Saturday, November 7, 2015

Social, Relational and Network Determinants of Unprotected Anal Sex and HIV Testing among Men Who Have Sex with Men in Beirut, Lebanon

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 (; ; ), 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 (; ) and elsewhere in the region (). 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 (), 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 (). 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 (), 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 ().

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 (), 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 (), 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 (); 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 (). 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…

Full article at: http://goo.gl/5g5cJM

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
  

No comments:

Post a Comment