Social,
relational and network determinants of condom use and HIV testing were examined
among 213 men who have sex with men (MSM) in Beirut. 64% reported unprotected
anal intercourse (UAI), including 23% who had UAI with unknown HIV status
partners (UAIU); 62% had HIV-tested. In multivariate analysis, being in a
relationship was associated with UAI and HIV testing; lower condom
self-efficacy was associated with UAIU and HIV testing; gay discrimination was
associated with UAIU; MSM disclosure was associated with UAI, UAIU and HIV
testing; and network centralization was associated with HIV testing.
Multi-level social factors influence sexual health in MSM.
…Consistent with other studies of MSM in MENA (Mumtaz et al., 2011; Maufoud et al., 2010; El-Sayyed, Kabbash &
El-Gueniedy, 2008), the rate of unprotected anal intercourse in this
sample of MSM in Beirut was high, with nearly two-thirds having unsafe sex in
the past 3 months, including a quarter who had no knowledge or certainty of the
HIV status of their sex partner(s). As for HIV testing, most men had been
HIV-tested prior to the study, including nearly half who had tested within the
past year, which compares favorably to the much lower rates observed in an
earlier study in Beirut (Maufoud et al., 2010; Nakib & Hermez, 2002) and elsewhere in the
region (El-Sayyed, Kabbash &
El-Gueniedy, 2008). Our findings also revealed the influence of
several social factors affecting condom use and HIV testing, at the level of
sexual partnerships as well as MSM peers and respondents’ overall social
networks.
Relationship status appears to be a strong determinant
of both condom use and HIV testing behavior. Consistent with our qualitative
research with this population (Wagner, Aunon, Kaplan, Rana,
Khouri & Tohme, 2012), men in committed relationships were
almost 3 times more likely to engage in unprotected anal sex when the HIV
status of their sex partner was known; for most, this partner was the person
they were in a relationship with, as the majority of men in relationships
reported that their significant other was their only sex partner in the past 3
months. Members of a couple are also more likely to know each other’s HIV
status, and this is supported by our finding that men in relationships are much
more likely to have tested for HIV, as well as our qualitative research in
which men described getting tested with their partner when entering a
relationship as a step towards being comfortable not using condoms when having
sex with each other (Wagner, Aunon, Kaplan, Rana,
Khouri & Tohme, 2012). Conversely, men in relationships were
much less likely to have unprotected sex with men whose HIV status was unknown.
This all suggests that while men in relationships have more condomless sex, the
context of this sexual activity involves several aspects of risk reduction,
including mutual HIV testing and knowledge of partner’s HIV status, as well as
monogamy or limiting the number of sex partners. Yet studies of MSM in other
parts of the world have shown that transmission often occurs in the context of
sex with a regular partner (Sullivan, Salazar, Buchbinder
& Sanchez, 2009), implying a vulnerability for these men that
may be related to greater risk taking due to a false sense of safety
(associated with assumed monogamy), and engagement in sex with partners outside
of the relationship that is kept secret from one’s primary partner (Gomez, Beougher, Chakravarty,
Neilands, Mandic & Darbes, 2012).
Communication with sex partners about HIV status and
risk was associated with consistent condom use and HIV testing in our bivariate
analysis. These findings support the role of communication about HIV status and
risk as a key facilitator of sexual health and HIV protective behaviors, and
implies the need for HIV prevention interventions to focus on sexual risk
communication with partners prior to engaging in sex. Indeed, several
interventions have targeted communication about sex (Darbes et al., 2014), often through
role-playing conversations about HIV status and risk. Communication with
partner(s) about risk was a significant correlate in bivariate analysis, but
not in the multiple regression analysis, perhaps because the regression models
controlled for relationship status. Men in relationships may be more likely to
discuss HIV risk or at least know each other’s HIV status. Communication about
sensitive issues such as HIV status and risk may be less comfortable in a
casual relationship or with a relative stranger, and this may also explain why
condoms are used more with casual sex partners, as condom use may be viewed as
negating the need to enter into the awkward discussion of HIV status and risk.
Perceived normative behavior, or how one thinks their
peers behave, has been shown to influence health behavior including condom use
among MSM (Amirkhanian et al., 2006), so it is not
surprising that our data revealed MSM peers to be influential with regards to
both condom use and HIV testing in bivariate analysis. Receiving more support
and encouragement from MSM peers for sexual health and HIV protective
behaviors, as well as the perception that MSM peers are using condoms and
getting HIV tested, were associated with consistently using condoms with
partners of unknown HIV status and HIV testing. The potential influence that
MSM peers can have on individual protective behaviors is further highlighted by
our finding that having more MSM in one’s social network is associated with
using condoms consistently in bivariate analyses.
The other social network compositional variable
associated with condom use and HIV testing was the proportion of network
members who know the respondent is an MSM. Our data also showed that virtually
all network members who know the respondent is an MSM are also supportive,
rather than stigmatizing, of the respondent’s sexuality. This social network
characteristic was positively associated with HIV testing, but also with
greater risk taking in terms of unprotected anal intercourse, including with
unknown HIV status partners. This latter finding may seem counterintuitive, as
social support is generally thought to protect against risk behavior (Hoff, Chakravarty, Beougher,
Neilands & Darbes, 2012); however, this finding is similar to
other analyses from this study that we have reported in which greater integration
into the gay community was also associated with higher odds of engaging in
unprotected anal sex (Tohme, Wagner & Mokhbat, 2014). In
comparison to other cities in MENA, Beirut has a well-developed gay community
and infrastructure of community organizations that provide support and services
to MSM; therefore, it is plausible that men who are more involved in the gay
community and receive affirmation for their sexuality are likely to be more
exposed to information about HIV and people living with HIV and this may serve
to desensitize some men to the threats of HIV disease (particularly in the
context of effective HIV antiretroviral therapy), leading to disinhibition
regarding condom use. In contrast, more isolated men may be more fearful and
anxious about HIV risk and thus safer in their sexual behavior; alternatively,
these men may also have fewer sexual encounters and therefore fewer
opportunities to engage in risky sex. Further research is needed to examine
these hypotheses.
Men who had been HIV-tested had social networks with a
higher level of centralization. Centralization is an indicator for the extent
to which connections or relationships between network members run through one
or a few network members who serve as “hubs” for network relationships. These
hubs can serve as gatekeepers of information, support and perceived network
norms for specific behaviors and attitudes. The behavior and attitudes of these
hub members have the potential to exert more influence on other members in both
positive and negative ways. Given our findings, it is possible that men who had
been HIV-tested may have hub members in their network who had also been tested
and help set the tone for this behavior within the network; whereas networks
that have lower centralization allow for a broader diffusion of information and
social influence regarding perceived normative behavior…
By: Glenn J. Wagner, PhD,a Matthew Hoover, MPH,a Harold Green, PhD,a Johnny Tohme, MA,b,c and Jacques Mokhbat, MDb,d
aRAND Corporation, Santa Monica, CA, USA
bLebanese AIDS Society, Beirut, Lebanon
cMarsa, Sexual Health Centre, Beirut,
Lebanon
dDivision of Infectious Diseases,
University Medical Center Rizk Hospital, Beirut, Lebanon
Corresponding Author: Glenn Wagner; RAND Corporation,
1776 Main St., Santa Monica, CA, USA 90407; (310) 393-0411, x7698; fax: (310)
260-8159; Email: gro.dnar@rengawg
