Epidemiological research has sometimes addressed the impact on men who have sex with men (MSM) sexual behaviour of being “non-gay identifying” (NGI) (Yun, Wang et al. (http://sti.bmj.com/content/87/7/563.full?sid=a367a77d-f830-46ee-b761-eec8d9e22da2 ); Mercer & Cassell (http://ijsa.rsmjournals.com/content/20/2/87.full) or of belonging to a culture in which openness about sexuality by MSM is sometimes difficult and personally costly (Lane, Kegeles et al. (http://sti.bmj.com/content/84/6/430.full?sid=ab090fad-0769-479b-a7d5-e6ba10da5609).
The position of MSM in the US military under the recently abolished “Don’t Ask, Don’t Tell” (DADT) policy was an extreme case – possibly a limit-case – of this situation: up until September 2011, an admission of sexual orientation by MSM, or evidence such as hand-holding, could result in ejection from the military.
How does this kind of situation influence patterns of HIV transmission among MSM, and what is the impact on the sexual behaviour of those MSM who engage in relationships with men regardless? Would we expect the repressive effects of DADT to result in a relatively lower proportion of total HIV infection due to MSM sexual contact than in the general population – or the reverse?
Results of a recent online survey of the sexual behaviour prior to forced HIV testing of US Navy and Marine Corps personnel who sero-converted under DADT intriguingly lifts the lid on this formerly closed epidemiological world – and perhaps, to some degree, on other similarly closed worlds. Of course, the survey itself has major limitations: most importantly its restriction to a minority (64 (524): 26%), and an apparently not very representative minority, who responded to the survey; also the often considerable lapse of time since the behaviours reported. Despite all these limitations the forced imposition of an HIV test on the whole group allows the survey to capture HIV prevalence at a moment in time.
Among the men who became HIV-infected 84% had had sex with men in the 3-year period prior to diagnosis: 55% reporting sex with just men, and 30% reporting sex with both men and women. DADT would not then appear to have had much impact on reducing the burden of MSM infection as a proportion of total burden. This higher figure relative to earlier surveys of the US military (84% as opposed to 59% reporting sex with men) probably reflects the liberalizing effects of DADT repeal. The frequency of inconsistent condom use with anal sex was 65%, and more than three quarters expressed surprise at their HIV diagnosis.
The story these figures tell mirrors other “repressive” settings such as those with which we began our blog. On the whole, a culture of repression drives the unwelcome sexual behaviour underground rather than eliminating it, while, at the same time, discouraging responsible behaviour and the adoption of risk-reduction strategies. As the authors note, “Several opportunities for primary prevention messaging now possible after DADT repeal are evident”.