To date, the numbers of men who have sex with men (MSM) in various parts of the world who are contracting sexually transmitted infections (STI), including human immunodeficiency virus infection, are increasing. Risk-reduction interventions need more nuanced information to further understand how anal intercourse without using condoms (AIWC), the main driver of the growth in the STI prevalence among MSM populations, can be better addressed. This report reviews published research-based data on the prevalence of AIWC among MSM samples and the characteristics of MSM having AIWC. Overall, the findings indicate that there are large numbers of MSM samples reported to have engaged in AIWC (range: 12.6%-72.4%). There are a variety of characteristics found to be statistically significantly related with AIWC, many of which are related with the general life aspects of MSM. Risk-reduction interventions need to do more in reaching out to the MSM populations by broadening the focus, substance and impact of their efforts.
Keywords: anal intercourse without using condoms, men who have sex with men, HIV/AIDS, literature review, risk-reduction interventions
Many systematic studies in various parts of the world explore the sexual behavior of men. Their research purposes tend to vary, but most of these studies, from the 1980s till the present, zero-in on men’s sexual behavior in their efforts to draw the implications of the said behavior for the spread and prevention of sexually transmitted infections (STIs). Men are an important sector to study, because they engage in risky sexual behavior, such as having more sexual partners (Fisher, 2012), than women. Providing men with effective interventions would lessen their chances of acquiring and transmitting STIs, including endangering their own and their sexual partners’ lives. There is evidence to suggest that efficacious interventions tend to lead to significant sexual behavioral changes in individuals (Lu et al., 2013) and to a reduction in the chances of individuals to acquire and spread STIs. However, given the complexities of human sexual behavior (Mirzaei, Ahmadi, Saadat, & Ramezani, 2016), the behavioral impact of interventions is not always assured. In other words, the nexus between interventions and sexual behavior is far from being linear and straightforward; thus, interventions do not necessarily produce the desired results. To date, there remain high numbers of sexually active men in several countries, such as the USA (Potenza, 2016), who are suffering from STIs, some of whom are knowingly or unknowingly transmitting their infections to others. It only takes a handful of these at-risk men to elevate and sustain the prevalence of STIs at serious levels. Interventions would have to further deepen their efforts, therefore, to be able to induce the most optimal behavioral impact among at-risk men. In this respect, interventions require more nuanced information for strengthening their work.
This report provides a review of empirical findings on the riskiest sexual behavior in men who have sex with men (MSM) as well as corresponding perspectives for risk-reduction interventions. As a sub-group of the male population, MSM comprise an important target audience in STI-related research and interventions in several countries worldwide, because many MSM engage in sexual behaviors having far-reaching ramifications for the acquisition, transmission and prevention of STIs, including HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome). This report focuses on MSM’s riskiest sexual behavior, which is having anal intercourse without using condoms (AIWC).
Facts on Anal Intercourse
The USA’s Centers for Disease Control and Prevention (CDC) (2016) provides ample information on anal intercourse (visit https://www.cdc.gov/hiv/risk/analsex.html). Foremost, the CDC describes anal intercourse as a sexual behavior with the highest risk level for HIV transmission. When MSM have anal intercourse, they perform an insertive (or top) and/or a receptive role (or bottom). The CDC highlights that MSM who perform receptive anal intercourse have a greater risk for HIV infection than those who perform insertive anal intercourse. Specifically, MSM who perform receptive anal intercourse is 13 times more at risk for HIV infection than MSM who perform insertive anal intercourse. The risks between these types of anal intercourse differ because their respective mechanisms of HIV transmission vary. The CDC explains that receptive anal intercourse has a very high risk for HIV infection because “the lining of the rectum is thin and may allow HIV to enter the body during anal sex”. Insertive anal intercourse is likewise risky for HIV infection, because the virus “may enter the top partner’s body through the opening at the tip of the penis or urethra, or through small cuts, scratches, or open sores on the penis”.
Engaging in AIWC exposes MSM not only to HIV infection but to the following STIs as well:
- Hepatitis A, B, and C,
- Parasites like Giardia and intestinal amoebas,
- Bacteria like Shigella, Salmonella, Campylobacter,
- E. coli, and
- Syphilis or herpes (even with condom use).
According to the CDC, infections can be effectively prevented by:
- Using latex or polyurethane male condoms consistently, from start to finish for each act of anal intercourse. Condom is the most effective measure against HIV and other STIs. (The CDC notes that consistent condom use reduces the risk of getting HIV: on average, 63% through insertive anal intercourse with an HIV+ partner and 72% through receptive anal intercourse with an HIV+ partner. Furthermore, the CDC advises the use of sufficient water- or silicone-based lubricant to prevent condom breakage and tearing of tissue; and to use c ondoms, given that it is not 100% effective, in tandem with other prevention methods to further reduce the risk).
- (For those who are HIV+ and at a very high risk for HIV), taking daily pre-exposure prophylaxis (PrEP) to reduce the risk of acquiring HIV from sexual intercourse by more than 90%. The CDC notes that, since PrEP is not 100% effective at preventing HIV, its use should be accompanied by other prevention methods to further reduce the risk.
- (For those who are being potentially exposed to HIV during sex), taking post-exposure prophylaxis (PEP) to prevent getting an infection. The CDC suggests that “PEP should be used only in emergency situations and must be started within 72 hours after a possible exposure to HIV, but the sooner the better”. The CDC underscores that PEP must be taken once or twice daily for 28 days and considers it as effective when administered correctly, albeit it cautions that the method is not 100% effective.
- (For those living with HIV), taking the antiretroviral therapy (ART) consistently. The CDC reports that ART “can reduce the amount of virus in the blood and body fluids to very low levels, if taken the right way, every day”. It adds that, “when taken consistently, ART can reduce the risk of HIV transmission to a HIV- partner by 96%”. The CDC notes that, ART is not 100% effective at preventing HIV, thus it advises the use of other prevention methods to further reduce the risk”.
- Adopting other behavioral choices to lower the risk of getting or transmitting HIV, such as choosing less risky behaviors like oral sex, which has small or no risk of transmission; and getting tested and treated for other STIs.
AIWC among MSM—in terms of its prevalence and the characteristics of those who have AIWC—has been systematically examined in several countries worldwide. Regardless of their geographic origins, studies collect data to help improve and sustain the impact of interventions (World Health Organization, 2008). The need for programmatic improvements is compelling: the prevalence of STIs, including HIV/AIDS, continues to be highly problematic among the MSM populations (Wilton, 2015). For example, in the Philippines, 95% of new HIV cases from 2012 to 2017 are MSM (DOH, 2017). Although their data collecting tools are highly similar in terms of contents and styles, studies vary in their designs (i.e., having quantitative and/or qualitative purpose) and sample sizes (i.e., involving a small or large number of participants).
While many studies have been carried out in various countries—in Asia, Africa, the Americas, Europe and Oceania—few attempts have consolidated the extant research findings, and there are compelling gaps in these analyses. For instance, in the systematic review and meta-analysis of Meng et al (2015), the focus is mostly on the act of anal intercourse alone; little consideration is given to whether the MSM populations are using condoms or not, and whether these MSM come from certain backgrounds or of specific characteristics. Certainly, AIWC, which lies at the top of the hierarchy of high-risk sexual behaviors for HIV infection, should be a most important concern for risk-reduction interventions, and must be understood in further terms. What have studies found about the extent of having AIWC among the MSM populations from various countries? What are the characteristics of MSM engaging in AIWC? What perspectives could be drawn from these findings to inform the development of more effective risk-reduction interventions? This report provides answers to the foregoing questions.
A review of the published research literature was performed. The review covered published journal articles that were identified and accessed using university-based subscribed databases (i.e., Proquest, PsychArticles and ScienceDirect). To be included as a review material, a journal article must be based on a study that:
1) Was published in 2000-2017,
2) Involved a sample of MSM,
3) Had a sample size of at least 200 MSM, and
4) Described the percentages and characteristics of MSM having AIWC.
Journal articles that failed to meet any of the foregoing criteria were excluded. Data culled out from each eligible journal article were tabled in two matrices—one showing some of the article’s descriptive information (e.g., authors’ names, study sites) and reported percentage/s of MSM samples having AIWC; and the other showing statistically significant characteristics of MSM who have AIWC. Based on the tabled data, which were analyzed descriptively for this report, appropriate interpretations and conclusions were made. This analysis is not necessarily exhaustive.
Table 1 has the summary information on the 25 reviewed studies, including information on their authors, study sites, sample sizes and sampling methods, and their reported percentages of their MSM samples having AIWC.
The mostly primary studies reviewed in this report were multi-authored, which means that these were pursued as collaborative efforts; were carried out in various countries, notably the US; had varying sample sizes, ranging from 200 to 16,373; and had involved various groups of MSM, whose ages ranged from 18 to 75 years old. All the reviewed studies were undertaken in various locations (e.g., online, bars, clinics, events, interventions). In addition, these studies utilized mainly non-probability sampling methods. For example, some studies employed the snowball sampling, which involves asking initial sets of respondents to refer friends and acquaintances as potential study respondents. Other studies used the time-location sampling, which is also known as time-space sampling and venue-based sampling. In this sampling method, locations are randomly selected from the sampling frame of locations (e.g., gay bars), and persons are enrolled as participants by sampling at these locations (Karon & Wejnert, 2014). One reviewed study was found to have employed the respondent-driven sampling, which features two main innovations for sampling hard-to-reach populations. These innovations consist of “a design for sampling from the target population and a corresponding strategy for estimating properties of the target population based on the resulting sample” (Gile & Handcock, 2010).
The prevalence rates presented here refer to the various categories of MSM samples with AIWC. Some of these prevalence rates simply report the percentages of MSM who have AIWC, without indicating for instance if these MSM have insertive and/or receptive anal intercourse, or if these MSM are HIV+ or HIV-. In contrast, other prevalence rates are more specific. For example, they not only report the percentages of MSM having AIWC, but also report the percentages of MSM having anal intercourse without using condoms (IAIWC) and receptive anal intercourse without using condoms (RAIWC). Other prevalence rates further indicate the partner types (i.e., primary, casual), individual HIV status (i.e., HIV+, HIV-) and partnership HIV status of MSM having IAIWC and/or RAIWC. One prevalence rate was drawn from an MSM sample whose viral load was considered. Overall, the studies reviewed in this report have varying research designs and prevalence rates, but they offer critical information on MSM having AIWC.
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