The incidence of HIV infection among homosexual men in the United Kingdom is increasing despite efforts to reduce high risk sexual behaviour.1 The likelihood of engaging in high risk sexual behaviour may be increasing as new treatments reduce concern about infection.2 We report the results of a repeated survey of sexual behaviour among gay men in London.
Methods and results
A survey was conducted in 1996, 1997, and 1998 using the same methodology each year.3 A sampling frame was compiled of all commercial gay venues (bars, clubs, and saunas) and genitourinary medicine clinics within inner London. A sample of venue types and locations was then selected. Between 59 and 72 venues were sampled each year. Whenever possible the same venues were selected each year; if venues had closed they were replaced in the sample by similar ones. Health promotion workers distributed questionnaires with 16 items that covered demographic information and sexual behaviour. All men present at or queuing to enter a venue during a specific period were invited to participate. Altogether 6671 of 8384 (80%) questionnaires distributed were returned; similar numbers were returned each year. Data were analysed using SPSS.
Respondents were aged from 15 to 78 years (median 31). Men sampled in 1998 were significantly older than in previous years (table). Altogether, 5660 of 6354 (89%) of men were white and 4410 of 6232 (71%) resided in inner London.
In each year, about a third of the men (729/2263 (32%), 694/1943 (36%), 730/1916 (38%), respectively) reported having had unprotected anal intercourse during the previous year. However, in every year high risk sexual behaviour (for example, unprotected anal intercourse in the previous year) was significantly associated with younger age (occurring among 108/252 (43%) of those aged under 25 and 103/340 (30%) of those over 40, P<0.01 in 1998) and recruitment from a genitourinary medicine clinic (odds ratio 1.39, 95% confidence interval 1.13 to 1.71, P<0.01 in 1998).
Using 1996 as the baseline, there was a significant increase in the reporting of unprotected anal intercourse after adjusting for age and place of recruitment (1997 odds ratio 1.17 (1.03 to 1.33); 1998 odds ratio 1.23 (1.12 to 1.45)) (table). The adjusted odds of having had unprotected anal intercourse with partners whose HIV status was unknown or discordant also increased. However, there may be some misclassification error: of the 724 men who reported having had unprotected anal intercourse with partners of the same status, 118 (16%) had never had an HIV test. There was no significant increase in the adjusted odds of having had an HIV test.
When only those 25 venues sampled every year were selected for analysis the increase in the adjusted odds of having had unprotected anal intercourse in the past year remained significant.
Comment
This is the first report of an increase in unsafe sex occurring among gay men in England; this increase has recently been observed in the United States.2
The 80% response rate showed that the survey was acceptable to participants. However, only those men who were socially active or using genitourinary medicine services were invited to participate. Although there are difficulties in interpreting trends in repeated cross sectional surveys, we believe that these results are important as they represent an apparent change in behaviour among gay men using the most frequented venues in London.3,4
HIV transmission can be reduced by ensuring that men have unprotected anal intercourse only with partners of a concordant HIV status; for this strategy to succeed, the importance of HIV testing must be promoted. Despite recent campaigns and the availability of new treatments, we found no evidence of an increase in the uptake of testing.
Our results, combined with the reported increase in gonorrhoea cases among gay men5 and the increasing prevalence of HIV infection associated with longer survival, highlight the potential for the continuing spread of the epidemic and the need for more health promotion initiatives that have been shown to be effective.
Supplementary Material
Table.
Changes in two measures of high risk sexual behaviour among gay men completing anonymous questionnaires in London. Odds ratios calculated using logistic regression and adjusted for age and place of recruitment
| Year of questionnaire
|
Significance
|
|||||
|---|---|---|---|---|---|---|
| 1996 | 1997 | 1998 | χ2 (df) | P | ||
| % response | 75 (2482/3318) | 80 (2121/2639) | 85 (2068/2427) | 94.7 (1) | <0.001* | |
| Median (range) age (years) | 30 (16-71) | 31 (16-73) | 32 (15-78) | 27.9 | <0.001† | |
| % who had unprotected anal intercourse with >1 partner in past year: | 32 (729/2263) | 36 (694/1943) | 38 (730/1916) | 14.7 (2) | <0.001‡ | |
| Adjusted odds ratio (95% CI) | 1 | 1.17 (1.03 to 1.33) | 1.23 (1.12 to 1.45) | |||
| % who had sexual partner with unknown or discordant HIV status in past year: | 18 (375/2147) | 19 (348/1851) | 21 (378/1796) | 8.43 (2) | <0.02‡ | |
| Adjusted odds ratio (95% CI) | 1 | 1.10 (0.94 to 1.3) | 1.26 (1.08 to 1.49) | |||
| % who had an HIV test in past year: | 29 (683/2347) | 31 (614/2006) | 33 (654/1994) | 3.5 (2) | 0.17‡ | |
| Adjusted odds ratio (95% CI) | 1 | 1.03 (0.9 to 1.19) | 1.14 (0.99 to 1.31) | |||
Using χ2 test for trend (1 df).
Using Kruskal-Wallis test.
Using χ2 test for variation in adjusted odds between years from logistic regression (2 df).
Acknowledgments
We thank the Camden and Islington Health Authority for its financial support. We thank Dr Andrew Copas for statistical advice. We also thank members of the working group.
Editorial by Grulich
Footnotes
Funding: Camden and Islington Health Authority.
Competing interests: None declared.
The members of the working group appear on the BMJ's website
References
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