Socio-cultural influences on the transmission of HIV among gay men in rural China

Bisexual behaviours are relatively common among men who have sex with men in China. This pilot study aims to reveal the complex processes through which such men manage their sexuality, family responsibilities and sexual behaviours in a rural Chinese setting. A total of 15 men who have sex with men were recruited by purposive sampling. Face-to-face in-depth interviews were conducted to explore participants’ views about their sexual experiences and practices. The Chinese traditional moral code, family values and gender roles that form the crucial components of Confucianism were reflected in the participants’ efforts to maintain familial and social harmony through a compromised form of sexual partnership. Most study participants demonstrated a mixed experience of social stigma, sexual naiveté and ignorance of HIV and sexually transmitted infections (STIs). Under cultural and family pressure, men who have sex with men entered heterosexual marriages with the intention of maintaining a balance between their collectivist (familial) obligations and their individualistic (same-sex sexual) desires. However, the opaque nature of their concurrent sexual relationships may endanger their personal health and accelerate HIV and STI transmission. Reducing the stigma and social prejudice associated with male same-sex sexual relations is essential for any culturally sensitive HIV-prevention programme to succeed in rural China.     

HIV prevention and men who have sex with women and men in México: Findings from a qualitative study with HIV‐positive men

Unprotected sex between men is the major risk factor for HIV infection in México and many other Latin American countries. There is a substantial body of literature demonstrating that the relationship between sexual identity and sexual practice is not binary or causal — men who have sex with other men do not necessarily perceive themselves as gay — and there is increasing interest in HIV prevention with men who have sex with both men and women. In México, HIV prevention with men who have sex with women and men and who are not socially affiliated or identified with gay men is lacking. This paper explores the sexual histories and HIV‐risk perception of HIV‐positive Mexican men who indicated that they have sex with women in a screening interview and then in the context of an in‐depth interview also reported having had sex with men. We consider the sexual practices and sexual and social identities of these men, examining their explanations for having sex with other men, the strategies used to affirm their masculinity, the management of their sexual identity in their social networks, HIV‐risk perception before diagnosis and sexual practices after diagnosis. Recommendations are made to improve HIV prevention for men who have sex with men as well as women and who do not assume a gay or bisexual identity.     

Socio-demographic correlates, HIV/AIDS-related cofactors, and measures of same-sex sexual behaviour among northern Thai male soldiers

We use data from an anonymous self-administered 1991 survey of military personnel in northern Thailand to estimate overall levels of and socio-demographic differentials in same-sex sexual behaviour in this population. Additionally, we examine the relationship between sexual experience with another male and a variety of outcomes relevant to HIV prevention and policy. Overall, 16.3 per cent of the sexually active soldiers report ever having had anal or oral sex with other males. Same-sex sexual behaviour in this sample is positively associated with several indicators of higher socio-economic status. All of the men who report having had sex with other men report having had vaginal intercourse with females as well. Comparison of our estimate of same-sex sexual behaviour with those obtained from two similar samples drawn in 1991 suggests that the lower estimates observed in the other two studies are largely due to differences in data collection methods. Regarding the HIV/AIDS-related outcomes we examined, men who have had sex with other men are significantly more likely than those who have not to have ever injected drugs, to personally know someone with HIV/AIDS, to have had sex with a female prostitute in the last six months, and to have had a sexually transmitted disease in the last six months. In this sample, men who have had sex with other men are also less knowledgeable about HIV/AIDS than are men who have not. These results are discussed in terms of their implications for HIV-prevention policy in Thailand.     

HIV prevention and men who have sex with women and men in México: findings from a qualitative study with HIV-positive men

Unprotected sex between men is the major risk factor for HIV infection in México and many other Latin American countries. There is a substantial body of literature demonstrating that the relationship between sexual identity and sexual practice is not binary or causal -- men who have sex with other men do not necessarily perceive themselves as gay -- and there is increasing interest in HIV prevention with men who have sex with both men and women. In México, HIV prevention with men who have sex with women and men and who are not socially affiliated or identified with gay men is lacking. This paper explores the sexual histories and HIV-risk perception of HIV-positive Mexican men who indicated that they have sex with women in a screening interview and then in the context of an in-depth interview also reported having had sex with men. We consider the sexual practices and sexual and social identities of these men, examining their explanations for having sex with other men, the strategies used to affirm their masculinity, the management of their sexual identity in their social networks, HIV-risk perception before diagnosis and sexual practices after diagnosis. Recommendations are made to improve HIV prevention for men who have sex with men as well as women and who do not assume a gay or bisexual identity.     

Men who have sex with men's sexual relations with women in Bangladesh

Studies of men who have sex with men in South Asian countries including Bangladesh have tended to focus mainly on measuring male-to-male sexual risk behaviours, with less attention being given to understanding the nature and meaning of their sexual relations with women. This can result in missed opportunities for HIV/AIDS-related intervention. This paper, based on a small scale qualitative study, attempts to develop a cultural model to understand men who have sex with men's sexual relations with women within a gender and masculinity framework. Findings reveal that in Bangladesh men who have sex with men frequently surrender to societal pressures to marry, become husbands and shoulder fatherhood. This forces some women to become the silent sufferers of some of the negative consequences of hetero-normative patriarchal practice. Importantly, however, men who have sex with men consider sex with women a form of real sex within a framework of masculine sexual potency irrespective of preference, desire or eroticism. Thus, challenges exist to undertaking sexual health promotion and HIV/AIDS prevention in culturally sensitive ways.     

Structural and environmental factors are associated with internalised homonegativity in men who have sex with men: Findings from the European MSM Internet Survey (EMIS) in 38 countries

Internalised homonegativity refers to a gay person's negative feelings about homosexuality and is believed to stem from negative societal stereotypes and attitudes towards homosexuality. Surprisingly, little research has centred on this link. In this research, we aimed to examine the associations between internalised homonegativity and structural forces, cultural influence, and access to sexual health promotion measures among a sample of 144,177 men who have sex with men (MSM) in 38 European countries. Participants were recruited as part of the European MSM Internet Survey (EMIS) during 2010. It was a self-completion, multilingual Internet-based survey for men living in Europe who have sex with men and/or feel attracted to men. Assumed causal relations were tested through multiple regression models. Variables at the structure of rule-systems (macro-level) that were significantly and negatively associated with internalised homonegativity were the presence of laws recognising same-sex relationships and same-sex adoption. In the meso-level model, greater proportions of the population expressing that they would not like to have homosexuals as neighbours predicted higher internalised homonegativity. In the last model, five variables were significantly and negatively associated with internalised homonegativity: being exposed to HIV/STI information for MSM, access to HIV testing, access to STI testing, access to condoms, and experience of gay-related hostility. In turn, men who had tested for HIV in the past year evidenced lower internalised homonegativity. This is the largest and certainly most geographically diverse study to date to examine structural and environmental predictors of internalised homonegativity among MSM. Our results show that one insidious consequence of society's stigma towards homosexuals is the internalisation of that stigma by gay and bisexual men themselves, thus, drawing attention to the importance of promoting social equity for self-acceptance around gay identity in building a positive sense of self.     

Sexual behavior and HIV risk among age-discrepant,same-sex male couples

Research has suggested that men who have sex with men and who have older sexual partners are at increased risk of HIV infection. However, while several studies have explored risk among men in age-discrepant non-primary partnerships, only two have explored age discrepancy and risk in primary same-sex male relationships. We used data from semi-structured in-depth interviews to explore sexual behaviour and HIV risk among 14 Black, white and interracial (Black/white) same-sex male couples with an age difference of 10 or more years. Most couples regularly used condoms, and sexual positioning tended to lead to lower risk for younger partners. Some serodiscordant couples abstained from anal sex, while others used seropositioning to avoid transmission within the relationship. Within some couples, older partners acted as mentors on HIV prevention and broader life lessons. Future studies should further explore the potential risks and benefits of large age differences in same-sex male primary relationships.     

HIV risks among women who are married to men who have sex with men in India: a qualitative investigation

In countries such as India, men who have same-sex partnerships may marry women due to cultural pressures regardless of their sexual desires and preferences. The wives of such men may be at risk for HIV but limited existing research addresses this issue. This qualitative study used in-depth interviews to investigate HIV-related risk among married men who have sex with men (n = 34) and women who were aware of their husband’s same-sex behaviour (n = 13) from six research sites in five states and a Union Territory in India: Delhi (Delhi), Visakhapatnam (Andhra Pradesh), Hyderabad (Telangana), Bengaluru (Karnataka), Chennai and Madurai (Tamil Nadu). Thematic analysis revealed that wives of men who have sex with men were at risk for HIV from their husbands’ sexual practices, which are often hidden to avoid the potential consequences of stigmatisation, as well as from gender-based inequities that make husbands the primary decision-makers about sex and condom use, even when wives are aware of their husband’s same-sex behaviour. Innovative interventions are needed to address HIV-related risk in couples where wives remain unaware of their husband’s same-sex behaviour, and for wives who are aware but remain within these marriages.     

The other side of the bridge: exploring the sexual relationships of men who have sex with men and their female partners in Mumbai,India

Behaviourally bisexual men have been identified as a ‘bridge’ population of HIV transmission to heterosexual women in India. Little is known about the sexual relationships that these men have with their female sex partners. The primary objective of this study was to explore the sexual practices and relationship dynamics between married and unmarried behaviourally bisexual men and their female sex partners in Mumbai, India. In 2009, semi-structured qualitative interviews were conducted with 32 men who reported sex with men and women. Participants discussed a variety of sexual practices and arrangements with female sex partners. Irrespective of marital status and sexual identity, many said that they had satisfying sexual experiences and feelings of affection for female sex partners. However, sexual incompatibility between married partners was also reported. Explanations of bisexual concurrency were discussed in terms of both sexual satisfaction and sexual preference. Self-perceived HIV risk related to same-sex sexual behaviour motivated many men to use condoms with female partners. Expectations of unprotected marital sex and perceptions of partner risk were barriers to condom use. HIV-prevention programmes for this population may benefit from tailored risk-reduction counselling that attends to the variations of these sexual and social relationship dynamics.     

男男性接触者性伴网络特征与HIV传播

目的了解男男性接触者（MSM）性伴网络特征,探讨人类免疫缺陷病毒/性传播疾病（HIV/STDs）从该人群向普通人群传播的途径,为开展HIV/STDs的预防与控制提供依据.方法以同性恋酒吧为研究现场,以其中男男性接触者为对象进行匿名问卷调查.调查内容包括社会人口学特征、HIV/STDs感染状况、性伴类型及数量等.结果某市酒吧中MSM的HIV和STDs感染报告率分别为3.4%和10.3%;多性伴现象在MSM中普遍存在,且性伴类型广泛.在最近2个月中,50.0%的MSM有同性偶然性伴,17.8%有同性商业性伴,63.8%目前有同性固定性伴.曾有过异性性伴者为55.7%.拥有3种类型性伴者为19.5%,4种类型性伴者为12.6%.拥有不同类型性伴的MSM亚群之间相互关联,核心亚群为拥有异性性伴和拥有同性商业性伴亚群.结论 MSM以多维的性伴网络相互连接,不仅在MSM人群内部具有HIV/STDs的多向传播通道,而且已经形成了向普通人群传播的桥梁.     

Same-Sex Behavior and Health Indicators of Sexually Experienced Filipino Young Adults

The Philippines is one of seven countries in which HIV incidence has recently increased—much of this increase has been among men who have sex with men. Despite this trend, knowledge on sexuality and same-sex behaviors in the Philippines is limited. This study examines same-sex behavior, sexual outcomes, substance use, and psychological distress among young adults participating in the 2005 Cebu Longitudinal Health and Nutrition Survey (CLHNS). We use gender-stratified, multivariate models to compare young adults who reported same-sex behaviors and those who did not. Among a cohort of 1,912 Filipino young adults (ages 20–22), 58.2 % were sexually experienced and 15.1 % of them reported same-sex sexual contacts or romantic relationships. Compared to females, more males reported same-sex sexual contact (19.4 vs. 2.3 %) or same-sex romantic relationships (9.2 vs. 4.1 %). Young adults reporting same-sex behavior had higher odds of smoking, drug use, perceived stress, and more sexual partners as compared to their peers. Males who reported same-sex behavior initiated sex earlier than those males who did not report same-sex behaviors. There were no significant differences in depressive distress. Earlier sexual initiation and higher levels of substance use among Filipino young adults engaging in same-sex behavior highlight the need to address unique health issues within this population. Mixed findings for depressive distress and perceived stress indicate that further investigation is needed to explore the potential impacts of same-sex status on mental health outcomes, particularly in lower- and middle-income countries such as the Philippines.     

How intersectional constructions of sexuality,culture, and masculinity shape identities and sexual decision-making among men who have sex with men in coastal Kenya

Men who have sex with men are increasingly recognised as one of the most vulnerable HIV risk groups in Kenya. Sex between men is highly stigmatised in Kenya, and efforts to provide sexual health services to men who have sex with men require a deeper understanding of their lived experiences; this includes how such men in Kenya construct their sexual identities and how these constructions affect sexual decision-making. Adult self-identified men who have sex with men (n = 26) in Malindi, Kenya, participated in individual interviews to examine sociocultural processes influencing sexual identity construction and decision-making. Four key themes were identified: (1) tensions between perceptions of ‘homosexuality’ versus being ‘African’, (2) gender-stereotyped beliefs about sexual positioning, (3) socioeconomic status and limitations to personal agency and (4) objectification and commodification of non-normative sexualities. Findings from this analysis emphasise the need to conceive of same-sex sexuality and HIV risk as context-dependent social phenomena. Multiple sociocultural axes were found to converge and shape sexual identity and sexual decision-making among this population. These axes and their interactive effects should be considered in the design of future interventions and other public health programmes for men who have sex with men in this region.     

Correlates of Sexual Risk among Recent Gay and Bisexual Immigrants from Western and Eastern Africa to the USA

We examined correlates of sexual risk among gay and bisexual men, who recently migrated from western and eastern African countries to the USA and lived in New York City and who are HIV negative or of unknown status. These men migrate from countries where same-sex sexuality is socially rejected and mostly illegal contributing to the motivation to migrate. Their background might predispose these men to engagement in sexual risk practices, while they are not specifically addressed in HIV prevention programming. Participants (N?=?62) reported in face-to-face interviews on pre- and postmigration experiences, psychosocial determinants of sexual risk, and current sexual practices. Operationalization of sexual risk was based on the number of men with whom they had condomless receptive and/or insertive anal sex. Over a third of the men reported always having used condoms in the past year; among the other men, sexual risk varied. Multivariate analyses showed that sexual risk was lower among men with a stronger motivation to avoid HIV infection and higher among men who currently engaged in transactional sex. Further analyses indicated that housing instability was independently associated with reduced motivation to avoid HIV infection and with engagement in transactional sex in the USA. In recent western and eastern African gay and bisexual immigrants to the USA, structural factors, including housing instability, are strongly associated with sexual risk.     

Stigma, social inequality, and HIV risk disclosure among Dominican male sex workers

Some quantitative behavioral studies in the USA have concluded that bisexually behaving Latino men are less likely than White men to disclose to their female partners that they have engaged in same-sex risk behavior and/or are HIV-positive, presumably exposing female partners to elevated risk for HIV infection. Nevertheless, very little theoretical or empirical research has been conducted to understand the social factors that promote or inhibit sexual risk disclosure among Latino men who have sex with men (MSM), and much of the existing literature has neglected to contextualize disclosure patterns within broader experiences of stigma and social inequality. This paper examines decisions about disclosure of sex work, same-sex behavior, and sexual risk for HIV among male sex workers in two cities in the Dominican Republic. Data derive from long-term ethnography and qualitative in-depth interviews with 72 male sex workers were used to analyze the relationships among experiences of stigma, social inequality, and patterns of sexual risk disclosure. Thematic analysis of interviews and ethnographic evidence revealed a wide range of stigma management techniques utilized by sex workers to minimize the effects of marginality due to their engagement in homosexuality and sex work. These techniques imposed severe constraints on men's sexual risk disclosure, and potentially elevated their own and their female partners' vulnerability to HIV infection. Based on the study's findings, we conclude that future studies of sexual risk disclosure among ethnic minority MSM should avoid analyzing disclosure as a decontextualized variable, and should seek to examine sexual risk communication as a dynamic social process constrained by hierarchical systems of power and inequality.     

Moving beyond “the Down Low”: A critical analysis of terminology guiding HIV prevention efforts for African American men who have secretive sex with men

HIV continues to affect African American populations in the United States at disproportionate levels. Recent reports have described potentially high-risk behaviors of African American men who identify as heterosexual but who engage in secretive sex with other men. These men have been referred to as being “on the Down Low,” and this terminology has been used to label subgroups of African American men and explain sexual risks for HIV infection in the African American community. In this paper, we argue that an uncritical use of this terminology for guiding public health and HIV prevention strategies can be problematic and counterproductive because it (a) stigmatizes and exoticizes secretive same-sex sexuality as a unique issue among African American men, and (b) ignores the social conditions under which HIV transmission occurs. We explore some historical roots contributing to current perspectives on African American men's sexuality, describe the use of the term “on the Down Low” and its application to same-sex behavior among African American men, and explain how this term can both clarify and potentially ambiguate efforts to address HIV risk among African American men. Recommendations for research and HIV prevention strategies are also provided.     

萍乡市男男同性恋性病艾滋病哨点监测结果分析

目的了解男同人群的性相关危险因素特点,找出有效的途径或策略,进一步有效控制艾滋病的流行。方法问卷调查与实验室检测。结果总共监测310名男同,其中酒吧会所监测占30.97%,网络监测占69.03%;90%被监测男同是高中以上文化程度;最近一年患性病的占14.19%;310人当中HIV感染者8例,感染率为2.58%;网络招募人中HIV感染为3.27%。艾滋病知识知晓率为98.71%;有将近15%的感染者有过商业性行为(包括3名感染者);有商业性行为的男男同性恋艾滋病感染率与没有商业性行为的男男同性恋的艾滋病感染率两者比较有明显差异;与女性发生性关系的时候有三分之一不使用安全套,每次都会使用的不到一半,最近一次与女性发生性关系有三分之一没有使用安全套。结论男同容易将艾滋病性病进行婚内、外传播;男同存在掌握相关HIV防治知识与实际防范结果背离现象;网络加大了男同交往的频率和范围,也加大了艾滋病传播风险;同性商业性行为风险性更高;男同的双性性关系及无保护性性交在艾滋病传播中起到一个非常重要的桥梁作用;今后要把宣传干预重点放在双性恋、男性性商业服务人群、男同配偶或性伴、甚至青年妇女、青年学生身上。     

Bisexually Active Black Men in the United States and HIV: Acknowledging More Than the “Down Low”

HIV is disproportionately impacting Black men who have sex with men and heterosexual women in the United States. Current speculation posits a "bisexual bridge" of HIV transmission connecting these two subpopulations of the Black community. Specifically, bisexually active Black men who identify as heterosexual but do not disclose their same-sex behavior, or "down low" (DL) men, have received the most attention and blame as the primary group fueling this epidemic. This essay explores the current knowledge and limitations of public health research on bisexually active Black men. Implications for future research initiatives are discussed.     

Relationship Characteristics and HIV Transmission Risk in Same-Sex Male Couples in HIV Serodiscordant Relationships

Unprotected anal intercourse (UAI) remains a main risk factor for HIV among men who have sex with men (MSM) and this is of particular concern for partners of HIV serodiscordant status. However, HIV transmission risk has been demonstrated to vary by the sexual position adopted among partners. Guided by interdependence theory, this study examined how relational factors were differentially associated with risk taking (HIV-positive/insertive and HIV-negative/receptive) and strategic positioning (HIV-positive/receptive and HIV-negative/insertive) UAI within serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (n _couples = 91; n _individuals = 182) simultaneously but independently completed computerized questionnaires and HIV-positive men had blood drawn for viral load. A minority of couples (30 %) engaged in risk taking and/or strategic positioning unprotected anal sex. Results of multinomial logistic regression indicated that HIV-negative partners’ levels of relationship commitment were positively associated with the odds of engaging in strategic positioning sexual behaviors. For HIV-negative partners, reports of relationship intimacy, and sexual satisfaction were negatively associated with odds of reporting risk taking behavior. In contrast, HIV-positive partners’ reported sexual satisfaction was positively associated with odds of engaging in risk taking behavior. Findings suggested that aspects of relational quality may be differentially associated with sexual decision making for same-sex male couples in serodiscordant relationships. Study findings lend support for the incorporation of discussions of HIV risk reduction strategies, enhancing communication between partners, and support for general relationship functioning in HIV care.     

Maintaining a Heterosexual Identity: Sexual Meanings Among a Sample of Heterosexually Identified Men Who Have Sex with Men

Heterosexually identified men who have sex with men are an understudied group for whom there is little knowledge of the social and sexual meanings of their same-sex encounters. This study employed qualitative methods to better understand the maintenance of a heterosexual identity in the face of discordant sexual behaviors. Open-ended, in-depth, semi-structured interviews were conducted with 21 heterosexually identified men (M age, 39.85 years) who reported at least one sexual encounter with a male in the previous year but not more than one sexual encounter per month with a male. Of the participants, 61.9% were African American/black, 28.6% were currently married, 71.4% reported current substance use, and 57.1% were HIV infected. Participants did not consider their same-sex activities as discrepant with their heterosexual identity as these activities were coded as infrequent, recreational, accidental, or an economic necessity. They avoided intimacy by depersonalizing male sexual partners, limiting gestures (e.g., kissing, hugging, eye contact, conversation), and by distancing themselves from gay-identified venues. Participants transferred responsibility for their same-sex sexual activities by blaming external factors, such as a fight with their wife or substance use, for the sexual encounters. Despite their ability to compartmentalize these sexual encounters, many participants expressed guilt and shame when discussing their same sex experiences.     

Comparing Gay and Bisexual Men on Sexual Behavior, Condom Use, and Psychosocial Variables Related to HIV/AIDS

Interviews were conducted with 750 men, recruited from a variety of sources in Chicago, who reported sex with men in the past 3 years. Behavioral criteria were used to establish groups of gay and bisexual men. We predicted that gay men, compared to bisexual men, would report more male sexual partners, more experience with receptive sex, and more tolerant attitudes toward homosexuality. The only reliable difference between the gay and bisexual men with respect to number of partners was that gay men were more likely to have had a steady male partner or lover. Gay men were more likely than bisexual men to have engaged in receptive sex, including unprotected receptive anal sex. Bisexual men were more self-homophobic and saw other people as less accepting of same-sex activity. There were no differences between gay and bisexual men in other psychosocial variables. Interventions designed to reduce the transmission of HIV/AIDS need to consider differences in gay and bisexual men's sexual behavior and attitudes toward homosexual behavior.