A partnership between academic, community and government experts will provide new knowledge of HIV-related behaviour for under-researched groups.

New national research targeting gay, bisexual and heterosexually identified men who have sex with men (MSM) will ensure Australia’s HIV response stays relevant to the changing HIV epidemic. The survey will examine how a range of MSM understand and manage their HIV risk and sexual health.

The survey is part of a five-year project aimed at engaging harder-to-reach MSM – overseas-born men, bisexual men and men less connected to gay networks – to improve their health outcomes. The research will provide critical new knowledge of their HIV-related behaviour and health literacy to refine HIV prevention and testing programs.

UNSW’s Centre for Social Research in Health (CSRH) is partnering with the Australian Federation of AIDS Organisations (AFAO), the Kirby Institute, the National Association of People with HIV Australia (NAPWHA), and state government departments of health on the NHMRC-funded project.

“Australia’s HIV epidemic is rapidly changing,” says lead investigator Professor Martin Holt from CSRH. “New technologies, particularly pre-exposure prophylaxis (PrEP) and antiretroviral drugs, have revolutionised HIV prevention.

“Australia has succeeded in driving down annual HIV diagnoses by 23% in the last five years. However, this overall fall masks a lack of progress, particularly among harder-to-reach groups. Addressing these disparities is vital if Australia wants to capitalise on its initial success with PrEP.”

Globally, 1.5 million people per year continue to be infected with HIV. Gay, bisexual and other MSM have the highest risk of HIV infection, being 28 times more likely to become infected than the general population.

Australia is one of the few countries that has conducted regular behavioural surveillance of its primary HIV-affected population, gay and bisexual men, in line with World Health Organisation recommendations, Prof. Holt says.

The research project, Enhancing behavioural surveillance to address gaps and disparities in Australia’s HIV response in a changing HIV epidemic, builds on more than 20 years of behavioural surveillance through the annual Australian Gay Community Periodic Surveys and the Gay Asian Men’s Surveys, conducted by CSRH in collaboration with other UNSW researchers, policymakers and community organisations.

“Governments and community organisations rely on this data to guide HIV policy and practice,” Prof. Holt says. “However current challenges demand new evidence and methods to ensure behavioural surveillance is fit-for-purpose.”

One of the activities in the project is a new national survey of bisexual and heterosexually-identified men who have sex with men. Representative samples of adult Australians suggest that the ratio of behaviourally bisexual men to homosexual men is 2:1, and that many identify as heterosexual.

“These men are relatively invisible and under-researched, making it difficult to design appropriate services and interventions.” The historical focus on gay men in the existing surveys, for example, may deter bisexual and heterosexual MSM from participating, he says.

The survey, which will be supplemented by in-depth interviews, will consider MSM’s sex and relationships with male, female and non-binary partners as well as their attitudes towards disclosing their sexual behaviour to partners and health service providers.

Combining survey data with in-depth interviews will help identify barriers and enablers to engaging bisexual and heterosexual MSM in HIV prevention, says chief investigator Professor Christy Newman from CSRH. Prof. Newman is leading the qualitative component of the survey.

“The interviews will help us identify participants’ preferred forms of HIV testing and prevention, as well as increasing our understanding of the ways they negotiate sex and relationships with different partners,” she says.

“Knowledge about their strategies for maintaining secrecy or decisions to disclose, and the issues this can generate for them, will help us revise state and territory prevention programs to better serve their needs.”

The research will also target MSM outside inner-city suburbs. While HIV diagnoses in gay-identified men in inner-city suburbs have dramatically decreased, diagnoses have not declined among men living in suburban locations.

“To ensure the continued recruitment of the most-at-risk men who have sex with men in the GCPS, we will trial the expansion of face-to-face and online recruitment targeting non-inner-city locations,” Prof. Holt says.

Increased HIV risk for MSM from Southeast Asia

Additionally, HIV diagnoses have increased among overseas-born MSM, particularly those recently arrived from East and Southeast Asia. In New South Wales and Victoria, overseas-born MSM are now more likely than Australian-born MSM to be diagnosed with HIV.

“Cultural norms, connections and deeply-rooted stigmatisation mean that Asian men who have sex with men in Australia are often less likely to identify exclusively as gay men,” says Associate Professor Limin Mao from CSRH who leads the Gay Asian Men’s Survey. “They may have inadequate information and access to local HIV services and continue to conceal homosexual preferences from family and friends.”

A/Prof. Mao will lead the engagement of overseas-born MSM, liaising with multicultural health organisations.

Homosexuality is still illegal in many Asian countries, hampering regional HIV responses, she says. “When men who have sex with men from the Asia-Pacific region migrate to Australia, temporarily or permanently, they may take advantage of Australia’s relatively tolerant cultural climate towards diversity in gender and sexuality.

“Inadequate connections and support to link with local HIV clinical and community services may put them or their partners at risk – they may not know where or how or may feel fearful about accessing HIV and other appropriate sexual health services,” she says. 

“Additionally, racism coupled with homophobia may exacerbate risks in sex and relationships between men, particularly those who are recent arrivals. Fears about visa rejection and a lack of formal access to Medicare for temporary migrants, such as international students, reduce the chance of overseas-born MSM engaging with a range of sexual health services, HIV testing, prevention, treatment and long-term care.”

While the current surveys can be accessed online in a variety of languages, they are typically promoted in English. The project will make translated surveys available to participants recruited at venues and events, and through digital targeting and overseas student and migrant networks.

Community organisations are critical to Australia’s HIV response, advocating for affected communities, ensuring research responds to community priorities, Prof. Holt says.

“Our research in collaboration with peak organisations and government will extend the relevance and reach of existing behavioural surveillance in Australia to meet changing patterns of HIV among gay, bisexual and other men who have sex with men. This will enable the continued provision of valuable data on trends over time.”

The research will inform HIV policy reform and contribute to the virtual elimination of HIV transmission, says AFAO chief executive, Darryl O’Donnell. “Australia has made tremendous gains in HIV prevention but we must go further by giving more people access to the education, prevention and treatment they need,” he says.

“Our partnership is committed to meeting the UNAIDS 95-95-95 targets [95% of people knowing their HIV status, 95% on treatment, and 95% having an undetectable viral load].”

This article was originally published in 2022.

Written by Kay Harrison
Professor, Research Director (Compliance and Capacity Building) Martin Holt
Professor, Research Director (Compliance and Capacity Building)
Professor and Associate Dean (Engagement and Impact) Christy Newman
Professor and Associate Dean (Engagement and Impact)
Associate Professor Limin Mao
Associate Professor