Vulnerability to HIV among older men who have sex with men users of dating apps in Brazil

Artur Acelino Francisco L.N. Queiroz Alvaro Francisco Lopes de Sousa Sandra Brignol Telma Maria Evangelista Araújo Renata K. Reis About the authors

ABSTRACT

Introduction:

The elderly population is increasingly benefiting from recent technological advances. In this scenario, geolocation-based dating applications provide a viable alternative for finding partners in a practical and timely manner, but may be accompanied by certain risk behaviors for HIV infection. Although there are considerable number of users over 50 on these applications, no studies have addressed this problem. The aim of the present study was to analyze factors of vulnerability to HIV/Aids among the population of men who have sex with men (MSM) age 50 years or older who use dating apps.

Methods:

This was a cross-sectional, population-survey-based, analytical study, conducted exclusively online with a sample of 412 MSM. The data was collected from the following apps: Grindr®, Hornet®, Scruff® and Daddy Hunter®.

Results:

Factors associated with a higher chance of having HIV were: sexual relations with an HIV-infected partner (ORa = 5.53; 95%CI = 2.23-13.73); chemsex (ORa = 3.97; 95%CI = 1.72-8.92); and, above all, having an HIV-infected partner (ORa = 8.02; 95%CI = 2.01-32.01). The belief that apps increase protection against sexually transmitted infections (ORa = 0.43; 95%CI = 0.19-0.95) and not being familiar with post-exposure prophylaxis (ORa = 0.43; 95%CI = 0.19-0.95) were associated with decreased chances of having HIV.

Conclusions:

We highlight some important factors that structure the vulnerability of the MSM surveyed in relation to HIV infection. The findings should be used to customize care for this population, which could bring them in more for health care services.

Keywords:
Men who have sex with men; HIV/Aids; Sexually transmitted infections; Mobile phone applications; Middle-aged men

Introduction

In recent decades, the population of middle-aged and older men (50 years or older) has enjoyed the benefits of improved quality of life, which has increased their life expectancy. Furthermore, technological advances in the field of medicine, especially those relative to hormone replacement treatment and erectile dysfunction medications, have allowed these men to continue to be sexually active.11 Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM, Stephens-Shields AJ, Cauley JA, et al. Effects of testosterone treatment in older men. NEJM. 2016;374:611-24.

Aging and the expression of sexuality commonly refer to the confluence between body and culture and are considered mutually exclusive in Western societies, especially because of the loss of physical activity and the sense of asexuality experienced in old age. However, nowadays, these ideas are constantly challenged. This conflict reaches its apex when considering male gay culture, which is marked by complacent hedonism associated with being obsessed with physical attributes capable of eliciting attraction and desire.22 Mojola SA, Williams J, Angotti N, Gómez-Olivé FX. HIV after 40 in rural South Africa: a life course approach to HIV vulnerability among middle aged and older adults. Soc Sci Med. 2015;143:204-12.,33 Simões JA. Corpo e sexualidade nas experiências de envelhecimento de homens gays em São Paulo. A terceira idade. 2011;22:7-19.

As part of this rediscovery of their own bodies and sexuality, middle-aged and older men who have sex with men (MSM) have gradually freed themselves of the social restrictions and norms historically imposed on people of this age regarding sexuality, recreating and remodeling norms to better suit their experiences, sexual needs, and desires.44 Lyons A, Croy S, Barret C, Whyte C. Growing old as a gay man: how life has changed for the gay liberation generation. Ageing Soc. 2015;35:2229-50.

The use of online digital social media, especially geosocial dating apps for sexual purposes, helps meet the demand of this male population, providing an effective and convenient mechanism to quickly locate sexual partners, in comparison with other, more traditional or offline methods.55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18.,66 Sousa AFL, Queiroz AAFLN, Fronteira I, Lapão LV, Mendes IA, Brignol S. Testing for HIV among middle-aged and older men who have sex with men (MSM): a blind spot?. Am J Mens Health. 2019;13:1557988319863542.

These mobile apps allow users to filter possible partners according to their preferences (age, sex positions, race, and physical attributes, among others), streamlining the creation of partnerships, especially sexual.55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18.,66 Sousa AFL, Queiroz AAFLN, Fronteira I, Lapão LV, Mendes IA, Brignol S. Testing for HIV among middle-aged and older men who have sex with men (MSM): a blind spot?. Am J Mens Health. 2019;13:1557988319863542. This agility in establishing partnerships, however, can contribute to condomless anal sex and other practices that can increase exposure to sexually transmitted infections (STIs), especially the human immunodeficiency virus (HIV).77 Whitfield DL, Kattari SK, Walls NE, Grindr Al-Tayyib A. Scruff, and on the hunt: predictors of condomless anal sex, internet use, and mobile application use among men who have sex with men. Am J Mens Health. 2017;11:775-84, http://dx.doi.org/10.1177/1557988316687843.
http://dx.doi.org/10.1177/15579883166878...
,88 Queiroz AA, Matos MC, Araújo TM, Reis RK, Sousa AF. Sexually transmitted infections and factors associated with condom use in dating app users in Brazil. Acta Paul Enferm. 2019;32(5). Furthermore, lack of discussions about the sexual health of MSM aged 50 years or older contributes to this scenario, because it reinforces the invisibility of the LGBT community and the sexuality of older persons.99 Valdes B, Gattamorta K, Jones SG, Fenkl EA, De Santis JP. Social support, loneliness, depressive symptoms, and high-risk sexual behaviors of middle-aged hispanic men who have sex with men. J Assoc Nurses AIDS Care. 2019;30:98-110.

The literature about factors related to HIV infection among middle-aged and older MSM is scarce, especially when considering the use of social media, even though data from international offices, such as the US Centers for Disease Control, show that the incidence of the infection has grown considerably among the MSM population.99 Valdes B, Gattamorta K, Jones SG, Fenkl EA, De Santis JP. Social support, loneliness, depressive symptoms, and high-risk sexual behaviors of middle-aged hispanic men who have sex with men. J Assoc Nurses AIDS Care. 2019;30:98-110.

10 Emlet CA, Shiu C, Kim HJ, Fredriksen-Goldsen K. Bouncing back: resilience and mastery among HIV-positive older gay and bisexual men. Gerontologist. 2017;57(suppl 1):S40-9.

11 Tsang EY, Qiao S, Wilkinson JS, Fung AL, Lipeleke F, Li X. Multilayered stigma and vulnerabilities for HIV infection and transmission: a qualitative study on male sex workers in Zimbabwe. Am J Mens Health. 2019;13:.
-1212 UNAIDS, Geneva. Available from: The Global Gender gap Gap report. 1st ed; 2018 http://reports.weforum.org/global-gender-gap-report-2018/the-global-gender-gap-index-2018/
http://reports.weforum.org/global-gender...
The contextual factors that could explain this population's greater vulnerability to HIV are still unknown. The objective of the present study was to analyze factors of vulnerability to HIV/Aids among the population of MSM aged 50 years or older who use dating apps.

The concept of vulnerability adopted here consists of three fundamental aspects or dimensions-individual, social, and programmatic-that are used to describe the susceptibility of population groups to important health problems. In the context of the HIV/Aids epidemic, vulnerability is related to the idea that people's chances of being exposed to the virus (and of developing Aids) are the result of a set of individual, collective, and contextual aspects, which together lead to greater susceptibility to infection and disease.1313 Mann JM, Tarantola DJM, Netter TW. AIDS in the world. 1st ed. Boston: Harvard University; 1992.

Individual vulnerability is of a cognitive nature and includes biological, emotional, cognitive and attitudinal aspects relative to social relationships, understood as the quantity and quality of the information available to individuals, in association with their ability to process it. The social aspect of vulnerability is defined by cultural, social, and economic aspects that determine people's opportunities to access goods and services. Programmatic (healthcare) vulnerability refers to the necessary social resources to protect individuals from risks to their physical, psychological, and social integrity and well-being. Any study of vulnerability depends on the analysis of the combination of the three domains.1414 JRCM Ayres, França JI, Calazans GJ, Salletti H. Vulnerabilidade e prevenção em tempos de AIDS. In: Barbosa RM, Parker R, editors. Sexualidade pelo avesso: direitos, identidade e poder, 34. Rio de Janeiro: Editora; 1999.

Methods

This article is part of a multicenter study called "Behaviors, practices, and vulnerabilities among men who have sex with men and use geolocation (geosocial) dating apps in Brazil". It was a cross-sectional, population-survey-based, analytical study carried out with MSM aged 50 years or older who use dating apps, conducted exclusively online in all the regions of Brazil.

Sample

For sample definition we used a modification of time location sampling (TLS). This technique seeks to approach probabilistic sampling by mapping the universe of places where the target population can be found in large numbers and then randomly selecting a specific day, time and place for recruitment and systematically selecting participants from that location.1515 Queiroz AAF, Sousa AF, Matos MC, Araújo TM, Reis RK, Moura MEB. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm. 2018;71:1949-55. Volunteers who were specifically approached through the applications and who agreed to respond to the online questionnaire were considered. The inclusion criteria were: identified as a cisgender male; being 50 years or older; and being online at the time of data collection. Users who did not reside in Brazil were excluded.

Specific procedures

To find participants, four apps commonly used by MSM were selected: Grindr®, Hornet®, Scruff® and Daddy Hunter®.88 Queiroz AA, Matos MC, Araújo TM, Reis RK, Sousa AF. Sexually transmitted infections and factors associated with condom use in dating app users in Brazil. Acta Paul Enferm. 2019;32(5). The computer-assisted self-interview (CASI) technique was used for data gathering.1515 Queiroz AAF, Sousa AF, Matos MC, Araújo TM, Reis RK, Moura MEB. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm. 2018;71:1949-55. The participants were approached through the selected apps for four consecutive months (February to May of 2017), in the afternoon, evening and at night. The participants were informed about the research objectives and the importance of their participation. After gaining consent, the researchers shared the hyperlink to the survey form, where the participants answered specific questions of interest to this study.

To cover the participants' social and demographic characteristics, sexual behavior, and health information, the questionnaire was divided into four sections, which included both mandatory and optional questions: personal information; sociocultural information; health issues; and sexual practices. The system only allowed participants to proceed to the next section if all the mandatory questions were answered. Furthermore, the questionnaires were only computed if, at the end, all the conditions were met. Incomplete surveys were not saved by the system.

To answer the questionnaire, participants provided their email address, preventing duplicated entries. If a participant was unwilling to participate, the next online user was approached. Recruitment was conducted by two adult cisgender male researchers who are experts in the studied field. They created accounts with public profiles (open, with a photo) in the apps to gain access to the users.

The analysis of the data was based on the adopted vulnerability framework.1313 Mann JM, Tarantola DJM, Netter TW. AIDS in the world. 1st ed. Boston: Harvard University; 1992.,1414 JRCM Ayres, França JI, Calazans GJ, Salletti H. Vulnerabilidade e prevenção em tempos de AIDS. In: Barbosa RM, Parker R, editors. Sexualidade pelo avesso: direitos, identidade e poder, 34. Rio de Janeiro: Editora; 1999. The research variables were grouped according to the three domains of vulnerability:

  1. Individual: age, marital status, living situation, number of partners, type of sexual partnership established, sexual practices (sex positions, consistent use of condoms, bareback sex, group sex), forms of prevention (condoms, withdrawal, no penetration), chemsex (using drugs during sexual relations), use of erectile dysfunction drugs, and the presence of STIs;

  2. Social: educational level, sexual orientation, religion and going to saunas; and

  3. Health care (programmatic): being familiar with post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP); going to healthcare services; and prior testing for HIV.

Variables that allowed more than one response, such as prevention and sexual position, were presented to the participants in multiple-choice format.

Data analysis

Descriptive analysis was employed to describe the vulnerability factors and other factors of interest, for both the numerical and categorical variables. The data were analyzed using IBM® SPSS version 23.0. Associations between positive serological status for HIV and the categorized vulnerability factors were assessed using the Pearson's chi-squared test and Fisher's exact test, with a 0.05 significance level. To construct the confidence interval, the reliability was set at 95%. The outcome of interest was positive HIV status, which was assessed using the question: Do you know your HIV status? The answer options were: "I am HIV positive", "I am HIV negative", and "I do not know/I'm not sure".

Multivariate logistic model was adopted to produce the adjusted odds ratios (ORa), considering the factors that presented statistical significance in univariate analysis.

Ethical aspects

The study was approved by the CEP/CONEP system (no. 1.523.003) and strictly complied with all the ethical precepts that guide research with human subjects. The participants read the free and informed consent form and then signed it, indicating their agreement with the proposed objectives and willingness to participate in the study. This consent was applied and obtained online.

Results

In all, 412 participants were recruited; Table 1 shows their sociodemographic characteristics. There was a predominance of individuals between 50 and 59 years old (42%), mean age of 61.6 years (ranging between 50 and 97, SD = 9.2). Most had a higher education (61.7%) and did not practice any religion (52.7%). Most were single (61.4%), had not been in a relationship in the last 30 days (71.1%), identified themselves as homosexuals (77.4%), and lived alone (40.5%).

Table 1
Sociodemographic characteristics of men aged 50 years or older who have sex with men (MSM) and use dating apps. Brazil, 2017.

The most common type of sexual partnership established was casual (63.1%), which resulted in a mean of 2.7 sexual partnerships via the apps in the 30 days prior to the survey. The most popular apps were Grindr (59.7%) and Hornet (45.1%), which were used primarily to facilitate sexual encounters (88%).

Regarding frequency of use, emphasis goes to the daily use of the apps (60%), especially in the evening (63%) and on weekdays (64.8%). In terms of the presence of STIs, 22.1% reported at least one in the year prior to the survey, with emphasis on infection by HIV (11.7%) and syphilis (10.2%).

The most common form of prevention was condoms (86.2%). However, it is worth noting that 38% opted for withdrawal. Furthermore, 31.3% of the participants chose the insertive sexual position exclusively, 27.7%, the receptive sexual position exclusively, and 33.5%, both (versatile). Among those who had receptive intercourse, 25.7% had done so condomless at least once in the 30 days prior to the survey. HIV prevalence was 11.7% (48), and 30.8% (127) did not know their serological status. Also noteworthy is the fact that 47.3% (195) of the subjects had not had HIV testing recently (in the previous 12 months).

Univariate analysis of positive serological status for HIV showed associations with the following factors: educational level (p = 0.039); sex position (p < 0.001); HIV testing (p = 0.020); bareback practice (p = 0.010); chemsex (p = 0.003); group sex (p = 0.004); use of erectile dysfunction drugs (p = 0.002); presence of STIs (p < 0.001); knowledge of PEP (p < 0.001) and PrEP (p < 0.001); going to saunas (p = 0.040); using withdrawal (p = 0.010) as a form of prevention; use of PrEP (p = 0.050) and testing (p = 0.020); and knowing the partners' status (p < 0.001) (Table 2).

Table 2
HIV serological status according to vulnerability factors. Brazil, 2017.

Multivariate analysis revealed that the following variables were independently associated with increased chances of having HIV: having relations with someone with HIV (ORa = 5.53; 95%CI = 2.23-13.73); chemsex (ORa = 3.97; 95%CI = 1.72-8.92); and, especially, having a partner with HIV (ORa = 8.02; 95%CI = 2.01-32.01). The belief that apps increase protection against STIs (ORa = 0.43; 95%CI = 0.19-0.95) and not being familiar with PEP (ORa = 0.43; 95%CI = 0.19-0.95) were associated with reduced chances of having HIV (Table 3).

Table 3
Multivariate analysis of factors associated with vulnerability to HIV infection by MSM aged 50 years or older and who use dating apps. Brazil, 2017.

Discussion

The results showed a high prevalence of HIV among MSM aged 50 years or older (11.7%) who are users of dating apps in Brazil, especially when compared with the general Brazilian population (0.39%).1616 Benzaken AS, Oliveira MCP, Pereira GFM, Giozza SP, Souza FMA, Souza ARC. Presenting national HIV/AIDS and sexually transmitted disease research in Brazil. Medicine. 2018;97(Suppl 1):S1-2. However, this prevalence is still lower than that found in a recent study with MSM in 12 Brazilian cities, which reported a prevalence of 18.4%.1717 Kerr L, Kendall C, Guimarães MDC. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine. 2018;97(Suppl 1):S9-15. It is worth noting that these studies used different methodological approaches to estimate prevalence rates.

The prevalence in our study was also lower than in other studies conducted with MSM in Latin America. A study conducted in large urban centers in Colombia revealed a prevalence of 15%,1818 Rubio Mendoza ML, Jacobson JO, Morales-Miranda S, Sierra Alarcón CÁ, Luque Núñez R. High HIV burden in men who have sex with men across Colombia's largest cities: findings from an integrated biological and behavioral surveillance study. PLoS One. 2015;10:e0131040. while another carried out in Mexico showed a prevalence of 16.9%.1919 Semple SJ, Pitpitan EV, Goodman-Meza D, Strathdee SA, Chavarin CV, Rangel G, et al. Correlates of condomless anal sex among men who have sex with men (MSM) in Tijuana, Mexico: the role of public sex venues. PLoS One. 2017;12:e0186814.However, these two studies addressed young MSM, with mean ages of 29.7 and 25 years, respectively. These rates are quite elevated when compared to HIV prevalence among MSM in European countries (6.0%).2020 Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 2012;380:424-38.

In Brazil, there is little information about the HIV epidemic and risk and vulnerability factors for STIs and HIV infection among MSM over 50 years old. The most recent studies have found prevalence rates and other information about the general population of MSM, with a small representation of men in older age groups.88 Queiroz AA, Matos MC, Araújo TM, Reis RK, Sousa AF. Sexually transmitted infections and factors associated with condom use in dating app users in Brazil. Acta Paul Enferm. 2019;32(5).,1515 Queiroz AAF, Sousa AF, Matos MC, Araújo TM, Reis RK, Moura MEB. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm. 2018;71:1949-55.,1717 Kerr L, Kendall C, Guimarães MDC. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine. 2018;97(Suppl 1):S9-15.

In the international literature there are also few studies that focus on this MSM subgroup, which limits knowledge about the specific characteristics of these men and makes their vulnerability and health conditions invisible.2121 Schildcrout J. Queer justice: the retrials of Leopold and Loeb. J Pop Cult. 2011;34:175-88.

22 Budhwani H, Hearld KR, Barrow G, Peterson SN, Walton-Levermore K. A comparison of younger and older men who have sex with men using data from Jamaica AIDS Support for Life: characteristics associated with HIV status. Int J STD AIDS. 2016;27:769-75.
-2323 Kupprat SA, Krause KD, Ompad DC, Halkitis PN. Substance use and cognitive function as drivers of condomless anal sex among HIV-positive gay, bisexual, and other men who have sex with men aged 50 and older: the gold studies. LGBT Health. 2017;4(6):434-41. To our knowledge, this is the first study to provide original data focusing on the vulnerability factors for HIV infection among MSM aged 50 and older who are users of geosocial dating applications. Studies previously carried out on this subject have concentrated on the general MSM population (young/adult).55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18.

The sociodemographic profile of the study participants revealed that most were homosexual and presented high educational levels (university degree), a finding similar to that in a recent literature review.55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18. This profile can help MSM better manage their vulnerabilities, because when equipped with knowledge and other resources, they are able to select the prevention strategies that better fit their lifestyle.1515 Queiroz AAF, Sousa AF, Matos MC, Araújo TM, Reis RK, Moura MEB. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm. 2018;71:1949-55. There was also a predominance of participants who lived alone or who were not in a stable relationship, a factor that can influence their social support.2020 Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 2012;380:424-38.

App use profile - social vulnerability

Although most of the social vulnerability factors related to app use did not present statistical significance in the multivariate analysis, it is important to discuss these findings, since they differed from other studies2424 Holloway IW, Pulsipher CA, Gibbs J, Barman-Adhikari A, Rice E. Network influences on the sexual risk behaviors of gay, bisexual and other men who have sex with men using geosocial networking applications. AIDS Behavior. 2015;19(Suppl 2):112-22. and have direct implications for the sexual practices of MSM. Analysis of app use showed characteristics that clearly defined differences between the consumption of different generations of MSM, which can contribute to the understanding of some aspects of these men's vulnerability. For example, in relation to reasons for using these apps, younger MSM used them for sexual purposes (64.7%),88 Queiroz AA, Matos MC, Araújo TM, Reis RK, Sousa AF. Sexually transmitted infections and factors associated with condom use in dating app users in Brazil. Acta Paul Enferm. 2019;32(5). a lower rate than that found among MSM aged 50 years or older (88.0%). This may reflect the importance of this tool in the daily lives of the participants and corroborates other studies indicating that older adults tend to better adopt technologies that serve specific objectives.2525 Schulz R, Wahl HW, Matthews JT, Dabbs AV, Beach SR, Czaja SJ. Advancing the aging and technology agenda in gerontology. Gerontologist. 2015;55:724-34.,2626 Hubers C, Lyons G. New technologies for the old: potential implications of living in later life for travel demand. Transport Policy. 2013;30:220-8.

These factors can affect the sexual behavior of users because the more an app is used, the greater the familiarity with its tools, and the greater the ease and speed of finding partners, as evidenced by previous studies.55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18.,2727 Winetrobe H, Rice E, Bauermeister J, Petering R, Holloway IW. Associations of unprotected anal intercourse with Grindr-met partners among Grindrusing young men who have sex with men in Los Angeles. AIDS Care. 2014;26:1303.,2828 Holloway IW, Pulsipher CA, Gibbs J, Barman-Adhikari A, Rice E. Network influences on the sexual risk behaviors of gay, bisexual and other men who have sex with men using geosocial networking applications. AIDS Behavior. 2015;19:112-22. This familiarity can influence the speed and ability of establishing partnerships. A study revealed that the average time of use of these apps among youths was 50% less than among participants of the present study (12 months and 27 months, respectively).55 Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18. Accordingly, the number of partnerships established through the apps was also higher in the present study (2.7 partners in the last 30 days) when compared with other studies with younger MSM who used apps in the United States (2.03 and 1.9).2929 Lehmiller JJ, Ioerger M. Social networking smartphone applications and sexual health outcomes among men who have sex with men. PLoS One. 2014;9:e86603.,3030 Landovitz RJ, Tseng CH, Weissman M, Haymer M, Mendenhall B, Rogers K. Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California. J Urban Health. 2013;90:729-39.

It is important to highlight that the safety that comes from the anonymity and discretion provided by the apps is useful for some MSM, especially those who identify themselves as heterosexual or bisexual and who do not choose to disclose their affective and sexual behavior to protect themselves against violence, stigma, discrimination, homophobia and family rejection.3131 Altman D, Aggleton P, Williams M, Kong TSK, Reddy V, Harrad D. Homophobia: What is it? What are its effects? How can it be reduced? In: International AIDS Conference. International AIDS Society, 2012. The Conference's web site is located at http://pag.aids2012.org/session.aspx?s=650.
http://pag.aids2012.org/session.aspx?s=6...
,3232 Oliveira FBM, Queiroz AAFLN, Sousa AFL, Moura MEB, Reis RK. Sexual orientation and quality of life of people living with HIV/Aids. Rev Bras Enferm. 2017;70:1004-10. The use of new digital technologies makes it easier to contact friends and establish new relationships (affective and sexual), and this is constantly being updated. Consequently, new issues emerge, such as relationships between older and younger MSM.3333 Bird JD, LaSala MC, Hidalgo MA, Kuhns LM, Garofalo R. "I had to go to the streets to get love": pathways from parental rejection to HIV risk among young gay and bisexual men. J Homosex. 2017;64:321-42.

It is worth remembering that "believing that apps help prevent HIV infection," that is, believing that using apps to establish partnerships can somehow help prevent HIV infection, was statistically associated with being a protecting factor against HIV infection. In other words, the participants perceived that this form of digital interaction mediated by social media can somehow help prevent infections.

Individual vulnerability

The sex position preferred by men, whether insertive or receptive, is an important factor in the sexual experience of MSM. Preference for the insertive position (insertive-only or versatile-insertive position) is associated with an image of greater masculinity, which is highly valued in gay sociability,3434 Iribarren SJ, Ghazzawi A, Sheinfil AZ, Frasca T, Brown W, Lopez-Rios J. Mixed-method evaluation of social media-based tools and traditional strategies to recruit high-risk and hard-to-reach populations into an HIV Prevention Intervention Study. AIDS Behav. 2018;22:347-57.

35 Dangerfield DT, Smith LR, Williams J, Unger J, Bluthenthal R. Sexual positioning among men who have sex with men: a narrative review. Arch Sex Behav. 2017;46:869-84.
-3636 Oliveira JMD, Costa CG, Nogueira C. The workings of homonormativity: Discourses of lesbian, gay, bisexual and queer people on discrimination and public display of affections in Portugal. J Homosex. 2013;60:1475-93. and also presents a lower risk of infection by HIV and STIs.2020 Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 2012;380:424-38.,3737 Meng X, Zou H, Fan S, Zheng B, Zhang L, Dai X. Relative risk for HIV infection among men who have sex with men engaging in different roles in anal sex: a systematic review and meta-analysis on global data. AIDS Behav. 2015;19:882-9.

Even though the participants in the present study reported preferring the insertive position, other risk factors for HIV (Table 2) presented high frequency, which can increase the chances of transmission of HIV.3838 Davis O. A special issue of Sexualities: bareback sex and queer theory across three national contexts (France, UK, USA). Sexualities. 2015;18:120-6. These results were similar to those found in the literature, where many of the findings of the present study (erection difficulties, using condoms only with casual partners and not with steady partners or when engaging in chemsex) are factors associated with HIV infection among MSM.3939 Surkan PJ, Li Y, Jacobson LP, Cox C, Silvestre A, Gorbach P. Unsafe sexual behavior among gay/bisexual men in the era of combination antiretroviral therapy (cART). AIDS Behav. 2017;21:2874-85.,4040 Jacobs RJ, Kane MN, Ownby RL. Condom use, disclosure, and risk for unprotected sex in HIV-negative midlife and older men who have sex with men. Am J Mens Health. 2013;7:186-97.

However, there is also evidence that people with undetectable HIV viral load, or who use PrEP, can maintain safe sexual relations even with serodiscordant partners.4141 Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316:171-81. The repertoire of sexual practices involves factors from the individual dimension of vulnerability, issues that must be addressed to prevent HIV and STIs,4242 Belus JM, Kline T, Carney T, Myers B, Wechsber G. Measuring relationship functioning in South African couples: a strategy for improving HIV prevention efforts. Sex Relation Ther. 2018;1:1-13. because "not being familiar with PEP," "having a partner with HIV," and openness to "having relations with someone with HIV" and "chemsex" emerged as significantly associated with HIV infection in this study.

Chemsex is a differentiated, non-unitary and intentional sexual behavior that combines sexual activity and consumption of psychoactive substances. This is an important factor associated with positive HIV status, and has recently been addressed by the literature, which has identified an increase in this behavior among MSM.4343 Glynn RW, Byrne N, O'Dea S, Shanley A, Codd M, Keenan E. Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland. Int J Drug Policy. 2018;52:9-15. Among the reasons for this increase are growing capacity for engaging in the desired form of sex (increased arousal and libido, sexual confidence and increased sexual stamina), coupled with the improvement of qualities valued in sex, such as intensified sensation, reduced inhibitions, and greater ease of having sexual adventures.4444 Sewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. Int J Drug Policy. 2017;43:33-43.

These effects are due to the substances used in chemsex, which provide men with the ability to improve their performance and sexual experiences, increasing arousal, endurance, and pleasure. For older men, the invigorating effect of these substances seems to be the main motivation for their use, enabling improved sexual performance that corresponds to the ideals of masculinity shared by the gay community, especially when having relations with younger partners.4545 Gurevich M, Mercer Z, Cormier N, Leedham U. Responsible or reckless men? Sexuopharmaceutical messages differentiated by sexual identity of users. Psychol Men Mascul. 2017;18:341-51.

Programmatic vulnerability

In Brazil, MSM face difficulties when accessing health services because of issues relative to stigma and social violence, in addition to discrimination suffered in health services.4646 Dourado I, Silva LAVD, Magno L, Lopes M, Cerqueira C, Prates A. Building bridges: interdisciplinarity in practice. PopTrans Study: a study with transvestites and transsexual women in Salvador, Bahia State, Brazil. Cad Saude Publica. 2016;32:e00180415. Even though a set of national health policies is directed toward the LGBT community,4747 Ministério da Saúde, Brasília. Available from: Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. 1st ed; 2013 http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_lesbicas_gays.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
effective implementation of these services and reducing discrimination are still a challenge for the Brazilian Unified Health System.4848 Gomes SM, Sousa LMP, Vasconcelos TM, Nagashima AMS. SUS out of the closet: conceptions of municipal health managers on the LGBT population. Saude Soc. 2018;27:1120-33. The results of the present study showed that "visiting health services at least once a year" was a protective factor against HIV infection, which reinforces the importance of improving access to health services for these men.

One of the important issues in the context of the HIV epidemic that still need to be addressed is late diagnosis of HIV infection among MSM,4646 Dourado I, Silva LAVD, Magno L, Lopes M, Cerqueira C, Prates A. Building bridges: interdisciplinarity in practice. PopTrans Study: a study with transvestites and transsexual women in Salvador, Bahia State, Brazil. Cad Saude Publica. 2016;32:e00180415. especially those over 50 years old,4949 Oraka E, Mason S, Xia M. Too old to test? Prevalence and correlates of HIV testing among sexually active older adults. J Gerontol Soc Work. 2018;61:460-70.,5050 Centers for Disease Control and Prevention, Available at: https://http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf. Accessed April 13, 2017 CDC FACT SHEET: HIV Among Gay and Bisexual Men. 2016; 2016.
https://http://www.cdc.gov/nchhstp/newsr...
since this is an important marker for access to HIV and STI prevention strategies in health services.4646 Dourado I, Silva LAVD, Magno L, Lopes M, Cerqueira C, Prates A. Building bridges: interdisciplinarity in practice. PopTrans Study: a study with transvestites and transsexual women in Salvador, Bahia State, Brazil. Cad Saude Publica. 2016;32:e00180415.,5151 Tan K, Black BP. A systematic review of healthcare provider perceived barriers and facilitators to routine HIV testing in primary care settings in the Southeastern United States. J Assoc Nurses AIDS Care. 2017;29:357-70. Programmatic vulnerability is associated with barriers to access to health services, which are still discriminatory environments for MSM, in addition to flaws in prevention policies, since dissemination of and access to these services and supplies for MSM is still notably limited.

It is imperative that Brazilian society and public health managers face the reality of the vulnerability of MSM presented by various studies in terms of the HIV and Aids epidemics. It is urgent that existing health policies be implemented, and efforts be made to strengthen prevention and intervention actions that effectively reduce the spread of HIV and Aids in Brazil.

The present study has some limitations: a convenience sample consisting of MSM aged 50 years or older was used; a portion of the key variables for the study (testing and HIV status) were self-reported; incomplete responses were not saved in Google Forms; and the finding that the majority of participants in this study had a high level of education.

Furthermore, the study was limited to reporting findings for a specific population who used mobile social networks for given purposes, which can influence results and hinder generalizations about the MSM population over 50 years who do not use these apps. Much of the discussion was based on research involving younger MSM, due to lack of research with MSM 50 years old or older who are users of dating apps.

Despite these limitations, the results effectively reflect important aspects of individual, social and healthcare vulnerabilities of MSM aged 50 years and older in Brazil.

Conclusion

A high prevalence of HIV was observed among MSM 50 years old and older who use dating apps. Furthermore, some of the factors that affect vulnerability of MSM regarding HIV infection were: types of partnership established; partner's serological status; knowledge of prevention measures; chemsex; educational levels; sex position; group sex; presence of STIs and the use of PrEP; use of erectile dysfunction drugs; going to saunas; prevention through withdrawal; and frequency of visits to health services and HIV testing.

Acknowledgement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

  • 1
    Snyder PJ, Bhasin S, Cunningham GR, Matsumoto AM, Stephens-Shields AJ, Cauley JA, et al. Effects of testosterone treatment in older men. NEJM. 2016;374:611-24.
  • 2
    Mojola SA, Williams J, Angotti N, Gómez-Olivé FX. HIV after 40 in rural South Africa: a life course approach to HIV vulnerability among middle aged and older adults. Soc Sci Med. 2015;143:204-12.
  • 3
    Simões JA. Corpo e sexualidade nas experiências de envelhecimento de homens gays em São Paulo. A terceira idade. 2011;22:7-19.
  • 4
    Lyons A, Croy S, Barret C, Whyte C. Growing old as a gay man: how life has changed for the gay liberation generation. Ageing Soc. 2015;35:2229-50.
  • 5
    Queiroz AAFLN, Sousa AFL, Araújo TME. A review of risk behaviors for HIV infection by men who have sex with men through geosocial networking phone apps. J Assoc Nurses AIDS Care. 2017;28:807-18.
  • 6
    Sousa AFL, Queiroz AAFLN, Fronteira I, Lapão LV, Mendes IA, Brignol S. Testing for HIV among middle-aged and older men who have sex with men (MSM): a blind spot?. Am J Mens Health. 2019;13:1557988319863542.
  • 7
    Whitfield DL, Kattari SK, Walls NE, Grindr Al-Tayyib A. Scruff, and on the hunt: predictors of condomless anal sex, internet use, and mobile application use among men who have sex with men. Am J Mens Health. 2017;11:775-84, http://dx.doi.org/10.1177/1557988316687843
    » http://dx.doi.org/10.1177/1557988316687843
  • 8
    Queiroz AA, Matos MC, Araújo TM, Reis RK, Sousa AF. Sexually transmitted infections and factors associated with condom use in dating app users in Brazil. Acta Paul Enferm. 2019;32(5).
  • 9
    Valdes B, Gattamorta K, Jones SG, Fenkl EA, De Santis JP. Social support, loneliness, depressive symptoms, and high-risk sexual behaviors of middle-aged hispanic men who have sex with men. J Assoc Nurses AIDS Care. 2019;30:98-110.
  • 10
    Emlet CA, Shiu C, Kim HJ, Fredriksen-Goldsen K. Bouncing back: resilience and mastery among HIV-positive older gay and bisexual men. Gerontologist. 2017;57(suppl 1):S40-9.
  • 11
    Tsang EY, Qiao S, Wilkinson JS, Fung AL, Lipeleke F, Li X. Multilayered stigma and vulnerabilities for HIV infection and transmission: a qualitative study on male sex workers in Zimbabwe. Am J Mens Health. 2019;13:.
  • 12
    UNAIDS, Geneva. Available from: The Global Gender gap Gap report. 1st ed; 2018 http://reports.weforum.org/global-gender-gap-report-2018/the-global-gender-gap-index-2018/
    » http://reports.weforum.org/global-gender-gap-report-2018/the-global-gender-gap-index-2018/
  • 13
    Mann JM, Tarantola DJM, Netter TW. AIDS in the world. 1st ed. Boston: Harvard University; 1992.
  • 14
    JRCM Ayres, França JI, Calazans GJ, Salletti H. Vulnerabilidade e prevenção em tempos de AIDS. In: Barbosa RM, Parker R, editors. Sexualidade pelo avesso: direitos, identidade e poder, 34. Rio de Janeiro: Editora; 1999.
  • 15
    Queiroz AAF, Sousa AF, Matos MC, Araújo TM, Reis RK, Moura MEB. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm. 2018;71:1949-55.
  • 16
    Benzaken AS, Oliveira MCP, Pereira GFM, Giozza SP, Souza FMA, Souza ARC. Presenting national HIV/AIDS and sexually transmitted disease research in Brazil. Medicine. 2018;97(Suppl 1):S1-2.
  • 17
    Kerr L, Kendall C, Guimarães MDC. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine. 2018;97(Suppl 1):S9-15.
  • 18
    Rubio Mendoza ML, Jacobson JO, Morales-Miranda S, Sierra Alarcón CÁ, Luque Núñez R. High HIV burden in men who have sex with men across Colombia's largest cities: findings from an integrated biological and behavioral surveillance study. PLoS One. 2015;10:e0131040.
  • 19
    Semple SJ, Pitpitan EV, Goodman-Meza D, Strathdee SA, Chavarin CV, Rangel G, et al. Correlates of condomless anal sex among men who have sex with men (MSM) in Tijuana, Mexico: the role of public sex venues. PLoS One. 2017;12:e0186814.
  • 20
    Beyrer C, Sullivan PS, Sanchez J, Dowdy D, Altman D, Trapence G. A call to action for comprehensive HIV services for men who have sex with men. Lancet. 2012;380:424-38.
  • 21
    Schildcrout J. Queer justice: the retrials of Leopold and Loeb. J Pop Cult. 2011;34:175-88.
  • 22
    Budhwani H, Hearld KR, Barrow G, Peterson SN, Walton-Levermore K. A comparison of younger and older men who have sex with men using data from Jamaica AIDS Support for Life: characteristics associated with HIV status. Int J STD AIDS. 2016;27:769-75.
  • 23
    Kupprat SA, Krause KD, Ompad DC, Halkitis PN. Substance use and cognitive function as drivers of condomless anal sex among HIV-positive gay, bisexual, and other men who have sex with men aged 50 and older: the gold studies. LGBT Health. 2017;4(6):434-41.
  • 24
    Holloway IW, Pulsipher CA, Gibbs J, Barman-Adhikari A, Rice E. Network influences on the sexual risk behaviors of gay, bisexual and other men who have sex with men using geosocial networking applications. AIDS Behavior. 2015;19(Suppl 2):112-22.
  • 25
    Schulz R, Wahl HW, Matthews JT, Dabbs AV, Beach SR, Czaja SJ. Advancing the aging and technology agenda in gerontology. Gerontologist. 2015;55:724-34.
  • 26
    Hubers C, Lyons G. New technologies for the old: potential implications of living in later life for travel demand. Transport Policy. 2013;30:220-8.
  • 27
    Winetrobe H, Rice E, Bauermeister J, Petering R, Holloway IW. Associations of unprotected anal intercourse with Grindr-met partners among Grindrusing young men who have sex with men in Los Angeles. AIDS Care. 2014;26:1303.
  • 28
    Holloway IW, Pulsipher CA, Gibbs J, Barman-Adhikari A, Rice E. Network influences on the sexual risk behaviors of gay, bisexual and other men who have sex with men using geosocial networking applications. AIDS Behavior. 2015;19:112-22.
  • 29
    Lehmiller JJ, Ioerger M. Social networking smartphone applications and sexual health outcomes among men who have sex with men. PLoS One. 2014;9:e86603.
  • 30
    Landovitz RJ, Tseng CH, Weissman M, Haymer M, Mendenhall B, Rogers K. Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California. J Urban Health. 2013;90:729-39.
  • 31
    Altman D, Aggleton P, Williams M, Kong TSK, Reddy V, Harrad D. Homophobia: What is it? What are its effects? How can it be reduced? In: International AIDS Conference. International AIDS Society, 2012. The Conference's web site is located at http://pag.aids2012.org/session.aspx?s=650
    » http://pag.aids2012.org/session.aspx?s=650
  • 32
    Oliveira FBM, Queiroz AAFLN, Sousa AFL, Moura MEB, Reis RK. Sexual orientation and quality of life of people living with HIV/Aids. Rev Bras Enferm. 2017;70:1004-10.
  • 33
    Bird JD, LaSala MC, Hidalgo MA, Kuhns LM, Garofalo R. "I had to go to the streets to get love": pathways from parental rejection to HIV risk among young gay and bisexual men. J Homosex. 2017;64:321-42.
  • 34
    Iribarren SJ, Ghazzawi A, Sheinfil AZ, Frasca T, Brown W, Lopez-Rios J. Mixed-method evaluation of social media-based tools and traditional strategies to recruit high-risk and hard-to-reach populations into an HIV Prevention Intervention Study. AIDS Behav. 2018;22:347-57.
  • 35
    Dangerfield DT, Smith LR, Williams J, Unger J, Bluthenthal R. Sexual positioning among men who have sex with men: a narrative review. Arch Sex Behav. 2017;46:869-84.
  • 36
    Oliveira JMD, Costa CG, Nogueira C. The workings of homonormativity: Discourses of lesbian, gay, bisexual and queer people on discrimination and public display of affections in Portugal. J Homosex. 2013;60:1475-93.
  • 37
    Meng X, Zou H, Fan S, Zheng B, Zhang L, Dai X. Relative risk for HIV infection among men who have sex with men engaging in different roles in anal sex: a systematic review and meta-analysis on global data. AIDS Behav. 2015;19:882-9.
  • 38
    Davis O. A special issue of Sexualities: bareback sex and queer theory across three national contexts (France, UK, USA). Sexualities. 2015;18:120-6.
  • 39
    Surkan PJ, Li Y, Jacobson LP, Cox C, Silvestre A, Gorbach P. Unsafe sexual behavior among gay/bisexual men in the era of combination antiretroviral therapy (cART). AIDS Behav. 2017;21:2874-85.
  • 40
    Jacobs RJ, Kane MN, Ownby RL. Condom use, disclosure, and risk for unprotected sex in HIV-negative midlife and older men who have sex with men. Am J Mens Health. 2013;7:186-97.
  • 41
    Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316:171-81.
  • 42
    Belus JM, Kline T, Carney T, Myers B, Wechsber G. Measuring relationship functioning in South African couples: a strategy for improving HIV prevention efforts. Sex Relation Ther. 2018;1:1-13.
  • 43
    Glynn RW, Byrne N, O'Dea S, Shanley A, Codd M, Keenan E. Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland. Int J Drug Policy. 2018;52:9-15.
  • 44
    Sewell J, Miltz A, Lampe FC, Cambiano V, Speakman A, Phillips AN. Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics. Int J Drug Policy. 2017;43:33-43.
  • 45
    Gurevich M, Mercer Z, Cormier N, Leedham U. Responsible or reckless men? Sexuopharmaceutical messages differentiated by sexual identity of users. Psychol Men Mascul. 2017;18:341-51.
  • 46
    Dourado I, Silva LAVD, Magno L, Lopes M, Cerqueira C, Prates A. Building bridges: interdisciplinarity in practice. PopTrans Study: a study with transvestites and transsexual women in Salvador, Bahia State, Brazil. Cad Saude Publica. 2016;32:e00180415.
  • 47
    Ministério da Saúde, Brasília. Available from: Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. 1st ed; 2013 http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_lesbicas_gays.pdf
    » http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_saude_lesbicas_gays.pdf
  • 48
    Gomes SM, Sousa LMP, Vasconcelos TM, Nagashima AMS. SUS out of the closet: conceptions of municipal health managers on the LGBT population. Saude Soc. 2018;27:1120-33.
  • 49
    Oraka E, Mason S, Xia M. Too old to test? Prevalence and correlates of HIV testing among sexually active older adults. J Gerontol Soc Work. 2018;61:460-70.
  • 50
    Centers for Disease Control and Prevention, Available at: https://http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf Accessed April 13, 2017 CDC FACT SHEET: HIV Among Gay and Bisexual Men. 2016; 2016.
    » https://http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf
  • 51
    Tan K, Black BP. A systematic review of healthcare provider perceived barriers and facilitators to routine HIV testing in primary care settings in the Southeastern United States. J Assoc Nurses AIDS Care. 2017;29:357-70.

Publication Dates

  • Publication in this collection
    25 Nov 2019
  • Date of issue
    Sep-Oct 2019

History

  • Received
    13 May 2019
  • Accepted
    28 July 2019
  • Published
    28 Aug 2019
Brazilian Society of Infectious Diseases Rua Augusto Viana, SN, 6º., 40110-060 Salvador - Bahia - Brazil, Telefax: (55 71) 3283-8172, Fax: (55 71) 3247-2756 - Salvador - BA - Brazil
E-mail: bjid@bjid.org.br