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
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]
Background: The “Gay Scene” in Beirut
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
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]
Purpose
• There is limited published research about
psychosocial factors influencing HIV risk behaviors
among MSM in Lebanon
• The purpose of this study is to explore the
psychosocial processes influencing condom use and
HIV testing among MSM in Beirut
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
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
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
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
Results: Partnership Characteristics
Casual 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.”
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.”
Results: Partnership Characteristics
Sex 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.”
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.”
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.”
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.”
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%)
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
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Acknowledgements
•
Study Staff:
▫ Danielle Khouri, Project Director
▫ Johnny Tohme
▫ Rabih Maher
▫ Simon Nehme
▫ Chantal Chedid
▫ Karine Nasssar
•
Lebanese Collaborators:
▫ Lebanese AIDS Society
▫ National AIDS Program, Lebanon
▫ Helem
▫ Marsa Sexual Health Center
▫ SKOUN
▫ Soins Infirmiers developpement communautaire (SIDC)
▫ Lebanese American University School of Medicine
•
Funders:
▫ National Institute of Mental Health, 5R21MH093204-02
Thank You
Frances Aunon
faunon@rand.org