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AIDS:
Epidemiology & Social

Seeking sex on the Internet and sexual risk behaviour among gay men using London gyms

Elford, Jonathan; Bolding, Graham; Sherr, Lorraine

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From the Department of Primary Care and Population Sciences and Royal Free Centre for HIV Medicine, Royal Free and University College Medical School, University College London, London, UK.

Received: 17 November 2000;

revised: 9 March 2001; accepted: 15 March 2001.

Sponsorship: Camden and Islington Health Authority.

Correspondence to Dr Jonathan Elford, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. Tel: +44 (0)20 7794 0500, ext. 4382; fax: +44 (0)20 7794 1224; email: j.elford@pcps.ucl.ac.uk

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Abstract

Objective: To examine the association between seeking sex on the Internet and sexual risk behaviour among gay men in London.

Methods: In January–February 2000, gay men in London gyms were asked to complete self-administered questionnaires concerning use of the Internet, history of sexually transmitted diseases (STD) and recent unprotected anal intercourse (UAI). Internet sex seekers were compared with other men, also with Internet access, who did not seek sex in this way.

Results: Of 743 gay men included in the analysis (121 HIV-positive, 465 HIV-negative, 157 never-tested), 80.9% (601) had access to the Internet. Among those who had access, 34.4% (207) had used the Internet to find a sexual partner; this did not vary significantly by HIV status (P = 0.3). Internet sex seekers were more likely to have had an STD (HIV-negative men, 26.9 versus 17.5%, P = 0.04) or gonorrhoea (HIV-positive men, 22.2 versus 5.8%, P = 0.04) in the previous year than other men with Internet access. HIV-negative Internet sex seekers were also more likely to report non-concordant UAI in the previous 3 months [23.1 versus 11.8%; adjusted odds ratio (aOR), 1.9; 95% confidence interval (CI), 1.2–3.5;P = 0.01]. HIV-positive Internet sex seekers were more likely to report UAI with another positive man (37.8 versus 7.4%; aOR, 7.9; 95% CI, 1.8–34.6;P = 0.006).

Conclusion: Seeking sex on the Internet was associated with recent STD and high-risk sexual behaviour among HIV-positive and -negative gay men in London. The contribution of seeking sex on the Internet to the recent increase in high-risk behaviour among London gay men merits further investigation.

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Introduction

In the USA seeking sex on the Internet appears to be a potential risk factor for HIV and STD [1–3]. A study conducted in a public HIV testing clinic in Denver, Colorado found that people who sought sex on the Internet were more likely to have had a sexually transmitted disease (STD) or report sexual exposure to a person with HIV than those who did not seek sex on the Internet [2]. They were also more likely to be male, homosexual and report anal sex. One of the conclusions from this study was that gay men were more likely to use the Internet to find a sexual partner than other men. However, the investigators did not examine the sexual behaviour of gay men separately from that of heterosexual men or women. Nor did they consider the HIV status of the respondents and their sexual partners. This information is crucial for assessing the level of risk associated with unprotected anal intercourse [4]. Nonetheless, the US study raises the question as to whether the risk for HIV/STD is also elevated among London gay men who seek sex on the Internet.

The objective of this study was to examine the association between seeking sex on the Internet and sexual risk behaviour among gay men in London, focusing on the HIV status of the respondents and their partners.

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Methods

In January—February 2000, gay men using any one of six gyms in central London were asked to complete a confidential self-administered questionnaire as part of an annual behavioural surveillance programme [5]. Questionnaires were distributed in each gym over a 1-week period. Men were asked to provide information on their socio-demographic characteristics (age, ethnicity, employment status, education) and HIV status (positive, negative, never tested). Optimism in the light of new HIV drug therapies was explored by asking men whether they agreed with each of the following statements: I am less worried about HIV now that treatments have improved; I believe that new drug therapies make people with HIV less infectious [6]. Information was also sought on use of steroids [7], Viagra [8], recreational drugs (heroin, cocaine, ecstasy, amphetamines, ketamine, LSD) [9] and being paid for sex in the previous 12 months.

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Sexual risk behaviour

Men were asked whether they had had unprotected anal intercourse (UAI) in the previous 3 months and if so, the type (main or casual) and HIV status of their UAI partner(s). UAI was classified as either seroconcordant (i.e. with a partner of the same HIV status) or non-concordant (with a partner of unknown or discordant HIV status). Seroconcordant UAI presents no risk of HIV transmission if both men are certain that they share the same HIV status. On the other hand non-concordant UAI does present a risk. For men who reported more than one UAI partner in the previous 3 months, UAI was only classified as seroconcordant if they said all their partners were the same status as themselves. UAI reported by men who had never been tested for HIV was classified as non-concordant since, being unaware of their own HIV status, they were not able to establish concordance with their sexual partner. Respondents were also asked whether they had had a sexually transmitted disease in the previous 12 months.

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Internet

Men were asked whether they had access to the Internet at home, work or both. If so, had they used the Internet for, or to get information on, any of the following items concerning HIV risk behaviour, treatments and prevention: finding a sexual partner, safer sex, HIV/sexual health services, HIV testing, HIV treatments, recreational drugs, steroids and Viagra.

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Statistical analysis

In univariate analyses, χ2-, t- and Kruskall–Wallis tests were used for examining differences in proportions, means and medians. Data on access to and use of the internet are presented in Table 1. In Table 2 and Table 3 men who used the Internet to find a sexual partner were compared with other men, also with Internet access, who did not seek a sexual partner in this way. Significant univariate associations between seeking sex on the Internet and UAI were further explored in a multivariate logistic model. In this model the independent variable was seeking (versus not seeking) sex on the Internet whereas the dependent variable was UAI (versus no UAI). The analysis was restricted to men with Internet access; separate analyses were conducted for: (1) any UAI; (2) concordant UAI; and (3) non-concordant UAI. To identify potential confounding factors, variables known to be associated with UAI in this sample of gay men were compared between Internet sex seekers and other men with Internet access. These variables were: age; being in a relationship [5]; optimism in the light of new treatments for HIV [6], and use of steroids [7], Viagra or recreational drugs [8] (Table 2). Ethnicity, employment, education and being paid for sex were also examined although they are not associated with UAI in this group of men [5]. The odds ratios in the multivariate models were adjusted for confounding factors identified in this manner.

Table 1
Table 1
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Table 2
Table 2
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Table 3
Table 3
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Results

During the survey period, we estimated that 1534 questionnaires were distributed to gay men using the gyms. Completed questionnaires were returned by 792 men (52%). This figure represents a minimum estimate for the response rate (see Discussion). The respondents were predominantly young (median age, 35 years), white (90.6%), currently employed (84.4%) and educated (81.3% with higher education). Data were analysed for 743 men who provided data on HIV status as well as use of the Internet: 121 (16.3%) were HIV positive, 465 (62.6%) HIV negative, and 157 (21.1%) had never-tested for HIV.

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The Internet

Of the 743 men, 80.9% (601) had access to the Internet; HIV-positive men 75.2%, HIV-negative men 83.7%, never-tested men 77.1% (P = 0.04) (Table 1). HIV-positive men were less likely to have access to the Internet at work than other men (P < 0.001). This reflected the lower level of employment among HIV-positive men (52.4%) compared with their HIV-negative and never-tested counterparts (90.5%, 89.9%) (P < 0.001).

Among the 601 men with access to the Internet, 34.4% (207) had used it to find a sexual partner, the majority (172 of 207; 83.1%) on more than one occasion; HIV-positive men 40.7%, HIV-negative 34.4%, never-tested 29.8% (P = 0.3) (Table 1). Overall, men were more likely to have used the Internet for finding a sexual partner than for seeking information about safer sex, HIV/sexual health services, HIV treatments, HIV testing, recreational drugs, steroids or Viagra (Table 1). This general pattern was seen for both HIV-negative and never-tested men but differed somewhat for HIV-positive men. More than half the HIV-positive men (51.7%) had used the Internet to get information on HIV treatments and 40.7% on HIV or sexual health services. Among HIV-negative men, those who had used the Internet to find a sexual partner were more likely to have also used it to get information on HIV or sexual health services than men not seeking sex on the Internet (16.2 versus 8.3%, P = 0.02). A similar trend was seen for never-tested men (17.1 versus 4.7%, P = 0.06) but not for those who were HIV positive (45.9 versus 37.0%, P = 0.5).

In comparison with other respondents, HIV-positive men were significantly more likely to have used the Internet to get information on recreational drugs, steroids and Viagra (P ≤ 0.03).

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Characteristics of Internet sex seekers

Among men with access to the Internet, there were no significant differences between those who had and those who had not used the Internet to find a sexual partner in ethnicity, education, employment or being paid for sex (Table 2). However, HIV-positive Internet sex seekers were younger (median age 34 versus 37 years, P < 0.01, more likely to use steroids (45.9 versus 22.2%, P = 0.02) and to believe that new drug therapies made people with HIV less infectious (38.9 versus 14.8%, P = 0.01). These differences were not seen among HIV-negative or never-tested men. HIV-negative Internet sex-seekers were less likely to be in a relationship (51.5 versus 66.3%, P = 0.02) and more likely to say they were not as worried about HIV now that treatments have improved (22.4 versus 14.7%, P = 0.07). These differences were not seen among HIV positive or never-tested men.

As a group, HIV-positive men were more likely to have used recreational drugs, steroids and Viagra than HIV-negative or never-tested men (P < 0.001). With the exception of steroid use among HIV-positive men, however, there was no significant difference in the use of these substances between men who had or had not used the Internet to find a sexual partner (Table 2).

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Sexually transmitted disease

Among men with access to the Internet, 20.2% (120 of 595, data missing for six men) said they had had an STD in the previous year; HIV-positive men 29.5% (26 of 88), HIV-negative men 20.7% (80 of 386), never-tested men 11.6% (14 of 121) (P = 0.005). HIV-positive and -negative Internet sex seekers were more likely to have had an STD in the previous 12 months than other men with Internet access (Table 3). This differential was statistically significant for HIV-negative men reporting any STD (P = 0.04), whereas for HIV-positive men it was significant for gonorrhoea only (P = 0.04). For never-tested men, 8.3% (three of 36) of Internet sex seekers reported an STD in the previous 12 months compared with 12.9% (11 of 85) of other men with Internet access (P = 0.6).

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Unprotected anal intercourse
HIV-positive men

Overall 45.1% (41 of 91) of HIV-positive men with Internet access reported UAI in the previous 3 months; Internet sex seekers 64.9%, other men with Internet access 31.5% (P = 0.003) (Table 3). After controlling for age, steroid use and HIV optimism (confounding factors identified in Table 2) this two-fold difference in risk became non-significant [adjusted odds ratio (aOR), 2.0; 95% confidence interval (CI), 0.7–5.7;P = 0.2]. In univariate analysis, HIV-positive men who used the Internet to find a sexual partner were significantly more likely to report concordant UAI (i.e. UAI with another HIV-positive man) than those who did not seek sex in this way (37.8 versus 7.4%, P < 0.001). For HIV-positive men, concordant UAI was usually with a casual rather than with a regular partner. This association remained significant after controlling for age, HIV optimism and steroid use (aOR for concordant UAI, 7.4; 95% CI, 1.8–34.6;P = 0.006). On the other hand, for HIV-positive men, no significant univariate association was seen between seeking sex on the Internet and non-concordant UAI, that is to say UAI with a person of unknown or discordant HIV status (P = 0.2).

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HIV-negative men

Just over one-third (35.5%, 138 of 389) of HIV-negative men reported UAI in the previous 3 months; Internet sex seekers 35.8%; and other men with access to the Internet 35.3% (P =1.0) (Table 3). However, HIV-negative men who had used the Internet to find a sexual partner were significantly more likely to report non-concordant UAI in the previous 3 months than other negative men with Internet access (23.1 versus 11.8%, P = 0.02). Among HIV-negative men, non-concordant UAI was usually with a casual partner of unknown HIV status. After controlling for relationship status and HIV optimism (confounding factors identified in Table 2), the aOR for non-concordant UAI was 1.9 (95% CI, 1.1–3.5;P = 0.02). Conversely, HIV-negative Internet sex seekers were less likely to report concordant UAI than other negative men. This was of borderline significance in univariate analysis (P = 0.06). After adjusting for relationship status and HIV optimism in a multivariate logistic model significance decreased further (aOR for concordant UAI, 0.6; 95% CI, 0.3–1.1;P = 0.09).

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Never-tested men

Overall, 19.8% (24 of 121) of never-tested men with Internet access reported non-concordant UAI (all UAI reported by never-tested men was classified as non-concordant); Internet sex seekers 16.7% (six of 36), other never-tested men 21.2% (18 of 85) (P = 0.7).

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Discussion

Seeking sex on the Internet was associated with high-risk sexual behaviour and recent STD among HIV-positive and -negative gay men in London. For HIV-negative men, the increased sexual risk was predominantly with a casual partner of unknown HIV status. This is an established risk for the transmission of HIV and STD, as reflected by the elevated prevalence of STD among HIV-negative men seeking sex on the Internet. For HIV-positive Internet sex seekers, elevated risk behaviour was predominantly with a casual partner of the same HIV status. This raises the possibility that HIV-positive men are using the Internet to meet other positive men for unprotected sex. Although this presents no risk of HIV transmission to an uninfected person, it has important implications for the health of the HIV-infected men themselves. Seroconcordant UAI between HIV-positive men may result in cross infection and drug resistance, which clearly has important treatment implications for those who acquire resistant virus [10]. Seroconcordant UAI may also result in the transmission of STD, as reflected by the significantly increased prevalence of gonorrhoea among HIV-positive Internet sex seekers.

Our analysis throws into sharp focus the importance of distinguishing concordant UAI from non-concordant UAI [4,5]. Among HIV-negative men there was little difference in the overall rate of UAI between Internet sex seekers and other men. However, separating concordant from non-concordant UAI revealed a significant association between seeking sex on the Internet and non-concordant (i.e. high risk) UAI among these men. For HIV-positive Internet sex seekers, much if not all of the elevated rate of any UAI could be accounted for by their younger age and steroid use. However, the increased rate of seroconcordant UAI among HIV-positive Internet sex seekers could not be explained in this way. The distinction between non-concordant and concordant UAI is clearly important not only for behavioural research but also for developing health promotion and HIV prevention strategies.

This is the first report from the UK of an association between seeking sex on the Internet and high-risk sexual behaviour among gay men, previously described in the USA [1–3]. It was not possible in our study to establish whether the excess risk for HIV and STD occurred with sexual partners whom respondents had met through the Internet. This clearly merits further investigation. The possibility that HIV-positive men may use the Internet to seek unprotected anal intercourse with other HIV-positive men also requires further exploration; as does the question of causality which could not be established in this cross-sectional study. Does seeking sex through the Internet prompt an increase in high-risk sexual behaviour or is it individuals with a high-risk profile who use the Internet to find sexual partners? Although there were some differences in the background characteristics of those who did or did not seek sex on the Internet in our study (which were taken into account in the analysis) the two groups were similar in many respects. This provides evidence that the risk profile of the Internet sex seekers alone could not account for the observed differentials in sexual behaviour.

Compared with other respondents, HIV-positive men were more likely to take, and use the Internet to get information about, recreational drugs, steroids and Viagra. Recreational drug use has been shown to be associated with high-risk sexual behaviour, although the relationship may not necessarily be causal [9,11]. Clearly the Internet has an important role to play in promoting risk reduction and harm minimization practices among people who seek information about recreational drugs, steroids or Viagra on the Internet. The potential for using the Internet for HIV and STD prevention is further supported by the fact that Internet sex seekers (HIV-negative and never-tested) were more likely to have also used the Internet to get information on HIV and sexual health services than other men with Internet access. Nearly half the HIV-positive men had also used the Internet for this purpose.

The response rate of 52% should be seen as a minimum estimate because, by using the managers’ upper limit for the estimated proportion of gay men in their gyms, we may have overestimated the number of gay men who were handed a questionnaire (the denominator) [5,12]. Using the lower limit reduced the overall size of the denominator and raised the estimated response rate to 55–60%. This figure is comparable with response rates reported in recent behavioural studies among gay men in the USA [13–15] although lower than in some UK studies [16,17]. Nonetheless, the demographic and behavioural characteristics of the gym sample recruited in January–February 2000 were similar to those of nearly 2000 men surveyed in London gay bars, clubs and genito-urinary medicine clinics 2 months earlier. This study achieved a response rate of 76% (personal communication, J. Dodds).

Our findings can not however, be generalized to all gay men in London because the study population, recruited in central London gyms, was not a random sample. For example, men in the gym study were older (median age 35 versus 32 years, P < 0.05 and more likely to have had a higher education (81.3 versus 58.0%, P < 0.001) than men surveyed in bars and clubs. On the other hand, there were no differences in their ethnicity and employment status.

The analysis was restricted to men with access to the Internet since the appropriate comparison group for Internet sex seekers was men, also with Internet access, who chose not to find a sexual partner in this way. However, repeating the analysis comparing Internet sex seekers with all other men in the sample regardless of Internet access did not alter the findings. Men were not asked whether their UAI was receptive or insertive, a factor which may influence the likelihood of HIV transmission or acquisition. Consequently, among HIV-negative internet sex seekers we were not able to examine whether their elevated level of non-concordant UAI was moderated by their choosing insertive rather than receptive UAI as a risk reduction strategy. We were also not able to establish what proportion of men who sought sex through the Internet actually had sex with partners they met in this way. Information on Internet-specific partners will be collected in future surveys.

Between 1996 and 1998, the percentage of London gay men reporting high-risk sexual behaviour increased by 26%[18]. Similar increases in high-risk sexual behaviour have been reported among gay men in Australia [19], Canada [20] and the USA [21]. It has been suggested that high-risk sexual behaviour may be increasing because new treatments for HIV have reduced concern about infection [22]. In fact surveys conducted in Europe [6], North America [23] and Australia [24] have shown that only a minority of gay men say they are less concerned about HIV now that treatments have improved. Furthermore, in London the recent increase in high-risk sexual behaviour was seen equally in gay men who were less concerned and those who were just as concerned about HIV in the light of new HIV treatments [25]. It is unlikely therefore that ‘HIV treatments optimism’ alone can explain the recent increase in high-risk sexual behaviour among London gay men. During the last few years, however, access to the Internet has risen dramatically [26,27]. The majority of gay men in our study had access to the Internet, one-third of whom had used it to find a sexual partner. The contribution of seeking sex through the Internet to the recent increase in high-risk behaviour among gay men merits further investigation as does the possibility of using the Internet for HIV and STD prevention [28].

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Acknowledgements

We would like to thank the managers and members of the gyms for their support and participation in the project.

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References

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Keywords:

gay; risk factors; sexual behaviour; Internet

© 2001 Lippincott Williams & Wilkins, Inc.

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