What are the aims for MSM?

When we described the 10 choices associated with precautionary and risky behaviour we also described the needs associated with making those choices (or not making them). Needs are factors which we intend to influence, and can be grouped as knowledge needs (information that can help men form an attitude) and the opportunities, resources, and skills necessary to enact choices. In the following three sections these same needs are articulated as aims for interventions. These aims are presented as knowledge aims; opportunity and resource-related aims; and skills-related aims.

Aims for knowledge based interventions

The human immune deficiency virus

All MSM know that:

  • HIV is a virus that can infect humans.
  • HIV is an incurable infection, once someone has it they cannot get rid of it.
  • HIV infection can cause a disease where the body is unable to defend itself against infections.
  • HIV infection can increase the likelihood of cancers and cardio-vascular diseases.
  • HIV infection is a stigmatised disease and people diagnosed with it are sometimes shunned and blamed for their illness.
  • In *2009 about 35,000 gay and bisexual men were living with HIV in the UK and about 2,500 are diagnosed with the infection each year.
  • HIV is now a treatable medical condition.
  • The majority of people who have been diagnosed with the virus remain fit and well on treatment.
  • The long-term effects of both HIV and anti-HIV drugs can be debilitating.
  • Although drugs can prevent most people with HIV from dying, about 200 gay and bisexual men die from HIV infection each year in the UK.
  • The longer HIV goes undiagnosed and untreated the more likely a person is to die of HIV disease.

The HIV test

All MSM know that:

  • Medical tests exist which can determine whether we are infected with HIV or not.
  • HIV infection has a ‘window period’ where very recent infection may not be detected – the length of this period varies by the type of test used.
  • The most modern HIV tests (called 4th generation assay tests) can detect infections from 12 days following exposure, however such tests may not be available at our local service.
  • We can ask for a free and confidential test at our local sexual health clinic and other services providing HIV tests.
  • HIV tests usually use a blood sample (from a vein or a finger prick) and sometimes a saliva sample.
  • Some tests can provide results within minutes and some testing services can provide results at the same visit.
  • Some clinics still need to send samples away to be tested but rapid HIV testing clinics can offer results at the same visit as giving the blood sample.
  • A test result applies only to the person taking the test and not to any of their sexual partners.
  • A negative test result (if the window period has passed) means we are almost certainly not infected with HIV, but does not mean we are immune, even if we know we have been exposed to HIV  - subsequent risk taking will mean we can no longer rely on a negative result.
  • A positive HIV test result means we are infected with HIV.
  • Having HIV infection does not depend on whether that infection is diagnosed or not: if we have the virus it does not go away if we ignore it.
  • Men with undiagnosed HIV may pass their virus to others unawares.

(Un)diagnosed infection

All MSM know that:

  • If we acquire HIV, having it diagnosed means we may benefit from health monitoring, medical treatment and support services that would be unavailable if our infection remained undiagnosed.
  • Late diagnosis is the most important factor associated with HIV-related illness and death in the UK.
  • About a quarter of gay and bisexual men with HIV in the UK do not know they are infected and the average length of time men spend with undiagnosed infection is about four years.

Sero-conversion illness

All MSM know that:

  • People can experience symptoms when they acquire HIV that can then pass despite people remaining HIV infected.
  • Many people who acquire HIV experience flu-like symptoms in the first few weeks after infection that then pass.
  • Common symptoms of seroconversion are fever, rash and sore throat occurring together.
  • A fever, rash and sore throat occurring together after recent sexual risk are warning signs of having picked up HIV.

Viral load and infectivity

All MSM know that:

  • Only people with HIV infection can pass the infection to others.
  • An HIV positive man with a detectable viral load is able to pass the infection to his sexual partners.
  • An undetectable plasma viral load may mean an HIV positive man is unable to pass HIV infection if he stays free of other STIs.
  • HIV plasma viral load tests do not necessarily reflect seminal viral load.
  • HIV plasma viral load alone cannot be used as a guide to infectiousness.
  • If an HIV infected man engages in unprotected anal intercourse and acquires a penile infection which increases seminal viral load, he may be highly infectious.

Other sexually transmitted infections

All MSM know that:

  • As well as HIV, six other STIs can be fatal (syphilis, hepatitis B and hepatitis C can kill; human papillomavirus, herpes (HPV) can cause cancers which kill; chlamydia and gonorrhoea can cause pelvic inflammatory disease (PID) in women which can kill)
  • As well as HIV, three other STIs are incurable (human papillomavirus (HPV), herpes and hepatitis B).
  • Some STIs can increase the likelihood of HIV infected people transmitting the virus during sexual encounters.
  • Some STIs can increase the likelihood of people being infected with HIV during sexual encounters.

HIV treatment

All MSM know that:

  • HIV treatment slows the spread of HIV in the body, prevents illnesses and prolongs life; by taking HIV treatment doctors believe that people with HIV can lead a more or less normal lifespan.
  • Untreated HIV infection can lead to a wide range of health complications.
  • The goal of HIV treatment is undetectable viral load.
  • HIV plasma viral load tests do not necessarily reflect seminal viral load: HIV plasma viral load alone cannot be used as a guide to sexual infectiousness.
  • Current treatments include fewer pills and less severe side effects than in the 1990s.
  • For HIV treatment to be effective it needs to be taken at the right time and in the right way 95% of the time.
  • HIV drugs can cause side-effects; many of these are manageable.
  • Having an undetectable viral load reduces the risk of sexual transmission to sexual partners if sexual exposure to an uninfected person occurs.
  • Fully virally suppressive anti-retroviral therapy reduces but does not eliminate the risk of transmission.
  • Virally suppressive treatment may have a similar effectiveness to consistent condom use.
  • Sexually transmitted infections can increase seminal viral load; if an HIV infected man engages in unprotected anal intercourse and acquires a penile infection which increases seminal viral load, he may be highly infectious.

Sexual partner change

All MSM know that:

  • The more people we have sex with the more likely we are to pick up sexually transmitted infections.
  • The more people we have sex with between STI screens the more likely we are to pick up and pass on an STI.
  • The more sex partners we have the more likely we are to be sexually assaulted.

Telling our partners about our infections

All MSM know that:

  • We can be prosecuted for passing any serious STI we are aware of to a sexual partner who does not know about our infection.
  • There are both HIV-uninfected and HIV-infected homosexually active men in all areas of England and in every country in the world.
  • A man’s appearance, age, ethnic group, life experience and behaviour are neither accurate nor reliable ways of telling whether he is infected with HIV or not.
  • People can have HIV without experiencing any symptoms.
  • We cannot tell if someone has HIV or not by looking at them.
  • Some men believe their HIV status to be other than it actually is: many men who have HIV have not yet been diagnosed and still believe themselves to be HIV uninfected.
  • Some men who do know their HIV/STI status will engage in sexual intercourse without disclosing their HIV status, irrespective of any legal sanction.

Monogamy and open-relationships

All MSM know that:

  • Couples in sexually open relationships increase their STI risks by sharing the risks with each other.
  • Many male couples choose and succeed in having monogamous relationships.
  • If neither partner in a monogamous relationship has HIV, they cannot pass it to each other whatever their sexual practices.
  • Relationships agreed to be monogamous are not always monogamous - some men cheat on their partners.
  • Couples who agree to limit unprotected intercourse to each other do not always stick to that agreement.

Anal intercourse

All MSM know that:

  • HIV is carried in semen, pre-seminal fluid, anal mucus and blood.
  • A body fluid from an infected person must enter the body of an uninfected person for infection to occur.
  • Receiving the ejaculate of a man with HIV into the rectum is by far the most common and easiest method of acquiring HIV infection.
  • HIV can and is also being acquired during receptive anal intercourse without ejaculation, and during insertive anal intercourse.
  • Condoms are not 100% effective.
  • Anal intercourse (with or without a condom) carries a greater risk of HIV and STI transmission than sex without anal intercourse.
  • The more men we engage in intercourse with, the more likely it is that we will be involved in HIV transmission.
  • HIV is very unlikely to be passed between partners who avoid anal intercourse and other STIs are also less likely to be passed on.
  • Many gay men choose to not include anal intercourse with many of their sexual partners, or in many of their sexual sessions with the same partner.

Condoms and lubricant

All MSM know that:

  • If anal intercourse occurs, there are health and hygiene benefits to using condoms whatever the HIV status of the partners.
  • If anal intercourse occurs, proper condom use greatly reduces the chances of HIV/STIs being transmitted if one or other partner is infected.
  • Putting a condom on the penis before and throughout anal intercourse greatly reduces the chances HIV will be passed.
  • The use of a condom also reduces the likelihood of infection with HIV, gonorrhoea, NSU, syphilis and herpes if they have intercourse with someone who is infected.
  • Condoms can break or slip off but are much less likely to do so if used correctly.
  • Condoms come in different shapes and sizes so some will be more comfortable than others and be less likely to fail.
  • Water or silicon based lube will greatly reduce breakage by lubricating the condom – latex condoms rot very quickly and break if exposed to oil present in some lubricant.
  • Condoms also come in non-latex varieties that can safely be used with oil based lubricant.
  • Incorrect use of condoms increases the rate at which they fail.
  • Wearing two condoms (one on top of the other) increases the likelihood they will tear.
  • Putting lubricant inside the condom (or on the penis) before putting the condom on increases the likelihood it will slip off during intercourse.
  • Condoms are more likely to fail if they are used for an extended period of intercourse - using a fresh condom every 30 minutes will reduce the chance of failure.

Ejaculation

All MSM know that:

  • HIV is primarily carried in semen.
  • HIV is also carried in pre-cum - ejaculation into the rectum or mouth is not necessary for transmission to occur.
  • Infections primarily carried by body fluids are more likely to be transmitted if ejaculation into the body occurs.
  • Withdrawal before ejaculation is less likely to result in HIV / STI transmission than ejaculation into the body.
  • Many men find it difficult to interrupt intercourse (or fellatio) as they are approaching orgasm and an intention to withdraw is often not carried through.

Poppers

All MSM know that:

  • Poppers cause our blood vessels to expand, our blood pressure to drop and our heart to race.
  • Poppers use doubles the risk of HIV being transmitted if an HIV uninfected man has receptive unprotected anal intercourse with an HIV infected man.
  • Infections can still be passed in the absence of poppers use.

Post-Exposure Prophylaxis (PEP)

All MSM know that:

  • Taking anti-HIV drugs within 72 hours of exposure to HIV can very greatly reduce the chances we get HIV: these drugs are called post-exposure prophylaxis (PEP).
  • The sooner PEP is taken after exposure the better, and they must start within 72 hours of exposure.
  • The sooner PEP is taken, the more likely it is to prevent infection.
  • PEP must be taken for a month afterwards for the drugs to work.
  • Both Accident & Emergency and clinical sexual health services should be able to provide PEP, but in practice this might be difficult especially at weekends.
  • PEP should be prescribed by a doctor - sharing a positive person’s HIV medication is unlikely to work and may cause harm.

Aims for opportunity and resource based interventions

All risk reduction choices

All MSM have:

  • Physical autonomy (not being physically forced).
  • Economic power.
  • Control over sex, including through negotiation beforehand.
  • Control over our alcohol and drug use.
  • Opportunities for psycho-social change.
  • Access to information about HIV, its transmission and prevention.

STI / HIV testing

All MSM have:

  • Access to a trusted HIV / STI testing service and to current treatments for infections that are diagnosed.
  • The time to attend when the HIV / STI service is open.
  • Freedom to choose to test for HIV / STIs (not being prevented from testing).

HIV treatments

All MSM have:

  • Access to free NHS care.
  • Access to social support.

Declining, deferring, dating

All MSM have:

  • Physical autonomy (not being sexually assaulted).
  • The ability to afford to say no to sex (not being financially exploited).
  • Access to social alternatives to drink, drugs and sex.
  • The belief that they do not have to have sex just because they are expected to do so.

Sharing knowledge of infections

All MSM have:

  • The ability to raise and respond to discussion of HIV / STIs and safer sex.
  • The ability to judge the ‘best moment’ to bring up HIV and safer sex with a partner.
  • Freedom from fear of violence for sharing their HIV / STI status.

Negotiating relationships

All MSM have:

  • A partner who has a positive attitude toward sexual exclusivity.
  • An ability to establish trust with a regular sexual partner.
  • An ability to negotiate sexual exclusivity and contingencies should that agreement be broken.

Non-penetrative sex or intercourse

All MSM have:

  • A location to have sex.
  • Physical autonomy (not being forced).

Condoms and lubricant

All MSM have:

  • Access to appropriate condoms and water-based lubricant.

Poppers

  • (No additional opportunities or resources needed to avoid poppers were identified)

PEP

All MSM have:

  • Safe access to PEP assessment and prescription.
  • Social and emotional support to adhere to PEP drugs for a month if prescribed.

Aims for skills based interventions

All risk reduction choices

All MSM have:

  • Sexual negotiation skills.
  • The ability to anticipate risk and to own our reactions to it.
  • The ability to balance own desires with expectations of others.
  • The interpersonal skills to negotiate sex.
  • A sense of social inclusion (not alienation)
  • Self-esteem.
  • The ability to envisage a future for themselves and a means to achieve it.
  • The ability to recognise their sexual behaviour to be a problem if it repeatedly involves risks later regretted.
  • The self-confidence to negotiate sex.

And, all MSM feel:

  • Equipped and competent to negotiate sex.
  • Happy with their sexuality.

No MSM feel that:

  • They are not worth caring for.
  • Their sexuality is a problem to them.
  • They have no future for themselves.
  • Their sexual behaviour is a problem others (although their sexual behaviour is not a problem to their sexual partners).

STI / HIV testing

All MSM have:

  • Confidence to access an STI / HIV testing services.

HIV treatment

All MSM (epscially those with diagnosed HIV) have:

  • The ability to adhere to daily medication.
  • The ability to communicate effectively with clinicians.

Declining, deferring, dating

All MSM have:

  • The ability to decline sexual contact, either verbally or non-verbally.

Sharing information

All MSM have:

  • Assertiveness and interpersonal skills.
  • The ability to disclose their HIV status to sexual partners.
  • The ability to respond sensitively and respectfully to disclosure of HIV status by partners.

Negotiating relationships

All MSM have:

  • Interpersonal negotiation skills.
  • Conflict resolution skills.

Non-penetrative sex

All MSM have:

  • Sexual competence to have non-penetrative sex.

Condoms and lubricant

All MSM have:

  • Skills to use condoms and lubricant correctly.

Ejaculation

All MSM have:

  • The ability to interrupt anal intercourse before the insertive partner ejaculates.

Poppers

  • (no additional skills to those above)

PEP

All MSM feel:

  • Able to access a PEP assessment and prescribing service.
  • Able to approach sexual health clinical services and can talk honestly about our sexual behaviour with clinic staff.

Page last updated: 5 July 2013