1. Contributions of Behavioral Research to HIV/AIDS Studies and to Health Promotion EDCTP workshop, Prague 23.October 2009

2. Trends in high-risk sexual behaviour among men who have sex with men from Eastern, Central and West Europe participating in the SIALON project MUDr. Džamila Stehlíková, Manager for National HIV/AIDS Programme in Czech Republic, National Institute for Public Health MUDr. Ivo Procházka, CSc, Institute of Sexuology, 1st Faculty of Medicine Charles University Prague RNDr. Marek Malý, CSc, National Institute for Public Helath

3. National response to HIV/AIDS The govermental resolution from 2008 –National programme for HIV/AIDS in the Czech Republic for 2008-2012 and National Health Strategy „Health 21“ Projects and programmes are funded from the national budget and are coordinated with the Ministry of Health and Survelaince Committee.

4. Behavioural studies of HIV/AIDS as a base of prevention policy Great advances have been made over the past decade in behavioral research on how to help persons avoid contracting HIV infections (primary prevention), how to reduce or alleviate adverse consequences among persons who are living with HIV disease (secondary prevention) and which intervention components are most effective in influencing those behaviors. It has been estimated that nearly one-half of the more than 60 million new HIV infections expected to occur by 2015 could be prevented by accelerating research in this area and improving access to effective prevention strategies.

5. Main prevention groups: Men who have sex with men (MSM) Sex workers Injecting drug users Prisoners Youth at risk People Living with HIV

6. The significance of the behavioural studies of HIV/AIDS consists in understanding the causes of dramatic spread of HIV among vulnerable groups, first of all MSM communities in many Western European and Central European countries and prepearing of intervention, which can lead to significant risk reduction

8. The share of homosexual ways of transmission compared with heterosexual way in reported HIV-positive and AIDS cases in the Czech Republic in the period 1985-2009

9. The incidence of HIV infection among MSM in Czech Republic is increasing despite efforts to reduce high risk behaviour Since the year 2005 there is a clear evidence of increase HIV transmission by homosexual sex. It has now reached up to 56 percentage of all HIV transmission (cummulative data since 1985). Homosexual transmission was in the year 1995 less common than heterosexual one (14:18 cases). In 2005 this ratio has been completely reversed (52 homosexual transmission: 29 heterosexual transmission). Now is homosexual transmission more than twice higher than heterosexual one and is still increasing. There were identified 74 new cases of homosexual transmission in this year (data available until September 2009) and 26 cases of heterosexual transmission.

10. EU Project SIALON In an effort to comlete and append current understanding of dramatiy HIV/AIDS spread among men who have sex with men (MSM) in Eastern Europe and some states od Central Europe, to identify gaps in knowledge, and to develop a roadmap for future research and intervention, European commission brought together experts from seven countries (Italy, Spain, the Czech Republic, Slovakia, Slovenia, Romania and Greece) for the comparative research of MSM in the connection with HIV/AIDS

11. Frequency of high risk sexual practice

12. Good knowledge of HIV transmission routes in Czech gay community is associated with very risky personal behaviour An analysis of the frequency of high risk sexual practice (unprotected anal and oral intercourse) among the respondents from Prague, Bratislava, Barcelona, Bucharest, Ljubljana and Verona showed that in comparison with MSM from western European countries (Italy and Spain), the Czech respondents tended to take the greatest risk in their sexual behavior, especially in the sense of a more frequent engagement in unprotected active and passive anal intercourse and unprotected orogenital sex with ejaculation into the partner´s mouth. Two thirds of Czech respondents (66,3 %) admitted during last sexual intercourse these high risk sexual practice compared with cca 36,9 % Spanish and 38,1 % Italian respondents.

13. High risk behavior in MSM 1. Unprotected anal intercourse 2. Ejaculation into mouth during oral sex 3. Casual (anonymous) unprotected sex 4. Sex with HIV positive partner (especially unprotected anal sex but sometimes any uprotected sex generally) 5. Oral sex (especially with the respect to syphilis and other STIs) 6. Contact of sperm with conjunctiva, mucosa or wounded skin 7. SM practices including fisting 8. Group sex, „dark rooms“

14. Frequency of high risk sexual practice with casual partner

15. Risky behaviour with stable partners is much more common More than two thirds had such partner at the time of interview (70 percent). 90 percent had with him unprotected oral sex and three quarter of them ejaculated into his mouth. More than half had unprotected anal sex with him (62 percent in insertive role and 57 percent in receptive role. The data show the safer sex practices among MSM in Prague are not so wide common and sustainable as in the most western countries. There is a high potential for increasing spreading of HIV (and even more of syphilis, because it is not often considered as a serious healthy risk and the preventive behavior does not usually involve minimizing other STIs).

16. The high potential risk for STI spread The Sialon data show the safer sex practices among MSM in Czech Republic and other Eastern a Central European countries are not so wide common and sustainable as in the most western countries. There is a high potential for increasing spreading of HIV (and even more of syphilis, because it is not often considered as a serious healthy risk and the preventive behavior does not usually involve minimizing other STIs).

17. The reasons of sustainable high prevalence of HIV/AIDS and other STI among MSM: The increasing HIV and syphilis prevalence in the MSM community causes each year the higher chance to meet infected partner. Additionally growing syphilis epidemic among MSM may increase the number of new HIV transmissions. The high frequency of risk sexual behaviour The lower number of sexual partner among MSM, especially with anal sex is not true any more and especially in Prague. The visibility of PLWHA is low because of low tolerance to them even within gay community. This opinion are supported by findings from Sialon study on more than 2400 men visiting gay venues in Prague, Bratislava, Barcelona, Bucharest, Ljubljana and Verona. The data were collected in 2009.

18. Development and delivery of new interventions for MSM is needed Because most studies were conducted among MSM in Western Europe, more evaluations of interventions are needed for MSM in East Europe. Further research measuring the incidence of HIV and other STIs in MSM is needed. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management. More research is also needed to further clarify which behavioral strategies are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

19. Behavioral strategies for prevention - reducing HIV transmission among MSM keeping condoms available reducing unprotected anal sex, permanent use of condom during anal sex with all partners reducing anal sex even with condom use having oral sex instead of anal sex reducing uprotected oral sex with ejaculation condom use during oral sex with casual partner reducing number of partners avoiding serodiscordant partners avoidance of casual sex avoidance to visit bars with dark rooms and saunas discussion with partner about previous risks

20. Thank you for your attention stehlikova@szu.cz