Transactional Sex: Supply and Demand Among European Men Who have Sex with Men (MSM) in the Context of Local Laws.

Objectives: Transactional sex (TS) is generally defined as the trading of sex for material goods. Cast within the broader context of prostitution laws, we examined variations in the sociodemographic profile of men who have sex with men engaging in TS by payment direction (buying/selling). Methods: The data were collected as part of the 38-country European Men who have sex with men Internet Survey project, conducted in 2010. Results: About 12% of respondents reported engaging in TS in the past year. TS was associated with laws, age, education, employment, and residence. Conclusions: The striking sociodemographic differences in TS by payment direction suggest a power differential and a leading role of socioeconomic factors in TS

Age biases in a large HIV and sexual behaviour-related internet survey among MSM.

BACKGROUND: Behavioural data from MSM are usually collected in non-representative convenience samples, increasingly on the internet. Epidemiological data from such samples might be useful for comparisons between countries, but are subject to unknown participation biases. METHODS: Self-reported HIV diagnoses from participants of the European MSM Internet Survey (EMIS) living in the Czech Republic, Germany, The Netherlands, Portugal, Sweden and the United Kingdom were compared with surveillance data, for both the overall diagnosed prevalence and for new diagnoses made in 2009. Country level prevalence and new diagnoses rates per 100 MSM were calculated based on an assumed MSM population size of 3% of the adult male population. Survey-surveillance discrepancies (SSD) for survey participation, diagnosed HIV prevalence and new HIV diagnoses were determined as ratios of proportions. Results are calculated and presented by 5-year age groups for MSM aged 15-64. RESULTS: Surveillance derived estimates of diagnosed HIV prevalence among MSM aged 15-64 ranged from 0.63% in the Czech Republic to 4.93% in The Netherlands. New HIV diagnoses rates ranged between 0.10 per 100 MSM in the Czech Republic and 0.48 per 100 in The Netherlands. Self-reported rates from EMIS were consistently higher, with prevalence ranging from 2.68% in the Czech Republic to 12.72% in The Netherlands, and new HIV diagnoses rates from 0.36 per 100 in Sweden to 1.44 per 100 in The Netherlands. Across age groups, the survey surveillance discrepancies (SSD) for new HIV diagnoses were between 1.93 in UK and 5.95 in the Czech Republic, and for diagnosed prevalence between 1.80 in Germany and 4.26 in the Czech Republic.Internet samples of MSM were skewed towards younger age groups when compared to an age distribution of the general adult male population. Survey-surveillance discrepancies (SSD) for EMIS participation were inverse u-shaped across the age range. The two HIV-related SSD were u- or j-shaped with higher values for the very young and for older MSM. The highest discrepancies between survey and surveillance data regarding HIV-prevalence were observed in the oldest age group in Sweden and the youngest age group in Portugal. CONCLUSION: Internet samples are biased towards a lower median age because younger men are over-represented on MSM dating websites and therefore may be more likely to be recruited into surveys. Men diagnosed with HIV were over-represented in the internet survey, and increasingly so in the older age groups. A similar effect was observed in the age groups younger than 25 years. Self-reported peak prevalence and peak HIV diagnoses rates are often shifted to higher age groups in internet samples compared to surveillance data. Adjustment for age-effects on online accessibility should be considered when linking data from internet surveys with surveillance data

Illicit drug use among gay and bisexual men in 44 cities: Findings from the European MSM Internet Survey (EMIS).

BACKGROUND: Anecdotal evidence suggests that men who have sex with men (MSM) are increasingly combining sex and illicit drugs (an activity referred to as 'chemsex'), in particular GHB/GBL, ketamine, crystal meth, or mephedrone (here called 4-chems). Use of such drugs has been associated with mental health and sexual health harms. We aim to compare patterns of illicit drug use among MSM in 44 European urban centres. METHODS: In 2010, EMIS recruited 174,209 men from 38 countries to an anonymous online questionnaire in 25 languages. As harm reduction services for drugs and sex are organised at a local level, we chose to compare cities rather than countries. We defined 44 cities based on region/postal code and settlement size. For multivariable regression analyses, three comparison groups of MSM not living in these cities were applied: MSM living in Germany, the UK, and elsewhere in Europe. RESULTS: Data from 55,446 MSM living in 44 urban centres were included. Use of 4-chems (past 4 weeks) was highest in Brighton (16.3%), Manchester (15.5%), London (13.2%), Amsterdam (11.2%), Barcelona (7.9%), Zurich (7.0%) and Berlin (5.3%). It was lowest in Sofia (0.4%). The rank order was largely consistent when controlling for age, HIV diagnosis, and number of sexual partners. City of residence was the strongest demographic predictor of chemsex-drug use. CONCLUSION: Use of drugs associated with chemsex among MSM varies substantially across European cities. As city is the strongest predictor of chemsex-drug use, effective harm reduction programmes must include structural as well as individual interventions

Estimating the size of the MSM populations for 38 European countries by calculating the survey-surveillance discrepancies (SSD) between self-reported new HIV diagnoses from the European MSM internet survey (EMIS) and surveillance-reported HIV diagnoses among MSM in 2009.

BACKGROUND: Comparison of rates of newly diagnosed HIV infections among MSM across countries is challenging for a variety of reasons, including the unknown size of MSM populations. In this paper we propose a method of triangulating surveillance data with data collected in a pan-European MSM Internet Survey (EMIS) to estimate the sizes of the national MSM populations and the rates at which HIV is being diagnosed amongst them by calculating survey-surveillance discrepancies (SSD) as a measure of selection biases of survey participants. METHODS: In 2010, the first EMIS collected self-reported data on HIV diagnoses among more than 180,000 MSM in 38 countries of Europe. These data were compared with data from national HIV surveillance systems to explore possible sampling and reporting biases in the two approaches. The Survey-Surveillance Discrepancy (SSD) represents the ratio of survey members diagnosed in 2009 (HIVsvy) to total survey members (Nsvy), divided by the ratio of surveillance reports of diagnoses in 2009 (HIVpop) to the estimated total MSM population (Npop). As differences in household internet access may be a key component of survey selection biases, we analysed the relationship between household internet access and SSD in countries conducting consecutive MSM internet surveys at different time points with increasing levels of internet access. The empirically defined SSD was used to calculate the respective MSM population sizes (Npop), using the formula Npop = HIVpop*Nsvy*SSD/HIVsvy. RESULTS: Survey-surveillance discrepancies for consecutive MSM internet surveys between 2003 and 2010 with different levels of household internet access were best described by a potential equation, with high SSD at low internet access, declining to a level around 2 with broad access. The lowest SSD was calculated for the Netherlands with 1.8, the highest for Moldova with 9.0. Taking the best available estimate for surveillance reports of HIV diagnoses among MSM in 2009 (HIVpop), the relative MSM population sizes were between 0.03% and 5.6% of the adult male population aged 15-64. The correlation between recently diagnosed (2009) HIV in EMIS participants and HIV diagnosed among MSM in 2009 as reported in the national surveillance systems was very high (R(2) = 0.88) when using the calculated MSM population size. CONCLUSIONS: Npop and HIVpop were unreliably low for several countries. We discuss and identify possible measurement errors for countries with calculated MSM population sizes above 3% and below 1% of the adult male population. In most cases the number of new HIV diagnoses in MSM in the surveillance system appears too low. In some cases, measurement errors may be due to small EMIS sample sizes. It must be assumed that the SSD is modified by country-specific factors.Comparison of community-based survey data with surveillance data suggests only minor sampling biases in the former that--except for a few countries--do not seriously distort inter-country comparability, despite large variations in participation rates across countries. Internet surveys are useful complements to national surveillance systems, highlighting deficiencies and allowing estimates of the range of newly diagnosed infections among MSM in countries where surveillance systems fail to accurately provide such data

Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study : some public health implications of homophobia

Objectives Internalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. Design and setting We examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. Participants 181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. Methodology An anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. Results Three clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was ‘out’ as gay to others and older age. ‘Outness’ was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. Conclusions IH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with ‘outness’ and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM