A survey of close to 128,0000 gay and bisexual men living across Europe shows that just 3.3% have ever taken pre-exposure prophylaxis (PrEP), although 7% had tried to obtain it and 45% would be likely to use it if it were available and affordable. The European MSM Internet Survey (EMIS) 2017 also shows that significant numbers of men do not know that ‘undetectable = untransmittable’; that chemsex is reported by small numbers of men throughout the continent; and that internalised homonegativity and poor mental health are common.
The comprehensive report for EMIS 2017 has data on a huge range of indicators. The report shows considerable differences between countries, reflecting Europe’s diversity with respect to sexual health and behaviour of gay and bisexual men. This article picks out a few highlights, but further analyses are likely to be published over the coming months and years.
The 2017 European MSM Internet Survey was a collaborative HIV prevention needs assessment for men who have sex with men, following on from a similar survey conducted in 2010. It was available in 33 languages, with four-fifths of men recruited from dating apps and websites including Planet Romeo, Grindr and Hornet. Additional recruitment was through Facebook, Twitter, community organisation websites and email lists.
Data are included on 127,792 men living in the 28 member states of the European Union; the six Balkan states and Turkey which are candidates to join the EU; Switzerland, Norway, Iceland, Belarus, Ukraine, Moldova and Russia; and also Israel and Lebanon.
The survey was available between October 2017 and January 2018.
EMIS 2017 shows massive gaps in the PrEP cascade: 63% of men were aware of PrEP; 45% of men who were not diagnosed with HIV would be likely to use PrEP if it was available and affordable (equally split between ‘very likely’ and ‘quite likely’); 9% of men had had a conversation with a healthcare professional about PrEP; 7% had tried to get PrEP; and 3.3% had ever used it and 3.0% were currently using it.
There was considerable variation between countries. PrEP awareness and use was highest in the UK (87% aware, 22% discussed it at a health service and 8.6% using it) and France (83% aware, 19% discussed it at a health service and 8.4% using it).
But results were notably poor in some other western European countries, such as Germany (60% aware, 6.7% discussed and 2.1% using), Sweden (46% aware, 2.7% discussed and 0.8% using) and Italy (56% aware, 2.6% discussed and 0.4% using).
Further east, there was very little access to PrEP in most countries, including Poland (49% aware, 2.3% discussed and 0.6% using) and Russia (35% aware, 1.5% discussed and 0.9% using). In six Balkan states and Turkey, 39% were aware of PrEP, 2.5% had discussed it with a healthcare professional and 0.7% were using it.
PrEP awareness and use tended to be lower in men under the age of 25, men over the age of 65, men who were ‘out’ to very few people, refugees and asylum seekers, and trans men.
Overall, 3.3% had ever used PrEP. The tablets were most commonly obtained with a prescription (51%), from an online pharmacy (30%) or by being a participant in a research study (13%). Seven per cent said that they used pills prescribed for post-exposure prophylaxis (PEP) or another person’s HIV treatment.
Amongst current PrEP users, 1.9% were taking it daily and 1.1% were using an event-based regimen.
What about awareness that undetectable = untransmittable? Men taking part in the survey were presented with the following statement: “A person with HIV who is on effective treatment (called ‘undetectable viral load’) cannot pass their virus to someone else during sex.”
Across Europe, 57% said they already knew this, 20% weren’t sure, 15% didn’t know it, 1.1% didn’t understand it and 6.5% didn’t believe it. Therefore, overall 43% lacked understanding of this key fact. In no country other than Denmark did less than 30% of gay and bisexual men lack understanding of this. Among men with diagnosed HIV, 87% knew they were undetectable, but 6% either did not know whether their last test result was undetectable or had never been medically monitored, while 8% had a detectable viral load.
As for PrEP, a lack of U=U knowledge was especially common in men under the age of 25, men who were ‘out’ to very few people, refugees and asylum seekers, and trans men. In those with diagnosed HIV, the same groups were more likely not to have an undetectable viral load.
Given increasing concern about ‘chemsex’, the survey asked a series of questions about substance use, including in sexual contexts. The substances most commonly used by respondents were alcohol (83% had used it in the past month), tobacco (43%), poppers (21%), Viagra and similar drugs (13%), cannabis (13%) and sedatives or tranquilisers (6.4%).
Other drugs were less commonly reported: cocaine (3.9% in the past month), ecstasy pills (3.2%), GHB/GBL (2.8%), ecstasy powder (2.2%), GHB/GBL (2.1%), ketamine (1.5%), crystal meth (1.4%), mephedrone (1.2%), various synthetic stimulants (0.8%), synthetic cannabinoids (0.6%), LSD (0.4%), crack cocaine (0.2%) and heroin (0.2%).
Only 1.2% of men had injected a drug to get high in the past year. Half of these men had injected four times or less in the past year.
In the past month: 76% of respondents had had sex; 64% of respondents had had sober sex (not involving any alcohol or drugs); and 5.2% had had chemsex (“used stimulant drugs to make sex more intense or last longer”).
Looking at a longer time period, 10% had had chemsex in the past year. There was less variation in engagement in chemsex by country, compared to the PrEP and U=U indicators. In three-quarters of the countries, between 2 and 7% of men reported recent chemsex. The outlier countries with the greatest engagement in chemsex were the Netherlands (15%), Belgium (11%), France (7.8%) and Spain (7.6%).
Recent chemsex was more common in men with diagnosed HIV (17%), men who sometimes sell sex (15%), men who had migrated to live more openly as gay or bisexual (8.7%), men who were ‘out’ to almost everyone (7.8%) and men aged 40-64 (6.4%).
The survey highlights issues related to mental health and social support that are likely to have an impact on sexual health and behaviour.
To assess internalised homonegativity (negative feelings towards one’s own homosexuality), men were asked about another series of statements, including “I feel comfortable in gay bars”, “I feel comfortable being a homosexual man” and “Even if I could change my sexual orientation, I wouldn’t”.
Scores were poorest in Turkey, Lebanon, the six EU candidate countries in the Balkans, Ukraine, Belarus, Russia, Romania, Poland and Bulgaria.
They were most favourable in Iceland, Denmark, Switzerland, Germany, Austria, Sweden, Norway, Spain, UK, the Netherlands, Belgium, Czech Republic, Estonia and Ireland.
To gauge social support, men were asked about statements such as “There are people I can count on in an emergency”, “I feel part of a group of people who share my attitudes and beliefs” and “There is no-one who shares my interests and concerns”.
Across Europe, 11.7% were assessed as lacking social support. In no country other than Iceland was this figure below 7%. The list of countries with the poorest scores was virtually identical to that for internalised homonegativity.
Questions about symptoms of anxiety and depression in the past two weeks indicated that 10.7% may have moderate anxiety or depression, while 7.7% have severe anxiety and depression. While many of the countries with the worst scores are the ones mentioned above, they were also elevated in the UK (10.7% with severe depression), Estonia (11.0%) and Croatia (10.1%).
A lack of social support and severe anxiety/depression were both more common in men under the age of 25, refugees and asylum seekers, men who sell sex, trans men, men who are ‘out’ to few people, and men who don’t have a stable partner.