Barebacking Among HIV-Positive Gay Men in London : Sexually Transmitted Diseases

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Barebacking Among HIV-Positive Gay Men in London

Elford, Jonathan PhD*; Bolding, Graham MSc*; Davis, Mark PhD*; Sherr, Lorraine PhD; Hart, Graham PhD

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Sexually Transmitted Diseases: February 2007 - Volume 34 - Issue 2 - p 93-98
doi: 10.1097/01.olq.0000223247.68174.f9
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BAREBACKING—DEFINED AS INTENTIONALLY seeking or engaging in unprotected anal sex—among HIV-positive gay men has gained increasing attention in recent years.1–4 A number of studies in the United States have examined barebacking in large cities such as New York and San Francisco in the light of increasing high-risk sexual behavior and HIV/sexually transmitted disease diagnoses among gay men.5–8 As is often the case with hard-to-reach groups, this research has been conducted among gay men recruited in venues such as bars and clubs6–8 or through the Internet.5 There is no doubt that these convenience samples provide important insights into the emergence of barebacking among HIV-positive gay men. One of their disadvantages, however, is that they cannot provide reliable estimates of the prevalence of barebacking and its overall contribution to sexual risk taking in this group of men.9

In the United Kingdom, National Health Service (NHS) outpatient clinics provide free clinical care to the majority of people diagnosed with HIV.10 Consequently, in the United Kingdom, a clinic sample is broadly representative of all those living with diagnosed HIV. An NHS HIV outpatient clinic provides, therefore, an excellent opportunity for examining barebacking among a wide cross-section of HIV-positive gay men. Furthermore, comparing an NHS clinic sample of HIV-positive men with men recruited through the Internet will offer a valuable insight into the biases associated with online convenience samples in relation to barebacking.

To date, there has been little quantitative research into barebacking among HIV-positive gay men in the United Kingdom. The objectives of this study were to: 1) examine the extent to which HIV-positive gay men in London intentionally seek unprotected anal intercourse (UAI), 2) estimate the contribution this makes to total sexual risk taking among these men; and 3) compare barebacking among HIV-positive gay men surveyed in a clinic with those surveyed on the Internet.

Methods

Samples

HIV Outpatient Clinic.

There are several NHS outpatient clinics providing HIV treatment and care in London. Gay/bisexual men diagnosed with HIV infection attending a large NHS outpatient clinic in north London between October 2002 and May 2003 were invited to participate in the study. People with limited English language skills were ineligible for the study as were those who were too ill to complete a questionnaire. Once they had provided written consent, men were asked to complete and return a self-administered pen-and-paper questionnaire in the clinic. The methods have been described in detail elsewhere.11

Internet.

Over a 4-week period in May through June 2003, men using U.K. chatrooms or personal profiles on www.gaydar.com or www.gay.com were invited to take part in the study, which was advertised using banners and popups. www.gaydar.com and http://uk.gay.com are 2 of the U.K.’s most popular web sites for gay men (H. Badenhorst, M. Watson, personal communication). Clicking on a popup or banner took men to the homepage of the online questionnaire. Men who agreed to complete the self-administered questionnaire then did so online. The methods have been described in detail elsewhere.11

Questionnaire

The questions in the pen-and-paper and online questionnaires were worded identically to ensure direct comparability. Men were asked about their age, ethnicity, employment, education (higher education was defined as having had 3 or more years education after the age of 16 years), socioeconomic status (based on occupation for those currently employed), access to the Internet, relationship status, whether they identified as gay or bisexual, whether they had sex with men only, HIV treatment optimism,12,13 recreational drug use (including steroids), and feeling depressed, lonely, or having suicidal thoughts in the previous 3 months. They were also asked whether they were currently taking highly active antiretroviral therapy (HAART), their most recent CD4 count, and viral load.

Men were asked whether they had looked for and met sexual partners (of all kinds, not just bareback partners) through the Internet in the previous year (i.e., looked for sex online). They were also asked whether they had looked for and met sexual partners (of all kinds) in bars, clubs, saunas, and so on (anywhere except on the Internet) in the previous year (i.e., looked for sex offline). The men who completed a questionnaire online (in May–June 2003) were asked whether they had also completed a questionnaire in the NHS outpatient clinic (between October 2002 and May 2003).

Barebacking

Men were asked 2 questions to establish whether they had intentionally looked for anal sex without a condom. The first question asked “Have you used the Internet to intentionally look for anal sex without a condom with a man in the last 12 months?” The second question asked whether, in the last 12 months, they had intentionally looked for anal sex without a condom in a bar club, sauna, and so on, i.e., anywhere except the Internet. To each question, they could answer: yes, with an HIV-positive man; yes, with an HIV-negative man; yes, with a man whose HIV status I did not know; or no. Men could tick more than one “yes” response in each question. Some of the men who ticked all 3 or who ticked “yes, with a man whose HIV status I did not know” may have been indicating that the HIV status of their potential partner was unimportant.

Men who said they had intentionally looked for UAI online (through the Internet) or offline (in bars, clubs, and so on) are referred to in this article as “barebackers” regardless of whether they actually reported UAI. Men who looked for UAI only with another HIV-positive man are referred to as positive–positive barebackers. Men who said they had looked for UAI with an HIV-negative man or a man of unknown status are referred to as nonconcordant barebackers. Men who said they had looked for UAI with both HIV-positive men as well as with partners of unknown or discordant status were classified according to the greater risk of HIV transmission to an uninfected partner, i.e., as nonconcordant barebackers.

Sexual Behavior

Men were asked whether they had had UAI in the previous 3 months and if so, type (main or casual) and HIV status of their UAI partner(s). They were also asked whether they had met their casual UAI partners through the Internet (online partners) or in places such as bars, clubs, saunas, and so on (offline partners).

UAI was classified either as concordant (with another HIV-positive man) or nonconcordant (with a partner of unknown or negative status).12,14 UAI was only classified as concordant if the respondent said he knew his partner was HIV-positive. When a respondent said he assumed his partner was HIV-positive, UAI was classified as “status unknown.” We did not ask whether the reported UAI was intentional. Men were also asked about their history of sexually transmitted infections (STIs) in the previous 12 months.

Statistical Analysis

Data were analyzed using SPSS for Windows 11. Chi-squared, Fisher’s exact, and t-tests were used for examining differences in proportions and means between barebackers and other men in each sample. Positive–positive and nonconcordant barebackers were analyzed separately. Men reporting UAI with a casual partner were divided into 3 groups: those reporting only concordant UAI, those reporting both concordant and nonconcordant UAI, and those reporting only nonconcordant UAI. The univariate association between barebacking and UAI with a casual partner was initially explored in a logistic model. Significant univariate associations were further explored in a multivariate logistic model controlling for confounding factors, i.e., factors found to be associated with both barebacking and UAI with a casual partner in these samples.

For men who looked for sex through the Internet, the McNemar test was used to examine whether there was a significant difference between the percentage of men reporting UAI with casual partners they met online rather than offline, taking into account men who reported UAI with both. The Wilcoxon test also examined this differential but was more robust because it also took into account the number of online and offline UAI partners. This analysis was conducted for all men and then separately for barebackers and other men.

Results

Samples

HIV Outpatient Clinic.

Between October 2002 and May 2003, 1001 male patients attended the NHS HIV outpatient clinic of whom 939 were eligible for the study; 864 were asked to complete a questionnaire and 620 did so (response rate, 72% of those offered a questionnaire, 66% of all eligible men). Of the men who completed a questionnaire, 528 described their sexual orientation as gay or bisexual or had had sex with another man in the previous year; 481 provided sufficient information to be included in this analysis. Of these men, 415 (86.3%) said they had access to the Internet at home or work (or both).

Internet.

Over the 4-week study period in May through June 2003, 595 gay or bisexual men living in London completed the online questionnaire of whom 579 men provided information on their HIV status: 67 were HIV-positive, 315 HIV-negative, and 197 had never had an HIV test.11 Of the 67 HIV-positive men, 66 provided sufficient information to be included in this analysis; 65 (98.5%) said they had access to the Internet at home or work (or both). Only 5 of the 66 men (7.6%) said they had also completed a questionnaire in the HIV outpatient clinic. Based on estimates provided by www.gaydar.com and http://uk.gay.com on the number of people using their chatrooms and profiles during the survey period, it is likely that less than 1% of all their users completed the questionnaire.

HIV Outpatient Clinic Sample

Barebackers.

Of the 481 HIV-positive gay men in the clinic sample, 59 (12.3%) said they had intentionally looked for UAI in the previous 12 months and were classified as barebackers, 34 (7.1%) said they had looked for UAI only with another HIV-positive man (positive–positive barebackers), 3 (0.6%) said they looked for UAI with an HIV-negative man, and 22 (4.6%) with a man of unknown HIV status (nonconcordant barebackers, n = 25 [5.2%]) (Table 1). Of the 25 nonconcordant barebackers, 14 said they had intentionally looked for UAI with an HIV-positive man as well.

T1-8
TABLE 1:
Number (%) of Men Who Intentionally Looked for Anal Sex Without a Condom

Compared with other men, barebackers were younger, less likely to be on HAART, and more likely to use recreational drugs or steroids. In general, these differences were seen for both positive–positive and nonconcordant barebackers (Table 2). Nonconcordant barebackers were also less worried about HIV in the light of HAART and more likely to believe that HAART makes people with HIV less infectious. However, there were no significant differences between barebackers and other men in ethnicity, employment, education, gay identity, having sex only with men, being in a relationship, depression, loneliness, or having suicidal thoughts (P > 0.05).

T2-8
TABLE 2:
Social, Demographic, and Behavioral Characteristics of Men According to Whether or Not They Intentionally Looked for Anal Sex Without a Condom

Sexual Behavior of Barebackers.

Barebackers were more likely than other men to have looked for sex (of any kind, not just UAI) both online and offline and more likely to have had sex (of any kind) with someone they met online or offline. Barebackers were also more likely to have had an STI in the last year (Table 2).

In addition, barebackers were more likely to report UAI with a casual partner in the previous 3 months than other men. Of the 25 men who had intentionally looked for UAI with a partner of unknown or discordant HIV status, 20 (80.0%; 36.0% + 44.0%) reported this behavior compared with 11.6% (1.9% + 9.7%) of the men who did not intentionally look for UAI (P < 0.001) (Table 2). Among these 20 men were 3 who said they had intentionally looked for UAI with a partner of discordant HIV status. However, all 3 reported UAI with casual partners of unknown rather than discordant status. Over one third of the positive–positive barebackers (38.2%) reported UAI only with another HIV-positive man compared with 3.2% of men who did not intentionally seek UAI (P < 0.001).

After adjusting for confounding factors (age, recreational drugs, steroids, HAART, seeking sex through the Internet, treatments optimism), the differences in sexual risk behavior between barebackers and other men remained significant in a multivariate model (P < 0.001).

Contribution of Barebackers to Sexual Risk Taking.

Of the 481 men in the clinic sample, 85 reported nonconcordant UAI with a casual partner in the previous 3 months (Table 2: only nonconcordant UAI 3 + 11 + 41 = 55; nonconcordant and concordant UAI, 13 + 9 + 8 = 30). Twenty (9 + 11) of these 85 men (23.5%) had intentionally looked for UAI with a partner of unknown or discordant HIV status, whereas the remaining 65 men reporting nonconcordant UAI (76.5%) had not.

Where Barebackers Looked for and Met Unprotected Anal Intercourse Partners.

Of the 59 barebackers, 54 had looked for UAI partners online; 27 had only looked online, whereas 27 had looked both on- and offline. Five men had only looked offline. The same pattern was seen for both positive–positive and nonconcordant barebackers (Table 1).

Because all barebackers said they had looked for sexual partners (of any kind) through the Internet (Table 2), the following analysis is restricted to men who used the Internet to look for sex and who provided complete information on where they met their casual UAI partners.

Nonconcordant Unprotected Anal Intercourse.

For the clinic sample overall, HIV-positive men who looked for sex through the Internet were just as likely to only meet nonconcordant UAI partners offline (13.2%) as online (12.1%; McNemar P = 0.9; Table 3). A similar pattern emerged when nonconcordant barebackers were examined separately; 3.4% only met their nonconcordant UAI partner(s) offline and 5.2% online (McNemar P = 0.6) (Table 3).

T3-8
TABLE 3:
Where HIV-Positive London Gay Men Who Used the Internet to Look for Sex Met Their Casual Unprotected Anal Intercourse (UAI) Partners

Concordant Unprotected Anal Intercourse.

For the clinic sample overall, HIV-positive men who looked for sex through the Internet were more likely to meet their concordant UAI partners only online (10.3%) rather than offline (4.0%; McNemar P < 0.05; Table 3). A similar pattern emerged when positive–positive barebackers were examined separately; 6.3% only met their concordant UAI partner(s) online vs. 0.0% offline, McNemar P < 0.01; Table 3).

Internet Sample

Barebackers.

Of the 66 HIV-positive gay men in the Internet sample, 32 (48.5%) said they had intentionally looked for UAI in the previous 12 months and were classified as barebackers, 15 (22.7%) said they had looked for UAI only with another HIV-positive man (positive–positive barebackers), 3 (4.5%) said they looked for UAI with an HIV-negative man, and 14 (21.2%) with a man of unknown HIV status (nonconcordant barebackers, n = 17 [25.8%]) (Table 1). Of the 17 nonconcordant barebackers, 11 said they had intentionally looked for UAI with an HIV-positive man as well.

Because of small numbers, it was not possible to compare the background characteristics of the positive–positive barebackers (n = 15), nonconcordant barebackers (n = 17), and the other HIV-positive men (n = 34) in the Internet sample. However, of the 17 men in the Internet sample who had intentionally looked for UAI with a partner of unknown or discordant HIV status, 13 (76.5%) reported this behavior compared with one third of the other men (32.7% [16 of 49]) (P < 0.01).

Where Barebackers Looked for and Met Unprotected Anal Intercourse Partners.

Of the 32 barebackers, 31 said they had looked for UAI partners online; 14 had only looked online, whereas 17 had looked both on- and offline. One man had only looked offline (Table 1). HIV-positive men who looked for sex through the Internet were more likely to meet their concordant casual UAI partners online rather than offline as was seen for men in the clinic sample (Table 3). However, they were just as likely to meet nonconcordant UAI partners offline as online.

Discussion

Among nearly 500 HIV-positive gay men surveyed in a London outpatient clinic, one in 8 (12%) said they had intentionally looked for anal sex without a condom in the previous year (referred to here as “barebackers”). More than half the barebackers (7% of the sample) said they had looked for unprotected anal sex only with another HIV-positive man (positive–positive barebackers). That is to say, they were serosorting. The remaining barebackers (5% of the sample) said they had looked for unprotected sex with someone whose HIV status they did not know or with an HIV-negative man (nonconcordant barebackers). It is possible that some of these men were looking for UAI with anyone, regardless of HIV status, rather than seeking UAI with someone of unknown or discordant status per se. Only 3 men said they had intentionally looked for unprotected anal sex with HIV-negative men.

A strength of this analysis is that it is based on a broad cross-section of gay men diagnosed with HIV living in London. Because the majority of people diagnosed with HIV in the United Kingdom receive treatment and care in NHS outpatient clinics, an NHS clinic sample is broadly representative of people living with an HIV diagnosis.10 Our study provides, therefore, a robust estimate for the prevalence of barebacking among HIV-positive gay men in London.

The barebackers had a higher risk profile than other men as has been reported elsewhere.5–8 They were younger, more likely to use recreational drugs, and more likely to look for sex (of any kind) both online and offline. Not surprisingly, barebackers were more likely to report UAI than other men. Nearly all the men in the clinic sample who had intentionally looked for UAI with a person of unknown or discordant HIV status reported this behavior in the previous 3 months. Although we were not able to establish whether the reported behavior (nonconcordant UAI) was a direct consequence of the expressed intention, other research suggests that this was likely to be the case.1

Barebackers made a substantial contribution to sexual risk taking in this group of men. In the clinic sample, men who looked for UAI with a partner of unknown or discordant HIV status accounted for 5% of the study group but for nearly 25% of all men reporting this behavior. Nonetheless, the remaining 75% of men reporting UAI with a partner of unknown or discordant HIV status had not intentionally looked for it. This serves to remind us that a substantial proportion of high-risk sex reported by HIV-positive gay men cannot be attributed to barebacking.15,16

Among researchers, interest in barebacking arose in the light of the recent increase in high-risk sexual behavior and HIV/STI diagnoses among men who have sex with men.1,2,5,8 Our analysis among London gay men suggests that although barebacking may have contributed to this increase, it is not the only factor.

The overwhelming majority of barebackers said they had intentionally looked for UAI through the Internet. On the other hand, approximately half said they had also looked offline in bars, clubs, and other venues. Although positive–positive barebackers were more likely to meet their HIV-positive UAI partners online rather than offline, this was not the case for men looking for UAI with a partner of unknown or discordant HIV status. These men (nonconcordant barebackers) were just as likely to meet their nonconcordant UAI partners offline as online. In relation to the Internet, nonconcordant barebackers appear to be no different to other HIV-positive gay men in London who report UAI with a partner of unknown or discordant HIV status. There was no evidence that the Internet per se created a risk for nonconcordant UAI whether men intentionally sought it or not.17 On the other hand, the Internet seems to facilitate serosorting among HIV-positive men who intentionally seek UAI with other HIV-positive men. Positive–positive barebackers were more likely to meet their HIV-positive UAI partners online rather than offline in part because they found it easier to disclose their HIV status online.17,18

Compared with the clinic sample, a substantially higher proportion of HIV-positive men in the Internet sample reported barebacking. Nearly half the HIV-positive men recruited through the Internet (48.5%) said they had intentionally looked for anal sex without a condom compared with one in 8 men in the clinic (12.5%). One fourth of the men in the Internet sample (22.7%) said they had looked for UAI with a partner of unknown or discordant status compared with only 5% of men surveyed in the clinic. This differential is not entirely surprising. All the barebackers in the clinic sample said they had looked for sex (of any kind) through the Internet and nearly all of them had intentionally looked for UAI partners on the Internet (although they may not have met a UAI partner online). Consequently, barebackers will be overrepresented in an Internet sample. There is no doubt that a convenience sample recruited through the Internet provides a valuable opportunity for examining barebacking among HIV-positive gay men. However, the disadvantage of an Internet sample is that it will substantially overestimate the true prevalence of barebacking among HIV-positive gay men and its contribution to overall sexual risk taking in this group of men. Researchers recruiting men through the Internet should be alert to this important source of bias.5

Our study has some limitations. As is the case with much behavioral research, our analysis was based on self-reported risk.9 It is possible that high-risk behaviors such as barebacking may have been underreported because of social desirability bias. To minimize this bias, all questionnaires were confidential and anonymous for the analysis, which protected individual respondents from being identified. The elevated prevalence of barebacking seen in the Internet sample could reflect, in part, an increased willingness to report this behavior in a web-based survey. On the other hand, in a national sex survey in the United Kingdom, no consistent mode effect was seen when computer-assisted and pen-and-paper self-completion interviews were compared.19

Although we asked men whether they had intentionally looked for UAI and whether they had engaged in UAI, we did not ask whether specific episodes of UAI were themselves intentional. Also, we did not ask in any detail about sexual behaviors based on perceptions of relative safety (e.g., adopting the receptive role during UAI to reduce the risk of HIV transmission to an uninfected partner).

Although nearly 600 London gay men completed the online survey during a 1-month period, only 67 were HIV-positive. Although a larger Internet sample of HIV-positive men would have strengthened the analysis, for logistic reasons, the online survey could only be posted on the Internet for 1 month. The mental health variables (depression, loneliness, suicidal thoughts) were all measured using single-item scales because of limited space in the pen-and-paper questionnaire. Multiitem, validated scales would have provided more robust measures.

A further point that needs to be considered is the definition of “barebacking.” In recent years, researchers have used this term to describe the emergence of a new behavior among gay men who intentionally seek or engage in UAI.1–8 On the other hand, in everyday parlance, many men use “barebacking” to describe anal sex without a condom regardless of whether this involves intent or not.20 In our questionnaires, to avoid confusion, we did not use the term “barebacking.” Instead, we asked men whether they had intentionally looked for UAI and then, in our analysis, used the term barebacking to describe this behavior.

Intentionality raises a number of important theoretical issues that could not be addressed in this article. Clearly, it is important to differentiate between intention and behavior. In our study, not all those who engaged in UAI had a preconceived intention nor did all those with an intention engage in UAI (although most did). Further research will help elucidate the relationship between intention and behavior and the implications for interventions.21

In conclusion, although one in 8 HIV-positive gay men surveyed in a London clinic had intentionally looked for anal sex without a condom, over half these men had looked for anal sex only with other HIV-positive men (i.e., they were serosorting). We found that just 5% of HIV-positive men had intentionally looked for UAI with a man who was not HIV-positive (i.e., nonconcordant). They accounted for 25% of all men reporting nonconcordant UAI. The remaining 75% of HIV-positive men reporting nonconcordant UAI, however, had not intentionally looked for it. This serves to remind us that a substantial proportion of high-risk sex reported by HIV-positive gay men cannot be attributed to barebacking. Furthermore, an Internet sample substantially overestimates the prevalence of barebacking among HIV-positive gay men because of sampling bias. HIV prevention initiatives clearly need to take barebacking into account. Interventions should be tailored to meet the needs of the minority of HIV-positive gay men who intentionally seek UAI with nonconcordant partners. Our analysis suggests, however, that we should continue to address the needs of those HIV-positive men who do not express such intentions (the majority) yet who are also at risk.

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