HIV risk practices among Indigenous Australian and Anglo-Australian gay and bisexual menadmin
HIV risk practices among Indigenous Australian and Anglo-Australian gay and bisexual men
HIV Australia | Vol. 11 No. 3 | October 2013
By Toby Lea and Martin Holt1
Aboriginal and Torres Strait Islander (‘Indigenous Australian’) gay and other homosexually active men, transgender people and sistergirls are identified as priority populations in the Third Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy.
While there have been similar rates of HIV diagnosis per capita in the Indigenous and non-Indigenous populations over the past decade, there are differences in transmission patterns which could place Indigenous Australians at a higher risk of exposure to HIV.
For example, in the five years up to 2011, around half of HIV notifications among Indigenous Australians were attributed to homosexual sex between men, compared to almost three-quarters of notifications among non-Indigenous Australians.2
A much higher proportion of new HIV cases among Indigenous Australians was attributed to injecting drug use than among non-Indigenous Australians (16% vs 2%).
An additional 8% of notifications among Indigenous Australians was attributed to men who have sex with men who also injected drugs, compared with 3% of notifications among non- Indigenous Australians.3
To date, there has only been one published study that has provided information about the sexual and drug use risk practices of Indigenous Australian gay and bisexual men.
That paper, which analysed data from the Gay Community Periodic Surveys from 2000 to 2004, found that while there were no differences between Indigenous and non-Indigenous men in the proportion living with HIV (around 11%), Indigenous men were somewhat more likely to report unprotected anal intercourse with casual male partners (UAIC) in the past six months compared to non-Indigenous men (24% vs 21%), and almost twice as likely to report injecting drug use in the past six months (11% vs 6%).4
We recently updated this analysis to review HIV prevention, sexual health and harm reduction needs among Indigenous Australian gay men, using data from the Gay Community Periodic Surveys from 2007 to 2011.
The Gay Community Periodic Surveys (GCPS) are anonymous, cross-sectional, self-completed surveys of gay and other homosexually-active men that are routinely conducted in six Australian states and territories.
Trained staff recruit men at gay community events (e.g., Sydney Mardi Gras Fair Day), social venues (e.g., bars, clubs and gyms), sexon- premises venues and clinics with high caseloads of gay men.
We included data from all Indigenous and Anglo-Australian men who participated in the survey between 2007 and 2011, representing 25,280 respondents, 1,278 (5.1%) of whom identified as Indigenous Australian.
We compared Indigenous Australian and Anglo-Australian men on sociodemographic characteristics, HIV status, testing for HIV and STIs, sexual risk practices, and patterns of drug use.
About the sample
Indigenous men were on average younger than Anglo-Australian men (mean age: 34 vs 37 years), were less likely to be full-time employed (62% vs 70%), and less likely to identify as gay (82% vs 89%).
There were no differences between Indigenous and Anglo-Australian men in terms of HIV status (10% reported being HIV-positive, 76% HIV-negative).
Among HIV-positive men, similar proportions of Indigenous men (77%) and Anglo-Australian men (74%) reported currently being on combination antiretroviral therapy.
In the past 12 months, the majority of men had been tested for STIs (55%) and among men who were not HIV-positive, just over half had been tested for HIV (55%).
Patterns of illicit drug use
The majority of men reported illicit drug use in the past six months (61%).
While there was no difference in the proportion of Indigenous and Anglo-Australian men reporting any drug use, Indigenous men were somewhat more likely to use specific drugs, for example, cannabis (40% vs 34%), speed (24% vs, 16%) and heroin (4% vs 1%).
Differences in the use of crystal methamphetamine (14% vs 11%) and amyl nitrite (38% vs 37%), were small.
Erectile dysfunction medications were less commonly used by Indigenous men compared to Anglo-Australian men (14% vs 18%).
Indigenous men were twice as likely as Anglo-Australian men to report injecting drug use in the past six months (9% vs 4.5%).
When taking into account the influence of socio-demographic characteristics (e.g., education and employment) and sexual and drug use practices, these differences became less pronounced.
In the adjusted analysis, controlling for known differences between Indigenous and non-Indigenous men, Indigenous men were 43% more likely to report injecting drug use compared to Anglo-Australian men.
Sexual risk practices with male partners
There was a small difference between Indigenous and Anglo-Australian men in the proportion reporting a regular male partner in the past six months (73% vs 69%), although both groups were similarly likely to report any UAI with regular partners (41% vs 38%).
Among HIV-negative men with regular partners, Indigenous men were no more likely than Anglo-Australian men to report UAI with a serodiscordant partner (both around 5%).
Among HIVpositive men who had regular partners, Indigenous men were no more likely than Anglo-Australian men to report UAI with a serodiscordant partner (40% vs 36%).
Two-thirds of men in both groups reported having had sex with casual male partners in the past six months (66% vs 65%).
However, while the proportion of men reporting casual partners did not differ according to cultural background, Indigenous men were more likely than Anglo-Australian men to report UAIC during this period (28% vs 21.5%).
When adjusting for the effects of socio-demographic and behavioural characteristics, there was a slight attenuation in the difference reported, with Indigenous men remaining 30% more likely than Anglo-Australian men to report UAIC.
In this paper, we found higher levels of recent UAIC and injecting drug use among Indigenous men compared to Anglo-Australian men, but no difference in self-reported HIV prevalence.
These findings are consistent with the findings of the previous analysis by Lawrence and colleagues.5
The higher occurrence of UAIC among Indigenous men but similar HIV prevalence to Anglo-Australian men is noteworthy given that UAIC is a key route of HIV transmission.6
This may suggest that the partners with whom HIV-negative and untested Indigenous men have UAIC come from sexual networks with a lower HIV prevalence (e.g., outside of major cities), or that Indigenous men are using risk reduction strategies such as serosorting and strategic positioning to reduce the likelihood of HIV transmission during UAI.7 However, these interpretations are speculative and warrant further investigation.
The high rates of injecting drug use among both Indigenous and Anglo-Australian men were concerning, especially when compared with the low rates reported in the general population (around 0.5% of the general population reported injecting in the past 12 months in the 2010 National Drug Strategy Household Survey).8
That Indigenous Australian men in our study were twice as likely as other gay and bisexual men to report injecting is mirrored in Australian HIV notification data, where Indigenous men diagnosed with HIV are twice as likely non-Indigenous men to be classified as homosexually active and a person who injects drugs.9
This underlines the need for culturally appropriate harm reduction services for Indigenous Australian gay and bisexual men, whether men are accessing Indigenous, mainstream or gay-oriented services.
To our knowledge, this is the largest study of Indigenous Australian gay and bisexual men conducted to date, and these findings are likely to be valuable in focusing prevention priorities and support needs in this population.
However, there are some important limitations. Firstly, the urban composition of the sample and gay community focus of recruitment means that caution should be taken in generalising these findings to men outside of urban areas and to those not engaged with the gay community.
That said, the majority of Australian HIV diagnoses occur in major cities for both Indigenous and non-Indigenous men.
Secondly, the Gay Community Periodic Surveys are brief surveys for the routine surveillance of sexual and drug use practices associated with HIV transmission.
As such, detailed data are not collected that would provide a more nuanced understanding of HIV risk practice, such as motivations for UAI, and barriers and incentives to accessing HIV and STI testing and treatment.
These findings suggest that Indigenous Australian gay and bisexual men should remain a focus for HIV prevention, care and support and the reduction of drug-related harm, but that they may not be at an elevated risk of HIV transmission for reasons that are not well understood.
There is little or no research on the educational and support preferences of Indigenous Australian gay and bisexual men, or barriers to help-seeking.
Our findings suggest this information would be valuable in guiding culturally appropriate HIV prevention and harm reduction services for this priority population.
Dr Toby Lea is a Research Associate at the Centre for Social Research in Health (formerly National Centre in HIV Social Research) at the University of New South Wales.
Dr Martin Holt is a Senior Research Fellow at the Centre for Social Research in Health.
1 We would like to acknowledge the other authors of the original paper from which this article was drawn from: Michael Costello, Limin Mao, Garrett Prestage, Iryna Zablotska, James Ward, John Kaldor and John de Wit. Thanks also to the men who participated in the Gay Community Periodic Surveys, and the state and territory health departments who funded the surveys.
2 The Kirby Institute. (2012). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2012. The Kirby Institute, the University of New South Wales, Sydney.
4 Lawrence, C., Rawstorne, P., Hull, P., Grulich, A., Cameron, S., Prestage, G. (2006). Risk behaviour among Aboriginal and Torres Strait Islander gay men: Comparisons with other gay men in Australia. Sex Health 3(3), 163–7.
6 Zablotska, I., Prestage, G., Middleton, M., Wilson, D., Grulich, A. (2010). Contemporary HIV diagnoses trends in Australia can be predicted by trends in unprotected anal intercourse among gay men. AIDS 24(12), 1955–8.
7 Mao, L., Kippax, S., Holt, M., Prestage, G., Zablotska, I., de Wit, J. (2011). Rates of condom and non-condom-based anal intercourse practices among homosexually active men in Australia: deliberate HIV risk reduction? Sex Transm Infect. 87(6), 489–93.
8 Australian Institute of Health and Welfare (AIHW). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. AIHW, Canberra.
9 The Kirby Institute, op. cit.