Research on HIV sexual risk behaviour among MSM from ethnoracial communities: A synthesis of the literature

Despite the wealth of HIV-related knowledge and prevention programs, recent statistics indicate that HIV is again on the rise among gay, bisexual and other men who have sex with men (gay/MSM). The following report on the current situation includes sections on: an overview of research on determinants of sexual risk taking, a review of current sexual risk behaviour research on gay/MSM from identified ethno-racial communities, an overview of various HIV prevention programs and campaigns, and an epidemiological update on HIV infection rates in Ontario.

The first chapter of this report offers a critical review of the current research on HIV risk among gay, bisexual, and other men who have sex with men. Adam identifies various factors, contexts and predispositions that have been linked to increased risk of HIV transmission including: sexual and domestic abuse, sensation seeking personalities and behaviours, personal disruption (e.g., loss of a job or partner), depression and social isolation, drug and alcohol use, condom trouble (both physiological and symbolic), particular settings and social interactions (e.g., settings which emphasize casual or quick sex; places that emphasize a ‘buyer beware’ mentality), certain circuits and currents which are supportive of unprotective sex (e.g., barebacking scene), and treatment optimism. Also noted in the research as a potential risk factor for HIV transmission is couple communication and interaction. Condom use tends to decrease with length of romantic relationships and men may find it harder to negotiate safety in long term relationships where partners assume monogamy. The introduction of condoms by one partner may signal distrust or infidelity to the other partner. Factors related to age, bisexuality, social class, and ethno-cultural backgrounds are also noted. Adam concludes that it is important to address how the social aspects of HIV relate to transmission risk. HIV risk cannot be addressed with just one type of preventive effort, as HIV risks are diverse, each segment of the population having its own unique risk-related issues.

The second chapter addresses the research, or rather lack of research, on ethno-racial gay/MSM. The term ‘ethno-racial’ is defined as individuals from both ethnic and racial gay/MSM communities, including: African, Caribbean, East Asian (Chinese, Vietnamese, Filipino, etc.), South Asian (Indian, Pakistani, Bangladeshi, etc.), and Latino (Venezuelan, Argentinean, Mexican, etc.). The review also includes Portuguese speaking populations, Italian, Slavic, and Francophone Canadians, and non-Christian religious traditions (Muslims, Hindus, Jews, etc.), but found the research on these communities to be sparse. This section addresses the social and individual factors that affect HIV transmission risk and offers recommendations for prevention efforts for each ethno-racial community. Ethno-racial communities face unique factors when negotiating HIV risk, such as: religious and cultural beliefs, racism, immigration status, discrimination, and peer norms. Hart, Blanco and Williams offer specific recommendations, stressing the importance of HIV prevention programs that better reflect ethno-racial and linguistic diversity, and the specific factors related to each community’s cultural and social realities. The authors stress the need for programs to acknowledge not only factors that differ among individuals but also the multiple sites of oppression and the resulting potential for social isolation faced by ethno-racial communities.

The third chapter reviews current HIV prevention programs and focuses the discussion on a variety of themes found in the programs including: the mechanics of condom use, the role of the internet, questioning assumptions about HIV risk, drug and alcohol use, safely introducing men to new scenes and cruising, relationships, access to and building community with other men, building self esteem through empowerment and social support, health promotion and counseling, programs for sex trade workers, campaigns directed at youth, and prevention for people living with HIV. Bortolin suggests that while there does exist a diverse range of prevention programs, each is integral to the prevention of HIV and must be tailored to specific group needs within the population of gay, bisexual, and other men who have sex with men.

The final chapter of this report provides an epidemiological analysis by Remis and Liu, revealing that from October 1985 to December 2005, 26,461 HIV-infected persons were newly diagnosed in Ontario of whom 64% were gay/MSM. While gay/MSM constituted a decreasing proportion of HIV diagnoses (~90% in the 1980s to ~50% in recent years), gay/MSM continue to be the population most affected by HIV infection in Ontario. It is estimated that 14,900 gay/MSM in Ontario were infected with HIV as of 2004, or 16.3% of Ontario gay/MSM. Of these 10,650 gay/MSM in Toronto were infected, constituting 71% of the Ontario total. HIV incidence among gay/MSM appears to have almost doubled since 1996, from 467 to 866 new infections in 2004; while HIV prevalence increased by 42% during the same period. The age group most affected by HIV/AIDS continues to be those 25-44 years old, though in recent years older men constitute an increasing proportion of new HIV diagnoses (11% compared to 5%). Ethno-racial communities comprise an increasing proportion of HIV diagnoses, reflected both in HIV data from Toronto and Ottawa and AIDS cases from Ontario as a whole. An estimated 69% of reported AIDS cases in Ontario since 1981 have been among gay/MSM. Though AIDS incidence among gay/MSM has decreased by over 80% from its peak in 1994, it now appears to have increased from 2002 to 2004. The authors conclude that despite dramatic improvements in survival related in large part to the advent of HAART in 1996, the epidemic of HIV infection among gay/MSM in Ontario is still not effectively controlled.

This report offers an overview of the current state of research into risk behaviour among the gay/MSM populations and provides recommendations for future prevention programs, stressing the importance of addressing ethno-racial and other kinds of diversities that make up men who have sex with men inside and outside gay communities. HIV infection rates, according to current epidemiology, are unstable and increasing and it is necessary to identify and acknowledge shifts and currents within gay and bisexual communities to better meet the challenges posed by HIV disease.