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Background: Framework

A Qualitative Exploration of Factors Influencing Sexual Risk Behavior and HIV Testing Among Men Who Have Sex with Men in Beirut, Lebanon . Glenn J. Wagner, Frances M. Aunon , Yashodhara Rana, Rachel L. Kaplan, Danielle Khouri, Johnny Tohme, Jacques Mokhbat

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Background: Framework

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  1. A Qualitative Exploration of Factors Influencing Sexual Risk Behavior and HIV Testing Among Men Who Have Sex with Men in Beirut, Lebanon Glenn J. Wagner, Frances M. Aunon, Yashodhara Rana, Rachel L. Kaplan, Danielle Khouri, Johnny Tohme, Jacques Mokhbat International AIDS Conference 2012 Washington, DC, USA Funded by NIMH 5R21MH093204-02

  2. Background: Framework • Sexual risk behavior and HIV testing may be influenced by three factors: • social influences including sexual stigma, discrimination, social support[3], and peer normative behavior[4],  • relationship characteristics, such as partner type[1], and trust and commitment within a relationship[2], • aspects of sexual identity development, including self-acceptance and disclosure of one’s sexual orientation[5, 6]

  3. Background: The “Gay Scene” in Beirut

  4. Background: Homosexuality in Beirut • Homosexuality is illegal in Lebanon • Article 534 criminalizes "unnatural sexual intercourse;" but is largely not enforced in Beirut • And homosexuality remains highly stigmatized

  5. Background: MSM Sex Behavior • HIV In Lebanon: • Reported HIV prevalence and HIV testing rates are low, (3.6% and 24%, respectively,) BUT good HIV surveillance data is generally lacking [8] • Local organizations and HIV providers suggest most new infections are among MSM and marginalized populations • MSM Sex Behavior: • Over 60% Lebanese MSM don’t use condoms regularly [9] • 25% reported using a condom in their last sex encounter [10] • Average ~10 sex partners per year [11, 12]

  6. Purpose • There is limited published research about psychosocial factors influencing HIV risk behaviors among MSM in Lebanon • The purpose of this studyis to explore the psychosocial processes influencing condom use and HIV testing among MSM in Beirut

  7. Methods • First phase of a mixed-methods study (later stage will involve respondent driven sampling and quantitative surveys) • Semi-structured qualitative interviews with 31 MSM living in greater Beirut • Purposive sample so that half were 18-25 years, and half were >25 years • All interviews were recorded, transcribed, and coded in Atlas-ti to identify themes and extract counts

  8. Results: Demographics • Age: 28.4 years (range 19-65) • 87% had at least some college education • 90% either employed or attending university • Religious affiliation: • 57% Christian • 29% Muslim • 14% Atheist • Sexual Orientation: • 77% self-identified as gay • 23% self-identified as bisexual

  9. Results: Sample Characteristics • Sexual History: • Average age of sexual initiation: 13.9 years • Average age of sexual encounter with a man: 17.6 years • Partnerships: • Median number of male sex partners in past year: 8 • 10/31 respondents also reported recent sex with men and women • Safe sex: • 16/31 respondents reported either consistent condom use or having unprotected sex only in context of a committed relationship (n=5) • HIV Status (self-report): • 20/31 were HIV negative • 1/31 were HIV positive • 7/31 had never been tested

  10. Results: Main Themes • Partner Characteristics • Casual vs regular sex partners • Meeting sex partners online • Sex with women • Fear and Anxiety • Comfort with Sexuality • Disclosure of Sexuality

  11. Results: Partnership CharacteristicsCasual vs. regular partners • Over half of the sample (17/31) reported inconsistent condom use with regular sex partners • Trust, commitment, and desire for more intimate, pleasurable sex are in play • “There are some [partners] that I sleep with more than once through the year, so I don't use condom because I trust them.” • A regular partner motivated for testing: • “When [my boyfriend and I] started having sex, we used condom. We discussed the necessity to get tested so we could remove the condom.”

  12. Results: Partnership Characteristics Meeting sex partners online • 25/31 participants reported meeting sexual partners through MSM-oriented social networking websites • Meeting partners online makes it easier to discuss HIV risk and condom use • “Since most of my meetings are through the internet, [discussing HIV/STI status] happens before meeting while we are chatting [online]. When you meet someone in a club, usually you don’t have a lot of time to discuss such issues.”

  13. Results: Partnership CharacteristicsSex with Women • Respondents perceived women as less likely to have HIV, and were fearful that discussing HIV risk might lead the woman to suspect the respondent is a MSM • “If my partner was a woman, I might not even ask her [about her HIV status]. I usually have this predisposition of thinking that it is just the gays who have HIV.” • Respondents who used condoms with women did so mostly in order to prevent pregnancy. • “I always put a condom on with my girlfriend because I don’t want her to get pregnant.”

  14. Results: Effects of anxiety and fear of HIV infection • Many respondents expressed anxiety and fear of infection, which promoted condom use: • “Risky [unprotected] sex is a way to commit suicide.” • “Lots of gays have HIV, so I am not taking the risk to end my life just for sex.” • However, for some, such negative affect impeded HIV testing: • “I might be afraid to reveal my name or even afraid from the result knowing I have been unsafe a couple of times.” • This fear also inhibits discussion of HIV risk and condoms with sex partners: • “I tried talking about HIV, and the guy thought I was talking about it because I am positive. I’ve never done it again.”

  15. Results: Comfort with Sexual Orientation • One third (11/31) of the sample felt very comfortable with their sexual orientation • “I know it is not a choice. I am not sad about it.” • The majority (20/31) felt discomfort with their sexual orientation, stemming from religious guilt, social stigma, and societal expectations • “I do believe that prophet Mohamed prohibited sex between men and every time I pray, I really feel guilty.” • “I know that in order to be successful in this society I have to get married and have kids, and my homosexuality prevents me from doing that, therefore I hate it”. • “I am comfortable [with my sexual orientation], but I can’t do it in public. Everything that you want to do you have to in secret. That is what hurts.”

  16. Results: Disclosing Sexual Orientation • MSM who were more comfortable with their sexual orientation were more likely to disclose; only half suspected at least one of their parents knew of their sexual orientation • Fear of a negative reaction was a primary barrier to disclosing: • “If they know I am homosexual, [they] will kill me. If they found out, I’d escape.” For those who did disclose: • Families and friends responded differently, with some offering support: • “[My family says] that they love me no matter what…My sister is my biggest supporter. We always joke about who's going to get this guy or that guy.” And others created a hostile environment: • “[Being gay] has hurt me a lot and created a lot conflicts inside my family. That's why I left the house and moved to another place.”

  17. Link between sexual identity and sexual risk behaviors/HIV testing • Men who were uncomfortable with and did not disclose their sexual orientation tended exhibit higher sexual risk behaviors • higher rates of unsafe sex (69% versus 33%) • more annual sexual partners (mean=37 versus 17) • lower rates of being HIV-tested (54% versus 89%) • lower rates of discussing HIV risk with their sex partners (39% versus 89%)

  18. Conclusions • Decisions and behaviors regarding condom use and HIV testing are influenced by a wide array of individual, interpersonal and social factors including: • 1) partner characteristics, • 2) fears and anxiety about HIV infection and interpersonal rejection, • 3) processes of social identity development • These patterns give credence to the need for further examination of the role of sexual identity development in promoting sexual health

  19. Works Cited • Hensel, DJ, Rosenberger JG, Novak DS, Reece, M (2012) Sexual event-level characteristics of condom use during anal intercourse among HIV-negative men who have sex with men. Sexually Transmitted Diseases 39:550-555. • Nyoni, JE, Ross MW (2012) Condom use and HIV-related behaviors in urban Tanzanian men who have sex with men: A study of beliefs, HIV knowledge sources, partner interactions and risk behaviors. AIDS Care E-pub. • O'Leary, A, Wolitski RJ, Remien RH, Woods WJ, Parsons JT, et al. (2005) Psychosocial correlates of transmission risk behavior among HIV-seropositive gay and bisexual men. AIDS 19: S67-S75. • Marks, G, Crepaz N, SenterfittJW, Janssen RS (2005) Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes 39: 446-453. • Crawford, I, Allison KW, Zamboni BD, Soto T (2002) The influence of dual-identity development on the psychosocial functioning of African-American gay and bisexual men. Journal of Sex Research 39: 179-189. • Shoptaw, S, Weiss RE, Munjas B, Hucks-Ortiz C, Young SD, et al. (2009) Homonegativity, substance use, sexual risk behaviors, and HIV status in poor and ethnic men who have sex with men in Los Angeles. Journal of Urban Health 86: 77-92. • Remien, RH, Chowdhury J, Mokhbat JE, Soliman C, El Adawy M, et al. (2009) Gender and care: access to HIV testing, care and treatment. Journal of acquired immune deficiency syndromes 51: S106-110. • Afifi, R, DeJong J, El-Barbir F, El-Khoury D, Ghanem M, et al. (2008) Mishwar: An integrated bio-behavioral surveillance study among most at risk populations in Lebanon: Female sex workers, injections drug users, men who have sex with men, and prisoners, in Final Report. Ministry of Public Health: Beirut, Lebanon. • Mahfoud, Z, Afifi R, Ramia S, Khoury DE, Kassak K, et al. (2010) HIV/AIDS among female sex workers, injecting drug users and men who have sex with men in Lebanon: results of the first biobehavioral surveys. AIDS 24: S45. • Kahhaleh, JG, El NakibM,Jurjus AR (2009) Knowledge, attitudes, beliefs and practices in Lebanon concerning HIV/AIDS, 1996-2004. East Mediterr Health J 15: 920-933. • WHO, UNICEF,UNAIDS (2011) Global HIV/AIDS response: epidemic update and health sector progress towards universal access, in Progress Report 2011. World Health Organization: Geneva, Switzerland. • Nakib, ME,Hermez J (2002). HIV/AIDS Prevention Among Vulnerable Groups in Beirut, Lebanon. in XIV International AIDS Conference AIDS 2002. Barcelona, Italy. • Glick, SN, Morris M, Foxman B, Aral SO, Manhart LE, Holmes KK, Golden MR (2012) A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. Journal of Acquired Immune Deficiency Syndromes 60: 83-90. • Sullivan, PS, Salazar L, BuchbinderS,Sanchez TH (2009) Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS 23: 1153-1162.

  20. Acknowledgements • Study Staff: • Danielle Khouri, Project Director • Johnny Tohme • Rabih Maher • Simon Nehme • Chantal Chedid • KarineNasssar • Lebanese Collaborators: • Lebanese AIDS Society • National AIDS Program, Lebanon • Helem • Marsa Sexual Health Center • SKOUN • SoinsInfirmiersdeveloppementcommunautaire (SIDC) • Lebanese American University School of Medicine • Funders: • National Institute of Mental Health, 5R21MH093204-02

  21. Thank You Frances Aunon faunon@rand.org

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