International mobility, sexual behaviour and HIV-related characteristics of men who have sex with men residing in Belgium

The human immunodeficiency virus (HIV) continues to disproportionally affect men who have sex with men (MSM), an epidemic that remains a challenge for European public health. In most Western European countries, including Belgium, the number of yearly diagnoses of new HIV infections in MSM remains high [1, 2]. Several factors are contributing to the rates of new HIV infections among MSM, including an increase in sexual risk behaviour, combined with a high prevalence of HIV infection in some networks of MSM [3‐5]. It has also been suggested that travel behaviour and sexual mobility could potentially be a factor in the spread of HIV and sexually transmitted infections (STI) among European MSM [1, 4]. Travelling has been considered an important component of gay lifestyle and identity, as gay men travel to destinations where they can socialize with peers and in some cases avoid the social constraints and intolerance of their home environments [6]. For some gay men, social and sexual networking are highly intertwined and sexual identity is a central factor for some gay men in deciding on the travel destination [7]. Furthermore, globalization and European integration have resulted in shifts in travel decision making, among other reasons because of cheaper flights, which made gay men and other MSM even more internationally mobile than before. These processes have not developed to the same extent across Europe, and some countries have a different general tourism profile than others [8, 9]. At European level, most Western European countries have been at the international forefront in implementing legal equality and anti-discrimination laws for lesbians, gays, bisexuals and transgenders (LGBT). In this changing context, some bigger cities such as Barcelona (ES), Berlin (DE) or Paris (FR), but also Antwerp (BE) have invested in- and attracted more LGBT tourism by means of different social marketing strategies. These cities offer a diverse mixture of cultural and festive experiences directed at sexual minorities and especially MSM, mirroring the diversity of gay subculture. These efforts seem to influence the choice of travel destination for MSM. For instance, results from the recent European MSM Internet study (EMIS) showed that Spain, Germany and France were the countries to which the majority of MSM traveled [10, 11]. The factors above may explain the higher probability of finding more gay men and in a broader sense, MSM, in a given travel destination.

There is a need to better understand the dynamics that are at the basis of the European HIV/STI epidemics among MSM, particularly how sexual networks across countries may contribute to the current HIV epidemic among European MSM. Different United States-based studies showed that, in the context of recreational travel, MSM reported specific patterns of unprotected anal intercourse (UAI) and related substance use [12, 13]. However, limited attention has been paid thus far to investigate sexual behaviour of European gay men while travelling. The present study aims at filling this gap by analysing HIV-related individual- and contextual characteristics of MSM residing in Belgium travelling abroad. Belgium functions here as a case study for sexual behaviour among mobile MSM in the European context. We use data from the first pan-European MSM internet survey EMIS to explore individual and contextual determinants of sexual behaviour among MSM who were residing in Belgium at the time of data collection and who reported having had sexual contact abroad in the preceding 12 months.

The present study used data from the European Internet MSM Survey (EMIS) to investigate sexual behaviour of MSM who were sexually active when travelling abroad in the last 12 months prior to the survey. Our results for the case of Belgium show that HIV and STI are highly prevalent among travelling MSM, and that they adopt more sexual risk behaviours than MSM who were not sexually active abroad. This evidence supports cross-border development of prevention activities for HIV and STI among MSM.

MSM residing in Belgium who had sexual contact abroad were more likely to be expatriates and to be living in a bigger city. This finding can probably be explained by the substantial population of expatriates living in Brussels and working at its many European and international institutions. Belgian resident MSM having had sex abroad were also better educated and on average older than their counterparts who did not report any sexual activity abroad. Being able to travel implies disposable income to do so. Similar results were found in a study on gay resorts [17]. This study also demonstrates that sexual identity does play a role in travel behaviour as was suggested in other studies [6, 10, 18]. Significantly more sexually mobile MSM identified as homosexual or gay and less often as bisexual. The majority of MSM residing in Belgium who had sex abroad mostly did so in Belgium’s neighboring countries: Germany, France, The Netherlands and the United Kingdom, but also in Spain. Local evidence corroborates this cross border mobility. Of the 642 participants in a recent venue-based HIV prevalence study among MSM in Antwerp, Belgium, 1 in 5 men were of non-Belgian nationality, mostly Dutch [4]. These findings are in line with the mobility dynamics of European MSM. According to the EMIS final report, Spain and Germany are the most frequented countries for having sex abroad [11].

Our findings showed that the proportion of HIV-positive men was higher among sexually mobile men. This may be due to a higher number of casual sex partners and more UAI with these casual sex partners, although it cannot be established to what extent seroconversion affected the sexual behaviour of the now positive men. Sexually mobile men were also tested for HIV and STI more frequently during the last 12 months. However, mobile positive men reported higher rates of STI and substance use, and lower rates of condom use during anal sex while seroconcordant UAI with a casual partner in the last 12 months was higher compared to negative and untested MSM. This is in line with other research pointing to the fact that MSM and specifically some networks of HIV positive MSM are highly mobile and apply additional risk reduction strategies next to condom use based on their own and their partner’s HIV-status, HIV treatment and viral load status [19, 20]. However, these strategies do not seem to protect well against other STIs. Over the last years networks of HIV positive men have been confronted with several co-occurring epidemics of for instance Lymphogranuloma Venereum (LGV) [21] and more recently Hepatitis C [1, 22‐24]. Our study corroborated a link between the use of specific types of substance use, a higher number of non-steady partners and visiting patterns of specific venues where sexual contact is facilitated, which has also been established in other research [4, 20, 25‐27]. Over one third of sexually mobile men searched for a sex partner through the Internet for their last sexual encounter abroad, confirming findings from other studies [12]. However, this study did not find an association between UAI abroad and searching for sex partners through the Internet before or during travel. An important finding in our study is that Belgian resident men, who tested HIV positive in the last 12 months, were more likely to report UAI abroad. This finding suggests that international sexual mobility may well have contributed to recent infections with HIV among European MSM. However, the data does not allow to pinpoint the exact moment of seroconversion in the last 12 months and an HIV positive diagnosis during that period may well have influenced the individual’s sexual behaviour and eventually the likelihood of performing UAI.

It has to be stressed that these results cannot be generalized to all MSM, HIV negative or positive, because a majority of the study participants were recruited through specific Internet sites aiming at social and sexual networking. Being more active on these Internet sites could be an indicator of heightened sexual activity. However, the strengths of this study are its large sample size and anonymity of data collection through the Internet, which may also contribute to the validity of sensitive data [14, 28]. Another limitation is that the EMIS survey did not investigate travel motivations or other more in-depth factors connected to travel behaviour.

The results of this EMIS study provide evidence for the role of international mobility and sexual behaviour regarding the spread of HIV and STI among MSM in Europe, while travelling abroad. As the epidemiology of HIV infection among Belgian MSM mirrors developments in its neighbouring countries, the findings underline the need for development of cross-border HIV and STI interventions with coherent messages and prevention policies for MSM. Systematic cross-border cooperation and exchange of epidemiological and behavioural data for the development of prevention activities for MSM at a regional European level should inform future prevention effort for the target population. Further research should explore in more detail the purpose of travelling and context-related characteristics that lead MSM to be sexually active while being abroad. This could inform the development of targeted prevention campaigns supporting sexually mobile MSM to reduce high risk behaviour. The presented evidence also underscores the need for multiple-behaviour interventions, targeting not only sexual behaviour but also substance use. In this context, multiple-behaviour interventions could have a greater impact on public health than single-behaviour interventions [29, 30]. Further research is needed on development of effective multiple-behaviour interventions for this target group, which also must be tailored to the needs of specific subgroups such as HIV positive men [20, 31‐33] and HIV negative men, who are at greater risk for infections with HIV/STI [34].