014). In other words, countries which have accessible HIV prevention services have better informed populations.

They also looked at the services data in relation to the inequality-adjusted Human Development Indicator. This is a score which the United Nations uses to rank countries, and which takes into account life expectancy, years of education, average income and income inequality.

They also found a strong correlation between a country’s level of development and access to services (R2=0.69104).

“Structural interventions addressing economic, social and political inequalities should be essential to efforts to improve knowledge related to HIV and coverage by prevention programmes,” say the authors.

Individual level associations

The researchers also looked at the individual characteristics of men who had poorer access to services. In multivariable analysis (after controlling for age, education and country of residence), the following results were all statistically significant. Migrants from outside Europe and men with a clandestine sexuality were less likely to be reached by prevention services:

  • Men born in southeast Asia (adjusted odds ratio = 0.58)
  • Men born in Latin America or the Caribbean (adjusted odds ratio = 0.63)
  • Men who did not have any friends who also have sex with men (adjusted odds ratio = 0.82)
  • Men identifying as bisexual (adjusted odds ratio = 0.88)
  • Men who used sex venues (adjusted odds ratio = 0.87).

Conversely, men who were out about their sexuality or who used gay social venues had better access to services. “Consequently, reaching men beyond these groupings should be a goal for future interventions,” say the authors.


EMIS 2010: The European men-who-have-sex-with-men internet survey. Findings from 38 Countries. Click here to download.