Living in a stigmatizing country increases HIV risk for MSM in Europe

Men who have sex with men (MSM) living in European countries with laws and attitudes that stigmatize male homosexuality often conceal their sexual orientation, have unmet HIV prevention needs and high levels of sexual risk behaviour, investigators report in AIDS.

The research involved over 150,000 MSM living in 38 countries. “Our results suggest that MSM in highly stigmatizing countries are particularly vulnerable to HIV infection,” comment the authors.

Globally, MSM are one of the groups most affected by HIV. The European MSM Internet Survey (EMIS) provided an opportunity to investigate the impact of country-level stigma on concealment of sexuality and unmet HIV prevention need across 38 European countries.

Over 150,000 adult MSM completed the survey between June and August 2010.

Country-level stigma was assessed by reviewing the presence of supportive legislation (e.g. same sex marriage, employment non-discrimination), and discriminatory policies. Legislation varied across Europe, with Russia and Ukraine the most unsupportive and Sweden the most supportive.

Country-level attitudes were evaluated using the 2008 European Values Survey. The investigators included questions assessing the proportion of participants in each country who thought homosexuality could be justified; agreed that same-sex couples should be allowed to adopt children; did not mind if a homosexual couple was their neighbour.

MSM participating in the study were asked if they concealed their sexuality, had been diagnosed with HIV, and how many non-steady sexual partners they had had in the previous year. Participants were also asked a series of questions to assess their knowledge of HIV prevention, their sexual risk behaviour and access to HIV prevention services.

Men reporting concealing their sexuality to a high degree were more likely to be younger p < 0.001), single (p < 0.001), in employment (p < 0.01), live in smaller towns and cities (p < 0.001), have lower levels of education (p < 0.001) and live in countries with high levels of stigma (p < 0.001).

Men living in countries with high levels of stigma were less likely to be diagnosed with HIV (AOR = 0.68; 95% CI, 0.57-0.82) and had fewer sexual partners (AOR = 0.75; 95% CI, 0.67-0.83).

There was clear evidence that stigma was associated with increased HIV risk. Living in a stigmatizing country was associated with inadequate HIV service coverage (p < 0.001), lack of HIV knowledge (p < 0.001), not testing for HIV or sexually transmitted infections in the previous year (p < 0.01), unprotected anal sex with non-steady partners (p < 0.01) and not discussing sexuality when testing for HIV (p < 0.01).

Country level stigma predicted the odds of concealing sexuality (AOR = 2.47; 95% CI, 2.10-2.91). Concealment was in turn associated with not accessing HIV services, poorer knowledge of HIV prevention and higher levels of risk taking.

“Those interested in public health should encourage open self-expression among all individuals and promote the environmental conditions that facilitate it, regardless of individuals’ sexual orientation, and regardless of associations among stigma, concealment and health,” conclude the authors.

Pachankis JE et al. Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey. AIDS 29; 1239-46, 2015.