Newly arrived Asian-born gay men in Australia: exploring men’s HIV knowledge, attitudes, prevention strategies and facilitators toward safer sexual practices

HIV diagnosis rates for Australian-born gay, bisexual and other men who have sex with men (gbMSM) are declining since widespread implementation of pre-exposure prophylaxis (PrEP) in 2016 [1]. However, among Asian-born gbMSM living in Australia, HIV diagnosis rates have more than doubled from 2008 to 2017, with men in this group making up 23% of new diagnoses in Australia in 2017 (up from 9% in 2008) [2]. Differential access to government-subsidized healthcare (Medicare)–which greatly reduces the cost of PrEP–may contribute to the increase in the proportion of Asian-born gbMSM diagnosed with HIV [3]. A study of Asian-born gbMSM newly-arrived (within four years) diagnosed with HIV between 2014 and 2017 in Australia found that most (88%) did not have access to Medicare [4]. Additionally, a study of HIV testing among gbMSM in Melbourne in 2017 showed newly-arrived Asian-born gbMSM were less likely to take PrEP than Australian-born gbMSM (6.8% vs 11.1%) [5]. This study also suggested however, that the difference in the proportion of PrEP use between Asian-born and Australian-born gbMSM was unlikely great enough to account for the four-fold difference in HIV diagnoses between these two groups, and that other factors may contribute to this disparity, such as restricted access to HIV testing and treatment [5].

Despite the rising rates of HIV among newly-arrived Asian born gbMSM in Australia, this group has reported fewer numbers of casual sex partners and less condomless anal sex with casual partners than their Australian counterparts [4]. It is possible that the lower reported risk factors are in part due to increased internalised sexual identity and HIV-related stigma, as studies indicate both are prevalent in various countries in Asia [6‐14]. Stigmatising attitudes toward HIV are associated with increased sexual risk behaviours [9, 15].

The primary aim of this study was to examine the experiences of Asian-born gbMSM newly arrived in Australia and recruited from a sexual health clinic, specifically in terms of their knowledge of and attitudes toward HIV, HIV prevention strategies and facilitators of safer sexual practices.

Data were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. [16].

Overall, 117 men registered their interest in participating in the study, 97 of whom met the eligibility criteria. Of those eligible, 38 scheduled an interview and of these men 24 completed an interview before data saturation was met. The average length of an interview was 42 min (range 25–57). Participant demographics are reported in Table 2.

Three major themes and seven subthemes emerged from the study (Table 3).

The primary HIV prevention strategies of men were varied and changed over the course of their time in Australia as their sexual health knowledge levels increased and they became more aware of alternatives such as PrEP. Table 5 summarizes men’s HIV prevention strategies at the time of the interview.

Many men described changing HIV prevention strategies to reduce their risk after arriving and during their time in Australia. For some, this change occurred in the form of learning about and taking PrEP for the first time, while for others it resulted in increased or consistent condom use. Changes largely occurred as a result of increased knowledge of HIV risk and prevention strategies which were facilitated by increased social connections and sexual health counselling.

Most men reported that a friend or sex partner had told them about the recruiting sexual health clinic and that prompted them to get tested for HIV and STIs. For several men, they assumed such a clinic would cost money or would not be covered by their overseas health insurance and thus would otherwise not have come.

I didn't know where and all I know is that when you come to a clinic you have to pay so I didn't really look up into it until my friend told me. He's American… He said "you can go to this place. Actually it helps. It's complimentary and it's giving you some information." That was six months ago as well so one month ago I decided to come because I know I think I should do it to have a check-up.

—Participant 20, Malaysia, 3 years in Australia

A couple of men had never been tested for HIV before and attending a sexual health clinic was not something they had planned on doing before a friend suggested it.

The first time I came here was because it was free, but I was kind of reluctant coming here, because I don’t know how people would see me…A friend told me [about the sexual health clinic], and I thought, I haven’t done that, I just really want to check out if this place is good, then I came.

—Participant 7, China, 1.5 years in Australia

One participant in particular, described how revealing his sexual identity to his first friend was a ‘turning point’ for him since his friend encouraged him to attend the recruiting sexual health clinic for his health and to find his community—a suggestion that led him to a local LGBTQI support group. To him, opening up to a friend about his sexual identity led him to not only learning about sexual health but also to feeling accepted as part of the gay community.

I didn’t come out until October, it means, like, I come out one year ago, to one of my friends, he just hugged me and told, like, that’s alright, so that’s the day I realised that alright, I shouldn’t be act as a straight person, I should be myself. So, that was the turning point, and that’s why I come to here, I come to MSHC or whatever, because of him. He taught me that you’re normal… Everything done by my friend, he told me to find your community. If I wanted to [give advice to someone in my situation it would be] tell someone, just come out to one of your friend, and you know, like, someone you can [trust]… the first thing, I think, is the knowledge about everything – STIs, but the other thing is, you know, at least one person who knows about yourself is really important.

—Participant 15, Sri Lanka, 2 years in Australia

While most participants described learning more about sexual health after arriving in Australia, one participant described how his initiation to sexual health was facilitated by the support of a friend in his country of origin. An openly gay friend in China encouraged him to be tested for HIV and accompanied him to have the test since he was very afraid of the experience and had never been tested before. As he described, support from a friend helped him learn about his sexual health and encouraged him to embrace his sexual identity; a step he felt was very important to maintaining sexual health.

…one of my friends, like in the undergraduate, he is very open, he's openly gay. He told me a little bit about that you have to protect yourself. You have to test regularly... I fear about the test or something… The first time I got tested [for HIV] my friend, [accompanied] me. I feel more comfortable to do that, so yeah…When you first accept you're gay and you know who you are and you [learn] you have higher risk, like to get some infection, you do feel like necessary, oh I have to go to test, I have to use a condom to protection and maybe I have the obligation to tell other gay people and my gay friends to do the same things.

—Participant 17, China, 3 years in Australia

One of the biggest drivers for sexual practice change was an increased awareness and knowledge of PrEP and consistent condom use. Of the men on PrEP at the time of the interview, three had learned about and decided to start PrEP after receiving counselling at the recruiting sexual health clinic and another had learned about it during a consultation with a doctor at the recruiting clinic. Two initiated PrEP after attending sexual health workshops provided by community organisations for people who are LGBTQI (one in Victoria, and another in Singapore—the sole participant who had initiated PrEP in his country of origin). The final participant on PrEP learned about PrEP after attending sexual health education workshops provided by his university in his country of origin, however he felt he could only access PrEP after arriving in Australia and attending the recruiting sexual health clinic as he did not think it was prescribed in his country of origin. Thus, all men on PrEP initiated PrEP after connection to a sexual health service and most had counselling or LGBTQI-specific support. Similarly, those who began using condoms consistently after arriving in Australia credited counselling and LGBTQI organisations for educating them on sexual health. These men described the benefits of sexual health counselling and involvement with LGBTQI services not only in terms of increasing their knowledge of STI and HIV prevention, treatment and support services, but also imparting on them the importance of embracing their sexual identity. For one participant the counselling session made him see how risky his sex practices were given that he never thought to use condoms for anal sex. For him, HIV was not something he ever considered he could get and through counselling he learned about the actual risk and explored what it would mean for him if he were to be infected with HIV.

I had counselling and that [counsellor told] me all the horrors of HIV and if I have to go back to Pakistan and there will be no, very advanced medicine there, and it is very, very expensive to [get] HIV medicine to get in Pakistan and things like that. I made a conscious decision to go on condom.

—Participant 1, Pakistan, 2.5 years in Australia (consistent condom user now)

A couple of participants also described benefiting from involvement with LGBTQI community organisations in terms of establishing social connections with people who can relate to them because they are going through similar struggles.

It’s hard for a straight person to relate to a gay person’s feelings because they can’t really put themselves in our shoes. Even though how understanding they might want to be or how much they want to be there for you. It’s not the same as talking to a gay person itself, because the struggles and what they feel is more in line as to what you’re feeling. I feel it’s really nice to meet like gay people that you can really bond and be really close with to just pour your feelings out to. I’m glad I’ve met them through these events yes.

—Participant 16, Singapore, 3 months in Australia (on PrEP after involvement in LGBTQI organisation in Singapore)

One participant initially heard about PrEP from the internet but did not imagine it would be right for him. He worried about the side effects of PrEP as well as the routine of needing to have regular check-ups on PrEP. It wasn’t until he had an experience of condomless sex where he forgot to use a condom in the heat of the moment and he attended a workshop run by a community organisation for people who are LGBTQI that he realised he cannot always be in control of using condoms. He made the switch to PrEP to avoid getting caught up in the moment and having condomless sex again in the future.

Mostly [I heard about PrEP] from the internet…I wasn’t ever actual[ly] think[ing] about that [taking PrEP]. Then, I got to know that more, when I went to one of the workshop at the Victorian AIDS Council…[at that] point I realised there’s no way I’m in control of that [condomless sex in the heat of the moment]. At first, I guess, the idea that, like – oh, there might be side effect, and you know, and also, it [PrEP] might potentially affect your kidney function. Then, also, it’s part of the routine that you basically have to check in, and I have a feeling that I might not be able to keep up with that routine. In a way, I was slightly a little bit discouraged with that, but then, when I had that experience [of condomless sex] I realise I better get on that [PrEP], rather than find myself in that situation again.— Participant 21, Vietnam, 3 years in Australia

For one participant, involvement with a state-based organisation that supports LGBTQI communities facilitated not only his sexual health knowledge in terms of learning about using PrEP and the risks associated with condomless sex, but his understanding of what it means to be gay and what relationships could look like. Prior to his involvement with this organisation he did not know that he could be gay and also have a family one day or that relationships could be open.

…after I come out to my friend, he told [me]… I should learn about myself first, that’s what he told [me]. Like, you must go with your own community…So, that advice lead me to go for Thorne Harbour [a local LGBTQI organisation in Melbourne], and I went to three workshops in there…They was amazing, so amazing, because you’re like – it talked about sex, and lifestyles, and relationships, and to be friends, and hang out, and how you’re going to live in the public. It’s like, we are going for bowling, to cinemas sometimes, it’s really – you know that knowledge gives us that…you are a human being, also, and just be yourself…After attending to my workshops, I learnt how to do safe sex, what does unsafe sex mean, what does the PrEP mean, what is the PEP mean, what is the vaccinations. I think that knowledge is really important… Sometimes, we know who we are, but we don’t know who we really are. You know, like, you can make a family, if you want to do open relationship or closed relationship, or whatever. So, I never had that type of idea about these kinds of things.

—Participant 15, Sri Lanka, 2 years in Australia (Consistent condom user now)

In this study exploring sexual practices and HIV prevention strategies among newly-arrived Asian-born gbMSM recruited from a sexual health centre, we found that most arrived in Australia with only basic knowledge about HIV. Most initially relied on condoms to prevent HIV, with frequency of use varying, and most reported experiences of condomless anal sex in Australia, despite a strong fear of acquiring HIV. Among infrequent condom users, some reported relying on their intuition when deciding to use a condom or not, basing their decision on preconceived and inaccurate notions of HIV and trust in their partner. Major facilitators to changing men’s sexual health practices were sexual health counselling and involvement with LGBTQI-specific community groups. Most PrEP and consistent condom users adopted these practices after involvement with such services. Participants engaging with counselling and LGBTQI organisations increased their awareness of HIV risk, HIV prevention strategies, and the importance of embracing their sexual identity.

Almost all participants were prompted by friends or sex partners to attend the recruiting sexual health clinic for their first time. For some, the clinic was their first introduction to sexual health and testing for HIV and STIs. All but one PrEP user had decided on PrEP after sexual health counselling or attending sexual health workshops provided by organisations that support LGBTQI communities; the other was encouraged by a clinic doctor. Participants who were on PrEP disclosed more negotiated safety practices within their regular partnerships than those who relied on condoms; describing an open dialog about sex and HIV prevention strategies outside and inside the relationship with their regular partner. Negotiated safety is a particular type of sexual agreement within partnerships that typically entails condom use with casual partners outside the relationship. A previous scoping review found that having a sexual agreement with partners (beyond negotiated safety) was associated with engaging in condomless anal sex within the relationship and outside the relationship in several studies [19]. Similarly, Findings from repeated cross-sectional surveys in Australia from 2013 to 2018 found that PrEP use was associated with agreements between partners that allow condomless sex with casual partners, with almost 40% of PrEP users in relationships having such agreements [20]. While participants in our study who were on PrEP described negotiated safety within their partnerships, further research is required to understand whether there is an increase in other types of sexual agreements which allow condomless anal sex in this population. Such research would be important to inform rates of STIs.

This study suggests that central to increasing HIV prevention strategies within this group is reducing their feelings of stigma related to sexual identity and HIV, which may be facilitated by increasing connections with sexual health services and organisations that support LGBTQI communities. Our findings reinforce peer support as an important facilitator to sexual health [21, 22] and indicate that one-on-one counselling and involvement with organisations that support LGBTQI communities can increase knowledge levels and implementation of PrEP and condom use as well as enhance acceptance of sexual identity. Our findings reflect those from a study of 763 young Asian and Pacific Islander men who have sex with men in the United States in 2011, which found that positive dual identity (attitudes toward both their sexual identity and their ethnic identity) was associated with greater social support and HIV testing. [23] Further research on the effectiveness of peer support and involvement with organisations that support LGBTQI communities for increasing sexual health and how these services can be expanded to further reach this population is warranted.

Participants in our study had several misconceptions about their HIV risk upon arrival in Australia, such as believing they could sense when a potential sexual partner has HIV based on their hygiene, social circle, or appearance. Some participants felt they could trust their intuition or partners to keep from getting HIV. These findings reflect previous qualitative work among Chinese GBMSM which found that trust in partners was a barrier to HIV testing and that despite being an important component of healthy relationships, was a point of threat considering rising rates of HIV and low HIV testing rates in this population [24]. Further research on HIV risk perception among newly arrived GBMSM to Australia is warranted to inform sexual health education from clinicians to this population.

There were several limitations that should be noted. Firstly, it is possible participants may not have reported actual risk due to social desirability bias. Secondly, participants were exclusively recruited from a sexual health clinic and were therefore already connected into a sexual health service in some capacity. Our findings may not reflect men who are not getting tested for HIV and other STIs. This limitation highlights the importance of targeted future research into methods of increasing engagement and undertaking larger scale studies on sexual health among newly-arrived Asian-born gbMSM. Similarly, these interviews were conducted in English and therefore do not include experiences of men who do not speak English and may be further marginalised. Our participants were also relatively well-educated, and it is possible those with less education have less sexual health knowledge. However, a high proportion of new HIV diagnoses in Australia are among international students [4], so insights from this population are particularly important. This study provides key insights into how gay and bisexual men who were newly arrived in Australia became connected to sexual health, as well as how their HIV prevention strategies change over the course of their time in Australia as they become connected to sexual health.

Future studies should focus on ways to reduce internalised sexual health and HIV-related stigma and shame in this population, such as, facilitating peer support groups, offering counselling services for mental and sexual health, and enhancing connections with LGBTQI community groups. It is not known what proportion of men in this population are offered counselling at this or other sexual health clinics in Australia. Given the lower reported risk from this population it may be difficult to identify those men who could potentially benefit from such services, a challenge future research will have to take into consideration.