Low STI Knowledge, Risk Perception, and Concern about Infection among Men Who Have Sex with Men and Transgender Women at High Risk of Infection

Abstract

Background:

Amidst an increase in STI rates among men who have sex with men (MSM) and transgender women (TGW), there is little research on STI knowledge, risk perception, and concern about infection in these populations.

Methods:

This mixed-methods study explored these constructs among sixty racially-and ethnically diverse MSM and TGW who regularly engage in condomless anal intercourse with multiple partners.

Results:

Participants had a mean age of 40.63 years. Most (95%) identified as a man and as gay/homosexual (73%); 55% were college graduates. Almost half of respondents reported a prior STI. Participants correctly answered a mean of 55.36% STI- and 76.90% HIV-knowledge items. STI knowledge was positively correlated with education and prior HIV tests, and was higher among those with a prior STI. During in-depth interviews, some participants expressed concerns about limited knowledge of STIs and syphilis. Half reported low concern about syphilis infection, due to prior treatment that was perceived as relatively simple, lack of STI infection in the past, erroneous information about transmission routes, or simply not thinking about it.

Conclusions:

Among this high risk sample who perceived themselves to be at low risk of infection, knowledge was primarily gained through being diagnosed and treated for an STI, rather than from acquiring knowledge to prevent STI infection. Participants expressed interest in increasing their STI knowledge and recognized the importance of regular STI testing. Dissemination of targeted information about STI prevention, routinizing of STI testing, and STI self-testing might contribute to decreasing STI infection rates among this population.

Amidst a sharp increase in rates of sexually transmitted infections (STIs), there is little research on STI knowledge, risk perception, and concern about infection among men who have sex with men (MSM) and transgender women (TGW) at high risk of infection. Participants had limited knowledge of STIs, perceived themselves to be at low risk of infection, and many expressed low concern about infection. Dissemination of targeted information about STI prevention, routinizing of STI testing, and STI self-testing might contribute to decreasing STI infection rates among this population.

INTRODUCTION

Theoretical models of behavior change, including those most frequently used to promote the prevention of HIV transmission, include HIV knowledge as a fundamental component.(1) As such, studies exploring factors related to HIV risk behavior have often included assessments of HIV knowledge which, in general, have shown that men who have sex with men (MSM) are knowledgeable about how HIV is transmitted and prevented.(2–5) However, numerous studies have shown significantly lower levels of HIV knowledge among subsets of MSM, such as those who are not gay-identified,(3,4) those with lower educational levels,(3,4) racial/ethnic minorities,(3,4,6) and those in many low- and middle-income countries.(3,6,7) This is concerning, as higher HIV knowledge can diminish the vulnerability to HIV, whether through decreased sexual behavior(8,9) or more frequent testing.(10)

In contrast, little research has focused on assessing knowledge about sexually transmitted infections (STIs) other than HIV, even among populations at high risk of infection. Groups whose knowledge of STI have been assessed include adolescents in Australia,(11,12) Denmark and Germany,(13) and the USA;(14,15) adult Mexican crack users,(16) and Chinese university students.(17) A thorough search of the literature, however, yielded little research on STI knowledge among MSM. One study, among Dutch MSM,(18) found significantly less knowledge (63% vs. 83% of questions answered correctly; p<0.0005), and less perceived severity (2.9 vs. 3.9, respectively on a scale of one to four; p= <0.0005) about STIs than HIV. Another study also found limited knowledge of STI symptoms among MSM in Ecuador.(19) Other studies reported assessing HIV/STI knowledge, yet findings on STIs other than HIV were not presented nor the assessments described.(20,21) Lastly, our literature review failed to identify a single STI knowledge assessment tailored for men with exclusively male partners.

Amidst an epidemic of STIs among MSM,(22,23) this absence of research findings and assessments on STI knowledge is striking for a number of reasons. First, is the health consequences of STI infection, which, though mostly treatable, can lead to significant negative sequelae if they are left untreated. Second, increasing rates of STIs among MSM highlight the need for interventions to help individuals reduce risk of infection or, if infected, seek care to avoid onward transmission to others. Lastly, reducing STIs among MSM becomes critical given the association between STI and HIV infection.(24–27)

To begin to address this gap in the literature, this mixed-methods study presents findings on STI and HIV knowledge, risk perception, and concerns about syphilis infection among a high-risk group of MSM and transgender women (TGW) who regularly engage in condomless anal intercourse with multiple partners—a sample that would be a key focus for STI prevention interventions.

METHODS

Recruitment

Sixty participants were recruited via geospatial sexual networking applications (Grindr, Growlr, etc.), online (Craigslist, etc), and in-person for a study on self- and partner HIV and syphilis testing. Participants were MSM and transgender women (TGW), 18 years of age or older, HIV-uninfected, non-monogamous, reported rarely or never using condoms during anal intercourse, and who reported an average of three or more occasions of condomless anal intercourse per month.

Procedures

All participants were screened for eligibility criteria by telephone and, if eligible, were asked to come to our research offices to complete their study visit. During their visit, participants were asked to complete a questionnaire using a computer assisted self-interview (CASI) that included assessments of demographic characteristics, HIV and STI knowledge and risk perception, HIV and STI testing experiences, and pre-exposure prophylaxis (PrEP) use. After completing the CASI, participants self-tested for HIV and syphilis using either the mChip dongle,(28) a prototype HIV and syphilis rapid test (n = 39), or the INSTI HIV-1/HIV-2® rapid test and the Syphilis Health Check® tests (n = 20). Lastly, participants underwent an in-depth interview (IDI) that explored the experience of using the rapid HIV and syphilis tests to test themselves, which included questions about participants’ concern about syphilis infection.

Participants received $50 in compensation for their time. All procedures were approved by the Institutional Review Board of the New York State Psychiatric Institute.

Quantitative Measures

HIV Knowledge.

The HIV knowledge questionnaire is a 14-item questionnaire adapted for MSM from the HIV Knowledge Questionnaire-18 item (HIV-KQ-18).(29) The adapted questionnaire omitted items related to HIV transmission with female sex partners or during childbirth, and items that were answered correctly by almost all MSM participants in a prior study. Items on PrEP and transmission in the context of undetectable viral loads were added.

STI Knowledge.

The 32-item true/false assessment of STI knowledge was developed from STI information provided on the Centers for Disease Control website. We selected items that focused on STI transmission, prevention, symptoms, and availability of treatment. Items on syphilis were overrepresented because the parent study focused on the use of a rapid HIV and syphilis self-test. All items were tailored for male sex partners only, with no items assessing knowledge of vaginal transmission or symptoms of STIs.

HIV and STI Risk Perception.

The risk perception rulers were two items, “Considering your usual sexual behavior, how likely is it that you will get HIV in your lifetime?” and “Considering your usual sexual behavior, how likely is it that you will get a sexually transmitted disease (STD), not including HIV, in the next year?”, that were answered on a scale ranging from 1 (Extremely unlikely) to 10 (Extremely likely). Participants were also asked “how many times in total have you been tested for HIV?”; to indicate which STIs they had ever tested positive for from a list of ten STIs; and whether they had ever used PrEP.

Data Analysis

Quantitative.

Descriptive statistics were calculated for demographics, STI/HIV knowledge, and risk perception variables. Pearson correlations tested the association between STI/HIV knowledge and demographics/risk perception. Two-group comparisons (e.g., those with PrEP experience vs. not; history of STI vs. not) were conducted for STI/HIV knowledge scores by t-tests. To conduct these analyses, HIV and STI knowledge scores were attained by adding the number of items correctly answered by a participant.

Qualitative.

IDIs were audio-recorded, transcribed, and reviewed for accuracy. Development of the codebook originated with the general areas of inquiry of the IDI guide and further refined through repeated reading of transcripts by a team of four researchers. Codes were defined with inclusion and exclusion criteria including examples. Subsequently, three staff members independently coded the interviews; 20% of the interviews were double-coded and discrepancies between coders were discussed until consensus was reached. For this manuscript, the report on “Concerns about syphilis” was pulled and reviewed to identify modal responses and cases that contradicted the main trends as well as quotes to be included in the text. Quoted text has been edited for clarity and readability without compromising the integrity of the content.

RESULTS

Demographics

Participants (N=60) had mean of 40.63 (SD=13.26) years of age and annual income of $37,389 (SD=$37,418). Almost all respondents (95%) identified as a man and nearly three-quarters (73%) as gay/homosexual. Nineteen percent of participants reported their ethnicity as Latino/Hispanic; almost half (48%) identified their race as African-American/Black. Fifty-five percent of the participants were college graduates, half of whom reported having a graduate degree. A large minority of participants (40%) reported full-time employment. Almost half of respondents (48%) reported a prior STI and 49% had used PrEP. On average, participants had been tested for HIV 20.00 (SD= 20.19) times in their lifetimes.

STI and HIV Knowledge

Table 1 summarizes the percentage of participants who answered each STI and HIV knowledge item correctly. The mean percentage of STI knowledge items answered correctly was 55.36 (SD=26.24). The mean percent of items answered correctly was greater for Gonorrhea (68.33; SD=32.37) and Chlamydia (70.33; SD=33.04) than for Syphilis (50.28; SD=29.87), Hepatitis B (42.00; SD=30.96), and Hepatitis C (53.00; SC=33.11). In contrast, the mean percentage of HIV knowledge items answered correctly was 76.90 (SD=12.91). Although level of education was correlated with STI and HIV knowledge scores (see Table 2), age was only correlated with hepatitis C knowledge (r=.26; p=.041) and income was not correlated with STI or HIV knowledge.

Table 1.

Proportion of sample answering STI/HIV knowledge items correctly (N=60)

	Percent Correct
HIV
Pulling out the penis before a man climaxes or cums keeps his partner from getting HIV during sex (F)	88%
Showering, or washing one’s genitals or private parts, after sex keeps a person from getting HIV (F)	95%
A person can be infected with HIV without knowing it (T)	98%
Having a sexually transmitted disease (STD) can make it easier for someone to get HIV (T)	80%
You can tell if someone is infected with HIV by looking at them (F)	93%
If the amount of virus of an HIV+ person is consistently undetectable, that person can no longer infect someone else (T)	20%
There is a vaccine available to the public that can protect people from getting HIV (F)	60%
People are likely to get HIV by deep kissing, putting their tongue in partner’s mouth, if partner has HIV (F)	90%
Taking HIV medications immediately after being exposed can reduce chances of becoming infected (T)	63%
Although BOTH partners are at risk during sex without condoms, the ”top” is at greater risk for HIV (F)	83%
During the first three months after infection, a person may still test negative for HIV (T)	83%
Oral sex is just as risky as anal sex for transmitting HIV (F)	67%
Using Vaseline or baby oil with condoms lowers the chance of getting HIV (F)	83%
Taking HIV medications regularly can protect uninfected people from getting HIV (T)	72%
SYPHILLIS
In the early (primary) stage of syphilis, a painful sore usually appears at the site of infection (T)	50%
Syphilis lesions only appear on the genitals (F)	50%
If your partner does not have a visible syphilis sore, you are at no risk of infection (F)	75%
A urine test is used to diagnose syphilis (F)	42%
A syphilis lesion (chancre) can appear up to 90 days after the initial infection (T)	48%
The syphilis bacteria can enter your body through cuts in the skin or mucous membranes (T)	70%
Syphilis infections have been declining in the U.S. in recent years (F)	55%
The syphilis chancre (sore) disappears in a few weeks with or without treatment (T)	35%
Syphilis can be spread by using the same toilet or bathtub as an infected person (F)	52%
Early-stage (primary) syphilis is easily cured with antibiotics (T)	65%
Syphilis symptoms can go away and come back (T)	53%
Syphilis can cause pain during urination (F)	8%
GONORRHEA
A person can get gonorrhea from sitting on a toilet seat that was sat on by someone with gonorrhea (F)	62%
There is a cure for gonorrhea (T)	68%
Persons who have had gonorrhea in the past are protected from getting it again (F)	77%
There is a vaccine that prevents a person from getting gonorrhea (F)	60%
Gonorrhea can produce a penile discharge (T)	75%
CHLAMYDIA
Chlamydia can be transmitted to another person during oral sex (T)	70%
Chlamydia can cause pain during urination (T)	78%
There is a vaccine that prevents a person from getting Chlamydia (F)	58%
Chlamydia can be cured by antibiotics taken orally (T)	77%
You can have Chlamydia without having symptoms (T)	68%
HEPATITIS B
Hepatitis B is spread in the same ways as HIV (T)	63%
Most people who have hepatitis B will not feel symptoms for months (T)	47%
There is a cure for hepatitis B (F)	27%
For most people with a normal immune system, hepatitis B will go away on its own (T)	17%
There is a vaccine that prevents a person from getting hepatitis B (T)	57%
HEPATITIS C
Hepatitis C can only be spread through contact with infected blood (T)	57%
Hepatitis C affects the liver (T)	78%
There is a cure for hepatitis C (T)	43%
People who acquire hepatitis C infection will feel symptoms right away (F)	47%
There is a vaccine to prevent hepatitis C (F)	40%

Table 2.

Correlations between STI/HIV knowledge scores, demographic, and risk perception variables (N=60).

	Knowledge Scores
	Total STI1		Syphilis		Gonorrhea		Chlamydia		Hepatitis B		Hepatitis C		HIV
	r	p	r	p	r	p	r	p	R	p	r	p	R	p
Demographic Variables
Age	.13	.324	.12	.377	.09	.493	−.04	.753	.10	.447	.26	.041	.00	.999
Education	.31	.017	.30	.021	.34	.007	.28	.029	.20	.123	.11	.416	.36	.005
Annual income2	−.01	.955	−.03	.858	−.08	.552	−.02	.894	.14	.323	−.01	.924	.06	.696
Risk Perception Variables
Number of times tested for HIV2	.36	.005	.34	.007	.29	.027	.34	.008	.19	.156	.27	.039	.51	<.001
Lifetime HIV risk perception score3	−.02	.862	−.01	.943	−.02	.889	−.03	.826	−.03	.813	−.02	.878	-.31	.020
Next year STI risk perception score3	.30	.019	.26	.049	.25	.059	.27	.039	.25	.054	.24	.070	.10	.462

¹Excluding HIV.

²Log-transformed prior to correlations due to skewed distributions.

³High scores indicate higher risk perception.

During the IDI inquiry participants often expressed concerns about limited knowledge of syphilis, which was often highlighted through their difficulty answering the STI knowledge questions on the CASI component of this study.

To be honest with you, I don’t know much about syphilis. I had never been tested for it before. I’ve never had symptoms, I’ve never had reason, so. I am misinformed about syphilis, I mean I don’t know much about it.

(PTID 128)

I would say not as much as I thought that I knew and I would say that I definitely need to not sleep on syphilis and maybe -- not maybe, but definitely find out more about syphilis, as far as like as the symptoms, and what it can do to the body if not treated in an efficient amount of time.

(PTID 123)

Although the majority of participants could provide some key information about syphilis, very few were able to express confidence in or demonstrate thorough knowledge about syphilis or other STIs.

I do know that it’s -- it can be very undetectable. So you could get a rash -- if you do get it contracted, you could get a rash that’s unnoticeable. Again, for the first 90 days, that goes dormant and as far as this bug is sitting in you for years and you may not know. So it is imperative to get tested.

(PTID 185)

Well, I’ve heard that syphilis is on the rise. And I’m glad that I had a negative test, because I think I engage in a lot more activities that are likely to give me syphilis as opposed to HIV. Meaning, I don’t necessarily have anal intercourse every time I have sex with someone. But I do, most of the time, you know, have oral sex, or other forms of sex…where I can pick up other STIs.

(PTID 159)

Yes, the symptoms come and go. I know that you can get a mark, that you can get a sore. But I don’t know if that sore can come and go. So I realized I knew less about, like, syphilis symptoms. And actually, (laughs) that most of the information I have about syphilis come from -- I don’t know, like, 18th century novels. And it’s really problematic. So when you think of syphilis, I think of, like, people’s noses falling, like, and -- you know, like --And so now when I think of it, I think, I can get rid of that with penicillin. It’s like getting Chlamydia, or gonorrhea, or, yeah. Not like getting herpes, but –

(PTID 166)

HIV/STI Risk Perception and Knowledge

We explored the association between HIV and STI knowledge and three different variables related to risk perception: risk perception rulers, prior number of HIV tests, prior history of STIs, and PrEP use. Based on the risk perception rulers, the mean next year STI risk perception score was 4.72 (SD= 2.53) while the mean lifetime HIV risk perception score was 4.03 (SD=2.26). Table 2 shows that participants’ next-year STI risk perception score was positively correlated with STI knowledge (r= .30; p=.019); however, HIV risk perception was negatively correlated with HIV knowledge scores (r=−.31; p=.020). Other results showed that compared to participants who had never used PrEP, those that had were more knowledgeable about gonorrhea (t=2.15; p=.036) and HIV (t=3.37; p=<.001). Lastly, compared to participants without a prior lifetime STI, those with a prior STI were more knowledgeable about gonorrhea (t=3.74; p=<.001), chlamydia (t=3.90; p=<.001), hepatitis B (3.26; p=.002), HIV (t=2.02; p=0.048), and had a higher mean total of STI items answered correctly. Number of prior HIV tests was also positively correlated with STI (r= .36; p= .005) and HIV knowledge (r= .51; p= <.001).

Concerns about syphilis infection

Data from the IDIs provided a nuanced contextualization of concerns about syphilis infection for many participants. However, almost half the participants clearly stated that they were not concerned about syphilis infection.

I don’t really think about it, to tell the truth, until now. So, no, I don’t really have a lot of concern about syphilis.

(PTID 104)

How concerned am I about syphilis? Getting it when I go out to have sex? It doesn’t cross my mind.

(PTID 177)

Knowing what I know -- which is not enough, not much -- I’m not very scared of it. I assume it’s a treatable disease.

(PTID 147)

Not really [concerned]. Because I’m more of a top, so I feel like if I keep protected, I don’t really get it.

(PTID 154)

For some, the low concern is based on information and prior experience with syphilis testing and treatment. For these participants, their regular syphilis tests, knowledge about treatment options, and lack of infection while sexually active, has reduced their concern about being infected or accessing treatment if infected.

I’m not too concerned about syphilis only because I get tested fairly regularly. I’ve never tested positive for syphilis.

(PTID 171)

It’s not that big a concern because I know I can go get treated for it. I’ve actually been treated for it twice. One time when I had it, and one time when I did not. That wasn’t fun. That shot is not pleasant. But the Department of Health treats before they get your results. And I understand why because Penicillin’s not really going to hurt you and if you have it, you need to be treated right away.

(PTID 126)

For a few participants, however, the possibility of contracting syphilis was very concerning.

I mean, somewhat concerned, but this is primarily -- like, I’m concerned about syphilis and gonorrhea primarily because I’m allergic to penicillin, and so that reduces the number of antibiotics that can treat any -- that can treat infections. And so, that hits, like, rrrrrrrrrrr. So yeah, I mean, it’s a concern for me.

(PTID 115)

The thing that scares me about Syphilis is that you can have it without knowing it. And that’s the part that I don’t like, because sometimes -- and that’s why I get tested regularly for Syphilis, as well. Not just for HIV, but for STDs, as well. I get everything done, because of that fact that sometimes you can have it without knowing it.

(PTID 145)

If I wasn’t getting tested regularly because of PrEP, I would be much more inclined to use the syphilis (self) test, because after having friends who got syphilis, it’s a real thing. And even though I can get rid of it with penicillin, my visions of it are horrifying. And I’ve heard from so many people that syphilis is, like, on the rise. I just moved back to New York after being a way for a year and a half, from Dallas. And it was a big thing there, syphilis… so it’s just, like, something that I kind of -- if I’m thinking about an STI, and having fear of getting one, it’s actually syphilis. Yeah.

(PTID 166)

DISCUSSION

To reduce the increasing incidence of STIs among populations at high risk of infection, STI knowledge and an interest in avoiding infection are key. However, findings from this study demonstrate low STI knowledge, risk perception, and concern of syphilis infection among a sample of MSM and TGW who regularly engage in sexual behavior that puts them at high risk of HIV and STI infection. Conversely, HIV knowledge, in general, was high among this sample. Nonetheless, while most participants knew about PrEP, few knew about the benefits of undetectable viral loads in preventing HIV transmission; which may increase through the dissemination of public health campaigns about Undetectable=Untransmittable.

While these findings are consistent with those of other studies,(18) they are disconcerting given the high sexual risk behavior of this sample and their relatively high levels of education. In this study, knowledge about Chlamydia and Gonorrhea was higher, possibly due to a higher percentage of participants having had those STIs in the past. Knowledge about syphilis, of which a prior diagnosis was reported by only 15% of participants, was particularly low in relation to symptom identification, which may lead infected individuals to misdiagnose themselves and not seek appropriate care. This is particularly worrisome given the sharp increase in syphilis rates among MSM.(23) It appears that among this high risk sample, who perceived themselves to be at low risk of infection, knowledge was gained through the experience of having an STI and undergoing treatment versus gaining knowledge to prevent STI infection.

Qualitative findings added valuable nuance to the quantitative results and showed a wide spectrum of concern about syphilis infection. The lack of concern among many individuals in this sample were worrying, although for some it was based on regular testing and knowledge about or personal experience with the relatively simple treatment available in case of infection. For these latter individuals, having gone through treatment of syphilis in the past may have increased their knowledge of it but they also learned that treatment was available, relatively brief, and effective, thus reducing their concerns about a future infection. For some participants though, the repeated testing with non-reactive results appeared to reinforce a sense of low risk of infection. For others, the lack of concern about infection was more naïve; they just didn’t think about it; and for a few, it was based on limited knowledge, (i.e., feeling protected because they use condoms for anal intercourse and not knowing of the possibility of oral transmission). Limited knowledge combined with low concern can result in infrequent testing and undiagnosed infection that may quickly lead to further transmission to other sexual partners, especially among such sexually active individuals.

Interestingly, completing the CASI for this study appeared to raise awareness of knowledge limitations and concerns for many participants. As such, it seems that there is an interest and an opportunity for targeted information about STI prevention, especially informational campaigns that can reach individuals without their having to actively seek out the information. However, while knowledge is a key component of behavior change models, by itself it is often insufficient to effect behavior change. Models such as the Information-Motivation-Behavioral Skills Model suggest that to take steps to reduce risk of STI infection, individuals would need not only knowledge about STIs, but also motivation to prevent it and the skills necessary to implement risk reduction actions, such as condom use, STI testing, etc. This is highlighted by findings from our study, where individuals with knowledge (and experience) about STI infection remained unmotivated to act to prevent future infection due to perceived ease of treatment. While informational campaigns can address the knowledge component, it is also critical to intervene to increase motivation to change behavior and build risk reduction skills. Some study participants expressed clear motivation to avoid STI infection and valued being provided with a syphilis test result. For others, public health campaigns that promote personal responsibility to undergo STI testing to access treatment if necessary, but also to avoid infecting others, may help effect community norms about STI prevention for self and sexual partners, as has been seen with individuals living with HIV/AIDS. [34–36] The aims of informational and motivation public health campaigns would be to routinize syphilis testing to increase its frequency, especially among high risk individuals, may result in decrease secondary transmission by those unaware of their infection. One useful approach to facilitate testing may be the use of rapid self-tests for syphilis and other STIs. HIV rapid tests have been shown to be highly acceptable among similar populations for self-testing (30,31) as well as to test partners prior to sex in order to avoid HIV exposure.(32,33)

While this study provides valuable insights into STI knowledge, risk perception, and concerns among at risk MSM and TGW, the results must be viewed with certain limitations. First, the newly developed STI knowledge assessment and the adapted HIV knowledge questionnaire and risk scales have not been validated; as such they may not accurately assess the underlying constructs. Second, this sample was recruited for a study on self and partner HIV and syphilis testing, thus the findings may not be generalizable to broader population of MSM and TGW, even others with similar sexual risk profiles. Lastly, the study occurred in the New York City metropolitan area, where substantial resources exist for HIV/STI information and testing; findings may be significantly different in areas of the U.S. where these resources are more limited. Nonetheless, given the limited literature on STI knowledge among high risk populations such as MSM and TGW, the findings from this study provide valuable insights into the need to heighten STI information, risk awareness, and concern of infection among such populations.