alexa Sexual Behavior and HIV Testing Practices among Men who have Sex with Men in Portugal | Open Access Journals
ISSN 2155-6113
Journal of AIDS & Clinical Research
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Sexual Behavior and HIV Testing Practices among Men who have Sex with Men in Portugal

Henrique Pereira*

Department of Psychology and Education, University of Beira Interior, Portugal

*Corresponding Author:
Henrique Pereira
Department of Psychology and Education
University of Beira Interior, Portugal
Tel: 351914572131
E-mail: [email protected]

Received date: March 19, 2015; Accepted date: Novmeber 20, 2015; Published date: November 27, 2015

Citation: Pereira H (2015) Sexual Behavior and HIV Testing Practices among Men who have Sex with Men in Portugal. J AIDS Clin Res 6:524. doi:10.4172/2155- 6113.1000524

Copyright: © 2015 Pereira H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of AIDS & Clinical Research

Abstract

The objective of the study was to explore sexual behavior and HIV-testing practices among men who have sex with men (MSM) in Portugal, in light of current international health guidelines that recommend frequent HIV testing for MSM who engage in high-risk behavior. Participants were 304 mostly young, gay or bisexual self-identified MSM. They provided information regarding their HIV status (67% negative, 7% positive, 26% didn’t know), 24% had never been tested for HIV, and 15.5% had been tested only once; main reasons for never having tested previously were: always using condoms, and not feeling at risk. Thus, HIV testing was infrequent and insufficient for early detection of infection, entry into treatment, and protection of sexual partners, since many unprotected sexual practices still occur. Those who tested more were older, self-identified as gay, living in major urban areas and employed. Linear regression predicted that the number of times MSM had penetrative sex without a condom was associated with the number of times they got tested, indicating that they might be using the test itself as a means to gain control of their unprotected sexual practices. Testing campaigns should aim to help MSM become more aware of their risk behavior, decrease fear of testing by explaining available treatment resources and decreasing the stigma associated with HIV, and by publicizing information about free and confidential testing locations.

Keywords

HIV testing; Sexual behavior; MSM; Portugal

Introduction

In Portugal there are an estimated 41,035 HIV-infected individuals [1], and one of the highest prevalence rates in Western Europe [2]. In addition, 81.7% of the people diagnosed with HIV were men, and although the highest rate of HIV infection is through heterosexual unprotected sex, approximately 15% of all infections were transmitted via homosexual and/or bisexual unprotected sex [1]. This is particularly important to mention given that this rate has doubled since 2001 among man who have sex with men (MSM) in Portugal, and these estimates only regard the notified cases, not considering the unreported cases. Therefore, MSM remain one of the most at risk groups for HIV transmission [3]. Despite these worrisome statistics, little systematic research has been conducted in Portugal on the contextual factors associated with unsafe sex among MSM, namely HIV testing practices and its relation to demographic variables and sexual behavior.

HIV testing facilitates early detection of infection among at-risk individuals, and early HIV detection is directly associated with improved quality of life and decreased sexual risk behavior [4-6]. Early and successful treatment of HIV-infected individuals with antiretrovirals (ARVs) significantly decreases the chances of HIV transmission to partners.

The US Centers for Disease Control and Prevention [7] recommend testing every three to six months for sexually active MSM. Given that large percentages of HIV-infected persons may be unaware of their infection [8,9], especially among MSM who remain at disproportionate risk of infection [10], frequent testing is important.

Although the percentage of MSM who have never tested for HIV is decreasing [11], many MSM remain untested or test infrequently [7,12,13]. Likelihood and frequency of testing may be related to demographic characteristics such as sexual orientation, age and ethnicity [14,9,15]; and to fear of positive results, perceived HIV risk, and beliefs about HIV treatment [16,17].

The uncertainty of unknown HIV status is an important motive for testing; however, denial is also a common response to uncertainty. Fear of the consequences of a positive HIV test is widespread and may take several forms. A sense of responsibility towards oneself or one’s partner may be a motive for testing. The perception of stigma, from other gay men or from the wider culture, is a barrier to testing [18].

The risk of acquiring HIV infection is related to an interaction of correct knowledge of one’s own HIV sero-status and the sero-status of one’s sex partner. Most of the research on frequency of HIV testing has occurred in the US, Australia, and China. Nevertheless, very little is known about the frequency of HIV testing among Portuguese MSM and the factors that facilitate or impede testing among this population. The only two studies that tried to describe testing behavior in the context of MSM in Portugal show that some 72% of men got tested but a lot still needs to be done for improving testing, namely adopting more innovative approaches to HIV testing to improve the efficacy of HIV prevention strategies [19,20].

Therefore, the aim of this study is to contribute to the understanding of the relationship between sexual practices and HIV testing among MSM in Portugal by reporting a sample of 304 demographically diverse men.

Methods

Participants

The inclusion criteria for participation in the study were: (1) being MSM, (2) being over 18 years of age, (3) being Portuguese and living in Portugal, and (4) willingness to participate in the study after knowing its objectives. Participants were recruited through snowball sampling, and two methods were used: (1) Informal social networks. The eligible MSM who agreed to participate were asked to refer their friends to participate in the study; and (2) The Internet. The local researcher distributed announcements via local gay websites to reach potential participants, emphasizing that participation was strictly voluntary and confidential.

Demographic data (Table 1) show that the sample is highly differentiated and educated, the majority of men are single and selfidentify as gay. Only 7.2% of participants state being HIV positive, approximately 26% report not knowing.

  n %
Self-identification    
Gay 213 70.06
Bisexual 91 29.94
Marital status    
Single 180 59.21
Emotional commitment 58 19.08
Divorced 16 5.26
Married to a man 7 2.3
Married to a woman 12 3.95
Civil Union to a man 23 7.57
Civil union to a woman 8 2.63
Education    
Up to 9 years of school 27 8.88
Up to 12 years of school 73 24.01
University/college attendance 79 25.98
Pre-graduate degree 56 18.43
Post-graduate degree 69 22.7
HIV status    
Negative   203 66.77
Positive 22 7.24
Does not know 79 25.99

Table 1: Demographic characteristics (n=304).

Measures

Demographic characteristics

The structured questionnaire covered age, education, marital status, and HIV status. Participants indicated whether they considered themselves (1) gay/homosexual, (2) bisexual, (3) other. The study was not designed to include transgender persons. For the purpose of data analysis, education and marital status were grouped into several categories.

Sexual practices

Participants were asked to recall their sexual experiences and their sexual behaviors over the last two months. Information was collected regarding: (1) receptive anal sex; (2) insertive anal sex; (3) receptive and insertive oral sex.

HIV testing history

We inquired whether the participants had tested for HIV previously, reasons for never testing, assumptions about status among those not tested, reasons for first testing among those tested, and frequency of testing for those with more than one test.

Analyses

Analysis was carried out using SPSS version 21. Variables were analyzed using simple frequency and percentage. Logistic regression was carried out on condom use to predict condomless intercourse (dependent variable) with sexual pleasure (independent variable), significant at p<0.05. The t-test and ANOVAs were used to compare differences in groups of MSM using a condom and not using a condom, within the previous two months. All tests were two-tailed.

Ethics statement

The Institutional Review Boards of the Research Unit of Health and Psychology from the Institute of Applied Psychology in Lisbon, Portugal, approved this study.

Results

Sexual practices

Table 2 shows the results for the sexual practices within the last two months, using or not using a condom. Significant differences were found between having sex with or without a condom for receptive anal sex (more men penetrated the participants with a condom, p=0.036), for insertive anal sex (more participants penetrated another man with a condom, p=0.012), and for oral sex (all differences indicate that a condom is much less used for this type of sex, p<0.001).

Sexual practices within the last two months With or Without a condom Mean Std. Deviation t p
How many times were you penetrated With a condom 2.89 6.78 -.03 .978
Without a condom 2.90 8.71    
How many men penetrated you With a condom 1.36 3.70 2.10 .036*
Without a condom .72 3.46    
How many times did you penetrate With a condom 3.69 9.60 .41 .680
Without a condom 3.36 9.13    
How many men did you penetrate With a condom 2.12 7.69 2.51 .012*
Without a condom 0.84 3.57    
How many times did you perform oral sex With a condom 1.38 6.60 -8.47 .000**
Without a condom 8.73 12.95    
How many men did you perform oral sex to With a condom .65 4.02 -4.86 .000**
Without a condom 3.23 7.88    
How many times did someone perform oral sex on you With a condom .85 4.54 -8.73 .000**
Without a condom 9.01 14.98    
How many men performed oral sex on you With a condom .71 4.29 -4.26 .000**
Without a condom 3.41 9.73    

Table 2: Results for “sexual practices within the last two months”, using or not using a condom (n=304).

HIV testing history

Table 3 shows the HIV testing history of the sample. About 24% of participants had never been tested for HIV, and about 16% had been tested only once. Also, nearly 24% of men had tested 6 or more time for HIV. Gay-identified men reported significantly higher proportions (t (293) = 4.63; <0.001) when compared to bisexual-identified men.

  Total Gay Bisexual    
  (N=304) (n=213) (n=91) t(df) p
  M (SD) M (SD) M (SD)    
Number of times tested for HIV 2.85 (2.33) 3.26 (2.24) 1.95 (2.29) 4.63(293) <0.001
0 23.9% 10.1% 13.8%    
1 15.5% 11.4% 4.0%    
2 9.4% 6.7% 2.7%    
3 10.1% 6.7% 3.3%    
4 9.4% 8.1% 1.3%    
5 7.7% 7.1% .7%    
+6 23.9% 18.5% 6.1%    

Table 3: HIV testing history and prevalence by sexual orientation

Table 4 shows the reasons for not testing among those who never tested. The most frequent reasons for not testing were always using condoms and not feeling at risk. No significant differences between gay or bisexual-identified men were found except for other reasons.

    Total Gay Bisexual    
    (N = 73) (n=31) (n=40) Chi-Square (df) p
Hard to get tested Yes 11.3% 5.0% 6.3% 0.016 (1) 0.900
No 88.8% 37.5% 51.2%
Not knowing where to get tested Yes 27.5% 11.3% 16.3% 0.031 (1) 0.859
No 72.5% 31.3% 41.3%    
Fear of discrimination Yes 12.5% 6.3% 6.3% 0.263(1) 0.608
No 87.5% 36.3% 51.2%
Shame to be perceived as homosexual Yes 12.5% 7.5% 5.0% 1.432(1) 0.231
No 87.5% 35.0% 52.5%
Fear of finding out results Yes 23.8% 12.5% 11.3% 1.047(1) 0.306
No 76.3% 30.0% 46.3%
Don’t feel at risk Yes 57.5% 21.3% 36.3% 1.361(1) 0.243
No 42.5% 21.3% 21.3%
Always using condoms Yes 75.0% 33.8% 41.3% 0.614(1) 0.433
No 25.0% 8.8% 16.3%
Other reasons Yes 13.8% 10.0% 3.8% 4.768(1) 0.029*
No 86.3% 32.5% 53.8%

Table 4: Reasons for not testing among those never tested.

Table 5 shows reasons for testing among those previously tested. Almost half of the men claimed their primary reason wanted to know if they were infected. Thirty seven per cent were tested as part of a physical exam and over 23% mentioned that they had started a relationship or had had unprotected sex. Only almost 6% found out that a sex partner was HIV infected. No significant differences between gay or bisexualidentified men were found.

    Total Gay Bisexual    
    (N = 231) (n=181) (n=50) Chi-Square (df) p
Wanting to know if was infected Yes 45.4% 34.4% 11.0% 0.090 (1) 0.764
No 54.6% 42.3% 12.3%
Had had unprotected sex Yes 23.3% 18.5% 4.8% 0.260 (1) 0.610
No 76.7% 58.1% 18.5%
Found out that a sex partner was HIV infected Yes 5.7% 4.4% 1.3% 0.001(1) 0.981
No 94.3% 72.2% 22.0%
Accompanied friend for testing and got motivated to get tested Yes 7.5% 5.3% 2.2% 0.378(1) 0.539
No 92.5% 71.4% 21.1%
Started a relationship Yes 23.8% 18.1% 5.7% 0.021(1) 0.885
No 76.2% 58.6% 17.6%
It was part of a physical Yes 37.0% 27.3% 9.7% 0.602(1) 0.438
No 63.0% 49.3% 13.7%
Other reasons Yes 9.7% 6.2% 3.5% 2.306(1) 0.129
No 90.3% 70.5% 19.8%

Table 5: Reasons for testing among those previously tested.

Table 6 presents the associations of demographic variables as well as sexual behavior without a condom variables and HIV testing (number of times tested over a lifetime). HIV testing was associated with age, sexual orientation, place of residence, marital status, work status, and how many times was penetrated without a condom.

  M (SD) t(df)/Beta/F(df) p
Age
Younger (<31)
Older (>32)
  3.46 (4.66)
4.76 (5.03)
  t(287)=-2.286   0.023*
Sexual Orientation
Gay
Bisexual
  4.62 (4.88)
2.92 (4.66)
  β=-0.233   <0.001**
Place of residence
Major Urban area
Smaller Urban area
  4.45 (4.99)
3.28 (4.49)
β=-0.127 0.029*
Marital Status
Single
Married or civil union to a man
Married or civil union to a woman
Emotional commitment to a man
Divorced
  4.25(5.29)
3.86(3.99)
2.14(2.49)
4.40(4.49)
4.47(5.05)
  β=0.043   <0.001**
Education
Up to 12 years of school
University education
  4.06 (5.49)
4.11 (4.53)
β=0.029 0.638
Work Status
Unemployed
Self employed
Employed by employer
Student
Other
  3.75 (4.71)
3.78 (4.37)
4.80 (5.07)
2.37 (4.30)
3.13 (3.60)
F (4; 290)= 3.008 0.019*
Sexual behavior within the last two months without a condom
How many times were you penetrated
How many men penetrated you
How many times did you penetrate
How many men did you penetrate
  2.90 (8.71)
0.72 (3.46)
3.36 (9.13)
0.84 (3.57)
  β=0.011
β=-0.101
β=0.000
β=0.199
  0.900
0.164
0.997
0.012*

Table 6: demographic variables and sexual behavior without a condom differences based on HIV testing (number of times tested).

Discussion

In this MSM sample, HIV testing was infrequent and insufficient, particularly in the case of bisexual-identified MSM. Several measures could be taken to counteract this situation. Testing campaigns could be aimed to help MSM, particularly those not gay identified, to become more aware of the behaviors that put them at risk. Given the observed variations in likelihood and frequency of HIV testing according to sexual identity, HIV testing campaigns should highlight that regardless of sexual or gender identity, individuals who engage in sexual risk behavior should be tested regularly. Furthermore, the finding that only 23.3% (18.5% for gay men, and 4.8% for bisexual men) reported having been tested because they had unprotected sex is worrisome considering the number of unprotected sexual practices that they engage in, and this is consistent with previous research [21,22]. This finding suggests very low risk perception in this population despite apparently high levels of risk behavior, considering that the majority of the participants say that they are not in a relationship.

Fear of testing and finding out about results was addressed by 24% of participants. This could be decreased by disseminating information on currently available treatments for those found to be infected.

27.5% mentioned that they didn’t know where to get tested, therefore, publicizing information about free and confidential testing locations in the country could further increase testing, particularly for those concerned about costs.

Although Portugal offers health coverage to all citizens, there is a network of HIV detection services, and free anonymous testing is available in health centers, discrimination and fear of rejection (not only because of the disease itself, but also because of being perceived as gay or bisexual) still exists, which may dissuade some people from seeking HIV testing at such facilities.

Furthermore, including HIV testing in regular physical exams, both in private and public settings, could increase both the number of individuals and the frequency of testing. Developing campaigns to decrease HIV-associated stigma could facilitate test-seeking behaviors. With the legalization of same-sex marriage, Portugal is now seen as an example in decreasing sexual-orientation-based discrimination. Lessons learned through that process should be applied to further erode stigmatization of HIV.

Finally, the association of the number of prior HIV testing with socio-demographic indicators of social marginalization (age, marital status, bisexual identity or work status) indicates an urgent need to promote and facilitate HIV testing among the most disenfranchised sectors. On the other hand, the persistent occurrence of risky sexual practices forces us to accept that much is still left to be done in the field of reducing HIV related behaviors and to promote HIV testing among MSM.

This was a cross-sectional study, and although data were collected at a single point in time, they are useful as a baseline measure against which other assessments at other times and at other venues can be compared. Nevertheless, limitations to this study include the fact that self-reported data provide an opportunity for response bias. The men surveyed in this study could have downplayed or overstated their actual behavior. Also, since this was a convenience sample, hence results cannot be generalized.

The results of the few studies conducted with Portuguese MSM [23] indicate that cultural variables may also be important in understanding MSM responses to HIV testing and its influence on the attribution of importance to sexual practices, since cultures transmit values and expectations that influence the sexual behaviors of their members. It is critical that we understand cultural influences on behaviors relevant to HIV risk to reduce the further spreading of HIV among MSM.

According to a report from the Commissioner for Human Rights from the Council of Europe [24], Portuguese people are not comfortable about having a homosexual person as neighbor, and are against samesex marriage and same-sex parenting. Consequently, the identity development of MSM individuals is restricted by these negative societal attitudes, which generally results in the internalization of the stigma associated with their sexual and/or gender identity [25], which has been shown to be associated with risky sexual behaviors [26].

Negotiations between HIV testing and a dislike of condoms seem to be given as justifications for unprotected sex between MSM. Portuguese (MSM) erotic culture, and stigma/discrimination, pressure to omit or concede their status, along with the added security of an undetectable viral load due to current adherence to medication all may lead to the rationalization of how risk is produced and Portuguese MSM may feel more likely to defend unprotected sex as not only being more pleasurable but also as signifying a return to an intimate relationship and to a sense of ‘normality’ weakened by the public health messages that view sexual risk through a biomedical lens only and deny the significance and meaning given to sex and condoms within a relationship and the unquestionable force of love, pleasure and intimacy [27].

Perceptions of low sexual control have been frequently used as justification for unprotected anal sex in studies with MSM, but failed to operationalize HIV testing patterns as a motivator for such exposure. Discrimination toward homosexual behavior is a context of risk and oppression, which have been found to be strong predictors of HIV risk among MSM men, but the contribution of this study forces us to admit that testing efforts that could counteract further spread of the epidemic needs to be prioritized in the development of condoms and other sexual safety measures as well as in the promotion of their use. Also, new strategies to implement access to the test in Portugal, such as rapid HIV screening, should be discussed.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 7835
  • [From(publication date):
    November-2015 - Aug 18, 2017]
  • Breakdown by view type
  • HTML page views : 7781
  • PDF downloads :54
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords