Zero Feet Away

Perspective on HIV/AIDS and Unprotected Sex in Men Who Have Sex with Men Utilizing Location-based Mobile Apps

Medical Affairs HIV Programs and Services January 29, 2013

Catherine Abate, President CEO Matthew A. Weissman, MD, MBA, FAAP Chief Medical Officer/VP of Medical Affairs

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Community Healthcare Network (CHN) has a long history of diagnosing and treating people with HIV and AIDS, going back to the early days of the epidemic. Today, the organization conducts over 30,000 HIV consultations, administers over 20,000 tests, and runs one of the leading care coordination programs. In light of rapidly rising HIV and AIDS rates among young gay men, CHN sought to explore this populations knowledge, attitudes, and opinions about the disease and their sexual practices. Given the increased use of social networking apps, particularly ones that connect gay men who are within close proximity, CHN decided to conduct an online survey of men who use these apps. The survey findings are by no means attributable to the actual apps and CHN does not believe that the apps encourage unsafe sex practices. Rather, the findings give CHN and other health care providers and educators an opportunity to rethink and revise prevention messaging and other efforts to match current technologies and evolving communications capabilities.

Dr. Freddy Molano Vice President of HIV Programs and Services Community Healthcare Network

Renato Barucco Transgender Family Program Manager Community Healthcare Network

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Zero Feet Away

Perspective on HIV/AIDS and Unprotected Sex in Men Who Have Sex with Men Utilizing Locationbased Mobile Apps

Renato Barucco Luis F. Molano Community Healthcare Network, 2013 Abstract Authors collected attitudes around HIV/AIDS and unprotected anal intercourse in men who have sex with men (MSM) who meet their sexual partners utilizing geosocial-networking apps on mobile devices. It is important to collect shifts in attitudes around HIV/AIDS and unprotected sex in targeted communities to create effective prevention initiatives and evaluate existing ones. Authors designed a survey according to literature recommendations and consumers input in December 2011. Survey was distributed in January 2012. Design included 5 areas: Demographics, HIV/AIDS, Unprotected Sex, Basic Knowledge, and Additional Information (optional). Recruitment occurred through advertisement on social network-based apps. The study revealed sufficient knowledge of HIV/AIDS transmission and risk taking behaviors amongst respondents. Review of the main reasons for unprotected anal intercourse suggests the need of in-depth evaluation of existing prevention initiatives.

people engage in potentially risky behaviors. Providers and policy makers should be aware of perceptions of HIV/AIDS in communities considered at high-risk. While the public opinion is shifting to an optimistic outlook on the HIV/AIDS epidemic, concerns are noted in communities that are mostly affected by the disease (Kaiser Family Foundation, 2011). A decreased sense of national urgency coexists with an alarming incidence of new infections among young gay and bisexual men. Though the annual number of HIV infections was stable between 2006 and 2009, there was a significant increase in HIV in MSM (men who have sex with men) aged 13-29 (Center of Disease Control, 2011). HIV incidence cannot be reduced nationally without better understanding HIV among gay and bisexual men. This fact will guide the direction of HIV prevention funding and programs (National HIV Prevention Strategy, 2011). As the reasons behind the increased HIV infection in young MSM are not fully known, it is important to be aware of attitudes towards HIV/AIDS in these communities to implement prevention activities that are factually, intellectually, and financially effective. With the recent advances in technology comes a new way for gay and bisexual men to find sexual partners. Since 2009 many developers launched location-based mobile apps geared towards gay and bisexual men (Kinkaid, 2009). These programs allow users to view lists of nearby men, chat with them and meet, often for sexual encounters. For example, Grindr one of the most popular all-men location-based app- counts over 3.5 million users in 192 nations in just three years from its launch suggesting a widespread and significantly increasing use of mobile social networking apps (Grindr, web, 2012). As service providers get ready to implement innovative prevention programs, it seems particularly important to understand behaviors related to the new ways available for gay and bisexual men to meet and more importantly- what their thoughts are on HIV/AIDS and unprotected anal intercourse, a

Introduction As the HIV/AIDS epidemic marks its thirty first year, not only have treatments, prevention initiatives and overall dynamics around the virus changed, but also the way people perceive HIV/AIDS and the way

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behavior which poses well known health hazards. Several studies linked unprotected anal intercourse, also defined as bareback sex (Parsons, Bimbi, 2006; Berg, 2009), with sexual behavior and sexual expectations while under the influence of alcohol and drugs (Halkitis, Parsons, & Stirratt, 2001; Irwin, Morgenstern, Parsons, Wainberg, & Labouvie, 2006; Worth, Rawstorne, 2005; Purcell, Moss, Rem- ien, Woods, & Parsons, 2005), the use of the Internet (Wolitski, 2005; Blackwell, 2007; Berg 2009), and utilization of sexually charged venues for locating potential sexual partners (Parsons, 2005a; Parsons & Vicioso, 2005, Blackwell, 2007). While most prevention initiatives focus on educational activities aiming to increase knowledge, studies underlined the importance of considering the role of personal perspectives and emotions in sexual experiences (Halkitis, 2005) and the inhernt complexity of human sexual behaviors. Haltski et al. (2007) have argued that understanding the variables that predispose some men to engage in unprotected anal intercourse should be the corner stone of HIV/AIDS prevention initiatives. Since the first years of the HIV/AIDS epidemic, the identification of factors related to unprotected sex in men who have sex with men became paramount (Parsons, Bimbi, 2006). The purpose of the present survey was to collect information around HIV/AIDS perspectives, HIV/AIDS knowledge, perceived risk of unprotected anal intercourse, and sexual behavior in men who have sex with men who meet their sexual partners through location-based mobile apps.

explained the studys purpose and the eligibility requirements. The study requirements included: (1) 18 years of age or older; (2) self-identify as man (both biological men and transgender men were eligible); (3) self-identify as gay or bisexual; (4) Utilize locationbased mobile apps to meet sexual partners. Participation in the survey was purely voluntary and did not include any incentive. The surveys initial questions verified eligibility. Participants were assured of the confidentiality of their responses and of the fact that individual responses wont be reported. The survey was anonymous and data collection did not include the respondents IP addresses. 725 participants started the survey. 81.2% of participants completed the survey. The remaining were not eligible or left the survey. Given the nature of the study, authors created a simple and fast survey to be easily completed on mobile devices. 686 respondents were born male, 16 were born female, and 1 was born intersex. 683 respondents identified as men, 13 as female, 4 both male and female, and 3 neither male nor female. The sample reported an average age of 36.4, range 18-64. The majority of the respondents were self-identified as White (82.4%, n = 543), followed by Other or Mixed Races (10.9%, n = 79), Black (31, n = 4.7%), Asian (2.9%, n = 19), American Indian/AK Native (1.5%, n = 10), and Native HI/Pacific Islander (0.6%, n = 4). 81%, respondents indentified as Non-Hispanic (n = 534), and 19% (n = 125) as Hispanic/Latino. The vast majority of respondents reported having sex exclusively with men (94.4%, n = 623), followed by those who reported having sex with both men and women (5.3%, n = 36). Respondents were primarily from the United States (489, 75.7%), followed by the United Kingdom (6.08%), and Canada (3.95) (Table 1). The preferred mobile app utilized to meet sexual partners was Grindr (63.2%), followed by Scruff (57.6%), Manhunt (35.1%), and Growlr (29.3%). Other apps utilized included Facebook, Recon, Jackd, OkCupid, Twitter, Mister, Adam4Adam, BareBackRT, and others (Figure 1).

Methods Participants and Procedure Participants (N = 725) were recruited through passive measures, such as advertisements and recruitment on social-network based apps (Facebook, Twitter). Participants were redirected to a survey. The first page briefly Page 4

Table 1: Participants by location

World Country Australia Belgium Brazil Canada China Colombia France Germany Ireland Israel Italy Japan Mexico Netherlands South Africa Switzerland Spain Sweden Turkey UK Unknown USA Total Number 16 1 7 26 1 1 2 4 1 2 11 2 11 2 2 5 16 2 3 40 6 498 659 Percentage (%) 2.43 0.15 1.06 3.95 0.15 0.15 0.3 0.61 0.15 0.3 1.67 0.3 1.67 0.3 0.3 0.76 2.43 0.3 0.46 6.08 0.91 75.7 United States State AL AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS NC NJ NM NY OH OK PA SC TX UT VA VT WA WI Total Number 1 1 3 72 4 1 19 1 21 12 2 1 48 2 2 3 2 3 14 2 2 5 3 22 1 2 16 5 144 8 1 4 2 32 7 11 1 14 4 498 Percentage (%) 0.2 0.2 0.6 14.5 0.8 0.2 3.82 0.2 4.22 2.41 0.4 0.2 9.65 0.4 0.4 0.6 0.4 0.6 2.81 0.4 0.4 1 0.6 4.42 0.2 0.4 3.22 1 30.24 1.61 0.2 0.8 0.4 6.43 1.41 2.21 0.2 2.81 0.8

Measures Demographics Authors collected the following demographic data: sex at birth, gender identity, age, city of residence, country of birth, race, ethnicity, sexual orientation, mobile apps of choice. Information about their HIV status was collected in a separate, optional section. Perspectives on HIV/AIDS Participants were asked whether they agreed or disagreed with the following statements (not sure was an option): I am afraid of getting HIV and AIDS. (If you are HIV-positive: I am afraid of getting reinfected with HIV and AIDS). People are more concerned about HIV than it is necessary.

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I know enough to protect myself from the HIV virus. AIDS is now a common and manageable chronic illness. I can tell if my partner is HIV positive.

their last HIV test, and whether or not they practiced unprotected anal intercourse.
Figure 1: Which of the following mobile social network/dating apps do you use to hook up? (By hook up we mean to have sex with someone)

Utilizing a likert type scale, participants were asked how comfortable they were having sex with known HIV-positive sexual partners and how comfortable they were asking their sexual partners their HIV status. Participants were also asked to indicate whether they thought HIV/AIDS was a serious problem for people they know. Perspectives on Unprotected Anal Intercourse Participants were asked whether they agreed or disagreed with the following statements (not sure was an option): Barebackers are well informed about HIV and aware of the risks. Barebacking is not too dangerous. Most barebackers are already infected with HIV and are having unprotected sex among them.

450 400 350 300 250 200 150 100 50 0 Mobile App
Grindr Scruff Facebook Twitter Jack'd Mister Manhunt Recon GuySpy Growlr Other

Barebacking was defined as unprotected anal sex without a distinction between receptive or insertive. Participants were asked to share their opinion about the reason behind bareback sex and the potential benefits of bareback sex through multiple choice questions HIV/AIDS Knowledge Basic HIV/AIDS knowledge was investigated through 9 questions. Additionally, respondents were asked to explain what they knew about pre-exposure prophylaxis and/or post-exposure prophylaxis in an open essay box. Optional Section Participants were able to complete the survey without answering questions about their HIV status,

Results Participants agreed with the statement I am afraid of getting HIV and AIDS or I am afraid of getting reinfected with HIV and AIDS (68.1%, n=361) while 80.9% (n=429) disagree with the statement People are more concerned about HIV than it is necessary. Almost all participants believe they know enough to protect themselves from the HIV virus (91.9%, n=487). Lastly, the majority of respondents agreed with the fact that it is not possible to tell if a sexual partner is HIV-positive (84.5%, n=448). Interestingly, 50.9% of respondents (n=270) concurred with the statement AIDS is now a common and manageable disease. When it comes to asking sexual partners their HIV status, 48.9% of respondents (n=259) feel very comfortable and 29.1% of them said they are comfortable having sex with HIV-positive partners

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(Figure 2). The majority of the sample feels that AIDS is a somewhat serious problem for people they know (52.5%, n=278), while 29.4% (n=156) consider it to be a serious problem.
Figure 2:

With condoms doesnt feel the same (84.6%); Impulsive sexual behaviors (73.8%); They are high on drugs (57.4%); They know their sexual partner status (49.5%); They dont care about HIV (48.2%).

How comfortable do you feel about asking a sexual partner about HIV status?

The survey proposed perceived and potential benefits of barebacking: Barebacking is hotter than sex with condoms (62.2%); Barebacking is sexier than sex with condoms (44.7%); Barebacking increases intimacy between men (42.4%).

3% 13%

6% 49%

29%

Very Comfortable Not Sure Very Uncomfortable

Comfortable Uncomfortable

Respondents were sufficiently knowledgeable about HIV/AIDS. The majority of people were able to identify the fluids that can transmit HIV, although only 56.6% know that breast milk is among those. 80.9% of respondents know that HIV is transmitted through unprotected anal sex, vaginal sex, and less frequently- oral sex. 82.1% know that HIV is present in pre-ejaculatory fluid, 77.5% are aware of the fact that other sexually transmitted infections can increase the chance of a person getting HIV/AIDS, and 89.8% know that at present there is not an available vaccine to prevent HIV. Respondents learned about HIV/AIDS: Through the media, such as radio, television, newspapers, and the internet (73.5%); From their doctor or other health professionals (57.2%); From friends and family (40.8%); At school (39%).

Barebacking is defined as unprotected anal intercourse (Berg, 2009). The majority of respondents (42.0%, n=218) believe barebackers are well informed about HIV and aware of the risks. 86.1% (n=447) disagreed with the statement barebacking is not too dangerous and 51.8% (n=269) disagreed with statement most barebackers are already infected with HIV and are having unprotected sex among themselves. The survey suggests several reasons that would explain why some men practice unprotected sex. The principal reasons are:

Respondents were split in terms of knowledge of preexposure prophylaxis (PrEP) and/or post-exposure prophylaxis (PEP). 51% said that they had never heard of PrEP and PEP, while the rest of the sample knew about one or both and in most cases were able to

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briefly define them. Some respondents voluntarily disclosed having accessed PEP services and some shared being part of PrEP studies. It is important to note that, while participants knew the general idea of how prophylaxis works, there were several misconceptions and incorrect details in the information provided by the sub sample of respondents who reported familiarity with PEP and PrEP. Most respondents decided to answer the questions in the optional section of the survey (n=485). In this sub sample, the percentage of men who never engage in unprotected anal intercourse (53.6%) is not significantly higher than the percentage of those barebacking either always, often, or sometimes (46.4%) (Figure 3). 71.9% of respondents in this sub sample self reported an HIV-negative status, 18.5% an HIV-positive status, and 9.6% an unknown status (Figure 4). However, 30.7% of the respondents last tested on or before January 2011, and 12.2% last tested between February 2011 and July 2011.
Figure 3: Do you have unprotected anal sex with guys you meet on mobile apps?

Figure 4: What is your HIV status?

10% 18%

72%

Positive

Negative

I am not sure

Discussion As noted in the Kaiser Family Foundations Survey of Americans on HIV/AIDS (2011), it seems that in the era of anti-viral medications, pre-exposure prophylaxis and post- exposure prophylaxis, people seem unsure how to view the disease. While the majority of respondents are afraid to be infected or re-infected and think that people should be more concerned about the epidemic and view it overall as s serious issue, 50.9% of them consider the disease to be common and manageable. Additionally, in contrast to the trends of other studies (Halkitis, Siconolfi, Fumerton & Barlup, 2008) respondents dont seem to have problems discussing partners serostatus. 50.4% reported being either comfortable or very comfortable having sex with HIV-positive partners, while 35.3% feel uncomfortable. The survey found that reasons behind risk taking behaviors during intercourse go well beyond lack of knowledge and serostatus. The vast majority of

3% 7%

4%

54% 32%

Never

Sometimes

Often

Always

Other

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respondents considers barebacking dangerous and believes barebackers are informed of the risk. Yet, in the sub- sample responding to the inquiry about sexual habits, almost half of respondents (46.4%) bareback either always, often, or sometimes versus 53.6% who reportedly never engage in unprotected anal intercourse. As found in other studies (Halkitis, Siconolfi, Fumerton & Barlup, 2008), our data suggest that lack of knowledge about HIV transmission and danger associated with unprotected anal intercourse do not explain risk-taking behaviors. Respondents identified the way condoms feel, impulsive behaviors and the use of drugs as the principal causes of decision making for barebackers, placing the locus of control externally, in tools that interrupt the sexual experiences fluidity (condoms) or in mental states that interfere with healthy choices (impulsive behaviors and drugs). Additionally unprotected sex is considered to be overall a better experience and a vehicle to increase intimacy with sexual partners. Halkitis et al. (2005) came to similar conclusions, indicating sexual compulsivity and drug use as predictive of identification as barebackers.

relating to falsification and social desirability. The complete anonymity of the survey and the venue might impact the generalizability of the findings.

Conclusions The survey found a large sample of gay and bisexual men who are undeniably knowledgeable about HIV/AIDS, possess skills to talk about it, and yet in many cases participate in risk-taking activities. Professionals developing prevention interventions cannot avoid considering factors that predispose their target population to barebacking. Our sample spoke clearly and identified two principal causes: men do not like condoms and men are led by powerful and deep cognitive factors (impulsivity and need of intimacy). Existing behavioral interventions focus primarily on three areas: providing HIV education, distributing condoms and encouraging safer sex, and teaching people behavioral strategies to facilitate decision making. There is a clear discrepancy between the reasons why men engage in unprotected anal intercourse and the way prevention initiatives attempt to address risk behaviors. Generations of HIV/AIDS workers have been distributing condoms to men who clearly do not like how condoms feel. Researchers have created cognitive tools to approach men who report being driven by impulsive needs, which, by definition, cannot be rationally controlled. Halkitis at al. (2005) suggested that prevention programs should be multifaceted and address psychological, emotional and behavioral aspects of barebacking. The survey reached similar conclusions for gay and bisexual men on mobile apps. It appears that the issue is not so much lack of knowledge or lack of awareness but the complicated variables that come into play during sexual encounters, which appear to be primarily emotional experiences rather then mechanical behaviors.

Limitations First and foremost, our survey allowed us to collect a large amount of quantitative data, but fell short of providing qualitative, detailed information. Our goal was to offer an extremely simple and brief survey for users of mobile devices. This choice allowed us to collect a large amount of data, while preventing us for asking open questions. While it was beyond the scope of this study to investigate the emotions evoked by bareback sex, it appears that an in-depth analysis is necessary. We decided to ask HIV status and sexual habits in an optional section to prevent respondents from abandoning the survey for fear of being traced, therefore we did not collect serostatus and sexual habits for all respondents. Lastly, while the survey is ecologically valid, it is not possible to control bias

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