Sex, love, friendship, belonging and place: is there a role for 'Gay Community' in HIV prevention today?

The impact of social connections and discrimination to HIV risk among Asian gay and bisexual men in Australia

BACKGROUND

Asian gay, bisexual, and other men who have sex with men (GBMSM) are overrepresented in new HIV diagnoses in Australia. Social engagement with other GBMSM has been associated with HIV testing and pre-exposure prophylaxis (PrEP) uptake. Asian GBMSM may be socially disconnected from LGBTQ+ people, which may increase their HIV risk. This analysis assessed the contribution of social connection on HIV risk among Asian GBMSM.

METHODS

Using an online cross-sectional survey of Asian GBMSM in Australia, we measured condomless anal intercourse (CLAI) in the last 6months without PrEP or an undetectable viral load (UVL), i.e. CLAI with a risk of HIV transmission. Bivariable and multivariable logistic regression models were performed to compare demographic characteristics and social engagement of participants who had CLAI without PrEP or UVL to those who had not. Analyses were restricted to participants who reported sex with casual partners in the last 6months.

RESULTS

Among 509 participants who had casual partners in the last 6months, 151 (29.7%) reported CLAI without PrEP or UVL. CLAI without PrEP or UVL was negatively associated with full-time employment, and recently being tested for HIV and was positively associated with experiencing discrimination based on sexual orientation. Social engagement with LGBTQ+ people was not associated with CLAI without PrEP or UVL.

CONCLUSIONS

CLAI without PrEP or UVL was not related to social connections with LGBTQ+ people but was more likely among Asian men who had experienced sexuality-related discrimination, suggesting that mitigating homophobia and biphobia may assist in improving HIV prevention among Asian GBMSM who live in Australia.

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.

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.

Is HIV prevention creating new biosocialities among gay men? Treatment as prevention and pre-exposure prophylaxis in Canada

The advancements of "treatment as prevention" (TasP), "undetectable viral load" (UVL) and "pre-exposure prophylaxis" (PrEP) are redefining HIV prevention standards. Relying on the concept of biosociality, this article explores how gay men rally around, debate, and sometimes disagree about these emerging HIV prevention technologies. This article is based on data from the Resonance Project, a Canadian community-based research project. Twelve focus groups (totalling 86 gay and bisexual men) were held in three Canadian cities (Montreal, Toronto, Vancouver) in 2013-2014. Respondents view UVL and PrEP through the prism of their generational experience of HIV prevention. In this respect, biosocialities highlight an experiential dimension that is tied to the context of the HIV epidemic. The biosocialities of HIV prevention are also built around serological identities. However, our study shows the diversity of these positions. Analysis grounded in biosocialities is useful for better understanding how scientific information circulates, is made sense of, and generates debate among gay men.

Santo Domingo's LGBT social movement: At the crossroads of HIV and LGBT activism

The emergent Dominican LGBT movement in Santo Domingo, Dominican Republic, has been embedded in local and global structures and discourses related to HIV/AIDS, women's health, and identity. This article explores how ongoing sociocultural changes, increased international HIV funding, and elite support facilitated a surge of collective actions and the institutional reconfiguration of the movement. However, the entry of new cohorts of leaders and the alignment of leaders with global discourses of gender and human rights exposed some rifts within the movement, including over the framing of identity, confrontational tactics, and the role of health issues. While creating political opportunities, international HIV/AIDS funding also consolidated the social movement around HIV at the expense of other issues. The rapid consolidation of the LGBT movement towards HIV issues in the Dominican Republic raises questions about the role of international health funding and health-related NGOs on a movement's discourses, strategies, and consolidation, and about the recruitment of social movement leaders as public health professionals. I suggest that the trajectories of new movements, when social and political opportunities arise, are ultimately defined by their ability to bridge over generational and ideological rifts, engage in a broader spectrum of strategies, and embrace intersectional collective actions.

A Narrative Review of Internet Use, Interpersonal Connectedness, and Sexual Behaviour Among Gay, Bisexual and Other Men Who Have Sex With Men

Researchers have often considered the impact that online dating has had on gay communities; with some arguing that changes in social behavior may impact the spread of HIV. However, these conclusions are based on the premise that the Internet has fundamentally changed the way gay and bisexual men connect with their communities. Addressing this issue, we searched the PubMed and Web of Science databases for studies examining Internet use and interpersonal connectedness among gay and bisexual men to determine whether those who used the Internet to find sexual partners exhibited different patterns of community connectedness. Though sporadic, findings suggest that Internet use may be associated with lower gay identity, community attachment, and social embeddedness. However, recent reports have suggested that online sex seeking might be associated with greater, not less, interpersonal connectedness. We conclude that additional longitudinal analyses and consistent measurement of gay men's social behavior are needed to draw more definite conclusions.

'Top, bottom, versatile': narratives of sexual practices in gay relationships in the Cape Metropole, South Africa

Sexual practices among gay and other men who have sex with men are evolving in South Africa and heteronormative stereotypes are being contested. This paper draws from a larger qualitative study on how men construct a gay identity and negotiate their relationships within contemporary South African contexts, following constitutional and legal changes, in this respect. A feminist, social constructionist approach was used to collect and analyse data from in-depth interviews with 15 self-identified gay men, aged 20 to 46 years, drawn from a university in the larger Cape Metropole, South Africa. Interviews were audio-recorded, transcribed verbatim and analysed using thematic and narrative analysis. 'Bottoms' revealed being powerful in receptive sex. Other men deconstructed the binaries of masculine/feminine and resisted heteronormativity by engaging in fluid constructions in their relationships, whereby participants 'switched' or 'flipped' or did not recognise stereotypical roles when practising sex. There may be value in making these flexible and reciprocal sexual practices better known about and promoted as non-normative African models of sexual practice.

This is who we are: building community for HIV prevention with young gay and bisexual men in Beirut, Lebanon

Young gay men in Beirut are at significantly elevated risk of HIV infection compared with the general Lebanese population. Despite nascent HIV prevention efforts in the region, there is a need for effective community-level HIV prevention interventions tailored for young gay men. This qualitative study examined internal dynamics within Beirut's gay community as a basis for developing community-level interventions. Peer ethnographers were trained to collect field notes on conversations between young gay men in public spaces in Beirut, and conducted follow-up focus groups with young gay men. Analyses revealed three major themes: (1) the need for safe spaces in which to socialise, (2) the importance of being able to locate and connect with other young gay men, and (3) ambivalence regarding a gay community that was supportive in some ways but also fragmented and often judgemental. Study findings also confirm the existence of external threats to community such as stigma, cultural and familial norms regarding heterosexuality and criminalisation of refugee status. Understanding such community dynamics and the environmental context is central to designing effective community-based HIV prevention programmes.

Abjection. Objection. Subjection: rethinking the history of AIDS in Australian gay men's futures

In coining the term 'post-AIDS' some 20 years ago, I was noting the dissolution of a singular and unified experience of HIV and AIDS for gay communities that had been the case until that time. Not only were HIV-positive and HIV-negative gay men having increasingly different experiences, but divergent trajectories were opening up. Since then, many other factors have come into play, for example age and generation; the ascendancy of the biomedical and the technosexual; and the supremacy of neoliberal politics (including sexual politics). Now, if gay men are to survive as such - and there is a question about this - are there larger issues than HIV and AIDS that ought to command our attention? Or do we need to rethink how we situate HIV and AIDS within the larger framework of gay men's health and wellbeing. This might be just a question of politics, or it could be a question of theory. Are we finally returning to the original gay liberation agenda of the eradication of difference, or simply being traduced (seduced?) by our success at intimate citizenship?

HIV risk and sense of community: French gay male discourses on barebacking

This paper analyses the use of the concept of 'barebacking' as a risk category in the discourses of French gay men. It discusses how the rise and spread of the term barebacking contributes to reframing gay men's personal experiences of HIV prevention and their sense of belonging (or a lack thereof) to a gay community. The study is based on 30 qualitative interviews with French gay men conducted between 2005 and 2008. An import from the USA, the term barebacking emerged publicly in France in the late-1990s and was first used to describe intentionally unprotected sexual practices. Debates surrounding this risk category were marked by violent controversy over its use and its definition among HIV prevention actors. There remains a general lack of consensus on the definition of the term, despite its use by activists, in porn culture and in the daily discourses of gay men. By focusing on the relational roots of risk perception, I consider how uses of the term barebacking invoke a moral framework around risk taking.

Community Cleavages: Gay and Bisexual Men's Perceptions of Gay and Mainstream Community Acceptance in the Post-AIDS, Post-Rights Era

Changes in gay and bisexual men's connectedness to the gay community are related to the declining public visibility of HIV/AIDS and greater acceptance for homosexuality and bisexuality in mainstream society. Little work, however, has focused on perceived acceptance for subgroups within the gay community or broader society. Using interviews (n = 20) and a survey (n = 202) of gay and bisexual men in a mid-sized Canadian city, we find perceived hierarchies of acceptance for the various subgroups as well as an age effect wherein middle-aged men perceive the least acceptance for all groups. These differences are linked with the uneven impact of social, political, and institutional changes relevant to gay and bisexual men in Canada.

Social Marginalization and Internal Exclusion: Gay Men's Understandings and Experiences of Community

A total of 27 gay and bisexual men were interviewed about how they perceived the criminal prosecution of persons living with HIV who do not disclose their HIV status. The stories that emerged from the interviews raise questions about the nature of the gay community. The findings centre on the participants' descriptions of (1) the heterosexual meta-culture, (2) the locales of gay life, and (3) unsupportive elements in the gay community. Analysis of the interview data situates the gay community as a place of both inclusion and exclusion and as a heterogeneous environment.

Attitudes toward methamphetamine use and HIV risk behavior in men who have sex with men

BACKGROUND AND OBJECTIVES

Methamphetamine use has been strongly associated with high-risk sexual behaviors, and its use has been increasing among men who have sex with men (MSM). Although the behavioral implications of methamphetamine use and sexual risk have been broadly examined, fewer studies have examined attitudes about methamphetamine use.

METHODS

This study investigates the relationship between personal beliefs regarding methamphetamine use, patterns of use, and sexual risk behaviors within a sample of MSM attending a gay pride event (N= 342).

RESULTS

A minority of MSM reported lifetime (27%) or recent (7%) methamphetamine use. Only a minority of MSM who had used methamphetamine believed that it enhanced sexual pleasure (32%) or incorporated methamphetamine use into their sexual activity (31%). Individuals who used methamphetamine during sexual activity were more likely to be recent users of the drug and more likely to engage in high-risk behaviors. A significant minority of participants endorsed items assessing the disinhibiting effects of methamphetamine including being less likely to use a condom (35%) and less selective in their choice of partners (26%).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Results suggest that prevention efforts may benefit from targeting the minority of methamphetamine users who perceive methamphetamine as enhancing sexual activity and use it for this purpose.

Between individual agency and structure in HIV prevention: understanding the middle ground of social practice

When HIV prevention targets risk and vulnerability, it focuses on individual agency and social structures, ignoring the centrality of community in effective HIV prevention. The neoliberal concept of risk assumes individuals are rational agents who act on information provided to them regarding HIV transmission. This individualistic framework does not recognize the communities in which people act and connect. The concept of vulnerability on the other hand acknowledges the social world, but mainly as social barriers that make it difficult for individuals to act. Neither approach to HIV prevention offers understanding of community practices or collective agency, both central to success in HIV prevention to date. Drawing on examples of the social transformation achieved by community action in Australia and Brazil, this article focuses on this middle ground and its role in effective HIV prevention.

At the intersection of marginalised identities: lesbian, gay, bisexual and transgender people's experiences of injecting drug use and hepatitis C seroconversion

Although the levels of injecting drug use among lesbian, gay, bisexual and transgender (LGBT) populations are high, we know little about their experiences of injecting drugs or living with hepatitis C virus (HCV) infection. The loss of traditional family and cultural ties means connection to community is important to the well-being of LGBT populations. Although some kinds of drug use are normalised within many LGBT communities, injecting drug use continues to be stigmatised. This exploratory qualitative study of people with newly acquired HCV used semi-structured interviews to explore participants' understandings and awareness of HCV, seroconversion, testing, diagnosis and treatment. We present a secondary thematic analysis of eight LGBT participants of the experience of injecting drugs, living with HCV and having a marginalised sexual or gender identity. Community was central to the participants' accounts. Drug use facilitated connection to a chosen community by suppressing sexual or gender desires allows them to fit in to the mainstream; enacting LGBT community norms of behaviour; and connection through shared drug use. Participants also described feeling afraid to come out about their drug use to LGBT peers because of the associated stigma of HCV. They described a similar stigma associated with HIV within the people who inject drugs (PWID) community. Thus, the combination of being LGBT/living with HIV (a gay disease) and injecting drugs/living with HCV (a junkie's disease) left them in a kind of no-man's-land. Health professionals working in drug and HCV care services need to develop capacity in providing culturally appropriate health-care for LGBT PWID.

New pleasures and old dangers: reinventing male sex work

Understandings of male sex workers (MSWs) shift with technological, conceptual, and social changes. Research has historically constructed MSWs as psychologically unstable, desperate, or destitute victims and their clients as socially deviant perverts. These perceptions, however, are no longer supported by contemporary research and changing societal perceptions of the sex industry, challenging how we understand and describe "escorts." The changing understandings of sexuality and the increasing power of the Internet are both important forces behind recent changes in the structure and organization of MSWs. The growth in the visibility and reach of escorts has created opportunities to form an occupational account of MSWs that better accounts for the dynamic and diverse nature of the MSW experience in the early 21st century. Recent changes in the structure and organization of male sex work have provided visibility to the increasingly diverse geographical distribution of MSW, the commodification of race and racialized desire, new populations of heterosexual men and women as clients, and the successful dissemination of safer sexual messages to MSWs through online channels. This article provides a broad overview of the literature on MSWs, concentrating its focus on studies that have emerged over the past 20 years and identifying areas for future research.

The MaBwana Black men's study: community and belonging in the lives of African, Caribbean and other Black gay men in Toronto

In Canada, there is a paucity of research aimed at understanding Black gay men and the antecedents to risk factors for HIV. This study is an attempt to move beyond risk factor analysis and explore the role of sexual and ethnic communities in the lives of these men. The study utilized a community-based research and critical race theory approach. Semi-structured interviews were conducted with eight key informants to augment our understanding of Black gay men and to facilitate recruitment of participants. In-depth interviews were done with 24 Black gay men. Our data showed that the construction of community for Black gay men is challenged by their social and cultural environment. However, these men use their resilience to navigate gay social networks. Black gay men expressed a sense of abjuration from both gay and Black communities because of homophobia and racism. It is essential for health and social programmers to understand how Black gay men interact with Black and gay communities and the complexities of their interactions in creating outreach educational, preventive and support services.

Epistemic fault lines in biomedical and social approaches to HIV prevention

This paper raises the question of how knowledge creation is organized in the area of HIV prevention and how this concatenation of expertise, resources, at-risk people and viruses shapes the knowledge used to impede the epidemic. It also seeks to trouble the discourses of biomedical pre-eminence in the field of HIV prevention by examining the claim for treatment as prevention, looking at evidence constructed through the biomedical frame and through the lens of the sociology of science. These questions lie within a larger socio-historical context of lagging worldwide attention and funding to prevention in the HIV area and, in particular, neglect of populations at greatest risk. Much contemporary HIV prevention research relies on a population science divided over an epistemic fault line from the communities and individuals who must make sense of the intrusion of a life-threatening disease into their pursuit of pleasure and intimacy. There are, nevertheless, lessons to be learned from prevention success stories among sex workers, injection drug users, and gay and bisexual men. The success stories point to a need for a robust social science agenda that examines: the ways that people are socially organized and networked; the popular strategies and folk wisdoms developed in the face of HIV risk; socio-historical movement of sexual and drug cultures; the dynamics of popular mobilization to advance health; the institutional sources of HIV discourses; and popular understandings of HIV technologies and messages.

Gay men and ambivalence about 'gay community': from gay community attachment to personal communities

The concept of 'gay community', and gay men's attachment to and involvement in gay community activities, has held both a symbolic and practical role in understanding and guiding responses to HIV in developed world contexts. In the West, the HIV epidemic has disproportionately affected gay men. Being involved in and connected to gay community activities (what, in Australia, is described as 'gay community attachment') predicted the adoption of safe sex practices. However, the meaning of gay community is changing. This presents a challenge to those working in HIV prevention. With reference to previous research, the meaning of gay community is analysed in qualitative interviews conducted with Australian gay men. The interview data indicate that gay men are often ambivalent about gay communities, suggesting a need for subtlety in the ways we think about and address gay men in HIV education and health promotion. The concept of 'personal communities' may better reflect the ways in which gay men engage with each other and their social networks. Recognising and responding to the changing nature of gay life will ensure that the flexibility and pragmatism of HIV programmes aimed at gay men are maintained.

Contact with HIV prevention services highest in gay and bisexual men at greatest risk: cross-sectional survey in Scotland

BACKGROUND

Men who have sex with men (MSM) remain the group most at risk of acquiring HIV in the UK and new HIV prevention strategies are needed. In this paper, we examine what contact MSM currently have with HIV prevention activities and assess the extent to which these could be utilised further.

METHODS

Anonymous, self-complete questionnaires and Orasure™ oral fluid collection kits were distributed to men visiting the commercial gay scenes in Glasgow and Edinburgh in April/May 2008. 1508 men completed questionnaires (70.5% response rate) and 1277 provided oral fluid samples (59.7% response rate); 1318 men were eligible for inclusion in the analyses.

RESULTS

82.5% reported some contact with HIV prevention activities in the past 12 months, 73.1% obtained free condoms from a gay venue or the Internet, 51.1% reported accessing sexual health information (from either leaflets in gay venues or via the Internet), 13.5% reported talking to an outreach worker and 8.0% reported participating in counselling on sexual health or HIV prevention. Contact with HIV prevention activities was associated with frequency of gay scene use and either HIV or other STI testing in the past 12 months, but not with sexual risk behaviours. Utilising counselling was also more likely among men who reported having had an STI in the past 12 months and HIV-positive men.

CONCLUSIONS

Men at highest risk, and those likely to be in contact with sexual health services, are those who report most contact with a range of current HIV prevention activities. Offering combination prevention, including outreach by peer health workers, increased uptake of sexual health services delivering behavioural and biomedical interventions, and supported by social marketing to ensure continued community engagement and support, could be the way forward. Focused investment in the needs of those at highest risk, including those diagnosed HIV-positive, may generate a prevention dividend in the long term.