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Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV
  1. G Elam1,
  2. N Macdonald2,
  3. F C I Hickson3,
  4. J Imrie4,5,
  5. R Power6,
  6. C A McGarrigle7,
  7. K A Fenton8,
  8. V L Gilbart7,
  9. H Ward2,
  10. B G Evans7
  1. 1
    Centre for Sexual Health and HIV Research, Royal Free and University College Medical School, London, UK
  2. 2
    Department of Infections Disease Epidemiology, Imperial College Faculty of Medicine, London, UK
  3. 3
    Sigma Research, University of Portsmouth, Portsmouth, UK
  4. 4
    National Centre in HIV Social Research, University of New South Wales, Sydney, Australia
  5. 5
    Africa Centre in Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
  6. 6
    The Centre for International Health, Burnet Institute for Medical Research and Public health, Melbourne, Australia
  7. 7
    Department of HIV and STIs, Health Protection Agency–Centre for Infections, London, UK
  8. 8
    National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, USA
  1. Gillian Elam, Centre for Sexual Health and HIV Research, Royal Free and University College London, Mortimer Market Centre, Mortimer Market, off Capper Street, London WC1E 6BT, UK; gillian{at}


Objectives: The INSIGHT case-control study confirmed that HIV serodiscordant unprotected anal intercourse (SdUAI) remains the primary risk factor for HIV infection in gay men in England. This paper uses qualitative follow-up data to examine the contexts of SdUAI and other risk factors among the case-control study participants.

Methods: In-depth interviews were conducted with 26 recent HIV seroconverters and 22 non-converters. Purposive selection was used to provide diversity in demographics and sexual behaviour and to facilitate exploration of risk factors identified in the case-control study.

Results: Condoms were perceived as barriers to intimacy, trust and spontaneity. The potential consequences of the loss of these were traded off against the consequences of HIV infection. Previous negative HIV tests and the adoption of risk reduction strategies diminished the perceived threat of HIV infection, supporting beliefs that HIV was something that happened to others. Depression and low self-esteem, often combined with use of alcohol or other drugs, led to further risk taking and loss of control over risk reduction strategies.

Conclusions: A range of psychosocial reasons led some men to engage in UAI with serodiscordant or unknown partners, despite high levels of risk awareness. Men in their mid-life, those in serodiscordant relationships and men that had experienced bereavement or other significant, negative, life events revealed factors related to these circumstances that contributed to increases in risky UAI. A diverse portfolio of interventions is required to build confidence and control over safer sex practices that are responsive to gay men’s wider emotional needs.

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  • ▸ Table 2 is published online only at

  • Funding: INSIGHT was supported by grant funding from the Medical Research Council (MRC) Sexual Health and HIV Research Strategy Committee (Strategic Grant Number G0100183). The study was co-ordinated by the Behavioural Surveillance and Research Unit at the Health Protection Agency Centre for Infections (CFI) London, in collaboration with clinicians, academics and researchers working with gay and bisexual men. The views expressed are those of the authors and not necessarily those of the MRC or the Department of Health.

  • Competing interests: None.

  • Ethics approval: Ethics approval provided by South West Multi-Centre Research Ethics Committee and the local Ethics Committees covering the participating clinic sites.

  • Contributors: GE conducted the qualitative component of INSIGHT, including fieldwork, analysis and reporting. NM was the study co-ordinator and conducted the case-control study. FH, JI, RP, CM, KF and VG were co-investigators and on the study steering group. HW was on the steering group. BE was the principal investigator.

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