Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia

Factors associated with intention of HIV testing among Asian American men: a path analysis

Research has pointed to myriad cultural and socio-psychological factors associated with HIV testing, such as acculturation, social norms about HIV testing, masculinity, homonegativity, and constructs from the Theory of Planned Behavior. However, the interrelationships of these factors on the intentions of HIV testing among the population of Asian American men remains unknown. A dataset of 425 Asian American men in the U.S., collected online with convenience sampling method during 2020-2021, was analyzed to test a conceptual framework that aimed to fill this gap. Results from a path model with two endogenous variables (homonegativity and HIV testing intention) indicated that perceived social norms about HIV testing, attitude about HIV testing, and perceived HIV risk had directandindirect relationships with the intentions of HIV testing in the study population. However, social norms about HIV testing and perceived HIV risk showed stronger direct effects (standardized estimates = 0.37 and 0.34, respectively, p-value < 0.001). Additionally, we found that the relationships of these factors with HIV testing intention were also mediated by homonegativity. Findings from this study advance our understanding of pathways of associations between a host of cultural and socio-psychological factors with HIV testing intention among an understudied population - Asian American men. Our results will help inform the development of future intervention programs to increase HIV testing in this population.

Dyadic Moderators of the Minority Stress-HIV Risk Association in Male Couples

Minority stressors have been linked to HIV risk behaviors among gay, bisexual, queer, and other men who have sex with men (MSM). Committed partnerships are a key context for new HIV infections and coping with minority stress among MSM, but very little work has tested the minority stress-HIV risk link among male couples, and little is known about how processes within one's relationship may exacerbate or buffer this association. The present study examined links between minority stress (i.e., internalized stigma, microaggressions) and HIV transmission risk behaviors (i.e., condomless anal sex with outside partners, breaks in relationship agreements) among male couples, as well as relationship-based moderators (i.e., social support, dyadic coping) of these associations. An analytic sample of male couples from a large cohort study (analytic N = 410 individuals, 205 dyads) completed self-report measures of minority stress, relationship-based moderators, and HIV transmission risk behaviors which were submitted to moderated actor-partner interdependence models (APIMs). In many cases, coping with stress with one's partner buffered the minority stress-HIV transmission link risk. However, findings also suggested situations in which partners may overburden one another with coping, thus exacerbating HIV-related risk behaviors.

Reshaping the narrative: Tracing the historical trajectory of HIV/AIDS, gay men, and public health in Sweden

The human immunodeficiency virus (HIV) emerged as an endemic health crisis in the United States during the early 1980s. Initially labelled a "gay disease" due to its prevalence among gay men, the spread of HIV led to widespread fear and moral panic, as there was limited medical knowledge on preventing its transmission. While HIV is often associated with Sub-Saharan Africa, this article focuses on Sweden, a pioneering nation that became the first to achieve the remarkable Joint UNAIDS/WHO 90-90-90 continuum in addressing the epidemic. However, despite this significant milestone, the punitive legislation and attitudes prevalent in Sweden have had a counterproductive effect on curbing the virus's spread. Drawing upon a comprehensive triangulation of various data and sources on the evolution of public policy in Sweden, this article argues for the urgent need to reduce stigma surrounding HIV and AIDS. By undertaking further measures to combat stigmatisation, we not only have the potential to prevent the spread of HIV but also significantly enhance the quality of life for individuals living with the virus. An essential step in this journey is to eliminate the legally-enforced mandatory disclosure of one's HIV status, which would mark a tremendous victory for all those affected. With limited evidence to support the effectiveness of criminalisation and penal laws, no longer being viewed as criminals for non-disclosure would be a monumental achievement, positively transforming the lives of people living with HIV and fostering a more inclusive and supportive society.

Association of same-sex criminalisation laws and national HIV policies with HIV testing in African MSM: an ecological single-level and multilevel cross-sectional study of sub-Saharan African countries

BACKGROUND

HIV incidence among men who have sex with men (MSM) in sub-Saharan Africa (SSA) remains high compared with the general population. Many countries in the region still criminalise consensual homosexual relationships, and some are yet to adopt WHO-recommended interventions for MSM into national HIV policies. This study examines how HIV testing of adult MSM in SSA varies according to the legal climate and presence of targeted HIV policy using data from the cross-sectional 2019 Global LGBTI Internet Survey study.

METHODS

Using data from 3191 MSM in 44 SSA countries, we assessed associations of legal climate and HIV policy with ever and recent HIV testing using linear ecological and logistic multilevel analyses. From the single-level analysis, we can compare our findings to previously reported data, then, extending to a two-level multilevel analysis, we account for the hierarchical structure of the population and simultaneously adjust for differences in context and composition in each country. We then test the sensitivity of our analyses to excluding countries from the model.

RESULTS

We find evidence that legalised same-sex relationships were associated with increased odds of ever testing (OR=2.00, 95% CI 1.04, 3.82) in multilevel analyses. We also find evidence of an association of targeted HIV policies with increased odds of ever testing (OR=2.49, 95% CI 1.12, 5.52). We did not find evidence of an association of the legal climate (OR=1.01, 95% CI 0.69, 1.46) and targeted HIV policies (OR=1.26, 95% CI 0.78, 2.04) with recent testing.

CONCLUSIONS

This study suggests elimination of discriminatory laws and policies might be important for increasing HIV status awareness of MSM, an important first step in epidemic control. Additionally, we highlight heterogeneity between South Africa and other SSA countries, which has implications for studying SSA countries as a homogeneous group.

Is Internalised Homonegativity associated with HIV testing and HIV risk behaviours of men who have sex with men: a multilevel cross-sectional study of sub-Saharan African countries

OBJECTIVES

This study assessed the associations of Internalised Homonegativity (IH) with HIV testing and risk behaviours of adult men who have sex with men (MSM) in sub-Saharan Africa (SSA) and effect modification by the legal climate.

DESIGN

We used data from the cross-sectional 2019 Global Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI+) Internet survey study.

SETTING AND PARTICIPANTS

Overall, the 2019 Global LGBTI Internet Survey collected data from 46 SSA countries. In this secondary analysis, we included data from 3191 MSM in 44 SSA countries as there were no eligible MSM responses in the 2 countries excluded.

OUTCOME MEASURES

Our response variables were self-reported binary indicators of ever tested for HIV, recently tested in the past 6 months (from those who reported ever testing), transactional sex (paying for and being paid for sex in the past 12 months), and unprotected anal sex (that is without a condom or pre-exposure prohylaxis (PrEP)) with a non-steady partner (in the past 3 months).

RESULTS

Our findings showed high levels of IH (range 1-7) in MSM across SSA (mean (SD)=5.3 (1.36)). We found that MSM with higher IH levels were more likely to have ever (adjusted OR (aOR) 1.18, 95% CI 1.03 to 1.35) and recently tested (aOR 1.19, 95% CI 1.07 to 1.32) but no evidence of an association with paying for sex (aOR 1.00, 95% CI 0.89 to 1.12), selling sex (aOR 1.06, 95% CI 0.95 to 1.20) and unprotected sex (aOR 0.99, 95% CI 0.89 to 1.09). However, we observed that a favourable legal climate modifies the associations of IH and paying for sex (aOR 0.75, 95% CI 0.60 to 0.94). Increasing levels of IH had a negative association with paying for sex in countries where same-sex relationships are legal. We found no associations of IH with unprotected anal sex in the population surveyed.

CONCLUSIONS

We confirm that IH is widespread across SSA but in countries that legalise same-sex relationships, MSM were less likely to engage in transactional sex compared with those in countries where homosexuality is criminalised.

Prevention of HIV in the MSM Population: A Cultural-Historical Comparison of Sweden and the Netherlands

The aim of this article is to compare the cultural-historical events and decisions regarding how to deal with the higher risks of HIV in MSM, and more specifically, gay populations in Sweden and the Netherlands. A narrative literature was used, based on 46 scientific articles and 20 additional semi-scientific resources. The themes of the arrival of HIV and AIDS, blood donations, offender/victim, the balance of risks with respect to the statistical probabilities and the human factor, and finally, prevention were discussed. It is concluded that certain context-specific historical events (the Dutch Bloody Sunday and the Swedish gay sauna ban) and culturally determined processes (trust in others in the Netherlands, and disapproval of casual sex in Sweden) have led to some important differences in how HIV and AIDS and the higher risks for gay men and MSM have been dealt with. In the Netherlands, there is a stronger protective attitude when it comes to the freedom and autonomy of MSM both when it comes to decisions about sexual behavior and to sharing any positive HIV status. In Sweden, on the other hand, there is a stronger tendency to enforce informing others of their HIV status. In both countries, despite efforts to prevent this, HIV has increased stigma for gay men and other MSM.

Encouraging Parental Sexual Communication with Teen Sons: A Social Norms Experiment

Parent-child sexual communication is associated with myriad positive sex-related outcomes for young people, but these conversations tend to be infrequent and limited in scope. Using the Social Norms Approach, we hypothesized that learning that other parents talk with their children about sex-related topics would motivate parents to talk about more sex-related topics with their son. In an online experiment, parents in the United States (N = 378) with a son aged 13-16 were asked how many of 30 sex-related topics they had discussed with their son after exposure to one of the two SNA messages or a control. A 30-day follow-up study repeated these questions. The experiment revealed no significant differences between the three conditions, but all three conditions resulted in greater intentions to discuss more topics with their son in the future. Regardless of condition, parents who identify their sons as gay or bisexual talked about more sex-related topics than parents of sons who identify their sons as straight. The results from this study suggest that social norms messages are not more effective at increasing parents' communication intentions. Parents in all conditions planned to discuss more sex-related topics with their son, suggesting that simply bringing these topics to parents' attention may be enough to increase intentions to have these conversations. Findings are discussed in light of motivating and equipping parents to handle these conversations and tailoring educational materials for parents based on their child's sexual and romantic orientation.

Impact of Migration and Acculturation on Turkish Men Who Have Sex with Men in Germany: Results from the 2010 European MSM Internet Survey

To examine the impact of migration and acculturation of Turkish men who have sex with men (MSM) to Germany, using data from the European MSM Internet Survey (EMIS-2010), on measures of acculturation including circumcision status, internalized homonegativity (IH), HIV/STI knowledge, sexual orientation, outness, HIV-testing, and sexual behaviors. We compared four groups of MSM: MSM born and residing in Germany who had completed the questionnaire in German (n = 38,915), MSM born and residing in Germany, with a father or mother born in Turkey (n = 97), MSM residing in Germany who were born in Turkey or whose parents were born in Turkey (n = 262), and MSM who were born and residing in Turkey and who completed the questionnaire in Turkish (n = 1,717). Data showed that there were significant dose-response curves between level of migration and several outcome variables. As exposure to Germany increased, MSM had lower IH, higher HIV/STI knowledge, increased outness, and were less likely to be circumcised. There were similar significant findings with regard to sexual HIV risk behavior (condomless anal intercourse with partners of unknown (or sero-discordant) HIV status). Data were consistent with acculturation over generations in immigrant groups in MSM migrating from Turkey to Germany. Integration includes both cultural aspects (circumcision) and integration into a more homopositive gay environment (IH, outness, increased HIV/STI knowledge), and sexual HIV risk behavior. Migration and associated acculturation may constitute a risk change for HIV/STI and mental health issues associated with IH and outness.

"Today one partner, tomorrow another one, and no one is suspicious that you are gay": A Qualitative Study of Understanding HIV Related Risk Behavior Among MSM in Bosnia and Herzegovina

Men who have Sex with Men (MSM) are often exposed to stigma and discrimination, especially in developing countries. Discrimination might have an impact on their sexual behavior. The proportion of MSM among HIV positive persons is rising in Bosnia and Herzegovina (B&H). The aim of this qualitative study was to understand the country context and HIV-related risk behaviors among MSM in B&H. We found that MSM in B&H have a dominant fear of expressing their sexual orientation in the homophobic societal environment, including their own family. Disclosures are often connected with escalated family violence, followed by the silence and ignorance. The fear of being connected to one particular partner and being labeled as a gay lead to the need of "masking" their sexual orientation, and having sexual intercourse with non-steady sexual partners. Although most MSM were aware of the risk of HIV and other STIs, the fear of rejection and remaining alone, shapes their decisions to agree to have sex without condoms.

Internalized homophobia and HIV testing among Korean gay and bisexual men: a study in a high-income country with pervasive HIV/AIDS stigma

Limited research has been conducted on factors contributing to HIV testing among sexual minority populations in South Korea (hereafter, Korea), where stigma against homosexuality and HIV/AIDS is pervasive. We used a nationwide cross-sectional survey of 907 Korean cisgender gay and bisexual (GB) men who were HIV-negative or HIV-unknown in 2016. Regarding internalized homophobia (IHP), participants were categorized into tertiles (low, moderate, and high). Past 12-month HIV testing was assessed via a single yes/no question. Using a modified Poisson regression model, we examined the association between IHP and HIV testing among cisgender GB men in Korea. The overall prevalence of obtaining an HIV test was 41.8% among Korean cisgender GB men. We also found a statistically significant association between IHP and past 12-month HIV testing in this population. Specifically, participants with low IHP had a higher prevalence of HIV testing (adjusted PR = 1.37, 95% CI = 1.14-1.65) compared to those with high IHP. Given these findings, more efforts are needed in Korea to enhance GB men's access to HIV testing, such as improving social circumstances to lower IHP of GB men and creating an environment that enables and facilitates GB men to receive HIV testing without stigma against their sexual identity.

Correlates of Homonegativity Towards Men Who Have Sex With Men Among Black Individuals in the United States

This study aims to identify the factors that are associated with homonegativity toward men who have sex with men (MSM) within Black communities since the expansion of LGBTQ rights. A survey was completed in 2016 by a nationally representative sample of 868 Black respondents, 18-50 years old, via e-mail. Demographics, perception of same-gender sexual behaviors, religiosity, experienced racism, and contact with the carceral system (CS) were assessed. 61.6% of respondents endorsed at least one homonegative belief. Being male, residing in the South, attending religious services, receiving homonegative faith messaging, and having contact with the CS were significantly associated with homonegativity toward MSM while experiencing racism, older age, and residing in a non-metropolitan area were not. Education efforts on LGBTQ identities in Black communities should engage faith communities, extend to metropolitan and non-metropolitan areas of the South, and include younger and older adults. Programs that decrease the arrest of Black individuals may also help reduce homonegativity toward MSM.

Predictors of Uncertainty and Unwillingness to Receive the COVID-19 Vaccine in Men Who Have Sex with Men in France

The development of vaccines against COVID-19 has given hope to populations. Public acceptability of vaccination is a major driver in containing the disease. However, in marginalized and stigmatized populations, uncertainty and unwillingness may be a challenge. This study aimed to analyze the factors associated with uncertainty and unwillingness to vaccinate against COVID-19 in men who have sex with men (MSM) living in France. The data used came from Rapport au Sexe (ERAS) 2021, a voluntary, cross-sectional, anonymous, self-administered, online survey conducted from 26 February to 11 April 2021. Among the 15,426 respondents included in the analysis, 60.5% were willing to vaccinate (these included persons already vaccinated), 17.5% were not, and 22% were uncertain. Factors independently associated with uncertainty and unwillingness were lower education level, low health literacy level, financial hardship, being under 30 years of age, and living in a rural area. HIV-positive MSM were less likely to report vaccination uncertainty and unwillingness than HIV-negative MSM and those with unknown serostatus. Although more impacted by COVID-19, socioeconomically vulnerable MSM were the sub-group most unwilling to vaccinate. To improve acceptability of COVID-19 vaccination in MSM, policy makers and researchers must increase access to and understanding of medical information by considering the general public's health literacy when developing information sources. Moreover, a dedicated global care approach, which ensures these populations can be reached, is necessary.

Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men

Structural stigma shapes men who have sex with men's (MSM's) mental health and sexual behaviours. The aim of this study was to examine how stigmatizing policies interact with downstream anxiety/depression and sexual behaviours to structurally pattern HIV disparities among European MSM. We conducted a secondary data analysis of the European Men-who-have-sex-with-men Internet Survey (EMIS) from 2017. We included a total of 98,600 participants living in 39 European countries. We used the Rainbow Index, a score given to countries based on their sexual and gender minority policies as the predictor of HIV diagnosis. We conducted adjusted random intercept and slope multi-level logistic regressions. In adjusted models, higher Rainbow Index scores was associated with lower predictive probabilities of diagnosed HIV, regardless of the number of condomless intercourse partners. The predictive probability of HIV diagnosis was also lower, regardless of severity of anxiety/depression, where the Rainbow Index score was better. Country-level policies interact with downstream sexual behaviours and anxiety/depression to structurally influence HIV diagnosis among MSM in Europe.

Cultural adaptation and validation of a measure of prejudice against men who have sex with men among healthcare providers in western Kenya

Sexual prejudice toward men who have sex with men (MSM) is a pressing concern in sub-Saharan Africa (SSA). Given the high HIV infection risk among this population, sexual prejudice perpetuated by healthcare providers, affects access to and willingness of MSM to seek HIV care services. However, data on healthcare providers' attitudes towards MSM in SSA are limited, and there are no locally-adapted measures of sexual prejudice. We adapted a scale to measure sexual prejudice with a sample of 147 healthcare providers in western Kenya. Results from exploratory factor analysis revealed a single-factor structure. The scale demonstrated high internal consistency with Cronbach's α = 0.91. Healthcare providers who had prior interpersonal contact with MSM, had ever been trained on counselling MSM, and had higher knowledge about MSM health needs reported lower sexual prejudice scores, compared with peers who lacked these experiences (p < 0.001). In contrast, healthcare providers who had experienced secondary stigma (negative judgments from peers and community) for providing care to MSM reported higher scores of sexual prejudice scale (p < 0.001) compared with providers who had not experienced secondary stigma. The scale provides a contextualised tool to assess healthcare providers' attitudes toward MSM in Kenya and countries in SSA with similar cultural norms.

HIV Stigma, Homophobia, Sexual and Gender Minority Community Connectedness and HIV Testing Among Gay, Bisexual, and Other Men and Transgender People Who Have Sex with Men in Kazakhstan

Although HIV incidence is rising among gay, bisexual, and other men (MSM) and transgender people who have sex with men (TSM) in Kazakhstan, whether stigmatizing attitudes and connectedness are associated with HIV testing in this region is not known. We analyzed data from one-time interviews with 304 adult MSM and TSM conducted 2018-2019 in three cities in Kazakhstan. Logistic regression determined whether HIV stigma, internalized homophobia, sexual and gender minority (SGM) connectedness predicted HIV testing (within the lifetime, past year, and past 6 months) before and after adjustment for sociodemographic characteristics. 80% of participants reported ever receiving an HIV test. Gay-identified participants reported less HIV stigma and internalized homophobia as well as greater connectedness relative to those with bisexual or other identities. In adjusted models, those who had ever tested reported lower HIV stigma (aOR 0.83, 95% CI 0.76-0.91, P < .001) and higher connectedness (aOR 1.17, 95% CI 1.06-1.29, P = .003) than those who had not; those who had ever tested reported lower internalized homophobia in the unadjusted model only (OR 0.95, 95% CI 0.91-0.99, P = .01). Similar differences and trends were found in models examining testing in the past year and past 6 months. Addressing stigmatizing attitudes and connectedness may improve uptake of HIV testing among MSM and TSM in Kazakhstan.

Translation and validation in Brazilian Portuguese of the reactions to homosexuality scale

Internalized homonegativity results from the acceptance of negative attitudes about one's same-sex orientation, which has negative consequences for the health of gay, bisexual and other men who have sex with men (GBM). We translated the 7-item Reactions to Homosexuality Scale (RHS) to Brazilian Portuguese and assessed its factor structure, validity and reliability. The first step included the translation, back-translation, evaluation, peer review, and pre-testing of the scale. Then, we piloted the scale in two convenience samples of adult Brazilians recruited online during October 2019 and February to March 2020 through advertisements on Grindr and Hornet, respectively. The largest sample was randomly split into two groups for exploratory factor analysis (EFA) then confirmatory factor analysis (CFA). Criterion and construct validity were assessed via correlations between scale scores and study variables. A total of 5573 GBM (sample 1: 218; sample 2: 5355) completed the RHS. EFA (N = 2652) yielded two eigenvalues greater than one (Factor 1: 3.5 and Factor 2: 1.1). A one-factor solution provided the most interpretable model based on examination of scree plot and item factor loadings (χ2(14) = 1373.1, p < 0.001; CFI = 0.89; TLI = 0.84; RMSEA = 0.19; SRMS = 0.09). Though one-factor CFA showed moderate fit, freeing errors terms to covary, based on item content and interpretation, significantly improved model fit (χ2(12) = 309.1, p < .001; CFI = 0.97; TLI = 0.96; RMSEA = 0.09; SRMR = 0.02). As hypothesized, men who did not self-identify as gay (mean score 17.9 compared to those self-identifying as gay: 11.8) and men who reported no sex with men in the past 6 months (mean score 12.6 compared to those who reported sex with men: 10.6) scored higher reflecting higher internalized homonegativity. The RHS was effectively translated and validated in Brazilian Portuguese and can be used to evaluate the role of internalized homonegativity on GBM's health, as well as its impact on the uptake of HIV prevention technologies.

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.

Being in the Closet. Correlates of Outness Among MSM in 13 European Cities

Data for MSM continue to show a high risk of acquiring HIV-STIs. Within this population, outness seems to have an impact on both risk-taking and on health seeking behaviors. The objective of this study was to assess the relationship between socio-demographic, behavioral characteristics, testing behaviors, and outness level among MSM using data from a multi-center bio-behavioral cross-sectional study carried out in 13 EU cities. A multilevel analysis was conducted to identify factors associated with being open ("out") versus not being open ("in"). A total of 4,901 MSM were enrolled in the study and were classified as "out" in 71% of the cases. MSM "out" were more likely to report HIV testing and being reached by HIV prevention programs compared to MSM who were "in." The results confirm the key role of outness in relation to different healthy and risky behavior, ranging from testing to party-drug use.

Mapping the current knowledge in syndemic research applied to men who have sex with men: a scoping review protocol

INTRODUCTION

Men who have sex with men (MSM) are disproportionally affected by a number of health conditions that are associated with violence, stigma, discrimination, poverty, unemployment or poor healthcare access. In recent years, syndemic theory provided a framework to explore the interactions of these health disparities on the biological and social levels. Research in this field has been increasing for the past 10 years, but methodologies have evolved and sometimes differed from the original concept. The aim of this paper is to provide an overview of the existing literature on syndemic theory applied to MSM in order to identify knowledge gaps, inform future investigations and expand our understanding of the complex interactions between avoidable health conditions in a vulnerable population.

METHODS AND ANALYSIS

The proposed scoping review will follow the methodological framework developed by Arksey and O'Malley with subsequent enhancements by Levac et al, Colquhoun et al and Peters et al as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review. A systematic search of MEDLINE, PsycInfo, Scopus, Cochrane Central Register of Controlled Trials and ProQuest Sociological Abstracts will be conducted. Reference lists of the included studies will be hand-searched for additional studies. Screening and data charting will be achieved using DistillerSR. Data collating, summarising and reporting will be performed using R and RStudio. Tabular and graphical summaries will be presented, alongside an evidence map and a descriptive overview of the main results.

ETHICS AND DISSEMINATION

This scoping review does not require ethical approval. Data and code will be made accessible after manuscript submission. Final results will be disseminated through publication in a peer-reviewed journal and collaboration with grassroots Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+) organisations.

REGISTRATION

This protocol was registered on manuscript submission on the Open Science Framework at the following address: https://osf.io/jwxtd; DOI: 10.17605/OSF.IO/JWXTD.

Hepatitis C Screening in Community-Based Voluntary Counselling and Testing Services in Europe: An Observational Study from the COBATEST Network 2014-2018

The COBATEST Network links community-based voluntary counselling and testing (CBVCT) services in the European region and collects testing data using standardised data collection tools. This study aims to describe the population being screened for anti-HCV antibodies in the COBATEST Network and identify risk factors associated with a reactive HCV screening test result in the period 2014-2018. Clients aged > 16 screened for HCV in the period 2014-2018 at one of the Network's CBVCT services were included in the study. In the 5 year period, 7426 clients were screened for HCV in 22 centres in 10 countries and anti-HCV antibodies were detected in 113 (1.5%). The majority of people screened were aged 25-44, men who have sex with men (MSM), not HIV+ , not reporting a history of injecting drug use or sex work. Detection of anti-HCV antibodies was associated with being HIV + MSM (aOR 9.1, 95% CI 3.8; 21.8 compared to HIV-clients) and being a person who injects drugs (PWID, aOR 28.1, 95% CI 17.6; 45.0, compared to people with no history of injecting drug use). This study demonstrates that HIV-MSM with no history of injection drug use are using CBVCT services for HCV screening, but reactive screening test is associated with being HIV+ or PWID. The integration of HCV screening into the CBVCT service model may widen access to testing for populations that may otherwise not be tested.

Perceptions of Protection under Nondiscrimination Law

Nondiscrimination rules-statutes, regulations, and soft law protections-are critical for reducing health and health care disparities. Although scholarship has interrogated how nondiscrimination rules affect behavior by discriminators, comparatively little has considered how protections can affect choices made by members of protected groups. A number of states and some interpretations of federal law protect people from discrimination on the basis of sexual orientation. This Article seeks to identify relationships between actual state law, perceived state law, and experiences of discrimination and medical mistrust. This Article reports the results of a national cross-sectional survey of over 3,000 men using Grindr to meet male partners. Participants scored comparable to chance in knowledge about state nondiscrimination protections, with "optimistic errors" (erroneous beliefs that one was protected) significantly more common than pessimistic errors. Perceptions of protection were significantly correlated with lower medical mistrust and greater uptake of care, as well as lower perceived barriers to disclosure and care-seeking. Actual state law protections, however, were significant predictors of having had discussions with providers that depended on disclosure of sexual behavior or orientation. Building on these results, this Article considers pathways by which nondiscrimination law may exert welcome mat (and "unwelcome mat") effects.

Interface of Internalized Homophobia and Community Connectedness on Frequency of Doctor's Visits for Rural and Urban MSM in Oklahoma

PURPOSE

Men who have sex with men (MSM) face persistent risk of stigma, with past studies showing unequal treatments of MSM in health care settings. Contextual factors, such as internalized homophobia and connectedness to one's community, have shown to serve as a barrier or facilitator (respectively) with regard to MSM's decisions to seek preventative treatment. These studies, however, predominately feature urban populations, with less consideration given to rural MSM. The current study comparatively investigates these contextual factors between rural and urban MSM to detect differences in the frequency of doctor's visits.

METHODS

A 2-by-2 (rural/urban × doctor visit yes/no) multivariate analysis of variance (MANOVA) was conducted to investigate if significant differences and/or interactions existed for internalized homophobia and community connectedness.

FINDINGS

Results show a significant interaction between rurality and doctor's visits in our sample of predominantly white, self-identified gay men. Higher levels of internalized homophobia and lower levels of community connectedness were seen in rural individuals who had visited a doctor in the past 12 months and in urban individuals who had not seen a doctor in the past 12 months.

CONCLUSIONS

Study findings have implications for future public health research and for health promotion interventions, practices, and policies for MSM in rural areas. Social exclusion reinforces the invisibility of lesbian, gay, bisexual, and transgender (LGBT) populations, particularly in rural areas. Stigma and marginalization of MSM promote structural barriers inhibiting care. Our results give evidentiary support for programs which inform the work of clinicians on mechanisms to create LGBT-inclusive practice settings.

Are men who have sex with men in Europe protected from hepatitis B?

Hepatitis B vaccination is recommended for men who have sex with men (MSM) in many countries, but information on vaccine coverage is scarce. We studied hepatitis B vaccination programmes and coverage among MSM in Europe to guide prevention. From a large (N = 174 209) pan-European MSM survey (EMIS-2010), we used data on self-reported hepatitis B vaccination, age, education, settlement size and disclosure of the same-sex sexual orientation ('outness'). We excluded participants with a history of hepatitis B. In multilevel (participants, countries) logistic regression models, we calculated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). We analysed data of 163 987 MSM in 38 European countries: 38.3% were 'out' to all or almost all, 56.4% reported vaccination against hepatitis B and 65.5% lived in countries with free recommended hepatitis B vaccination for MSM. In the final model the odds for being vaccinated increased with outness ('out to all or almost all': aOR 1.76, 95% CI 1.70-1.83 vs. 'out to no one') and with living in countries, where hepatitis B vaccination was recommended and free-of-charge for MSM (aOR 2.21, 95% CI 1.47-3.32 vs. 'no or unclear recommendation'). To increase hepatitis B vaccination coverage among MSM, implementation of MSM-specific recommendations and improvement of the societal climate for MSM is needed.

Lack of HIV testing and dissatisfaction with HIV testing and counselling among men having sex with men in Hungary

Background

Using data from a large internet-based survey of European men having sex with men (MSM), we assessed factors associated with HIV testing and reasons for dissatisfaction with HIV testing and counselling among Hungarian MSM.

Methods

A total of 2052 Hungarian MSM provided evaluable data for the European MSM Internet Survey (EMIS) in 2010. χ2 tests and Poisson regression with a robust variance estimator were used to assess factors associated with HIV testing and dissatisfaction with HIV testing and counselling.

Results

A total of 42.1% of MSM reported never being testing for HIV. Over one-half of men (54.1%) who reported condomless anal intercourse (CAI) in the prior 12 months with a person of unknown or sero-discordant HIV status reported no lifetime HIV testing. The factor most strongly associated with dissatisfaction with HIV testing and counselling was test site with increased dissatisfaction with inpatient hospital settings vs. community-based organizations. Both lack of HIV testing and dissatisfaction with testing were independently associated with MSM who reported that no one, or only a few people, knew they were attracted to men.

Conclusions

Lack of HIV testing was strongly associated with CAI. MSM reported that community-based organizations better supported confidentiality and were more respectful during HIV testing.

Discovering thematic change and evolution of utilizing social media for healthcare research

Background

Social media plays a more and more important role in the research of health and healthcare due to the fast development of internet communication and information exchange. This paper conducts a bibliometric analysis to discover the thematic change and evolution of utilizing social media for healthcare research field.

Methods

With the basis of 4361 publications from both Web of Science and PubMed during the year 2008–2017, the analysis utilizes methods including topic modelling and science mapping analysis.

Results

Utilizing social media for healthcare research has attracted increasing attention from scientific communities. Journal of Medical Internet Research is the most prolific journal with the USA dominating in the research. Overly, major research themes such as YouTube analysis and Sex event are revealed. Themes in each time period and how they evolve across time span are also detected.

Conclusions

This systematic mapping of the research themes and research areas helps identify research interests and how they evolve across time, as well as providing insight into future research direction.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0757-4) contains supplementary material, which is available to authorized users.

Prevalence and correlates of lifetime and recent HIV testing among men who have sex with men (MSM) who use mobile geo-social networking applications in Greater Tokyo

Men who have sex with men (MSM) are disproportionately burdened by the human immunodeficiency virus (HIV), accounting for 78% of all Japanese male HIV cases in 2016. Over 30% of newly identified HIV infections in Japan are diagnosed as AIDS annually, suggesting a large proportion of people living with HIV were unaware of their own infection status. An estimated two-thirds of Japanese men who have sex with men (MSM) are not attached to the gay community, and previous studies have largely sampled gay venues, thus, previous studies have likely failed to reach many men in this population. This study therefore examined HIV testing prevalence and correlates among MSM in Greater Tokyo who use gay mobile geo-social networking applications (gay mobile apps), which have been found to increase access to MSM not traditionally accessible through venue-based surveys. Among a sample of 1657 MSM recruited through advertisements on gay mobile apps, the prevalence of lifetime and six-monthly HIV testing was 72.8% and 29.7% respectively. In multiple regression analysis, higher lifetime HIV testing was associated with older age, education, HIV knowledge, anal intercourse with regular and casual male partners, and gay venue attendance. Testing was negatively associated with regular male partner condom use, marriage, residing outside central Tokyo and having both male and female partners. These results indicated that MSM who use gay mobile apps in Greater Tokyo do not meet the CDC yearly testing recommendations for high risk populations. Considering limited HIV prevention funding in Japan for MSM, moderate lifetime and recent testing, and the large number of gay mobile app users, utilization of popular gay mobile apps to promote nearby HIV testing facilities may be an effective prevention policy to target non-community attached MSM, particularly at-risk youth and individuals at risk of sudden-onset AIDS.

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.

Measurements of Sexuality-Based Stigma among Gay, Bisexual, and Other Men Who Have Sex with Men (GBMSM) in Resource-Poor Settings: A Review

Gay, bisexual, and other men who have sex with men (GBMSM) in resource-poor settings are disproportionately affected by the HIV/AIDS epidemic. GBMSM living in these settings may face unique barriers to HIV prevention, including legal barriers and increased sexuality-based stigma. It is therefore imperative to tailor HIV prevention and care resources to recognize the lived realities of GBMSM in these settings. Central to this is the accurate measurement of sexuality-based stigma. However, there is wide inconsistency in how sexuality-based stigma is measured among GBMSM in resource-poor settings. This paper reviews recent studies of sexuality-based stigma among GBMSM in resource-poor settings, finding great variability in measurements. The results of the review call for greater attention to the development of contextually and culturally specific measures of sexuality-based stigma for GBMSM living in resource-poor settings.

Structural Validation and Multiple Group Assessment of the Short Internalized Homonegativity Scale in Homosexual and Bisexual Men in 38 European Countries: Results From the European MSM Internet Survey

Internalized homonegativity (IH) is the internalization of negative attitudes and assumptions about homosexual people by homosexual people themselves. To measure IH, Smolenski, Diamond, Ross, and Rosser (2010) and Ross, Rosser, and Smolenski (2010) revised the Reactions to Homosexuality Scale (RHS) to develop the Short Internalized Homonegativity Scale (SIHS) with eight items. Using the European Men Who Have Sex With Men Internet Survey (EMIS) data, with an analytic sample of 130,718 gay and bisexual men in 38 European countries, we confirmed the validity of the SIHS scale in both training and validation data, in strata of Ross, Berg, et al.'s (2013) three "homosexual discrimination" country clusters, of age, and of education level. However, the performance was less adequate in comparison of gay versus bisexually identified individuals. The latent SIHS structure contains only minor variations across these three strata. The seven-item scale performed as well as the eight-item scale. The SIHS is a promising candidate for standard IH measures, which is invariant across cultural, age, and educational strata.

Sexual Stigma Patterns Among Nigerian Men Who Have Sex with Men and Their Link to HIV and Sexually Transmitted Infection Prevalence

Sexual stigma facilitates the spread of HIV and sexually transmitted infections (STIs) but little is known about stigma affecting Nigerian men who have sex with men (MSM). We assessed patterns of sexual stigma across Nigerian MSM and their relationship to HIV and STIs. Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 Nigerian MSM enrolled from March 2013 to February 2016 using respondent driven sampling. Structural equation modeling was utilized to assess the association between stigma classes and HIV and STI prevalence, adjusting for participants' characteristics. A dose-response association was found between stigma class and HIV prevalence (27, 40, 55%, overall χ² p < 0.001) and STI prevalence (15, 21, 24%, overall χ² p = 0.011). These data suggest that stigma mitigation strategies, combined with increased engagement of MSM and retention in the HIV care continuum, need to be a component of interventions focused on reducing HIV transmission risks among MSM in Nigeria.

Syndemics of stigma, minority-stress, maladaptive coping, risk environments and littoral spaces among men who have sex with men using chemsex

There has been a steep rise in the use of drugs during sex (chemsex) by some men who have sex with men in economically developed countries, with associated increases in sexual risk for HIV and other STIs. This paper presents data from telephone interviews with 15 men attending sexual health clinics for post-exposure prophylaxis following a chemsex-related risk for HIV and discusses some of the theoretical approaches that have been employed to understand chemsex and inform interventions. Interviews were conducted as part of a larger intervention study, which used an adapted version of motivational Interviewing to explore risk behaviour and support change. Participants conceptualised their chemsex and HIV-related risks in a psycho-social context, highlighting the influences of psycho-socio-cultural challenges of homophobic marginalisation and the 'gay scene' on behaviour. Multiple influences of stigma, marginalisation, minority stress and maladaptive coping (including drug-use) contribute to syndemic 'risk-environments' and 'littoral spaces' in which chemsex and risk behaviours are played out.

Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review

Background

Stigma involves discrediting a person or group based on a perceived attribute, behaviour or reputation associated with them. Sex workers (SW) and men who have sex with men (MSM) are key populations who are often at increased risk for the acquisition and transmission of HIV and who are affected by stigma that can negatively impact their health and well-being. Although stigma was included as an indicator in the US National HIV/AIDS Strategic Plan and there have been consultations focused on adding a stigma indicator within PEPFAR and the Global Fund in relation to potentiating HIV risks among key populations, there remains limited consensus on the appropriate measurement of SW- or MSM-associated stigma. Consequently, this systematic review summarizes studies using quantitative, qualitative, or mixed methods approaches to measure stigma affecting sex workers and men who have sex with men.

Methods and findings

This systematic review included English, French, and Spanish peer-reviewed research of any study design measuring SW- or MSM-associated stigma. Articles were published from January 1, 2004 to March 26, 2014 in PsycINFO, PubMed, EMBASE, CINAHL Plus, Global Health, and World Health Organization Global Health Library Regional Indexes.

Of the 541 articles reviewed, the majority measured stigma toward MSM (over 97%), were conducted in North America, used quantitative methods, and focused on internalized stigma.

Conclusions

With the inclusion of addressing stigma in several domestic and international HIV strategies, there is a need to ensure the use of validated metrics for stigma. The field to date has completed limited measurement of stigma affecting sex workers, and limited measurement of stigma affecting MSM outside of higher income settings. Moving forward requires a concerted effort integrating validated metrics of stigma into health-related surveys and programs for key populations.

Pathways from sexual stigma to incident HIV and sexually transmitted infections among Nigerian MSM

OBJECTIVES

Sexual stigma affecting MSM in Nigeria may be an important driver of HIV and other sexually transmitted infections (STIs), but potential mechanisms through which this occurs are not well understood. This study assessed the contributions of suicidal ideation and sexual risk behaviors to causal pathways between stigma and HIV/STIs.

DESIGN

Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 MSM from Abuja and Lagos, Nigeria.

METHODS

Participants enrolled from March 2013 to February 2016 were classified into three stigma subgroups based on a latent class analysis of nine stigma indicators. Path analysis was used to test a model where disclosure led to stigma, then suicidal ideation, then condomless sex with casual sex partners, and finally incident HIV infection and/or newly diagnosed STIs, adjusting the model for age, education, having had female sex partners in the past 12 months, and sex position. Both direct and indirect (mediational) paths were tested for significance and analyses were clustered by city.

RESULTS

As stigma increased in severity, the proportion of incident HIV/STI infections increased in a dose-response relationship (low: 10.6%, medium: 14.2%, high 19.0%, P = 0.008). All direct relationships in the model were significant and suicidal ideation and condomless sex partially mediated the association between stigma and incident HIV/STI infection.

CONCLUSION

These findings highlight the importance of the meaningful integration of stigma-mitigation strategies in conjunction with mental health services as part of a broader strategy to reduce STI and HIV acquisitions among Nigerian MSM.

Correlates of condomless anal sex among men who have sex with men (MSM) in Tijuana, Mexico: The role of public sex venues

Condomless anal sex between male partners is the primary risk factor for HIV transmission among men who have sex with men (MSM). Correlates of condomless anal sex have been well-studied in developed countries, but they have received less attention in lower-to-middle income countries (LMIC), where MSM are often subject to stigma, discrimination, intolerance, and even the criminalization of same sex behavior. In Mexico, a LMIC where traditional views on homosexuality are common, HIV prevalence among MSM is high (16.9%), yet little research has been conducted on the correlates of condomless anal sex in this high-risk population. The present study examined correlates of condomless anal sex among 201 MSM recruited in Tijuana, Mexico, with a focus on the role of public sex venues in relation to sexual risk behavior. Eligibility requirements were: biologically male, 18 years of age or older, resident of Tijuana, and self-reported anal or oral sex with a male partner in the past year. Participants completed an interviewer-administered, demographic and psychosocial survey, and were tested for HIV and syphilis. A hierarchical multiple linear regression model was tested to identify correlates of condomless anal sex. Thirty-eight percent of participants (N = 76) reported condomless anal sex with a male partner in the past 2 months. Higher levels of condomless anal sex were associated with higher levels of depressive symptoms, greater sexual compulsivity, and more frequent seeking out of sex partners in a public venue in the past 2 months. In view of these findings, we recommend the development of multi-level, “combination” interventions, which in the Mexican context should include enhanced condom promotion and distribution, improved availability and access to mental health treatment and counseling services, and expanded HIV/STI testing in public venues.

The Geography of Sexual Orientation: Structural Stigma and Sexual Attraction, Behavior, and Identity Among Men Who Have Sex with Men Across 38 European Countries

While the prevalence of sexual identities and behaviors of men who have sex with men (MSM) varies across countries, no study has examined country-level structural stigma toward sexual minorities as a correlate of this variation. Drawing on emerging support for the context-dependent nature of MSM's open sexual self-identification cross-nationally, we examined country-level structural stigma as a key correlate of the geographic variation in MSM's sexual attraction, behavior, and identity, and concordance across these factors. Data come from the European MSM Internet Survey, a multi-national dataset containing a multi-component assessment of sexual orientation administered across 38 European countries (N = 174,209). Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes toward sexual minorities held by the citizens of each country. Results demonstrate that in more stigmatizing countries, MSM were significantly more likely to report bisexual/heterosexual attractions, behaviors, and identities, and significantly less likely to report concordance across these factors, than in less stigmatizing countries. Settlement size moderated associations between country-level structural stigma and odds of bisexual/heterosexual attraction and behavior, such that MSM living in sparsely populated locales within high-structural stigma countries were the most likely to report bisexual or heterosexual behaviors and attractions. While previous research has demonstrated associations between structural stigma and adverse physical and mental health outcomes among sexual minorities, this study was the first to show that structural stigma was also a key correlate not only of sexual orientation identification, but also of MSM's sexual behavior and even attraction. Findings have implications for understanding the ontology of MSM's sexuality and suggest that a comprehensive picture of MSM's sexuality will come from attending to the local contexts surrounding this important segment of the global population.

'The Devil has entered you': A qualitative study of Men Who Have Sex With Men (MSM) and the stigma and discrimination they experience from healthcare professionals and the general community in Bosnia and Herzegovina

Men who have sex with men (MSM) are often exposed to unequal treatment in societies worldwide as well as to various forms of stigma and discrimination in healthcare services. Bosnia and Herzegovina (B&H) is a postconflict developing country located in Southeast Europe and the Western Balkans, where little is known about the experiences of MSM regarding their communities and interactions with healthcare services. The aim of this study was to explore the types of experiences MSM face and to assess the level of stigma and discrimination they are exposed to in this setting. We conducted twelve in-depth face-to-face interviews with MSM who were 16 to 45 years old and residing in B&H. The main findings indicated that they all experienced various levels of stigma, discrimination, prejudice and inequities in treatment and attitudes from different segments of society, including the health care sector, that prevented them from fully developing their human and health potential. Additionally, these experiences were adversely related to opportunities to receive good quality health care services due to the insufficiently educated and old-fashioned health professionals who sometimes believed in black magic practices. The findings present numerous opportunities for educational trainings and structural reform to create a society that provides and guarantees equal opportunities for all.

Cross-cultural and socio-demographic correlates of homophobic attitude among university students in three European countries

PURPOSE

The aim of this study was to investigate homophobic attitudes in three European countries: Italy, Albania, and Ukraine. One thousand and forty-eight students were recruited in Italian (n = 766), Albanian (n = 180), and Ukrainian (n = 102) university centers.

METHODS

A socio-demographic questionnaire and Homophobia Scale (HS) were administered by our staff.

RESULTS

Cross-cultural and significant differences among Italian, Albanian, and Ukrainian students were found on the Homophobia Scale (HS; Italy: mean = 22.26 ± 16.73; Albania: mean = 38.15 ± 17.28; Ukraine: mean = 59.18 ± 16.23). The analysis of socio-demographic characteristics revealed that the male gender emerged as main predictor of homophobic attitude in all the three countries, although also a conservative political orientation and the religious belief predict higher homophobia levels in Italy and Albania, particularly.

CONCLUSIONS

This study revealed that in these European countries assessed, attitudes toward homosexuality are different. Ukrainians display higher levels of homophobia than Albanians and Italians, confirming the central role of cultural differences in homophobic attitudes. Nevertheless, some socio-demographic aspects such as identification as male have a similar influence on homophobic attitudes in all assessed populations.

Mental health in 2020 for men who have sex with men in the United States

Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond.

Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR?

BACKGROUND

Gay men and other men who have sex with men are disproportionately burdened by HIV infection. Laws that penalize same-sex intercourse contribute to a cycle of stigma, homonegativity and discrimination. In many African nations, laws criminalizing homosexuality may be fueling the epidemic, as they dissuade key populations from seeking treatment and health care providers from offering it.

OBJECTIVES

We analyzed the ways in which policies and practices of the US President's Emergency Plan for AIDS Relief (PEPFAR) program addressed pervasively harsh anti-homosexuality laws across Africa. Given the aim of the US PEPFAR program to reduce stigma surrounding HIV, we explored how PEPFAR may have used its influence to reduce the criminalization of homosexuality in the countries where it operated.

METHODS

We assessed homosexuality laws in 21 African countries where PEPFAR funding sought to reduce the HIV epidemic. We examined PEPFAR Policy Framework agreements associated with those countries, and other PEPFAR documents, for evidence of attempts to reduce stigma by decriminalizing homosexuality.

RESULTS

We found 16 of Africa's 21 PEPFAR-funded countries had laws characterized as harsh in relation to homosexuality. Among the top eight PEPFAR-funded countries in Africa, seven had harsh anti-homosexuality laws. Most (14) of the 16 African 'Partnership Framework' (PEPFAR) policy agreements between African governments and the US State Department call for stigma reduction; however, none call for reducing penalties on individuals who engage in homosexual behavior.

CONCLUSIONS

We conclude that while PEPFAR has acknowledged the negative role of stigma in fueling the HIV epidemic, it has, so far, missed opportunities to explicitly address the role of the criminalization of homosexuality in feeding stigmatizing attitudes. Our analysis suggests mechanisms like PEPFAR Partnership Framework agreements could be ideal vehicles to call for removal of anti-homosexuality legislation.

Sexual identity and behavior in an online sample of Indian men who have sex with men

Indian men who have sex with men are disproportionately impacted by HIV. While prevention efforts to date have focused on men who visit drop-in centers or physical cruising sites, little is known about men who are meeting sexual partners on virtual platforms. This paper explores issues related to sexual identity and sexual behaviors in an online sample of men who identified as gay (n = 279) or bisexual (n = 123). There were significant differences in outedness between the two groups, with 48% of bisexually identified men reporting that they were out to "no one" and 82% stating that they present themselves as heterosexual to family and friends. Corresponding rates for gay-identified men were 15% and 41%, respectively (both p < .001). Twenty-nine percent of bisexually identified men reported being married, compared to only 3% of the gay-identified men (p < .001). Bisexually identified men were also more likely to report having exclusively insertive anal sex (49% vs 30% p < .001), while gay-identified men were more likely to report exclusively receptive anal sex (41% vs 13% p < .0001). Rates of unprotected anal sex (UAS) in the two groups were similar; however, married men were significantly more likely to report unprotected vaginal sex (76% vs 35%, p < .012). Positive attitudes toward UAS and lower self-efficacy were associated with sexual risk in both groups; however, substance use was associated with sexual risk only among bisexually identified men. These findings show that a large proportion of Indian bisexually identified men lead closeted lives, especially in their interactions with friends and family, with the vast majority presenting as heterosexual. The lower condom use with wives may be due to societal pressures to have children. The results suggest that bisexually identified men may benefit from targeted programs and non-directive, non-judgmental individual or couples counseling which emphasizes condom use with both male and female partners.

The Prevalence and Correlates of HIV and Undiagnosed Infection among Men Who Have Sex with Men in Hanoi, Vietnam: Findings from a Cross-sectional, Biobehavioral Study

INTRODUCTION

Men who have sex with men (MSM) are a key population for HIV infection in Vietnam, and the use of amphetamine type substances (ATS) is prevalent and possibly increasing in this population. The reported analysis examines the association between ATS use before or during sex and HIV infection among MSM in Hanoi, Vietnam.

METHODS

This cross-sectional study of 210 MSM was conducted in Hanoi, Vietnam, in late 2014. Men tested for HIV and answered questions about demographic characteristics, sexual sensation seeking, depression, belief in HIV prevention strategies, homosexuality-related stigma and discrimination, recent accessing of HIV prevention services, sexual behaviors and ATS, and other drug use behaviors. We performed logistic regression to assess correlates of HIV infection.

RESULTS

HIV prevalence was 6.7% (14/210), and 85.7% (12/14) of HIV-positive men were not aware of their HIV status. Of the 210 participants, 10.5, 2.9, and 3.8% of men had used methamphetamine, amphetamine, and ecstasy before or during sex in the last 3 months. In multivariable analysis, HIV infection was associated with recent sex-related methamphetamine use [adjusted odds ratio (AOR): 5.03, 95% confidence interval (CI): 1.35-18.68], engaging in recent sex work (AOR: 3.55, 95% CI: 1.07-11.75), and homosexuality-related perceived stigma (AOR: 2.32, 95% CI: 0.98-5.47).

CONCLUSION

Findings underscore the importance of integrating methamphetamine use interventions into HIV prevention services and scaling-up of gay-friendly, non-stigmatizing HIV testing services for MSM in Hanoi. We recommend the routine assessment of ATS use and undiagnosed infection in this population.

Associated factors of self-reported psychopathology and health related quality of life among men who have sex with men (MSM) with HIV/AIDS in Dalian, China: a pilot study

Background

Despite the availability of Anti-Retroviral Therapy (ART), the health-related quality of life (HRQoL) among HIV-positive men who have sex with men (HIVMSM) in China remains poor. This study aimed to explore the relationship between self-reported psychopathology and HRQoL among HIVMSM in Dalian, China.

Methods

A cross-sectional study was conducted in 112 HIVMSM. Symptom check list 90 (SCL 90): a measure of psychopathology and World Health Organization quality of life in HIV infection (WHOQOL-HIV-Bref): a measure of HRQoL were used. Correlation and multiple regression analysis were employed to explore the association between self-reported psychopathology and HRQoL in HIVMSM.

Results

Out of the total 112 HIVMSM cases, 9 (8 %) cases were homosexuals and 103 (92 %) ones were bisexuals. The participants who had low family income (P = 0.001), perceived discrimination (P = 0.001) and lack of regular attendance in medical follow-ups (P = 0.014) reported poorer HRQoL than their counterparts. Somatization, obsession, depression, phobia and overall SCL 90 scores in self-reported psycholpathology had a negative impact on the domains of HRQoL among HIVMSM.

Conclusions

Total quality of life was predicted by family income, perceived discrimination, and medical follow-up attendance. Self-reported psychopathology was negatively correlated with HRQoL in HIVMSM. The Strategies that target MSM focusing on linking and engaging HIV-positive patients in medical care is the key step to improve their HRQoL. More emphasis is needed on the newly diagnosed HIVMSM in Dalian in order to develop a more targeted intervention to prevent perceived discrimination and lack of proper medical follow-up services.

Trial registration

The trial registration number does not require for this manuscript. The study is cross-sectional design that do not involve intervention at all, it is not a clinical trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0204-z) contains supplementary material, which is available to authorized users.

Collective Self-Esteem and Depressive Symptomatology in Lesbians and Gay Men: A Moderated Mediation Model of Self-Stigma and Psychological Abuse

The context of stigma, in which lesbians and gay men live in most countries, exposes them to possible discrimination and promotes the internalization of negative attitudes about their own sexual orientation, which may have negative consequences for their mental health. Their psychological distress may increase when lesbians and gay men are exposed to other sources of stress such as intimate partner violence. With the aim of analyzing the relationship between these variables, this study intends to present a moderated mediation model that proposes: (a) self-stigma mediates the relationship between private collective self-esteem and depressive symptomatology; (b) receiving psychological abuse within same-sex couples moderates the relationship between self-stigma and depressive symptomatology. For this purpose we conducted an online survey with a sample of 357 Spanish lesbians and gay men. Our findings show that self-stigma mediates the relationship between private collective self-esteem and depressive symptomatology. Furthermore, participants who had higher levels of self-stigma and received more psychological abuse by the partner showed stronger negative effects on depressive symptomatology. Theoretical and practical implications are discussed.

HIV and STI Testing and Related Factors Among Men Who Have Sex with Men in Estonia

HIV and sexually transmitted infections (STI) testing rates among men who have sex with men (MSM) in Estonia are low. We collected data from 265 MSM in a national, online survey. Lifetime HIV testing was related to risky sexual behaviors and contacts with health care services, while lifetime STI testing was related only to contacts with health care services. In addition, some personal values were significant predictors of testing. For example, high achievement (personal success through demonstrating competence according to social standards) had a negative impact on lifetime HIV testing, and high interpersonal conformity (avoiding upsetting others) had a negative impact on lifetime STI testing. The results demonstrate the need to develop gay-friendly health services and to recognize the role of personal values and individual differences in values when designing attractive interventions to increase HIV/STI testing rates among MSM.

COBA-Cohort: a prospective cohort of HIV-negative men who have sex with men, attending community-based HIV testing services in five European countries (a study protocol)

INTRODUCTION

Community-based voluntary counselling and testing (CBVCT) services for men who have sex with men (MSM) can reach those most-at-risk and provide an environment for gay men that is likely to be non-stigmatising. Longitudinal data on the behaviour of HIV-negative MSM are scarce in Europe. The aim of this protocol, developed during the Euro HIV Early Diagnosis And Treatment (EDAT) project, is to implement a multicentre community-based cohort of HIV-negative MSM attending 15 CBVCT services in 5 European countries.

RESEARCH OBJECTIVES

(1) To describe the patterns of CBVCT use, (2) to estimate HIV incidence, and to identify determinants of (3) HIV seroconversion and (4) HIV and/or sexually transmitted infection (STI) test-seeking behaviour.

METHODS AND ANALYSIS

All MSM aged 18 years or over and who had a negative HIV test result are invited to participate in the COmmunity-BAsed Cohort (COBA-Cohort). Study enrolment started in February 2015, and is due to continue for at least 12 months at each study site. Follow-up frequency depends on the testing recommendations in each country (at least 1 test per year). Sociodemographic data are collected at baseline; baseline and follow-up questionnaires both gather data on attitudes and perceptions, discrimination, HIV/STI testing history, sexual behaviour, condom use, and pre- and post-exposure prophylaxis. Descriptive, exploratory and multivariate analyses will be performed to address the main research objectives of this study, using appropriate statistical tests and models. These analyses will be performed on the whole cohort data and stratified by study site or country.

ETHICS AND DISSEMINATION

The study was approved by the Public Health authorities of each country where the study is being implemented. Findings from the COBA-Cohort study will be summarised in a report to the European Commission, and in leaflets to be distributed to study participants. Articles and conference abstracts will be submitted to peer-reviewed journals and conferences.