Among European gay men, rates of unsafe sex rise the further east you go

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The largest ever study of the sexual behaviour of men who have sex with men, which recruited 174,209 men from across the European continent, has found important variations in sexual behaviour according to the country in which men live.

Dr Axel J. Schmidt told the Future of European Prevention among MSM (FEMP) conference in Stockholm this month that compared with men living in some countries in western Europe, men in Latvia, Lithuania, Bulgaria and Romania had two and a half times the odds of reporting unsafe sex. 

The European MSM Internet Sex Survey (EMIS) was an  internet-based questionnaire that was made available in 25 languages across Europe in 2010. (Other results from EMIS, on access to sexual health services and on internalised homonegativity have been previously reported on Aidsmap). Because the survey used the same recruitment methods, questions and definitions of risky behaviour with participants across Europe, the data it produces on different countries are comparable.   


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’. 

unprotected anal intercourse (UAI)

In relation to sex, a term previously used to describe sex without condoms. However, we now know that protection from HIV can be achieved by taking PrEP or the HIV-positive partner having an undetectable viral load, without condoms being required. The term has fallen out of favour due to its ambiguity.

multivariate analysis

An extension of multivariable analysis that is used to model two or more outcomes at the same time.

heterogeneous or heterogeneity

Diverse in character or content. For example, the ‘heterogeneity’ of clinical trials means that they, and their results, are so diverse that comparisons or firm conclusions are difficult.

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

The key variable in the following analysis is having had at least one episode of unprotected anal intercourse in the past year with a partner whose HIV status was either unknown or thought to be different from the respondent’s (i.e. non-concordant unprotected anal intercourse).  

Schmidt argued that this measure was preferable to indicators which did not take the partner’s HIV status into account, although the issue of an HIV-positive man’s use of virally suppressive treatment remains ignored. 

The EMIS results showed that the proportion of men reporting unprotected anal sex with partners not known to have the same HIV status tends to be greater the further east a country is. 

Whereas across Europe, 32% of respondents reported non-concordant unprotected anal sex, this ranged from 21% to 49% depending on the country. 

In a multivariate analysis which took into account the age of the respondents and the way in which they were recruited, the countries with the lowest rates were Luxembourg, Austria, Slovenia and Switzerland.  

Taking that group of countries as the comparison group, respondents in the following countries had a slightly higher odds of reporting unsafe sex (odds ratios up to 1.3): France, Germany, Greece and Belgium. 

The next group of countries, with odds ratios up to 1.5 were drawn from western Europe and Scandinavia: Italy, Portugal, Spain, Denmark and Finland. 

The next-riskiest group (odds ratio up to 1.7) is more heterogeneous, including countries in western Europe, Scandinavia, central Europe and the Balkans: the United Kingdom, the Netherlands, Sweden, Norway, Malta, Poland, Hungary, the Czech Republic, Macedonia, Serbia, and Bosnia & Herzegovina. 

The group of countries with odds ratios up to 2.0 consists of Ireland, Cyprus, Estonia, Ukraine, Russia, Bulgaria, Croatia, Moldova, and the Slovak Republic.

Greater risks were reported by men (odds ratio up to 2.5) in Latvia, Lithuania, Belarus and Romania. Finally, men in Turkey had an odds ratio of 3.2 for reporting non-concordant unprotected anal intercourse. 

A further analysis, presented by Marita van de Laar, showed that the biggest geographical variation in reporting of non-concordant risky sex occurred with steady, rather than casual, partners. Having unprotected sex with a steady partner of unknown or different HIV status was almost twice as common in the countries of central and eastern Europe (newer members of the European Union or non-members) than in western Europe (long-standing EU members). 

It is suggested that this is because of the availability of HIV testing - because of poor access to testing services, men in some countries are more likely to have unprotected within a relationship, without previously establishing that they have the same HIV status.


Schmidt AJ et al. Non-concordant unprotected anal intercourse among MSM across Europe.  The Future of European Prevention among MSM conference, Stockholm, November 11 2011. 

van de Laar M et al. Demographic distribution of non-concordant unprotected anal intercourse in three European regions.  The Future of European Prevention among MSM conference, Stockholm, November 11 2011.