Health inequalities

• Author: Ford Hickson - Axel J. Schmidt - David S. Reid - Peter Weatherburn - Ulrich Marcus - Susanne B. Schink
• Pages: 110-137

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8. Health inequalities

This chapter asks ‘What are the levels of (1) sexu al morbidities, (2) ri sk and precaution behavio ur, (3) unmet

prevention needs and (4) u se of interventions, across the varied groups of MSM in the population that a re targets

for sexual health promotio n?’ To do this we consider how the binary indicators described i n Chapters 4 to 7 vary

across key target groups for s exual health promotion i dentified in Chapter 3.

We take this descriptive approach in order to facilitate acc ess to data that can addr ess the many specific qu estions

EMIS data users may have. Ou r partners and stakeholde rs have many different health concerns about a wide-

range of sub-populations of M SM. This chapter provid es data more tailored to thei r concerns. For example, the

chapter shows the percentag e of men with diagnosed HIV exper iencing anxiety/depressio n, or the percent of men

under 25 years who do not h ave access to condoms.

We look at the indicators acro ss four key demographics: age; ‘outness’; relationship status; and HIV diagnos is. We

also consider four minori ty MSM groups (trans MSM; MSM injecting drugs; asylum seeking and refugee MSM; an d

MSM selling sex) using the same set of indicators.

We provide data on total of 54 binary health indicators: 12 morbidity indicato rs; eight behaviour indicator s; 19

needs indicators; and 15 intervention indicators. We provide these binary indicato rs for a total of 24 groups: four

age groups; three ‘outness’ groups; three relationsh ip groups; two HIV diagnosis gro ups; four sex/gender identity

groups; two injecting groups; four mi grant groups; and two selling sex groups. In total, thi s chapter supplies 1 296

measures.

The chapter also consider s the question ‘Which subgroups of men have mult iple prevention needs that ar e poorly

met and should be priorit y target groups?’ In all of the subsequent tables shadi ng indicates the sub-group in which

the indicator is most extr eme. This highlights the sub-group with most morbidity, most risk beh aviour or least

precaution behaviour, greatest unmet health promotion needs, least experience of int erventions to improve health

and most experience of healt h-diminishing interventions. Columns with many highlighted cells indicate sub-groups

with consistently greater mor bidities, higher risks, lower precautions, gre ater unmet needs and les s experience of

interventions relative to oth er sub-groups. This allo ws for identification of priority groups in terms of those

characteristics.

Our approach to data pres entation is descriptive rather than statistical. We have not c alculated the probabiliti es of

these observed differences bei ng random as this is a no n-probability sample. We have not provided unadjusted

associations (e.g. odds ratios, risk ratios) between th e demographic target group s and the indicators as these can

be calculated from the data in the tables. We have not pro vided adjusted association s between the demographic

target groups and the indic ators (i.e. controlling for membership o f the other demographic target groups) as we

are not asking questions a bout the causality of th ese associations but de scribing the levels of the many indicators

in the myriad target group s.

In the tables below, where the denominat or for a cell is fewer than 20, we have not supplied the figure and instead

the cell contains the ch aracters ‘n<20’.

8.1 Summary

Age

• Morbidities: participants u nder 25 years were more likely to report poor mental health (anxiety/d epression

and suicidal thoughts) and sexual unhappiness, and if they h ad diagnosed HIV they were most likely to have

detectable viral load. A lcohol dependency and ac quisition of STIs was mo st common in 25–39-year-olds.

• Behaviour: sexual risk behavio ur was most common in 40–64-year-olds, who wer e also most likely to en gage

in precautionary behavio ur (taking ART and PrE P). While the under-25s wer e less likely to enga ge in risk

behaviour they were also least likely to be t aking ART if they had HIV or PrEP if they did n ot.

• Needs: participants under 2 5 years had higher levels of unmet need for most indicators.

• Interventions: the oldest and the youngest participants were least likely to access interventions. Under-25s

diagnosed with HIV were least likely to have ever had their infection monitor ed; to have had it monitored in the last

six months; and to h ave an undetecta ble viral load. Under-25s were also least likely to have ever received a

hepatitis A or a hepatitis B vaccination; or to have undertaken a full STI screen in the last 12 m onths.

Sex at birth and gender identity

• Morbidities: cis men were m ore likely to report diagnosed HIV and other STI infections. Trans men and non-

trans identified men who were female at birth w ere most likely to repor t severe anxiety and de pression,

suicidal thoughts and alcohol dependency.

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• Behaviour: non-steady sexual partner risks w ere less common in trans than cis men, as wa s using PrEP.

While injecting drugs w as as common in trans men as cis men, cis men were m uch more likely to eng age in

sexualised drug use.

• Needs: trans groups had gr eatest needs for almost all indicators.

• Interventions: access to in terventions was lower in trans groups and tra ns men (female at birt h) were most

likely to experience homophobic insult or abuse.

‘Outness’

• Morbidities: alcohol dep endency and infections wer e higher in participan ts with high levels o f ‘outness’, while

sexual unhappiness and po or mental health were more common in partici pants who were out to few or none

of the people they knew.

• Behaviour: sexual risk behavi our and precautions w ere more common in part icipants with high levels of

‘outness’. Participants w ho were not out were l ess likely to use ART if they had HIV, or PrEP if th ey did not.

• Needs: on almost all indic ators unmet need was m ore common in participan ts who were out to fewer people.

Participants who were out to few or no people kn ew less, had less con fidence, less access, les s support and

more concerns.

• Interventions: despite bein g most likely to be i n need, participants who were not out were less li kely to

access interventions (bu t also less likely to en counter homophobic abuse) .

Partnership status

• Morbidities: single partic ipants were more likel y to be sexually unhappy but most other morbiditi es were more

common among participants in partnerships, espec ially complicated ones. Participants in steady partnerships

had lower levels of anxi ety/depression and sexua l unhappiness.

• Behaviour: single particip ants and those in ‘co mplicated’ or multiple rel ationships had similarl y high average

numbers of non-steady partners and were al most as likely as each other to report condom less intercourse

with them.

• Needs: unmet need was most common in single men.

• Interventions: single parti cipants and those that reported their relation ship status was ‘compl icated’ have less

access to most interventio ns compared to partici pants with a steady part ner. While HIV prevalen ce is highest

in participants in a ste ady relationship, sin gle and ‘it’s complicated’ participants with diag nosed HIV were less

likely to have ever had th at HIV monitored; to hav e had it monitored in th e last 6 months; and to have

undetectable viral load.

Migrancy

• Morbidities: refugees and asylum seekers were mo re likely to report poor mental health, alco hol dependency

and/or to have been recently diagnosed with HIV and to have detectable viral load. No n-migrants were less

likely to report any mental h ealth morbidities an d less likely to report HIV infection in the la st 12 months, or

any of the other STIs.

• Behaviour: sexual risk with non-steady partners, injecting an d combining drugs and sex were most common

among participants who had migrat ed to live sexually lib erated lives. Refugees and asylum seekers were

more likely than average t o be injecting drugs but were less likely to be using ART or PrEP. Non-mi grants are

substantially less likel y to report all risk beh aviour, including having less non-steady partners in the last year.

• Needs: for most indicators it w as refugees and asylum se ekers who were most likely to be in need.

• Interventions: refugees and asylum seekers experien ced a high level of h omophobic abuse and wer e less

likely to encounter informatio n about safer sex or acc ess vaccinations.

HIV diagnosis

• Morbidities: all other in fections were more comm on among participants w ith diagnosed HIV, as wa s poor

mental health.

• Behaviour: sexual risk beh aviour, injecting dru gs and combining stimul ants and sex were notabl y more

common in participants dia gnosed with HIV.

• Needs: neither HIV diagnos is group showed a particularly gr eater need than the oth er.

• Interventions: participants n ot diagnosed with HIV wer e less likely to acces s all interventions.

Drug injecting

• Morbidities: all morbiditi es were more common among injectors, than non-in jectors, except sexual

unhappiness. The group of injectors included many more participant s with diagnosed HIV and w ere much

more likely to have been diagnosed with HIV in t he last 12 months.

• Behaviour: participants who injected had far higher numbers of sexual partners and were much more likely to

engage in sexual risk beh aviour but were also m ore likely to be using PrEP .