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Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men


Structural stigma shapes men who have sex with men’s (MSM’s) mental health and sexual behaviours. The aim of this study was to examine how stigmatizing policies interact with downstream anxiety/depression and sexual behaviours to structurally pattern HIV disparities among European MSM. We conducted a secondary data analysis of the European Men-who-have-sex-with-men Internet Survey (EMIS) from 2017. We included a total of 98,600 participants living in 39 European countries. We used the Rainbow Index, a score given to countries based on their sexual and gender minority policies as the predictor of HIV diagnosis. We conducted adjusted random intercept and slope multi-level logistic regressions. In adjusted models, higher Rainbow Index scores was associated with lower predictive probabilities of diagnosed HIV, regardless of the number of condomless intercourse partners. The predictive probability of HIV diagnosis was also lower, regardless of severity of anxiety/depression, where the Rainbow Index score was better. Country-level policies interact with downstream sexual behaviours and anxiety/depression to structurally influence HIV diagnosis among MSM in Europe.

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Data are not available given General Data Protection Regulations of the European Union.

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The coding for statistical analysis is available to review upon request.


  1. References to Kosovo shall be understood to be in the context of United Nations Security Council Resolution 1244 (1999).


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We begin by thanking all the men who took part in EMIS-2017. EMIS-2017 was coordinated by Sigma Research at the London School of Hygiene and Tropical Medicine (LSHTM) in association with the Robert Koch Institute (RKI) in Berlin. EMIS core team @ Sigma Research (LSHTM): Axel J. Schmidt, Ford Hickson; David Reid, and Peter Weatherburn; in association with Uli Marcus and Susanne B. Schink @ RKI. EMIS NGO partners recruited 17% of all respondents through activities on Facebook and other social media and by placing EMIS banners on their websites. We thank all our partners for being part of something huge. The following list acknowledges all partners in EMIS by country. Individual names are mentioned if a freelancer was the main contact and/or translator or where input on the questionnaire development came from a person not formally representing an organisation. The order (if available) is: main NGO partner, other NGO partners, academic partners, governmental partners, individuals. Europe: PlanetRomeo, European AIDS Treatment Group (EATG), Eurasion Coalition on Male Health (ECOM), European Centre for Disease Prevention and Control (ECDC), European Monitoring Centre for Drugs & Drug Addiction (EMCDDA), European Commission (DG SANTE). AT: Aids Hilfe Wien, Dr Frank M. Amort. BA:, Masha Durkalić. BE: SENSOA, exaequo, Observatoire du SIDA et des sexualités, Sciensano. BG: HUGE, GLAS Foundation, Dr Emilia Naseva, Petar Tsintsarski. BY: Vstrecha. CH: Swiss AIDS Federation, Cantonal Hospital St. Gallen, Centre Hospitalier Universitaire Vaudois, University Hospital Zurich, Fachhochschule Nordwestschweiz, Swiss Federal Office of Public Health. CY: AIDS Solidarity Movement, University of Cyprus. CZ: AIDS pomoc, National Institute of Public Health, Tereza Zvolska, Dr Michal Pitoňák. DE: Deutsche AIDS-Hilfe, Robert Koch Institute, BZgA, Dr Michael Bochow, Dr Richard Lemke. DK: AIDS-Fondet, Statens Serum Institut, François Pinchon, Jakob Haff. EE: Eesti LGBT, VEK LGBT, Estonia National Institute for Health Development, Dr Kristi Rüütel. ES: Stop Sida, CEEISCAT, Ministerio de Sanidad. FI: Positiiviset, Hivpoint, SeksiPertti, Trasek, National Institute for Health and Welfare. FR: AIDES, Coalition PLUS, SexoSafe, Santé Publique France, INSERM. GR: Ath Checkpoint, Thess Checkpoint; Positive Voice. HR: Iskorak,, Zoran Dominković, Vjeko Vacek. HU: Háttér Society, Tamás Bereczky. IE: Gay Health Network, Man2Man, HIV Ireland, Outhouse, GOSHH, Sexual Health Centre Cork, AIDSWEST, Gay Community News, Health Service Executive, Gay Men's Health Service, Sexual Health and Crisis Pregnancy Programme, Health Protection Surveillance Centre, Mick Quinlan. IS: Samtökin '78. IT: Arcigay, Fondazione LILA Milano ONLUS, University of Verona, Dr Raffaele Lelleri. LT: demetra, LGL, Gayline. LV: Testpunkts, Baltic HIV Association, Dr Antons Mozalevskis, Indra Linina. MD: GENDERDOC-M. MK: Subversive Front, Dr. Kristefer Stojanovski. MT: Malta LGBTIQ Rights Movement, Allied Rainbow Communities, Infectious Disease Prevention and Control Unit, Silvan Agius, Russel Sammut. NL: Results in Health, Maastricht University, Amsterdam Pink Panel, Soa Aids Nederland, Rutgers, Rijksinstituut voor Volksgezondheid en Milieu, Dr Wim Vanden Berghe, Marije Veenstra. NO: Helseutvalget, Norwegian Directorate of Health, Folkehelseinstituttet, Dr Rigmor C. Berg. PL: Spoleczny Komitet ds AIDS, Kampania Przeciw Homofobii, Lambda Warszawa, National Institute of Public Health/National Institute of Hygiene, Dr Łukasz Henszel. PT: GAT Portugal, CheckpointLX, Associação ABRAÇO, rede ex aequo, SexED, dezanove, ILGA Portugal, Trombeta Bath, Instituto de Saúde Pública da Universidade do Porto. RO: Association “Eu sunt! Tu?”, PSI Romania, ARAS Romania, Tudor Kovacs. RS: Association Duga, Association Red Line, Omladina JAZAS-a Novi Sad, Institute of Public Health of Serbia, Sladjana Baros, Dr Marija Pantelic. RU: The Charity Foundation For Support of Social Initiatives and Public Health/LaSky Project. SE: RFSL, University of Gothenburg, Folkhålsomyndigheten. SI: ŠKUC, Legebitra, LJUDMILA. SK: PRIDE Košice, Light-House Slovakia, Slovak Medical University, Public Health Authority of the Slovak Republic, Dr Zuzana Klocháňová. TR: Pozitif Yaşam, Sami Sarper Yazıcılaroğlu. UA: Alliance for Public Health,,, Oleksii Shestakovskyi. UK: Terrence Higgins Trust, NAM, PrEPster, Antidote, Horizon Drugs and Alcohol Support, LGBT Foundation, Yorkshire MESMAC, MESMAC Newcastle, Derbyshire LGBT +, Trade Sexual Health, London Friend, GMFA, Spectra, International HIV Partnerships, International Planned Parenthood Federation, Bristol University, University College London, Sigma Research, Raul Soriano. Other: Dr John Pachankis, Dr Mark Hatzenbühler, Dr Valeria Stuardo Ávila, Dr Michael W. Ross.


EMIS-2017 was carried out as part of ESTICOM, under the service contract 2015 71 01 with The Consumers, Health, Agriculture and Food Executive Agency (Chafea), acting under powers delegated by the Commission of the European Union. The contract arises from the Call for tender No Chafea/2015/Health/38. Other financial contributions were received from: Swedish Ministry of Health for recruitment in the Nordic Countries; The Arctic University of Norway and University Hospital of North Norway for Russia.

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Authors and Affiliations



KS conceptualized the paper, conducted all analyses, and wrote the first draft. EJK, MCE, KRA, and ATG provided critical guidance on the methods, supported analytic interpretations, and reviewed various drafts of the paper. AJS was involved in the survey design and managed survey implementation, including data collection and cleaning, and provided feedback on iterations of the paper.

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Correspondence to Kristefer Stojanovski.

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The authors have no competing interests to declare that are relevant to the content of this article.

Ethical Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval to conduct the study was granted by The Observational Research Ethics Committee at the London School of Hygiene and Tropical Medicine (reference 14421/RR/8805). The University of Michigan Health and Behavioural Sciences Institutional Review Board categorized this secondary analysis of the data as exempt (HUM00165101).

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Informed consent was obtained from all individual participants included in the study. No images or personal data are published in this manuscript.

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Stojanovski, K., King, E.J., Amico, K.R. et al. Stigmatizing Policies Interact with Mental Health and Sexual Behaviours to Structurally Induce HIV Diagnoses Among European Men Who Have Sex with Men. AIDS Behav (2022).

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  • MSM
  • Europe
  • Policy
  • Stigma
  • HIV
  • Structural determinants