This study was conducted with the aim of obtaining the very first information on the sexual risk behavior of Croatian
men who have sex with men (MSM). There were 1127 respondents recruited at four venues: three physical meeting places
of the Croatian MSM population (disco club, bar and sauna) in Zagreb and one virtual (gay oriented web-site) meeting
place of the Croatian MSM population. The overall response rate was only 19%. The rate of condom use during last anal
intercourse was 59% and 56% of those who used a lubricant had chosen an incorrect product to use with latex condoms.
There was no connection between drug-use and unprotected anal intercourse (UAI). Only a fifth of those who had also
had sex with women (MSM/MSW) during last 12 months regularly used protection. The obtained findings will serve for
focused and effective prevention activities and a basis for comparison in future research

Branko Kolarić

Ira Gjenero-Margan

Luka Bielen

English

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Coll. Antropol. 32 (2008) 3: 687–691Original scientific paperRisk Behaviors for Getting HIV Infection amongthe Croatian Men Who Have Sex With MenBranko Kolari}1, Luka Bielen2 and Ira Gjenero-Margan11 HIV/AIDS Department, Croatian National Institute for Public Health, Zagreb, Croatia2 School of Medicine, University of Zagreb, Zagreb, CroatiaA B S T R A C TThis study was conducted with the aim of obtaining the very first information on the sexual risk behavior of Croatianmen who have sex with men (MSM). There were 1127 respondents recruited at four venues: three physical meeting placesof the Croatian MSM population (disco club, bar and sauna) in Zagreb and one virtual (gay oriented web-site) meetingplace of the Croatian MSM population. The overall response rate was only 19%. The rate of condom use during last analintercourse was 59% and 56% of those who used a lubricant had chosen an incorrect product to use with latex condoms.There was no connection between drug-use and unprotected anal intercourse (UAI). Only a fifth of those who had alsohad sex with women (MSM/MSW) during last 12 months regularly used protection. The obtained findings will serve forfocused and effective prevention activities and a basis for comparison in future research.Key words: Croatia, MSM, MSM/MSW, behavior, drug-useIntroductionMen who have sex with men (MSM) are worldwide atparticularly high risk for acquiring and transmittingHIV infection1. However, there has been very little sys-tematic study of sexual risk practices and characteristicsof MSM population in South-Eastern Europe. Successfulinternational HIV prevention interventions designed toreduce sexual risk behavior of MSM were associated witha significant decrease in unprotected anal intercourse(UAI), in the number of sexual partners and with a sig-nificant increase of condom use during anal intercour-se2,3. The design of effective HIV prevention programsfor MSM requires a clear understanding of their sexualrisk behavior in relation to the type of sexual inter-course, number of sexual partners, condom use, and sub-stance use immediately before sexual intercourse and ex-istence of sexual intercourse with women4,5. All of thesefactors influence individual risk of HIV infection/trans-mission.It is well established that the type of sexual inter-course (oral, vaginal, anal) influences risk for HIV trans-mission. Per-contact risk of acquiring HIV is greater inUAI than in unprotected oral intercourse6. It is knownthat UAI is associated with sexual situation specific useof marijuana, crystal methamphetamine, ecstasy andketamine7. MSM who also have sex with women (MSM/MSW), the so-called bridging population, can transmitHIV onto a large heterosexual population.Croatia has some special prerequisites for entrance ofthe HIV epidemic into the country – open borders, citi-zens traveling abroad, migrant workers and developedtourism industry which puts Croatian MSM populationat higher risk8. On the other hand, having in mind thatabout 40% of persons with HIV infection and 44% ofAIDS patients in Croatia are MSM or MSM/MSW9 we un-dertook this study to get a clearer view of the sexual riskbehavior of MSM so that effective HIV prevention pro-grams could be designed. This is the first study of thiskind in Croatia.Materials and MethodsThe respondents were recruited at three physicalmeeting places of the MSM population (a disco club, abar and a sauna) in Zagreb and one virtual (gay orientedweb-site) meeting place of the Croatian MSM populationwhich was chosen due to the fact that many people haveturned to the Internet to seek love and sex10.687Received for publication April 4, 2007The research was conducted in a month’s timeframe(November-December 2005) using an anonymous ques-tionnaire with all the visitors of the above named placesbeing included in the study. At a bar or a sauna each visi-tor received a copy of the questionnaire and after fillingit in, placed it in the box prepared for returning the ques-tionnaires. At a club, visitors received a copy of the ques-tionnaire with an enclosed paid return envelope. Theowners/staff of the bar and sauna received a reward of 2 €per questionnaire filled in by their visitors. A regularcustomer of the club was employed for motivating thevisitors of the club to fill in the questionnaire. On theweb-site, a message was sent to all registered users witha kind request to fill in the questionnaire. The only crite-rion for exclusion of a respondent from the study was thefilling in of the questionnaire within the last month. Tobe able to calculate the response rate we used the denom-inator data as it was provided by the field researchers –the number of questionnaires delivered and the numberof web-site users that had received an e-mail invitation tojoin the survey.The questionnaire was created for this particular re-search. It consisted of 22 multiple choice questions andwas divided into several parts: socio-demographic data,knowledge about HIV infection, use of drugs prior to sex-ual intercourse, sexual intercourse with men and sexualintercourse with women. Regarding drug use we in-quired about the use of the following substances: mari-juana, butyl/isobutyl nitrate (»poppers«), cocaine, am-phetamine, heroin and »some other drug«. We did notinvestigate into multiple drug use or alcohol use, but intothe most commonly used drug.For comparison of categorical variables among groupsof respondents we used the Chi-square test. For ordinalvariables comparisons we used the Kruskal-Wallis test.ResultsThere was a total of 1127 respondents. The overall re-sponse rate was 19% (1127/5892) and according to venuediffered from 10.1 to 87.5%. The median age was 27, theminimum being 15, maximum 88 and interquartile range10 (Table 1).The summary of results is shown in Table 2.Drug useWe did not find a statistically significant differencebetween drug use and frequency of condom use at inter-courses during last 12 months (p=0.16, Chi-square test,d.f. 4) or drug use and condom use at last anal inter-course (p=0.447, Chi square test, d.f. 2). There was a sig-nificantly lower number of respondents who did not haveintercourse during last year among drug users (p=0.026,Chi-square test, d.f.=2).Sexual behaviorsWithin the last year 1035/1127 (91.8%) respondentsstated having oral sexual intercourse, out of which 723(69.9%) have never used a condom during such inter-course and 63 (6.1%) had used a condom at each oral in-tercourse. The median number of partners with whichthe respondents had oral intercourse within the last yearwas 2, with a minimum of 2 and a maximum of 70.Eighty-five point four percent (963/1127) of the re-spondents had had anal sexual intercourse in the last 12months. Out of those 963 respondents 454 (47.1%) used acondom at each anal intercourse, 174 (18.1%) often, 101(10.5%) sometimes, 58 (6%) rarely and 176 (18.3%) never.Out of those respondents who had anal intercourse inthe last year and used a condom at last intercourse therewas 456/630 (71%) who also used a lubricant out of whicha little less than half used a water based lubricant 219/456(48%). The median number of partners with whom therespondents had anal intercourse was 1, the minimumamounting to 0 and the maximum to 100. The mediannumber of partners with whom the respondents hadother sexual activities (excluding oral and anal inter-course) was 1, the minimum being 0 and the maximum300.While having anal sex with man, sub-population ofMSM who also have sex with women (MSM/MSW) usedcondoms more frequently than the rest of respondents(p=0.021, Chi-square test, d.f.=2).DiscussionThis was the first behavioral study on MSM popula-tion in Croatia and one of the most important findings isthe fact that the Croatian MSM population was not will-ing to participate in the research – the overall responseto the study was very low (19%) – probably due to the stillstrong stigmatization of the MSM population in Croatia.This implies that the scientific community interested inHIV research should make extra effort to improve thecontact with the MSM population. An exception was thebar with an unusually high response rate which can beexplained by an extraordinary interest of the owner/staffto motivate the respondents and having closer contactwith them.Knowledge on the possibilities of protection from HIVby using condoms was relatively high (except in the bar),but still we find there is need for improvement andreaching the desired level: we would like to make theB. Kolari} et al.: Risk Behaviors among Croatian MSM, Coll. Antropol. 32 (2008) 3: 687–691688TABLE 1AGE AND RESPONSE RATE ACCORDING TOVENUE OF RECRUITMENTVenue Median age(interquartile range)Response rate n/N(%)Online(www.gay.hr)26 (9) 863/5012 (17.22)Disco club 27 (8) 77/581 (13.25)Bar 33 (11) 175/200 (87.5)Sauna 35 (7) 10/99 (10.1)Total 27 (10) 1127/5892 (19.1)benefits of using condoms known to every citizen inCroatia, particularly in vulnerable populations. The lo-wer level of knowledge in the bar underlines the impor-tance of specific interventions regarding this venue.The next important finding is that the testing rate isvery low comparing to United States data11 which is veryconcerning with respect to secondary HIV preventionmeasures in Croatia and implies lack of promotion of vol-untary counseling and testing among MSM population.In our research, marijuana and »poppers« are usedmore commonly and heroin less than other authorsfound12,13. As the light drugs use has been shown to be arisk14–16 for entering into sexual intercourse without pro-tection, additional research and analyses are required totry to identify which sub-population uses drugs more fre-quently and aim focused interventions towards thosesubpopulations4,17. In this research we found no statisti-cally significant difference in having UAI with respect todrug use.The fact that more than 40% of the overall respon-dents have not used a condom at last anal intercourse isof great concern. There are many contextual factors thatB. Kolari} et al.: Risk Behaviors among Croatian MSM, Coll. Antropol. 32 (2008) 3: 687–691689TABLE 2KNOWLEDGE ABOUT HIV/AIDS, HIV TESTING AND SEXUALRISK BEHAVIOR OF CROATIAN MSM* N=1127 n (%)Ever heard of HIV/AIDSNo answerAnsweredYesNo16 (1.4)1111 (98.6)1104 (99.4)7 (0.6)Condom is an effective means of protection from HIVNo answerAnsweredYesNoDon’t know3 (0.3)1124 (99.7)850 (75.6)139 (12.4)135 (12.0)Undergone HIV testingNo answerAnsweredNeverOnceSeveral times3 (0.3)1124 (99.7)598 (53.2)241 (21.4)285 (25.4)Type of drug used before sex within the last monthNo answer/ not applicableAnsweredMarijuanaButyl/isobutyl nitrate (poppers)CocaineAmfetamineHeroinSome other drug919 (81.5)208 (18.5)82 (39.4)61 (29.3)23 (11.1)18 (8.6)4 (1.9)20 (9.6)Condom use during oral intercourse within the last yearNo answer/ not applicableAnsweredAlwaysOftenSometimesRarelyNever92 (8.2)1035 (91.8)63 (6.1)37 (3.6)76 (7.3)136 (13.1)723 (69.9)Condom use during last anal intercourseNo answerAnsweredYesNo36 (3.2)1091 (96.8)642 (58.7)449 (41.3)Reasons for not using condoms during last anal intercourseNo answer/ not applicableAnswered»Intercourse was not a risky one«»I was overwhelmed with passion andI didn’t think«»I don’t like sex with condoms«»I did not have a condom on me at that moment«»The partner did not want to use a condom«»Condoms are too expensive«Other reasons700 (62.1)427 (37.9)136 (31.9)61 (14.3)48 (11.2)34 (7.9)19 (4.4)3 (0.7)126 (29.5)Lubricant use during last anal intercourseNo answerAnsweredYesNo44 (3.9)1083 (96.1)723 (66.8)360 (33.2)Most frequently used lubricants within the last yearNo answer/ not applicableAnsweredWater based lubricantBody lotion/milkVaselineOil/butterSomething else327 (29.0)800 (71.0)356 (44.5)214 (26.8)157 (19.6)18 (2.3)55 (6.8)Intercourse with women within the last yearNo answerAnsweredYesNo55 (4.9)1072 (95.1)383 (35.7)689 (64.3)Condom use during intercourse with women within the lastyearNo answer/ not applicableAnsweredAlwaysOftenSometimesRarelyNever744 (66.0)383 (34.0)78 (20.4)19 (5.0)16 (4.2)20 (5.2)250 (65.3)*Percentages for »no answer/ not applicable« pertain to percent-ages from the total sample. All other percentages are percent-ages from the total number of participants who answered thequestion.influence the decision to engage in UAI18,19. Our resultssuggest that the decision (of having UAI) was basedmostly on trust into the HIV status of the partner or hap-pened due to not thinking of risk or not finding pleasurein sexual intercourse using condoms which is consistentwith the results of other studies worldwide20–25, and isnot satisfactory – HIV risk is obviously influenced bysome other psychological dimensions of personality andnot solely by the knowledge factor itself. A little over athird of the respondents had sexual intercourse withwomen (MSM/MSW) in the last 12 months, and only afifth of them regularly used protection which is consis-tent to finding in Croatia’s neighboring country – Hun-gary26. From this reason we can conclude that the socalled bridging population’s behavior is very risky andthat there is danger of transmitting the outbreak fromthe MSM into the general population through a hetero-sexual route of transmission. In contrast, an interestingresult which differs from recent scientific literature11,24is that the Croatian MSM/MSW sub-population practicessafer sex with male partners more often than those menwho do not practice sex with women (p=0.021, Chi--square test, d.f.=2). The reason for this would probablybe that they find sexual intercourse with women lessrisky than sexual intercourse with men.With respect to condom use, the rate lubricant useduring last anal intercourse is even less than what hasbeen found in other studies27. Furthermore, among thosewho did use it, less than a half of the respondents haveused a water-based product.To conclude, while the results of the first survey onCroatian MSM population suggest a relatively high levelof knowledge, we are still not satisfied with the high levelof risk behaviors. The obtained findings will serve for fo-cused and effective prevention activities and as a base-line for a future time-location research of risk behaviortrends within the framework of Second generation sur-veillance of HIV infection in Croatia28.The main limitation of the study is the generaliza-bility of the results. Even though we could not dare tospeak of any level of representativity of the results, thesample size does give a certain weight to the informationobtained. Through good cooperation with nongovern-mental organizations, we hope for a better response ofthe MSM population in future studies, all with the pur-pose of decreasing risk for HIV in a population which forthe time being, seems to be at greatest risk for this infec-tion in Croatia.AcknowledgementsThe authors would like to thank the members of theNGO Iskorak – Sexual and gender minorities center, par-ticularly to Mr. Dalibor Stanic as well as the owners ofvenues at which this research was conducted for provid-ing truly invaluable help. Thanks to Jasmina Pavlic fortaking care of our English.R E F E R E N C E S1. UNAIDS, 2006 Report on the global AIDS epidemic: A UNAIDS10th anniversary special edition (UNAIDS, 2006). — 2. HERBST JH,SHERBA RT, CREPAZ N, DELUCA JB, ZOHRABYAN L, STALL RD,LYLES CM, J Acquir Immune Defic Syndr, 39 (2005) 228. — 3. CHOI KH,GIBSON DR, HAN L, GUO Y, AIDS Educ Prev, 16 (2004) 19. — 4. FOL-CH C, MARKS G, ESTEVE A, ZARAGOZA K, MUNOZ R, CASABONA J,AIDS Educ Prev, 18 (2006) 227. — 5. O’CONNELL JM, LAMPINEN TM,WEBER AE, CHAN K, MILLER ML, SCHECHTER MT, HOGG RS,AIDS Behav, 8 (2004) 17. — 6. VITTINGHOFF E, DOUGLAS J, JUD-SON F, MCKIRNAN D, MACQUEEN K, BUCHBINDER SP, Am J Epide-miol, 150 (1999) 306. — 7. RUSCH M, LAMPINEN TM, SCHILDER A,HOGG RS, Sex Transm Dis, 31 (2004) 492. — 8. BENOTSCH EG, SEE-LEY S, MIKYTUCK JJ, PINKERTON SD, NETTLES CD, RAQSDALEK, Sex Transm Dis, 33 (2006) 706. — 9. GJENERO-MARGAN I, KOLA-RIC B, Coll Antropol, 30 (2006) 11. — 10. CHIASSON MA, PARSONS JT,TESORIERO JM, CARBALLO-DIEQUEZ A, HIRSHFIELD S, REMIENRH, J Urban Health, 83 (2006) 73. — 11. SANCHEZ T, FINLAYSON T,DRAKE A, BEHEL S, CRIBBIN M, DINENNO E, HALL T, KRAMER S,LANSKY A, MMWR Surveill Summ, 55 (2006) 1. — 12. RIETMEIJERCA, WOLITSKI RJ, FISHBEIN M, CORBY NH, COHN DL, Sex TransmDis, 25 (1998) 353. — 13. CHOI KH, OPERARIO D, GREGORICH SE,MCFARLAND W, MACKELLAR D, VALLEROY L, AIDS Educ Prev, 17(2005) 418. — 14. BAUTISTA CT, SANCHEZ JL, MONTANO SM, LA-GUNA-TORRES VA, LAMA JR, KUSUNOKI L, MANRIQUE H, ACO-STA J, MONTOYA O, TAMBARE AM, AVILA MM, VINOLES J, AGU-AYO N, OLSON JG, CARR JK, Sex Transm Infect, 80 (2004) 498. — 15.COLFAX G, COATES TJ, HUSNIK MJ, HUANG Y, BUCHBINDER S,KOBLIN B, CHESNEY M, VITTINGHOFF E, J Urban Health, 82 (2005)62. — 16. ABSALON J, DELLA-LATTA P, WU F, EL-SADR WM, J NatlMed Assoc, 97 (2005) 25. — 17. HURTADO I, ALASTRUE I, FERREROSI, DEL AMO J, SANTOS C, TASA T, HERNANDEZ-AQUADO I, PEREZ--HOYOS S, Sex Transm Infect, 83 (2007) 23. — 18. SUAREZ T, MILLERJ, Arch Sex Behav, 30 (2001) 287. — 19. AMIRKHANIAN YA, KELLY JA,KUKHARSKY AA, BORODKINA OI, GRANSKAYA JV, DYATLOV RV,MCAULIFFE TL, KOZLOV AP, J Acquir Immune Defic Syndr, 15 (2001)407. — 20. MACKELLAR DA, VALLEROY LA, SECURA GM, BEHEL S,BINGHAM T, CELENTANO DD, KOBLIN BA, LALOTA M, SHEHAN D,THIEDE H, TORIAN LV, AIDS Behav, 11 (2007) 263. — 21. HALKITISPN, PARSONS JT, WILTON L, Arch Sex Behav, 32 (2003) 351. — 22.CARBALLO-DIEQUEZ A, BAUERMEISTER J, J Homosex, 47 (2004) 1.— 23. MANSERGH G, MARKS G, COLFAX GN, GUZMAN R, RADER M,BUCHBINDER S, J Acquir Immune Defic Syndr, 16 (2002) 653. — 24.DANDONA L, DANDONA R, GUTIERREZ JP, KUMAR GA,MCPHERSON S, BERTOZZI SM, J Acquir Immune Defic Syndr, 19(2005) 611. — 25. LAU JT, KIM JH, LAU M, TSUI JT, Sex Transm Infect,80 (2004) 459. — 26. CROSBY R, METTEY A, J Acquir Immune DeficSyndr, 37 (2004) 1496. — 27. CSEPE P, AMIRKHANIAN YA, KELLY JA,MCAULIFFE TL, MOCSONOKI L, Int J STD AIDS, 13 (2002) 192. — 28.UNAIDS, WHO, Second generation surveillance for HIV: The next de-cade, (UNAIDS, WHO, 2000).B. Kolari}Croatian National Institute of Public Health, Rockefellerova 7, 10000 Zagreb, Croatiae-mail: branko.kolaric@hzjz.hrB. Kolari} et al.: Risk Behaviors among Croatian MSM, Coll. Antropol. 32 (2008) 3: 687–691690RIZI^NA PONA[ANJA ZA HIV INFEKCIJU ME\U HRVATSKIM MU[KARCIMAKOJI PRAKTICIRAJU SEKS S MU[KARCIMAS A @ E T A KIstra`ivanje je provedeno s ciljem dobivanja prvih informacija u rizi~nim seksualnim pona{anjima u hrvatskih mu-{karaca koji prakticiraju seks s mu{karcima (MSM). U studiju je bilo uklju~eno 1127 ispitanika iz tri fizi~ke (bar, saunai disko klub) lokacije u Zagrebu i jedne virtualne (web stranica namijenjena gay populaciji) lokacije na kojima se okupljaHrvatska MSM populacija. Ukupna stopa odziva bila je samo 19%. U~estalost kori{tenja kondoma pri zadnjem analnomodnosu bila je 59%, a 56% onih koji su koristili lubrikant izabralo je sredstvo neadekvatno za kori{tenje s lateks kon-domima. Nije prona|ena povezanost izme|u kori{tenja droga i u~estalosti neza{ti}enog analnog odnosa. Samo petinaispitanika koji su imali seksualni odnos sa `enama u zadnjih 12 mjeseci redovito je koristila kondom. Rezultati istra-`ivanja koristit }e za ciljane preventivne aktivnosti i kao baza za pra}enje trenda pona{anja u budu}nosti.B. Kolari} et al.: Risk Behaviors among Croatian MSM, Coll. Antropol. 32 (2008) 3: 687–691691

Risk Behaviors for Getting HIV Infection among the Croatian Men Who Have Sex With Men

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