aNational Centre in HIV Social Research, and bNational Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia.
Sponsorship: This study was supported by the New South Wales Health Department and implemented in association with the AIDS Council of New South Wales and People Living With HIV/AIDS (NSW) Inc. The National Centre in HIV Social Research and the National Centre in HIV Epidemiology and Clinical Research are funded by the Commonwealth Department of Health and Aged Care.
Received: 4 August 2000;
revised: 6 September 2000; accepted: 14 September 2000.
HIV in Australia has largely affected gay men who account for approximately 85% of infections [1,2]. From the mid-1980s to the mid-1990s there was a decrease in the percentage of gay men in Australia practising unprotected anal intercourse . Concomitantly, there was a decrease in the estimated number of new HIV infections among gay men from over 2500 in 1984 to a plateau of 400–500 infections per annum from 1991 to now [1,2].
The introduction of improved antiretroviral therapies in Australia and other western industrialized countries from the mid-to-late 1990s has occurred at the same time as an increase in gay men's sexual risk practices [4–8], with an increased incidence of new HIV infections reported in North America [9,10]. Examinations of sexual risk practices have found an association with optimism that antiretroviral therapy results in reduced infectivity [11–14], although comparative studies show the heterogeneity across different countries of gay men's responses to HIV therapies .
We examined findings from cross-sectional surveys (February 1996 to February 2000) assessing sexual risk behaviour among gay men in Sydney. Using an anonymous, self-completed questionnaire, surveys were conducted 6 monthly at four consistent sites: two sex-on-premises venues, a gay sporting venue and a sexual health centre. Five identical surveys were conducted at the annual (February) Sydney Gay and Lesbian Mardi Gras Fair Day.
Men were recruited if they had had sex with another man in the past 5 years. In addition, they had to live in Sydney or have participated regularly in the Sydney gay community. All men at the four consistent sites were approached with the aim of recruiting 100% of those in attendance. At the Fair Day, recruiters were positioned at strategic stalls and alleyways and they approached as many men as possible.
A six-item scale of optimism–scepticism in the context of HIV treatments (Cronbach's alpha 0.76) was included in the February 2000 questionnaire . Total scores on the scale could range from 6 (sceptical) to 24 (optimistic).
For the analysis of behavioural trends, data from the four consistent sites and the Fair Days, and for HIV-negative and HIV-positive men, were analysed separately. Retaining each of the whole samples as the base, anal intercourse with casual partners was collapsed into a binary variable: any unprotected anal intercourse (with or without ejaculation) with casual partners in the previous 6 months (UAI-C) versus no unprotected anal intercourse with casual partners. (Where trends were not significant overall, data from the reduced base of ‘men who engaged in anal intercourse with casual partners’ were examined for underlying trends.)
In all, 10 960 men ranging in age from 16 to 81 years (median 34 years) were recruited, 5084 at the four consistent sites (overall response rate 80.0%; range across sites 56.1–100%) and 5876 at the Fair Days (overall response rate 71.1%; range over time 65.3–81.7%). From the four consistent sites, 2748 (54.1%) were recruited at the sex-on-premises venues, 546 (10.7%) at the sporting venue and 1790 (35.2%) at the sexual health centre, and these proportions were quite stable over time. Self-reported HIV status was 7612 (69.5%) HIV-negative, 2042 (18.6%) HIV-positive and 1306 (11.9%) unknown or missing data.
As shown in Table 1, men recruited at the four consistent sites generally reported more UAI-C than their Fair Day counterparts. At the four consistent sites, there was a significant upward trend in UAI-C (assessed by Mantel–Haenszel test) among both HIV-negative and HIV-positive men. HIV-positive men had significantly higher rates of UAI-C at most data collection points. However, the trends in UAI-C for HIV-negative and HIV-positive men were not significantly different (assessed by a time × serostatus interaction term in logistic regression).
At the Fair Days, there was a significant upward trend in UAI-C among HIV-negative men. Among HIV-positive men, UAI-C fluctuated and there was no significant trend. However, for the reduced base of HIV-positive men who had anal intercourse with casual partners, there was a significant upward trend in UAI-C. As for the four consistent sites, HIV-positive men recruited at the Fair Days mostly had significantly higher rates of UAI-C than their HIV-negative counterparts.
In February 2000, mean scores on the HIV optimism scale tended towards scepticism. Nonetheless, HIV-negative men (n = 1220) who reported UAI-C had a higher mean score (indicating greater optimism) than their counterparts who reported no UAI-C (9.5 versus 8.7 respectively, P = 0.003). Likewise, HIV-positive men (n = 256) who reported UAI-C had a higher mean score than HIV-positive men who reported no UAI-C (10.1 versus 8.7 respectively, P = 0.002).
The significant increase in sexual risk behaviour among gay men in Sydney parallels that documented elsewhere [5–8]. Although HIV-positive men have higher rates of UAI-C on the whole, increased risk-taking has occurred among HIV-negative and HIV-positive men alike. The trends have been most evident among men recruited from gay community-based venues and clinics. However, by February 2000, trends emerged among men recruited at the Fair Day. This highlights the importance of undertaking behavioural surveillance work across a range of settings, not just Pride Festivals, because different patterns of sexual risk taking may emerge from different sites.
Corroborating reports from elsewhere [11–14], there is a significant association between sexual risk behaviour and HIV optimism. The current data, however, do not permit us to imply causality.
Contrary to recent North American data [9,10], there has been no increase in new HIV infections among gay men in Australia , despite a national surveillance system for newly acquired HIV infection . One possible explanation is Australia's relatively low prevalence of HIV and high-level access to and uptake of antiretroviral treatment [1,18], with resultant reduced transmission. Another potential explanation is that the monitoring system for newly acquired HIV infection is insufficiently sensitive to detect small increases. This is an important juncture in the epidemic, requiring close scrutiny of behavioural trends and HIV incidence rates, and an effective educational response, to prevent a resurgence in HIV infection related to a breakdown in safe sex norms that have served gay communities so well.
Paul Van de Vena
1. National Centre in HIV Epidemiology and Clinical Research. 1999 HIV/AIDS, hepatitis C and sexually transmissible infections in Australia: annual surveillance report.
Sydney: NCHECR, The University of New South Wales; 1999.
2. National Centre in HIV Epidemiology and Clinical Research. Australian HIV surveillance report (vol. 16, no. 2).
Sydney: NCHECR, The University of New South Wales; 2000.
3. Crawford J, Bermingham S, Kippax S. An analysis of trends over time in social and behavioural factors related to the transmission of HIV in men who have sex with men.
Canberra: Australian Government Publishing Service; 1996.
4. Van de Ven P, Prestage G, French J. et al
. Increase in unprotected anal intercourse with casual partners among Sydney gay men in 1996–98.
Aust NZ J Pub Health 1998, 22: 814 –818.
5. Dodds JP, Nardone A, Mercey DE, Johnson AM. Increase in high risk sexual behaviour among homosexual men, London 1996–8: cross sectional, questionnaire study.
BMJ 2000, 320: 1510 –1511.
6. Denning P, Nakashima AK, Wortley P. Increasing rates of unprotected anal intercourse among HIV-infected men who have sex with men in the United States. XIIIth International AIDS Conference
. Durban, July 2000 [Abstract no. ThOrC714].
7. Ekstrand ML, Stall RD, Paul JP. et al
. Gay men report high rates of unprotected sex with partners of unknown or discordant HIV status.
AIDS 2000, 13: 1525 –1533.
8. Dukers N, de Wit J, Goudsmit J, Couthino R. Recent increase in sexual risk behavior and sexually transmitted diseases in a cohort of homosexual men: the price of highly active anti-retroviral therapy? XIIIth International AIDS Conference
. Durban, July 2000 [Abstract no. ThOrC715].
9. McFarland W, Schwatcz S, Kellog T, et al
. Implications of highly active antiretroviral treatment for HIV prevention: the case of men who have sex with men (MSM) in San Francisco. XIIIth International AIDS Conference
. Durban, July 2000 [Abstract no. MoPpD1127].
10. Calzavara L, Burchell A, Major C, et al
. Increasing HIV incidence among MSM repeat testers in Ontario, Canada, 1992–1998. XIIIth International AIDS Conference
. Durban, July 2000 [Abstract no. ThOrC718].
11. Kelly J, Hoffman R, Rompa DJ. et al
. Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex.
AIDS 1998, 12: F91 –F95.
12. Remien RH, Wagner G, Carballo-Diéguez A. et al
. Who may be engaging in high-risk sex due to medical treatment advances?
AIDS 1998, 12: 1560 –1561.
13. Vanable PA, Ostrow DG, McKirnan DJ. et al
. Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men.
Health Psychol 2000, 19: 134 –135.
14. Van de Ven P, Kippax S, Knox S. et al
. HIV treatments optimism and sexual behaviour among gay men in Sydney and Melbourne.
AIDS 1999, 13: 2289 –2294.
15. Van de Ven P (on behalf of International Collaboration on HIV Optimism). International differences among gay men in HIV optimism and sexual risk behaviour: a report from London, Melbourne, Sydney and Vancouver. XIIIth International AIDS Conference
. Durban, July, 2000 [Abstract no. LbPpC7078].
16. Van de Ven P, Crawford J, Kippax S. et al
. A scale of optimism-scepticism in the context of HIV treatments.
AIDS Care 2000, 12: 171 –176.
17. McDonald AM, Gertig DM, Crofts N, Kaldor JM. A national surveillance system for newly acquired HIV infection.
Am J Public Health 1994, 84: 1923 –1928.
18. National Centre in HIV Social Research. 1999 HIV/AIDS and related diseases in Australia: annual report of behaviour.
Sydney: NCHSR, The University of New South Wales; 1999.
© 2000 Lippincott Williams & Wilkins, Inc.