In a study of the economic implications of HIV infection in the UK, it has been estimated that the lifetime HIV-related costs for diagnosed HIV-positive individuals is between £280,000 and £360,000 and preventing the HIV infections acquired and diagnosed in the UK in 2008 would save £1.1 billion in future HIV-related costs . MSM, who accounted for over a third of diagnoses in 2008, most of which were probably acquired in the UK , are therefore a high priority for HIV prevention interventions. This is the first UK paper to report engagement with HIV prevention strategies in MSM since the advent of antiretroviral treatment in 1996.
The majority of the MSM in our community-based surveys reported having contact with HIV prevention activities in the past 12 months. Obtaining free condoms was reported by almost three quarters of the sample. Half also reported picking up sexual health leaflets in a bar, club or sauna or looking for safer sex or sexual health information on the Internet. Talking to outreach workers in gay venues or participating in one to one or group counselling on sexual health or HIV prevention was less common, reported by just one in ten respectively. Comparable data are not available elsewhere in the UK, but our findings are similar to those of the US National HIV Behavioural Surveillance survey of MSM, which found 80% had received free condoms, but few had participated in individual or group HIV prevention interventions in the past 12 months (15% and 8%, respectively) .
In multivariate analysis, each of the HIV prevention activities remained associated with frequency of gay scene use, but not with sexual risk behaviours (with the exception of having ten or more sexual partners, which itself only remained associated with obtaining free condoms). Frequency of gay scene use could be taken as a proxy for risk behaviour and the two were correlated, but there were no significant interactions between the two in any of the multivariate HIV prevention models and when separate models were fitted for each of the correlated variables and compared with the final models to check for the effects of collinearity, no substantively important differences were observed (data not shown). It is also of particular note that contact with HIV prevention activities (with the exception of accessing sexual health information) remained associated with either HIV or other STI testing in the past 12 months, with utilising counselling also more likely among men who reported having had an STI in the past 12 months and HIV-positive men.
There are some limitations to note when considering these results. Only men who visited the venues surveyed had the opportunity to participate and caution should be taken when generalising to a wider population of gay men. The data are cross-sectional and participants were only asked if they had contact with a pre-determined list of HIV prevention activities, not the extent of this contact, the quality, intensity, or frequency of exposure to these activities, or what, if any, impact it had on them. Other activities could have been available to, and utilised by, the men who participated in this survey. It is recognised that these factors should be assessed in the future to accurately assess the potential of prevention services to change risk behaviour. Furthermore, our examination of associations between prevention activities and sexual risk is limited to the behaviours for which data were collected and these aggregate measures may miss more complex risk reduction strategies being employed by individual men. However, the results provide interesting insight into men's current contact with a range of HIV prevention activities available to them and the following discussion concentrates on the implications of the findings for future HIV prevention efforts.
It is encouraging that the majority of men had some contact with HIV prevention activities. Condom provision is a core component of HIV prevention . Considerably more men reported obtaining free condoms than any of the other activities and it presents an opportunity for further prevention efforts and community engagement (e.g. using existing condom distribution methods to distribute other sexual health or HIV communications). Half of the men surveyed had accessed such sexual health materials, either via leaflets or online, and mass communication, or social marketing, campaigns (some of which include the provision and distribution of leaflets in addition to more general poster or media advertising) continue to be frequently employed as a means of HIV-related health promotion . Indeed, the recently published Scottish HIV Action Plan includes a specific recommendation to develop and implement social marketing materials for MSM . With the Internet now a recognised setting that MSM are likely to utilise to meet sexual partners , and evidence supporting online health promotion , interest has grown in using the Internet as a setting for HIV prevention interventions. However, both mass communication and Internet interventions are often difficult to evaluate and, to date, have been shown to have limited impact on risk behaviour [20, 23].
Talking to outreach workers in bars, clubs or saunas, though markedly less common than obtaining free condoms or accessing sexual information via leaflets or the Internet, appears to continue to have a role in increasing access to sexual health services, as evidenced here by the association between this and HIV/STI testing. Our previous evaluation of the Gay Men's Task Force peer education intervention reported similar findings, with higher rates of service use among men who had talked to peer educators in bars . Outreach workers are ideally placed to direct at risk men to sexual health services and to support other, more general, social marketing campaigns.
Utilising one to one or group counselling on sexual health or HIV prevention, the most intensive form of prevention examined here, was also the least commonly reported. The association between testing, HIV, STIs and counselling could reflect the risk reduction counselling provided by sexual health practitioners when men present for testing or treatment. As such, these interactions represent the opportunity for interventions to effect behaviour change, as noted in existing UK guidance . Intervention delivery by health care providers, and in settings where people receive routine HIV care or services, are two of the characteristics of successful interventions . Sexual health services would be appropriate settings for such interventions in the UK. They would also be the most appropriate setting for the combination of these with biomedical interventions, such as early treatment for HIV to contribute to reducing community viral load, in which there is growing interest [26–29].
This is a highly sexually active sample, and at the bivariate level, contact with HIV prevention activities was consistently more common among men with more sexual partners and greater sexual risk behaviours (with the exception of UAI with partners of unknown or discordant HIV status). Although this suggested men at greater risk were making use of existing activities (which theoretically could help reduce their risk), it is striking that these associations did not remain significant in multivariate analysis (though, as noted above, frequency of gay scene use could be taken as a proxy for risk behaviour). Prevention efforts have been ongoing at a time when HIV-related sexual risk behaviour has essentially stabilised in this population (at a high level first observed in 2002 [13, 30]). Although this plateau could be interpreted as evidence of successful prevention efforts, and stabilisation of risk behaviours during periods of intensified prevention efforts have been noted elsewhere [31, 32], continued efforts are needed to address sexual risk among the minority of men for whom this appears to have become the norm . Our results suggest high-risk men, those in contact with sexual health services, are accessing HIV prevention. Therefore, it is possible such prevention needs to be renewed, reinvigorated, or changed entirely, if reductions in sexual risk behaviours are to be achieved.