HIV and Men Who Have Sex with Men

HIV and men who have sex with men

Professional briefing

This briefing is for anyone who works with men who have sex with men (MSM), whether as a practitioner, voluntary, or community worker. It will help you answer questions about HIV, explains why MSM are especially at risk, and the importance of having regular HIV tests and using condoms and lubrication (‘lube’).

The areas covered include: policy, transmission and epidemiology, awareness and risk, prevention, testing, and further information sources.

The term ‘men who have sex with men’ is applicable to any man who has sex with other men, whether they view themselves as gay, bisexual or straight. It doesn’t matter if they’re out on the gay scene or not, or how many sexual partners they have, or how often they have sexual contact with another man.

HIV stands for human immunodeficiency virus. This infection weakens the immune system so the body is vulnerable to other infections and cancers. Acquired immunodeficiency syndrome (AIDS) is the term used when someone with HIV gets one of these other infections or cancer.

1. Policy

There are two substantial national policies in Scotland aimed at promoting positive sexual health among MSM and at reducing levels of HIV transmission – Respect and Responsibility and the HIV Action Plan.

Respect and Responsibility: A strategy and action plan for improving sexual health, published in 2005, aims to remove barriers and normalise HIV testing, particularly in the genito-urinary medicine (GUM) setting. The Chief Medical Officer’s letter in 2007 encouraged greater HIV detection in primary care. In 2008, Respect and Responsibility: Delivering improvement in sexual health outcomes 2008-2011 set out specific actions to reduce levels of HIV transmission.

The main aims of the 2009 HIV Action Plan in Scotland are to provide a refocus on HIV, particularly on reducing transmission and undiagnosed infection, and better coordinated service provision. It recognises the continued efforts needed to address the rise in HIV, especially among populations at greatest risk of acquiring the infection, including men who have sex with men.

1 2. Transmission and epidemiology

HIV is found in certain body fluids, particularly in blood and semen. There is no risk of infection from sweat, tears, spit or urine (unless they contain significant amounts of blood). HIV can be transmitted by infected fluids getting into someone else’s bloodstream through sores, cuts or inflamed skin or ‘mucous membrane’ found in the mouth or anus and on the penis. Unprotected anal sex is the main route of HIV transmission among MSM.

Unprotected anal sex is high risk because the skin (mucosa) lining the rectum is easily damaged, which can allow the infection to enter the bloodstream. Also anal mucous is rich in the immune system cells that HIV targets.

Receptive anal sex is riskier than insertive anal sex but a lot of factors can affect the likelihood of transmission, such as the presence of another sexually transmitted infection (STI) or the viral load of a sexual partner.

HIV is a particular issue for MSM because the chances of having sex with a partner who has HIV are, on average, much higher than for men who only have sex with women.

The prevalence of HIV infection among MSM in Scotland is not known but about 3% to 4% of those tested have a positive result.

At least half of all transmissions occur within a few months of a man becoming infected. This is because he is probably unaware that he is infected and so may not use condoms. Also, because his immune system can’t control the infection, he’ll have a high concentration of the infection in his semen. Once someone is diagnosed and begins treatment, they are much less likely to transmit HIV to others.

HIV tests and diagnoses

New reports of HIV have been increasing by about 300 to 400 per year since 2004. MSM account for between 40% and 50% of diagnoses each year. In recent years, the majority (67%) of people who acquired HIV in Scotland were MSM.

Between 2004 and 2008 there was a 71% increase in HIV testing. However, there are still some MSM who remain undiagnosed until they fall ill with AIDS. (For more information on this, see www.documents.hps.scot.nhs.uk/bbvsti/ sti/publications/sshi-2009-11-24.pdf).

One negative test result can sometimes give false reassurance. In 2008 in Scotland, 15 MSM who were diagnosed positive had tested negative earlier in the same year. That is why it is important for MSM who change partners to get tested every six months.

2 Co-infections

As a result of unprotected anal sex, MSM are particularly at risk of having other STIs such as syphilis and gonorrhoea, as well as chlamydia, genital warts and herpes. Overall in 2009, 13% of MSM with acute sexually transmitted infections attending GUM clinics were known to be co-infected with HIV. Of those diagnosed with gonorrhoea, 17% had concurrent chlamydia, and 24% of those with infectious syphilis had HIV (where this status was known).

Partner notification, which involves identifying and contacting sexual partners of individuals with STIs, is important in tracing contacts of MSM given they may also be in a relationship with a woman.

3. Awareness and risk HIV symptoms

MSM should be particularly encouraged to get tested if they present with a set of symptoms that could indicate early HIV infection, although these can also be symptoms of other conditions. The link with HIV may not be immediate, especially if assumptions are made about sexual activity (for example, only having a heterosexual relationship). This can sometimes result in late diagnosis and resultant limited treatment options.

Although many people with HIV feel well most of the time, there are some symptoms that can indicate possible HIV infection. These include:

• fever, night sweats • rash • mouth ulcers • joint and muscle pain • poor appetite • weight loss • tiredness • chronic diarrhoea.

However, these symptoms aren’t just associated with HIV. They could be caused by another more benign condition. Only a negative test result will offer that reassurance.

Providing HIV information and support

While many MSM may think they are well informed about HIV, in reality this is often not the case. This can lead to complacency and unsafe sexual practices. In addition, fear of being rejected by friends, family, and sexual partners can deter some men from seeking information or asking for an HIV test.

One in four men who have sex with men say they don’t know anyone with HIV, but they may have had sex with someone who has HIV without knowing it. Once someone is diagnosed and begins treatment, they are much less likely to transmit HIV to others.

Men may not be aware that the latest HIV treatment offers a greater chance of living a long and healthy life, if the infection is diagnosed early enough.

3 Be ready to give clear, impartial and up-to-date information on HIV prevention, testing and available treatment if someone has tested positive.

• Make sure that condoms and lube are promoted and freely available. • Encourage men to get tested every six months (or sooner if they have had unprotected anal intercourse). HIV status and disclosure

There may often be little discussion about HIV between regular as well as casual partners. Many men stop using condoms as soon as they start a relationship because they incorrectly believe or assume they both share the same HIV status. Even when HIV status is discussed, a man who has recently been infected may believe he is negative based on a previous test result.

HIV transmission and the law

Very few people in Scotland have been prosecuted for passing on HIV, but it can happen in certain circumstances.

In Scotland, an HIV positive person may be prosecuted if they ‘recklessly endanger’ someone, that is having sex without a condom, even if that other person isn’t infected in the process. In practice, a prosecution is more likely to occur where someone who has tested HIV positive doesn’t disclose his status to a partner he knows to be negative, and he doesn’t use a condom for penetrative sex so the negative partner becomes infected as a result and makes a formal complaint to the police. For more information go to www.hivscotland.com

Safer sex among MSM

MSM are no different from the general population in being neither consistently safe nor consistently risky when it comes to sexual activity. They may practise safer sex for months or years at a time, but still take occasional risks because of error, misjudgement, drugs or alcohol, love or lust.

The more sexual partners a man has, the more likely it is that he will come into contact with someone who has HIV. Some forms of sex between men are safer than others such as mutual masturbation. The best protection is to always wear a condom and to use it properly alongside lube.

There is still a risk if someone is ‘receptive/passive’ or ‘insertive/active’ during penetrative sex, especially if the ‘insertive’ partner has broken skin on his penis, ejaculates inside the anus, or either man has another untreated STI. Some men still mistakenly believe that the ‘insertive/active’ partner is not at risk of HIV.

Without using condoms and lube, anything that increases the risk of bleeding makes HIV easier to pass on, such as rough sex, sex toys, enemas, and long or group sex sessions.

Using drugs and alcohol

Using drugs (poppers being the most popular) and alcohol can encourage sexual partners to take risks, particularly as they help reduce inhibitions and relax muscles making anal penetration easier, encouraging rougher sex. The effects can mask any pain from skin damage and awareness of bleeding, increasing the risk of HIV transmission.

4 4. Prevention Condom failure

One in 10 men say that they have experienced a condom splitting during sex. Condom failure is usually the result of condoms and lube not being used properly rather than a fault with the product.

The common causes of condom failure are:

• insufficient lube • using oil-based lube or spit that can damage latex condoms • lubrication inside the condom so it slips off • wrong size condom • unrolling and stretching a condom before putting it on • friction from long or rough sex sessions • using two condoms at once • using condoms past their expiry date or with no kite or CE mark.

Encourage proper and consistent use. Condoms need to be checked during sex, taken off carefully to avoid spillage, replaced after 30 minutes and with every new partner. They should also be used on sex toys. Latex gloves offer protection if fingers are inserted in the anus.

Emergency treatment

PEPSE (post exposure prophylaxis for sexual exposure), sometimes known as PEP, is a powerful four-week course of drugs that can help prevent the HIV infection from becoming established if started within 72 hours of exposure. It is taken for a month following a high risk exposure and reduces the risk of HIV transmission by around 80%. Side effects can include diarrhoea, headaches and vomiting, but these can usually be controlled.

MSM may not know what PEPSE is or how to get it, be embarrassed to ask for it or concerned about side effects. It is available from GUM clinics, accident and emergency departments and some other out-of-hours medical services. Find out which of your local services offer this so that you have the information easily to hand when you need it.

5. Testing

Getting tested is a simple process. Providing clear and accurate information on what’s involved and where testing is available will encourage people to undergo first-time tests and regular retests.

Before having a test, the doctor or nurse will usually cover:

• the likelihood of having HIV (based on a risk assessment) • the ‘window period’ for seroconversion • how test results will be provided.

Seroconversion describes the period between acquiring HIV and the infection showing up in the bloodstream. It can take up to three months (the ‘window period’), so an HIV test within this period may not be conclusive. This is why regular testing is important.

5 MSM should be encouraged to get tested, but not pressurised. You could suggest they confide in a close friend or family member before testing, so someone is ready to offer them support, if required, following a positive result.

Early testing, retesting and testing results

MSM may only actively seek a test when they’re particularly worried about HIV – for instance, if they’ve had unprotected sex with a man they’ve since found out is living with HIV.

The later someone is diagnosed, the more chance HIV will have seriously damaged their immune system and leave them vulnerable to life-threatening infections, increased hospital admissions, and time off work/disrupted home life.

Regular testing every six months is recommended as a realistic timeframe for sexually active MSM. It enables HIV to be diagnosed early, but should not be too much of an inconvenience. MSM who frequently have unprotected anal sex, especially with a lot of partners, should be encouraged to get retested more often.

A positive result can be seen within a few weeks of someone becoming infected. In some cases, seroconversion can be delayed by up to three months. Anyone who asks for a test less than three months after exposure to risk should be given one, with a recommendation to retest after the window period. Don’t encourage someone to defer testing for any reason – if they’re asked to come back later, the chances are they won’t come back at all.

Types of test

Most tests involve having blood taken from a vein in the arm but, in some areas, fingertip pin-prick testing is offered. You may be asked about new tests, such as ones that use saliva or which give results after a few minutes, but these are not routinely available in Scotland. Home-testing kits (often advertised online) are not recommended as they don’t provide the necessary advice and support.

Testing locations

Anyone can get an HIV antibody test from a GUM or sexual health clinic – this doesn’t have to be their nearest one. Private clinics also offer HIV testing but it can be expensive.

GPs can offer HIV testing or refer patients to another practice, although some MSM might prefer to go to specialist sexual health services who offer anonymous testing.

Barriers to HIV testing

Some men may have particular reasons for not protecting themselves against HIV or getting tested to find out their HIV status, but these may be based on misconceptions or false assumptions.

Not knowing where to go for a test, what a test involves, such as how long it will take, fear of prosecution or even just getting to test location, can put people off. In particular, men born outside the UK, whose first language is not English, may choose not to get tested because they’ve been misinformed about the cost of tests and treatment in Scotland. Undocumented migrants should, in principle, be charged for healthcare. However, in practice, this is dependent on their particular circumstances; the seriousness of their illness; whether the treatment involved a hospital stay; and the interests of public health.

6 MSM should be encouraged to see that the benefits of HIV testing outweigh any perceived inconvenience.

Confidentiality and anonymity: A common barrier to HIV testing is concern about whether confidentiality can be guaranteed, and if it is ‘safer’ to go to a clinic rather than their GP for an HIV test, especially as test requests don’t contain patient details. Men should be made aware of confidentiality protocols regardless of the test setting. GPs offer a confidential service although testing is unlikely to be anonymous.

Impact on insurance: Previously, someone who had been tested for HIV may have been refused insurance. Now life insurance companies don’t usually impose conditions or refuse cover because someone has had an HIV test. They can ask for access to medical records, with the person’s consent.

GPs do not need to report negative HIV tests when writing insurance reports and can refuse to answer questions about ‘lifestyle’ or STI risks. GPs should not disclose whether a patient has ever had a negative test or the reasons for testing.

Test results and next steps

Results are available within a week, usually in person. A result will be negative, positive or undetermined. An undetermined result means another test is necessary.

Men who test negative should not be complacent about the risk of HIV but knowing they are HIV negative can motivate them to stay that way through practising safer sex.

A positive result means someone has HIV. Clinics will always repeat such a test to make sure that the blood specimen came from the correct person. A positive result usually comes as a shock and may be difficult to cope with. Post-test counselling to explore treatment options and available support is important.

Starting treatment

Treatment recommendations are based on two main factors: the extent to which HIV has weakened a person’s immune system, and whether they have any symptoms. If treatment is not started straight away, ongoing support will be provided.

7 6. Further information Research and statistics on prevalence, prevention and treatment

Aidsmap www.aidsmap.com

AVERT www.avert.org

Sigma Research www.sigmaresearch.org.uk

Health Protection Scotland www.hps.scot.nhs.uk

NHS Health Scotland www.healthscotland.com/wish

Clinical guidance on treatment, testing and standards

Medical Foundation for AIDS and sexual health www.medfash.org.uk

British Association for Sexual Health and HIV www.bashh.org

British HIV Association www.bhiva.org

NHS Quality Improvement Scotland www.nhshealthquality.org

Support and advice

HIV Scotland www.hivscotland.com

Terrence Higgins Trust Scotland www.tht.org.uk/contactus/scotland

Gay Men’s Health www.gmh.org.uk

Waverley Care www.waverleycare.org

National Aids Trust www.nat.org.uk

Campaign resources

To access the posters and leaflets promoting regular testing and condoms and lube, and to download this briefing, see www.healthscotland.com/wish