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Prevention Research

Physical Distancing Due to COVID-19 Disrupts Sexual Behaviors Among Gay and Bisexual Men in Australia: Implications for Trends in HIV and Other Sexually Transmissible Infections

Hammoud, Mohamed A. PhDa; Maher, Lisa PhDa; Holt, Martin PhDb; Degenhardt, Louisa PhDc; Jin, Fengyi PhDa; Murphy, Dean PhDa; Bavinton, Benjamin PhDa; Grulich, Andrew PhDa; Lea, Toby PhDb; Haire, Bridget PhDa; Bourne, Adam PhDd; Saxton, Peter PhDe; Vaccher, Stefanie PhDa; Ellard, Jeanne PhDf; Mackie, Brentg; Batrouney, Colinh; Bath, Nickyi; Prestage, Garrett PhDa

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: November 01, 2020 - Volume 85 - Issue 3 - p 309-315
doi: 10.1097/QAI.0000000000002462
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Abstract

INTRODUCTION

The 2019 novel coronavirus (SARS-CoV-2) which causes the disease COVID-19 was identified in December 2019.1 Similar to other coronaviruses, SARS-CoV-2 is transmitted mainly by droplets2 and is highly transmissible through close proximity or physical contact with an infected person.3,4 Without an effective vaccine or treatment, countries across the globe have implemented public health and physical measures to prevent onwards transmission and reduce the burden on health care settings.5 These include increased hygiene measures, such as hand washing and respiratory etiquette; travel restrictions and related measures, including border closures and quarantining of people returning from overseas; and physical distancing. Physical distancing measures apply to both individuals and the community, through restrictions on mass gatherings, closure of schools, workplaces, and public spaces, and recommendations for keeping at least 1.5 m (5 ft) distance from other people.5

From early March 2020, Australian state and commonwealth governments began to respond to the threat of COVID-19 with escalating measures, alongside a growing sense of concern in the community.6 Australia initially implemented a ban on incoming travelers from China on February 1, and from March 15, all incoming travelers from all countries were required to self-isolate for 14 days. On March 16, restrictions on public gatherings commenced. Although these varied from state-to-state, generally gatherings were limited to 500 people with appropriate physical distancing but were rapidly reduced to a maximum of 100 people, then 10 people. From March 20, foreign nationals were banned from entering Australia, and by March 21, 5 of 8 state and territory governments had closed borders to preventing interstate travel. Over the coming days, governments imposed progressively stronger restrictions and recommended not leaving the house unless for essential purposes—to access food or medical services, attend work that was deemed necessary, or to exercise. Public venues such as restaurants, libraries, and gyms were closed. By March 29, all public gatherings for people who did not reside together were restricted to 2 people, and a minimum of 1.5-m distance between individuals had to be maintained.6

Although restrictions varied between jurisdictions, people were either banned or strongly discouraged from visiting sexual partners with whom they did not cohabit.6 Specific messaging for different populations, including by gay community organizations, was also developed, recommending people avoid casual sex and focus on masturbation and virtual sex.7,8 If individuals abide by these recommendations, the reduction in casual sexual contacts during the period of enforced physical distancing restrictions during the COVID-19 pandemic has the potential to substantially impact HIV and sexually transmissible infection (STI) transmission in Australia.9

The HIV epidemic in Australia is concentrated among gay and bisexual men (GBM).10 HIV prevalence among GBM in Australia is estimated to be 7.9%.10–12 Between 2008 and 2017, 84% of newly acquired HIV notifications in Australia were attributed to male-to-male sex.10 GBM also experience higher rates of other STIs than their heterosexual peers, and the incidence of all STIs among GBM has increased between 2013 and 2017.10 In 2018, 25% of HIV-negative GBM and 45% of HIV-positive GBM reported a STI diagnosis in the previous 12 months.13

Condomless anal intercourse between casual partners is the key driver of HIV infections among GBM in Australia.14,15 Between 2007 and 2015, almost two-thirds (66.1%) of Australian GBM recently diagnosed with HIV cited sex with “new” or casual partners as the source of their HIV infection.16 A further 23.3% of recently diagnosed GBM cited nonromantic regular sexual partners or “fuckbuddies,” and the remaining 10.6% cited their romantic regular partner, or “boyfriend,” as the likely source of their infection.16

The risk of contracting HIV and other STIs may be exacerbated by GBM who have a higher number of sexual partners or engage in group sex (involving more than 2 men).17 Greater partner numbers increases the chances of sexual encounters with GBM who have a detectable HIV viral load or a STI, which may increase the risk of HIV transmission among men not using other forms of HIV prevention such as condoms or pre-exposure prophylaxis.18,19 Modeling indicates that 59% of new HIV infections among GBM in Australia originate from the estimated 8% of HIV-positive GBM with undiagnosed infection.20 The higher number of partners and frequency of partner change among people who engage in group sex and participate in sex partying networks can also create HIV transmission clusters, especially if one or more members have acute undiagnosed infection.10

Physical distancing due to COVID-19 reduces opportunities for all close contact with others, including for sexual and physical intimacy. The disruption of sexual contacts operates at both an interpersonal and network level, therefore reducing opportunities for sexually transmissible pathogens to spread.21 Early data from the United States indicate that GBM have reduced their number of sexual partners and frequency of sex during the pandemic,9 although the extent to which this has occurred among Australian GBM remains as yet unknown. However, it is also unclear whether and how these restrictions may differentially impact different forms of sexual partnerships between GBM. These disruptions to sexual connections between GBM may result in short-term declines in new HIV infections and other STIs depending on the extent and nature of the changes in sexual behavior. Understanding how physical distancing measures affect sexual behavior among GBM will be critical to monitoring and understanding short-term trends in new HIV and STI diagnoses. Although the longer-term impacts of ongoing COVID-19 transmission, including potential future waves, on risk behaviors, and health seeking among GBM is currently unknown, changes in these behaviors may lead to fluctuations in the rates of new HIV and STI diagnoses over time.

This article investigates the impact of COVID-19 on sexual behavior involving different partner types among Australian GBM and discusses the potential impact on trends in HIV and STI infections and the wider HIV prevention response.

METHODS

Study Design and Procedure

The Following Lives Undergoing Change (Flux) Study is a national, online, open, prospective observational study of GBM in Australia which launched in 2014. A detailed description of the study protocol has been published previously.22 Men were eligible to participate in the study if they were at least 16 years of age, identified as gay or bisexual or had sex with a man in the previous 12 months, and lived in Australia.

Study promotion occurred by online advertising through social media, including popular gay “dating” sites and apps, and Facebook. At enrolment, online informed consent was obtained from all participants. Study eligibility, inclusion, and exclusion were assessed automatically through the study online platform. Participants who did not meet the criteria were unable to complete the consent form. For participants who met the criteria, an automatically generated email was sent to their nominated email address. On enrolment, participants were required to respond to the email before being able to commence study participation, thereby verifying that they intended to join the study.

Once enrolled, participants completed online surveys at 6-monthly intervals. Starting on April 04, 2020, all participants were invited to complete a special survey round with questions about the impact of COVID-19; this survey forms the basis of the present analyses. No compensation was offered for participation at enrolment or any subsequent follow-up. Ethical approval was granted by the Human Research Ethics Committee of UNSW Sydney.

Measures

The questionnaire items included demographic items such as age, country of birth, and sexual identity, as well as self-reported HIV serostatus and testing histories, and sexual contact with other men. Three categories of sex partners were included: “boyfriends” or “husbands” (a regular committed partner with whom they maintained a romantic relationship), “fuckbuddies” (nonromantic regular partners), and casual partners.23 Because any form of sexual contact could be regarded as representing a risk for COVID-19 transmission, men were asked about any sexual contact with each of these partner types. They were specifically about any incidents of group sex because it would represent a significantly increased risk of transmission.

COVID-19-related items were developed by the study team to measure changes in sexual and other risk behaviors due to COVID-19 in Australia and reasons for those changes. Men were also asked to specify the date on which they first became concerned themselves about COVID-19. Whereas in previous survey rounds participants had reported on sexual behaviors with each partner type during the 6 months before the survey, on this occasion those questions were adapted to report whether they had engaged in sexual behaviors with each partner type in the 6 months before the date from which they became concerned about COVID-19 (hereafter referred to as “before COVID-19”) in Australia. They were then asked about their equivalent sexual behaviors since the date they became concerned about COVID-19 (hereafter referred to as “since COVID-19”). These comprised the 2 reporting periods described. The small number of men who indicated they were not concerned about COVID-19 were categorized as having been concerned about COVID-19 for 0 days.

Analysis

The average number of partners per day was calculated by dividing the total number of partners reported in each reporting period by the number of days in that same period. Descriptive statistics were used to characterize men according to their reported changes in behavior, along with their ascribed reasons for such changes. Paired t tests were conducted to compare means before and since COVID-19 using a Type 1 error rate of 5%. Data were analyzed using SPSS version 26 software.

RESULTS

Participants

Of a total of 3273 men who had ever enrolled in the Flux cohort, the number of respondents in each year varied from 557 in 2014, to 1820 in 2017, and 1000 in 2019. In April 2020, cohort participants were invited to complete a survey about the impact of COVID-19 between April 4, 2020, and April 29, 2020. A total of 940 participants provided fully useable responses. Compared with these 940 men, those who did not respond or who did not complete the questionnaire were younger (Mean 36.5 vs. 39.9) but were otherwise similar, including for number of sexual partners and sexual behavior in the previous 6 months.

The mean age of the 940 men included in this analysis was 39.9 years (SD: 13.4), with ages ranging from 18 to 81 years; 16.9% were aged under 30% and 49.0% were aged 31–50. Most men described themselves as gay (92.7%) or bisexual (5.2%). Of the remaining 19 men, 10 identified at least somewhat with the term “gay.” Over a third (36.8%) said most or all of their friends were gay, with 11.8% spending “a lot” of their time with them. Over two-thirds (69.5%) had university-level education. Most (96%) had ever been tested for HIV. A total of 74 men (7.9%) reported being HIV-positive.

The majority of participants (98.7%; n = 910) were aware of COVID-19 before survey launch. Individual participants recalled becoming concerned about COVID-19 from December 2019 until April 29, 2020, with 33.3% being concerned about COVID-19 by the end of February, rising to 71.4% by March 15, and 93.9% by March 31 (Fig. 1). At the time they completed this survey, men had reported an average of 37 days (mean = 37.5; median = 34) of being concerned about COVID-19. Two-thirds of men indicated they had begun avoiding close physical contact (66.1%) and sex with casual partners (64.0% of those reporting previous sex with casual partners) due to COVID-19 at least 3 weeks before survey. Overall, 70.3% reported having confined themselves from others to prevent being infected with COVID-19, and 94.6% having avoided group gatherings. Most men (93.4%) stated that engaging in casual sex during the COVID-19 pandemic was “too risky.”

FIGURE 1.
FIGURE 1.:
Dates of first becoming personally concerned about the COVID-19 pandemic.

Overall, most men (88.3%) reported sex with other men during the 6 months before COVID-19. Whereas the majority of men (68.3%) reported sex with partners other than their primary romantic partner before COVID-19, only a minority (16.4%) continued to do since COVID-19.

The mean number of sexual partners among all participants decreased more than 12 fold from the before COVID-19 reporting period to the since COVID-19 reporting period (Table 1). The reporting period before becoming concerned about COVID-19 covered 181 days, whereas the mean number of days in the reporting period after becoming concerned was 37.5 days. Adjusting for the number of days in the reporting periods, men reported a mean of 0.062 partners per day in the period before COVID-19 and a mean of 0.026 partners per day since COVID-19, representing a reduction of 58.1% in average number of partners per day (P < 0.001). Among the 664 men who reported sex with any nonrelationship partners (either fuckbuddies or casual partners) before COVID-19, the mean number of sexual partners decreased more than 15 fold since COVID-19. Adjusting for number of days in the reporting periods, men reported a mean of 0.09 partners per day in the period before COVID-19 and a mean of 0.03 partners per day since COVID-19, representing a reduction of 65.2% in average number of partners per day (P < 0.001).

TABLE 1. - Number of Partners Before and Since Introduction of COVID-19 Physical Distancing Measures
Before COVID-19 Since COVID-19
Range Mean (SD) Median Range Mean (SD) Median
No. of days in the survey period 181 181 0–127 37.468 (20.160) 34
Whole sample (n = 940)
 Total no. of partners 0–300 11.300 (27.708) 4 0–50 0.755 (2.078) 0
 Average no. of partners per day 0–1.660 0.062 (0.125) 0.022 0–1.500 0.026 (0.081) 0
Men reporting sex with nonrelationship partners (n = 664)
 Total no. of partners 1–300 16.040 (26.027) 8 0–50 0.893 (2.473) 0
 Average no. of partners per day 0.010–1.660 0.089 (0.144) 0.044 0–1.500 0.031 (0.097) 0

Sexual Behavior With Primary Relationship Partner

Over half (53.2%; n = 500) of respondents had a primary relationship partner such as a boyfriend or husband, and among those, most (73.6%) reported living with their regular partner. Half (49.4%) of men in relationships continued to have sex with their primary relationship partner since COVID-19.

Whereas 150 men (30.0%) indicated that they were having less sex with their primary relationship partner since COVID-19, 8.0% (n = 40) reported they were having more sex with their primary relationship partner.

Changes in Sexual Behavior With Fuckbuddies

More than half of respondents (53.5%; n = 503) reported having previously had sex with fuckbuddies in the 6 months before COVID-19. Among these men, just 1 quarter (24.0%; n = 122) of those who had previously had sex with fuckbuddies continued to do so since COVID-19 (Table 2). Five men reported sex with fuckbuddies since COVID-19 who had not previously been having sex with fuckbuddies. Most men also described themselves as having sex with fuckbuddies less often since COVID-19. No demographic characteristics were associated with reporting less sex with fuckbuddies. One in 8 (12.6%; n = 16) of those who reported sex with fuckbuddies since COVID-19 indicated that they were currently living with those partners.

TABLE 2. - Men Reporting Sex Before and Since COVID-19 (Total Sample)
n (%) Sex with Fuckbuddies (n = 503) Sex With Casual Partners (n = 588) Group Sex (n = 319)
Any sexual contact
 Only before COVID-19 381 (75.0) 494 (84.0) 283 (88.7)
 Only since COVID-19 5 (1.0) 1 (0.2) 12 (3.8)
 Both before and since COVID-19 122 (24.0) 93 (15.8) 24 (7.5)
Perceived changes in frequency of sex
 Much less sex 447 (88.0) 503 (85.5) 286 (89.7)
 Somewhat less sex 28 (5.5) 29 (4.9) 20 (6.3)
 About the same 30 (5.9) 53 (9.0) 12 (3.8)
 Somewhat more sex 3 (0.6) 2 (0.3) 1 (0.3)
 Much more sex 0 (0.0) 1 (0.2) 0 (0.0)
Total number in each column was of the number of men who reported sex with the respective partner types, either before or since COVID-19.

Changes in Sexual Behavior With Casual Partners

Although over three-fifths (62.4%; n = 588) of men reported having previously had sex with casual partners, fewer than 1 in 6 (15.8%; n = 93) of those men continued to do so since COVID-19 (Table 3). One man reported sex with casual partners since COVID-19 who had not previously been having sex with casual partners. Most also described themselves as having less sex with casual partners since COVID-19. No demographic characteristics were associated with the likelihood to report less sex with casual partners. One in 12 (8.5%; n = 8) men who reported sex with casual partners since COVID-19 indicated that they were currently living with those partners.

TABLE 3. - Reasons for Changes in Sexual Behavior Among Men Who Reported Sex With Fuckbuddies or Casual Partners Before or Since the COVID-19 Pandemic
n (%) Continued Having Sex with Fuckbuddies and Casual Partners since COVID-19 (n = 112) Did not continue having sex with Fuckbuddies and casual partners since COVID-19 (n = 539) P
Avoiding sex in general 47 (42.0) 392 (72.7) <0.001
Trying to have sex less often 12 (10.7) 103 (19.1) 0.020
Using hook-up apps or cruise sites less often 42 (37.5) 147 (27.3) 0.021
Avoiding sex venues 38 (34.2) 176 (32.7) 0.747
Checking sex partners for symptoms 7 (6.3) 62 (11.5) 0.106
Asking sex partners if they have been overseas 6 (5.4) 39 (7.2) 0.489
Asking sex partners if they have been in contact with anyone who has COVID-19 5 (4.5) 46 (8.5) 0.0150
Having sex with younger men 1 (0.9) 14 (2.6) 0.278
Restricting sex to only men I know well 38 (33.9) 109 (20.2) 0.002
Only having sex with the men I live with 50 (44.6) 55 (10.2) <0.001
Restricting sex to 1 sex partner 64 (57.7) 184 (34.1) <0.001
Having sex without body contact 18 (16.2) 125 (23.2) 0.106
There is not much risk of COVID-19 with fuckbuddies 12 (10.8) 57 (10.6) 0.941

Changes in Group Sex Behaviors

Among the one-third of men (32.7%; n = 307) who reported having had group sex before COVID-19, fewer than 1 in 10 (7.5%; n = 24) had continued to have group sex since COVID-19. Twelve men reported group sex since COVID-19 who had not previously been having group sex. Most described themselves as engaging in group sex less often since COVID-19. No demographic characteristics were associated with the likelihood to report less group sex.

Factors Associated With and Reasons for Stopping Sex

Among the 651 men who reported any sex with either fuckbuddies and/or casual partners, either before COVID-19 or since COVID-19, 112 men (17.2%) reported that they had had sex with those partners since COVID-19. Only age was associated with stopping sex with these partners, with older men being more likely to have made this change (mean age 45.9 vs. 41.2 years; P = 0.002). Nonetheless, although 89.1% of men aged older than 55 had stopped having sex with fuckbuddies and casual partners, 77.2% of men aged 35 and under had also performed so. The most commonly ascribed reason for engaging in less sex was “avoiding sex in general,” but this reason was reported by less than half the men who continued having sex with fuckbuddies and casual partners (Table 3). Men who continued having sex with these partners were more likely to indicate that they were restricting the types of partners with whom they had sex.

DISCUSSION

Most GBM in Australia have dramatically reduced their sexual contacts with other men since becoming concerned about COVID-19. The number of sexual contacts reported for each partner type in the 6 months before COVID-19 in this cohort was consistent with proportions previously reported in other samples of GBM in Australia.24,25 The reduction in average daily sexual contacts occurred across all partner types outside a committed relationship. Despite sex with live-in partners being allowed under physical distancing rules, the observed reductions in sexual behavior may be attributable to concerns about COVID-19 infection and the pressures of physical distancing diminishing sexual desire overall.26,27

Our data indicated that there were substantial decreases in the mean number of sexual partners per day, particularly among those who previously reported sex with casual partners and those who had previously engaged in group sex. Inevitably, the observed reduction in sexual contact during this period is likely to impact on rates of HIV and other STIs in this population, at least in the short term. Fluctuations in epidemiological trends may be attributed to the impact of COVID-19 on both the number and frequency of sexual contacts, and the possibility of decreased testing because of reduced availability of HIV and sexual health testing services. Our data indicate that, for the most part, respondents have adhered to the physical distancing restrictions imposed by the Australian government to combat the spread of COVID-19, as they relate to sexual practices. Although there was a small minority of men who continued to have sexual encounters with casual and other nonromantic partners after physical distancing restrictions were implemented, even these men seem to have also substantially reduced their number and frequency of sexual contacts because restrictions were implemented (with most only reporting 1 or 2 partners during the period of restrictions).

These data are supported by the reasons men provided for reducing their sexual contacts, namely, that most men have been avoiding sex, or, for some, restricting their sexual contacts to known partners, as per community messaging.28 In asking about reasons for changing their sexual behaviors, men were also asked about behaviors that would have permitted them to continue having sex, albeit in a more restricted manner. Some of these reasonings may be less effective than others. They included such items as checking partners for symptoms, restricting sexual partners to men that might be deemed as less “risky,” or restricting the amount of body contact during sex. For the most part, only a minority of men endorsed these strategies, but men who continued to have sex with fuckbuddies and casual partners since COVID-19 were more inclined to restrict their partners to men with whom they were familiar. This willingness to engage in some degree of sexual risk behavior with familiar partners has been previously noted in relation to HIV risk.29

Although younger age was associated with a greater likelihood to continue having sex with fuckbuddies and casual partners since COVID-19, even among younger men a large majority had also stopped having sex with these partner types. Nonetheless, there would be value in further investigating reasons for why younger men may be less inclined to make the dramatic changes to sexual behavior observed in these data.

This study used an online convenience sample and findings may not be representative of all GBM men in Australia. There may also be selection bias due to participants who were more concerned about COVID-19 choosing to participate. However, the sociodemographic characteristics and the prevalence of sexual behaviors before COVID-19 that is reported in this sample is similar to that observed in other Australian community–based samples recruited online or in person.25 The calculations in this article were reliant on accurate recall of when participants initially became aware, and concerned, about COVID-19, which may be inconsistent between individuals. A small number of men indicated that they were aware of COVID-19 very early, in late 2019, although that would be improbable. Although the recall periods for sexual behaviors before and after the implementation of physical distancing restrictions differed, we were able to compare the periods by adjusting for this period of recall and calculating the average number of contacts per day. Furthermore, the decrease in the mean number of sexual partners per day reported since physical distancing restrictions commenced were dramatic, and participants also noted their intentions to limit their number of sexual partners during this period. These changes in behavior during the COVID-19 pandemic also reflect recent findings from another sample of GBM in the United States,9 highlighting some commonality despite differing government policies and the level of restrictions implemented across jurisdictions.

CONCLUSIONS

To whatever extent physical distancing measures have been adhered to by the Australian population, the reduction in new daily COVID-19 cases in Australia (from a national peak of 611 cases on March 23, 2020, to 2 cases on May 22, 2020) suggests that people are broadly complying with these restrictions.30 GBM in Australia have dramatically reduced their sexual contacts with other men since becoming concerned about COVID-19 and since the physical distancing measures were implemented in response to the COVID-19 pandemic. Although the observed reduction in sexual contacts has the potential to reduce new HIV and STI diagnoses in the short term, any such reductions are likely to be transient as physical distancing restrictions are eased and reinstated over time, after fluctuations in COVID-19 case numbers. Monitoring and interpretation of ongoing surveillance of behavioral trends among GBM will rely on adaptive surveillance using existing mechanisms, including the Flux Study.14,22 Both underlying behavioral and testing data will need to be closely examined to assess the impact that the COVID-19 pandemic has had on HIV and STI notifications, particularly during periods when physical distancing restrictions were in place, and as they are eased. Future work will also need to consider appropriately targeted policy responses and harm reduction interventions as people return to a “new normal” after the easing of restrictions, or adjust to the ongoing impact of COVID-19 on people's sexual behavior.31 Public health measures may ease and then be reimposed, depending on the course of the pandemic, in which case there may be an opportunity to assess whether reductions in new HIV and STI diagnoses will accompany these measures and whether the reverse will also apply as and when the measures are eased.

ACKNOWLEDGMENTS

The study investigators thank all participants for their continued participation in the Flux Study.

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Keywords:

GBM; HIV; men who have sex with men (MSM); SARS-CoV-2; coronavirus (COVID-19); physical distancing; STIs

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