Chapter 4: Population-specific HIV/AIDS status report: Gay, bisexual, two-spirit and other men who have sex with men - Factors that impact resilience and vulnerability

Chapter 4 – Current Evidence on Factors that Impact Resilience and Vulnerability to HIV/AIDS

4.1 Introduction

A comprehensive population health approach must take into account any social and economic factors that affect the population's health. This chapter summarizes available evidence on factors that impact the vulnerability of gay, bisexual, two-spirit and other men who have sex with men in Canada to HIV infection through the lens of the determinants of health. Though most relevant research focuses on this population's vulnerability to HIV/AIDS, resilience is also examine in areas where available literature addresses it.

The following determinants of health are examined in this chapter:

• Biology and Genetic Endowment
• Gender
• Healthy Child Development
• Culture
• Social Support Networks
• Income and Social Status
• Social and Physical Environments
• Health Services
• Personal Health Practices and Coping Skills

Homophobia and heterosexism are also examined as factors that contribute to the vulnerability of gay and other MSM to HIV and AIDS. This chapter begins with a brief examination of the history of the impact of HIV on gay and other MSM, and the population's overall resilience in the face of stigma and discrimination.

As discussed in Chapter 1, the epidemiological category of men who have sex with men (MSM) encompasses a broad variety of individuals. This population is a diverse group with distinct identities and a wide range of personal circumstances, coming from all ethnocultural, socio-economic and demographic backgrounds. Moreover, some MSM identify as gay, bisexual, two-spirit or even heterosexual, while others may not identify with any of the above.

4.2 Determinants of Health

In the past, HIV prevention models have assumed that individuals will make informed decisions based on the information provided them to reduce their risk of infection. However, it is now recognized that socio-economic factors—known as the determinants of health—influence the vulnerability of individuals and populations to HIV infection. In other words, the determinants of health affect their ability to control and act on decisions to take protective measures.

The links between the determinants of health and the well-being of individuals and communities are well documented. Nonetheless, there "is very little literature...that places HIV/AIDS in this broad population health context. Instead the literature most often explores the association between a particular social determinant and behaviour that places a person at risk of HIV infection." (1)

Some international research links specific determinants of health to HIV vulnerability or resilience among gay and other MSM. Equivalent Canadian research, however, is scarce to non-existent. In light of the lack of Canadian research on the determinants of health related to HIV vulnerability or resilience, the report's methodology was altered to include studies that explore broader links between the health status of gay and other MSM and the broader determinants of health.

4.2.1 Vulnerability and Resilience

Most research on HIV/AIDS among gay and other MSM focuses on this population's vulnerability to infection. Herrick et al. (2011) describe resilience against HIV/AIDS among MSM as an "untapped resource" in behavioural intervention design. (2) Resilience can be understood as "the element of risk being mitigated by protective factors to produce a positive outcome or adjustment". (3) While research interest in resilience as an approach to HIV prevention for this population is growing, there is little published Canadian research on resilience against HIV/AIDS among gay men.

What research there is, however, suggests that gay and other MSM form strong and innovative relationships, communities and social support networks. Gay men also developed an early and effective community response to AIDS beginning in the 1980s. On an individual level, research suggests that many gay and other MSM use condoms consistently and correctly and negotiate safer sex. (4;5) (For more about this topic, see Section 4.1.10 Personal Health Practices and Coping Skills.)

The history of gay, lesbian, bisexual and transgender activism in Canada has had a profound impact both on the social environment in which gay and other MSM live today, and on the Canadian response to HIV/AIDS. The Stonewall riots in New York City in 1969 and the decriminalization of homosexuality in Canada the same year sparked a decade of community organizing and advocacy among gay, lesbian, bisexual and transgender people. (6)

Following the first reports from the United States in 1981 and then Canada in 1982 of a mysterious new illness affecting gay men, AIDS quickly became a health crisis among gay men, and the most significant issue in gay men's community organizing. Gay men were at the epicentre of the emerging AIDS epidemic, with 74.7% of all positive HIV tests reported in Canada from 1985 (when national data collection began) to 1994 being attributed to the MSM exposure category. (7)

When the disease first emerged, there was no effective treatment for HIV infection. The impact of the deaths of thousands of gay men from AIDS in a short period of time served as a call to action. Gay men responded to the emerging epidemic through community organizing, and played key roles in setting up the first community organizations to provide prevention, care and support services for people living with HIV and AIDS (8) in cities across Canada. (6) The AIDS epidemic mobilized gay communities in unprecedented ways, leading to the establishment of community networks, AIDS service organizations and political organizations that successfully advocated for attention and resources for HIV. This community infrastructure still exists, and in many cases has been expanded. The response to the AIDS epidemic is a sign and the resultant community infrastructure a source of community resilience against HIV.

Understanding and harnessing resiliencies at the individual, interpersonal and population levels may help to enhance HIV-prevention programs and interventions for this population.

As individuals and as communities, gay men have demonstrated great resilience in the face of difficult times and harsh social injustices, including homophobia, heterosexism, racism, colonialism, economic injustice and discrimination on the basis of seropositivity. We have developed insightful analyses and practices, often through challenging injustices we experience by resisting them in creative and constructive ways. We have been and will continue to be actors in the pursuit of our health and wellness, including that of HIV prevention, at the individual, interpersonal, cultural and structural levels. (9)

4.2.2 Homophobia, Heterosexism, and Related Stigma and Discrimination

Research has indicated clearly that homophobia undermines our ability to adequately address HIV infection. Homophobia is a risk factor in HIV prevention and care. Confronting, reducing and eliminating homophobia and heterosexism are crucial in any systemic approach to HIV infection in Canada. (10)

The word homophobia literally means "fear of sameness" or "fear of the similar." (11) The term is widely understood to encompass the individual, social, institutional and internalized negative feelings toward lesbian, gay, bisexual, two-spirit and transgender individuals. (12) Homophobia manifests in a number of ways, each of which can have an impact on an individual's likelihood of engaging in HIV risk behaviours:

I like being gay now... but in high school I did so much to try to hide it... I even beat up this dude who looked like he was gay... I realize now that all of this was done to try to hide how I felt so different.

—Twenty-one-year-old gay male (13)

Internalized homophobia occurs when homophobic prejudices and biases are integrated into an individual's belief system. (12) Internalized homophobia can occur among gay and other MSM, such that feelings of shame and fear can cause them to repress their sexuality and experience deep internal conflict. (14;15) Internalized homophobia can lead to mental health issues, such as anxiety and depression, and can increase people's propensity to engage in behaviours that increase their risk of HIV infection.

External homophobia occurs when internal homophobic feelings shape people's behaviour towards others that they perceive as different; for example, by prompting social avoidance, verbal abuse, discrimination and in some cases violence. (12) Statistics Canada reports that hate crimes motivated by actual or perceived sexual orientation are more likely to involve violence and result in physical injury than hate crimes motivated by other factors such as race and religion. (16) A 2002 Vancouver study of gay and other MSM indicated that 48% of its respondents reported that they had been "gay bashed" at some point in their lives. Those who had experienced gay bashing were twice as likely to engage in risky sexual behaviours as those who had not. (17)

Institutional homophobia refers to discriminatory practices and policies based on sexual orientation exercised by governments, businesses, religious organizations, educational institutions and other institutions. (12) Broad systematic barriers fuelled by homophobia can limit gay men's and other MSM's access to employment, education, housing, (10) and appropriate health care. (60)

Heterosexism refers to the belief—often held on a broad social or cultural level—that everyone is or should be heterosexual, and that this sexual orientation is normative or superior, while homosexuality is deviant, immoral or constitutes a danger or threat. (12) Heterosexism can manifest as opposition, discrimination and sometimes violence against sexual minorities. (12)

Like wouldn't it be wonderful to not be hassled when you walk down the street with your partner, hand in hand, or when you do the same things that the straight couples do, and it will be accepted?

—A gay male (10)

Homophobia and heterosexism often lead to discrimination against self-identified gay, bisexual, and two-spirit persons. It also creates a social environment in which other MSM are less likely to self-identify. Both homophobia and heterosexism have an overarching influence on all of the determinants of health of gay and other MSM discussed in this chapter, which in turn influence HIV vulnerability. The direct relationship between homophobia and an individual's risk of acquiring HIV has not been widely studied in Canadian literature. There is Canadian literature, however, which suggests that homophobia is linked to negative mental health outcomes, increased social exclusion (10,12) and decreased access to social support and health services, (12, 60) all of which may increase an individual's likelihood of engaging in HIV risk behaviours. (9, 12)

4.2.3 Coming Out

Coming out is a time of great personal turmoil in which the risk of HIV infection is heightened, due to the need to address and confront obstacles at the individual, interpersonal, cultural and structural levels. (9)

Coming out is "the process through which lesbian, gay, bisexual and transgender (LGBT) people recognize and acknowledge their non-heterosexual orientation and integrate this understanding into their personal and social lives." (20) The term is also sometimes used to describe the specific act of disclosing one's sexual orientation or gender identity. (20)

The ability to be open about one's sexual orientation has a significant impact on both mental and physical health, as well as one's ability to access relevant health information, including HIV prevention information, and appropriate health care. (21, 93) Coming out is a key determinant of gay men's health that can also affect a range of other determinants of health, including income and social status, social support networks, healthy child development, employment and working conditions and health services. (9) Emerging research suggests that the ability to come out in a safe and supportive environment can have a powerful effect on the entire course of the lives of young gay and other MSM, particularly in relation to vulnerability and resilience to HIV. (21;23) For example, research on syndemics conducted by University of Pittsburgh researcher Ron Stall on a sample of over 2,000 self-identified gay men concludes that multiple psychosocial epidemics among gay men, such as homophobic violence, substance abuse, and mental illness, interact to drive HIV risk and HIV infection rates among gay men. Stall's research also suggests that suffering homophobic victimization and violence at an early age may be a root cause of these syndemics among gay men. (22; 24)

Coming out can present unique challenges for ethnic minority gay and other MSM. Psychosocial research conducted with ethnocultural minority gay and lesbian people shows that they see themselves as existing simultaneously in three rigidly defined and independent communities: their ethnic minority communities, the gay and lesbian community and society as a whole. (25) Homophobia experienced by individuals within both their ethnocultural community and homophobia experienced by them within society at large can make it challenging to self-identify as gay or bisexual and to integrate sexual and ethnic identities. (25)

4.2.4 Biology and Genetic Endowment

There is no known biological or genetic factor specific to gay men and other MSM that predisposes them to HIV infection.

4.2.5 Gender

a) Male Gender Norms

Although Canadian evidence is not available, research from the United States is beginning to document heterosexist assumptions in male gender norms and their impact on homophobia, heterosexism and ultimately on HIV vulnerability experienced by gay and other MSM over the course of their lives. (22) Research is needed to understand this dynamic in the Canadian context.

b)Transmen Who Have Sex With Men

Transmen refers to female-to-male transgender persons; that is, individuals who were born biologically female but identify as male and may seek sex reassignment surgery. This section addresses HIV/AIDS vulnerability and resilience among transmen who have sex with men. PHAC's Population-Specific HIV/AIDS Status Report: Women includes a summary of available Canadian evidence on the vulnerability/resilience to HIV/AIDS among transwomen.

Research on HIV among transgender persons focuses primarily on transwomen, highlighting the unique risks faced by transwomen for acquiring HIV. However, little research exists on transmen and HIV risk. (26) HIV prevalence among transmen in Canada is unknown. However, several U.S. studies with small sample sizes have found that transmen have low HIV prevalence rates, especially relative to transwomen. (97; 98) Moreover, a 1999 qualitative study of trans people and HIV risk in Quebec found that transmen generally did not consider themselves to be at risk for HIV. (27) However, for transmen who have sex with men, this self-perception may not be accurate, given the higher rates of HIV incidence and prevalence among gay men and other MSM in Canada. Some studies indicate that transgender persons living in particular regions in Canada, such as Montréal and Vancouver's Downtown Eastside, may have a higher prevalence of HIV infection than the general population. (28) These studies, however, generally have much higher participation rates of transwomen than transmen.

Certain groups of transgender persons have higher HIV prevalence rates than others. These groups include transgender persons who are also ethnic minorities, sex workers and people who use injection drugs. (28) A few U.S. studies with small sample sizes found that transmen were more likely to engage in risky sexual behaviour compared to transwomen. (99; 100) However, it is difficult to track epidemiological data on this population since HIV test reports from female-to-male transgender persons are likely included among male data, given that transmen identify and live as men.

Further, transmen may also be at risk of HIV infection resulting from sharing intramuscular needles used to inject testosterone, as is done by many transmen due to a lack of intramuscular needles within needle exchange programs. (27) In addition, low self-esteem may prevent transmen from practising safer sex and using safer drug injection practices. (27)

I think it's harder to negotiate condom use when you have trouble talking about your body.

–A transman (26)

Transgender persons are highly susceptible to homophobic bullying and harassment based on perceived sexual orientation, (29) as well as transphobic bullying and harassment where their trans status is known. They are therefore at increased risk of social exclusion, stigma and discrimination, drug use and mental health issues; all of which are risk factors for HIV infection. (30) A national study focusing on homophobia in schools in Canada found that 90% of trans youth heard transphobic comments every day or week from other students, while 23% heard such comments from teachers. Trans youth also reported high levels of harassment, including verbal (74%) and physical (25%), while a high proportion of trans students reported feeling unsafe in school (78%). (29; 94)

How about raising awareness? So that when you walk into the doctor's office for the first time, you can say, "Hi, I am trans," and they don't get this glazed, blank look that goes "Oh yeah, I've never seen one of you before."

—Trans person (94)

In addition, transmen face certain institutional barriers to accessing health care, which may increase the risk of HIV infection. The administrative practices of the health care system and social service organizations (including an inability to identify as trans), may prevent transmen from accessing care and services, thus exacerbating risk. (27) For example, transmen may possess female genitalia and require pap tests as part of their routine health care, which are not typically offered to persons who appear male. (94) Moreover, a lack of transgender-specific knowledge on the part of medical professionals may limit transmen's quality of care, thus impeding their ability to access appropriate care and medical advice, and ultimately exacerbating HIV risk. (30)

4.2.6 Healthy Child Development

International research has demonstrated an association between experiences of homophobic victimization in adolescence and higher incidences of mental health issues among gay, lesbian and bisexual youth, such as depression, anxiety, post-traumatic stress and suicide. (31-33) International research has also found an association between homophobic stigma and/or victimization of gay, lesbian and bisexual youth and health risk behaviours, including substance use, suicide and sexual risk behaviours, (34;35) which can put them at increased risk of HIV infection. Equivalent Canadian research linking experiences of homophobia directly to HIV risk behaviours is not available. However, results from two Canadian studies suggest that gay and other sexually diverse youth are more likely than their heterosexual peers to experience harassment and victimization. (29; 36)

As identified in Section 4.1.1, emerging research suggests that the ability to come out in a safe and supportive environment can have a powerful effect on the life course of young gay men and other MSM, particularly in relation to vulnerability and resilience to HIV. (21;23) Homophobia present in communities, schools and within the family unit compounded with the overall pressures of adolescence can gravely impact the coming out process of gay and bisexual youth. (10)

Findings of a 2008 national study of over 1,700 students in Canadian schools suggest that homophobic harassment in this environment persists. Over half (57.3%) of gay, lesbian and bisexual students surveyed reported having been verbally harassed about their sexual orientation, and 24.7% reported having been physically harassed about their sexual orientation. (29) Approximately three quarters (76.7%) of all survey participants reported that they had heard derogatory comments used daily in school, such as "that's so gay," while 49.4% heard specific homophobic slurs such as "faggot" and "dyke" daily. (29)

Results from the BC Adolescent Health Survey are similar: gay and bisexual males were more likely to experience discrimination than their heterosexual peers. Discrimination based on sexual orientation was reported in 2003 by 60% of gay males and 36% of bisexual males—an increase from 1998. (36) Gay and bisexual males also reported significantly higher rates of victimization in school, such as purposeful exclusion, verbal harassment and physical assault. (36)

It was so hard to find people you can identify with...[sigh]. You did not know who to trust, I mean you really could not mess with the high school boys cause if they got mad then everybody knew your business...I could not have that happen so I maintained and did what I did on the low and outside of school. School was about school ,that's it, which probably was a good thing.

—A 21 year old gay male (37)

a) Childhood Abuse:

There are few studies that examine the frequency and implications of sexual violence among gay and other MSM. (96) There is, however, evidence that supports an association between childhood sexual violence and HIV risk behaviours. [24; 95; 96] One study conducted in British Columbia, which used data from the Vanguard Project and the Vancouver Injection Drug Users Cohort (VIDUS), found that MSM have a higher occurrence of sexual violence in their lifetimes (28% among Vanguard men), versus other men who use injection drugs (15%). (96)The occurrence of sexual violence among MSM-IDU was highest (54%). (96) In addition, the onset of sexual violence in childhood was strongly associated with involvement in the sex trade, which can also increase the risk of HIV infection. (96)

Other studies report that men who were sexually abused as children report higher rates of unprotected anal sex with casual partners (a risk factor for HIV infection) than men who did not experience sexual abuse. (89) Childhood abuse is also linked to other HIV risk behaviours, such as drug use, having multiple sexual partners, sex work and sexual risk taking. Interviews with gay and bisexual men in Quebec who were victims of childhood sexual abuse, reveal that mental health issues and sexual and relationship difficulties are common and further complicate the ability to negotiate safer sex. (38) Moreover, higher rates of childhood abuse are reported among HIV-positive men than HIV-negative men, (96;89) suggesting an increased vulnerability to infection among those who experienced such abuse as children.

Domestic violence among men in same-sex relationships is studied less often than abuse within heterosexual relationships. However, same-sex domestic abuse does exist and international research suggests that, like domestic abuse in heterosexual relationships, it may have an impact on vulnerability to HIV. Two U.S. studies suggest that men who experienced childhood sexual abuse are more likely to be in abusive relationships as adults, and that men who engage in unprotected anal intercourse are more likely to experience domestic abuse than men who do not. (89;23) It should be noted that estimates of abuse among same-sex male couples are likely underestimates as a result of "an unwillingness to report sexual activity of any nature with another man, or because the psychological effects of sexual violence could cause participants to not acknowledge their own experiences." (96)

In sum, childhood abuse negatively affects the ability of men to engage in HIV prevention behaviours, such as practising safer sex.

4.2.7 Culture

a) Racialized and ethnocultural minority groups of MSM

Racism, as a system of domination and oppression, works in the same way as sexism and homophobia. In fact, these systems of oppression are interlocking—they do not operate in a vacuum or separately—they are interwoven and their intersections serve to worsen the situation of those who cannot be neatly categorized into any one group. (101)

Ethnocultural minorities and racialized groups tend to be doubly burdened by racial stereotyping from both outside and within the gay community. (102) There is a tendency for men from marginalized sub-groups to be less likely to be "out" and to participate in gay-identified social venues, reducing both social capital-related health benefits and exposure to prevention messaging. (103) Little epidemiological data disaggregated by ethnicity or race exist, because of inconsistent reporting of ethnic identifiers linked to newly identified HIV infections, and because "research normally groups MSM, particularly Caucasians, as a homogenous unit, [thus] failing to locate individuals by cultural identity and place of birth [which] may result in confounded outcomes." (103) The lack of Canadian research in this area highlights the need to address specific sub-communities in research, prevention and programming. (104; 105; 60)

Youth who are recent Canadian immigrants may be particularly at risk of HIV. Ryerson University's Youth Migration Project in Toronto outlines some of the following links to HIV vulnerability:

• Rejection, or fear of rejection by their families and communities;
• Isolation from their cultural communities;
• Belief that their own families are more "backward" than mainstream Canadian families;
• Transphobia, within queer communities and beyond;
• A lack of culturally-appropriate and language-specific sexuality and HIV programs and resources; and
• Barriers to access to services. (39)

Studies of East and South Asian MSM indicate that social and cultural barriers faced by Asian MSM cause alienation from the community, hinder a positive self-image, and adversely affect sexual health. (40) This is a result of experiencing racism from within the gay community, and homophobia within their specific ethnic communities, as well as the general public. Cultural taboos regarding sexuality and a lack of health and social support services tailored to specific ethnocultural needs are also significant barriers. (40; 106; 107)

Being homosexual you're at the bottom of the barrel. You add AIDS to that, you're underneath the damn barrel... And then you're just totally shunned.

—HIV-positive Trinidadian man (41)

Gay, bisexual, two-spirit and other Aboriginal MSM also face homophobia and racism, particularly in the context of the lingering effects of colonization, as well as a result of multiple forms of oppression:

Today's Two-Spirited people face incredible obstacles. They are of two worlds, the world of differently-gendered, and the world of being Native. In essence, they are subject to multiple oppressions. As part of a minority based on gender or sexuality differences, they are oppressed and influenced by the surrounding dominant culture....Taking this into consideration, sound identity formation is an upward struggle. (42)

Available research, which examined the social conditions of two-spirit Aboriginal people in Canada, found that this population experiences "high unemployment, poverty, poor housing, homelessness, homophobia, racism, HIV/AIDS discrimination, and ostracism by the Aboriginal community." (18) As a result, this population is more prone to mental health disorders, such as depression and anxiety, which may lead to risky sexual behaviour. In addition, homophobic discrimination may also prevent two-spirit people from accessing necessary sexual health services, thus increasing their risk of acquiring HIV. (18)

My reserve chief and council are 'blind' to the fact that two-spirit exist. They shun you when they know you are GLBT. They need facilitators to inform them.

—Two-Spirit male (18)

4.2.8 Social Support Networks

Family, friends and a feeling of belonging to a community give people the sense of being a part of something larger than themselves. Satisfaction with self and community, problem- solving capabilities and the ability to manage life situations can contribute to better health overall. The extent to which people participate in their community and feel that they belong can positively influence their long-term physical and mental health. (43)

Social support networks such as family, friends and communities greatly impact an individual's sense of self and belonging. For some gay men, the coming out process and life afterwards can be heavily enriched by a strong social support system. However, gay men may also face social exclusion from family and friends, and may have created their own networks for support in response. (45)

Many gay and bisexual men have formed "chosen families" in addition to, or as a result of being alienated from their biological families. Chosen families are typically composed of friends and former lovers (with whom there may not necessarily be a current sexual relationship), who offer a familial type of support. (44) While gay men's sexual behaviours are relatively well-understood, the ways in which gay and other MSM form and sustain supportive relationships with families, romantic partners, and their broader communities, and the impact of these social support networks on vulnerability to, and resilience against, HIV require further study.

a) Relationships

Romantic relationships can be a source of social support for gay men, increasing health and well-being, while "lack of social supports or isolation is conversely considered a 'disease determinant.'" (45) For HIV-positive gay men, romantic relationships can be a source of social and emotional support in coping with HIV infection. (46)

The 2004 Sex Now Survey, conducted in British Columbia, provides some detail on gay and bisexual men's romantic relationships. In terms of longevity, about one third of relationships last less than one year (32.3%); one third last between one and five years (30.3%) and a little more than one third last more than five years (37.4%). In addition, a higher proportion of men over the age of 30 are in a partnership arrangement (56.6%) than younger men (45.3%). Similarly, a higher proportion of single men are in a lower income bracket (71.3%) when compared with partnered men (58.2%). (47)

Having multiple partners and engaging in unprotected sex are risk factors for HIV infection. It has been suggested that "gay men can potentially benefit from increased support in managing sexual pluralism—planned or unplanned—within couples negotiating unprotected anal intercourse" (9) as a strategy to reduce the risk of HIV infection. The majority (73%) of partnered gay and bisexual men interviewed for the 2006 Sex Now Survey reported having an explicit agreement with their partners regarding activity outside the relationship. One quarter (25%) said they had a monogamy agreement with their partner. Of those who had some kind of partnership agreement, 27% said that they had broken this agreement. (48)

Regarding social support, approximately 70% of M-Track respondents reported that emotional and social support were available to them most of the time, with a slightly lower percentage of respondents reporting support for daily chores if needed. (4)

[My parents] actually came to me and go...at least bi, you can have kids, right...the first thing they assumed was oh...now you're gay, you can't have a normal life, you can't have an education. And, they just automatically threw everything down the drain.

-Asian Male (102)

Data provided in Figure 20 suggest that gay and bisexual men on average experience less social support on a consistent basis than the overall male population^Footnote16. (49) Self-identified gay and bisexual men who participated in the 2007-2008 Canadian Community Health Survey (CCHS) reported statistically significant lower levels of various forms of social support, such as having someone to listen to them and having someone who shows love and affection, than the total male population^Footnote17. This is consistent with findings of the Sex Now Atlantic Region 2006 Survey, which also noted lower levels of social support for gay and other MSM when compared with results for all men from the 2005 CCHS. (50)

Figure 20: Gay/bisexual males by selected variables, Ontario, Alberta, British Columbia and Northwest Territories, 2007-2008

Source: Statistics Canada, Canadian Community Health Survey, 2007/8 (49)

While it is established in the literature that a lack of social support and alienation from family and community can result in negative health outcomes, further research is needed to understand the specific implications of these data on HIV vulnerability for gay and other MSM. (9;43)

b) Internet

The rise of the Internet in the last two decades has permanently changed the scope of social support networks. Traditional social support systems were once limited to one's immediate physical environment. Now instant connections with others all over the world are possible. The expansion of social networks has led to many gains for gay men and other MSM, as well as some potential risks. (51)

The Internet is potentially a useful way to deliver information regarding safer sex and the transmission and prevention of HIV and sexually transmitted infections among MSM.(109) However, the research available focuses primarily on the Internet as means for soliciting anonymous, casual or long-term sexual partners, and the associated risks for HIV and other STIs.

Some studies indicate that using the Internet to find sex partners may increase other high-risk behaviours such as multiple sex partners and sex with serodiscordant partners and therefore increase vulnerability to HIV. (108; 5)

A 2006 literature review examined research related to the Internet as a sex-seeking tool for MSM. The review suggests that most research is quantitative with few qualitative studies available. It refers to a meta-analysis, which indicated that around 40% of MSM have looked for sexual partners online and approximately 30% have had a sexual encounter with someone they met online. (109) PHAC's M-Track data offer a consistent finding: 39% of men who participated revealed that they looked for sex on the Internet in the previous six months with 57% of those men revealing they did so on a regular basis (more than once a month). (4)

The meta-analysis mentioned above suggests "a higher prevalence of unprotected anal intercourse (especially with serodiscordant partners) was found among MSM who sought sex online than those who did not." (109) Yet other studies suggest that there is no difference with respect to unprotected anal intercourse (UAI) in men who use the Internet and those who do not. (109)

One study, which recruited 2,262 men from Canada and the U.S. who had had sex with someone they met online at least once, sought to determine whether the behaviours of these men had changed since they started using the Internet to find sex. Sixty percent of the men indicated that their behaviour had changed: 51% reported an increase in the number of sexual partners, 41% oral sex, 30% anal sex and 26% increased the use of condoms during anal sex. (52)

A few open-ended questions in the above study revealed that some men had experienced other types of changes through the Internet, such as finding men with similar interests, feeling more comfortable being out as gay, and having safer sex. (52) Similarly, other studies suggest that Internet use has helped gay men combat social isolation caused by living in rural areas or due to discomfort with going to gay bars and other gay-identified establishments. Chat rooms were seen as a preferred avenue to communicate with other gay men and also as places to seek out sexual health information. (109)

4.2.9 Income and Social Status

Income and social status are key determinants of health for LGBT people, as their educational achievement and career opportunities can be affected by the prejudice and phobic reactions they experience at school, in the workplace, or elsewhere. (53)

As discussed in Chapter 2, demographic data regarding gay and other MSM are limited, including information on income and social status. According to one 2008 study, Canadian gay men have personal incomes that are 12% lower than their heterosexual peers, (54) while data available from the Canadian Community Health Survey suggest that gay and bisexual men tend to have incomes similar to those of other men. (49)

People with low incomes or living in poverty are more likely than those with higher incomes to be at risk for HIV infection, to have HIV, to progress from HIV to AIDS and to succumb to AIDS more quickly. (1) One report notes that "people living with HIV in Canada, most of whom are gay men, are frequently reduced to poverty or to great financial hardship." (9) For example, a study of 5,100 self-identified gay and bisexual men living in Vancouver estimated that those who were HIV-positive (16%) were more likely to earn less than $20,000 per year and not to be employed full-time. (19) For more information on income as a social determinant of health for people living with HIV, please see the Population-Specific HIV/AIDS Status Report: People Living with HIV/AIDS.

Social status and hierarchies can also influence an individual's sense of desirability to others. Gay men who feel disadvantaged by their age, ethnicity, income or physical appearance may feel compelled to make trade-offs during sex where condoms are forsaken, if they are considered an impediment to fulfilling the sexual encounter, thus increasing their vulnerability to HIV. (89;102)

4.2.10 Social and Physical Environments

Homophobia and heterosexism have historically contributed to the development of physical spaces for, and by, gay men and men who have sex with men, including public spaces that afford relative anonymity and privacy in sexual relations (including parks, public washrooms, and so on). (9)

As described in Chapter 2, gay and other MSM live in a social context shaped by homophobia. This has an important effect on the social and physical environments inhabited by these populations. Conversely, supportive social and physical environments created by, and for, gay and other MSM can be "safer spaces" that allow for socialization without the threat of homophobia or violence. (9) There are numerous social venues, which are attended by gay and other MSM. Although the volume of research may not reflect the actual proportion of gay and other MSM who frequent this type of establishment, bathhouses are the subject of a substantial body of research as locations that can be associated with sexual risk behaviours. Further research is required to better understand the impact of a broad range of social and physical environments on vulnerability and resilience to HIV among gay and other MSM.

The 2006 Sex Now Survey reveals some common community activities of gay and bisexual men. The majority (65.0%) of participants indicated that they spent half or more of their free time with other gay men. In addition, 62.0% indicated that they are active in sporting activities, and 51.0% indicated a high level of engagement in social groups, volunteering or otherwise participating in social activities in the gay community. (47) This suggests the existence of gay-positive social networks. The 2004 Ontario Men's Survey identified several popular social venues (Figure 21) including gay bars and, to a lesser degree, LGBT dances, straight bars and bathhouses. (55)

It is important to note, however, that high levels of engagement in gay-specific activities may be particular to those men who are "out" as gay or bisexual, and that the methodology of venue-based sampling may have artificially inflated such findings, relative to those who self-identify as other than gay men (i.e., bisexual or another category of MSM).

Figure 21: Socializing in the gay community: frequency of participation in various social events, Ontario, 2004

Source: Myers, T., et al. Ontario. 2004. (55)

As detailed in Figure 22, the Ontario Men's Study indicated venues, including virtual spaces, where men sought out one another for sexual purposes. Men have most commonly visited gay bars in the last 12 months to look for sex (60.3%). The Internet (35.3%) and bathhouses (31.4%) are also highly frequented settings where men look for sex with men in Ontario.

Figure 22: Socializing within the gay community: where men look for sex with men, Ontario, 2004

Source: Myers, T., et al. Ontario. 2004 (55)

a) Bathhouses

Gay bathhouses were some of the first gay social spaces, beginning in the late nineteenth century, in a context of the criminalization of gay sex and the stigmatization of those who engaged in it. In the mid-twentieth century, the first exclusively gay bathhouses opened, specifically designed to cater to the social and sexual needs of gay men. Bathhouses served as a private refuge from society's prejudices against homosexuality, and a relatively safe space in which to meet like-minded men for companionship and sex. As social spaces, bathhouses played an important role in the development of a modern gay identity among men who were sexually and romantically attracted to other men. Later on, they served as triggers for community activism, as gay men organized against police raids in the 1970s and early 1980s. (56)

Today, bathhouses are usually commercial spaces designed to enable sexual and social encounters among men. (57;110) A study that examined bathhouses in North America found that most bathhouses in Canada are located in Canada's three largest urban centres: Toronto, Montréal and Vancouver. (58)

Most existing research on the impact of social and physical environments on HIV vulnerability and resilience among gay men and other MSM focuses on bathhouses in urban areas and concentrates on levels of HIV knowledge, user characteristics and sexual behaviours. (57) Though research to date is inconclusive as to whether bathhouses are more likely sites than others for HIV sexual risk behaviours, one model suggests that relative anonymity, reports of alcohol and drug use, and the social practice of largely non-verbal communication may constitute barriers to practising safer sex, despite high levels of preventive knowledge and the availability of safer sex equipment. (57)

Unlike the United States, Canada did not experience many bathhouse closures as a result of the emergence of AIDS in the 1980s. (58) Following the emergence of HIV, consultations were held in several cities between public health officials and representatives of gay communities in an attempt to strike a balance between public health's mandate to prevent the spread of disease and the community's ability to protect its members using peer-based strategies. (57) As known sexual and social spaces for gay and other MSM, bathhouses in Canada were and continue to be targeted by HIV risk reduction services. In cities across Canada, AIDS service organizations (ASOs) and municipal public health authorities regularly visit bathhouses to provide clients with safer sex materials, such as condoms and lubricant, sexual health information, referrals, anonymous HIV and syphilis testing, and even access to professional counselling.

A small qualitative study of 23 gay and bisexual men extracted from the Polaris HIV Seroconversion Study sought to explore the experiences and perceptions of HIV risk associated with bathhouses. Though participants indicated that casual and/or anonymous sex was commonplace, they described the atmosphere in bathhouses as "HIV aware." Still, the HIV risk level was considered high despite the availability of condoms and lubricant because of non-verbal solicitation of sex, and drug and alcohol use. Participants also revealed a heightened feeling of safety in terms of stigma, discrimination and violence, compared to other environments, such as parks and bars. (57)

Research suggests that men who engage in one high-risk behaviour tend to engage in other high-risk behaviours, forming clusters of men at higher risk of HIV transmission. This will be discussed in greater detail in Section 4.2.12 Personal Health Practices and Coping Skills. However, in terms of social and physical environments in which higher risk activities are reported, it is important to note that men who seek sex in environments such as bathhouses also tend to partake in or seek sex in other environments, such as public settings and through Internet sites, which may increase their vulnerability to HIV. (57; 72; 80; 111-115)-59)

4.2.11 Health Services

These greater inherent economic and societal injustices coupled with homophobia often lead to depression, low self-esteem and a turn to risky sexual behaviour. Additionally, due to discrimination, particularly homophobic discrimination, two-spirited individuals and LGBT may not feel safe in accessing healthcare services. This delays exposure to preventative HIV/AIDS education, diagnosis of infection and care, treatment and support. (18)

There is little Canadian literature available concerning health and healthcare access for gay and other MSM. (116; 117) However, a review of what does exist indicates that fear of stigma and discrimination, lack of confidentiality, sensitivity and awareness, as well as proximity of services, all impact the quality and frequency of care received by members of these populations.

Two studies that are arms of the PHAC's M-Track enhanced surveillance program have found that the majority of respondents disclosed to a healthcare professional that they had male sexual partners. Results from the ManCount survey (the Vancouver arm of M-Track) showed that 79% of respondents disclosed to a physician or nurse that they had male sexual partners. (59) Similarly, the 2008-09 cycle of the ARGUS survey (the Montréal arm of M-Track) found that 88.9% of respondents' physicians were aware of their patients' sexual orientation. (118) However, these results also indicate that some gay and other MSM do not discuss their sexual behaviour with healthcare staff, which can reduce access to appropriate health care.

A study on access to health care found that fear of stigma and discrimination can make gay and other MSM reluctant to communicate their health needs to staff. 60) The authors also note that the emotional and mental stress resulting from an inability to be open about their sexual orientation and gender identity in healthcare contexts can result in complacency about health issues becoming a coping mechanism. As a result, access to necessary preventive information, counselling and treatment can be delayed or not accessed at all. (119)

Living in a rural area with fewer physicians and nurses can also influence the ability of gay and other MSM to access health services. For example, fearing a loss of confidentiality can often be an issue in smaller communities. This can affect men's willingness to disclose vital health information to their physicians. (14;60) Gay men from different ethno-racial minority communities face additional barriers in accessing health care. Consequently, they may suffer from more health issues, which are underreported and therefore go untreated. (14)

There may also be differences experienced by MSM in terms of access to certain types of sexual health services. A study of young gay men in Vancouver sought to determine how often healthcare providers offered sexual risk reduction counselling. One hundred and thirty-one men enrolled in the survey, 66% of which were White and 12% were First Nations. The latter were less likely to have reported being counselled (26%) when compared with the former (62%). Repeated counselling is vital among both HIV-positive and negative individuals as a means of prevention for HIV and other STIs. (61)

In addition, healthcare providers may not be knowledgeable about the unique needs of gay and other MSM, including those who are HIV-positive and those with healthcare needs unrelated to HIV. The "serostatus of sexual partners, patient perceptions regarding the impact of antiretroviral treatments on transmissibility and feelings of HIV prevention fatigue" (120) are all factors that must be considered by a healthcare provider. Stigma, discrimination and ignorance about the specific needs and realities of this population are all identified as issues that affect access to health care for gay and other MSM. (120)

4.2.12 Personal Health Practices and Coping Skills

As discussed in Chapter 3, the number of new positive HIV tests attributed to the MSM exposure category is not decreasing. Although many MSM practise safe sex all or most of the time, HIV transmission between gay and other MSM continues to occur.

a) Safer Sex Practices

Studies have shown that many gay men and other MSM consistently practise safer sex, especially with casual partners. (4; 5) According to results from the M-Track survey, over 60% of participants used condoms the last time they had anal intercourse, although less than half of those with a casual partner used a condom consistently during insertive (47.0%) and receptive anal sex (49.6%). Men who had sex with regular partners with the same HIV status as themselves also were less likely to report consistent condom use than men having sex with regular partners with a different status. (4)

Data from the Sex Now Survey further suggest that HIV-related risk behaviours were largely confined to one quarter of survey participants. The survey also found that although casual sex was common among participants (64%), a majority of these men reported consistently safe practices (61%), while 39% reported some HIV-related risk behaviour(s). Moreover, just over half of the men (52%) who reported anal sex with a casual partner had used a condom consistently. (5)

b) Unprotected Anal Intercourse

Unprotected anal intercourse (UAI), specifically receptive UAI is reported as the most common risk factor for seroconversion among MSM. (67; 80; 111; 121) Although the majority of MSM continue to practise safe sex, a significant subset of the population engage in UAI. (5; 122; 123) Unprotected receptive anal sex is generally considered to be riskier than other types of sex for several reasons:

• The lining of the anus provides a large surface area containing a large number of immune cells, which are the preferred target of HIV. (62;63)
• Although HIV can cross the lining of the anus and enter the bloodstream on its own, tears can make it easier for HIV to do so. The rectum is particularly susceptible to tearing during intercourse because the lining of the anus and rectum are very thin and the rectum does not produce extra lubrication during intercourse. (62;63)

Like insertive vaginal sex, insertive anal sex is also a high-risk activity, although generally less risky than receptive anal sex. The lining of the urethra and the foreskin of the penis in uncircumcised men contain many immune cells, creating a ready target for HIV, which may be present in rectal fluids or blood. (62;63) Other biological factors, such as viral load and the presence of other sexually transmitted infections that can cause ulcers or vesicles on the penis or in the rectum, can also increase the risk of HIV transmission. (64)

In the literature, a number of factors have been associated with UAI: the unavailability of, and difficulty using condoms (including erectile difficulties); (71; 124; 125) trust and relationship issues; (47; 118) momentary lapses; (110) depression and stressful events; and assumptions about the safety of partners and situations. (66;47;67) Furthermore, as discussed in the Section 4.1.7 of this report, Income and Social Status, trade-offs are sometimes employed by men who feel inferior and therefore forsake sex with condoms out of fear of losing the sexual encounter. (89; 102) Gay men and other MSM engage in unprotected sex and other HIV-related risk behaviours as a result of various interconnected environmental, psychosocial, and personal factors. (47; 65; 90; 108; 111; 113; 118; 126; 127)

Initially we always had protected sex and then at some point we discussed monogamy and we both felt confident in the other person, that we could trust the other person, that if....we both tested, we both were negative and we both trusted each other that we could have unsafe sex until such time as something happened, an extramarital affair or something like that, or an extra-relational affair, and in which case we would have to renegotiate things.

—British HIV-positive male (68)

"Barebacking," also known as "raw sex" or "skin-to-skin sex," (69) is a phenomenon that has gained research interest in the past decade. Although there is some inconsistency in the use of the term, barebacking has been defined in the literature as "intentional anal sex without a condom with someone other than a primary partner." (70) Barebacking is a sociocultural and behavioural phenomenon marked by the intentional and conscious decision to seek unprotected sex. However, not all men who engage in UAI identify this practice as barebacking. The intentional aspect of barebacking distinguishes it from more general UAI discussed earlier. Some men engage in barebacking as a means of increasing physical intimacy with their partners even in cases of casual or anonymous sex, (69; 124; 128; 129) such that it is seen as more intimate, natural and pleasurable when compared with sex with condoms. (71)

Some men who routinely engage in barebacking may endorse a specific set of values and rationales regarding sexual practices different from other gay men and other MSM. (72) Adam et al., recruited a small group of 34 men who practise barebacking to analyze this set of values and beliefs. The authors attributed high-risk behaviours and situations to diverse attitudes among distinct groups of MSM and "taken-for-granted rules of conduct for sexual interactions." For example, many of the HIV-positive men interviewed spoke of "being part of a social environment where 'everybody knows' a set of rules whereby sex without condoms can happen as default circumstance to be interrupted only when a partner asserts a need to protect himself." (73)

Bareback culture is sometimes associated with HIV-positive men, which accounts for a small subset of the population engaging in risky sexual behaviour contributing to the increasing rates of UAI among HIV-positive men. (72; 89; 124)

c) Mental Health

Research suggests that gay and bisexual men often experience poorer health outcomes than their heterosexual counterparts. (12) Specifically, gay and bisexual men report higher rates of anxiety and mood disorders, as well as increased rates of suicidal ideation. (130) The effects of homophobia and stigma and discrimination largely contribute to mental health issues among gay and bisexual men, particularly youth. (53; 60; 75; 101; 131-133)) "Experiences of discrimination [and] exposure to unpredictable, episodic, or daily stress resulting from the social stigmatization of one's identity are important contributors to health disparities associated with minority sexual orientations." (132)

When my self-esteem is down...or I'm depressed and just sort of, you know, feeling downtrodden by the world. It's just I...get into that "I don't care" mode.

—Thirty-year-old HIV-positive male (74)

There is some evidence that mental health issues can lead to risky sexual behaviours such as UAI, (74) and may also lead to increased substance use. (75) In one study, an analysis of the link between stressful life events and risk of HIV infection was conducted using a sample from the Polaris HIV Seroconversion Study. The findings reveal that gay and bisexual men experiencing stressful life events were at increased risk of HIV infection. Specifically, more men who had reported periods of high stress had engaged in UAI than those who did not report stressful life events. (76)

Very up and down in my world: change of jobs, still grieving, you know, the loss of my partner, change in cities that I was living in, change in homes, selling my home and moving here in Toronto, so a lot of sh-t going on. Yeah a lot of emotional upheaval at the time.

–HIV-negative male in his 60s speaking about the events which led to unprotected sex (74)

The BC Adolescent Health Survey, which interviewed students from Grades 7-12 throughout British Columbia in 1992, 1998 and 2003, found that in general gay and bisexual males experienced emotional distress, such as feelings of nervousness and/or pressure, anxiety as well as suicidal ideation more often than heterosexual males. (36) Other studies in Victoria, Vancouver and Montréal have also found that gay and bisexual youth had poorer mental health outcomes when compared with heterosexual youth. (134; 135)

In addition, findings from the three BC Adolescent Health Surveys reveal that rates of sexual and physical abuse, as well as suicide attempts, had declined among gay male youth. However, rural gay and bisexual males were more likely to have experienced sexual abuse and to have attempted suicide within the last year when compared with gay and bisexual males from urban areas. (36)

A separate analysis of responses from the Vanguard Project (January 1998-January 2000) found that a high number of respondents had experienced some form of non- consensual sex, which was significantly associated with mental health issues, including alcohol abuse, suicidal ideation, suicide attempts and mood disorders, such as depression, anxiety and bipolar disorder. (136)

d) Drug Use

Drug use before or during sex has been associated with higher risk sexual behaviours. Injection drug use is both an important HIV risk behaviour and the primary mode of transmission for HCV. (4) A significant amount of research reveals "statistical links between substance use and a host of behaviours deemed high risk for HIV transmission among gay and bisexual men." (137)

Phase 1 of M-Track sought to assess patterns and trends regarding recreational drug use among MSM in Canada. Participants were asked about their lifetime use of recreational drugs and their drug use behaviour in the previous six months.

Approximately 83% had used one or more recreational substances (including alcohol) before or during sex in the previous six months, and 61% had done so excluding alcohol. The most frequently used drugs were alcohol (74.1%), sexual enhancers—defined here as poppers and Viagra (39.8%)—and marijuana (38.0%). Other less frequently used substances included cocaine/crack/freebase (15.9%) and heroin or other opioids (<3.0%). "Other recreational drugs" includes Special K, Ecstasy, crystal meth, GHB, psychedelics and other amphetamines, which 21.2% of men reported using. (4)

The 2006 Sex Now study reported a number of findings related to drug use among gay and bisexual men in British Columbia: 90% of those surveyed use alcohol and 52% use marijuana. Users of crystal methamphetamine, a factor considered high risk for HIV infection, were most likely to live in urban areas (86.9%), particularly Vancouver (69.1%), were Caucasian (74.9%), under age 45 (82.8%), not HIV positive (75.1%) and single (55%). (5)

Research supports a connection between recreational drug use and UAI. (137-140) Recreational drug use has also been associated with seroconversion. (80) In some cases, "club drugs," such as ecstasy, nitrites, ketamine (Special K), and amphetamines are used to lower inhibitions while in social settings. (74; 137; 141) In a sub-sample of HIV-positive gay and bisexual men from the Polaris cohort, qualitative interviews revealed that some men attributed their seroconversion to impaired judgements as a result of recreational drug use. The participants reported becoming less inhibited and more careless with drug use. (137) Similarly, in a small Vancouver study, some participants indicated that they used club drugs such as crystal methamphetamine and ecstasy to enhance socialization and connectedness in group settings. "However, unlike ecstasy, crystal was associated with a distinct pattern of sexual arousal that frequently included unprotected (sometimes group) sex, was more likely to be used regularly by HIV-positive men and reportedly highly addictive and problematic." (141)

You shouldn't be doing drugs, shouldn't be doing barebacking, so...it just feels so...unbelievable. You've never had hotter sex.... In a nutshell, I find barebacking very erotic and the use of the drugs was enough to...lower my reasoning, inhibitions, to allow me to go for it.

—Gay male (128)

Furthermore, some studies suggest that gay men and other MSM take certain drugs to enhance their sexual performance. (141) Yet the link between these drugs and risky sexual behaviour is unclear. Myers et al., found that sexual enhancement drugs "increase sexual arousal, facilitate sexual encounters, increase the capacity for sexual behaviours, prolong sexual experiences and increase the capacity to prostitute." (137) Specifically, increased sexual activity has been attributed to crystal methamphetamine use. (5) However, the causal role it plays in risky sexual behaviours, such as multiple sexual partners and UAI, is not well understood. Some suggest that men may take on receptive positions during anal intercourse to off-set the erectile dysfunction caused by the methamphetamine use. (77) Other studies suggest that methamphetamines attract men who are inclined to risky sexual behaviours with or without the influence of drugs or alcohol. (89)

e) MSM-IDU

Research suggests that men who have sex with men and inject drugs (MSM-IDU) are at a particularly high risk of acquiring and transmitting both HIV and HCV. (113; 115) The prevalence of HIV and related risk behaviours (e.g., sharing needles) is higher among MSM-IDU than other MSM or IDU. (113; 115)

In a Vancouver-based study of 910 MSM, 12% (106) had injected drugs while 88% (804) had not. Of the 106 MSM-IDU, 8.5% were HIV-positive while 2.0% (795) of MSM were HIV-positive. A multivariate analysis of the sample revealed that MSM-IDUs were twice as likely to report UAI with casual partners when compared with the MSM sample. In addition, the MSM-IDUs in this cohort were more likely to be Aboriginal, younger than the MSM sample, have engaged in the sex trade and were more likely to have had sex with females. Further analysis of this cohort revealed that the most likely route of seroconversion for the MSM-IDU was through UAI rather than injection-related exposure. (138)

Targeting MSM-IDU for HIV prevention programs is essential, since they may serve as an important bridge between high and low HIV-prevalence populations, as a result of their sexual and drug-using relationships with other MSM and/or IDU and/or heterosexual women. (142)

f) Commercial Sex Workers

Little data is available on male sex workers. According to the 2006 Report of the Subcommittee on Solicitation Laws, 20% of street-involved sex workers are male or transgender. Clients of both female and male sex workers are mostly men. Off-street sex work among males is typically limited to private establishments and clubs. (78) Studies suggest that male sex workers are less likely to be assaulted by their clients than females, but more likely to encounter violence by members of the public. (78)

M-Track respondents were asked about their involvement in the commercial sex trade in the previous six months, which was defined as having given or received money, drugs or other goods or services in exchange for oral or anal sex with a male partner. Overall, 10.2% of M-Track respondents reported giving money, drugs, or other goods or services in exchange for sex in the six months preceding the study; the proportion ranged from a low of 3.4% in Winnipeg to a high of 11.3% in Montréal. (4) Similarly, 10.1% of respondents reported receiving money, drugs or other goods or services in exchange for sex. Variations across sites were more pronounced, ranging from a low of 5.4% in Victoria to a high of 36.7% in Winnipeg. (4)

More research is needed on the impact of sex work on male HIV vulnerability and resilience.

g) Risk Reduction Strategies

Sero-sorting

HIV-positive and negative men sometimes look for seroconcordant partners for the purpose of reducing the risk of HIV transmission and for the opportunity to have seemingly less risky unprotected sex. (120; 128) In some cases, men choose to have sex with other men regardless of the other's status and employ risk reduction strategies accordingly, such as using a condom with a serodiscordant partner. (74; 128)

The authors of the Men, Sex and Love Web Study reported from a subsample of data on partnered men that HIV-discordant couples were significantly more likely to consistently use a condom during anal sex. By contrast, being in a partnership of unknown concordance was not associated with consistent condom use. (79)

He was interested in unprotected [anal sex] and I said, ''Well, you know, I'm HIV positive and I don't want to get what you have.... I know you're a positive too but like, yeah, it's not okay, anyways, regardless 'cause I could get what you have and I'm really not interested in getting what you have right now.''

—Thirty-year-old HIV-positive male (143)

Sero-sorting often relies on assumptions instead of explicit disclosure of HIV status. (144) For instance, the literature indicates that some men make assumptions regarding their partner's serostatus based on willingness to use a condom. (89; 128) However, the assumptions are often based on perceptions related to high risk, which can be inaccurate, and can also lead to other risks such as delayed condom use and exposure to other sexually transmitted infections. (80)

Strategic positioning

Strategic positioning is another risk-reduction strategy. The practice involves placing the HIV-negative man in the insertive role in anal sex when his partner is HIV-positive or has an unknown HIV status. As with sero-sorting, this practice can rely on assumptions about a partner's HIV status rather than explicit disclosure. While HIV transmission risk is somewhat lower for the insertive partner, unprotected anal sex remains a high-risk activity for both insertive and receptive partners. (81)

Viral load and antiretroviral-based prevention

Recent studies on sero-discordant heterosexual couples show that beginning treatment with antiretroviral medications as soon as a person is diagnosed HIV positive can reduce blood viral load to undetectable levels, and thus significantly reduce the risk of onward transmission. (82) However, no equivalent studies have been conducted on sero-discordant gay couples and other MSM.

Nonetheless, some HIV-positive individuals who are currently taking antiretroviral medications may rely on having an undetectable viral load to reduce the risk of HIV transmission to sexual partners. (82) Research shows, however, that HIV can still be present in semen and other fluids, even though the virus is undetectable in the blood, meaning the risk of HIV transmission remains. In addition, recent studies have also shown that "pre-exposure prophylaxis" with antiretroviral medications for HIV-negative individuals can significantly reduce the risk of seroconversion.(145)

Positive prevention

Positive (or "poz") prevention is an approach that engages people living with HIV/AIDS (including gay and other MSM who are HIV positive) in activities that can contribute to preventing onward transmission of HIV. Positive prevention may involve behaviour change, developing the communication skills and confidence to make decisions to take care of one's own health and reduce possible harm to one's sexual partners. This topic is discussed more fully in the Population-Specific HIV/AIDS Status Report: People Living with HIV/AIDS.

Post-exposure prophylaxis (PEP)

For individuals who have had high-risk exposure to HIV, such as through unprotected sex, a condom breaking during sex, or sexual assault, post-exposure prophylaxis with antiretroviral drugs can reduce the risk of sero-conversion. (84) Recommendations vary by jurisdiction, and the decision to offer PEP should be made in conjunction with an HIV specialist and in accordance with provincial, territorial or regional accords. PEP should be started no later than 72 hours after exposure, and continued for 28 days. (85) PEP is not 100% effective in preventing HIV infection. PEP is generally available to those who have experienced occupational exposure, i.e., exposure on the job, such as a needle stick in a healthcare setting. Following non-occupational exposure, it may be available in some emergency rooms and urgent care clinics, but is not always readily available. While occupational PEP is typically covered by workplace insurance, non-occupational PEP may or may not be covered by public or private insurance. This may create an access barrier, as a month-long course of PEP can cost over $1000. Safety concerns associated with PEP include potential side effects and their effect on adherence, creation of a false sense of security leading to risk behaviours and the potential for drug resistance. (84)

AIDS optimism and HAART

When HIV/AIDS first emerged in the early 1980s, little was known about the disease. For those who became infected with HIV, fear was immense and death seemed inevitable. Twenty-five years later, the perception of the virus has changed; it is now largely viewed as a chronic but manageable condition with many HIV-positive individuals leading active and productive lives. (86) This is in large part due to the advancement in HIV therapies including highly active antiretroviral therapy (HAART). Despite an initial decrease in new HIV infections in the mid-1990s, developments in treatments, and increased prevention knowledge and awareness, the number of new infections among MSM is not declining. (87)

Some have attributed the ongoing transmission of HIV among gay and other MSM to "AIDS optimism." The availability of HAART combined with the assumption that a low viral load reduces the risk of transmission has diminished the fear of AIDS, and thus increased unsafe sex. (80; 144; 146; 147) However, evidence suggests that AIDS optimism only explains a part of the recent increase in risky sexual behaviours; and studies do not support the connection between an increase in unsafe sex and the use of HAART and existence of undetectable viral loads. (144)

One study examined data from a subsample of the MAYA study, looking at the influence of viral load level on risk-taking with different types of partners among HIV-positive MSM. While the proportion of HIV-positive MSM in the study who did not use a condom changed depending on the HIV status of their partner (22.1% did not use a condom with a regular HIV-negative partner; 44.1% did not use a condom with a regular partner of unknown HIV status; 59.3% did not use a condom with a regular HIV-positive partner), viral load levels were not associated with risk-taking behaviours. (88)

In addition, a meta-analysis of 25 studies, the majority of which contained MSM, did not reveal a compelling connection between the use of HAART and an increase of unprotected sex. (86) Nevertheless, "unprotected sex was significantly more common in individuals who believed HAART decreased HIV transmission....lack of awareness of HIV infection status is a likely reason for continuing high-risk behaviours in MSM." (86)

Disclosure

I mentioned it at the bar. That's the way I am. When I meet someone and...there's [a] good chance that we're going to end up doing anything, I'm right up front with it.

—French Canadian male (74)

Sero-sorting as a risk management strategy depends on individuals accurately informing their partners of their serostatus before engaging in risky sexual behaviour. This is often complicated by some men's unwillingness to disclose their status. Shame, fear and insecurity all contribute to the decision not to disclose one's HIV status. (89)

It has been noted that disclosure is less common with casual partners and more frequent with partners that are more familiar to one another. (89) One study indicates that men may engage in brief sexual encounters to avoid disclosing their serostatus. (89)

A study that used data from the Ontario Men's Survey found that the likelihood of reporting UAI with both regular and casual partners was higher among men who always and sometimes (vs. never) disclosed their HIV status, who reported being HIV-positive (vs. those of unknown serostatus), who reported more than 10 partners, who engaged in commercial sex, and among men who used recreational drugs. (90)

A number of people living with HIV/AIDS in Canada, including gay and other MSM, have been convicted of criminal offences in cases where non-disclosure of their positive status rendered their partner's consent to sexual activity invalid (i.e., the partner was exposed to a significant risk of bodily harm and would not have consented had the disclosure been made). Disclosure, non-disclosure, and their implication for people living with HIV/AIDS are discussed more fully in the Population-Specific HIV/AIDS Status Report: People Living with HIV/AIDS.

Testing

HIV testing uptake is fairly high among MSM in Canada, including subpopulations of MSM. For example, the majority of men who participated in Phase 1 of M-Track reported having been tested for HIV (86%). In addition, a large portion of men who indicated that their last test was HIV negative had been tested in the two years prior to survey participation (75.2%). (4) Further, men who report higher-risk behaviours also report higher odds of testing. (4; 92; 148) Non-consensual condom removal during anal sex and non-disclosure of HIV-positive status by a partner have been reported as reasons for seeking HIV testing among MSM. (92)

Furthermore, it is believed that the proportion of HIV-positive gay men and other MSM who are aware of their status is higher than in the general population. It was estimated that in 2008 19% of HIV-positive gay men and other MSM in Canada were unaware of their status, compared to an estimated 26% of HIV-positive individuals in the general Canadian population who were unaware of their status (PHAC, HIV estimates, 2008). This is supported by findings from M-Track. Of the Phase 1 M-Track participants who provided a biological sample of sufficient quantity for testing and who completed a questionnaire, the prevalence of HIV was 15%. Of the men whose biological sample tested positive for HIV, 19% were unaware of their HIV-positive status. (4)

4.3 References

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[4] Public Health Agency of Canada. M-Track: enhanced surveillance of HIV, sexually transmitted and blood-borne infections, and associated risk behaviours among men who have sex with men - Phase 1 Report. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada; 2011.

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[6] Warner T. Never going back: a history of queer activism in Canada. Toronto: University of Toronto Press; 2002.

[7] Health Canada. HIV and AIDS in Canada: surveillance report to December 31, 1999. Ottawa: Division of HIV/AIDS Surveillance, Bureau of HIV/AIDS, STD and TB, LCDC; 2000.

[8] Rayside DM, Lindquist EA. AIDS activism and the state in Canada. Studies in Political Economy 1992;39:37-76.

[9] Ryan B, Chervin M. Valuing Gay Men's Lives: Reinvigorating HIV Prevention in the Context of our Health and Wellness. Ottawa: Canadian Strategy on HIV/AIDS Health Canada; 2000.

[10] Ryan B. A new look at homophobia and heterosexism in Canada. Canadian AIDS Society; 2003.

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