Sexual behavior and condom use among a population of men who have sex with men attending a dermatology-sexually transmitted infection clinic in Beirut-Lebanon

Sir,

In Lebanon, men who have sex with men may account for most new human immunodeficiency virus (HIV) infections.^[1],[2] The proportion of people infected with HIV among men who have sex with men in 2011 is estimated at 3.6%.^[3]

Few studies of high risk behavior among men who have sex with men have been undertaken in Lebanon, probably because of the social and religious taboos and because homosexuality is highly stigmatized and even illegal.^[4] Studies in Lebanon have revealed that approximately 50% of men who have sex with men consistently use condoms; however, only 25% reported using a condom during their last sexual intercourse.^[5],[6],[7] On an average, men who have sex with men have 10–25 partners over a year.^[1],[6],[8] According to the new World Health Organization consolidated guidelines, HIV testing is on the top list of the services that can help to prevent spreading the virus yet, the testing rate is as low as 24% in Lebanon.^[3] All these studies included a group of men who have sex with men registered in non-governmental organizations; unfortunately, the population that seeks private care is almost unreachable.

During the first week of June 2015, 31 men who have sex with men attended the dermatology-sexually transmitted infection clinic for a medical consultation and they were invited to participate in the study. Data collected included (1) location, (2) age, (3) number of sexual partners in the preceding 6 months, (4) condom use in the last 10 sexual intercourses (oral sex excluded), (5) use of mobile dating applications, (6) alcohol and/or drugs during or before sex, (7) history of any sexually transmitted infection including human immunodeficiency virus, (8) frequency of sexually transmitted infection tests per year, (9) a subjective self-assessment of human immunodeficiency virus risk.

The questionnaire used for the study was based on one of the tools used for surveillance of HIV and other sexually transmitted infections among men who have sex with men in France.^[9] The Hammoud Hospital Ethics Committee advised that formal ethical approval for the study was not required as protocols did not deviate from routine clinical practice. Participants provided written informed consent to participate in this study. Interviews were conducted in the language preferred by the participant (Arabic, French or English) on internet-based software.

The location of study subjects, numbers of sexual partners, condom use, use of cell phone dating applications, use of alcohol and/or drugs with sex, previous sexually transmitted infections including HIV infection, frequency of testing for sexually transmitted infections and subjective assessment of risk behaviour are shown in [Table - 1].

Table 1: Characteristics of the population and summary of the survey results

This small study reporting data from a dermatology-sexually transmitted infection clinic helps to explore some factors of sexual behavior and condom use in men who have sex with men. This data can guide sexually transmitted infections screening and prevention strategies to be implemented in this hard-to-reach stigmatized population. As was the case in previous studies, this study suggests that unprotected anal sex is very common among this sample of mostly young and urban men. Eighteen (58.1%) participants had unprotected anal sex, which is slightly lower than the number found by Wagner et al. which was 64%.^[10]

Three (9.7%) men tested positive for human immunodeficiency virus in this sample which is a higher rate compared to the estimated percentage (1.5%) found in a previous larger study done on this population.^[10]

Our study population had a much higher rate of testing for sexually transmitted infections, 22 men (71%) had undergone at least one test in the past year than reported in other studies of men who have sex with men in Lebanon and the Middle East region.^[2],[10] This may be because of the health-care seeking behavoiur of our study participants or because of the increased awareness created by the national health programs. However, 29% did not undergo any tests. None of our participants had other sexually transmitted infections or syndromes, probably because they were treated by other specialists.

The mean number of sexual partners in the last 3 months, in a previous study, was reported to be 2.^[10] Most of our patients (45.2%) fell in the category of “2–5 partners for the last 6 months.”

New trends in sexual behavior among men who have sex with men in Lebanon that were not detected previously are (1) usage of online dating applications on the mobile phone (denied in only 35.5%) that may serve as a tool to reach potential partners (2) alcohol and/or drugs before/during sex (denied in 58.1%).

The presence of syphilis in 42.9% of our participants indicates a role for performing serological tests for syphilis routinely in this population. To the subjective question on whether they considered themseveles at risk of acquiring human immunodeficiency virus infection, the study patients equally answered “yes” or “no” (16.1% answered“I do not know.”) Thus, this population of young urban men is aware of the human immunodeficiency virus which is most probably due to the campaigns led by Lebanon's national acquired immune deficiency syndrome control program and local organizations.

A key limitation of our data was the low sample size and the poor representation of older (aged above 36) men. Other papers have reported similar limitations, the reason being, perhaps, a lack of intrinsic motivation to participate.^[11]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.