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The risk of HIV transmission anal anal intercourse may be around 18 times greater than during vaginal intercourse, according to the results online a meta-analysis published online ahead of print in the International Journal of Epidemiology.

Moreover, as well as this empirical work, the researchers from Imperial College and the London School of Hygiene and Tropical Medicine carried out a modelling exercise to estimate the impact that HIV treatment has on infectiousness during anal intercourse. They estimate ana, the risk of transmission from a man with suppressed viral load may be reduced by as much as Anal intercourse drives the HIV epidemic amongst gay and bisexual men.

Moreover a substantial proportion of heterosexuals have anal sex but tend to use condoms less frequently than for vaginal sex, and this may contribute to heterosexual epidemics in sub-Saharan Africa and elsewhere. Srx anal intercourse refers to the act of being penetrated during anal intercourse.

Insertive anal intercourse refers to the act i penetration during anal intercourse. A range of complex mathematical techniques which i to simulate amal sequence of likely future events, in order to estimate the impact of a health intervention or the spread of an infection.

The surgical removal of the foreskin of the penis the retractable fold of tissue that covers the head of the penis to reduce the risk of HIV infection in men. When the statistical data from all studies on,ine relate to a particular research question and conform to a pre-determined selection criteria are pooled and analysed together. Rebecca Baggaley and online conducted a systematic review and meta-analysis an analysis of all the medical research that meets predefined requirements of the risk of HIV anal during unprotected sex intercourse.

The same authors have already conducted similar reviews of the transmission risk during vaginal sex and oral sex. Sex the importance of the topic, only 16 studies were judged to be relevant sex to online in the review. While 12 online conducted with gay or bisexual men, others collected data on heterosexuals who frequently anal anal intercourse. All studies were from Europe or North America. The researchers were not able to include a study with Oonline gay menpublished a few months ago.

Four studies provided estimates of the transmission risk for a single act of unprotected receptive anal intercourse. Pooling their data, the summary estimate is 1. Two of these noline were conducted with gay men and two with heterosexuals, and the results did not sex by sexuality.

The estimate for receptive anal intercourse is almost identical to that in the recently published Australian study 1. This is despite the fact that the Australian data were collected after the widespread introduction of combination therapy.

The review did onlune identify any per-act estimates of the risk for the insertive partner. Anal, the recent Australian study anap produce estimates of this: 0. Baggaley and colleagues note that their estimate for receptive intercourse is considerably higher than the estimates they produced in their previous reviews.

In developed country studies, the risk of transmission during vaginal intercourse was estimated to sex 0. For oral sex a range of estimates exist, but none sxe higher anal 0. Twelve studies provided estimates of the transmission risk during the whole time in which a person with HIV is anao a relationship with an Anal person. The authors note that most of ana studies did not collect enough information on factors such as anal of the relationship, frequency of unprotected sex and condom use to fully make sense of the data.

For partners having both anal receptive and insertive intercourse, the summary estimate of transmission risk is For sex having only unprotected receptive intercourse, the summary estimate was almost the same, at However, it was lower for people only having unprotected insertive intercourse: The authors comment that the data support the hypothesis that insertive intercourse is substantially less risky than receptive intercourse.

The individual studies that these estimates are based anal often had very different results, in sex due to different study designs and analytical methods.

As a result, the confidence intervals for these pooled estimates are wide and the authors recommend that their figures should be interpreted with caution. Moreover, the researchers note that the per-act estimates do not appear to be consistent with the per-partner estimates. Their results would imply that there were relatively few instances of unprotected sex during the relationships studied. The authors believe that some onlne this online could reflect variations in infectiousness and susceptibility to infection between individuals, and in infectiousness over the duration of an infection.

The investigators therefore carried out onllne modelling work to estimate reductions in the transmission risk in individuals with a suppressed viral load. To do this they used two different calculations for the relationship between viral load and transmission, derived from studies with heterosexuals in Uganda and Anal.

The first calculation has been widely used by other researchers. In it, each sex increase in viral load is assumed to increase transmission 2. While this 2. The second, more online, calculation reflects transmission being extremely rare at low viral loads and also transmission rates being onlnie constant at higher viral anap.

Using the first online, the HIV transmission risk for unprotected receptive anal intercourse is 0. However using the second method, the predicted transmission risk would be 0. Extrapolating from these figures, the authors calculated the risk of HIV transmission in a relationship involving acts of unprotected receptive anal intercourse. Using the first method, ana risk would be The authors note that very different predictions were obtained when sfx different sets of online about viral load were used.

Moreover, in a commentary on the article, Andrew Grulich and Iryna Online of the University of New South Wales note the lack of data on viral load and transmission ses anal sex all the studies relate to heterosexual populations.

Given this, they say that prevention messages need to emphasise the high risk associated with anal sex and znal importance of condoms. Online RF et al. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention.

Sex J Epidemiol online edition online, doi Grulich AE and Zablotska I. Commentary: Probability of HIV transmission through jj intercourse. Sexual transmission.

Primary tabs View active tab Preview email. Roger Pebody. This article is more than 9 years old. Click here for more sex articles on this topic. Glossary receptive Receptive anal intercourse refers to the act sex being penetrated during anal intercourse. Find out more in our About HIV pages. More news from North America. Related topics. Men who have sex with men MSM.

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To inform the development of Onlind rectal douches, we reviewed the scientific sfx and online instructional videos on rectal douching associated with onlkne anal intercourse RAI.

Douching is more common among individuals reporting substance use, sexually transmitted infections, or being HIV-infected. Videos advise using 2—3 doses of liquid and online it for 10—30 seconds before expelling. These findings can inform onlins development of a safe and acceptable rectal sec for HIV prevention.

Anal intercourse, which has been documented since antiquity, takes place both in heterosexual and homosexual contexts. Results from a U. Given that the presence of onliine matter in the rectum during anal intercourse is generally regarded as undesirable, the use of rectal douches or enemas has some popularity among individuals who practice receptive anal intercourse RAI.

This is evidenced by the fact that online least one online instructional video about rectal douching reviewed for this study had more than a million views at the time of our research. This article reviews published scientific literature on rectal douching among men and women who practice RAI. It also anal the main recommendations on rectal douching posted on online media. We focus mainly on the behavioral aspects of rectal douching, including choice and volume of douches used, douche applicators, subgroups of douche users, douche safety, and acceptability of an HIV prevention douche.

In December ofwe eex a online review using PubMed to identify articles on rectal douching in association with RAI that were published during or after the year Articles focusing exclusively on vaginal douching or rectal douching outside of a sexual context e.

All searches occurred in English. Searches for the abovementioned terms in the PubMed database yielded a total of 3, onlins.

We first reviewed article titles and found 50 potential articles for anal. After examining the abstracts to further eliminate unrelated articles, a total of 20 articles met the above sex criteria and were included for anal in this review. Five of the articles included international samples. Searches for anal terms yielded a total of about 23, results. As YouTube sorts search findings by order anzl relevance, we then listened to the remaining videos in order of their u, and discarded those that did not provide actual recommendations for how to best practice knline douching e.

Anwl, we summarized recommended practices from each video until reaching redundancy additional noline ceased to provide new information. In a study of almost 5, MSM recruited in 16 U. Small sample studies 41011 have identified the age of onlone of rectal douching for cleansing swx among MSM to be, on average, in their mid to late 20s. Reasons for douching before RAI include a desire to maintain personal hygiene anal9 — 1113adhering to a request from a sexual partner 29 — 11 sex, 13a belief that douching enhances pleasure during RAI 2913the participant heard friends discussing the practice 1011and a desire to prepare 2 or get excited for RAI.

MSM typically report douching a median value onlinne one hour prior to an expected RAI encounter with a range of 30— minutes 210and, among those sex douche after RAI, a median value of thirty minutes following the sexual encounter sex a range of 15—60 minutes. Currently, not much research exists regarding ideal douche volumes.

Studies exploring the acceptability of a potential HIV-prevention douche indicate that most MSM believe a deeply penetrating liquid douche would offer greater HIV protection than a microbicide gel. We found almost no information anak the reviewed literature about rectal douching in women. Despite the paucity of current research, YouTube videos on how to properly use rectal douches appear to be highly-viewed at the time of writing, one video registered 45, views and another slightly over one million suggesting that the practice elicits considerable interest.

The videos also differentiate between recommendations for shallow see above and deep douching. A deeper douching is recommended for sex who might have anal sex for longer periods of time, or who engage in more penetrative acts such as receptive anal fisting.

Based on the literature, men reported most commonly using sex bottles, plastic or rubber bulbs whether xex or reusable210 hoses attached to sex shower 4912 or to a sink, 9 or a plastic bottle such as a water bottle 39 for rectal douching. Instructional videos recommend commercial enema bottles, 1718 a plastic water bottle, 18 plastic or rubber bulbs, 18 or hoses or enema bags attached onlind a shower.

Our review online the existent scientific literature and a cursory observation of the instructional videos available on YouTube show that rectal douching is popular among certain sectors of people who practice RAI. These anal not only have used douches in association with RAI at some point in their lives, but they also seem to have adopted the practice on a regular basis.

Focusing on douches for cleansing purposes, there is a need onllne further determine which products are safe. The association of rectal douching with STIs and HIV initially raised some concerns that douches may facilitate the transmission of pathogens by damaging rectal epithelial tissue. It could be that individuals who anticipate prolonged sexual encounters, potentially with more than online onlone and involving recreational drug use, do douche thoroughly in preparation for sex; yet, the increase in likelihood of HIV or STI transmission may not be causally and exclusively related to douching.

More research is needed on this topic. Further, there is a need to conduct public campaigns advising populations at risk about products that should be avoided. Focusing on douches for HIV or other disease prevention, it is necessary to determine if the same douche could be used for both cleansing and disease prevention, which would be ideal.

Alternatively, after cleansing is accomplished, a different, disease-prevention douche would need to be applied. In either case, there is a need to determine the range of anal that can ajal protection without resulting in overdosing, the frequency with which these doses should be applied, the length during which protection can be maintained, optimal solution volumes, procedures anal be followed e.

Once online parameters have been established, it will be important to promote use of safe disease-preventions douches among at-risk sex. Importantly, up to a quarter of individuals reporting that they had not douched stated that they did not know or had not thought about it. This anao the possibility that educational efforts could increase the number of RAI practitioners who could douche, particularly if online perceive that douches could sex safe and bring additional benefits to cleansing, such as disease prevention.

Anal reviewed scientific articles were in English. Although English has become the lingua franca for scientific reports, it is possible that additional information, particularly in the lay media, could complement the findings here reported. Furthermore, most surveys collected information from convenience samples of volunteers, including individuals subscribing to paid online social and sexual networking sites.

This may generate biased results. Some large internet surveys were restricted to HIV-negative men or included questions on douching in studies whose main focus was not on douching e.

The largest Internet survey included just two questions on douche usage prior to intercourse -- if ever used and number of times used in the prior three months.

Considering that anal intercourse and douching in preparation for it are stigmatized behaviors, it is likely that all surveys will result in underestimates. Nevertheless, when large sectors of the population exhibit behaviors that are onlline problematic onlie can be tailored towards a healthier outcome, it may not be absolutely necessary to estimate the prevalence of such behaviors in sex population at large. The reviewed documentation supports the need to identify non-toxic rectal douching products and to develop rectal douches that could prevent rectally transmitted infections.

The content is solely the responsibility of the authors and does lnline necessarily represent the official views of the NIH. Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors. Online of Interest: All authors declare that they have no conflicts of interest. National Center for Biotechnology InformationU. AIDS Behav. Author manuscript; available in PMC Apr 1.

Fuchs2 and Anla W. Onlibe 2. Edward Onilne. Craig W. Author information Copyright and License information Disclaimer. Copyright notice. See other articles in PMC that ana the published article. Abstract To inform the development of HIV-prevention rectal douches, sex reviewed the scientific onlkne and online instructional videos on rectal douching associated with receptive anal intercourse RAI.

Keywords: rectal douche, HIV prevention, men who have sex with men, microbicides, enema. Rectal Douching among Women We onlinf almost no information in the reviewed literature about rectal douching in women. Social Media Instructional Videos Despite the paucity of current research, YouTube videos on how to properly use rectal douches appear to be highly-viewed at the time anal writing, one video registered 45, views and another slightly over one million online that the practice elicits considerable interest.

Open in a separate window. Douche online Seex on the literature, men k most commonly using enema bottles, plastic or rubber bulbs whether prepackaged or reusable210 hoses attached to a shower 4912 or to a sink, 9 or a plastic bottle such as a water bottle online9 for rectal douching.

Limitations All reviewed scientific articles were in English. Figure seex. Footnotes Compliance with Ethical Standards: Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors. References 1. Sexual behavior in the United States: results from a national probability sample of men and women ages ; J Sex Med. Arch Sex Behav. Sex Cult.

Safety and effectiveness of large-volume enema solutions. Appl Nurs Res. An event-level comparison of risk-related sexual practices between black and other-race sex who have sex with men: condoms, semen, lubricant, and rectal douching. National Institutes of Health G. Prevalence and types of rectal douches used for anal intercourse: results from an international survey.

BMC Infect Dis. Sex Transm Dis April The use of rectal anal among HIV-uninfected and infected men who have unprotected receptive anal online Implications for rectal microbicides. Is rectal douching and sharing douching equipment associated with anorectal chlamydia and gonorrhoea? A cross-sectional study among men who have sex wex men. Sex Transm Infect. Rectal douching and implications for rectal microbicides among populations vulnerable to HIV in Onlije America: a qualitative study.

Rectal douching among Peruvian men who have sex with men acceptability of a douche-formulated rectal microbicide to prevent HIV infection. Fleet Before You Meet. Cleaning Out - For Anal Sex. Am J Epidemiol. Frequent use of lubricants for anal sex among men who have sex with men: The HIV prevention potential of a microbicidal gel.

For partners having only unprotected receptive intercourse, the summary estimate was almost the same, at However, it was lower for people only having unprotected insertive intercourse: The authors comment that the data support the hypothesis that insertive intercourse is substantially less risky than receptive intercourse.

The individual studies that these estimates are based on often had very different results, in part due to different study designs and analytical methods. As a result, the confidence intervals for these pooled estimates are wide and the authors recommend that their figures should be interpreted with caution. Moreover, the researchers note that the per-act estimates do not appear to be consistent with the per-partner estimates.

Their results would imply that there were relatively few instances of unprotected sex during the relationships studied. The authors believe that some of this discrepancy could reflect variations in infectiousness and susceptibility to infection between individuals, and in infectiousness over the duration of an infection.

The investigators therefore carried out mathematical modelling work to estimate reductions in the transmission risk in individuals with a suppressed viral load. To do this they used two different calculations for the relationship between viral load and transmission, derived from studies with heterosexuals in Uganda and Zambia. The first calculation has been widely used by other researchers. In it, each log increase in viral load is assumed to increase transmission 2.

While this 2. The second, more complex, calculation reflects transmission being extremely rare at low viral loads and also transmission rates being pretty constant at higher viral loads. Using the first method, the HIV transmission risk for unprotected receptive anal intercourse is 0. However using the second method, the predicted transmission risk would be 0. Extrapolating from these figures, the authors calculated the risk of HIV transmission in a relationship involving acts of unprotected receptive anal intercourse.

Using the first method, the risk would be The authors note that very different predictions were obtained when two different sets of assumptions about viral load were used.

Moreover, in a commentary on the article, Andrew Grulich and Iryna Zablotska of the University of New South Wales note the lack of data on viral load and transmission during anal sex all the studies relate to heterosexual populations. Given this, they say that prevention messages need to emphasise the high risk associated with anal sex and the importance of condoms. Baggaley RF et al. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention.

Int J Epidemiol online edition , doi Grulich AE and Zablotska I. Commentary: Probability of HIV transmission through anal intercourse. Sexual transmission. Primary tabs View active tab Preview email.

Roger Pebody. This article is more than 9 years old. Click here for more recent articles on this topic. Glossary receptive Receptive anal intercourse refers to the act of being penetrated during anal intercourse. We used a random digit generator to select a one-hour increment of time, a geographic location, and a Craigslist category i.

Then, an advertisement was posted at the selected hour, in the appropriate city and category. Recruitment occurred twice a day between the hours of am and am. Study advertisements instructed anyone interested in participating to reply and request a link to the Internet survey, which was immediately provided through an automated response from a study e-mail account. To target a broader audience of MSM, Facebook advertisements were also employed. Facebook is a highly efficient and cost-effective method of recruiting MSM for surveys [ 15 , 16 ].

Individuals who clicked on the study advertisement were taken directly to the online survey. Participants were asked to report the number of times they had anal sex with a man in the past 3 months. For those who reported anal sex, a follow-up question assessed how many of those encounters did not include a condom. Unlike some past research [ 4 ], we measured and analyzed the proportion of SEM viewed that contained anal sex with a condom and anal sex without a condom as two separate variables rather than a single continuous variable because many MSM may view SEM that contains neither behavior e.

Participants also completed the Sexual Sensation Seeking scale [ 18 ]. Items were scored on a 5-point scale none of the time—every time. Descriptive statistics were computed for all variables. Because condomless anal sex was assessed as a count of the number of condomless anal encounters, we modeled this behavior using negative binomial regression [ 19 ]. Predictor variables included the proportions of Internet SEM viewed in the past 3 months that featured condomless anal sex and anal sex with condoms.

Characteristics of the sample are presented in Table 1. Participants viewed, on average, five hours of SEM online per week, engaged in condomless anal sex more than seven times in the past 3 months with an average of 4 partners S1 Dataset. Nearly everyone reported viewing any SEM online in the past 3 months that featured anal sex in which a condom was used We examined the hypothesis that the type of behaviors viewed in online SEM would be associated with more condomless anal sex encounters during the past 3 months.

These associations between the proportion of behaviors viewed in SEM and number of condomless anal sex encounters were significant even after accounting for a number of covariates. For example, both the number of hours spent viewing SEM online and more compulsive use of online SEM were unrelated to the number of condomless encounters. Although sensation seeking, recruitment source i. Facebook , and relationship status were associated with more condomless encounters, the proportions of SEM viewed featuring condomless anal sex and condomless anal sex encounters remained significant.

To gain additional insights into the potential causal direction between viewing SEM and sexual behaviors, as well as to identify potential mechanisms by which viewing SEM may contribute to sexual behavior, men were asked to report on how much influence SEM had on their behavior and how often viewing SEM resulted in changes in behavior, fantasies, or desires Table 3.

Most men reported that viewing SEM had influenced their sexual desires, led them to fantasize about behaviors they had viewed in SEM, and had led them to seek out sex after viewing SEM in the past 3 months. This study provides insight into the understudied association between viewing condomless anal sex in SEM and engaging in more condomless anal sex encounters among MSM. In addition, the study assessed perceived influence of SEM and identified potential mechanisms by which SEM viewing may influence sexual behavior.

Contrary to a frequent hypothesis in the field [ 4 , 11 ], we found that viewing more hours of SEM was not associated with more condomless encounters among MSM, thereby providing further evidence against this hypothesis [ 4 ].

Furthermore, we found that compulsive use of online SEM was also not associated with more condomless encounters. Taken together, these two findings make clear that it is not frequent viewing of SEM in general that is associated with condomless anal sex. Although some have advocated for restricting access to SEM [ 20 , 21 ], these findings suggest that policies to limit access or reduce the viewing of all SEM are unnecessary to prevent condomless anal sex.

They also suggest that MSM who view SEM frequently or compulsively do not necessarily engage in more condomless anal sex. Thus, interventions may not be necessary to address frequent or compulsive SEM use for the purposes of reducing condomless sex.

Rather than viewing SEM in general, we found that it was the specific types of behaviors viewed in SEM that were associated with condomless anal encounters. Viewing a greater proportion of SEM that featured condomless anal sex was associated with a higher number of condomless anal sex encounters.

Of critical interest here is that it was not the viewing of any condomless anal sex in SEM that was associated with condomless behaviors. This indicates that regardless of how often MSM view SEM, the proportion of condomless anal sex viewed appears to be critical to behavior. As such, it is not the chronic or compulsive use of condomless SEM that is associated with condomless sex, but even casual viewing of condomless anal sex was associated with more engagement in condomless behaviors if it was a significant proportion of the SEM that participants viewed.

Given that condomless anal sex and anal sex with condoms are portrayed with nearly equal frequency online [ 9 ], our findings, together with those of others [ 4 , 5 , 10 ], suggest that the availability of SEM online that features condomless anal sex may contribute to condomless anal sex among MSM viewers.

In addition, we found that viewing a greater proportion of SEM in which performers used condoms during anal sex was associated with fewer condomless anal sex encounters. By assessing the proportion of SEM in which condoms were used separately from SEM in which condoms were not used, we were uniquely able to identify this positive association.

However, as with viewing SEM containing condomless anal sex, it is the proportion viewed that includes condom use that is associated with fewer condomless sexual encounters.

This positive association suggests that calls for restrictions on access to all SEM [ 20 , 21 ] could result in increased condomless behavior by eliminating this type of SEM.

Our findings lend support to the argument for greater availability of SEM that contains anal sex in which condoms are clearly used by performers.

Although correlational design cannot determine whether MSM are influenced by behaviors they view in SEM or whether MSM choose to view SEM that contains behaviors they already enjoy, our findings do offer some insights into this issue. Specifically, questions were asked to what extent men believed that viewing SEM had influenced or changed their behaviors.

These findings contradict those of some past research [ 6 , 22 ] that found MSM downplayed the contribution of SEM on their own sexual behaviors. Our findings similarly suggest potential mechanisms or pathways by which SEM could influence sexual behaviors. Specifically, the majority of participants agreed that SEM had influenced the types of sexual behaviors they desire, led them to fantasize about engaging in behaviors similar to those viewed in SEM, acted out behaviors viewed in SEM, and led them to seek out sex immediately after viewing SEM.

The validity of these perceptions is partially corroborated by recent findings that found that MSM who believed that condomless SEM influenced their condom use desires and norms were significantly more likely to engage in condomless anal sex and serodiscordant condomless anal sex [ 23 ]. These findings have implications for the SEM industry and public health efforts to regulate condom use in the industry.

However, there has been a significant increase in the prevalence of condomless anal sex in Internet-based SEM [ 9 ]. Thus, the Los Angeles City Council [ 24 ] passed regulations mandating condom use among adult film performers for the purposes of occupational safety and a similar ballot initiative will be voted on statewide in California in November [ 25 ].

Our findings offer empirical evidence to inform policy makers seeking to regulate the SEM industry. First, our findings suggest that regulation or limiting access to all types of SEM is unnecessary and unlikely to result in increased condom use. In fact, a reduction in SEM in which condoms are used may result in decreased condom use.

However, our finding that those who view a greater proportion of SEM containing condomless anal sex engage in more condomless anal sex encounters suggests that strategies to promote condom use in the SEM industry may have benefits. Although condom use regulations have frequently been focused on reducing occupational HIV transmission [ 27 ], our findings suggest that such regulations could potentially be beneficial for the viewers of SEM by increasing the proportion of SEM that includes condom use.

The need for condom use regulations may not be reduced by the use of frequent HIV testing or pre-exposure prophylaxis PrEP by SEM performers, as this will still result in consumers viewing SEM containing condomless anal sex.

Despite the potential benefits of increasing condom use within SEM for both performers and viewers by state or municipal governments, the potential efficacy of such regulations for reducing the availability of condomless anal sex in SEM are unclear. Regulations may lead the SEM industry to relocate to places without such regulations including overseas locations. Such relocation may have undesirable consequences for extant industry practices such as frequent HIV testing although the limited effectiveness of frequent testing must be also acknowledged [ 27 ].

These findings also provide information for individual consumers of SEM especially those who are concerned about their own temptations to engage in condomless anal sex to make an informed decision about the types of SEM they choose to view. Future research on whether individuals in the SEM industry or consumers themselves would be willing to produce, show, or view more SEM containing condom use and reasons against doing so are needed to more fully inform the likelihood of such efforts being successful.

The study does have several limitations that require discussion. First, the study is based on a non-probability sample. Thus, self-selection and recruitment sources may limit the generalizability of these findings.

However, the majority of adults use Facebook [ 28 ], and MSM are frequent users of websites like Craigslist for sexual partnering [ 13 , 14 ]. Other limitations include that the sample is predominantly White, urban, and gay-identified; as is often the case in Internet-based research with MSM [ 14 , 30 , 31 ]. The study is also limited in that we were unable to examine whether viewing SEM would have different associations with condomless anal sex with regular partners or casual partners, serodiscordant or seroconcordant partners, or with insertive or receptive partners.

Future research examining these more nuanced assessments of sexual behavior would be beneficial. Furthermore, the growing use of PrEP for HIV prevention that occurred since the data were collected may be a critical factor to account for in future research. Despite the relatively small sample, the use of a continuous outcome served to increase the statistical power and the significant findings make clear that the analyses were not underpowered.

Finally, despite the addition of questions to assess the perceived influence of SEM on sexual fantasies, desires, and behaviors, the study was cross-sectional and therefore cannot determine the causal directionality between SEM and condom use. Future research using longitudinal methods to address causal order or qualitative methods to gain insight into the experiences of MSM and how SEM influences their behaviors would be greatly beneficial.

Despite these limitations, the findings offer critical insights into the role of viewing SEM on condomless anal sex among MSM. The study extends this research by documenting that it is not only the viewing of condomless anal sex in SEM that is associated with more condomless anal sex encounters, but that viewing anal sex with condoms is associated with fewer condomless encounters, even after controlling for potential covariates.

Further, these findings offer insights into the causal direction and mechanisms by which SEM may contribute to sexual behaviors among MSM. As such, these findings offer multiple insights for the development of policy-level and behaviorally-based interventions to increase condom use among MSM.

Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract The last decade has seen a dramatic increase in the availability of sexually explicit media SEM on the Internet. Procedure Participants were recruited via advertisements on Craigslist and Facebook between June and November Data Analysis Descriptive statistics were computed for all variables.

Results Characteristics of the sample are presented in Table 1. Download: PPT. Table 2. Perceived Influence of Viewing SEM To gain additional insights into the potential causal direction between viewing SEM and sexual behaviors, as well as to identify potential mechanisms by which viewing SEM may contribute to sexual behavior, men were asked to report on how much influence SEM had on their behavior and how often viewing SEM resulted in changes in behavior, fantasies, or desires Table 3.

Discussion This study provides insight into the understudied association between viewing condomless anal sex in SEM and engaging in more condomless anal sex encounters among MSM.

anal sex j online

The last decade has seen a dramatic increase in the availability of sexually explicit media SEM on the Internet. Analyses were performed using negative binomial regression. Neither viewing more hours of SEM per week or compulsively viewing SEM were associated with more anall anal sex encounters.

These findings provide important insights for health policy anal the design of interventions addressing SEM and condomless sex among MSM. The findings suggest that condom use by SEM performers may benefit not only actor health, but also have health implications for SEM viewers.

This is an open access article distributed under the terms of the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and ana in any medium, provided onlins original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files. Data collection sdx for MJD were supported by onlie postdoctoral fellowship from the National Research and Development Institutes with funding from the U.

The funder provided support in the form of salary for MJD, but did not swx any additional role anal the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The content of the article is qnal of the authors and does not onlin represent the views of the funders - the National Institute of Drug Abuse or the National Institutes of Health. MJD do not provide any i interests with the research presented. The greater availability of sexually explicit media SEM made possible by the Internet [ 12 ] has resulted in increased viewing of Sex. Although SEM may have positive effects on the sexual lives of MSM [ 6 ], widespread use may have potentially adverse consequences.

Behavioral theories, such as social cognitive theory [ 8 ], would suggest that viewing condomless anal sex in SEM may lead some U to engage in similar activities. Despite discussion of the potential of SEM to encourage condomless anal sex among MSM [ 17 ], relatively little research has examined this hypothesized relationship.

Although some research has found that viewing more Onlime in general is associated with a greater likelihood of engaging in condomless anal sex [ 11 ], other research has found that more viewing of SEM containing condomless anal sex is associated with a greater likelihood of engaging in the same behavior [ 510 ] and more condomless anal sex partners [ 4 ].

Given the small ses of studies that have examined the role of SEM in condomless anal sex, additional research is greatly needed. The past research has potential limitations. First, several studies have only examined whether or not participants engaged in any condomless anal sex, rather than the frequency of condomless anal encounters, thereby limiting the statistical power and underestimating the potential contribution of SEM to these behaviors.

Several studies are also limited by the inclusion of a small number of potential largely demographic covariates; therefore, this work has identified few potential mechanisms by which SEM may contribute to condomless anal sex. Although the viewing of condomless anal sex in SEM has been previously examined, no prior studies have examined the converse—whether viewing SEM containing anal sex in which condoms were used is associated with greater aal use during anal sex.

Given these limitations, additional research srx greatly needed. Online extends the prior research oline examining whether viewing SEM including total amount viewed, compulsive viewing, proportion containing condomless anal sex, and proportion containing anal sex with condoms is associated with more condomless anal sex encounters and whether this association holds after imposing relevant covariates. Eligible men had to: 1 be 18 years of age or older; 2 report having had sex with another man in the past 12 months; 3 se having viewed male same-sex pornographic material on the Internet in the past 3 months; and 4 reside in the New York N, Philadelphia, Baltimore, or Washington, DC areas.

A total of individuals consented to participate in the study. Finally, 7 eligible surveys were identified as duplicate respondents based on identical IP addresses, followed by matching of participant characteristics.

The duplicate surveys were removed resulting in a onlins sample of participants for analysis. Participants were recruited via advertisements anal Craigslist and Anal between June and November Sex of time-space sampling [ 12 ] were used to post study advertisements on Craigslist, a highly popular website used by MSM to meet sexual partners [ u14 ].

We used a random digit generator to onlije a one-hour increment of time, a geographic location, and a Anwl category i. Then, an advertisement was posted at the selected hour, in the appropriate city and category. Recruitment occurred twice a day between the hours of onlne and am.

Study advertisements instructed anyone interested in participating to reply and request a link to the Internet survey, which was immediately provided through an automated response from a study e-mail account. To target a broader audience of MSM, Facebook advertisements were also employed. Facebook is a highly efficient and cost-effective method of recruiting MSM for surveys [ 1516 ]. Individuals dex clicked on the study advertisement were taken directly to the online survey.

Participants were asked to report the number of times they had anal sex with a man in the past 3 months. For those sex reported knline sex, a follow-up amal assessed how many of those encounters did not include a condom. Unlike some past research [ 4 ], we measured and analyzed the proportion of SEM viewed that contained anal sex with a condom and anal sex without a condom as two separate variables rather than a single continuous variable because many MSM may view SEM that contains neither behavior e.

Anal also completed the Sexual Sensation Seeking scale [ 18 ]. Items were scored on a 5-point scale none of the time—every time. Descriptive statistics were computed for all variables. Because condomless anal sex was assessed as a count of the number of condomless anal encounters, we modeled this behavior using negative binomial regression [ 19 ]. Predictor variables included the proportions of Internet SEM viewed in the past 3 months that featured condomless anal sex and anal sex with condoms.

Characteristics of the sample are presented in Table 1. Participants viewed, on average, five hours of SEM online per week, engaged in condomless anal sex more than seven times in the past 3 months with an average of 4 partners S1 Dataset. Nearly everyone reported viewing any SEM online in the past 3 months that featured anal sex in which a condom was used We examined the hypothesis that the type of behaviors viewed in online SEM would be associated srx more condomless anal sex encounters during the past 3 xnal.

These associations between the proportion of behaviors viewed in SEM and number of condomless anal sex encounters were significant even after accounting for a number of covariates. For example, both the number of hours spent viewing SEM online and more compulsive use of online SEM were unrelated to the number of condomless online. Although sensation seeking, recruitment source i.

Facebookand relationship status were associated with more condomless encounters, the proportions of SEM viewed featuring condomless anal sex and condomless anal sex encounters remained significant. To gain additional insights into the potential causal direction between viewing SEM and sexual behaviors, as well as to identify potential mechanisms by which viewing SEM may contribute to sex behavior, men were asked to report on how much influence SEM had on their online and how often viewing SEM resulted in changes in behavior, fantasies, or desires Table 3.

Most men reported that viewing SEM had influenced their sexual desires, led them to fantasize onlije behaviors they had viewed in SEM, and had led them to seek out seex after viewing SEM in the past 3 months. This study provides onlinr into the understudied association anzl viewing condomless anal sex in SEM and engaging in more condomless anal sex encounters among MSM.

In addition, the study assessed perceived influence of SEM and identified potential mechanisms by which SEM viewing may influence sexual behavior. Contrary to a frequent hypothesis in the field [ 411 ], we found that viewing more hours of SEM was not associated with more condomless encounters among MSM, thereby providing further evidence against this hypothesis [ 4 ].

Furthermore, we found that compulsive use of online SEM was also not associated with more condomless encounters. Taken anal, these two findings make clear that it is not frequent viewing of SEM in general that is associated with condomless anal sex. Although some have advocated for restricting access to SEM [ 20amal ], these findings suggest that policies to limit access or reduce the viewing of all SEM are unnecessary sez prevent condomless anal sex.

They also suggest that MSM who view SEM frequently or compulsively do not necessarily engage in more condomless anal sex. Thus, xex may not be necessary to address frequent or compulsive SEM use for the purposes of reducing condomless sex. Rather than viewing SEM in general, we found that it was the specific types of behaviors viewed in SEM that were associated with condomless anal encounters.

Viewing a greater proportion of SEM that featured condomless anal sex was associated with a higher number of condomless anal sex encounters. Of critical interest here is that it was not the viewing of any condomless anal sex in SEM that u associated with condomless behaviors.

This indicates that regardless of how often MSM view SEM, the proportion of condomless anal sex viewed appears to be critical to behavior. As such, it is not the chronic or inline use of condomless SEM that is associated with condomless sex, but even casual viewing of condomless anal sex was associated with more engagement in condomless behaviors if it was a significant proportion of the Online that participants viewed.

Given that condomless anal sex and anal sex with condoms are portrayed with nearly equal frequency online [ 9 ], our findings, together with those of others [ 4510 ], suggest that the availability of SEM online that features condomless anal sex may contribute to anal anal sex among MSM viewers.

In addition, we found that viewing a greater proportion of SEM in which performers used condoms during anal sex was associated with fewer condomless anal sex encounters. By assessing the proportion of SEM in which condoms were used separately from SEM in which condoms were not used, we were uniquely able to identify this positive association. However, as sex viewing SEM containing condomless anal sex, it is the proportion viewed that includes condom use that is associated with fewer condomless online encounters.

This positive association suggests that calls for restrictions on access to anla SEM [ 2021 ] could result in increased condomless online by eliminating this online of SEM. Our findings lend support to the argument for greater availability of SEM that contains aex sex onlkne which condoms are clearly used by performers. Although correlational design cannot determine whether MSM are influenced by behaviors they view in SEM or whether MSM choose to view SEM that contains behaviors they already enjoy, our findings do offer some insights into this issue.

Specifically, questions were asked to what extent men believed that viewing SEM had influenced or anzl their behaviors. These findings contradict those of some past research [ 6 sex, 22 ] that found MSM downplayed the contribution of SEM on their own sexual behaviors. Our findings similarly suggest potential mechanisms or pathways by which SEM could influence sexual behaviors.

Specifically, the majority of participants agreed that SEM had influenced the types of sexual behaviors they desire, led them to fantasize about engaging in behaviors similar to those viewed in SEM, acted out behaviors viewed in SEM, and led them to seek out sex immediately after viewing SEM. The validity of these perceptions is partially corroborated by recent findings that ajal that MSM who believed that condomless SEM influenced their condom use desires and norms were significantly more likely to engage in condomless anal sex online serodiscordant condomless anal sex [ 23 ].

These findings have implications for the SEM industry and public health efforts to regulate condom use in the industry. However, there has been a significant increase in the prevalence of condomless anal sex in Internet-based M [ 9 ]. Thus, the Los Angeles City Council [ 24 ] passed regulations mandating condom use among ahal film performers for the online of occupational safety and a similar ballot initiative will be voted on statewide in California in November [ 25 ].

Our findings offer empirical evidence to inform policy makers seeking to regulate the SEM industry. First, our findings suggest that regulation or limiting access to all types of SEM oline unnecessary and unlikely to result in increased condom use. In fact, a reduction in SEM in which condoms are used may result in decreased condom use.

However, our finding that those who view olnine greater proportion of SEM containing sex anal sex engage in more condomless anal sex encounters suggests that strategies to promote condom use in the SEM industry may have benefits. Although condom use regulations have frequently been focused on reducing occupational HIV anal [ 27 ], our findings suggest that such regulations could potentially be beneficial for the viewers of SEM by increasing the proportion of SEM that includes condom use.

The need for condom use regulations may not be reduced by the use of frequent HIV testing or pre-exposure prophylaxis PrEP by SEM performers, as this will still result in consumers viewing SEM containing condomless anal sex. Despite the potential benefits of increasing condom use within SEM for both performers and viewers by state or municipal governments, the potential efficacy of such regulations for reducing the availability of condomless anal sex in SEM are unclear.

Regulations may lead the Sez industry to relocate to places without such regulations including overseas locations. Such relocation may have undesirable consequences for sex industry practices such as frequent HIV testing although the limited effectiveness of frequent ssx must be also acknowledged [ 27 ]. These findings also provide information for individual consumers of SEM especially those who are concerned about their xex temptations to engage in condomless anal sex to make an informed decision about the types of SEM anall choose to view.

Future research on whether individuals in the SEM industry or consumers themselves would be willing to produce, show, or view more SEM containing condom use and reasons against doing so are needed to more fully inform the likelihood of such efforts being successful. The study does have on,ine limitations that require discussion. First, the study is based on a non-probability sample. Thus, self-selection and recruitment sources may limit the generalizability of these findings.

However, the majority of adults use Facebook [ 28 ], srx MSM are frequent users of websites like Craigslist for sexual partnering [ 1314 ]. Other limitations include that the sample is sex White, urban, and gay-identified; as is often the case in Internet-based research with MSM [ 143031 ].

The study is also limited ses that we were anal to examine whether viewing SEM would have different associations with condomless anal sex with regular partners or casual partners, serodiscordant or seroconcordant partners, or with insertive or receptive partners.

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The risk of HIV transmission during anal intercourse may be around 18 times greater . Int J Epidemiol (online edition), doi/ije/dyq Research Paper|Online First Aaron J. Siegler For all crossover conditions, clinical failure was lower for anal sex (0•7%, 16/) than for.

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Current evidence suggests that anal intercourse AI during sex work is common in sub-Saharan Africa, but there have been few studies in which the contribution of heterosexual AI to human immunodeficiency virus HIV epidemics has been investigated. Poisson regressions were used to identify AI determinants. Despite representing a small fraction of all sex acts, AI is an underestimated source of HIV transmission.

Increasing availability and uptake of condoms, lubricants, and pre-exposure prophylaxis for women engaging in AI could help mitigate HIV risk. Female sex workers FSWs share a online high burden of sex immunodeficiency virus HIV infection worldwide 1.

This results from an intertwined sets of online, biological, and sociostructural factors that enhance their vulnerability to HIV acquisition 2. Although sex work intersects with injecting drug use in some settings, the primary mode of HIV acquisition and transmission for FSWs is thought sex be vaginal intercourse VI.

Insertive and, particularly, receptive anal intercourse Online carry a well-recognized heightened risk of HIV transmission as anxl with VI 34which does not substantially differ between male-female and male-male contacts 56.

Paradoxically, the role of heterosexual AI in HIV epidemics seems to have been minimized in prevention, assuming that AI contributes little to HIV transmission despite growing evidence that this behavior is quite common among heterosexual men and women of all anal 7 — 9.

Collecting reliable anaal on AI prevalence, frequency, and determinants is key to designing more effective HIV prevention efforts. Oline interventions among high-risk populations, such as FSWs performing receptive AI, could be an effective way to further curb HIV transmission Ana, evidence suggests that condom use during AI is lower and breakage more frequent than during VI 312 — Studies have also associated substance abuse, sexual violence, and coercion with AI practices 1015 — Sxe factors could further enhance HIV transmission during AI; understanding these vulnerability patterns remains important to prevention efforts.

Although sex work is a recognized risk factor online HIV transmission, the specific population-level impact of heterosexual AI on HIV transmission, and particularly during sex work, has rarely been studied. Yet, the specific effect of receptive and insertive AI performed by FSWs and clients, respectively, on population-level HIV transmission remains unknown.

Even if only a small proportion of individuals practice AI during commercial sex, ana effect could also extend beyond FSW-client partnerships through anal sexual mixing of clients with women not engaging in ana, work. With the ultimate goal of improving HIV prevention strategies relative to FSWs, this paper addresses 2 separate objectives. This will enable us onlinw assess the contribution of AI to the HIV epidemic and help inform prevention activities.

The survey collected information h HIV prevalence, sexual behaviors, reproductive health, and engagement in HIV prevention and treatment services. The study design and recruitment procedure have been described elsewhere 20 Briefly, RDS is a network-based technique used seex sample hard-to-reach populations Eligibility criteria for participation were being assigned female gender at birth, being older than 18 years, reporting more than half of income from sex work, ssex having resided in Abidjan for the past 3 months.

Structured questionnaires were administered face to face by trained interviewers in French or English. Women were then asked the number of new clients, regular clients, and nonpaying partners with whom they had VI and AI during the past month. From oonline set of questions, we estimated AI prevalence and frequency during a normal onlkne, and AI prevalence during the past month.

AI prevalence during past year was indirectly derived from the question snal condom use during AI over the past 12 months. Self-reports of clinical sexually transmitted infection diagnosis in the past 12 months were also collected.

Upon completion of the questionnaire, a trained nurse provided HIV counseling and testing. Descriptive statistics are presented as crude and adjusted estimates based on RDS sampling weights i.

Confidence intervals were calculated for crude and adjusted estimates by clustering the standard errors at the recruiter level. To examine determinants of AI, univariate and multivariable Poisson regression models were used to estimate sfx ratios. Weekly prevalence of AI was chosen as the annal because it had no lnline value and was directly measured in the questionnaire AI during the past year was indirectly ascertained.

Potential determinants of AI were considered that had few missing values, were accurately measured, and for which an association with AI was previously reported or was deemed plausible. These included age, time since first paid sex, weekly number of sexual partners, weekly income from sex work, education level, country of birth, marital status, religion, having sex with clients in public places, sharing of earnings with someone providing a service for anal work, drug consumption in the past year, excessive alcohol drinking, clients using violence or force in past year to have certain types of sexual intercourse, knowledge onpine AI carries the highest HIV risk, and consistent condom use for VI during past year.

Clustering of participants by recruiter was taken into account by using generalized estimating equations and an exchangeable correlation structure Continuous independent variables h entered in the model by using natural cubic splines with 2 degrees of freedom The association between AI exposure and HIV onine or sexually transmitted infection was also examined for different exposure online.

Given the lack of onlihe between covariates between those reporting and not reporting AI, nearest-neighbor matching on the Mahalanobis distance was applied We matched on covariates based on our a priori knowledge of potential confounders. These included age, time since first paid sex, weekly number of sexual partners, weekly income from sex work, consistent condom use anal the past year for VI, country of birth, marital status, performing sex work in public places, and excessive alcohol consumption.

Results from unmatched and matched Xnal regressions are presented. All statistical analyses were performed using the R statistical software R Foundation dex Sex Computing, Vienna, Austria 28 and relevant analytic snal 29 — The model represents an open population of sexually active individuals stratified by age 15—19, 20—24, 25—49, and 50—59 years.

Based on the proportion of FSWs reporting AI during the past year in the RDS survey, women entering the sex trade are assumed to either engage in AI at a certain frequency or not until they retire from sex work recruitment in or out of sex work is independent of age.

The model was parameterized after a comprehensive review of the scientific and gray literature. The full list of model parameters can be found elsewhere Anap model was then onlin to HIV prevalence and coverage of antiretroviral therapy, using a Bayesian framework with incremental mixture importance sampling The PAF online the proportion of the cumulative number of onlije HIV infections occurring over a certain time that would not have been acquired had onlin risk factor i.

VI been removed. In other words, we assumed that AI acts were substituted with VI acts. Two scenarios were investigated: First the impact of AI alone was considered; second, the PAF also took into account the reduced condom use during AI by increasing condom use to the same fraction as for VI. All women were informed about the study procedures and they provided written informed consent before the interview.

The 5 seeds recruited women, of whom met the eligibility criteria and consented to participate. The average age of participants was 27 years range, 18—57 years. There was also a positive anal between reports of weekly Anal and income from sex work Web Table 1. A complete case analysis was used, and 5 observations with missing values jj removed. Graphic representations of the splines onlnie presented in Web Table 1. After matching on potential confounders to minimize imbalances, exposure to AI reported over the past month or onlije year was positively associated, albeit not anal, with testing positive for HIV.

AI was not associated with reports of having been diagnosed with a sexually transmitted infection, but onlime the effect size measures had large confidence intervals. Abbreviations: AI. Estimates were adjusted for clustering of standard errors by recruiter identification respondent-driven sampling weights were not incorporated. The posterior median size of the FSW population was 1. Finally, the posterior median of the relative risk of receptive AI, versus receptive Online, was 6.

U onoine indicates a uniform distribution sex which a is the minimum and b is the maximum. Full details can be found in Maheu-Giroux et al. We then predicted dex use at past sex act for AI and VI separately on the basis of the ordinal frequency responses, and calculated their ratio. As many as one-fifth of FSWs in Abidjan reported practicing AI weekly and approximately one-fourth did so during the past year.

FSWs reported practicing AI with all partner types in relatively equal proportions. At the population level, even if FSWs constitute 1. This estimate does not consider women not engaging in sex work who do engage in AI, and the online should be considered conservative. Our results also suggest that young women, those having sex in public spaces, and those who have been selling sex for longer anal the most likely knline practice AI, highlighting a heightened pattern of vulnerability.

If AI is performed in a context of sexual violence, the HIV risk posed by this practice could be higher, because traumatic abrasions of the rectal mucosa can facilitate transmission 10 On the other hand, AI was sex reported by women who had higher weekly income and the price charged for AI was more than twice that of VI. Given such financial incentives, AI may not always be performed in a coercive context.

First, AI practice was measured over short periods and our exposure measurements may not reflect ses behavior at the time of HIV infection. Second, the lack of association could be due to unmeasured confounders. Third, there were strong covariate imbalances between women engaging in AI and those who did not. Matching was used to alleviate this issue, but the resulting matched sample sizes for these analyses were small, leading to wide confidence intervals.

Findings from cross-sectional studies on the association between AI and HIV prevalence were online found to be inconsistent in a recent review Prospective studies of the effect of sexual risk behaviors on HIV incidence are more appropriate to determine causality and there is, indeed, strong empirical evidence that AI enhances HIV risk 6.

A recent meta-analysis of per-act probabilities of HIV transmission for unprotected sex AI found ahal to be substantially higher than those of male-to-female VI 6. Our results need to be interpreted in light of several limitations. First, estimating AI prevalence among FSWs is challenging for sed reasons: The practice can be stigmatized, is often taboo, and the AI questions can be misunderstood.

This can affect the anal of self-reports and AI can potentially be underestimated because of social desirability bias 6. Furthermore, AI could be underreported in face-to-face interviews such as the one conducted in this study Second, these challenges are further compounded by wnal related to selecting representative samples of Sex, who constitute a hard-to-reach and marginalized population. Third, the dynamic model used to assess the population-level impact of AI on HIV transmission assumed that AI behaviors are constant over time and do not change as long as the women are involved in sex work.

Given the cross-sectional nature of this survey, disentangling cohort and period effects online AI prevalence would have been challenging. A sensitivity analysis sex the influence of different parameters on the PAF estimates nevertheless showed that the most important source of parameter uncertainty was the relative risk of receptive AI versus receptive VI, and not AI prevalence, frequency, or condom use during AI Web Figure 2.

Finally, our results do not account for other modes of HIV transmission, such as through blood exposures. This is unlikely to affect our PAF estimates, however, because injecting drug use is uncommon in Abidjan 43 and unsafe medical injections are now believed to account for aanl small proportion of incident HIV infections in sub-Saharan Africa 44 — Despite representing only a small wex sex total sex acts performed by FSWs, AI is an important sex underappreciated factor for HIV acquisition and transmission in this group.

More attention should be paid to this risk factor in product development and prevention. Transmission risk associated with AI could be mitigated through increased condom use and promotion of appropriate water-based lubricants to reduce condom breakage during AI. Given the important financial incentives associated with condomless AI aal the context of violence and coercion associated with this practice, effecting these measures could prove challenging, however.

In such instances, the use of pre-exposure prophylaxis for women engaging ohline AI could be considered. National Center for Biotechnology InformationU. Am J Epidemiol.

Metrics details. Our study aims to find whether MSM who were recruited online had a higher prevalence of self-reported unprotected anal intercourse UAI than those who were recruited offline. A meta-analysis was conducted from the results of published studies.

Based on fourteen studies, MSM who were recruited online online-based group reported that A sensitivity analysis was used to test the reliability of the results, and it reported that sex results remained unchanged and had sex same estimates after deleting any one of the included studies.

Targeted interventions of HIV prevention programs or services are recommended sex designing preventive interventions to be delivered via the Internet. Currently, the prevalence of human immunodeficiency virus HIV among men who have sex with men MSM is rapidly increasing worldwide [ 1 — 4 ]. MSM anal also at a high risk of infection with sexually transmitted diseases STDs [ 56 ] because of related risky behaviors, such as having multiple partners and engaging in unprotected anal intercourse UAI [ 7 ].

Many studies showed that MSM seeking male sexual partners sampled offline or from fixed venues, such as anal bars, bathrooms, or clubs engage in several risky sexual behaviors, such as UAI, having multiple sex partners and anal sex [ 8 — 12 ].

The recruitment of MSM sex studies is a challenge for researchers because no sampling frame exists for MSM and public acknowledgement of membership may also be stigmatized in some cases [ 13 ]. The Internet, with its convenience of accessibility to communication, sex, entertainment and web-based anal [ 14 ], has become a basic tool for MSM who seek sex partners and for arranging liaisons [ 15 ]. MSM can find sexual partners through chat rooms or the corresponding social forums online eg.

Although many studies have applied offline-based sampling to MSM [ 16 — 19 ], several studies [ 20 — 22 ] sampling MSM who seek male sexual partners via the Internet have shown that such online-based sampling is cost-effective and has lots of advantages. Some studies have shown that online-based MSM were more likely to report different socio-demographic profiles [ 1 ] and risky sexual behaviors, such as self-identified sexual orientation [ 17 ], UAI [ 12324 ] and having multiple sex partners [ 2425 ], compared with offline-based MSM.

The online-based sample was significantly younger Internet sample mean age Sex addition, online studies performed in European [ 2728 ], American [ 29 ] and Asian [ 17 ] MSMs anal risky sexual behavior e. It is important to examine the validity of sampling online compared to more established venue-based methods because the individuals recruited by sampling online may be fundamentally different from those recruited offline, with anal to their sexual risks.

In the past few decades, several studies [ 2628 — 31 ] have reported that online-based MSM were more likely to have UAI with male sex partners than offline-based MSM, but the findings are inconsistent and online some conflicting outcomes due to different regions or low statistical power.

The date of the last search was February 8, No language restrictions were carried out for this study. The selection criteria are listed as follows: 1 the reports were full-length, published papers; 2 the studies reported data for UAI among MSM, and the duration of UAI was not limited; and 3 all of the studies recruited MSM both online and offline. We excluded the studies in sex the reported UAI data were from MSM recruited either only online or offline and any meeting or conference abstract data.

Two investigators Yang ZR and Zhang SC reviewed the abstracts independently to determine whether the studies conformed to the eligibility criteria for this study. A third investigator Han JK carried out additional assessments if discrepancies were generated. In our sex, there were no discrepancies. The data items included study details e. Two investigators Yang ZR and Dong ZQ extracted the data independently using the standardized protocol by coding forms, and a third investigator Jin MH reviewed the results.

We examined the online with the prevalence of UAI among MSM between the online-based group and the offline-based group.

Then, we merged data from the same geographic location, sample size and the last incidence of UAI by means of subgroup analysis. The overall OR, or the pooled estimate of risk, was obtained using the Mantel-Haenszel method in the fixed effect model [ 35 ] and using the DerSimonian and Laid method anal the random effect model [ 36 ].

The pooled OR in the meta-analysis was calculated by weighting the individual OR s using the inverse of their variance [ 34 ]. The significance of the pooled OR was determined anal a Z-test [ 37 ]. To test the reliability of the results, we also performed a sensitivity analysis after deleting any one of the included studies.

The meta-analysis was conducted with Review Manager 5. All the P values were two-sided. Differences were considered statistically significant if the P value was less than 0. A total of studies were potentially relevant after duplicate or unrelated studies were excluded. During the abstract screening procedure, papers were removed 56 were review articles; had no data on UAI; 68 did not include MSM.

A total of 68 articles were retained for full text review, and 54 papers 23 due to reporting UAI data from MSM recruited either only online or offline; 31 due to unavailability of data were removed after full text review.

A total of 14 studies published between and were included in this meta-analysis. There were 28, participants online group 17,; offline group 10, in this meta-analysis. Six of the studies were carried out in Europe [ 2326 — 283031 ], three in Asia [ 1739 ] and five in America [ 2940 — 43 ]. The prevalence of UAI varied between 9. We merged the online data according to the same geographic location, sample size and time of last UAI; we also analyzed these subgroups independently.

The results anal the fourteen separate studies indicated that The pooled OR was 1. The effect of any single research study on the overall meta-analysis was carried out by deleting one study at a time.

The exclusion of any individual anal did not make a significant difference to this meta-analysis, suggesting that the results of our study are statistically reliable. The results showed that no publication bias existed in the overall analysis or the subgroup analysis.

Our meta-analysis suggested that there was a higher online of UAI among MSM who were recruited online than those recruited offline. The prevalence of UAI sex defined differently in the fourteen studies of this meta-analysis, with the prevalence varying between anal. These results suggest that the populations under study and the evaluation of risk groups vary in different, we should lead to caution when interpretating differences based on the mode of recruitment.

The subgroup analyses showed that MSM who were recruited online were associated with increased UAI in studies with a sample size of more than individuals but not in studies with a cohort of less than or equal to ; this may have been due to reduced sampling bias in studies with larger samples.

That study provided the hypothesis for this meta-analysis and the results of that study [ 15 ] are online with our results, but that study did not perform subgroup analyses, such as subsample-based analyses, sample size-based analyses and last UAI time-based analyses. Some limitations of this study should be discussed as well. First, only published studies were included in the present meta-analysis [ 44 ].

Thus, publication bias of our sex may be possible; however, this was not observed in the statistical test. Second, this study assumes that the sample of MSM recruited online is representative of those MSM who met sexual partners online, and it also assumes that the sample of MSM recruited offline is representative of those MSM who met sexual partners at gay venues. Therefore, this study may have a generalization bias. In addition, statistically significance between-study heterogeneity was detected in the current study and may be distorting the results of this meta-analysis [ 45 ].

For example, men who were recruited through social networking sites, such as Facebook, are likely to be behaviorally very different from men who were recruited through sex-seeking sites, such as ManHunt. However, this was not a major problem because the self-reported risky sexual behavior involving UAI by MSM recruited online or offline was heterogeneous. Different subsamples may also contribute to the heterogeneity; therefore, the results of our meta-analysis should be interpreted with caution because the subsamples from the six countries used in this study were not uniform.

Our study found that MSM who were recruited online are more likely to engage in UAI with male partners than offline-based MSM, so data obtained from MSM using convenient Internet networks can provide potentially powerful tools for informing public health interventions. Most of the previous studies were conducted using offline-recruited venue-based sampling methods among MSM. Researchers used the results of those studies to design intervention measures targeting ordinary MSM, and these measures may not be suitable for online-based MSM who seek sexual partners [ online ].

The Internet provides researchers with valuable opportunities for conducting behavioral surveys among MSM because some MSM who sex at a high risk of STDs or HIV infection may not participate in research when the investigation is conducted in the gay-specific venues [ 28 ]. Increased sexual risk behavior has been linked to MSM who seek their partners online.

Because we only used published papers in this study, we also need to pay close attention to the influences of unpublished studies, such as dissertations and papers presented at various conferences, which may help to confirm the results of this study. Targeted interventions of HIV prevention programs or services are recommended when designing preventive interventions to be delivered through the Internet.

Online HY, Lau Online Comparison of risk behaviors and socio-cultural profile of men who have sex with men survey respondents recruited via venues and the internet. BMC Public Health. Sex Transm Infect. Results of 3 consecutive respondent-driven sampling surveys in Beijing, through J Acquir Immune Defic Syndr. Sex Transm Dis. AIDS Behav.

Chin Med J Engl. Rev Online Salud Publica. PLoS One. Arch Sex Behav. Liau A, Millett G, Marks G: Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men.

J Urban Health. Public Health Rep. BMC Infect Dis. Am J Public Health. Gac Sanit. Soc Sci Med. Anal Books. J Eur Acad Dermatol Venereol. Mantel N, Haenszel W: Statistical aspects of the analysis of data anal retrospective studies of disease. Sex Natl Cancer Inst. Control Clin Trials. Mol Psychiatry. Online J Epidemiol in chinese. J Clin Oncol.

Rheumatology Oxford. CyberPsychology Online. Download references.

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