Who is the intervention for?
Extensive data banks concerning sexual risk behavious and HIV prevention needs exist from the annual national Gay Men’s Sex Survey undertaken between 1997 and 2010 and a wide variety of other sources. Overall, these data suggest that all MSM HIV prevention programmes should over-serve:
- Men with HIV.
Among men without HIV HIV prevention programmes should over-serve:
- Men in sexual relationships with men with HIV.
- Men with larger numbers of sexual partners.
- Younger rather than older men.
- Men with lower rather than higher levels of education.
- Black men (Caribbean and African) rather than other ethnic groups.
This does not mean that men without HIV, older men, single men, men who have little sex and non-Black men should be ignored. Nor even that there should not be interventions specifically targeting men from these groups. It does mean that if a programme over-serves these rather than the groups above, it would be reducing the needs of those in less need and with a lower probability of involvement in sexual exposure in the future.
Recognising priority groups for interventions means attending to the setting in which they are carried out and selecting settings on the basis of increased coverage of priority groups.
Men with HIV
The first priority group identified are men with HIV infection (estimated at 5% of all gay men). This group is present in every area in the country, although it will vary in size.
We distinguish between those with undiagnosed infection (estimated at a fifth of those gay men infected) and those with diagnosed infection (estimated as four fifths of those infected). Because of the prevalence of HIV, both groups are more likely to be involved in exposure than uninfected men (estimated as 95% of MSM).
A man with HIV having UAI with a random partner will be at least 20 times more likely to have a HIV negative partner than a negative man engaged in exactly the same behaviour is to do so with a positive partner (since the ratio of positive men to negative men in the population is 1:20). On several indicators of HIV prevention need, particularly around negotiation and control, men with diagnosed infection also consistently show higher levels of unmet prevention needs.
Conversely, being more likely to be in contact with clinical HIV services, diagtnosed positive men are more knowledgeable about HIV and other STIs than men who have not tested positive. It is men who have never tested that are least knowledgeable about HIV and appear more naïve in their expectations that their health is primarily the responsibility of their sexual partners.
Men with undiagnosed HIV infection who have their HIV diagnosis needs unmet have the greatest amount of unmet HIV prevention need and should be the first priority for all programmes. However, because they are unidentifiable to themselves and others, they are usually bot addressed by prevention programmes.
The unmet HIV prevention needs that led a man to become infected with HIV are not resolved by his being diagnosed with HIV. Instead, they often continue to result in his involvement in sexual exposure, this time as the infected partner. Receiving a diagnosis may itself undermine men’s ability not to contribute to onward infection.
Partners of men with HIV
The second priority group for HIV prevention with gay men and other MSM in England are men in sexual relationships with people with diagnosed HIV. People in relationships with someone of a different HIV status to themselves have much more opportunity for sero-discordant sex than people not in such relationships.
Many of the MSM with HIV in the UK are in sexual relationships with people without HIV. CHAPS agencies agree that it is unethical to attempt to break up relationships where one partner has HIV and the other does not, in order to reduce sero-discordant sex. Similarly, CHAPS agencies are not trying to reduce the frequency of sex in HIV sero-discordant relationships. Therefore it is essential that people in sexual relationships with people with HIV have their HIV prevention needs met.
Men with larger numbers of partners
Different HIV prevention needs show different patterns by the number of male partners men have (Hickson et al. 2009). Men who have higher numbers of partners were more likely to be involved in sexual HIV exposure than those with fewer partners. However, they were less likely to be ignorant about HIV transmission and prevention. On most knowledge and awareness items men with fewer sexual partners show more need. Conversely, men with higher numbers of partners were most likely to report concern that the sex they had was not always as safe as they wanted.
We recommend that interventions concerned with increasing knowledge should disproportionately benefit men with fewer partners, while those concerned with increasing skills and social support networks to avoid HIV exposure and transmission should disproportionately benefit men with higher numbers of partners.
The average age at which men are diagnosed with homosexually acquired HIV infection is 34 years. Among men not diagnosed with HIV, exposure to HIV appears to be fairly even throughout adulthood. As men grow into older age their sexual activity tends to drop off and anal intercourse becomes less likely when they do have sex. Subsequently involvement in sexual HIV exposure is lower among senior citizens.
However, the context in which younger and middle-aged adult men are involved in HIV exposure may vary. Men in their teens and twenties appear more likely to be involved in exposure without knowing it, while men in their thirties and forties are more likely to be in relationships with positive men and to know that exposure is occurring. Of course, both situations arise in all age groups, but these descriptions suggest a different set of needs associated with exposure across the age range.
More important perhaps, is the observation that needs are more likely to be met with the interactions (with community members and services) that happen over time. On almost all measures of HIV prevention needs, younger men are more likely to be in need than older men.This suggests that the balance of prevention programmes should be weighted toward younger (teens and twenties) rather than older (thirties and forties) men.
Younger men have more unmet HIV prevention need and the greatest likelihood of acquiring HIV in the future. As they get older their needs are likely to be met and their probability of acquiring HIV will fall. The impact of interventions on future HIV infections will greatly vary by the age of clients. We recommend that, where a limited number of interventions can be made, they should disproportionately go to younger men. In practice, this means that:
- no face-to-face or talking intervention should have an average client age above 30 years, that is at least half of the clients of any face-to-face HIV prevention intervention aimed at MSM should be below the age of 30.
- written interventions and condom distribution should be placed in settings where the maximum proportion of men under 30 will encounter them, regardless of whether this means relatively more men over 30 will also encounter them.
How much lower than 30 the average (median) age should be depends on what prevention needs the intervention is addressing and how long the intervention’s impact is expected to last.
Less well educated men
Like almost all health morbidity, HIV is socially stratified among gay and MSM.Those men with least economic, social and political power are most likely to become infected and among those with infection are most likely to suffer poor health.When education is used as a marker of social stratification, we observe that men with lower levels of education take more sexual risks more often, are in greater need on almost all measures and are often least likely to benefit from service, community and policy interventions.
This inequality reflects the broader social stratification of health in the country and presents a substantial challenge to society, services, policy and gay communities. It is clear however, that the balance of activity to address HIV infection should be weighted toward men who have less formal education, less wealth and less social capital.
There is sufficient evidence to prioritise the HIV prevention needs of black men (men from or descended from Africa or the Carribean) over men of all other ethnic groups, including the white majority.
African men are over-represented in diagnoses of homosexually acquired infection and sex with men is over-represented in samples of African men with HIV (Chinouya & Davidson 2003). Black Caribbean men are also over-represented in HIV diagnoses and are more likely to acquire other STIs.
In the National Gay Men’s Sex Surveys, compared to the white majority, African, Caribbean and other black men have been found to have:
- higher incidence of HIV testing;
- higher prevalence of diagnosed HIV infection;
- higher incidence of recent diagnosis of HIV infection;
- higher incidence of other STIs;
- higher incidence of casual unprotected anal intercourse;
- higher incidence of multiple unprotected anal intercourse partners.
In making the recommendation that black men are over-served by HIV interventions and programmes we stress three points.
First, the term ‘black men’ covers a diverse population.The extent to which it is useful as a target group for interventions will depend on the specific population concerned. Distinguishing African men from Caribbean men may be a useful first step in refining interventions.We do not suggest that all black men have the same unmet HIV prevention needs.
Second, migration features prominently in the histories of black communities in Britain and continues to do so in the personal histories of many black gay men, bisexual men and other MSM. Migration has a major impact on health and well-being and is often the context in which men’s HIV prevention needs are elevated.
Third, and more broadly, it is important to note that the inequalities in the entire population are also reproduced in each ethnic group. For example, it is widely acknowledged that black and other minority ethnic (BME) groups in the UK are socially and economically disadvantaged relative to the white majority. We stress the need to ensure that it is the less well off strata of those groups which benefit. So for example, an intervention is not contributing to health inequalities if all of its recipients are black men who are disproportionately well educated, employed and relatively privileged members of that minority group.
With regard to men from other minority ethnic groups, even if equality of benefit from programmes is sought particular effort is needed with BME groups due to the continuing culture of racism. Interventions which are tailored for and / or targeted at men from specific ethnic groups may be required in order to ensure they benefit equally from programmes. Including consideration of ethnicity is a pre-requisite of good HIV prevention planning and management.
Page last updated: 5 July 2013