探討臺灣非異性戀男性愛滋篩檢、憂鬱情緒及其他心理社會因素與未保護性行為之關係

Abstract

背景： 臺灣愛滋感染人數至2020年6月已超越40,000人，其中以年輕男性為主，大部分是透過男性間性行為傳染。男性間性行為者以非異性戀男性為主（包含同性戀與雙性戀男性等），且與非固定性伴侶未保護性行為恐造成愛滋感染，為提升愛滋防治工作效能，探究非異性戀男性未保護性行為與潛在心理社會因素之關係有其必要性。 目的： 藉由質性訪談與量化問卷調查，了解非異性戀男性之愛滋暴險情境，及心理社會因素與其面對非固定性伴侶未保護性行為之關係。 方法： 本研究有25位曾有匿篩經驗非異性戀男性參與質性訪談，了解其對於愛滋篩檢服務之觀點與困境，以逐字稿及關鍵字編碼，歸納非異性戀男性之愛滋暴露風險與心理社會狀態。並運用相同方式對不同性取向者宣傳，透過多元管道於2019年8月至12月進行招募15-39歲台灣年輕男性，以線上匿名問卷方式調查其憂鬱情緒、心理社會因素與未保護性行為之實際觀點與現況，共有5,647人參與網路問卷填答。 結果： 從25位臺灣不同區域非異性戀男性訪談，非異性戀男性將愛滋篩檢視為一種健康檢查，對於愛滋篩檢服務較關注篩檢便利性、空間隱密性、人員性別友善度、客製化篩檢衛教、心理陪伴與支持、愛滋去汙名等六大面向，缺乏適當傾訴與管道，影響其心理健康，甚至增加未保護性行為之可能，顯示愛滋篩檢服務增加心理支持有其必要性。在量化研究中，同性戀與雙性戀相較於異性戀男性有較顯著的憂鬱情緒與過去一年未保護性行為，憂鬱程度與陽剛之性別氣質、研究所以上教育程度、有固定伴侶、知心好友數、工作狀態、每月收入有不同程度之負相關，嚴重憂鬱與規則飲酒和安非他命有關，而異性戀男性之憂鬱與過去一年非固定性伴侶未保護性行為及未來未保護性行為意圖有關，安非他命使用與同性戀及雙性戀男性未來未保護性行為意圖有關。進一步發現，在同性戀男性，憂鬱程度、過去一年非法物質使用、兒虐經驗、親密暴力彼此有顯著相關，且這些因素數量與過去一年為保護性行為與未來未保護性行為意圖有加乘性之效果，而在雙性戀男性並不顯著。此外，在結構方程式模型中，安非他命使用對於非異性戀男性過去一年與非固定性伴侶未保護性行為、HIV相關親密暴力有不同於其他非法物質之顯著關係。 結論： 從愛滋篩檢服務看見非異性戀男性之愛滋防治與心理社會困境，除了適合不同性取向需求之性健康知能外，亦需要友善之心理支持陪伴，而近年非異性戀男性之藥愛文化，需要進一步探究影響藥愛之心理社會因素。此外，同性戀男性與雙性戀男性可能有不同的特質，需要分別探討影響。愛滋防治工作若能跨領域合作，同時關注愛滋暴險行為底下之心理社會因素，讓愛滋防治工作成為更完整。

Background: According to statistics, over 40,000 cases of HIV infection had been reported in Taiwan up to June 2020. Most cases occurred among young men who have sex with men (MSM), mainly consisting of nonheterosexual men who identify themselves as gay, bisexual, or other MSM. They are at risk of contracting HIV, especially through unprotected sex with casual sex partners. Therefore, it is important to understand the significant psychosocial factors that influence intention to engage in unprotected sexual behavior among nonheterosexual men in order to optimize the effectiveness of HIV prevention efforts. Objectives: Through qualitative in-depth interviews and a quantitative survey, this study aimed to enhance our understanding about the context of HIV risk exposure and explore the relationships between the psychosocial factors and unprotected sexual behavior with casual sex partners among nonheterosexual men. Methods: Qualitative in-depth interviews were conducted with 25 nonheterosexual men who had HIV testing experience in the past to understand their views and barriers to using HIV testing services. Verbatim and keyword coding was employed to summarize their HIV risk exposure and psychosocial status. A cross-sectional anonymous online survey was conducted from August through December 2020, and participants were recruited using multiple channels. A total of 5,647 males aged 15–39 years in Taiwan participated in this survey. Results: The interviews with the 25 nonheterosexual men from different regions in Taiwan revealed that they viewed HIV testing as a health examination. In regard to HIV testing services, they are more concerned about the following six aspects: convenience, spatial privacy, gender friendliness, tailored sexual health education, psychological companionship and support, and HIV de-stigmatization. The lack of appropriate channels for self-disclosure may affect one’s mental health and even increase the likelihood of unprotected sexual behavior. This finding suggests that providing psychological support is imperative during the HIV testing process. The quantitative survey found that compared with heterosexual men, gay and bisexual men reported significantly more depression and unprotected sexual behavior in the past year. Depression was negatively associated with masculine gender characteristic, a master’s or higher degree, having regular sex partners, a larger number of close friends, employment status, and monthly income. Severe depression was related to regular drinking and amphetamine use in the past year. Among heterosexual men, depression was associated with unprotected sexual behavior in the past year and such intention with casual sex partners. Among gay and bisexual men, amphetamine use was significantly associated with future intention to have unprotected sexual behavior with casual sex partners. It was further discovered that, among gay men, depression, illicit drug use in the past year, child abuse experience, and intimate partner violence were significantly inter-related, and jointly the aforementioned syndemic factors had multiplicative effects on their unprotected sexual behavior in the past year and such intention in the future. However, this relationship was not significant among bisexual men. In addition, the structural equation models also showed that amphetamine use among nonheterosexual men was significantly linked to unprotected sex with casual partners and HIV-related intimate partner violence in the past year, which was different from the relationships found with other illicit drugs. Conclusions: Nonheterosexual men’s HIV testing experience revealed a psychosocial dilemma in HIV prevention. Besides tailored sexual health education for men of different sexual orientation, friendly psychological support is also needed. In light of the emerging chemsex practices, more research is warranted to explore the psychosocial factors associated with chemsex among nonheterosexual men. In addition, gay and bisexual men may have different characteristics and be driven by different mechanisms, and therefore need to be explored separately. In sum, HIV prevention programs could be optimized by strengthening interdisciplinary cooperation across various professional fields and tackling the psychosocial factors underlying HIV risk behavior.