1. Consistent and inconsistent use of HIV risk reduction strategies by Australian gay and bisexual men who report unprotected anal intercourse with casual male partners Martin Holt, Toby Lea, Limin Mao, Iryna Zablotska, Garrett Prestage, John de Wit

2. Background and primary research questions Behavioural research often classifies gay and bisexual men (GBM) in this way: –Any anal sex without condoms = high risk –No anal sex without condoms = low risk This may overlook risk reduction strategies used by GBM who have anal sex without condoms We decided to assess: –Range of risk reduction strategies used by GBM who report anal sex without condoms with casual partners –Consistency of use of risk reduction strategies –Correlates of consistent vs. inconsistent use

3. Sample derivation: N=15615, 2011 & 2012, Australian Gay Community Periodic Surveys

5. n=2942

6. Sample profile HIV-positive men (n=603) HIV-negative men (n=2339) p value Mean age (standard deviation)43.4yrs (9.8)36.7yrs (11.5) <.001 Anglo-Australian background73.8%68.1%.007 Full-time employed60.0%69.3% <.001 University educated39.8%48.2% <.001 Self-identified as gay95.0%89.7% <.001 Recruitment venue Gay social event or venue Health clinic Sex-on-premises venue 64.0% 8.1% 17.9% 79.8% 4.4% 15.9% <.001 On antiretroviral treatment77.9% Undetectable viral load79.1%

7. HIV risk reduction strategies during anal sex Condoms Serosorting (matching HIV status) before anal sex without condoms Strategic positioning during anal sex without condoms –HIV-positive partner takes receptive position –HIV-negative partner takes insertive position Withdrawal before ejaculation during anal sex without condoms We classified participants as often/always or occasionally/never practising each strategy in the six months prior to survey (frequent vs. infrequent use)

8. Frequent use of different strategies (by men who had had anal sex without condoms with casual partners)

9. Correlates of frequently (vs. infrequently) practising any risk reduction strategy HIV-positiveAOR (95% CI) Gay-identified2.39 (1.06, 5.38) Occasional anal sex without condoms with casual partners Often Ref. 1.70 (1.06, 2.73) No HIV disclosure Some Disclosed to all Ref. 2.28 (1.29, 4.02) 7.11 (3.70, 13.67)

10. Correlates of frequently (vs. infrequently) practising any risk reduction strategy HIV-positiveAOR (95% CI) Gay-identified2.39 (1.06, 5.38) Occasional anal sex without condoms with casual partners Often Ref. 1.70 (1.06, 2.73) No HIV disclosure Some Disclosed to all Ref. 2.28 (1.29, 4.02) 7.11 (3.70, 13.67) Unrelated to: HIV treatment status or viral load.

11. Correlates of frequently (vs. infrequently) practising any risk reduction strategy HIV-positiveAOR (95% CI)HIV-negativeAOR (95% CI) Gay-identified2.39 (1.06, 5.38)Age0.99 (0.98, 1.00) Occasional anal sex without condoms with casual partners Often Ref. 1.70 (1.06, 2.73) Occasional anal sex without condoms with casual partners Often Ref. 2.01 (1.53, 2.63) No HIV disclosure Some Disclosed to all Ref. 2.28 (1.29, 4.02) 7.11 (3.70, 13.67) No HIV disclosure Some Disclosed to all Ref. 1.76 (1.39, 2.21) 3.43 (2.66, 4.42) Unrelated to: HIV treatment status or viral load. 1-5 partners 6-10 >10 Ref. 1.50 (1.14, 1.98) 1.75 (1.36, 2.24) No regular partner Seroconcordant Nonconcordant Ref. 0.79 (0.63, 0.99) 0.58 (0.44, 0.75)

12. Correlates of frequently (vs. infrequently) practising any risk reduction strategy HIV-positiveAOR (95% CI)HIV-negativeAOR (95% CI) Gay-identified2.39 (1.06, 5.38)Age0.99 (0.98, 1.00) Occasional anal sex without condoms with casual partners Often Ref. 1.70 (1.06, 2.73) Occasional anal sex without condoms with casual partners Often Ref. 2.01 (1.53, 2.63) No HIV disclosure Some Disclosed to all Ref. 2.28 (1.29, 4.02) 7.11 (3.70, 13.67) No HIV disclosure Some Disclosed to all Ref. 1.76 (1.39, 2.21) 3.43 (2.66, 4.42) Unrelated to: HIV treatment status or viral load. 1-5 partners 6-10 >10 Ref. 1.50 (1.14, 1.98) 1.75 (1.36, 2.24) No regular partner Seroconcordant Nonconcordant Ref. 0.79 (0.63, 0.99) 0.58 (0.44, 0.75)

13. Summary Three-quarters of gay and bisexual men who engage in anal sex without condoms with casual partners frequently practise HIV risk reduction A quarter rarely practise risk reduction (and should remain a priority in HIV prevention) The most commonly used strategies are serosorting and condoms Risk reduction is most likely among men who: –More frequently engage in sex without condoms –More consistently disclose HIV status Risk reduction is less likely among HIV-negative men with HIV-negative or untested regular partners

14. Implications Most gay and bisexual men who have anal sex without condoms remain mindful of HIV and use risk reduction (although the effectiveness of these strategies may be variable) A minority appear to be at heightened increased risk of HIV because they rarely practise any strategy To improve the consistency of risk reduction we can: –Support more effective HIV disclosure –Support the choice of appropriate risk reduction strategies in different situations –Support GBM in making agreements about casual sex with their regular partners –Offer alternatives (like PrEP) to those unable or unwilling to use risk reduction strategies like condoms and serosorting

15. Acknowledgments The Gay Community Periodic Surveys are made possible by: The thousands of gay and bisexual men who participate each year State coordinators and teams of peer recruiters State/territory AIDS Councils, NAPWHA member organisations, gay men’s health organisations CSRH: Evelyn Lee, Peter Hull, Toby Lea, Limin Mao, John de Wit Kirby Institute: Iryna Zablotska, Garrett Prestage State/territory health departments Australian Government Department of Health