Gay couples’ sexual agreements

A survey of American gay couples found that many have a ‘sexual agreement’, both to minimise HIV risks and to maintain the quality of their relationship. Around half the agreements simply clarified that sex was not permitted with other people, while other agreements concerned the relationship being ‘open’ to a lesser or greater extent.

But the survey found that partners do not always agree on whether they have an agreement, on whether it was explicitly discussed, on what sex is allowed with other people, or in what circumstances.

And the agreement had been broken by one or both partners in just under half the couples studied. Few men told their partner that they had broken the agreement.

Other research has suggested that many gay men acquire HIV from their primary partner. Few long-term couples use condoms together, so if a man acquires an infection from a casual partner he can easily pass it on to his primary partner.

Therefore HIV-prevention interventions which support men in strengthening their relationships, making better agreements and having clearer communication would be warranted. Projects which allow couples to test together are one possibility.

Also this month, research from Malawi has described gender inequalities which put married women at risk of HIV infection. This study also draws attention to HIV transmission occurring within long-term relationships and the lack of HIV prevention interventions addressing these issues.

Gay men’s risk behaviour

A new analysis suggests that there was no increase in sexual risk behaviour by gay men in England, between 2001 and 2008. The researchers compared answers from the Gay Men’s Sex Survey in those two years.

Unprotected anal intercourse (UAI) was reported by 59% of men in 2001 and 57.5% of men in 2008 – not a statistically significant difference. Looking in more detail at sexual role, partner’s HIV status and use of condoms during anal intercourse, changes were not seen in a range of specific behaviours.

There was no evidence of more men adopting risk-reduction strategies such as ‘serosorting’ or ‘strategic positioning’.

However, there was evidence of fewer HIV-negative and untested men having multiple sexual partners. On the other hand, there was a significant increase in the number of men with diagnosed HIV who reported unprotected sex.

The analysis suggests that higher-risk behaviour became increasingly concentrated in men with diagnosed HIV. This confirms the ongoing need for prevention programmes to prioritise men with diagnosed HIV.

Aidsmap’s news report compares these data with other recent studies on gay men’s risk behaviour.

Sexual health framework for England

The Department of Health has released its sexual health framework, a document which outlines, for commissioners and providers, the government’s aspirations for good sexual health.

The framework draws attention to a number of important concerns, including the central role of HIV testing, HIV treatment as prevention, the sexual health needs of people over the age of 50, and the impact of drug and alcohol use on sexual health. The document clearly states that different commissioning organisations should collaborate so that services are not fragmented.

But critics say that the document lacks “teeth” and that there is no guarantee that local authorities will act on it. The framework was issued just before local authorities took on responsibility for planning and purchasing local sexual health services. As government policy is for decisions to be made at a local level, the central government document does not include firm goals or commitments.

Also, there has been criticism of both the Department of Health framework and the recent announcements from the Department for Education. Sex and relationships education remains a subject which schools can opt out of providing, with no obligation that classes address the needs of young gay or bisexual people.

HIV testing interventions

Two studies this month reported on new ways for people to take HIV tests.

‘Self testing’ or ‘home testing’ are not yet legal in the UK, although this may change soon. Researchers identified all relevant studies of self testing, and found that it offers an alternative for people who have particular concerns about convenience or privacy. Self-testing kits were easy to use, delivered accurate results, and were highly acceptable to a range of population groups.

But the researchers found that few randomised controlled trials had been conducted, and few studies had assessed whether people getting a reactive (positive) result made and kept contact with clinical and support services. The review found no evidence of extreme reactions, such as suicide following an HIV-positive result.

Another study looked into whether recruitment through social networks is an efficient way to increase demand for HIV testing among people at greater risk of infection. In a deprived urban area in California, some individuals taking an HIV test were encouraged to invite friends and acquaintances to test as well. The approach is based on the belief that people at high risk of infection are frequently in social networks with each other. In keeping with other HIV testing projects in the area, uptake was encouraged through financial incentives.

Results were mixed. The approach was successful at engaging individuals who had little contact with health services, who had not tested recently and who reported risk behaviours. But a number of people who had been previously diagnosed with HIV came in for testing unnecessarily.

In addition, a third study looked at sexually transmitted infection (STI) testing for people with diagnosed HIV. Although STI screening is recommended for people with HIV at least once a year, implementation is often poor. In north-west London HIV clinics, automatic prompts were added to the electronic patient records system, leading clinicians to offer check-ups more regularly. More infections were diagnosed, especially asymptomatic infections, in both gay men and heterosexual people.

Motivations to take an HIV test

A review of qualitative research studies examined the factors which encourage or discourage people from taking an HIV test. The focus of the review was studies conducted in sub-Saharan African countries, so the results may be of interest to people working with African communities in the UK, although not all factors will be relevant here.

Many individuals did not test because they perceived themselves to be at low risk of infection. This was sometimes motivated by low levels of sexual activity, a partner apparently being in good health, or a perception that HIV was primarily an issue for sex workers.

People feared losing sexual partners and social support if they were diagnosed with HIV, with divorce and domestic violence being possible consequences. For individuals who lack economic security, other people withholding material support could have profound consequences.

Conversely, when people did choose to test, the support of peers and family members was crucial. Social expectations in relation to key life events, such as marriage and pregnancy, could encourage HIV testing.

Perceived problems with confidentiality put people off testing, whereas trusted and more convenient facilities encouraged individuals to take an HIV test.

Interventions which encourage individuals to test should engage with these barriers and facilitators.

Other recent news headlines

Hepatitis C epidemic in US gay men is decades old

Hepatitis C virus (HCV) transmissions have been occurring in gay men since at least the early years of the HIV epidemic, investigators from the US report in the online edition of Clinical Infectious Diseases. The vast majority of infections involved men living with HIV. Unprotected receptive anal sex and recent infection with syphilis were both risk factors for incident infections, and for men living with HIV, there was a significant relationship between a lower CD4 cell count and acquiring HCV. Read more >>

Marriage is a risk factor for HIV infection in Malawi

Marriages in Malawi are characterised by such stark gender inequalities that marriage itself is a risk factor for HIV infection in women, according to qualitative research published last month in Global Public Health. Women with HIV who took part in the research were very aware of patterns of abuse and of their vulnerability due to non-monogamous husbands. Read more >>

Meta-analysis shows the massive global burden of HIV among transgender women

Almost a fifth of transgender women worldwide are infected with HIV, results of a meta-analysis published in The Lancet Infectious Diseases shows. A total of 39 studies involving over 11,000 transgender women in 15 different countries were included in the study, which also found that prevalence of HIV among transgender women was massively higher than that seen in the general population. Read more >>