Generational analysis of trends in unprotected sex in France among men who have sex with men: The major role of context-driven evolving patterns

Objective: Using a generational approach, this study analyses how unprotected anal intercourse has evolved since 1991 in France across different generations of men who have sex with men (MSM) whose sexual lives began at different periods in the history of the HIV epidemic. Design: Data were collected from 18–59 year-old respondents to the French Gay Press surveys Enquêtes Presse Gay, conducted repeatedly between 1991 and 2011 (N = 32,196) using self-administered questionnaires distributed in gay magazines and over the internet. Methods: Trends in unprotected anal intercourse (i.e. condomless anal sex) with casual partners of unknown or different HIV serostatus (hereafter “UAId” in this manuscript) were studied. Responses were analysed according to year and then reorganised for age-cohort analyses by generation, based on the year respondents turned 18. Results: UAId rates fell from 1991 to 1997, and then rose from 13.4% in 1997 to 25.5% in 2011 among seronegative respondents, and from 24.8% to 63.3%, respectively, among seropositive respondents. Both in seropositive and seronegative respondents, UAId increased over time for all generations, indicative of a strong period effect. Conclusion: Analyses of data from several generations of MSM who started their sexual lives at different time points in the HIV epidemic, revealed very similar trends in UAId between generations, among both seropositive and seronegative respondents. This strong period effect suggests that sexual behaviours in MSM are influenced more by contextual than generational factors. The fact that prevention practices are simultaneously observed in different generations and that there are most likely underlying prevention norms among MSM, suggests that PrEP could become widely accepted by all generations of MSM exposed to the risk of HIV.