Experiences of and attitudes towards HIV/STI prevention among holidaymaking men who have sex with men living in Sweden: A cross-sectional Internet survey

Abstract

Aim: Foreign travellers and men who have sex with men (MSM) are prioritised groups for human immunodeficiency virus/sexually transmitted infection (HIV/STI) prevention efforts in Sweden because of high prevalence of sexual risk-taking. This study aims to describe experiences of and attitudes towards HIV/STI prevention efforts, prior to travelling abroad, among MSM, and to investigate the kinds of prevention efforts that are desirable. Methods: The study is based on survey responses from 656 MSM who had travelled abroad. Recruitment took place through a Nordic website, and had a cross-sectional design. The analysis has mainly been descriptive, but bivariate analyses were performed using the chi-square test. The level of significance was p <.05. Results: Only a few of the participants had encountered HIV/STI prevention efforts in Sweden (5%) and abroad (23%), and a majority (58%) felt that it should be more prevalent. Having free access to condoms and lubricants was preferred among 68% of the men. Furthermore, having written information, as opposed to oral, was also preferred (68% vs. 26%). MSM felt that it was easy to find out information (79%) and claimed they would use the Internet to do so (87%). Conclusions: Service providers who offer their services to travellers are encouraged to provide helpful links to information about sexual health. Information that is geared towards risk groups such as young adults should be presented with awareness that MSM are also part of that group. It is important for information to be conveyed respectfully to everyone, but perhaps MSM in particular, since they may have experienced feelings of being stigmatised or discriminated against previously.

Keywords

Attitude holidays HIV infections MSM prevention STI Sweden

Introduction

In Sweden, the entire population is included in the preventive measures against human immunodeficiency virus/sexually transmitted infections (HIV/STIs). Certain groups who are particularly vulnerable or susceptible to infection, including foreign travellers and men who have sex with men (MSM), among others, are prioritised [1]. Within the group of MSM, which accounts for the largest domestic transmission of HIV, the incidence is between 3% and 4% in Sweden, which is a high figure, compared to 0.06% applicable to the general population [1]. Other STIs such as syphilis and gonorrhoea are more common among MSM than the general population [2], and a recent increase in the number of cases can be partly attributed to greater geographic mobility, together with an active sex life and greater sexual risk-taking [3,4]. A critical aspect of being infected with gonorrhoea or syphilis, for example, in addition to the diseases themselves as such, is that an on-going infection causes a several-fold increased risk of contracting HIV by exposure [3].

Sexual contacts among travellers are common, but various factors such as age, travel companion, gender and relationship status are important for the probability of exposing oneself to risk [4 –8]. In the European MSM Internet Survey (EMIS), conducted in 2010, 31% of Swedish men reported having had sex while abroad during the last 6 months [9]. For many, ‘vacation sex’ is unplanned [4], and a large proportion of those infected while abroad are infected at common tourist destinations [10]. It is evident that a significantly large proportion of MSM have sexual contacts abroad, compared to at home [7,11]. Those who were more inclined to have unprotected anal sex with a new partner while on holiday did so also while at home [11]. Thus, the serious consequence of getting infected while abroad is just as probable at home for these MSM [12,13].

Although Swedish MSM have good knowledge about HIV and risk for infection, unprotected sex within this group is common, especially among younger men [9]. The purpose of this study is to describe experiences of and attitudes towards HIV/STI prevention efforts prior to travel abroad among MSM and to investigate the kinds of prevention efforts that are desirable.

Research questions

Do MSM have personal experiences of HIV/STI prevention efforts prior to travelling abroad?

What are MSM perceptions of prevention efforts that they have previously encountered?

What types of prevention efforts against HIV/STI do MSM desire?

Methods

Design

A descriptive, cross-sectional design was used in this study.

The survey

The self-administered, anonymous, Internet survey consisted of questions relating to four subject areas: demographic data about participants, travels during the past year, experiences of HIV/STI prevention efforts, and attitudes towards prevention efforts. ‘Prevention efforts’ refer to distribution of condoms and lubricants, oral or written information/travel advice, easily accessible testing and ‘other’, for which respondents could specify their own alternatives. The survey questions were mainly based on a previous qualitative study [14] and from other Internet surveys involving MSM [9]. The survey, which was in Swedish, consisted of 25 questions. In addition to the fixed response alternatives, 11 of the questions also had room for comments.

Sample and procedure

The sample for the study was MSM aged 18–75 years who were living in Sweden and who had travelled abroad during the preceding year of the survey. Recruitment took place via the forum Qruiser, operated by QX Publishing AB, during 1 week in February 2013. Qruiser is the largest community for LGBT (lesbian, gay, bisexual and transgender) people in the Nordic region, with over 100,000 active members. On the Qruiser site, there are blogs, contests, discussion forums, polls and graffiti boards. Brief information about the inclusion criteria and purpose, as well as a link to the survey, were presented as a ‘pop-up’ advertisement for the target population (men, aged 18–75) after logging in to the forum.

Analysis

Descriptive statistics regarding frequency, mean, percentage and standard deviation were produced to summarise the sample characteristics. Other data were analysed by t-tests for continuous variables, and chi-square tests were used for categorical variables. Analyses of age (18–29, 30–45, 46–59, 60–75 years) and relationship status (in a relationship or not in a relationship) were carried out, as these factors were deemed to be associated with risk exposure during travel in previous studies [4 –8]. The age groups chosen were somewhat arbitrary, but were intended to represent expected lifestyles such as ‘young adults’ (18–29) and ‘seniors’ (60–75). Analyses of educational level (university educated or non-university educated) were also performed. Comparisons that did not show any significant differences between groups are not presented in detail in this study. All analyses were done using Statistical Product and Service Solutions, SPSS version 20, and the level of significance was set at p < .05.

The study was approved by the Regional Ethics Committee for Human Research, Faculty of Health Sciences, Linköping University, Sweden (Dnr 2012/243-31).

Results

During the week of data collection, Qruiser had about 108,000 members. The survey was viewed by 960 persons, of whom 708 responded (74%). Of these, 52 were excluded because they did not list any travel destinations the previous year. Thereafter, 656 people remained. On average, the men had made three or four trips, with a variation of one to seven trips during the previous year. The main purpose of travel was either pleasure (59%, n = 516) or work (17%, n = 107). Table I shows the demographic data and information regarding their most recent travel.

Table I.

Background characteristics of sample (n = 656) and their most recent travels.

	n=656	%
Age, mean (SD), range (years)	41.31 (13.1) 18–75
Highest completed education
< Elementary school	1	0.2
Elementary school	25	4.3
High school	216	32.9
Community college	22	3.4
College/university	389	59.3
Relationship status
In a relationship with a man	279	42.5
In a relationship with a woman	23	3.5
In a relationship with several persons	19	2.9
Not in a relationship	335	51.1
Current residence area
Smaller community/village	72	11.0
Small town (<50,000 inhabitants in urban area)	74	11.3
Large town (>50,000 inhabitants in urban area)	118	18.0
Major city (Stockholm, Gothenburg, Malmö)	392	59.8
Latest travel, destination
Europe	476	72.6
Asia	95	14.5
North America	50	7.6
Africa	21	3.2
South America	11	1.7
South Pacific	3	0.5
Travel companion, latest trip
Colleague(s)	61	9.3
Partner	178	27.1
Family	58	8.8
Friend/friends	178	27.1
Travelled alone	165	25.2
Other	16	2.4

Experiences of HIV/STI prevention efforts

The majority of respondents indicated that they had not encountered any kind of HIV/STI prevention efforts in Sweden or during their stay abroad in connection with booking or planning their trip (Figure 1).

Those in the age groups 30–45 and 46–59 reported that they had encountered prevention efforts during their stay abroad to a greater extent than those who were younger or older (p <. 001) (see Table II). However, there was no significant difference between age groups with regard to whether they encountered prevention efforts in Sweden.

Table II.

Experience of having encountered prevention efforts during the stay abroad, divided into age groups.

Age (years)	Yes, n (%)
18–29	18 (15.3)
30–45	67 (27.7)
46–59	56 (34.6)
60–75	8 (12.9)
Total	149 (25.5)

The response alternative ‘don’t know’ was excluded in this analysis.

Only 3% (n = 22) expressed that they had sought information on HIV/STI before their trip abroad, mostly through the Internet, at youth clinics, insurance companies, in connection with getting themselves tested or through gay organisations. Seventy-nine per cent (n = 518) felt that it was easy to find information on HIV/STIs. A majority (87%, n = 570) responded that they would seek information on the Internet, if necessary (Figure 2).

Among those who indicated that they used the Internet for seeking information, there was a significant difference between age groups, which showed that the younger the respondent the more likely that he would use the Internet (p < .001).

Attitudes towards HIV / STI prevention efforts

The majority of respondents felt it was very important (36%, n = 234) or somewhat important (36%, n = 235) that information about HIV/STIs was given before travel abroad. In the comments, the men justified that this was important because the understanding of HIV/STI among many was quite poor, and they believed that the lack of knowledge was greatest among younger men. Another reason given was that many people have sexual contacts abroad; however, they were not aware of the risks. Some respondents commented that some people, who are not open about their sexual orientation at home, are more open to having sex abroad.

A majority (58%, n = 383) felt that more information should be given (much more: 26%, n = 171; a little more: 32%, n = 212) on HIV/STI before travelling abroad. Several commented that the need for more or less information depended largely on travel companions, destination and purpose of trip. A large proportion (61%, n = 398) stated that they would not be offended if they received information about HIV/STIs. Many (68%, n = 444) of the men believed that behaviour could be influenced by information.

The majority (68%, n = 448) felt that free condoms and lubricants were proposals that would be appropriate prevention efforts towards MSM when travelling abroad. A large percentage (59%, n = 387) preferred to have written information, as opposed to 26% (n = 172) who preferred oral. Almost half (48%, n = 315) felt that accessible testing was an appropriate effort to reduce the transmission of HIV/STIs. In the comments, it was stated that it was impossible to know who the MSM were when booking travel; thus, it was not possible to offer ‘specific’ information to the group. Information that is directly targeted towards MSM could be perceived as stigmatising or discriminating. They also felt that it was important to be aware that although the group of MSM have higher risk behaviour than average, the individual could be offended if they received targeted information on HIV/STIs.

Discussion

MSM encounter prevention efforts prior to travelling abroad only to a small extent. Many are in favour of HIV/STI prevention efforts and desire to get information primarily via the Internet. It became evident that men in the youngest (18–29 years) and in the oldest (60–75 years) age groups had the least amount of experience with prevention efforts.

The result that only a few of the men in our study had experience of prevention efforts prior to travelling abroad, despite the fact that MSM travel more than the average population [15] and have a higher prevalence of HIV/STIs [16], suggests that it is difficult to reach this group before their trips abroad. Even though many felt that more information should be given, only a few had searched for information. However, previous studies [9] have shown that general HIV/STI prevention efforts do reach MSM, to a relatively high degree, and the Internet is often used for seeking health information [17]. This may explain why many of the men in our study considered themselves to be well informed and had knowledge about HIV/STIs.

We found that younger and older men had encountered prevention efforts to a lesser extent. Specifically, younger men have in previous studies, been found to be the biggest sexual risk-takers abroad [5,8,18], and also to have the highest incidence of chlamydia [3]. It is important to bear in mind that this does not only refer to young MSM, but also young adults in general [5,8,16]. Similar to Taylor and colleagues [15], we found that the men in our study were well travelled and had been abroad many times during the year prior to the survey. This, together with the fact that MSM take greater sexual risks on holiday than at home [11,19] highlights the importance of continuing to prioritise this risk group.

The men would like to encounter prevention efforts in the form of condoms and lubricants. Two factors that would facilitate the use of condoms are to make it easily accessible and to have them accompanied with clear instructions about correct use. In a Swedish observational study, access to condoms and lubricants nowadays, in environments where sexual encounters take place, was found to be more or less non-existent [20]. This is a concern that needs to be addressed. It has emerged that it is common for young MSM to perceive condom use as problematic [21 –23]. Thus, clear instructions on proper use are needed [24]. In our results, we found that after access to condoms and lubricants, written information about HIV/STIs, including risk behaviour and consequences, was preferred as a prevention effort. We believe that written information is required; however, behaviour does not change just by mere knowledge, rather it must be supplemented by conversations that focus on behaviour and change. It is important to respect an individual’s autonomy and take into account that there may be a plethora of different factors that influence one’s motivation to change behaviour [25]. Healthcare professionals, who work in the field of sexual health and travel clinics, as well as travel booking organisations, have an important role in providing and offering accurate and suitable information about sexual (risk) behaviour and HIV/STIs.

The men in our study preferred to get information via the Internet. Since recruitment for the study was through an Internet forum, this result is not surprising. A positive attitude towards health promotion online [26,27] and a willingness to participate in online prevention interventions has been seen among MSM [28]. The Internet is also used when information is needed or lacking [29], and online and offline resources are often compared to reach a consensus. The Internet is a common communication source in Sweden, and 91% of the Swedish population have Internet access at home. The high percentage of respondents who claimed they used the Internet for seeking information indicates that it is mainly through the Internet that information should be channelled to reach the greatest number in the intended group. However, more knowledge is needed concerning how the Internet is used. Our findings do not indicate whether the information these men are relying upon is accurate, if it is applicable to them or not, nor how they interpret the information. Understanding the skills of MSM in searching and processing the information is therefore vital when recommending the Internet as a suitable resource for distributing sexual health information. It is of great importance that health professionals have reliable Internet resources as a reference tool for these MSM. Although some of the men felt that specific information directed towards the group of MSM might convey a sense of discrimination and stigma, most were positive about prevention efforts. The majority believed that they would not take offence if prevention efforts were aimed at foreign travellers and MSM, even though sexual risk-taking and transmission of STIs are concerns applicable to the entire population.

One of the strengths of the study is the high number of participants; moreover, 74% of those who read information about the study chose to respond to the survey, which is a high figure, compared to studies with similar approaches [30]. This study has a cross-sectional design and a self-selected group, which limits the ability to generalise the results. Because of the lack of previous studies with similar focus, we did not have access to a validated instrument to use for data collection. On the other hand, this resulted in a survey specifically formulated for our purpose. The survey questions were designed with help from experts in the field who had experience of similar methods of data collection; however, it was not tested on a control group before the start of the study. Since studies that focus on experiences of and attitudes towards prevention efforts prior to foreign travel are limited, we believe that this study serves a purpose in highlighting the need for further investigation. Evaluations of implemented interventions for the group and knowledge about where MSM go to organise their travels are lacking; thus, more in-depth questions need to be asked concerning what type of Internet sites are being used for information on sexual health and the quality and accuracy of these in order to highlight potential Internet sites for possible interventions.

Conclusion

MSM have little experience of HIV/STI prevention efforts prior to travelling abroad. Many have a positive attitude towards prevention efforts and feel that there is a need for information and better knowledge within the group. Health and medical care personnel who meet MSM can take the opportunity to ask about any future travel plans during routine examinations or health check-ups, and assistance could be offered through links to information about sexual health on the Internet. Counselling regarding sexual health can be included routinely, since oral or written travel advice is given then, keeping in mind travellers going to destinations that have a particularly high incidence of HIV and/or sex tourism. Information that is geared towards other risk groups, such as young adults, should be presented with awareness that MSM are also part of that group. Moreover, it is important that this outreach is done in a respectful manner to avoid any feelings of stigmatisation and discrimination, which may have been experienced by MSM previously.

Footnotes

Acknowledgements

We acknowledge the men who answered the survey and generously shared their experiences and thoughts on HIV/STI prevention efforts before travelling abroad.

Conflict of interest

None declared.

Funding

We acknowledge financial support from the Medical Research Council of Southeast Sweden and ADLON, which is a knowledge centre that develops common strategies for increasing knowledge and competence within sexual healthcare.

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