AIDS and Behavior

, Volume 21, Issue 10, pp 2811–2834 | Cite as

Trends in Sexual Behavior Among Men Who have Sex with Men (MSM) in High-Income Countries, 1990–2013: A Systematic Review

  • Kristen L. Hess
  • Nicole Crepaz
  • Charles Rose
  • David Purcell
  • Gabriela Paz-Bailey
Substantive Review


HIV diagnoses among men who have sex with men (MSM) have been increasing in several high-income countries. A better understanding of the sexual behavior trends among MSM can be useful for informing HIV prevention. We conducted a systematic review of studies that examined behavioral trends (1990–2013) in any condomless anal sex, condomless anal sex with an HIV-discordant partner, and number of partners. Studies included come from the United States, Europe, and Australia. We found increasing trends in condomless anal sex and condomless anal sex with an HIV-discordant partner, and a decreasing trend in number of partners. The increase in condomless anal sex may help to explain the increase in HIV infections. More explanatory research is needed to provide insight into factors that contribute to these behavior trends. Continuous monitoring of HIV, risk behaviors, and use of prevention and treatment is needed to evaluate prevention efforts and monitor HIV transmission risk.


HIV Risk behaviors Men who have sex with men Condom use 


Diagnósticos de VIH en hombres que tienen sexo con hombres (HSH) han ido aumentando en varios países de altos ingresos. Una mejor comprensión de las tendencias de comportamiento sexual entre HSH puede ser útil para informar a la prevención del VIH. Se realizó una revisión sistemática de estudios que examinaron las tendencias de comportamientos sexuales (1990–2013) incluyendo: sexo anal sin condón, sexo anal sin condón con una pareja VIH discordante y número de parejas sexuales. Los estudios provienen de los Estados Unidos, Europa y Australia. Encontramos tendencias en aumento en el sexo anal sin condón y sexo anal sin condón con una pareja VIH discordantes y una tendencia decreciente en el número de parejas. El aumento en el sexo anal sin condón puede ayudar a explicar el aumento de infecciones por el VIH. Se necesita más investigación para explicar los factores que contribuyen a estas tendencias de comportamiento. Monitoreo continuo del VIH, comportamientos de riesgo y uso de la prevención y el tratamiento es necesario para evaluar los esfuerzos de prevención y control de la transmisión del VIH.



We would like to thank Amy Lansky for her feedback on the research questions, data interpretation, and manuscript.


The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


There was no external funding source for this work.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Beyrer C, Baral SD, Collins C, et al. The global response to HIV in men who have sex with men. Lancet. 2016;388(10040):198–206.CrossRefPubMedGoogle Scholar
  2. 2.
    Sullivan PS, Hamouda O, Delpech V, et al. Reemergence of the HIV epidemic among men who have sex with men in North America, Western Europe, and Australia, 1996–2005. Ann Epidemiol. 2009;19(6):423–31.CrossRefPubMedGoogle Scholar
  3. 3.
    Beyrer C, Sullivan P, Sanchez J, et al. The increase in global HIV epidemics in MSM. AIDS. 2013;27(17):2665–78.CrossRefPubMedGoogle Scholar
  4. 4.
    Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. Estimating per-act HIV transmission risk: a systematic review. AIDS. 2014;28(10):1509–19.CrossRefPubMedGoogle Scholar
  5. 5.
    Smith DK, Pals SL, Herbst JH, Shinde S, Carey JW. Development of a clinical screening index predictive of incident HIV infection among men who have sex with men in the United States. J Acquir Immune Defic Syndr. 2012;60(4):421–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Menza TW, Hughes JP, Celum CL, Golden MR. Prediction of HIV acquisition among men who have sex with men. Sex Transm Dis. 2009;36(9):547–55.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171–81.CrossRefPubMedGoogle Scholar
  9. 9.
    Grulich AE, Bavinton BR, Jin F, et al. HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. Conference on retroviruses and opportunistic infections; Poster No 1019LB; February 23–26, 2015; Seattle, Washington.Google Scholar
  10. 10.
    Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Okwundu CI, Uthman OA, Okoromah CA. Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals. Cochrane Database Syst Rev. 2012;7:CD007189.Google Scholar
  12. 12.
    Liu AY, Vittinghoff E, Chillag K, et al. Sexual risk behavior among HIV-uninfected men who have sex with men participating in a tenofovir preexposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr. 2013;64(1):87–94.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Marcus JL, Glidden DV, Mayer KH, et al. No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS ONE. 2013;8(12):e81997.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. Accessed 13 June 2016.
  15. 15.
    National HIV/AIDS strategy for the United States: updated to 2020. Accessed July 2015.
  16. 16.
    Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PLoS ONE. 2013;8(2):e55312.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Bezemer D, de Wolf F, Boerlijst MC, et al. A resurgent HIV-1 epidemic among men who have sex with men in the era of potent antiretroviral therapy. AIDS. 2008;22(9):1071–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Wilson DP. HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS Med. 2012;9(7):e1001231.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Abara WE, Hess KL, Neblett Fanfair R, Bernstein KT, Paz-Bailey G. Syphilis trends among men who have sex with men in the United States and western Europe: a systematic review of trend studies published between 2004 and 2015. PLoS ONE. 2016;11(7):e0159309.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    The World Bank: country and lending groups. Accessed 17 June 2016.
  21. 21.
    Leichliter JS, Haderxhanaj LT, Chesson HW, Aral SO. Temporal trends in sexual behavior among men who have sex with men in the United States, 2002 to 2006–2010. J Acquir Immune Defic Syndr. 2013;63(2):254–8.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    CDC. HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men—United States. MMWR Morb Mortal Wkly Rep. 2013;62(47):958–62.Google Scholar
  23. 23.
    Golden MR, Stekler J, Hughes JP, Wood RW. HIV serosorting in men who have sex with men: is it safe? J Acquir Immune Defic Syndr. 2008;49(2):212–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Kalichman SC, Eaton L, White D, et al. Beliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997–2006. J Behav Med. 2007;30(6):497–503.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Osmond DH, Pollack LM, Paul JP, Catania JA. Changes in prevalence of HIV infection and sexual risk behavior in men who have sex with men in San Francisco: 1997–2002. Am J Public Health. 2007;97(9):1677–83.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Scheer S, Kellogg T, Klausner JD, et al. HIV is hyperendemic among men who have sex with men in San Francisco: 10-year trends in HIV incidence, HIV prevalence, sexually transmitted infections and sexual risk behaviour. Sex Transm Infect. 2008;84(6):493–8.CrossRefPubMedGoogle Scholar
  27. 27.
    McFarland W, Chen YH, Nguyen B, et al. Behavior, intention or chance? A longitudinal study of HIV seroadaptive behaviors, abstinence and condom use. AIDS Behav. 2012;16(1):121–31.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Pantalone DW, Tomassilli JC, Starks TJ, Golub SA, Parsons JT. Unprotected anal intercourse with casual male partners in urban gay, bisexual, and other men who have sex with men. Am J Public Health. 2015;105(1):103–10.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Menza TW, Kerani RP, Handsfield HH, Golden MR. Stable sexual risk behavior in a rapidly changing risk environment: findings from population-based surveys of men who have sex with men in Seattle, Washington, 2003–2006. AIDS Behav. 2011;15(2):319–29.CrossRefPubMedGoogle Scholar
  30. 30.
    Kellogg TA, Hecht J, Bernstein K, et al. Comparison of HIV behavioral indicators among men who have sex with men across two survey methodologies, San Francisco, 2004 and 2008. Sex Transm Dis. 2013;40(9):689–94.CrossRefPubMedGoogle Scholar
  31. 31.
    Sudhinaraset M, Raymond HF, McFarland W. Convergence of HIV prevalence and inter-racial sexual mixing among men who have sex with men, San Francisco, 2004–2011. AIDS Behav. 2013;17(4):1550–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Reilly KH, Neaigus A, Jenness SM, et al. Trends in HIV prevalence and risk behavior among men who have sex with men in New York City, 2004–2011. AIDS Educ Prev. 2014;26(2):134–43.CrossRefPubMedGoogle Scholar
  33. 33.
    Fendrich M, Mackesy-Amiti ME, Johnson TP, Pollack LM. Sexual risk behavior and drug use in two Chicago samples of men who have sex with men: 1997 vs. 2002. J Urban Health. 2010;87(3):452–66.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Jansen IA, Geskus RB, Davidovich U, et al. Ongoing HIV-1 transmission among men who have sex with men in Amsterdam: a 25-year prospective cohort study. AIDS. 2011;25(4):493–501.CrossRefPubMedGoogle Scholar
  35. 35.
    Stolte IG, de Wit JB, van Eeden A, Coutinho RA, Dukers NH. Perceived viral load, but not actual HIV-1-RNA load, is associated with sexual risk behaviour among HIV-infected homosexual men. AIDS. 2004;18(14):1943–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Op de Coul EL, Warning TD, Koedijk FD, Dutch STIc. Sexual behaviour and sexually transmitted infections in sexually transmitted infection clinic attendees in the Netherlands, 2007–2011. Int J STD AIDS. 2014;25(1):40–51.CrossRefGoogle Scholar
  37. 37.
    Cowan SA, Gerstoft J, Haff J, Christiansen AH, Nielsen J, Obel N. Stable incidence of HIV diagnoses among Danish MSM despite increased engagement in unsafe sex. J Acquir Immune Defic Syndr. 2012;61(1):106–11.CrossRefPubMedGoogle Scholar
  38. 38.
    Casalino E, Choquet C, Leleu A, et al. Trends in condom use and risk behaviours after sexual exposure to HIV: a seven-year observational study. PLoS ONE. 2014;9(8):e104350.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Moreau-Gruet F, Dubois-Arber F, Jeannin A. Long-term HIV/AIDS-related prevention behaviours among men having sex with men: Switzerland 1992–2000. AIDS Care. 2006;18(1):35–43.CrossRefPubMedGoogle Scholar
  40. 40.
    Bozicevic I, Lepej SZ, Rode OD, et al. Prevalence of HIV and sexually transmitted infections and patterns of recent HIV testing among men who have sex with men in Zagreb, Croatia. Sex Transm Infect. 2012;88(7):539–44.CrossRefPubMedGoogle Scholar
  41. 41.
    Klavs I, Bergant N, Kastelic Z, Lamut A, Kustec T. Disproportionate and increasing burden of HIV infection among men who have sex with men in Slovenia: Surveillance data for 1999–2008. Euro Surveill. 2008;14(47):429–33.Google Scholar
  42. 42.
    Seng R, Rolland M, Beck-Wirth G, et al. Trends in unsafe sex and influence of viral load among patients followed since primary HIV infection, 2000–2009. AIDS. 2011;25(7):977–88.CrossRefPubMedGoogle Scholar
  43. 43.
    Zablotska IB, Kippax S, Grulich A, Holt M, Prestage G. Behavioural surveillance among gay men in Australia: methods, findings and policy implications for the prevention of HIV and other sexually transmissible infections. Sex Health. 2011;8(3):272–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Zablotska IB, Crawford J, Imrie J, et al. Increases in unprotected anal intercourse with serodiscordant casual partners among HIV-negative gay men in Sydney. AIDS Behav. 2009;13(4):638–44.CrossRefPubMedGoogle Scholar
  45. 45.
    Van de Ven P, Mao L, Prestage G. Gay Asian men in Sydney resist international trend: no change in rates of unprotected anal intercourse, 1999–2002. AIDS Educ Prev. 2004;16(1):1–12.CrossRefPubMedGoogle Scholar
  46. 46.
    Prestage G, Mao L, Fogarty A, et al. How has the sexual behaviour of gay men changed since the onset of AIDS: 1986–2003. Aust N Z J Public Health. 2005;29(6):530–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Chow EP, Tomnay J, Fehler G, et al. Substantial increases in chlamydia and gonorrhea positivity unexplained by changes in individual-level sexual behaviors among men who have sex with men in an Australian sexual health service from 2007 to 2013. Sex Transm Dis. 2015;42(2):81–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Holt M, Lee E, Prestage GP, Zablotska I, de Wit J, Mao L. The converging and diverging characteristics of HIV-positive and HIV-negative gay men in the Australian Gay Community Periodic Surveys, 2000–2009. AIDS Care. 2013;25(1):28–37.CrossRefPubMedGoogle Scholar
  49. 49.
    Vodstrcil LA, Fairley CK, Fehler G, et al. Trends in chlamydia and gonorrhea positivity among heterosexual men and men who have sex with men attending a large urban sexual health service in Australia, 2002–2009. BMC Infect Dis. 2011;11:158.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Mercer CH, Fenton KA, Copas AJ, et al. Increasing prevalence of male homosexual partnerships and practices in Britain 1990–2000: evidence from national probability surveys. AIDS. 2004;18(10):1453–8.CrossRefPubMedGoogle Scholar
  51. 51.
    Hickson F, Bonell C, Hargreaves J, Reid D, Weatherburn P. HIV testing and HIV serostatus-specific sexual risk behaviour among men who have sex with men living in England and recruited through the internet in 2001 and 2008. Sex Res Social Policy. 2013;10(1):15–23.CrossRefPubMedGoogle Scholar
  52. 52.
    Lattimore S, Thornton A, Delpech V, Elford J. Changing patterns of sexual risk behavior among London gay men: 1998–2008. Sex Transm Dis. 2011;38(3):221–9.CrossRefPubMedGoogle Scholar
  53. 53.
    Williamson LM, Dodds JP, Mercey DE, Johnson AM, Hart GJ. Increases in HIV-related sexual risk behavior among community samples of gay men in London and Glasgow: how do they compare? J Acquir Immune Defic Syndr. 2006;42(2):238–41.CrossRefPubMedGoogle Scholar
  54. 54.
    Hart GJ, Williamson LM. Increase in HIV sexual risk behaviour in homosexual men in Scotland, 1996–2002: prevention failure? Sex Transm Infect. 2005;81(5):367–72.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Saxton PJ, Dickson NP, Hughes AJ. Location-based HIV behavioural surveillance among MSM in Auckland, New Zealand 2002–2011: condom use stable and more HIV testing. Sex Transm Infect. 2014;90(2):133–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Saxton PJ, Dickson NP, Hughes AJ. Trends in web-based HIV behavioural surveillance among gay and bisexual men in New Zealand: complementing location-based surveillance. AIDS Care. 2015;27(6):762–6.CrossRefPubMedGoogle Scholar
  57. 57.
    George C, Alary M, Otis J, et al. Nonnegligible increasing temporal trends in unprotected anal intercourse among men who have sexual relations with other men in Montreal. J Acquir Immune Defic Syndr. 2006;41(3):365–70.CrossRefPubMedGoogle Scholar
  58. 58.
    Zablotska IB, Prestage G, Middleton M, Wilson D, Grulich AE. Contemporary HIV diagnoses trends in Australia can be predicted by trends in unprotected anal intercourse among gay men. AIDS. 2010;24(12):1955–8.CrossRefPubMedGoogle Scholar
  59. 59.
    Kippax S, Holt M. Diversification of risk reduction strategies and reduced threat of HIV may explain increases in condomless sex. AIDS. 2016;30(18):2898–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Paz-Bailey G, Mendoza M, Finlayson T, et al. Trends in condom use among men who have sex with men in the United States: the role of antiretroviral therapy and sero-adaptive strategies. AIDS. 2016;30(12):1985–90.CrossRefPubMedGoogle Scholar
  61. 61.
    Paz-Bailey G, Wejnert C, Mendoza MC, Prejean J. Response to diversification of risk-reduction strategies and reduced threat of HIV may explain increases in condomless sex. AIDS. 2016;30(18):2900–1.CrossRefPubMedGoogle Scholar
  62. 62.
    Vosburgh HW, Mansergh G, Sullivan PS, Purcell DW. A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men. AIDS Behav. 2012;16(6):1394–410.CrossRefPubMedGoogle Scholar
  63. 63.
    Kramer SC, Schmidt AJ, Berg RC, et al. Factors associated with unprotected anal sex with multiple non-steady partners in the past 12 months: results from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS 2010). BMC Public Health. 2016;16:47.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Alvy LM, McKirnan DJ, Mansergh G, et al. Depression is associated with sexual risk among men who have sex with men, but is mediated by cognitive escape and self-efficacy. AIDS Behav. 2011;15(6):1171–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sex Transm Dis. 2006;33(9):576–84.CrossRefPubMedGoogle Scholar
  66. 66.
    Melendez-Torres GJ, Nye E, Bonell C. Internet sex-seeking is inconsistently linked with sexual risk in men who have sex with men: systematic review of within-subjects comparisons. Sex Health. 2015;12(3):183–7.PubMedGoogle Scholar
  67. 67.
    McDaid LM, Hart GJ. Sexual risk behaviour for transmission of HIV in men who have sex with men: recent findings and potential interventions. Curr Opin HIV AIDS. 2010;5(4):311–5.CrossRefPubMedGoogle Scholar
  68. 68.
    CDC. HIV risk reduction tool. Accessed 13 April 2017.
  69. 69.
    Holt M, Lea T, Mao L, et al. Adapting behavioural surveillance to antiretroviral-based HIV prevention: reviewing and anticipating trends in the Australian Gay Community Periodic Surveys. Sex Health. 2016;. doi: 10.1071/SH16072.Google Scholar
  70. 70.
    Holt M. Time to accommodate antiretroviral-based HIV prevention. Lancet HIV. 2016;3(9):e400–1.CrossRefPubMedGoogle Scholar
  71. 71.
    Lasry A, Sansom SL, Wolitski RJ, et al. HIV sexual transmission risk among serodiscordant couples: assessing the effects of combining prevention strategies. AIDS. 2014;28(10):1521–9.CrossRefPubMedGoogle Scholar
  72. 72.
    CDC. Condom distribution as a structural level intervention. Accessed 3 April 2017.
  73. 73.
    UNAIDS. UNFPA, WHO and UNAIDS: position statement on condoms and the prevention of HIV, other sexually transmitted infections and unintended pregnancy. Accessed 3 April 2017.
  74. 74.
    Adams J, Neville S, Parker K, Huckle T. Influencing condom use by gay and bisexual men for anal sex through social marketing: a program evaluation of Get it On! Soc Market Quar. 2016:1–15.Google Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA)  2017

Authors and Affiliations

  1. 1.Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB PreventionCenters for Disease Control and PreventionAtlantaUSA

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