男同性戀者感染愛滋病毒時其生活情況如何？

個人、社區和結構等層面上的因素之組合導致了風險行為和愛滋病毒的感染

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本研究所使用經調整後之社會-生態架構圖

 

Roger Pebody，aidsmap news， 發佈時間：2017年9月8日；財團法人台灣紅絲帶基金會編譯

近期在公開閱覽的英國醫學期刊( BMJ Open )所發表的一項定性研究顯示，近期成為愛滋病毒陽性的英國男同性戀者描述了其可能導致感染的一系列複雜因素。

研究人員寫道：「個人曾在生命過程中逐漸經歷過或者更突然地發生多種壓力源的人，當社會環境創造了一種可以引發愛滋病感染風險的環境時，特別容易受愛滋病毒傷害，並被捲入性風險中」。個人和人際間的因素經常與社區或結構性等因素相結合，例如約會軟體的廣泛使用、藥愛(chemsex)和HIV的治療，以及對感染愛滋病毒其嚴重性認知上的改變等。

該研究描繪了一幅英國男同性戀者其感染愛滋病毒之個人和社會背景圖像。每年在英國，超過一半以上的愛滋病毒的診斷都是發生在男同性戀者當中了

 

本項研究

2015年初，倫敦大學學院的Annabelle Gourlay及其同事招募了於近期在倫敦或布萊頓被診斷出感染愛滋病病毒的21名同性戀男子，他們係近期感染愛滋病毒（通常在診斷前幾週）。他們在推估感染日期後平均六個月接受了採訪。研究人員選擇近期感染的男性，並假設他們相較於係較久以前感染愛滋病毒者更能準確地回憶起他們感染的方式。

參與者年齡在22至61歲之間（中位數為38歲），大多數是白人，受過良好教育和就業中。深入地訪談了涉及個人背景，移居倫敦/布萊頓以及這種轉變的經驗（如果適用），愛滋病毒診斷前的近幾年的生活，關係以及愛滋病毒感染時情況的看法。 

研究人員指出他們研究的兩個潛在局限性。首先，大城市中心的男同性戀白人的經歷對於其他種族和地理區域的男性來說可能並無法類推。其次，回應可能受到社會期望偏見的限制，換句話說，傾向於

以一種將被其他人看好的方式去回答問題。

 

個人和人際間因素

許多受訪者描述了童年時期的困難經歷，這些經歷對心理健康、吸毒和支持上產生了長期的影響。許多人描述了與父母之間功能失調或膚淺表面的關係，有酗酒或心理健康問題的家庭成員，或在學校被霸凌欺負。一名男子說：「我的父親是……一個酗酒者，他過去經常打我的母親和我……這對一個人是如何具破壞性的產生了一些影響，事實上，我從來沒有過任何無條件的愛，這在我成年期有時仍然會不斷去掙札奮戰的事情」。

一位男士說他從未被其父母「感覺係被撫養培育過」，他解釋說：「我總是需要透過他人來進行驗證……這尤其表現在性的背景下」。

有少數男性是在男同性戀者受到嚴重污名的環境中長大，這可能導致壓抑的性行為或低自尊。雖然大多數參與者都是在青少年或即將成年時「出櫃」，但其他人則僅是在二十幾歲或三十幾歲時才透露其性取向。在某些情況下，這些都會和對錯過機會的怨懟和對性探索的渴望等有關。

「在一個很晚才能了解你自己的環境中長大，你需要去……思考相關經驗，去查看其他性的事物，這些在以前你可能不需要去思考的，但因為你有點落後…… 就像說，我是否錯過了某些東西？」

在愛滋病毒被診斷之前的近期所經歷的壓力事件，導致許多參與者的心理困擾。這些包括親屬的嚴重疾病或死亡，關係破裂，暴力的伴侶，失去友誼和健康問題等。

有許多人暴露於多重的心理-社會上的風險因素中，而這些組合的因素可能是具毀滅性的。

「你知道嗎，我可能快崩潰了。我不是在一個穩定的地方，我沒有穩定的關係，我的經濟狀況不穩定，我剛剛在我的直系親屬身上遭受了相當嚴重的損失。這真的是那種到處都是的狀態」。

有些人經歷了「中年危機」。

「我的意思是，這可能是你所知道的完美風暴，它們[藥物] 在當時擄獲我…… 於四十多歲中期，當時我不那麼安全；這當中有一些問題，我一直在尋找樂趣……這是一種逃避，而在當時似乎……很愉快」。

情緒創傷可以使人們重新評估不安全性行為的潛在成本。

「我並沒有珍視自己的生活……因為發生了這麼多的事情，過去三、四、五年間經歷了許多……分手，失去一切，感情上的事情和死亡，上帝知道還有那些？」，情況幾乎變得有點「反正我的生活已經是如此的頹廢，而什麼才是重點呢，如果我真的感染到它，而我真的那麼在乎[HIV]嗎」？

 

社區和結構上的因素

男人們為倫敦和布萊頓所提供之開放的文化、自由和社交機會所吸引。幾乎所有人都在桑拿、俱樂部、放鬆之活動（通常涉及毒品和團體性交的聚會）或巡遊場所中遇到了伴侶。同志場域的誘惑實在難以抗拒。

「身為同志你星期五晚上去沃克斯豪爾[Vauxhall，倫敦南部的同性戀區]，直到五天後才回家。我覺得對年輕人而言在這些日子裡有很多誘惑，我也把自己包括在內」。

無論年齡大小，約會應用軟體為許多參與者在多重伴侶上提供了方便的途徑。它們甚至還可以導引男性去放鬆的活動( chill outs，常涉及毒品和團體性交的聚會 )和藥愛( chemsex )場域，一些受訪者認為他們促進了濫交和不負責任。許多男子回想起在男同性戀場域中有關性和藥物文化上的許多變化。

「藥物已經改變了…有更多的選擇…… G水( GHB )，卡西酮( mephedrone ) …..在開始時我非常害怕…… 隨後它便在同性戀場域中被標準化，你只是傾向於做其他人正在做的事情。會去靜脈注射也是一樣的情形。我的意思是這些日子看起來似乎並不那麼可怕」。

受訪者，特別是中年和老年男性，描述了同性戀社區對愛滋病毒認知上不斷的變化。

「我認為在倫敦幾乎已經到了人們不再關心它的地步。它不被視為死刑判決。我記得有一位醫生正在閱讀一篇文章，我知道很多同性戀者似乎已經讀過……他寧願感染愛滋病毒而不是糖尿病」。 

由於有效的愛滋病毒治療和良好的醫療保健服務，人們普遍認為愛滋病毒是一種可控制的疾病。這影響了行為的規範和對風險的態度。

現在每個人都知道有些人是陽性，並且知道他們安適並身體保持健康且每天吃幾顆藥……這就是為什麼很少有人會再使用保護措施的一個重要因素……因為它已成為一種可治療的疾病……我認為這改變了所有人的風險算計，因為即使最壞的情況確實發生，它也不再會是最糟糕的情形」。

一些年輕的參與者有意識的做出了選擇，包括與愛滋病毒陽性之伴侶，當他們體內的病毒載量已達到無法檢測之水準時，去進行無套性行為。有許多人曾經使用過暴露後預防（PEP），還有一些人則試圖由性健康診所接受預暴露前預防投藥（PrEP）。（PROUD的研究結果於2014年10月首次報告，訪談則於2015年初進行。）

一般來說，許多受訪者認為在同性戀社區中存在著對愛滋病風險和易感性的冷漠感。他們將此歸因於愛滋病治療的可用性和其他更新的預防選擇，對無法檢測到病毒載量的認識不斷增加、恥辱感的下降以及對愛滋病毒感知上的改變。  

 

各種因素交互作用的複雜情境

雖然一些受訪者用單一因素解釋了他們的感染，但大多數參與者認為多種因素的組合導致了風險行為和HIV感染。

「性與毒品和交友軟體同時交織在一起，我無法真正說出哪一個導致了另一個」。

研究人員指出，個人，社區和結構因素之間經常存在相互作用。例如，一個二十多歲的男人認為他的自傷性之性行為源自於童年和與母親的暴力關係，但也強調了「虐待」環境的作用，包括同性戀三溫暖中的性脅迫。

「我認為在性愛方面，我認為這是……環境，特別是在倫敦南部。在我看來，具風險的性，藥愛( chemsex的增加正在形成為一種流行病。你可以聽到現在有這麼多年輕的男同性戀者都是陽性… 透過這種生活方式。這是非常享樂主義的，真的是有很多問題很淫穢……我想，隨後，住在倫敦南部也讓我感染了愛滋病毒」。

心理問題和吸毒經常被合併提到。例如，一個四十多歲的男人將他感染HIV的重要因素認定為：

「是這些藥物…… 還有抑鬱症，也因為我一點也不在乎是否冒險……我放棄了」。

一些經歷過壓力事件的參與者亦表示，對愛滋病毒的看法的改變也有意識地或潛意識地影響了他們的行為，風險或利益之決策已經被改變了。

「當我們年輕的時候，對上帝的敬畏仍深植我心。如果你感染到它那你就死定了……現在它卻是可以控制的…你可以過正常的生活……我認為我過去所經歷的創傷已經改變了，我認為生活中的真正風險……還有其他更重要的事情……所以這是一個所有這些不同層面上的組合，我得出結論，如果我確實成為愛滋病毒陽性，那也將不再會是我生命中的重大事件」。

 

結論

研究人員使用社會-生態架構來指引他們的分析。（見下圖）。

 https://www.taiwanaids.org.tw/wp-content/uploads/2024/03/1QYX6AREBC.jpg” alt=”” width=”657″ height=”656″ />

 

這顯示可能導致愛滋病毒感染的因素可以被認為是在三個層面上運作：

 個人和人際間關係（例如困難的家庭關係，最近具有壓力的事件）

 社區（例如，對風險採取予以常態化的環境，社區對感染者生活上的認知看法）

 結構性（例如愛滋病毒治療的可及性，娛樂性藥物的可獲性）。

他們總結道：「男男間性行為者當中近期感染愛滋病毒感染者反映了在不同層面上運作之一系列複雜因素網絡」。

每個層級之因素的相對重要性因人而異。他們給出了三個例子，說明每個人如何在多個層面上相互作用並導致他的愛滋病毒感染。 （在此圖中，A，B和C各代表不同的受訪者。）

  

 https://www.taiwanaids.org.tw/wp-content/uploads/2024/03/GC1JPYDUXA.jpg” alt=”” width=”670″ height=”691″ />https://www.taiwanaids.org.tw/wp-content/uploads/2024/03/0HNFOPMKW7.jpg” alt=”” width=”654″ height=”621″ />https://www.taiwanaids.org.tw/wp-content/uploads/2024/03/ZCI2B4FGR4.jpg” alt=”” />

在愛滋病毒感染的情況很複雜，因此需要多層次的介入措施，以解決個人和人際間心理-社會層面上，社區層面和結構層面上的風險因素」，研究人員說。他們說這種多層次的介入措施可能包括：

  改進臨床上的評估，以找到愛滋病毒陰性的男性且需要更多支持者

  為年輕男同性戀者量身訂製的心理-社會支持體系 

  將社會中被孤立的男性與同儕支持聯繫起來的外展活動 

  關於藥愛(chemsex)的社區教育

  透過培訓以協助衛生專業人員具備文化上能力與男同性戀者就藥愛和風險行為進行討論

  在交友軟體上提供諮詢介入措施

提升人們對愛滋病毒確診於社會和心理上意涵的認知相關的計劃

  暴露前預防性投藥( PrEP )的取得和可及

 

 

 

 

 

 

 

 

 

 

What is going on in gay men’s lives when they acquire HIV?

Combinations of factors at individual, community and structural levels contribute to risk behaviour and HIV infection

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Image of the adapted socio-ecological framework used in the study.

Roger Pebody; Published: 08 September 2017

Gay men in England who have recently become HIV positive describe a complex web of factors which may have contributed to their infection, according to a qualitative study recently published in BMJ Open.

“Individuals who experienced multiple stressors, gradually over the life course or more suddenly, were especially vulnerable to HIV and being drawn into sexual risk situations, while the social environment created a context that enabled risk of HIV infection,” the researchers write. Individual and interpersonal factors frequently combined with community or structural factors, such as the widespread use of dating apps, chemsex and HIV treatment, as well as changing perceptions of the seriousness of an HIV infection.

The study paints a picture of the personal and social contexts within which gay men are acquiring HIV in the UK. Each year, more than half of HIV diagnoses in the UK are in gay men.

The study

In early 2015, Annabelle Gourlay of University College London and colleagues recruited 21 gay men who had recently been diagnosed with HIV in London or Brighton and who had, tests showed, very recently acquired HIV (usually just a few weeks before diagnosis). They were interviewed on average six months after the estimated date they were infected. The researchers selected men infected recently on the assumption that they were more likely to recall accurately how they got infected than men who acquired HIV longer ago.

Participants were aged between 22 and 61 (median 38) and were mostly white, well educated and employed. The in-depth interviews covered personal background, moving to London/Brighton and experiences of this transition (if applicable), life in recent years before HIV diagnosis, relationships, and perceptions of the circumstances at the time of HIV infection. 

The researchers note two potential limitations of their study. Firstly, the experiences of white gay men in large urban centres may not be generalisable to men in other ethnic groups and geographical areas. Secondly, responses may have been limited by social desirability bias, in other words a tendency to answer questions in a way that will be viewed favourably by others.  

Individual and interpersonal factors

Many respondents described difficult experiences during childhood which had long-lasting impacts on mental health, drug use and support. Many described dysfunctional or superficial relationships with their parents, family members who had alcohol or mental health issues, or being bullied at school. One man said:

“My father was…an alcoholic and he used to beat my mother and me…That may have had some impact on how destructive one is, and the fact I never had any unconditional love is something that I have struggled with in adulthood.”

One man who said he had never ‘felt nurtured’ by his parents explained:

“I always need validation from people…and that manifests itself in a sexual context.”

A few men grew up in environments where gay men were highly stigmatised, which could result in repressed sexuality or low self-esteem. While most participants had ‘come out’ as teenagers or young adults, others only disclosed their sexual orientation in their twenties or thirties. In some cases, this was associated with resentment of having missed opportunities and a desire for sexual exploration.

“Growing up in an environment where you are getting to know yourself quite late, you get to…thinking about experiences and seeing other sexual stuff that you might not have needed to think about before because you are a bit behind…You know, am I missing out on stuff?”

Recent stressful events experienced before HIV diagnosis caused psychological distress for many participants. These included severe illnesses or deaths of relatives, relationship break-ups, violent partners, loss of friendships and health problems.

A number of men were exposed to multiple psycho-social risk factors and the combination could be devastating.

“I was probably overwhelmed, you know. I wasn’t in a stable place, I wasn’t in a stable relationship, I wasn’t stable financially and I had just suffered some pretty serious losses in terms of my immediate family. It was kind of all over the place really.”

Some men experienced a ‘mid-life crisis’.

“I mean it probably was the perfect storm you know, they [drugs] got me at a time…mid-forties when I wasn’t that secure, there were a few issues, I was looking for fun…it was an escape and it seemed at the time that it was…enjoyable.”

Emotional trauma could make men re-evaluate the potential costs of unsafe sex.

“I didn’t value my life… Because so much had happened and I’d been through so much in the past three, four, five years with…break ups and losing everything and emotional things and deaths and God knows what else, it almost becomes a bit “all my life has just been so crap anyway what’s the point, do I really care if I get it [HIV] anyway?”

Community and structural factors

Men were attracted to London and Brighton for their open-minded culture, freedom and social opportunities. Almost all had met partners at saunas, clubs, chill outs (parties often involving drugs and group sex) or cruising grounds. The temptations of the gay scene could be hard to resist.

“You go to Vauxhall [gay district in south London] on a Friday night as a gay man and don’t come home until five days later. I think there is so much to tempt young people these days, I include myself in that.”

Dating apps provided convenient access to multiple sexual partners for many participants, regardless of age. They could also introduce men to chill outs and chemsex, and some interviewees felt that they promoted promiscuity and irresponsibility. Several men recalled changes in the cultures of sex and drug use on the gay scene.

“Drugs have changed…there are more choices…GHB, mephedrone…which I was quite scared of in the beginning…but then it’s normalised in the gay scene and you just tend to do what other people do. Same thing goes for injecting. I mean these days it’s not seen as so scary.”

Interviewees, especially middle-aged and older men, described the shifting perception of HIV in the gay community.

“I think in London it’s almost got to the point where people are not that concerned about it anymore. It’s not looked at as a death sentence. I remember reading an article by a doctor, which I know a lot of gay people seem to have read…that he would rather have HIV than diabetes.”

Thanks to the availability of effective HIV treatment and good medical care, HIV was widely perceived to be a manageable condition. This affected behavioural norms and attitudes to risk.

“Everyone knows somebody positive now and knows that they’re fit and healthy and they take a few pills a day…That’s a huge factor in why so few people use protection anymore…because it has become a treatable illness…I think it changed everyone’s risk calculations, because even if the worst did happen, it was no longer the worst.”

Some of the younger participants made conscious choices to engage in condomless sex, including with HIV-positive partners who had an undetectable viral load. Several had used post-exposure prophylaxis (PEP) and a few had unsuccessfully tried to get pre-exposure prophylaxis (PrEP) from their sexual health clinic. (PROUD study results were first reported in October 2014 and the interviews were conducted in early 2015.)

Generally, many respondents felt that there was a sense of apathy towards risks and susceptibility to HIV in the gay community. They attributed this to the availability of HIV treatment and newer prevention options, the increasing understanding of undetectable viral load, declining stigma and changing perceptions of HIV.

A complex interplay of factors

While a few interviewees explained their infection in terms of a single factor, most participants thought that a combination of factors contributed to risk behaviours and HIV infection.

“The sex and the drugs and the apps all intertwined simultaneously and I can’t really say which one led to the other.”

The researchers note that there was often an interplay between individual, community and structural factors. For example, one man in his twenties felt that his self-harming sexual behaviours stemmed from childhood and a violent relationship with his mother, but also highlighted the role of the ‘abusive’ environment, including gay saunas.

“I think with the sex, I think it’s…environment, especially in South London. The increase of risk sex, chemsex, is becoming an epidemic, in my opinion. You hear of so many young gay men now who are positive…and through this lifestyle. It’s very hedonistic, really nasty…I think, subsequently, living in South London has made me get HIV.”

Psychological issues and drug use were often mentioned in combination. For example, a man in his forties identified the important factors in his HIV infection as:

“The drugs…but also depression because I didn’t care about taking risks…I gave up.”

Some participants who had experienced stressful events suggested that changing perceptions of HIV had consciously, or subconsciously, influenced their behaviour. Risk-benefit decisions were altered.

“When we were young adults, the fear of God was put into us. If you got it you died…Now it is manageable…you could live a normal life…I think the trauma I have gone through has changed what I perceive as real risk in life… There are far more important things…So it was a combination of all those different aspects, I had come to the conclusion that if I did become HIV-positive it wouldn’t be a big event in my life.” 

Conclusions

The researchers worked with a socio-ecological framework to guide their analysis. (See graphic here).  

https://www.taiwanaids.org.tw/wp-content/uploads/2024/03/JI82AO3U9I.jpg” alt=”” width=”662″ height=”599″ />

This suggests that the factors which may contribute to HIV infection can be considered to operate at three levels:

individual and interpersonal (e.g. difficult family relationships, recent stressful events)

community (e.g. an environment which normalises risk taking, community perceptions of life with HIV)

structural (e.g. the availability of HIV treatment, the availability of recreational drugs).

“Recently acquired HIV infection among MSM [men who have sex with men] reflects a complex web of factors operating at different levels,” they conclude.

The relative importance of factors at each level varied for each person. They give three examples, showing how for each person, factors at more than one level interacted with each other and contributed to his HIV infection. (In this graphic A, B and C each represents a different interviewee.)

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“The circumstances surrounding HIV acquisition are complex and therefore require multi-level interventions that address individual and interpersonal psycho-social, community and structural-level risk factors,” the researchers say. They say that such multi-level interventions might include:

improved clinical assessments to identify HIV-negative men who need more support

tailored psycho-social support for young gay men

outreach activities to link socially isolated men to peer support

community education about chemsex

training to help health professionals have culturally competent discussions with gay men about chemsex and risk behaviour

counselling interventions provided on dating apps

programmes to raise awareness of the social and psychological implications of an HIV diagnosis

access to PrEP. 

Reference

Gourlay A et al. A qualitative study exploring the social and environmental context of recently acquired HIV infection among men who have sex with men in South-East England. BMJ Open 7:e016494, 2017. (Full text freely available.)