Objective: Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however. Design: Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N = 174 209). Methods: Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes. Results: MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes. Conclusion: Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM's public visibility, it also reduces MSM's ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

To identify risk factors for hepatitis C among HIV-positive men who have sex with men (MSM), focusing on potential sexual, nosocomial, and other non-sexual determinants. Outbreaks of hepatitis C virus (HCV) infections among HIV-positive MSM have been reported by clinicians in post-industrialized countries since 2000. The sexual acquisition of HCV by gay men who are HIV positive is not, however, fully understood. Between 2006 and 2008, a case-control study was embedded into a behavioural survey of MSM in Germany. Cases were HIV-positive and acutely HCV-co-infected, with no history of injection drug use. HIV-positive MSM without known HCV infection, matched for age group, served as controls. The HCV-serostatus of controls was assessed by serological testing of dried blood specimens. Univariable and multivariable regression analyses were used to identify factors independently associated with HCV-co-infection. 34 cases and 67 controls were included. Sex-associated rectal bleeding, receptive fisting and snorting cocaine/amphetamines, combined with group sex, were independently associated with case status. Among cases, surgical interventions overlapped with sex-associated rectal bleeding. Sexual practices leading to rectal bleeding, and snorting drugs in settings of increased HCV-prevalence are risk factors for acute hepatitis C. We suggest that sharing snorting equipment as well as sharing sexual partners might be modes of sexual transmission. Condoms and gloves may not provide adequate protection if they are contaminated with blood. Public health interventions for HIV-positive gay men should address the role of blood in sexual risk behaviour. Further research is needed into the interplay of proctosurgery and sex-associated rectal bleeding.

Internalised homonegativity refers to a gay person's negative feelings about homosexuality and is believed to stem from negative societal stereotypes and attitudes towards homosexuality. Surprisingly, little research has centred on this link. In this research, we aimed to examine the associations between internalised homonegativity and structural forces, cultural influence, and access to sexual health promotion measures among a sample of 144,177 men who have sex with men (MSM) in 38 European countries. Participants were recruited as part of the European MSM Internet Survey (EMIS) during 2010. It was a self-completion, multilingual Internet-based survey for men living in Europe who have sex with men and/or feel attracted to men. Assumed causal relations were tested through multiple regression models. Variables at the structure of rule-systems (macro-level) that were significantly and negatively associated with internalised homonegativity were the presence of laws recognising same-sex relationships and same-sex adoption. In the meso-level model, greater proportions of the population expressing that they would not like to have homosexuals as neighbours predicted higher internalised homonegativity. In the last model, five variables were significantly and negatively associated with internalised homonegativity: being exposed to HIV/STI information for MSM, access to HIV testing, access to STI testing, access to condoms, and experience of gay-related hostility. In turn, men who had tested for HIV in the past year evidenced lower internalised homonegativity. This is the largest and certainly most geographically diverse study to date to examine structural and environmental predictors of internalised homonegativity among MSM. Our results show that one insidious consequence of society's stigma towards homosexuals is the internalisation of that stigma by gay and bisexual men themselves, thus, drawing attention to the importance of promoting social equity for self-acceptance around gay identity in building a positive sense of self.

Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). Although the literature on stigma and mental health has focused on interpersonal and individual forms of stigma, emerging research has shown that structural stigma is also associated with adverse mental health outcomes. However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association. To address these questions, we use data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n = 123,428), which assessed mental health (i.e., Patient Health Questionnaire) and psychosocial mediators (i.e., sexual orientation concealment, internalized homonegativity, and social isolation). We linked these data to an objective indicator of structural stigma related to sexual orientation-including 15 laws and policies as well as aggregated social attitudes-in respondents' countries of origin (N = 178) and receiving countries (N = 48). Among respondents who still live in their country of birth (N = 106,883), structural stigma was related to depression and suicidality via internalized homonegativity and social isolation. Among respondents who moved from higher-to-lower structural stigma countries (n = 11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators. This study provides additional evidence that stigma is a sociocultural determinant of mental health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Community-based opportunistic self-completion surveying for sexual health programming is common among men-who-have-sex-with-men (MSM) in Europe, being used to generate evidence of unmet prevention need, for behavioural surveillance and as a platform for advocating HIV precautions. However, comparing survey findings across Europe is difficult because of varying measures and recruitment designs, and surveying has not occurred in all countries. EMIS (the European Men-who-have-sex-with-men Internet Survey) aimed to develop a pan-European Internet survey on HIV-related male homosexual behaviours and prevention needs both to increase research capacity and to move towards harmonisation of existing systems. Six associated partners (APs) recruited another 77 collaborating partners from academia, public health and civil society across 35 countries. Partners’ existing MSM surveys were collected and collated, producing a meta-survey which was discussed by all partners through rotating round-tables at a 2-day summit. Survey development continued iteratively through user piloting and partner feedback until the English language content was agreed. Transfer to an online survey application was followed by further testing before on-screen translation into 24 other languages, final testing and sign-off. The project’s visual identity and promotional materials were developed in close collaboration with national leads, tailoring products to match country specific needs while maintaining an overall project identity. Five international MSM dating websites were contracted to send carefully crafted instant messages to members in a series of waves. The survey sought common ground with stakeholders and respondents by endorsing ‘the best sex with the least harm’ for MSM. Real-time monitoring of responses allowed targeted spending of the advertising budget to maximise coverage and depth of responses. Fieldwork occurred during June–August 2010. Over 184,469 responses were submitted of which 94.4 % were eligible. Partners in 38 countries were supplied with a national database of 100 or more respondents for national analysis and outputs, while the AP team proceeded on international comparisons among 174,209 respondents in 38 countries. EMIS demonstrated the feasibility of multi-country community-based MSM Internet surveying with limited public funding. The concept of ‘the best sex with the least harm’ provided a common ground for a diverse range of stakeholders to collaborate. Meaningful involvement of a large number of collaborators in the survey design, its visual identity and in promotional strategies ensured unprecedented coverage and depth of recruitment. Flexible planning was essential and a patchwork of recruitment was required across a range of commercial and community partners. Careful design, piloting and presentation ensured the survey was acceptable and had both authority and perceived community benefit.