Identity formation, outness, and sexual risk among gay and bisexual men

Gay community involvement and the sexual health behaviours of sexual minority men: a systematic review and directions for future research

Considerable research has examined how involvement in gay-affiliated communities is associated with sexual health behaviours in sexual minority men (i.e., gay, bisexual, and other men who have sex with men), yet findings in this domain are often contradictory and inconclusive. This systematic review aimed to (a) synthesise the related empirical literature, and (b) identify potential factors driving inconsistent findings. Peer-reviewed publications were included if they contained quantitative data and at least one measure of the statistical association between gay community involvement and sexual health behaviour. The search strategy was implemented in six databases and returned 6,409 articles, of which 86 met the inclusion criteria. There was considerable heterogeneity in how gay community involvement was assessed across studies. Although gay community involvement was consistently associated with greater engagement in protective behaviours across studies, the association between gay community involvement and risk behaviours appeared to depend on how gay community involvement was conceptualised and measured (e.g., nightlife involvement vs. political activism). Findings emphasise a need for studies that employ validated measures that reflect the multidimensional nature of gay community involvement, as well as research designs better suited to address the causal effects of community involvement on HIV/STI transmission and prevention.

Sexual Racism on Geosocial Networking Applications and Identity Outness Among Sexual Minority Men in the US

Although the use of geosocial networking (GSN) applications for relationship seeking is prevalent among sexual minority men (SMM), SMM of color may be vulnerable to sexual racism online. Little is known about how sexual racism relates to SMM of color's identity outness, which is integral to the minority stress model and the focus of this study. Eighty SMM, recruited through social media (53.7% racial/ethnic minority), reported their experiences of race-based discrimination on GSN apps and identity outness. Chi-squared and Fisher's tests examined differences in race-based discrimination online by participants' race/ethnicity. A factorial MANOVA was performed on outness to family, peers, and healthcare providers. Nearly one-third of participants experienced race-based discrimination online. Higher percentages of SMM of color experienced race-based discrimination than White SMM. SMM who experienced race-based discrimination online reported lower outness to family than those who had not. Post-hoc analyses revealed that Asian SMM reported consistently lower outness than other groups. Our findings resonated with the mediation framework of minority stress, suggesting that sexual racism online may be a distal stressor that contributes to the group-specific process of identity outness. This also illustrated the importance of addressing sexual racism on GSN apps to buffer existing stress with outness among SMM of color.

Knowledge of viral load, PrEP, and HIV-related sexual risk among men who have sex with men in the Waterloo region

Gay, bisexual, and other men who have sex with men (GBMSM) remain most disproportionately affected by HIV in Canada. HIV-related sexual risk behaviours have been linked to high HIV risk among GBMSM, but prior research has not focused on knowledge of viral load, and the risk it presents for HIV acquisition. The purpose of this study was to explore the relationship between HIV-related sexual risk behaviour and knowledge of viral load among GBMSM. A cross-sectional survey was conducted using a convenience sample of individuals age 16 and older who self-identified as LGBTQ and lived, worked, or resided in the Waterloo region, an urban-rural area in southwestern Ontario ( N = 526). Responses were analyzed from those identifying as GBMSM ( N = 269). Logistic regression models were created to explore sociodemographic, outness, social support, and HIV-related sexual risk variables associated with knowledge of viral load. Multivariable regression models were built to explore the same associations while controlling for confounders. HIV risk was not associated with knowledge of viral load in bivariate or multivariable analyses. Point estimates for low/negligible (odds ratio [OR] 1.10; 95% CI 0.46–2.51) and high risk (OR 1.88; 95% CI 0.68–5.20) suggest trends of higher knowledge with increased HIV risk. Men who engage in sexual risk behaviour may have increased sexual health literacy and awareness of biomedical interventions (e.g., pre-exposure prophylaxis, or PrEP) that reduce HIV risk. Policies are needed that promote acceptance of sexual orientation, improve awareness and access to PrEP, and ensure optimal delivery of HIV education to at-risk groups prior to engagement in higher risk activities.

Campus Climate and the Sexual Assault Victimization of LGBQ College Students

Sexual minority college students are disproportionately impacted by sexual assault in college, however, there is a paucity of research exploring the role of the college environment in victimization. This study explores the relationship of campus climate with sexual assault victimization for these students. This sample included 1,110 current college students in the United States who identified as a sexual minority. Logistic regression results indicated that the more observations of harassment and discrimination of sexual minority students by participants, the more likely they were to experience sexual assault victimization in college. Also, the more out a participant was on campus, and the stronger sense of belonging they had to their college, the less likely they were to experience sexual assault victimization. Sexual assault prevention efforts on college campuses would benefit from programming and policies that support belonging and address discrimination and harassment.

Knowledge of viral load, PrEP, and HIV-related sexual risk among men who have sex with men in the Waterloo region

Gay, bisexual, and other men who have sex with men (GBMSM) remain most disproportionately affected by HIV in Canada. HIV-
related sexual risk behaviours have been linked to high HIV risk among GBMSM, but prior research has not focused on knowledge of viral load, and the risk it presents for HIV acquisition. The purpose of this study was to explore the relationship between HIV-related sexual risk behaviour and knowledge of viral load among GBMSM. A cross-sectional survey was conducted using a convenience sample of individuals age 16 and older who self-identified as LGBTQ and lived, worked, or resided in the Waterloo region, an urban-rural area in southwestern Ontario ( N = 526). Responses were analyzed from those identifying as GBMSM ( N = 269). Logistic regression models were created to explore sociodemographic, outness, social support, and HIV-related sexual risk variables associated with knowledge of viral load. Multivariable regression models were built to explore the same associations while controlling for confounders. HIV risk was not associated with knowledge of viral load in bivariate or multivariable analyses. Point estimates for low/negligible (odds ratio [OR] 1.10; 95% CI 0.46–2.51) and high risk (OR 1.88; 95% CI 0.68–5.20) suggest trends of higher knowledge with increased HIV risk. Men who engage in sexual risk behaviour may have increased sexual health literacy and awareness of biomedical interventions (e.g., pre-exposure prophylaxis, or PrEP) that reduce HIV risk. Policies are needed that promote acceptance of sexual orientation, improve awareness and access to PrEP, and ensure optimal delivery of HIV education to at-risk groups prior to engagement in higher risk activities.

Gay Community Involvement and Condomless Anal Sex Among Sexual Minority Men in the USA

Sexual minority men (SMM) remain disproportionately burdened by sexually transmitted infections. Although gay community involvement has been theorized to be protective against many negative health outcomes, research examining the association between community involvement and condomless anal sex (CAS) has yielded conflicting results. The current study, conducted between 2018-2020, examined whether the importance one places on various aspects of community involvement was associated with CAS among a sample of young adult SMM aged 18-34 years with body image concerns (N = 180). Gay community involvement was measured using the Importance of Gay Community Scale, and the results of an exploratory factor analysis indicated the presence of two factors: "social activism" and "going out/nightlife." A zero-inflated Poisson regression was conducted to examine the association between gay "social activism," "going out/nightlife," and their interaction with the number of CAS partners. Upon examining a significant interaction, "social activism" had a protective effect against CAS at low levels of "going out/nightlife," but this effect was non-significant at higher levels. These results suggest that encouraging gay community involvement through activism could be effective at reducing CAS and addressing the health disparity that exists within this population.

Outness and its correlates among gay and bisexual men attending university in China: a cross-sectional study

BACKGROUND

Disclosure of sexual orientation to others (outness) might be associated with sexual and mental health among gay and bisexual men (GBM) attending university. We aimed to characterise outness and investigate factors correlated with outness among GBM attending university in China.

METHODS

Between September 2018 and March 2019, GBM attending university were recruited in six cities in China. Information on sociodemographic characteristics, outness and sexual behaviours were collected using a self-administered questionnaire. Each participant was tested for HIV/STIs. Correlates of outness were assessed using multivariable logistic regression.

RESULTS

A total of 400 GBM attending university were recruited, of whom 251 (62.8%) had disclosed their sexual orientation. Men who served as student leaders (adjusted odds ratio [AOR]=2.28, 95% CI: 1.46-3.54) and donated blood (AOR 1.85, 95% CI: 1.05-3.24) were more likely to disclose their sexual orientation, whereas men who had sex with a female (AOR 0.19, 95% CI: 0.05-0.74) and had group sex (AOR 0.52, 95% CI: 0.30-0.89) were less likely to disclose their sexual orientation. Mental health status, HIV/STI infections were not associated with outness.

CONCLUSIONS

GBM attending university who disclosed their sexual orientation were more likely to be involved with student work and less likely to engage in high-risk sexual behaviours. More attention and education could focus on non-disclosing GBM men attending university through peer education or other ways.

Willingness, preferred ways and potential barriers to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in China

OBJECTIVE

To explore willingness and preferred ways to use HIV pre-exposure prophylaxis (PrEP), factors associated with willingness, and potential barriers to PrEP use among men who have sex with men (MSM) in Changsha, China.

DESIGN

A cross-sectional survey was conducted from 25 June to 31 August 2019. Two hundred and fifty-five MSM were recruited from three community-based organisations (CBOs) in Changsha City. Willingness and potential barriers to use PrEP were examined using researcher-created scales. Univariate and multivariate logistic regression was used to analyse the factors associated with willingness to use PrEP. P values <0.05 were considered significant.

SETTING

Three MSM inclusive CBOs in Changsha, Hunan Province, China.

PARTICIPANTS

255 HIV-negative MSM were recruited through their CBOs with snowball sampling.

RESULTS

Less than half of the participants (43.1%) had heard of PrEP and 15.3% were willing to use PrEP. The participants reported higher willingness to use event-driven PrEP (3.70±0.07) than daily PrEP (2.65±0.07). Higher self-rated risk and fear of contracting HIV (OR: 14.47, 95% CI 2.19 to 95.53), awareness of PrEP (OR: 4.20, 95% CI 1.64 to 10.73), sharing one's own sexual orientation with parents or siblings (OR: 2.52, 95% CI 1.54 to 7.20) and having a university education or above (OR:0.29, 95% CI 0.12 to 0.72) were associated with willingness to use PrEP. Only 12.2% of the sample was concerned about potential barriers to PrEP use.

CONCLUSION

Efforts to improve awareness and knowledge of PrEP, teach self-evaluation of HIV infection risk and provide social and emotional support for MSM are needed to scale up PrEP implementation in China.

Heterosexual Self-Presentation, Identity Management, and Sexual Functioning Among Men Who Have Sex with Men

Research and clinical work on sexual functioning in men has traditionally focused on the presence or absence of erectile dysfunction (ED) or the inability to maintain an erection sufficient for satisfactory sexual performance. However, for men who have sex with men (MSM), receptive anal intercourse is a common form of sexual expression. Existing work on men's sexual dysfunction does not effectively address receptive anal sex functioning, and there is a need to understand how stressors can impact this common sexual behavior. The goal of the present study was to understand how stressors can impact erective and receptive anal sex functioning among MSM. In the present study, we hypothesized that minority stress (as operationalized by integrating identity management and heterosexual self-presentation) would have an impact on MSM's sexual functioning overall and adapted a previous measure of sexual dysfunction (International Index of Erectile Functioning) to better assess this relationship. Data were collected from 228 men (M_age = 31.74, SD = 9.41); exploratory factor analysis was used to create a new measure of sexual functioning, and regression analyses were used to examine the relationships between heterosexual self-presentation and identity management and sexual functioning. Results demonstrated that higher heterosexual self-presentation was associated with more functional impairment in erectile function and receptive anal sex functioning as well as use of functional enhancement medications or substances. The results of the present study extend extant work on minority stress to sexual functioning of MSM and are relevant to the sexual health concerns of MSM.

Unhealthy closets, discriminatory dwellings: The mental health benefits and costs of being open about one's sexual minority status

RATIONALE

With a concealable stigmatized identity, sexual minorities not only face discrimination but the burden of deciding when to be open about their sexuality. What are the mental health costs and benefits to openness about sexual minority status? On the one hand, openness fosters integration within the LGBTQ + community (yielding downstream benefits), but it also heightens perceptions of discrimination towards oneself and the group at large (yielding downstream costs for mental health).

OBJECTIVE

Previous research has focused on openness as reflecting either a cost or a benefit to sexual minorities' mental health, resulting in apparent conflict. We propose an integrated view of openness as leading to both costs and benefits that work in tandem to steer mental health.

METHODS

In two pre-registered studies with nearly 4000 ethnically diverse, sexual minority participants, we propose a theoretically-driven serial mediation model to test opposing mediating mechanisms that operate on subjective wellbeing and mental health. Specifically, we determine how the relationship between openness about sexual minority status fosters LGBTQ + identity importance, community integration, and perception of discrimination.

RESULTS

Being more (vs. less) open strengthens LGBTQ identity importance, facilitating integration in the LGBTQ + community, which benefits mental health. However, openness and strengthened identity importance simultaneously prompt increased perceptions of discrimination, the burden of which adversely affects mental health. Together these opposing forces explain the weak association between greater openness and mental health - an association that indicates, overall, that openness does have a net benefit for LGBTQ + individuals' mental health.

CONCLUSIONS

By identifying opposing mechanisms that underlie the relationship between openness and mental health, we have provided a more integrated perspective on the role that openness plays on sexual minorities' mental health. Openness is associated with stronger group identity importance, greater community integration, and heightened perception that the group (and self) face discrimination.

Spirituality and Religious Engagement, Community Involvement, Outness, and Family Support: Influence on LGBT+ Muslim Well-Being

The current study utilized data from the Social Justice Sexuality Project to investigate influences on psychological well-being of LGBT+ Muslims (N = 75) in the United States. Specifically, path analyses were used to examine the association between spiritual and religious engagement, LGBT community involvement, outness, and family support with psychological well-being. Control variables included lifespan Islam involvement, age, income, and the age at which the participant came out to themselves. Findings illustrate spiritual and religious engagement, outness, and income were all positively related to psychological well-being. Moreover, individuals who had converted to Islam but were not raised in the faith had significantly lower psychological well-being than those who had a consistent experience with Islam from their childhood until the time of the study. The present investigation provides critical contributions to the study of gender and sexual minorities in the United States and the experiences of currently practicing LGBT+ Muslims and those who were raised Muslim. Clinical implications and future research suggestions are discussed.

Estimating the influence of Twitter on pre-exposure prophylaxis use and HIV testing as a function of rates of men who have sex with men in the United States

OBJECTIVES

Acceptance of pre-exposure prophylaxis (PrEP) and testing for HIV is likely to vary as a function of the norms and communications within a geographic area. This study examined associations involving county tweets, in person communications, and HIV prevention and testing in regions with higher (vs. lower) estimated rates of men who have sex with men (MSM).

DESIGN AND METHODS

Ecological analyses examined (a) tweets about HIV (i.e. tweet rates per 100 000 county population and topic probabilities in 1959 US counties); (b) individual-level survey data about HIV prevention and testing and communications about PrEP and HIV (N = 30 675 participants); and (c) estimated county-level MSM rates (per 1 000 adult men).

RESULTS

In counties with higher rates of MSM, tweet rates were directly associated with PrEP use and HIV testing (rs = .06, BF10 > 10). Topics correlated with PrEP use (rs = -0.06 to 0.07, BF10 > 10) and HIV testing (rs = -0.05 to 0.05, BF10 > 10). Mediation analyses showed that hearing about and discussing PrEP mediated the relations between tweet rates and PrEP use (bi∗ = 0.01-0.05, BF10 > 100) and between topics and PrEP use (bi∗ = -0.04- 0.05, BF10 > 10). Moreover, hearing about PrEP was associated with PrEP use, which was in turn associated with tweet rates (bi∗ = 0.01, BF10 > 100) and topics (bi∗ = -0.03 - 0.01, BF10 > 10).

CONCLUSIONS

Rates of MSM appear to lead to HIV tweets in a region, in person communications about PrEP, and, ultimately, actual PrEP use. Also, as more men hear about PrEP, they may use PrEP more and may tweet about HIV.

Minority Stressors and Identity Affirmation as Predictors of Condomless Sex Among Self-Identified Bisexual Men: The Role of Partner Gender

Bisexual men are at increased risk for HIV/STI and early pregnancy involvement compared to heterosexual men, and minority stressors (e.g., enacted and internalized stigma) are associated with sexual risk behavior in samples of gay and bisexual men. However, few studies have specifically focused on bisexual men, and little is known about the unique predictors of sexual risk behavior in this population. Further, few studies have focused on positive sexual orientation-related factors such as identity affirmation, which may be protective against sexual risk behavior. As such, the goals of the current study were to examine minority stressors and identity affirmation as predictors of condomless sex among self-identified bisexual men, and whether these associations differed as a function of partner gender. We used four waves of data spanning 24 months from a subset of self-identified bisexual men in a larger cohort of gay and bisexual men ages 16-29 years at enrollment. At each wave, participants reported on up to four partners, allowing us to examine within-person associations. We used mixed effects negative binomial models to examine the associations between our predictors (discrimination, internalized binegativity, and identity affirmation) and condomless sex acts. In addition, we tested whether partner gender moderated each of the associations by including interaction effects in each of the models. Results indicated that higher levels of internalized binegativity and lower levels of identity affirmation were associated with less condomless sex with female partners, but they were not associated with condomless sex with male partners. Discrimination was not associated with condomless sex with male or female partners. These findings suggest that predictors of condom use among self-identified bisexual men differ as a function of partner gender, and they highlight the need to identify strategies to promote sexual health while also supporting positive identity development in this population.

Social networks and condomless intercourse with female partners among male sex workers in the Dominican Republic

Male sex workers (MSW) in the Dominican Republic (DR) have multiple sexual partners, including personal and client-relationships, and are disproportionately affected by human immunodeficiency virus (HIV). We examined the prevalence of condomless anal and/or vaginal intercourse (CI) among MSW in the DR as a function of social network factors. Self-report surveys and social network interviews were administered to MSW recruited through venue-based sampling (N = 220). A generalized linear model was used to complete a Poisson Regression model and identify variables significantly associated with the outcome of interest. CI was more common with female (28.3%) than with male partners (4.9%). Factors associated with CI with the last female partner included older age of MSW, CI with the last male partner, having a stable female partner (a consistent or main partner), and having ≥1 family member in the participants' social network. Partner and social network characteristics associated with CI among MSW suggest the utility of dyadic and network interventions to reduce HIV risk.

Willingness to Use Pre-Exposure Prophylaxis (PrEP) for HIV Prevention and PrEP Implementation Preferences Among Transgender Women in Malaysia

Introduction: Transgender women (TW) face one of the highest HIV burdens worldwide. In Malaysia, 12.4% of TW are HIV infected, ∼30-fold higher than in the Malaysian adult population. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, however, little is known about TW's willingness to use PrEP or their preferences for receiving PrEP. This study examined the correlates of Malaysian TW's willingness to use PrEP and their attitudes and preferences related to delivery of PrEP and PrEP-related care. Methods: Between June and August 2017, 361 TW in Malaysia completed an online survey about their knowledge of and willingness to use PrEP for HIV prevention. Results: Only 20.2% of participants had ever previously heard of PrEP and none were currently taking PrEP. The majority (82.5%) expressed high willingness to take PrEP and most participants met the World Health Organization (WHO) indication for PrEP (82.3%). In the multivariate model, lifetime hormone use, prior postexposure prophylaxis use, and having completed a high school education were associated with higher willingness to use PrEP, while injection drug use, older age, and Chinese ethnicity were associated with lower PrEP willingness. Conclusion: TW in Malaysia are highly willing to use PrEP for HIV prevention. Differences in willingness to use PrEP identified by education, ethnicity, substance abuse, and age suggest different strategies may be needed to scale-up PrEP for this diverse community of TW.

Factors associated with interest in and knowledge of pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (GBMSM) in the Region of Waterloo, Ontario, Canada: Insights from the OutLook Study

Pre-exposure prophylaxis (PrEP) is an effective HIV-prevention tool for gay, bisexual, and other men who have sex with men (GBMSM), a group known to be disproportionately affected by HIV/AIDS. We aimed to identify sociodemographic, psychosocial, and health factors associated with awareness of PrEP or interest in PrEP among GBMSM in a mid-sized Canadian city, where PrEP availability is arguably more scarce compared to larger metropolitan regions. The OutLook Study was a comprehensive online survey of LGBTQ health and well-being that collected data from sexual minorities aged 16+ in the Region of Waterloo, Ontario, Canada. Participants were cisgender MSM with an unknown or negative HIV status (n = 203). Bivariate logistic regression was performed to analyze factors associated with both awareness of PrEP and interest in PrEP. Multivariate logistic regression explored sexual behaviours in the past 12 months while controlling for sociodemographic and psychosocial variables. Increasing number of sexual partners (OR: 1.10; 95% CI: 1.03–1.53) was significantly associated with interest in PrEP and lifetime experiences of homophobia remained significant from the bivariate model (ORs ranged from 1.11–1.12). Since GBMSM with low educational attainment were shown to have less knowledge about PrEP, educational campaigns could be targeted in high schools rather than colleges, universities, and trade schools. Prevention initiatives should be aimed at places where single or non-monogamous GBMSM frequent due to these men being disproportionately affected by HIV/AIDS. These findings provide insights for potential interventions targeting MSM from mid-sized cities.

Immigrant Status and Sexual Orientation Disclosure: Implications for HIV/STD Prevention Among Men Who Have Sex with Men in Seattle, Washington

Men who have sex with men (MSM) are disproportionately affected by HIV and may avoid disclosing their sexual preferences to others. With heightened attention on immigrant status in the United States, foreign-born MSM may be particularly concerned about disclosing their sexual orientation. We sought to examine how immigrant status is associated with sexual orientation disclosure among MSM and to assess the impact of disclosure on HIV/STD prevention outcomes stratified by nativity. We analyzed data from the 2014 and 2017 Seattle-area surveys of MSM from the National HIV Behavioral Surveillance (NHBS) system. Foreign-born MSM were less likely than U.S.-born MSM to have disclosed their sexuality to friends who are not gay, lesbian, or bisexual (85.0% vs. 95.5%; p < .001) or to family members (80.5% vs. 91.3%; p < .001). Further, disclosure to one's health care provider significantly increased the likelihood of having tested for HIV in the past 12 months among foreign-born and U.S.-born MSM. Findings highlight the need to better understand the risks and benefits of disclosure among foreign-born MSM. Future research may explore how responses and reactions to disclosure among foreign-born MSM shape pathways to HIV risk and prevention.

Sexuality Disclosure in U.S. Gay, Bisexual, and Other Men Who Have Sex With Men: Impact on Healthcare-Related Stigmas and HIV Pre-Exposure Prophylaxis Denial

INTRODUCTION

Stigma impairs access to health care by gay, bisexual, and other men who have sex with men. Gay, bisexual, and other men who have sex with men who are open about their sexuality, or out, are more resilient to stigma than those who are not out. Outness may influence healthcare utilization and prescription of HIV pre-exposure prophylaxis to HIV-negative gay, bisexual, and other men who have sex with men.

METHODS

Analyzing the 2018 American Men's Internet Survey during 2019, the adjusted prevalence ratios of healthcare stigmas and outness to healthcare providers were calculated. The effect of outness on annual healthcare visits and stigma was measured. Pre-exposure prophylaxis seeking and denial by providers was quantified and stratified by outness.

RESULTS

Of 5,794 respondents, 3,402 (58.7%) were out to their provider. Out gay, bisexual, and other men who have sex with men were less likely to experience anticipated stigma (adjusted prevalence ratio=0.75, 95% CI=0.72, 0.80) but more likely to experience enacted stigma or discrimination (adjusted prevalence ratio=1.23, 95% CI=1.18, 1.28). In a subsample of out gay, bisexual, and other men who have sex with men, recently experienced discrimination was associated with higher healthcare utilization (adjusted prevalence ratio=1.51, 95% CI=1.14, 1.51). Conversely, recent experienced discrimination was associated with lower healthcare utilization in not out gay, bisexual, and other men who have sex with men (adjusted prevalence ratio=0.67, 95% CI=0.54, 0.82). Of 3,104 out gay, bisexual, and other men who have sex with men, 1,417 (45.7%) discussed pre-exposure prophylaxis with their providers, compared with 120 of 1,711 (7.0%) gay, bisexual, and other men who have sex with men who were not out (p<0.001). Pre-exposure prophylaxis denials were less common among out (116/793, 14.6%) than not out (14/55, 25.5%) gay, bisexual, and other men who have sex with men (p=0.044).

CONCLUSIONS

Healthcare provider-related stigmas impair healthcare engagement among not out gay, bisexual, and other men who have sex with men who were also more commonly denied pre-exposure prophylaxis. Ending the HIV epidemic necessitates creating safe environments for disclosure of sexual preferences and practices to facilitate access to HIV prevention.

Political Environment and Perceptions of Social Inclusion After Nationwide Marriage Equality Among Partnered Men Who Have Sex with Men in the USA

The aim of this paper is to examine how nationwide marriage equality and minority stressors are associated with perceptions of social inclusion using a national sample of partnered men who have sex with men (MSM)(n=498). A four-item scale measuring changes in perceived social inclusion due to the nationwide legalization of same-sex marriage was created. Respondents were categorized into four distinct political environments using results from the 2016 US Presidential election. Multilevel modeling was used to examine associations between political environment, minority stressors, and perceived social inclusion. Changes in perceived social inclusion due to marriage equality did not significantly differ between political environments. Higher levels of internalized, anticipated, and enacted stigma were all associated with fewer gains in perceived social inclusion. An interaction between political environment and external stigma was significant in the most politically conservative areas. The legalization of marriage equality has improved perceived social inclusion overall, but less so among men who experience more discrimination and live in conservative environments. Multilevel interventions to change social norms are needed to help decrease minority stressors and improve perceived social inclusion in politically conservative areas with elevated levels of discrimination.

Homonegativity Experienced over the Life Course by Young Black Gay, Bisexual and Other Men Who Have Sex with Men (YB-GBMSM) Living with HIV in Atlanta, Georgia

Minority stress theory posits that homonegativity-whether experienced, anticipated, or internalized-adversely impacts health. We conducted qualitative interviews with 28 YB-GBMSM living with HIV to explore manifestations of homonegativity over the life course. Thematic analysis identified patterns in the ways that homonegativity was discussed at different points in participants' lives. Stifling, and sometimes traumatic, familial and religious environments led to experienced homonegativity early in life. These experiences led to anticipated and internalized homonegativity, which in turn shaped sexual identity formation processes in adolescence and into young adulthood. Ultimately, many participants distanced themselves from home environments, seeking and often finding extrafamilial support. Most participants eventually reached self-acceptance of both their sexuality and HIV status. In conclusion, experienced, anticipated and internalized homonegativity were pervasive as YB-GBMSM navigated family and religious environments over the life course. Future interventions should work with youth, families, and churches to prevent these harmful experiences.

Effect of a Community-Level HIV Prevention Intervention on Psychosocial Determinants of HIV Risk Behaviors among Young Black Men Who Have Sex with Men (YBMSM)

In contrast to intervention studies that assess psychosocial factors only as mediators or moderators of HIV risk, the present study assessed the effects of an Mpowerment-based community-level intervention on psychosocial determinants (e.g., depressive symptoms, sexual stigma) of HIV risk behavior among young black MSM. Approximately 330 respondents were surveyed annually for 4 years in each of two sites. General linear models examined change across time between the intervention and comparison communities, and participation effects in the intervention site. Social diffusion (spreading information within networks) of safer sex messages (p < 0.01) and comfort with being gay (p < 0.05) increased with time in intervention versus control. Cross-sectionally, intervention participants responded more favorably (p < 0.05) on social diffusion and depressive symptoms, but less favorably (p < 0.01) on sex in difficult situations and attitudes toward condom use. Findings suggest a need to address broader health issues of MSM as well as sexual risk.

Exploring the role of sex-seeking apps and websites in the social and sexual lives of gay, bisexual and other men who have sex with men: a cross-sectional study

Background The objective of this study was to explore the relationship between online sex-seeking, community/social attachment and sexual behaviour.

METHODS

Respondent-driven sampling was used to recruit 774 sexually active gay and bisexual men in Vancouver, Canada, aged ≥16 years. Multivariable logistic regression compared men who had used online sex-seeking apps/websites in the past 6 months (n=586) with those who did not (n=188).

RESULTS

Multivariable results showed that online sex seekers were more likely to be younger [adjusted odds ratio (aOR)=0.95, 95% CI: (0.93-0.96)], college educated [aOR=1.60, 95% CI: (1.07, 2.40)], have more Facebook friends [aOR=1.07, 95% CI: (1.01, 1.13)], spend more social time with other gay men [aOR=1.99, 95% CI: (1.33-2.97)], and were less likely to identify emotionally with the gay community [aOR=0.93, 95% CI: (0.86-1.00)]. Further, they had displayed high sensation-seeking behaviour [aOR=1.08, 95% CI: (1.03-1.13)], were more likely to engage in serodiscordant/unknown condomless anal sex [aOR=2.34, 95% CI: (1.50-3.66)], use strategic positioning [aOR=1.72, 95% CI: (1.08-2.74)], ask their partner's HIV-status prior to sex [aOR=2.06, 95% CI: (1.27-3.37)], and have ever been tested for HIV [aOR=4.11, 95% CI: (2.04-8.29)].

CONCLUSION

These findings highlight the online and offline social behaviour exhibited by gay and bisexual men, pressing the need for pro-social interventions to promote safe-sex norms online. We conclude that both Internet and community-based prevention will help reach app/web users.

Homophobia and heteronormativity as dimensions of stigma that influence sexual risk behaviors among men who have sex with men (MSM) and women (MSMW) in Lima, Peru: a mixed-methods analysis

BACKGROUND

Stigma differentially influences HIV and STI care among MSM, especially regarding partner notification practices. Recognizing the heterogeneous behaviors/identities within the category "MSM," we used mixed-methods to assess sexual risk behaviors among men who have sex with men only (MSMO) and behaviorally bisexual MSM (MSMW) with HIV and/or other STIs.

METHODS

MSMO/MSMW recently diagnosed (< 30 days) with HIV, syphilis, urethritis, or proctitis completed a cross-sectional survey assessing sexual risk behaviors, anticipated disclosure, and sexual partnership characteristics (n = 332). Multivariable generalized estimating equation models assessed characteristics associated with female compared to male partners in the last three partnerships. Follow-up qualitative interviews (n = 30) probed partner-specific experiences (e.g., acts and disclosure).

RESULTS

Among all participants, 13.9% (n = 46) described at least one of their last three sex partners as female (MSMW). MSMW (mean age of 31.8) reported a mean of 3.5 partners (SD = 4.5) in the past 3 months and MSMO (mean age 30.6) reported a mean of 4.6 partners (SD = 9.7) in the past 3 months. MSMW were more likely to report unprotected insertive anal sex (77.9%) than MSMO (43.1%; p < 0.01). Cisgender female partners were associated with condomless insertive sex in the last 3 months (aPR: 3.97, 95%CI: 1.98-8.00) and classification as a "primary" partnership (2.10, 1.34-3.31), and with lower prevalence of recent HIV diagnosis (0.26, 0.11-0.61). Planned notification of HIV/STI diagnoses was less common for female than for male partners (0.52, 0.31-0.85). Narratives illustrate internal (e.g., women as 'true' partners) and community-level processes (e.g., discrimination due to exposure of same-sex behavior) that position homosexual behavior and bisexual identity as divergent processes of deviance and generate vulnerability within sexual networks.

CONCLUSIONS

MSMW recently diagnosed with HIV/STI in Peru report varying partnership characteristics, with different partner-specific risk contexts and prevention needs. Descriptions highlight how behaviorally bisexual partnerships cut across traditional risk group boundaries and suggest that HIV/STI prevention strategies must address diverse, partnership-specific risks.

HIV Risk Behaviors and Utilization of Prevention Services, Urban and Rural Men Who Have Sex with Men in the United States: Results from a National Online Survey

Rural men who have sex with men (MSM) are heavily affected by HIV, and many lack culturally competent HIV prevention resources. Rural MSM may find sexual partners on the internet, which may also be a way to deliver prevention services to them. To understand the differences between rural and urban MSM with respect to HIV risk factors and behaviors and the utilization of online HIV prevention services, we used data from the 2012 Web-Based HIV Behavioral Survey (WHBS). Using WHBS data collected between June and August 2012, we compared the characteristics of MSM with positive or unknown HIV infection status who had sex with a male in the past 12 months, from rural vs urban areas using Chi square tests and median tests. We used logistic regression and calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to compare self-reported HIV risk behaviors, HIV/STI testing behaviors, use of prevention services, and perceived discrimination. Of the 8166 MSM included in our analysis, 3583 (44%) were from rural areas, and 4583 (56%) were from urban areas. Compared to urban MSM, rural MSM were less likely to ever test for HIV (aPR = 0.94, CI 0.92-0.95), to be tested for HIV in the last year (aPR = 0.83, CI 0.79-0.87), or to receive free condoms (aPR = 0.83, CI 0.79-0.86) or individual prevention counseling in the past year (aPR = 0.86, CI 0.78-0.95). Rural MSM were less likely to have been tested in the last year for syphilis, gonorrhea, or chlamydia (aPR = 0.70, CI 0.62-0.78; aPR = 0.72, CI 0.64-0.81; aPR = 0.75, CI 0.67-0.85, respectively). Rural MSM also reported perceiving less tolerance of gays and bisexuals within their community (aPR = 0.80, CI 0.77-0.84). HIV prevalence is lower among MSM in rural areas compared to MSM in urban areas, but rural MSM report that they are more likely to face intolerance and are less likely to use basic HIV prevention services compared to urban MSM. Therefore, this hard-to-reach population could benefit from prevention services offered through the internet.

Correlates of Unknown HIV Status Among MSM Participating in the 2014 American Men's Internet Survey (AMIS)

Increasing serostatus awareness is a key HIV prevention strategy. Despite expanded testing efforts, some men who have sex with men (MSM) remain unaware of their HIV status. This study explored demographic characteristics, sexual identity, sexual role, and behavioral factors associated with unknown HIV status among MSM in the United States. Data from 9170 MSM in the 2014 American Men's Internet Survey were analyzed using logistic regression to identify correlates of unknown HIV status. Young age, race, low education, rural residence, and lack of recent healthcare visits were significantly associated with unknown HIV status. In addition, nondisclosure of one's sexual orientation (OR = 3.70, 95% CI 2.99-4.59) and a self-identified sexual role as "bottom" (OR = 1.45, 95% CI 1.24-1.70) were predictors of unknown HIV status. Post-hoc analysis showed HIV-negative MSM not tested in the last year had fewer self-reported risk behaviors than recent testers, suggesting that repeat testing among MSM may be aligned with individual risk.

Social networks and social support among ball-attending African American men who have sex with men and transgender women are associated with HIV-related outcomes

The House Ball Community (HBC) is an understudied network of African American men who have sex with men and transgender women, who join family-like houses that compete in elaborate balls in cities across the United States. From 2011 to 2012, we surveyed 274 recent attendees of balls in the San Francisco Bay Area, focusing on social networks, social support, and HIV-related behaviours. Participants with a high percentage of alters who were supportive of HIV testing were significantly more likely to have tested in the past six months (p = .02), and less likely to have engaged in unprotected anal intercourse (UAI) in the past three months (p = .003). Multivariate regression analyses of social network characteristics, and social support, revealed that testing in the past six months was significantly associated with social support for safer sex, instrumental social support, and age. Similarly, UAI in the past three months was significantly associated with social support for safer sex, homophily based on sexual identity and HIV status. HIV-related social support provided through the HBC networks was correlated with recent HIV testing and reduced UAI. Approaches utilising networks within alternative kinship systems, may increase HIV-related social support and improve HIV-related outcomes.

Social Stressors and Intoxicated Sex Among an Online Sample of Men who have Sex with Men (MSM) Drawn from Seven Countries

BACKGROUND

Rates of drug and alcohol use are higher among men who have sex with men (MSM) than the general adult male population, and are often associated with increased sexual risk-taking.

OBJECTIVES

We aim to examine the prevalence of drunk or high sex and their associations with socio-demographic characteristics, gay social network size, and social stress among an online sample of MSM drawn from seven countries.

METHODS

Sexually-active MSM aged over 18 residing in Australia, Brazil, Canada, South Africa, Thailand, the United Kingdom, or the United States were recruited through Facebook for a quantitative survey (n = 2,403) in 2012. Two outcomes were examined via logistic regression: reporting being buzzed/drunk at last sex, and reporting being high at last sex.

RESULTS

Results highlight the role of social stressors in shaping drug use among MSM. Results were context-specific, though commonalities were seen across countries. Being in a male-male sexual relationship was associated with lower odds of being buzzed/drunk at last sex in five countries. Higher scores on measures of external homonegative discrimination and internalized homonegativity were associated with greater odds of reporting being high at last sex in three countries. Conclusions/Importance: Social networks and minority stressors can have significant effects on drug use and sex while drunk or high. This points to the importance of focusing on structural issues when designing interventions for MSM aimed at reducing the transmission of HIV and other STIs.

Clinically significant depressive symptoms among a diverse sample of same-sex male couples in Atlanta, Boston, and Chicago: An analysis of individual- and dyadic-level factors

Psychosocial and relationship factors are associated with depression outcomes in heterosexual couples. No known research has examined these relationships statistically among both partners within a same-sex male dyad. This study examined how socio-demographics, psychosocial and relationship factors influence depressive symptoms in a large sample of same-sex male couples in Atlanta, Boston, and Chicago. Linear and logistic regression models indicated that, at the individual level, age, polydrug use, relationship length, perceived love, and partner communication were associated with depression scores. Multinomial logistic regression models showed that couples with no sexual agreement or an agreement with restrictions were likely to exhibit depressive symptoms.

Willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Malaysia: Findings from an online survey

Objective

We examined willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia.

Methods

An online survey of 990 MSM was conducted between March and April 2016. Eligibility criteria included being biological male, Malaysian citizen, 18 years of age or above, identifying as MSM, and being HIV negative or unknown status. Participants’ demographics, sexual and drug use behaviors, attitudes towards PrEP, and preferences regarding future access to PrEP were collected. Bivariate analysis and logistic regression were performed to determine factors associated with willingness to use PrEP.

Results

Fewer than half of participants (44%) knew about PrEP before completing the survey. Overall, 39% of the sample were willing to take PrEP. Multivariate logistic regression indicated that Malay men (AOR: 1.73, 95% CI:1.12, 2.70), having 2 or more male anal sex partners in the past 6 months (AOR: 1.98, 95% CI: 1.29, 3.05), previous knowledge of PrEP (AOR: 1.40, 95%CI: 1.06, 1.86), lack of confidence in practising safer sex (AOR: 1.36, 95% CI: 1.02, 1.81), and having ever paid for sex with a male partner (AOR: 1.39, 95% CI: 1.01, 1.91) were independently associated with greater willingness to use PrEP, while men who identified as heterosexual were less willing to use PrEP (AOR, 0.36, 95% CI: 0.13, 0.97). Majority of participants preferred to access PrEP at affordable cost below 100 Malaysian Ringgit (USD25) per month from community based organisations followed by private or government hospitals.

Conclusions

Overall, MSM in Malaysia reported a relatively low level of willingness to use PrEP, although willingness was higher among those previously aware of PrEP. There is a need to provide PrEP at affordable cost, increase demand and awareness of PrEP, and to provide access to this preventative medication via diverse, integrated and tailored sexual health services.

Receipt and Perpetration of Intimate Partner Violence and Condomless Anal Intercourse Among Gay and Bisexual Men in Atlanta

Intimate partner violence (IPV) rates are disproportionately high among sexual minority populations, with increasing evident that gay men experience IPV at the same rates as heterosexual women. This study examines the relationship between self-reported condomless anal intercourse (CAI) and IPV among a sample of 750 gay and bisexual men. Participants answered questions regarding recent receipt and perpetration of IPV using the IPV-GBM Scale (Cronbach Alpha 0.90). Of the sample, 46.1% reported recent receipt of any type of IPV and 33.6% reported recent perpetration of any type of IPV. Overall, 55.1% of participants reported CAI at last sex. Significant associations were determined between several forms of IPV and increased odds of reporting CAI at last sex. These findings suggest that IPV may be a risk factor for CAI among men who have sex with men, and highlight the need to understand the IPV prevention and care needs of this population.

Racism and Sociopolitical Engagement Among Lesbian, Gay, and Bisexual Racial/Ethnic Minority Adults

Experiences of discrimination due to one’s racial; ethnic; or lesbian gay, or bisexual (LGB) status have been associated with higher levels of sociopolitical involvement in racial, ethnic, and sexual minority communities. In this study, we examined (a) the associations between perceived racism in the LGB community, sociopolitical involvement in LGB racial or ethnic minority communities, and outness; and (b) whether the association between perceived racism and sociopolitical involvement in the LGB community is moderated by outness among LGB racial or ethnic minority adults. The study draws on a sample that is diverse with respect to age, gender, sexual orientation, race, and ethnicity. Results revealed that Asian American participants perceived higher levels of racism in the LGB community than Latina/o participants. Perceptions of racism in the LGB community predicted sociopolitical involvement in LGB communities. Implications of these findings are discussed.

Minority Stress and Intimate Partner Violence Among Gay and Bisexual Men in Atlanta

Intimate partner violence (IPV) rates are disproportionately high among sexual minority populations. Few studies have examined the plausible relationship between minority stress and IPV among men who have sex with men. This study examines the associations between IPV and three indicators of minority stress: internalized homophobia, sexuality-based discrimination, and racism, in a large venue-based sample of gay and bisexual men from Atlanta, USA. Each of the minority stress measures was found to be significantly associated with increased odds of self-reporting any form of receipt of IPV. Significant associations were also identified between perpetration of IPV and minority stressors, with most types of IPV perpetration linked to internalized homophobia. This study confirms findings in a growing body of research supporting the relationship between minority stress and increased prevalence of IPV among men who have sex with men, and points to the need to address structural factors in IPV prevention programs for male-male couples.

Preexposure Prophylaxis and Patient Centeredness: A Call for Holistically Protecting and Promoting the Health of Gay Men

Preexposure prophylaxis has transformed HIV prevention, becoming widespread in communities of gay and bisexual men in the developed world in a short time. There is a broad concern that preexposure prophylaxis will discourage condom use among gay men (i.e., "risk compensation"). This commentary argues for broadening the focus on gay men's health beyond sexual health to address the holistic health and well-being of gay men. Gay men may benefit from being offered candid, nonjudgmental health promotion/HIV prevention messages not requiring condom use for anal sex. Lessons can be drawn from the family planning movement, which has undergone a similar shift in focus. The principle of patient centeredness supports such a shift in gay men's health toward the goal of providing men with the knowledge to evaluate various prevention approaches according to the specifics of their life circumstances and health needs. Bringing more nuance to discussions of sexual risk and sexual pleasure could facilitate more universally healthy attitudes regarding sex among gay men, in turn enabling healthier decisions more compatible with men's own values and preferences.

Ethical Considerations in Recruiting Online and Implementing a Text Messaging-Based HIV Prevention Program With Gay, Bisexual, and Queer Adolescent Males

PURPOSE

There is a dearth of HIV prevention/healthy sexuality programs developed for adolescent gay and bisexual males (AGBM) as young as 14 years old, in part because of the myriad ethical concerns. To address this gap, we present our ethics-related experiences implementing Guy2Guy, a text messaging-based HIV prevention/healthy sexuality program, in a randomized controlled trial of 302 14- to 18-year-old sexual minority males.

METHODS

Potential risks and efforts to reduce these risks are discussed within the framework of the Belmont Report: Respect for persons, beneficence (e.g., risks and benefits), and justice (e.g., fair distribution of benefits and burdens).

RESULTS

To ensure "respect for persons," online enrollment was coupled with telephone assent, which included assessing decisional capacity to assent. Beneficence was promoted by obtaining a waiver of parental permission and using a self-safety assessment to help youth evaluate their risk in taking part. Justice was supported through efforts to develop and test the program among those who would be most likely to use it if it were publicly available (e.g., youth who own a cell phone and are enrolled in an unlimited text messaging plan), along with the use of recruitment targets to ensure a racially, ethnically, and regionally diverse sample.

CONCLUSIONS

It is possible to safely implement a sensitive and HIV prevention/healthy sexuality program with sexual minority youth as young as 14 years old when a rigorous ethical protocol is in place.

Intimate partner violence and condom negotiation efficacy among gay and bisexual men in Atlanta

Background: The experience of intimate partner violence (IPV) has been shown to decrease condom negotiation efficacy among women; however, studies of this association among gay and bisexual men (GBM) are lacking. Methods: A venue-recruited sample of 745 GBM was recruited in Atlanta, GA, USA in 2012-13. Participants self-completed a survey including questions on recent (previous 12 month) experience and perpetration of IPV using the IPV-GBM Scale. Multivariate regression analysis examined the association between reporting low condom negotiation efficacy with the respondent's most recent sex partner (19.2% of respondents) and recent experience of IPV with the same or another partner. Results: Nearly half the sample (49.1%) reported recent receipt of IPV, although prevalence varied considerably across the forms of IPV. GBM who reported recent IPV experience were significantly less likely to report having felt able to negotiate condom use. Conclusions: These findings suggest that IPV may be a significant risk factor for HIV acquisition and transmission among GBM.

A Minority Stress Model for Suicidal Ideation in Gay Men

There is a dearth of research on mechanisms underlying higher rates of suicidal ideation among gay men compared to heterosexual men. The purpose of this study was to establish the link between social/psychological predictor variables and suicidal ideation by testing a hypothesized minority stress model. Structural equation modeling was used to assess the relationships posited in the model using data from a community sample of 167 gay men. Model fit was adequate and hypothesized relationships were partially supported. Also, depressive symptoms partially mediated the relationship between (less) outness predicting suicidal ideation. These findings imply that therapeutic approaches targeting the coming out process may be more effective than approaches targeting internalized homophobia when suicidal ideation is indicated in the clinical presentation of gay and bisexual men.

Homophobia and communal coping for HIV risk management among gay men in relationships

Men who have sex with men (MSM) remain disproportionately affected by the HIV epidemic in the US and estimates suggest that one to two-thirds of new infections occur among main partners. Previous research has focused on individual MSM and their risk for HIV, yet couples' ability to manage risk has been largely understudied. In particular, the role that homophobia plays in shaping the ability of gay male couples to cope with HIV risk is currently understudied. A sample of 447 gay/bisexual men with main partners was taken from a 2011 survey of gay and bisexual men in Atlanta. Linear regression models were fitted for three couples' coping outcome scales (outcome efficacy, couple efficacy, communal coping) and included indicators of homophobia (internalized homophobia and homophobic discrimination). Findings indicate that reporting of increased levels of internalized homophobia were consistently associated with decreased outcome measures of couples' coping ability regarding risk management. The results highlight the role that homophobia plays in gay male couples' relationships and HIV risk, extending the existing literature in the field of same-sex relationships as influenced by homophobia.

Sexual orientation- and race-based discrimination and sexual HIV risk behavior among urban MSM

Understanding what social factors are associated with risk of HIV acquisition and transmission among gay, bisexual and other men who have sex with men (MSM) is a critical public health goal. Experiencing discrimination may increase risk of HIV infection among MSM. This analysis assessed relations between experiences of sexual orientation- and race-based discrimination and sexual HIV risk behavior among MSM in New York City. 1,369 MSM completed a self-administered computerized assessment of past 3-month sexual behavior, experience of social discrimination and other covariates. Regression models assessed relations between recent experience of discrimination and sexual HIV risk behavior. Mean age was 32 years; 32 % were white; 32 % Latino/Hispanic; 25 % African American/Black. Of MSM who self-reported HIV-positive or unknown status (377), 7 % (N = 27) reported having unprotected insertive anal intercourse with an HIV-negative or unknown status partner ("HIV transmission risk"). Of MSM who self-reported HIV-negative status (992), 11 % (110) reported unprotected receptive anal intercourse with an HIV-positive or unknown status partner ("HIV acquisition risk"). HIV acquisition risk was positively associated with sexual orientation-based discrimination in home or social neighborhoods, but not race-based discrimination. We observed that sexual orientation-based discrimination was associated with sexual HIV risk behavior among urban-dwelling MSM. Addressing environmental sources of this form of discrimination, as well as the psychological distress that may result, should be prioritized in HIV prevention efforts.

Delayed HIV diagnosis and initiation of antiretroviral therapy: inequalities by educational level, COHERE in EuroCoord

OBJECTIVES

In Europe and elsewhere, health inequalities among HIV-positive individuals are of concern. We investigated late HIV diagnosis and late initiation of combination antiretroviral therapy (cART) by educational level, a proxy of socioeconomic position.

DESIGN AND METHODS

We used data from nine HIV cohorts within COHERE in Austria, France, Greece, Italy, Spain and Switzerland, collecting data on level of education in categories of the UNESCO/International Standard Classification of Education standard classification: non-completed basic, basic, secondary and tertiary education. We included individuals diagnosed with HIV between 1996 and 2011, aged at least 16 years, with known educational level and at least one CD4 cell count within 6 months of HIV diagnosis. We examined trends by education level in presentation with advanced HIV disease (AHD) (CD4 <200 cells/μl or AIDS within 6 months) using logistic regression, and distribution of CD4 cell count at cART initiation overall and among presenters without AHD using median regression.

RESULTS

Among 15 414 individuals, 52, 45,37, and 31% with uncompleted basic, basic, secondary and tertiary education, respectively, presented with AHD (P trend <0.001). Compared to patients with tertiary education, adjusted odds ratios of AHD were 1.72 (95% confidence interval 1.48-2.00) for uncompleted basic, 1.39 (1.24-1.56) for basic and 1.20 (1.08-1.34) for secondary education (P < 0.001). In unadjusted and adjusted analyses, median CD4 cell count at cART initiation was lower with poorer educational level.

CONCLUSIONS

Socioeconomic inequalities in delayed HIV diagnosis and initiation of cART are present in European countries with universal healthcare systems and individuals with lower educational level do not equally benefit from timely cART initiation.