A resurgence in diagnosed HIV has been noted among men who have sex with men (MSM) in North America, Western Europe, and Australia,1 and MSM remain the group most at risk of acquiring HIV in the United Kingdom.2 Unprotected anal intercourse (UAI) is the main risk factor for HIV among MSM, but risk varies by behavior (insertive vs. receptive UAI) and risk reduction strategies, such as serosorting (always knowing UAI partners' HIV status and only having concordant partners) and strategic positioning (selection of exclusive receptive UAI if HIV positive and exclusive insertive UAI if HIV negative).3 Recent trends in sexual behavior among MSM in the United Kingdom suggest that risk has plateaued, remaining at the high levels reached in the late 1990s/early 2000s.4,5 We previously found relatively high levels of sexual risk behavior among HIV-negative and HIV-positive MSM,6 but our analysis was limited by the data collected, which did not include details of sexual position during UAI. Here, we report on sexual position, and knowledge of partners' HIV status, during UAI to assess whether MSM in Scotland are using sexual risk reduction strategies.
The 2008 MRC Gay Men's Survey collected anonymous, self-complete questionnaires and Orasure oral fluid specimens (OraSure Technologies, Inc., Bethlehem, Pennsylvania, USA) (screened for anti-HIV using an enzyme immunoassay; positives rescreened, and repeat reactives confirmed using Western Blot). Questions on UAI, partner type (casual vs. regular), knowledge of partners' HIV status (always, sometimes, or never known), and sexual position (always or mostly insertive, equally either, or always or mostly receptive) were included. Participants were also asked whether any of their partners were HIV positive (all, some, none, or don't know), allowing perceived seroconcordance to be established.
A form of time and location sampling was used to recruit representative samples in the commercial gay scenes of Glasgow and Edinburgh (Scotland's 2 largest cities and the main hubs of the Scottish commercial gay scene), consistent with the approach used in previous years.6,7 Twelve bars (all but one of the exclusively gay bars in each city) and 2 saunas (1 in each city) were included. Bars were surveyed during a 2-week period in the early (7:00–9:00 PM) and late (9:00–11:00 PM) evening, and no bar was visited twice in the same evening. At the end of the 2-week period, each bar had been visited at both time points on each day of the week. Saunas were surveyed during 2 early evenings (5:00–7:00 PM) and 2 weekend late afternoons (4:00–6:00 PM). All men present or entering the venues were asked to participate. Of 2138 men approached, 1277 provided questionnaires and oral fluid samples (59.7% response rate). Forty nine men were excluded (45 heterosexual men reporting no sexual contact with men in the previous 12 months and 4 laboratory specimens not returned).
Ethical approval was granted by the University of Glasgow Faculty of Medicine Ethics Committee.
Of the 1228 MSM in the sample, 1171 (95.4%) tested HIV negative, 42 (3.4%) tested HIV positive and were diagnosed (aware of their HIV-positive status), and 15 (1.2%) tested HIV positive and were undiagnosed (reported having previously tested HIV-negative or never tested). Overall, 488 MSM (39.7%) reported any UAI in the past 12 months; 318 reported on partner HIV status and sexual position and are included in these analyses.
Being equally either the insertive or receptive partner during UAI was most commonly reported (Table 1). In all, 23.1% of HIV-negative MSM reported exclusive insertive UAI, 68.7% reported any receptive UAI, and 6.3% reported exclusive receptive UAI. In all, 239 HIV-negative MSM reported having had an HIV test, and of these, 54 (22.6%) reported exclusive insertive UAI (there was no statistically significant difference in sexual position of the HIV-negative MSM who had and had not been HIV tested). Of the 10 MSM with diagnosed HIV, 7 reported any insertive UAI and 3 reported being mostly the receptive partner (none reported being always receptive). Most of the MSM with undiagnosed HIV reported being equally insertive and receptive. Sexual position versatility increased with increasing partner numbers.
Two-thirds of MSM (67.0%) reported always knowing their partners' HIV status (Table 1). Knowledge of partner status and seroconcordance decreased with increasing partner numbers (P < 0.001). Five diagnosed HIV-positive MSM reported always knowing their partners' HIV status and only having HIV-positive partners (50.0% of those reporting UAI and 11.9% of the diagnosed HIV-positive sample); no undiagnosed MSM did so (2 reported some HIV-positive partners and 3 reported none; 4 thought that they were HIV negative). Among HIV-negative MSM, 160 reported having had an HIV test (and therefore being aware of their HIV-negative status), always knowing their partners' status, and only having HIV-negative partners (52.8% of those reporting UAI and 13.7% of the total HIV-negative sample). Among the 21 HIV-negative MSM who reported any discordant UAI partners, 5 (23.8%) reported exclusive insertive UAI and 13 (61.9%) reported any receptive UAI.
Among MSM in Scotland, there was some evidence that risk reduction strategies were being used. Always knowing partners' HIV status and only having concordant partners (behavior suggestive of serosorting) was reported by half of the diagnosed HIV-positive and HIV-negative MSM who had UAI. There was considerable versatility in sexual position, but almost one-quarter of HIV-negative MSM reported exclusive insertive UAI; behavior suggestive of strategic positioning. However, none of the diagnosed HIV-positive MSM reported exclusive receptive UAI. Sexual position versatility increased, and knowledge of partner status and seroconcordance decreased, with increasing partner numbers.
Some study limitations should be noted. The data are self-report and subject to the usual social desirability and response biases, but the anonymous, self-complete nature of the survey hopefully limited these. The cross-sectional data preclude assessment of causal associations between the risk reduction strategies and risk or HIV status. Caution should be exercised in interpreting or generalizing from our findings, particularly given the small numbers of diagnosed HIV-positive MSM. This was a bar and sauna sample so only MSM who visit the venues surveyed have the opportunity to participate, and risk reduction strategies in the wider population of MSM could be different and cannot be surmised from these results. The response rate for oral fluid samples was relatively low and may not be representative, but the overall survey response rate was higher (71%), and only age differed between the MSM who did and did not provide oral fluid specimens, indicating representativeness to the larger venue-based sample.8
Considerable variation in rates of serosorting and strategic positioning has been reported,5,9 – 15 and in our study, the former was more common than the latter. Some reports showed that serosorting has increased,5,11 but evidence is inconsistent,14 and although a modelling study has shown serosorting can be an effective risk reduction strategy,16 prospective studies have shown that serosorting presents a higher risk of HIV infection for HIV-negative MSM than not having UAI.11,17 Efficacy is further limited by a need for accurate knowledge of one's own and one's partners' HIV status,5,10,15 and not all of the HIV-negative MSM we surveyed reported having had a test to establish their own status. HIV testing rates among MSM in Scotland have increased markedly in recent years,8,18 but there is evidently further need to promote regular testing.
Insertive UAI (with more than one man,19 with HIV-positive partners,20 and exclusively with serodiscordant or casual partners21) has been identified as an independent risk factor for HIV infection. This questions its efficacy as a risk reduction strategy for HIV-negative MSM, and reports of exclusive adoption of this behavior by diagnosed HIV-positive MSM are variable.9,12 – 14
This is the first study to report on the possible use of serosorting and strategic positioning among MSM in Scotland, and our findings add to the literature in this area. With decreasing uptake with increasing partner numbers and general versatility in the sample's sexual behavior, they suggest that, even if the differential risks of insertive and receptive UAI are considered, serosorting and strategic positioning have a limited role in the MSM's sexual repertoires. There is a challenge in turning observational data on behavior into “risk reduction strategies” when such are not explicitly asked about, but it is common for studies to derive these from self-reported behavioral data.11 – 15,17,22 First, perhaps we should consider what risk reduction means to MSM in Scotland, and qualitative research would be best placed to explore contemporary understanding of sexual risk and adoption of behavior to reduce risk. Serosorting (but not strategic positioning) has been recommended (over not using condoms and in specific circumstances) as a risk reduction strategy for HIV-negative MSM,23 but our findings caution against promotion of this strategy. Inconsistent adoption of risk reduction strategies is unlikely to contribute greatly to HIV prevention, particularly when their efficacy is questionable and based on potentially inaccurate knowledge of HIV status. Accurate knowledge of one's own and one's partners' HIV status remains vital, and promotion of regular HIV testing should be central to HIV prevention efforts.
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