Social and sexual networks of newly diagnosed people living with HIV: a qualitative social network analysis

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As environmental and social context play an important role in explaining HIV acquisition despite the availability of effective HIV prevention, this study investigated the role of social and sexual networks in HIV prevention and risk behavior among people newly diagnosed with HIV, including their perceptions of how they acquired HIV and their ability to disclose their HIV status. Methods This qualitative study used an ego-centric social network approach, through in-depth interviews generating sociograms of social and sexual networks with 20 participants newly diagnosed with HIV. Results Friends, family members, regular sex partners and HIV physicians were placed closest to the ego on the sociogram. Self-identified gay men did not consider their casual sex partners as emotionally close enough to be included in the sociogram, even though these partners were often participants’ primary source of information about sexual health. HIV acquisition among this group was often attributed to increased sexual risk-taking under influence of drugs. Heterosexual and bisexual men who have sex with men (MSM), who had more diverse networks, often did not consider themselves at risk for HIV. Awareness of PrEP was higher among gay-identified MSM than among heterosexuals and heterosexual MSM, partly attributed to community-based prevention efforts. Most participants only disclosed HIV to those closest to them, and the anticipated and perceived lack of social support influenced HIV acceptance. Feelings of internalized HIV stigma and homophobia prevented HIV disclosure, especially among heterosexuals and heterosexual and bisexual MSM. Conclusion This study revealed important differences in the networks of gay-identified MSM, heterosexuals and hetero- and bisexual identified MSM influencing sexual risk taking and prevention behavior. Future prevention initiatives should be inclusive and mainstreamed to ensure to also address those who do not identify as the established transmission groups. Awareness of biomedical prevention should be raised in the general population, providing a base on which more tailored promotion can be built. Involving family physicians and social empowering people living with HIV may help to decrease (anticipated) HIV stigma. HIV Social Network Analysis behavior prevention Figures Figure 1 Introduction The HIV epidemic in Belgium remains at a comparatively high level within western Europe. Belgium has a high number of new HIV diagnoses (9.1/100 000 inhabitants compared with the EU average (5.1/100.000) 1 . The HIV epidemic in Belgium is concentrated among men who have sex with men (MSM) and heterosexual individuals of Sub-Saharan African origin. In 2022, 597 people were newly diagnosed with HIV, 51% were heterosexuals and 43% were MSM. Surveillance data showed a general slight decrease of new diagnoses over the last years, while in 2022 new HIV diagnoses increased among MSM aged 20 to 29 years and heterosexual women with a sub-Saharan African background 2 . HIV Pre-Exposure Prophylaxis (PrEP) is being reimbursed by the public health insurance in Belgium since 2017, and more than 6000 people have accessed it since 2 , 3 . Because there has been no significant reduction in new HIV cases, we need better insights into the dynamics that lead to new HIV acquisitions in particular key-populations. The most current study on recent HIV infections conducted in Belgium between May 2018 and December 2022 among 93 participants who most likely acquired HIV less than three months ago, showed that more than half of them were MSM (74%), 14% were heterosexual women and 12% were heterosexual men. Participants reported high sexual risk-taking behavior, such as frequent substance use during sexual activity (65%), having been previously diagnosed with STI (65%) and inconsistent condom use (44%). Nearly one-third of participants had engaged in sexual activity with multiple partners (i.e. average of two to five casual partners). However, over 20% of participants (11 MSM, 4 heterosexual men and 5 heterosexual women) reported exclusive sexual activity with their steady partner 4 . Also a Dutch study found that recent HIV acquisition was associated with having an STI in the past, multiple partners and condom use among MSM 5 . The variety in sexual and HIV prevention behavior found in these studies calls for an in-depth understanding of what causes the observed differences, including the social contexts in which social and sexual norms and behaviors are embedded, as those data are lacking for the Belgian context. Current research on recent HIV infections among MSM points to the fact that environmental and social context play an important role in explaining how HIV is acquired, how HIV prevention measures such as consistent condom use and PrEP are adopted and how frequently people get tested for HIV and other sexually transmitted infections (STIs) 6 , 7 . Sexual risk-taking has been shown to be partially influenced by community beliefs regarding treatment and HIV normalization 8 . Furthermore, alcohol- and substance use and sexual risk behavior may be encouraged in certain social environments such as online social media, dating apps, or in places where people practice sexualized drug use, a growing phenomenon in Belgium and Europe 9 . Several studies have used socio-ecological approaches to understand contextual and social influences 9 , 10 however a social network analysis (SNA) adds to deepen our understanding of how social and sexual networks influence individual prevention behavior and risk taking. In SNA, the relationship (i.e. the “tie”) between the ego (i.e. the participant) and alter (i.e. the people in their networks, sometimes also referred to as “nodes”) and its influence on social and sexual norms/behavior becomes the focus of analysis 11 . Therefore, exploring social and sexual networks is increasingly used as an approach to understand how personal attitudes and actions are shaped by interpersonal relationships 6 , 7 , 9 . The specific position that people have within their social networks may potentially influence HIV acquisition risks and may be useful for tailoring HIV prevention strategies within peer networks 12 . Despite current HIV combination prevention efforts including the availability of post-exposure prophylaxis (PEP) and PrEP, missed opportunities to reach specific groups at risk of acquiring HIV do exist, as evidenced by the reported number of new HIV infections. HIV testing is a crucial first step in the HIV continuum of care and considered the weakest part in the Belgian continuum of care 2 , 13 . Further understanding how peer-driven HIV testing in social/sexual networks can improve early detection of undiagnosed people living with HIV 14 , may be crucial for the development of social/sexual network HIV prevention and testing interventions. Therefore, this study included a brief pilot HIV self-testing intervention using a network approach. The main aim of this study was to describe social and sexual networks among people newly diagnosed with HIV and their influence on preventive and risk behavior, including their perceptions on how they acquired HIV. Methods Study design This qualitative egocentric social network study used a phenomenological approach 15 to collect data on participants’ social and sexual networks from the participants’ own point of view, i.e. their core personal networks 16 without further recruiting other individuals within their respective networks. We also embedded a brief HIV self-sampling intervention offering the study participants the opportunity to distribute HIV self-sampling kits among their networks. Study setting and participants This study was a sub-study to the quantitative study using a self-reported questionnaire (online or on paper) to assess factors associated with new HIV acquisitions covering topics on HIV testing, STIs, PrEP use, sexual behavior, partner notification and substance use 4 . inclusion in the quantitative study, participants needed to be adult people living with HIV (PLHIV) (≥ 18 years of age) who were newly diagnosed with HIV (i.e. diagnosis < 3 months after HIV infection). All participants who had already completed the questionnaire and gave permission to participate in follow-up research were invited to participate in this qualitative social network study. All participants were in follow-up at the HIV clinic in Ghent or Antwerp and had signed the informed consent form for participation in this SNA study. They received a €25 voucher to reimburse their participation in the study. Data collection We conducted interviews face to face or online using secure technologies from March to October 2022. Three trained interviewers (CVB, AR, and EVL) employed a sociogram-aided interviewing technique 7 , utilizing low-tech tools such as paper, pencils, and post-it notes. This approach aimed to jointly generate visual representations of participants' social and sexual networks focusing on the period around their HIV diagnosis. Interviewers used general name generator questions to compile a list of potential connections within their networks (i.e. "alters"). Subsequently, they asked participants to position each alter on a paper with concentric circles, representing hierarchical proximity to the ego (utilizing a hierarchical mapping sociogram, see Fig. 1). At this stage, additional alters could be added. By prompting the nature of the ties with each mentioned network members (or groups of members), the interviewers explored the relationships with the alters using color codes to distinguish with whom they had discussed their sexual life, advice on safe sex, support with sexual problems and sexual orientation (in analogy with Shell-Duncan et al. 7 , see Fig. 1 for legend). These egocentric social network maps served as a basis for further exploring topics aligned with the research objectives through unstructured interviewing. The resulting narratives contextualized and complemented the visually constructed data. Topics of exploration included participant’s daily life, support structures, significant relationships, as well as social, sexual, and preventive behaviors and social norms within their networks. We conducted one pilot interview to test the questions and methodology beforehand. After three interviews, the topic guide was slightly adapted by adding a category of (psycho-)social support arrows to the sociogram (see legend in Fig. 1). Interviews lasted around one hour and a half on average. At the end of the interview, we offered each participant up to five HIV self-sampling kits to voluntarily distribute to individuals in their social and sexual networks whom they believed to benefit from HIV testing. Participants who agreed to distribute kits provided consent to be contacted via telephone or email after three months, to document the number of kits distributed, the relationship between the participant and the recipients, and their experience with the distribution process. In collaboration with an ongoing HIV self-sampling project 17 , 18 , which procured the kits, we documented the number of kits used and the test results, linked to each participant via the specific kit codes. Data analysis Interviews were conducted in Dutch (n = 18), English (n = 1), or French (n = 1), audio-recorded and transcribed verbatim. We conducted the data analysis in two steps. First, we scrutinized the sociograms independently of the narratives. This involved a descriptive analysis of the sociogram structure, such as the quantity of alters, the characteristics of their relationships ("ties"), and an overall assessment of the visual data. We coded the types of ties assigning general categories, as described in the results. Subsequently, we compiled a detailed depiction of the visual data, describing the sociogram's appearance and the connections between alters and the ego. In the second step, we analyzed the verbatim transcribed interview data using a reflexive thematic analysis approach 19 , aimed at interpreting participants' perceptions regarding alters, ties, and the other explored topics. We immersed ourselves in the data by revisiting the sociograms, reviewing our field notes, and re-examining the transcripts. Subsequently, the entire dataset underwent coding to identify themes addressing our research question, while maintaining a focus on the social network perspective. We identified initial themes related to overarching patterns among the created codes. These themes were then cross-checked against the coded data and collaboratively discussed within the research team (CN, CVB, AR & EVL). Prior to finalizing the analysis, iterative cycles between various stages allowed for the refinement, redefinition, and naming of the ultimate themes. Reflexivity Data was collected by AR, CVB & EVL and analysed by CVB & EVL (first authors). CVB, AR and EVL are all women with a Belgian background and native Dutch speakers. EVL has a social science background and has been employed as a researcher in the field of HIV and sexual health for several years, focusing mainly on prevention among migrants. AR has a background as a pharmacist and public health specialist. She has been working as a researcher in the field of HIV and sexual health for several years, using mixed methods and has focused on PrEP user preferences. CVB combines research work focusing on quality of life and stigma among persons living with HIV with clinical practice as a psychologist/sexologist in an HIV clinic, allowing for daily professional contact with people living with HIV. Results Participant description Among the newly diagnosed participants from the quantitative study, 84 participants indicated their willingness to participate in follow-up research. All 84 were contacted by the researchers. Finally, 21 people participated in this qualitative study. One participant preferred not to continue after a few questions. This interview was excluded from the analysis, bringing the total number of participants completing the interview to N = 20. Table 1 provides an overview of the profiles of the 20 participants. Participant’s age ranged from 21 to 70 years, with a median age of 44 years. The majority were male (n = 19). Thirteen participants identified themselves as gay men who have sex with men (gMSM), two as heterosexual men who have sex with women (hMSW), one as a heterosexual men who has sex with only men (hMSM), one as heterosexual woman who has sex with men (hWSM), and three as bisexual men who only had sex with men (bMSM) at the time of diagnosis. 1 . All participants, except four, were diagnosed with a recent HIV infection (diagnosis 3 months after HIV infection. All participants had the Belgian nationality, five of them were born abroad. More than half of the participants had completed higher education (n = 12). Table 1 Overview of participants Participants Age category Sex at birth Country of birth Education level Sexual orientation*/identity Sexual behavior Relational status at moment of diagnosis Network composition (N = size) 1 [70–79] Male Belgium Higher education Bisexual Sex with men Single N = 9 Friends (n = 5) Family (n = 3) Health care provider (n = 1) 2 [60–69] Male Belgium Secondary education Homosexual Sex with men Single N = 6 Friends (n = 2) Co-workers (n = 1) Health care provider (n = 1) Family (n = 2) 3 [18–29] Male Non-European country Secondary education Homosexual Sex with men Married (male partner) N = 1 Life partner (n = 1) 4 [30–39] Male Belgium Primary education Homosexual Sex with men Married (male partner) N = 9 Life partner (n = 1) Friends (n = 3) Health care provider (n = 3) Acquaintance (volunteering) (n = 2) 5 [50–59] Male Belgium Higher education Homosexual Sex with men Married (male partner) N = 12 Friends (n = 6) Family (n = 4) Acquaintances (neighbours) Life partner (n = 1) 6 [40–49] Male Belgium Higher education Heterosexual Sex with women** Married (female partner) N = 14 Life partner (n = 1) Family (n = 7) Friends (n = 3) Co-worker (n = 1) Health care provider (n = 2) 7 [50–59] Male Belgium Secondary education Homosexual Sex with men Single N = 8 Friends (n = 5) Health care provider (n = 1) Ex-partner (n = 1) Family (n = 1) 8 [60–69] Male Belgium Higher education Bisexual Sex with men Married (female partner) N = 9 Life partner (n = 1) Family (n = 2) Regular sex partner (n = 2) Acquaintance (internet) Health care provider (n = 2) Casual sex partner (n = 1) 9 [50–59] Male Other European country Higher education Homosexual Sex with men Married (male partner) N = 10 Friends (n = 5) Family (n = 3) Life partner (n = 1) Health care provider (n = 1) 10 [50–59] Male Belgium Secondary education Heterosexual Sex with women Single N = 8 Family (n = 3) Co-workers (n = 1) Acquaintance (neighbor) (n = 1) Health care provider (n = 1) Ex-partner (n = 1) Sexual health organization (n = 1) 11 [40–49] Male Belgium Higher education Homosexual Sex with men Single N = 10 Friends (n = 3) Family (n = 3) Co-workers (n = 2) Health care provider (n = 1) Regular sex partner (n = 1) 12 [40–49] Male Belgium Secondary education Homosexual Sex with men In relationship (male partner) N = 11 Friends (n = 7) Co-workers (n = 1) Life partner (n = 1) Family (N = 1) Casual sex partner (n = 1) 13 [60–69] Male Belgium Higher education Heterosexual Sex with men Married (female partner) N = 7 Life partner (n = 1) Family (N = 2) Friends (n = 3) Casual sex partner (n = 1) 14 [60–69] Male Belgium Secondary education Bisexual Sex with men Married (female partner) N = 11 Friends (n = 2) Life partner (n = 1) Acquaintance (n = 1) Family (n = 4) Co-worker (n = 1) Regular sex partners (n = 2) 15 [18–29] Male Belgium Higher education Homosexual Sex with men Single N = 6 Family member (n = 2) Friends close (n = 1) Friends far Gayscene Casual sex partners (n = 1) 16 [30–39] Male Other European country Higher education Homosexual Sex with men Single N = 4 Family member (n = 1) Casual sex partners Acquaintances (hobby) (n = 1) Acquaintances (Neighbours)(n = 1) 17 [30–39] Male Non-European country Higher education Homosexual Sex with men In relationship (male partner) N = 7 Life partner (n = 1) Friends (n = 3) Co-worker (n = 1) Family member (n = 1) Casual sex partner (n = 1) 18 [30–39] Female Non-European country Secondary education Heterosexual Sex with men Single N = 6 Friend (n = 1) Family member (n = 2) Life partner (n = 1) Regular sex partner (n = 1) Casual sex partner (n = 1) 19 [30–39] Male Belgium Higher education Homosexual Sex with men Single N = 10 Friends (n = 5) Anonymous sex partner (n = 1) Regular sex partner (n = 3) Family (n = 1) 20 [30–39] Male Non-European country Higher education Homosexual Sex with men Single N = 6 Friends (n = 4) Ex-partner (n = 1) Casual sex partner *Sexual orientation is based on self-identification of participants (as homosexual, heterosexual or bisexual) **For all participants, except one (participant 6), sexual behavior is identical to their perception of HIV acquisition. For participant 6, the transmission mode is unknown *** Partners and sex partners are divided in the following categories; (1) “Life partner” is used in case of marriage or long term relationship, (2) “Regular sex partners” for known sex partners and steady sex partners and (3) “Casual sex partners” are loose sexual contacts, which could include anonymous contacts as well [insert Table 1 ] Description of personal social and sexual networks Sociograms and descriptives of alters Overall, we constructed 19 sociograms. One participant considered the alters he listed as not relevant for his sexual health or HIV prevention, not wanting to draw a sociogram but only discussing his networks during the interview. The name-generator questions resulted in a minimum of 1 and a maximum of 14 alters, with a mean of 8.26 (see Table 1 ). Participants differed in the number of alters that were added to the sociogram, i.e. ranging 1 to 13, mean: 6.11. Various reasons, such as grouping several alters together under one name (e.g. “choir friends”) or realizing that the alter was not very influential after all, accounted for this difference. The participants placed the alters on the sociogram in a way that felt most truthful to them. As one participant put it: Based on who I can go to with problems, based on who I do a lot with, based on... yes really purely on that Participant 15, gMSM The most frequently mentioned alter was ‘friend’. Participants described different kinds of friends, some were ‘just’ friends, others were described as ‘best friends’. Family members and health service providers (i.e. mostly HIV physicians) ranged second and third in terms of positions. Life partners and sex partners were also often mentioned, depending on the personal situation of the participant. One participant noted the ‘gay scene’ as an alter on his sociogram, as a resource where he could find information or support. Although many other participants did not place the gay scene or community as such in their sociograms, many mentioned its importance multiple times in their narratives. Consequently, the most mentioned tie fell into the ’friends’ category, mentioned 58 times across all participants. ‘Family’ ranked second, with family members being mentioned 41, then health care providers (n = 13), partners (n = 11) and regular sex partners (n = 10). The following paragraph describes the ties more in depth, in order of the frequency in which participants mentioned them. Description of ties Friends Many participants who identified as gMSM, described a difference between their “straight friends” (“ my hetero friend circle” ; participant 2, gMSM) and “gay friends”. The last group must not be confused with the gay scene, or casual sex partners, on which we describe more below. Male and female...uhm...yes, but I see my...how should I put it, the friends I've known the longest or who I'm still in touch with the most now, I think are the friends I met at uni. And that's both male, female, of the same age. And then there are also...uhm...yes, friends uhm...from the gay scene that I got to know. Yes, these are obviously male friends, but uhm...yes, that's a totally different group for me, that's still...actually that's still totally different Participant 15, gMSM However, some participants reported to deliberately have stayed away from the “gay scene”: And, uhm very little into the gay scene, yeah it wasn't like that. Always kind of stayed away there, also very consciously Participant 12, gMSM Family members Participants who reportedly had a good relationship with their parents indicated that family members were also be influential in life choices, such as the prevention of unwanted pregnancy, but mostly not in matters directly related to their sexuality. With my parents, you sometimes talk about sex, especially when you were a bit younger. Now it's rather that you sometimes laugh about it, but you don't have those deep questions about sex now either, especially at the age I am by now. When you were young, you do talk to your parents about sex and contraceptives, sexual health, the first time you had sexual contact with someone. Participant 6, hMSW Co-workers Participants often shared that many co-workers had become friends, with whom sexual behavior would sometimes be discussed, although not from a health perspective. Life and sex partners Life partners were important to participants, both emotionally and to talk about sexual health. As mentioned above, sex partners could also be a source of information regarding sexual health. Then also PrEP came up and so a lot of people take PrEP so it does come up often because people then ask of okay 'what are you taking?' or 'are you not taking it?' Participant 15, gMSM Health care providers Many participants included their health care providers in the sociogram because of the important role they played in their diagnosis and treatment, often being the first confidant and source of information when receiving the diagnosis. These were mostly physicians at sexual health clinics. Although many participants described also good relationships with their family physicians (FP), some reported to have been disappointed by the physician’s reaction to their HIV diagnosis, or the way they approached their sexual health. Participants who felt comfortable to initiate the topic of sexual health with the FP did so, however, many could not proactively begin such a discussion. One participant even highlighted that it was the FPs’ responsibility to initiate such conversations. Across the line, the specialized HIV physicians, however, received a special place in the sociograms: More distant, but definitely a confidant. I always look at the top left corner, then I do place them well within the circle. It's not like we're going out for drinks with [HIV physician], it remains a purely professional relationship. It's someone to whom we can tell a story and trust very deeply. Participant 5, gMSM Sex partners A few gMSM participants indicated their social and sexual networks overlapped, in that they might have had sex with a good friend, or that a sex partner had become a good friend afterwards. However, this was not very common. Unless a sex partner was also a life partner or a regular sex partner, participants often did not include them in the sociograms. If they did, they placed them at a big distance from the ego. This may indicate emotional distance between the ego and their casual sex partners: That's purely sexual, that's nothing like friendship or trust or anything Participant 2, gMSM Four participants described completely separate social and sexual networks. These were men who were having sexual relationships with men, but were married to a woman I am actually mostly straight, but circumstances have made me look more at men, meeting them and having sex with them. For love, I prefer a woman, but for sex I prefer a man. Participant 1, bMSM Mostly gMSM and some hMSM and bMSM participants preferred completely anonymous sexual contacts, seeking sex in public venues such as in saunas or parks: For me that’s something very… it’s stuck in that box, it’s closed and it doesn’t come out Participant 13, hMSM gMSM participants also shared experiences of meeting men for sex in similar circumstances: If all the gays in this city would spill the beans (...), a lot of men are going to get beaten up and not allowed out [by their wives]. (..). Then they usually say they are monogamous, that's the shame of it. Participant 11, gMSM bMSM and hMSM participants apparently struggled with explicitly naming their sexual identity. Some identified as bisexual, one as a man who has sex with other men, one man just labelled himself as straight (see quote above). Having to conceal their sexual behavior had an impact on their mental health. The compartmentalizing of both worlds and the hypervigilance in keeping them separate felt like a huge burden for these participants: “Should tomorrow my wife be gone and a man would say, "Are we going to live together?" I wouldn't be able to. No, not at all. I can't kiss with men either, very strange right. I can’t figure out why that is. You can't say to yourself am I gay or straight now or am I both? You can't place that, because if you then say I'm gay because I have sex with men, but I can't kiss with them and live with them....” Participant 14, bMSM Influence of social and sexual networks on prevention behavior The “gay scene” For many gMSM another influencing factor on prevention decisions was the “gay scene” or “gay community”; they perceived the many community-directed prevention efforts over the years as a positive, awareness-raising influence. In contrast, they found heterosexual communities as having lower HIV awareness, including a lack of information on PrEP and PEP, resulting in less frequently testing for HIV and generally a lower HIV risk perception. “I think that we, especially in the past 10 years, have been working on it [HIV prevention], especially in the gay community. There is definitely awareness. (…) I think specifically in the gay community, there is awareness; you just have to look at the long term. How many people openly talk about it there, it can be discussed. This wasn't the case about 5 years ago." Participant 5, gMSM Some gMSM participants were of the opinion that that straight people were just not aware of their HIV risk, as they “ think it doesn’t exist with them [the straights] ” (Participant 11, gMSM). Likewise, some gMSM perceived ‘straight’ men to be less aware of HIV prevention techniques, leading to risky behaviors and ultimately HIV transmission. The straights always have different thoughts about that [HIV], which is then 'with us' it doesn't happen. An accident is waiting to happen and I am living proof of that. I told them I got it from someone from 'with us' Participant 11, gMSM Some gMSM participants highlighted it was much easier to discuss sexual health with their gay friends, or casual sex partners than with their heterosexual friends: I also think you can broach those subjects [sexual health/sexuality] much easier because, yes, those are not people with whom that you have a whole history or who you also see in a different context. So I think I discuss sexual matters mainly with those gay friends or with those casual contacts Participant 15, g MSM On the contrary, heterosexual participants shared that real sexual matters were rarely discussed, if at all only jokingly, and mostly with friends or co-workers: Yes, at work that gets some laughs, but nothing serious now. I don't actually speak [about sexuality] ... except that you joke about it sometimes. Men will be men of course. Participant 10, gMSM Condom and PrEP use Participants indicated to mainly discuss their sexual health with people who have a similar sexual orientation, or with their sex partners. These network members also influenced decisions on HIV prevention and prevention behavior. Many participants reported that they used condoms only when their sex partner had explicitly asked for it, but explained that they often had performed condomless sex without clear communication and/or joint decision-taking. Reportedly, this was partly influenced by group dynamics, as one participant highlighted that asking for a condom could be considered disruptive in the sexual situation: " You don't want to be nagging. You don't want to be the one who says 'guys, let's all keep our condoms on'. It's not so much about not wanting to be a nag or a fool, but there's a flow in the evening where at that moment it doesn't matter so much anymore." Participant 19, gMSM At the time of diagnosis, some participants indicated to always have had the intention to use a condom, but that they sometimes forgot, or decided for condomless sex with a partner they trusted. Additionally, the only female participant added that most men just did not want to wear a condom, although she had tried. "Yeah, I really wanted to do that [use a condom], but yeah... yeah... it just doesn't work, you know. It just doesn't work with some men. Then you think 'okay, I tried'." Participant 18, hWSM Awareness of PrEP and/or PEP was higher among gMSM (n = 11/13) than among hMSM,bMSM (n = 2/4) and heterosexual participants (n = 0/3) at the time of the HIV diagnosis. However, many believed that it could have played an important role in preventing HIV, if they had had the opportunity to take P(r)EP. In some cases, where the FP was included within participant’s social networks and was of influence of discussing their sexual health, the FP had provided incorrect information: I asked the family physician for PrEP. She said that I was not living with someone who was HIV positive and that she could not prescribe it at that time Participant 8, bMSM gMSM were often aware of the existence of P(r)EP, but the FP did not always correctly estimate the person at risk for HIV: Something I regret is that at the beginning of the open relationship, we went to the family physician to ask for information and advice. He never talked about PrEP or the PEP pill. Afterwards, I thought 'damn, if the family physician had prescribed PrEP at the time we were discussing the open relationship, I would not be in this situation Participant 17, gMSM Practical considerations were also reported as reasons for not starting PrEP medication: Yes, I had asked my family physician for PrEP, but he said I had to come to the HIV reference center. I found that a little difficult. If I had gotten PrEP from my family physician, it would never have happened Participant 20, gMSM Some participants, while being aware of PrEP, did not use it, because they did not perceive themselves at risk for HIV, due to adopting other prevention strategies such as regular HIV testing, condom use or low risk perception: I went for STI screening. Although all results were negative, the doctor asked if I heard about PrEP and recommended to start with it. I remember saying something like 'no, I do not think it is necessary’ Participant 15, gMSM Substance use Many gMSM participants reported that their drug use often interfered with condom use. One participant explained how the normalisation of drugs led to sexual risk taking: "Social pressure might be a bit of a heavy term, but it was almost normal that when we went out, drugs would be used. (…) I felt that it made me less likely to say ‘no’ when I would have said ‘no’ if I hadn’t been under the influence. Under influence, I didn’t say it as quickly. Not because others encouraged me, but because of the influence of those drugs.” Participant 17, hMSW Participant’s perceptions of how they had acquired HIV Generally, participants had a good understanding of the circumstances leading to their HIV acquisition; only one heterosexual man reported that he had no idea of the transmission route. Bisexual participants indicated to have acquired HIV through sexual contact(s) with men; and also two heterosexual men reported to have acquired HIV through unprotected sex with men. There was HIV and ... but not with us, a distant matter. Kind of nonchalant thinking that it won't happen to me Participant 8, bMSM Most of the gMSM participants were aware of their sexual risk-taking behavior. Within their sexual networks, they perceived substance use as getting normalized and HIV acquisition often occurred under influence of alcohol and/or drugs. Yes, that's also the problem, the availability of drugs and alcohol at the parties. That makes it very difficult to discuss condoms when it comes to unprotected sex because you're in a certain higher atmosphere where it doesn't matter much anymore, and everybody does it Participant 19, gMSM Also, some gMSM, mainly those with a larger sexual network, reported going through a mentally difficult time and as a result, they engaged in taking more sexual risks. It was a shock while I knew I had risk behavior. In fact, it should not have been a shock Participant 19, gMSM Two gMSM participants mentioned that they got HIV infected through ‘bad luck’. These participants reported very small sexual networks and said to always have used condoms except during that one sexual contact. I was really, really careful. And then there was the accident Participant 7, gMSM Disclosure from a social/sexual network perspective Disclosure HIV disclosure to significant others remained a source of continuous stress that participants were facing. Many reported that it was a difficult consideration to decide who to (not) disclose their HIV status to. Most participants had disclosed to the persons placed closest to the ego in their sociograms. All, except one, have told at least one person within their social network, other than the medical staff, that they were HIV positive. The quality of participants’ ties to their alters clearly influenced communication about HIV, and in in particular who they had disclosed their HIV status to. “The diagnosis in itself made it acutely clear to me who I wanted to inform. The people I felt needed to hear from me, and felt like they needed to know because it’s the people I am close to or often spend time with” Participant 19, gMSM Disclosure had happened in most cases in the first weeks after diagnosis to closely related persons, mostly because of fear to transmit the virus (in the period in which they were not yet undetectable). This disclosure process went well for all participants, and no one had to deal with negative reactions from people within their social network. “’Just because you have HIV does not mean you are different. For me, that does not change anything.’ That was the response I got from the first person I told, so that was really positive” Participant 11, gMSM For those who could share that they were living with HIV within their social networks, they did so to be able to openly talk about their concerns, share experiences, and receive mental support. However, (anticipated) lack of social support influenced the acceptance of the HIV diagnosis. Persons who had little social support, found it more difficult to accept their HIV status. As a result, they continued to keep their HIV diagnosis secretely and thus could not benefit from social support to better cope with their diagnosis. “From the age of 12, I have always had a pretty closed ‘world of living’... No one knows, no I carry it all by myself... It is very hard to live with. I have everything, I have my own house, I have a car. I am not rich, but I have everything. But tomorrow, if they would say that there is a cure for HIV, they can have everything from me, I would even want to live on the street. I find it terribly hard to have” Participant 10, hMSW Often only sex partner(s) who were considered as ‘life partner(s)’ of ‘regular sex partner(s) were included in the social networks. In those cases, participants always informed their regular sex partner(s) about the HIV diagnosis, yet only after a few sexual interactions. Only one individual had shared his HIV status with casual sex partners. The following quote illustrates commonly mentioned reasons for non-disclosure to casual sex partners. “A casual sex contact should not know that. I take my medication. I am undetectable. I hope it stays that way. That reassures me so why should I tell?” Participant 2, gMSM HIV stigma Anticipated HIV-stigma could be identified as an important factor for non-disclosure to persons placed more distant from the ego in their social network. With network members belonging to the closer social network, participants often would not disclose HIV because they did not want to unnecessarily worry family members, or they wanted to protect them from negative reactions. Only few participants shared their HIV diagnosis with their professional network or with less good friends. “Because I believe the more people know the more likely it is that someday someone will react badly. And that will have an impact on my children. I don't expect that now, but I don't want to take that risk. That's a very conscious decision” Participant 6, hMSW Especially heterosexuals and bMSM kept themselves from sharing their diagnosis with persons within the social network because of feelings of both anticipated and internalized HIV stigma: “I think for my friends HIV is still linked to prostitution, homosexuality and drugs. If I did not have HIV myself, I might think like that too” Participant 6, hMSW Also, feelings of internalized homophobia determined non-disclosure of HIV: “Besides those few persons, no one knows about my HIV because I am also afraid to be confronted with that stigma. I am not a person like in the clichés of unsafe behavior and decadence etc. I like to go out and dance. I also took drugs, xtc, coke and alcohol from time to time, but never to the extent that I led a normless life, quite the contrary. No, the problem is that if I tell my friends or family that I am HIV positive than I will be stigmatized as gay. I am not gay because I do not like men, I only have sex with men” Participant 13,hMSM Peer distribution of HIV self-sampling kits Overall, nine participants accepted a total of 38 self-sampling kits for distribution, with each participant taking between one to five kits. Only four participants actually distributed the kits (N=11) within their networks. Participants who did not distribute the HIV self-sampling kits reported reluctance to disclose their HIV status, as distributing the kits would have demanded such disclosure. Additionally, they said to be unaware of individuals who could benefit from HIV self-sampling. Participants who did accept the kits for distribution (all gMSM), were those who reported to have experienced less difficulties to disclose their HIV status. One participant gave three kits to his children and one participant gave three kits to persons who visited the pharmacy in which he was employed. Another participant gave one of the five kits to someone who knew the participant’s HIV status and attempted to distribute the remaining kits to others in his network. However, they were not accepted due to their low perceived need (e.g. recipients already getting tested occasionally or having fewer sexual contacts). The last participant shared four kits among his sex partners. Nobody reported negative experiences when distributing the kits. Reasons for not distributing the remaining kits were the loss of the kits, forgetting it, or finding it too challenging to promote. One participant could not be reached for follow-up. None of the distributed tests were returned and thus no further analysis could be performed. Discussion This egocentric SNA study aimed to better understand how the social and sexual networks of people with a new HIV diagnosis may have influenced their sexual risk taking and HIV preventive behavior leading to their HIV acquisition. The participants’ networks varied widely in size, ranging from 1 to 14 alters, of which on average six were included in the sociograms. Alters were placed on the sociogram based on emotional closeness. Friends, family members and steady partners were considered the closest, HIV physicians and FPs had a significant role as confidants and trustful resources. gMSM participants typically discussed sexual health with friends of similar sexual orientation or their sex partners, who influenced HIV prevention decisions. Family members, although deemed influential by the participants, were generally not approached for discussions about sexuality. gMSM participants often had a clear distinction between their homosexual friends and straight friends. In contrast, heterosexual participants reported more homogeneous networks, with less distinction between different types of friends. Interestingly, the participants who did not identify themselves as homosexual, but were men who had sex with men displayed diverse network structures, including both male sex partners as female life partners. Anonymous or casual sex partners were often mentioned in the narratives but were not considered emotionally close enough to be included in the sociogram, despite participants indicating that these partners were often their primary source of information about sexual health. We found a clear difference in preventive behavior between heterosexual and homosexual participants. Most importantly, the heterosexuals (hMSW and hWSM) and bi- and heterosexual-identifying MSM (bMSM or hMSM) participants generally did not identify themselves as vulnerable to HIV and hence did not engage in prevention strategies. This may be due to HIV prevention messages predominantly targeting gMSM. This became evident among hMSM and bMSM. Apparently, they are not reached by targeted and/or community-based prevention messages because they do not identify themselves as gay or homosexual. The relative absence of general HIV awareness raising campaigns in Belgium during recent years may have resulted in this group being left behind. Additionally, the bi-or heterosexual-identifying MSM participants described having sexual relationships in high-risk settings such as saunas and public spaces. There, the prevailing social norm discouraged condom use and discussions about sexual health and prevention methods. Previous research found that the majority of participants with a recent HIV infection have engaged in high-risk behavior and were aware of their risk-taking. 4 Our data complements these quantitative findings for the group of gMSM, and further demonstrates that condom use often depended on rare explicit requests. Participants attributed condomless sex to a to lack of communication and group dynamics even when they had planned to use a condom. Some participants intended to use condoms but forgot or chose not to with trusted partners to increase emotional closeness and intimacy, a phenomenon that literature has established as motivation for condomless sex 20 . In addition, gMSM participants often had acquired HIV in the context of sexualized drug use, which is consistent with other studies in Belgium 21,22 and internationally 23–25 . This adds to the existing literature that sexual risk-taking can be partially influenced by community beliefs regarding treatment and risk perception, and may be encouraged in certain social environments 9 . The interviews conducted with hMSM and bMSM bring to our attention a discrepancy between sexual identity and sexual behavior. Despite ample international literature on sexual fluidity 26 , this group remains largely hidden and misunderstood. This could be partly due to persistent societal norms on the hetero-homosexual binary, and ideas of masculinity, which makes this group less prone to speak out 26 , even in a country with a comparatively high rainbow index of 78,48% 2 (compared to the European Union countries with 50,61%) 27 Awareness of biomedical HIV prevention methods, such as PrEP was higher among gMSM participants compared to the other participants, which is in line with previous studies investigating the knowledge of PrEP among PrEP eligible persons 28–30 . A recent French study comparing data from 2014 with 2021 data, demonstrated that the community context of declining condom use and increased rates of STIs in the era of biomedical prevention including treatment as PEP and PrEP, may have changed sexual behavior of newly diagnosed MSM towards more inconsistent condom use while having lower number of partners than in 2014 31 . This could be partly due to community-based prevention efforts targeting gay-identifying MSM. HIV prevention and sexual health promotion, have been well established for men who identify as gay. Greater efforts are needed to increase knowledge among those who do not identify as part of this category and were therefore excluded from receiving relevant prevention messages. However, caution is needed in interpreting this finding, as some participants were diagnosed in 2018, only shortly after PrEP became reimbursed and subsequently more widely used in 2017. The latter could also explain low knowledge and awareness. FPs often played an important role in the social networks of participants. Therefore, we recommend that they be (even) more involved in HIV prevention. Sexual health and screening for STIs and HIV, should be discussed on a regular basis by FPs, as it is a key preventive measure to reducing HIV transmissions 32,33 . Consistent with previous findings 34,35 , also in the domain of other chronic diseases 36,37 , participants in this study preferred that discussing sexual health should be initiated by the FPs, rather than leaving it to patients to talk about their concerns or ask specific questions. There is a need for proper sexual health counselling and STI testing with all patients during FPs’ consultations, not only with the most ‘at risk groups’. It should be an integral component of any routine health check in order to prevent and treat STIs while contributing to the normalization of HIV and Belgian guidelines for primary care already exist 38 . Evidence shows that FPs recognize the increased difficulties of accurately establishing person’s sexual risk 35 . Furthermore, awareness of P(r)EP should be raised among family physicians and discussed with patients 39,40 . Both factors may result in targeting the unknown risk groups by promoting P(r)EP. Our findings revealed that HIV disclosure was challenging for most participants, and occurred primarily to those closest in their social networks to gain support and reduce fear of transmission. Participants who have (a) sex partner(s) that was/were considered as ‘life partner(s)’ of ‘regular’ sex partner(s) always informed them about the HIV diagnosis, yet only after a few sexual interactions. The HIV status was never disclosed to casual sex partner(s), except for one participant. These findings are in line with the ‘Model of HIV disclosure’ 41 , which showed that disclosure of one’s HIV status is associated with one’s social and sexual relationships and its strengths 41 . Furthermore, anticipated HIV stigma remained high, similar as in a Belgian study 42 in which 85% of participants indicated to be careful about to whom they disclosed their status out of fear of rejection. Positively, in our study, HIV discrimination was absent within participants’ networks. Though, internalized stigma and fear of negative reactions influenced non-disclosure, especially among heterosexual and bisexual individuals. As HIV related stigma is associated with decreased quality of life and poorer mental health 43–45 specific interventions are needed to increase awareness of the general population about the low risk of HIV transmission among people living with HIV (PLWH) who are on effective treatment. Moreover, trainings that focus on social empowerment in PLHIV may decrease anticipated stigma 46 . Given the separated network structure apparent in our data, we may ask how effective a network approach to HIV prevention may be in the Belgian context. Indeed; peer distribution of HIV self-sampling kits was limited, with participants hesitant to disclose their HIV status, especially to casual sex partners. This may have resulted in the low acceptance of peer distribution of self-sampling kits. Additionally, the general lack of communication about HIV and sexual health, mainly in the social/sexual networks of heterosexual and bisexual identifying MSM, made it difficult for participants to identify those in need of testing. As a result, distributing HIV self-sampling kits among the social networks of newly diagnosed persons living with HIV is not likely to be successful, based on our data. Intervention research should investigate its potential among different MSM communities who do not struggle with HIV disclosure. Literature suggests that a network-based strategy for HIV self-test distribution is a promising intervention to increase testing uptake and reduce undiagnosed infections among key populations (such as MSM, people who use drugs, and sex workers. 47,48 While this study provides valuable insights into the role of social and sexual networks in HIV prevention behavior, several limitations must be considered when interpreting the findings. Firstly, due to our recruitment strategy and study setup, participant demographics do not fully correspond to the diversity of transmission groups reported in the Belgian HIV surveillance: only one woman and only two participants in the young age-group from 20-29 years were included. Although six participants were born abroad, none had a Sub-Saharan African background, limiting our insights into the social networks of these most vulnerable groups. Due to these limitations, we could not reach data saturation, considered as a common quality criteria in qualitative research. We acknowledge the limited transferability of our findings to the population of all people with a new HIV diagnosis in Belgium. Further studies using more targeted recruitment, focusing on specific key populations such as migrants, (Sub-Saharan African) women, and young people, are needed. Secondly, although participants were recruited soon after their HIV diagnosis, they could have been living with HIV for almost four years by the time of their interview, increasing the likelihood of recall bias as discussions primarily focused on the period around their diagnosis. Thirdly, all interviewers were white, heterosexual women, whereas all, except one participant were men, mainly gMSM. Although the interviewers emphasized rapport-building, encouraged an open communication and emphasized pseudonymity , interviewer bias cannot be completely ruled out. Participants may have hesitated to disclose all relevant information due to lesser affinity with the interviewer or due to social desirability. Finally, the ego-centric network approach is limited as it only provides insights from the participant’s perspective and cannot visualize the complete social network. The study, however, generated several important theoretical insights of how social and sexual networks do or do not influence individual HIV prevention behaviour, and subsequently also HIV acquisition. These insights lead to several recommendations for HIV prevention and sexual health promotion In addition to tailored messaging, sexual health promotion and HIV prevention should be inclusive and mainstreamed to ensure that those who do not identify with the current key population approach, but still are vulnerable to HIV are reached with effective prevention messages. In addition, sexualized drug use should be addressed to enable people to maintain in control of their sexual health risks. Information on PrEP and PEP should be more widely disseminated among the general population. Simultaneously, HIV stigma and intersecting forms of stigma, such as homophobia, as well as internalized homonegativity should also be addressed FPs should discuss sexual health, STIs/HIV testing and prevention measures such as P(r)EP with all patients as it remains a cornerstone of prevention efforts in sexual health care. At the level of individual patient support and counseling, encouraging HIV disclosure and open communication among the social and sexual networks of newly diagnosed HIV persons may result in a higher success rate of the distribution of HIV self-sampling kits. Conclusion This egocentric SNA study has provided valuable insights into the social and sexual networks of people newly diagnosed with HIV. The findings underscore the need for inclusive and comprehensive HIV prevention strategies that reach beyond the current key populations, emphasizing the importance of PrEP and PEP promotion among the general population and FPs. To enhance HIV prevention efforts, it is crucial to involve FPs more actively in discussing sexual health and HIV testing with all patients, irrespective of their perceived risk. Encouraging open communication and HIV disclosure within social and sexual networks remains vital for improving the quality of life and mental health of people living with HIV and can potentially increase the success of distributing HIV self-sampling kits. Furthermore, future efforts should aim to address low HIV risk perception and the influence of sexualized drug use to help individuals better manage their sexual health risks. List of abbreviations MSM Men who have sex with men PrEP HIV Pre-Exposure Prophylaxis STI Sexually Transmitted Infection SNA Social Network Analysis PEP Post-Exposure Prophylaxis PLHIV People living with HIV gMSM Gay-identified men who have sex with men hMSW Hetero-identified men who have sex with women hMSM Hetero-identified men who has sex with men hWSM Hetero-identified women who have sex with men bMSM Bisexual-identified men who have sex with men FP Family physician Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the Institute of Tropical Medicine Antwerp (1181/17). Written or oral informed consent for participation was obtained from all individual participants prior to participation by the respective researcher. Consent for publication Participants signed an informed consent sheet for participation, which also informed them that pseudonymized data may be published. No information that could personally identify study participants has been included in this manuscript. Availability of data and materials The data presented in this article are not readily publicly available because they contain information that could compromise the privacy of our research participants. A list of condensed meaning units or codes could be made available upon reasonable request to the corresponding authors. Competing interests The authors declare no conflict of interest. Funding This study was financed by Gilead Sciences. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results Authors contributions EVL Conceptualization, methodology, data collection, formal analysis, writing – original draft, writing – review & editing, visualization and project administration CVB Conceptualization, methodology, data collection, formal analysis, writing – original draft, writing – review & editing, funding acquisition and project administration AR Conceptualization, methodology, data collection, writing – review & editing, project administration JDB Conceptualization, methodology, writing – review & editing CV Conceptualization, methodology, writing – review & editing CN Conceptualization, methodology, writing – review & editing, supervision Acknowledgements The authors want to thank Gilead Sciences for financial support, Prof. Dr. Steven Callens for acquiring funding and all study participants for their contribution. 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Hu S, Jing F, Fan C, et al. Social network strategies to distribute HIV self‐testing kits: a global systematic review and network meta‐analysis. J Int AIDS Soc 2024;27(7):e26342. Lightfoot MA, Campbell CK, Moss N, et al. Using a social network strategy to distribute HIV self-test kits to African American and Latino MSM. JAIDS Journal of Acquired Immune Deficiency Syndromes 2018;79(1):38–45. Anonymous. People First Charter. n.d. Footnotes We subscribe the People First Charter 49 and we agree that it is best to avoid abbreviations when referring to people. However, we will have to resort to the aforementioned abbreviations for the sake of readability within this paper. ILGA-Europe’s Rainbow Map annually ranks 49 European countries on a scale between 0% (gross violations of human rights, discrimination) and 100% (respect of human rights, full equality) on the basis of laws and policies that have a direct impact on LGBTI people’s human rights. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Feb, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 02 Sep, 2024 Editor assigned by journal 30 Aug, 2024 Submission checks completed at journal 30 Aug, 2024 First submitted to journal 27 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4985105","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":348528137,"identity":"c1fb671c-f55e-4a0d-9526-4ed2ca963c60","order_by":0,"name":"Ella Van Landeghem","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYLCCBwwMjA0MPEBWhQSQ4CFCSwJcyxkJCRK1MLYxENbCL5H87EFCzR3Zfv61Bx/dnGdRJ+/Ae/ABPi2SM9LMDRKOPTOeOeNdsnHuNgkJwwN8yQb4tBicOWAmkcB2OHHDjTNm0mAtDTxmEvi02J85/k0i4d/hxP03zpj/zp0D1mL+A68t7D1mEoltQFv4e8yYcxskJOQZeMzw6WCQON5TJpHYd9h4xg0eY+mcYxKSG5j5kvE6jL+ZfZvEh2+HZfv7zxh+zqmp45dv7z34Aa81CPsSoE49TJx6kH0HILR8A9FaRsEoGAWjYIQAABT2S8CuuTjvAAAAAElFTkSuQmCC","orcid":"","institution":"Institute of Tropical Medicine Antwerp","correspondingAuthor":true,"prefix":"","firstName":"Ella","middleName":"Van","lastName":"Landeghem","suffix":""},{"id":348528138,"identity":"70c562eb-d126-48cb-8ab3-8f0a1dc8c971","order_by":1,"name":"Charlotte Vanden Bulcke","email":"","orcid":"","institution":"Ghent University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"Vanden","lastName":"Bulcke","suffix":""},{"id":348528139,"identity":"727348e6-af39-4729-a757-e13a8265a66f","order_by":2,"name":"Anke Rotsaert","email":"","orcid":"","institution":"Institute of Tropical Medicine Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Anke","middleName":"","lastName":"Rotsaert","suffix":""},{"id":348528140,"identity":"af1a83c6-8e5a-4b3d-9ef5-a09d2d01082f","order_by":3,"name":"Jessika Deblonde","email":"","orcid":"","institution":"Sciensano (Belgium)","correspondingAuthor":false,"prefix":"","firstName":"Jessika","middleName":"","lastName":"Deblonde","suffix":""},{"id":348528141,"identity":"cc344b05-1e59-40d1-92fb-47941c63a820","order_by":4,"name":"Chris Verhofstede","email":"","orcid":"","institution":"Ghent University","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"","lastName":"Verhofstede","suffix":""},{"id":348528142,"identity":"d10ad8a0-3e0a-449e-b637-da9c9e9922b0","order_by":5,"name":"Christiana Nöstlinger","email":"","orcid":"","institution":"Institute of Tropical Medicine Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Christiana","middleName":"","lastName":"Nöstlinger","suffix":""}],"badges":[],"createdAt":"2024-08-27 14:06:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4985105/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4985105/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-21708-5","type":"published","date":"2025-02-15T15:57:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66937653,"identity":"0c81f5fa-11ba-4cb1-8561-22f723bb1f9f","added_by":"auto","created_at":"2024-10-18 08:33:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":251491,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eExamples of pseudonimized and digitalized visualization of sociograms\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4985105/v1/2488322a022d876c8163135c.png"},{"id":76487508,"identity":"3c75904d-cf10-468f-ad3b-388638a4db93","added_by":"auto","created_at":"2025-02-17 16:08:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1471045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4985105/v1/14c91064-64fa-4212-b27e-36ba47c295c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Social and sexual networks of newly diagnosed people living with HIV: a qualitative social network analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe HIV epidemic in Belgium remains at a comparatively high level within western Europe. Belgium has a high number of new HIV diagnoses (9.1/100 000 inhabitants compared with the EU average (5.1/100.000)\u003csup\u003e1\u003c/sup\u003e. The HIV epidemic in Belgium is concentrated among men who have sex with men (MSM) and heterosexual individuals of Sub-Saharan African origin. In 2022, 597 people were newly diagnosed with HIV, 51% were heterosexuals and 43% were MSM. Surveillance data showed a general slight decrease of new diagnoses over the last years, while in 2022 new HIV diagnoses increased among MSM aged 20 to 29 years and heterosexual women with a sub-Saharan African background \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. HIV Pre-Exposure Prophylaxis (PrEP) is being reimbursed by the public health insurance in Belgium since 2017, and more than 6000 people have accessed it since\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Because there has been no significant reduction in new HIV cases, we need better insights into the dynamics that lead to new HIV acquisitions in particular key-populations.\u003c/p\u003e \u003cp\u003eThe most current study on recent HIV infections conducted in Belgium between May 2018 and December 2022 among 93 participants who most likely acquired HIV less than three months ago, showed that more than half of them were MSM (74%), 14% were heterosexual women and 12% were heterosexual men. Participants reported high sexual risk-taking behavior, such as frequent substance use during sexual activity (65%), having been previously diagnosed with STI (65%) and inconsistent condom use (44%). Nearly one-third of participants had engaged in sexual activity with multiple partners (i.e. average of two to five casual partners). However, over 20% of participants (11 MSM, 4 heterosexual men and 5 heterosexual women) reported exclusive sexual activity with their steady partner\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Also a Dutch study found that recent HIV acquisition was associated with having an STI in the past, multiple partners and condom use among MSM \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The variety in sexual and HIV prevention behavior found in these studies calls for an in-depth understanding of what causes the observed differences, including the social contexts in which social and sexual norms and behaviors are embedded, as those data are lacking for the Belgian context.\u003c/p\u003e \u003cp\u003eCurrent research on recent HIV infections among MSM points to the fact that environmental and social context play an important role in explaining how HIV is acquired, how HIV prevention measures such as consistent condom use and PrEP are adopted and how frequently people get tested for HIV and other sexually transmitted infections (STIs) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Sexual risk-taking has been shown to be partially influenced by community beliefs regarding treatment and HIV normalization \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Furthermore, alcohol- and substance use and sexual risk behavior may be encouraged in certain social environments such as online social media, dating apps, or in places where people practice sexualized drug use, a growing phenomenon in Belgium and Europe \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Several studies have used socio-ecological approaches to understand contextual and social influences\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e however a social network analysis (SNA) adds to deepen our understanding of how social and sexual networks influence individual prevention behavior and risk taking.\u003c/p\u003e \u003cp\u003eIn SNA, the relationship (i.e. the “tie”) between the ego (i.e. the participant) and alter (i.e. the people in their networks, sometimes also referred to as “nodes”) and its influence on social and sexual norms/behavior becomes the focus of analysis \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Therefore, exploring social and sexual networks is increasingly used as an approach to understand how personal attitudes and actions are shaped by interpersonal relationships \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe specific position that people have within their social networks may potentially influence HIV acquisition risks and may be useful for tailoring HIV prevention strategies within peer networks \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Despite current HIV combination prevention efforts including the availability of post-exposure prophylaxis (PEP) and PrEP, missed opportunities to reach specific groups at risk of acquiring HIV do exist, as evidenced by the reported number of new HIV infections. HIV testing is a crucial first step in the HIV continuum of care and considered the weakest part in the Belgian continuum of care \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Further understanding how peer-driven HIV testing in social/sexual networks can improve early detection of undiagnosed people living with HIV \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, may be crucial for the development of social/sexual network HIV prevention and testing interventions. Therefore, this study included a brief pilot HIV self-testing intervention using a network approach.\u003c/p\u003e \u003cp\u003eThe main aim of this study was to describe social and sexual networks among people newly diagnosed with HIV and their influence on preventive and risk behavior, including their perceptions on how they acquired HIV.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eThis qualitative egocentric social network study used a phenomenological approach \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e to collect data on participants’ social and sexual networks from the participants’ own point of view, i.e. their core personal networks \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e without further recruiting other individuals within their respective networks. We also embedded a brief HIV self-sampling intervention offering the study participants the opportunity to distribute HIV self-sampling kits among their networks.\u003c/p\u003e\u003cp\u003eStudy setting and participants\u003c/p\u003e\u003cp\u003eThis study was a sub-study to the quantitative study using a self-reported questionnaire (online or on paper) to assess factors associated with new HIV acquisitions covering topics on HIV testing, STIs, PrEP use, sexual behavior, partner notification and substance use\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. inclusion in the quantitative study, participants needed to be adult people living with HIV (PLHIV) (≥ 18 years of age) who were newly diagnosed with HIV (i.e. diagnosis \u0026lt; 3 months after HIV infection). All participants who had already completed the questionnaire and gave permission to participate in follow-up research were invited to participate in this qualitative social network study. All participants were in follow-up at the HIV clinic in Ghent or Antwerp and had signed the informed consent form for participation in this SNA study. They received a €25 voucher to reimburse their participation in the study.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eWe conducted interviews face to face or online using secure technologies from March to October 2022. Three trained interviewers (CVB, AR, and EVL) employed a sociogram-aided interviewing technique \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, utilizing low-tech tools such as paper, pencils, and post-it notes. This approach aimed to jointly generate visual representations of participants' social and sexual networks focusing on the period around their HIV diagnosis. Interviewers used general name generator questions to compile a list of potential connections within their networks (i.e. \"alters\"). Subsequently, they asked participants to position each alter on a paper with concentric circles, representing hierarchical proximity to the ego (utilizing a hierarchical mapping sociogram, see Fig.\u0026nbsp;1). At this stage, additional alters could be added. By prompting the nature of the ties with each mentioned network members (or groups of members), the interviewers explored the relationships with the alters using color codes to distinguish with whom they had discussed their sexual life, advice on safe sex, support with sexual problems and sexual orientation (in analogy with Shell-Duncan et al. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, see Fig.\u0026nbsp;1 for legend). These egocentric social network maps served as a basis for further exploring topics aligned with the research objectives through unstructured interviewing. The resulting narratives contextualized and complemented the visually constructed data. Topics of exploration included participant’s daily life, support structures, significant relationships, as well as social, sexual, and preventive behaviors and social norms within their networks. We conducted one pilot interview to test the questions and methodology beforehand. After three interviews, the topic guide was slightly adapted by adding a category of (psycho-)social support arrows to the sociogram (see legend in Fig.\u0026nbsp;1). Interviews lasted around one hour and a half on average. At the end of the interview, we offered each participant up to five HIV self-sampling kits to voluntarily distribute to individuals in their social and sexual networks whom they believed to benefit from HIV testing. Participants who agreed to distribute kits provided consent to be contacted via telephone or email after three months, to document the number of kits distributed, the relationship between the participant and the recipients, and their experience with the distribution process. In collaboration with an ongoing HIV self-sampling project \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, which procured the kits, we documented the number of kits used and the test results, linked to each participant via the specific kit codes.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterviews were conducted in Dutch (n = 18), English (n = 1), or French (n = 1), audio-recorded and transcribed verbatim. We conducted the data analysis in two steps. First, we scrutinized the sociograms independently of the narratives. This involved a descriptive analysis of the sociogram structure, such as the quantity of alters, the characteristics of their relationships (\"ties\"), and an overall assessment of the visual data. We coded the types of ties assigning general categories, as described in the results. Subsequently, we compiled a detailed depiction of the visual data, describing the sociogram's appearance and the connections between alters and the ego. In the second step, we analyzed the verbatim transcribed interview data using a reflexive thematic analysis approach \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, aimed at interpreting participants' perceptions regarding alters, ties, and the other explored topics. We immersed ourselves in the data by revisiting the sociograms, reviewing our field notes, and re-examining the transcripts. Subsequently, the entire dataset underwent coding to identify themes addressing our research question, while maintaining a focus on the social network perspective. We identified initial themes related to overarching patterns among the created codes. These themes were then cross-checked against the coded data and collaboratively discussed within the research team (CN, CVB, AR \u0026amp; EVL). Prior to finalizing the analysis, iterative cycles between various stages allowed for the refinement, redefinition, and naming of the ultimate themes.\u003c/p\u003e\u003cp\u003eReflexivity\u003c/p\u003e\u003cp\u003eData was collected by AR, CVB \u0026amp; EVL and analysed by CVB \u0026amp; EVL (first authors). CVB, AR and EVL are all women with a Belgian background and native Dutch speakers. EVL has a social science background and has been employed as a researcher in the field of HIV and sexual health for several years, focusing mainly on prevention among migrants. AR has a background as a pharmacist and public health specialist. She has been working as a researcher in the field of HIV and sexual health for several years, using mixed methods and has focused on PrEP user preferences. CVB combines research work focusing on quality of life and stigma among persons living with HIV with clinical practice as a psychologist/sexologist in an HIV clinic, allowing for daily professional contact with people living with HIV.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant description\u003c/p\u003e \u003cp\u003eAmong the newly diagnosed participants from the quantitative study, 84 participants indicated their willingness to participate in follow-up research. All 84 were contacted by the researchers. Finally, 21 people participated in this qualitative study. One participant preferred not to continue after a few questions. This interview was excluded from the analysis, bringing the total number of participants completing the interview to N\u0026thinsp;=\u0026thinsp;20. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of the profiles of the 20 participants. Participant\u0026rsquo;s age ranged from 21 to 70 years, with a median age of 44 years. The majority were male (n\u0026thinsp;=\u0026thinsp;19). Thirteen participants identified themselves as gay men who have sex with men (gMSM), two as heterosexual men who have sex with women (hMSW), one as a heterosexual men who has sex with only men (hMSM), one as heterosexual woman who has sex with men (hWSM), and three as bisexual men who only had sex with men (bMSM) at the time of diagnosis.\u003csup\u003e1\u003c/sup\u003e. All participants, except four, were diagnosed with a recent HIV infection (diagnosis\u0026thinsp;\u0026lt;\u0026thinsp;3 months after HIV infection). The others received their diagnosis\u0026thinsp;\u0026gt;\u0026thinsp;3 months after HIV infection. All participants had the Belgian nationality, five of them were born abroad. More than half of the participants had completed higher education (n\u0026thinsp;=\u0026thinsp;12).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex at birth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCountry of birth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSexual orientation*/identity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSexual behavior\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRelational status at moment of diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNetwork composition\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;size)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[70\u0026ndash;79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[60\u0026ndash;69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eCo-workers (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[18\u0026ndash;29]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eAcquaintance (volunteering) (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[50\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003eAcquaintances (neighbours)\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[40\u0026ndash;49]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with women**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003e(female partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eCo-worker (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[50\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eEx-partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[60\u0026ndash;69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (female partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eRegular sex partner (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eAcquaintance (internet)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eCasual sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[50\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[50\u0026ndash;59]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eCo-workers (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eAcquaintance (neighbor) (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eEx-partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eSexual health organization (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[40\u0026ndash;49]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eCo-workers (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eHealth care provider (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eRegular sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[40\u0026ndash;49]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn relationship (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003eCo-workers (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eCasual sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[60\u0026ndash;69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (female partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eCasual sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[60\u0026ndash;69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBisexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMarried (female partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eAcquaintance (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003eCo-worker (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eRegular sex partners (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[18\u0026ndash;29]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eFamily member (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eFriends close (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFriends far\u003c/p\u003e \u003cp\u003eGayscene\u003c/p\u003e \u003cp\u003eCasual sex partners (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003eFamily member (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eCasual sex partners\u003c/p\u003e \u003cp\u003eAcquaintances (hobby) (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eAcquaintances (Neighbours)(n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIn relationship (male partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eCo-worker (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily member (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eCasual sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHeterosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eFriend (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eFamily member (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003eLife partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eRegular sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eCasual sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelgium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003eAnonymous sex partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eRegular sex partner (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003eFamily (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[30\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-European country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHomosexual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSex with men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e \u003cp\u003eFriends (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003eEx-partner (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003eCasual sex partner\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*Sexual orientation is based on self-identification of participants (as homosexual, heterosexual or bisexual)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e**For all participants, except one (participant 6), sexual behavior is identical to their perception of HIV acquisition. For participant 6, the transmission mode is unknown\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*** Partners and sex partners are divided in the following categories; (1) \u0026ldquo;Life partner\u0026rdquo; is used in case of marriage or long term relationship, (2) \u0026ldquo;Regular sex partners\u0026rdquo; for known sex partners and steady sex partners and (3) \u0026ldquo;Casual sex partners\u0026rdquo; are loose sexual contacts, which could include anonymous contacts as well\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[insert Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDescription of personal social and sexual networks\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSociograms and descriptives of alters\u003c/h2\u003e \u003cp\u003eOverall, we constructed 19 sociograms. One participant considered the alters he listed as not relevant for his sexual health or HIV prevention, not wanting to draw a sociogram but only discussing his networks during the interview. The name-generator questions resulted in a minimum of 1 and a maximum of 14 alters, with a mean of 8.26 (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Participants differed in the number of alters that were added to the sociogram, i.e. ranging 1 to 13, mean: 6.11. Various reasons, such as grouping several alters together under one name (e.g. \u0026ldquo;choir friends\u0026rdquo;) or realizing that the alter was not very influential after all, accounted for this difference. The participants placed the alters on the sociogram in a way that felt most truthful to them. As one participant put it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBased on who I can go to with problems, based on who I do a lot with, based on... yes really purely on that\u003c/p\u003e\u003cp\u003eParticipant 15, gMSM\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe most frequently mentioned alter was \u0026lsquo;friend\u0026rsquo;. Participants described different kinds of friends, some were \u0026lsquo;just\u0026rsquo; friends, others were described as \u0026lsquo;best friends\u0026rsquo;. Family members and health service providers (i.e. mostly HIV physicians) ranged second and third in terms of positions. Life partners and sex partners were also often mentioned, depending on the personal situation of the participant. One participant noted the \u0026lsquo;gay scene\u0026rsquo; as an alter on his sociogram, as a resource where he could find information or support. Although many other participants did not place the gay scene or community as such in their sociograms, many mentioned its importance multiple times in their narratives.\u003c/p\u003e \u003cp\u003eConsequently, the most mentioned tie fell into the \u0026rsquo;friends\u0026rsquo; category, mentioned 58 times across all participants. \u0026lsquo;Family\u0026rsquo; ranked second, with family members being mentioned 41, then health care providers (n\u0026thinsp;=\u0026thinsp;13), partners (n\u0026thinsp;=\u0026thinsp;11) and regular sex partners (n\u0026thinsp;=\u0026thinsp;10). The following paragraph describes the ties more in depth, in order of the frequency in which participants mentioned them.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDescription of ties\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eFriends\u003c/h2\u003e \u003cp\u003eMany participants who identified as gMSM, described a difference between their \u0026ldquo;straight friends\u0026rdquo; (\u0026ldquo;\u003cem\u003emy hetero friend circle\u0026rdquo;\u003c/em\u003e; participant 2, gMSM) and \u0026ldquo;gay friends\u0026rdquo;. The last group must not be confused with the gay scene, or casual sex partners, on which we describe more below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMale and female...uhm...yes, but I see my...how should I put it, the friends I've known the longest or who I'm still in touch with the most now, I think are the friends I met at uni. And that's both male, female, of the same age. And then there are also...uhm...yes, friends uhm...from the gay scene that I got to know. Yes, these are obviously male friends, but uhm...yes, that's a totally different group for me, that's still...actually that's still totally different\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 15, gMSM\u003c/p\u003e \u003cp\u003eHowever, some participants reported to deliberately have stayed away from the \u0026ldquo;gay scene\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAnd, uhm very little into the gay scene, yeah it wasn't like that. Always kind of stayed away there, also very consciously\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 12, gMSM\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFamily members\u003c/h2\u003e \u003cp\u003eParticipants who reportedly had a good relationship with their parents indicated that family members were also be influential in life choices, such as the prevention of unwanted pregnancy, but mostly not in matters directly related to their sexuality.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWith my parents, you sometimes talk about sex, especially when you were a bit younger. Now it's rather that you sometimes laugh about it, but you don't have those deep questions about sex now either, especially at the age I am by now. When you were young, you do talk to your parents about sex and contraceptives, sexual health, the first time you had sexual contact with someone.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 6, hMSW\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCo-workers\u003c/h2\u003e \u003cp\u003e Participants often shared that many co-workers had become friends, with whom sexual behavior would sometimes be discussed, although not from a health perspective.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLife and sex partners\u003c/h2\u003e \u003cp\u003e Life partners were important to participants, both emotionally and to talk about sexual health. As mentioned above, sex partners could also be a source of information regarding sexual health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThen also PrEP came up and so a lot of people take PrEP so it does come up often because people then ask of okay 'what are you taking?' or 'are you not taking it?'\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 15, gMSM\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eHealth care providers\u003c/h2\u003e \u003cp\u003eMany participants included their health care providers in the sociogram because of the important role they played in their diagnosis and treatment, often being the first confidant and source of information when receiving the diagnosis. These were mostly physicians at sexual health clinics. Although many participants described also good relationships with their family physicians (FP), some reported to have been disappointed by the physician\u0026rsquo;s reaction to their HIV diagnosis, or the way they approached their sexual health. Participants who felt comfortable to initiate the topic of sexual health with the FP did so, however, many could not proactively begin such a discussion. One participant even highlighted that it was the FPs\u0026rsquo; responsibility to initiate such conversations. Across the line, the specialized HIV physicians, however, received a special place in the sociograms:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMore distant, but definitely a confidant. I always look at the top left corner, then I do place them well within the circle. It's not like we're going out for drinks with [HIV physician], it remains a purely professional relationship. It's someone to whom we can tell a story and trust very deeply.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 5, gMSM\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSex partners\u003c/h2\u003e \u003cp\u003e A few gMSM participants indicated their social and sexual networks overlapped, in that they might have had sex with a good friend, or that a sex partner had become a good friend afterwards. However, this was not very common. Unless a sex partner was also a life partner or a regular sex partner, participants often did not include them in the sociograms. If they did, they placed them at a big distance from the ego. This may indicate emotional distance between the ego and their casual sex partners:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThat's purely sexual, that's nothing like friendship or trust or anything\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 2, gMSM\u003c/p\u003e \u003cp\u003e Four participants described completely separate social and sexual networks. These were men who were having sexual relationships with men, but were married to a woman\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI am actually mostly straight, but circumstances have made me look more at men, meeting them and having sex with them. For love, I prefer a woman, but for sex I prefer a man.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant 1, bMSM\u003c/h2\u003e \u003cp\u003eMostly gMSM and some hMSM and bMSM participants preferred completely anonymous sexual contacts, seeking sex in public venues such as in saunas or parks:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor me that\u0026rsquo;s something very\u0026hellip; it\u0026rsquo;s stuck in that box, it\u0026rsquo;s closed and it doesn\u0026rsquo;t come out\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 13, hMSM\u003c/p\u003e \u003cp\u003egMSM participants also shared experiences of meeting men for sex in similar circumstances:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf all the gays in this city would spill the beans (...), a lot of men are going to get beaten up and not allowed out [by their wives]. (..). Then they usually say they are monogamous, that's the shame of it.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 11, gMSM\u003c/p\u003e \u003cp\u003e bMSM and hMSM participants apparently struggled with explicitly naming their sexual identity. Some identified as bisexual, one as a man who has sex with other men, one man just labelled himself as straight (see quote above). Having to conceal their sexual behavior had an impact on their mental health. The compartmentalizing of both worlds and the hypervigilance in keeping them separate felt like a huge burden for these participants:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Should tomorrow my wife be gone and a man would say, \"Are we going to live together?\" I wouldn't be able to. No, not at all. I can't kiss with men either, very strange right. I can\u0026rsquo;t figure out why that is. You can't say to yourself am I gay or straight now or am I both? You can't place that, because if you then say I'm gay because I have sex with men, but I can't kiss with them and live with them....\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipant 14, bMSM\u003c/p\u003e \u003cp\u003eInfluence of social and sexual networks on prevention behavior\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe \u0026ldquo;gay scene\u0026rdquo;\u003c/h2\u003e \u003cp\u003eFor many gMSM another influencing factor on prevention decisions was the \u0026ldquo;gay scene\u0026rdquo; or \u0026ldquo;gay community\u0026rdquo;; they perceived the many community-directed prevention efforts over the years as a positive, awareness-raising influence. In contrast, they found heterosexual communities as having lower HIV awareness, including a lack of information on PrEP and PEP, resulting in less frequently testing for HIV and generally a lower HIV risk perception.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think that we, especially in the past 10 years, have been working on it [HIV prevention], especially in the gay community. There is definitely awareness. (\u0026hellip;) I think specifically in the gay community, there is awareness; you just have to look at the long term. How many people openly talk about it there, it can be discussed. This wasn't the case about 5 years ago.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipant 5, gMSM\u003c/p\u003e \u003cp\u003eSome gMSM participants were of the opinion that that straight people were just not aware of their HIV risk, as they \u0026ldquo;\u003cem\u003ethink it doesn\u0026rsquo;t exist with them [the straights]\u003c/em\u003e\u0026rdquo; (Participant 11, gMSM).\u003c/p\u003e \u003cp\u003eLikewise, some gMSM perceived \u0026lsquo;straight\u0026rsquo; men to be less aware of HIV prevention techniques, leading to risky behaviors and ultimately HIV transmission.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe straights always have different thoughts about that [HIV], which is then 'with us' it doesn't happen. An accident is waiting to happen and I am living proof of that. I told them I got it from someone from 'with us'\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 11, gMSM\u003c/p\u003e \u003cp\u003eSome gMSM participants highlighted it was much easier to discuss sexual health with their gay friends, or casual sex partners than with their heterosexual friends:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI also think you can broach those subjects [sexual health/sexuality] much easier because, yes, those are not people with whom that you have a whole history or who you also see in a different context. So I think I discuss sexual matters mainly with those gay friends or with those casual contacts\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 15, \u003cem\u003eg\u003c/em\u003eMSM\u003c/p\u003e \u003cp\u003eOn the contrary, heterosexual participants shared that real sexual matters were rarely discussed, if at all only jokingly, and mostly with friends or co-workers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYes, at work that gets some laughs, but nothing serious now. I don't actually speak [about sexuality] ... except that you joke about it sometimes. Men will be men of course.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 10, gMSM\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCondom and PrEP use\u003c/h2\u003e \u003cp\u003e Participants indicated to mainly discuss their sexual health with people who have a similar sexual orientation, or with their sex partners. These network members also influenced decisions on HIV prevention and prevention behavior. Many participants reported that they used condoms only when their sex partner had explicitly asked for it, but explained that they often had performed condomless sex without clear communication and/or joint decision-taking. Reportedly, this was partly influenced by group dynamics, as one participant highlighted that asking for a condom could be considered disruptive in the sexual situation:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\" You don't want to be nagging. You don't want to be the one who says 'guys, let's all keep our condoms on'. It's not so much about not wanting to be a nag or a fool, but there's a flow in the evening where at that moment it doesn't matter so much anymore.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipant 19, gMSM\u003c/p\u003e \u003cp\u003eAt the time of diagnosis, some participants indicated to always have had the intention to use a condom, but that they sometimes forgot, or decided for condomless sex with a partner they trusted. Additionally, the only female participant added that most men just did not want to wear a condom, although she had tried.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Yeah, I really wanted to do that [use a condom], but yeah... yeah... it just doesn't work, you know. It just doesn't work with some men. Then you think 'okay, I tried'.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipant 18, hWSM\u003c/p\u003e \u003cp\u003eAwareness of PrEP and/or PEP was higher among gMSM (n\u0026thinsp;=\u0026thinsp;11/13) than among hMSM,bMSM (n\u0026thinsp;=\u0026thinsp;2/4) and heterosexual participants (n\u0026thinsp;=\u0026thinsp;0/3) at the time of the HIV diagnosis. However, many believed that it could have played an important role in preventing HIV, if they had had the opportunity to take P(r)EP. In some cases, where the FP was included within participant\u0026rsquo;s social networks and was of influence of discussing their sexual health, the FP had provided incorrect information:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI asked the family physician for PrEP. She said that I was not living with someone who was HIV positive and that she could not prescribe it at that time\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 8, bMSM\u003c/p\u003e \u003cp\u003egMSM were often aware of the existence of P(r)EP, but the FP did not always correctly estimate the person at risk for HIV:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSomething I regret is that at the beginning of the open relationship, we went to the family physician to ask for information and advice. He never talked about PrEP or the PEP pill. Afterwards, I thought 'damn, if the family physician had prescribed PrEP at the time we were discussing the open relationship, I would not be in this situation\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 17, gMSM\u003c/p\u003e \u003cp\u003ePractical considerations were also reported as reasons for not starting PrEP medication:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYes, I had asked my family physician for PrEP, but he said I had to come to the HIV reference center. I found that a little difficult. If I had gotten PrEP from my family physician, it would never have happened\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 20, gMSM\u003c/p\u003e \u003cp\u003eSome participants, while being aware of PrEP, did not use it, because they did not perceive themselves at risk for HIV, due to adopting other prevention strategies such as regular HIV testing, condom use or low risk perception:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI went for STI screening. Although all results were negative, the doctor asked if I heard about PrEP and recommended to start with it. I remember saying something like 'no, I do not think it is necessary\u0026rsquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 15, gMSM\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubstance use\u003c/h2\u003e \u003cp\u003eMany gMSM participants reported that their drug use often interfered with condom use. One participant explained how the normalisation of drugs led to sexual risk taking:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Social pressure might be a bit of a heavy term, but it was almost normal that when we went out, drugs would be used. (\u0026hellip;) I felt that it made me less likely to say \u0026lsquo;no\u0026rsquo; when I would have said \u0026lsquo;no\u0026rsquo; if I hadn\u0026rsquo;t been under the influence. Under influence, I didn\u0026rsquo;t say it as quickly. Not because others encouraged me, but because of the influence of those drugs.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipant 17,\u003c/p\u003e \u003cp\u003ehMSW\u003c/p\u003e \u003cp\u003eParticipant\u0026rsquo;s perceptions of how they had acquired HIV\u003c/p\u003e \u003cp\u003e Generally, participants had a good understanding of the circumstances leading to their HIV acquisition; only one heterosexual man reported that he had no idea of the transmission route. Bisexual participants indicated to have acquired HIV through sexual contact(s) with men; and also two heterosexual men reported to have acquired HIV through unprotected sex with men.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere was HIV and ... but not with us, a distant matter. Kind of nonchalant thinking that it won't happen to me\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 8, bMSM\u003c/p\u003e \u003cp\u003e Most of the gMSM participants were aware of their sexual risk-taking behavior. Within their sexual networks, they perceived substance use as getting normalized and HIV acquisition often occurred under influence of alcohol and/or drugs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYes, that's also the problem, the availability of drugs and alcohol at the parties. That makes it very difficult to discuss condoms when it comes to unprotected sex because you're in a certain higher atmosphere where it doesn't matter much anymore, and everybody does it\u003c/p\u003e\u003cp\u003eParticipant 19, gMSM\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlso, some gMSM, mainly those with a larger sexual network, reported going through a mentally difficult time and as a result, they engaged in taking more sexual risks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt was a shock while I knew I had risk behavior. In fact, it should not have been a shock\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 19, gMSM\u003c/p\u003e \u003cp\u003eTwo gMSM participants mentioned that they got HIV infected through \u0026lsquo;bad luck\u0026rsquo;. These participants reported very small sexual networks and said to always have used condoms except during that one sexual contact.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was really, really careful. And then there was the accident\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 7, gMSM\u003c/p\u003e \u003cp\u003eDisclosure\n from a social/sexual network perspective\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDisclosure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHIV disclosure to significant others remained a source of continuous stress that participants were facing. Many reported that it was a difficult consideration to decide who to (not) disclose their HIV status to. Most participants had disclosed to the persons placed closest to the ego in their sociograms. All, except one, have told at least one person within their social network, other than the medical staff, that they were HIV positive. The quality of participants’ ties to their alters clearly influenced communication about HIV, and in in particular who they had disclosed their HIV status to.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The diagnosis in itself made it acutely clear to me who I wanted to inform. The people I felt needed to hear from me, and felt like they needed to know because it’s the people I am close to or often spend time with”\u0026nbsp;\u003c/em\u003e\u003cbr\u003e\u0026nbsp; Participant 19, gMSM\u003c/p\u003e\n\u003cp\u003eDisclosure had happened in most cases in the first weeks after diagnosis to closely related persons, mostly because of fear to transmit the virus (in the period in which they were not yet undetectable). This disclosure process went well for all participants, and no one had to deal with negative reactions from people within their social network.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“’Just because you have HIV does not mean you are different. For me, that does not change anything.’ That was the response I got from the first person I told, so that was really positive”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 11, gMSM\u003c/p\u003e\n\u003cp\u003eFor those who could share that they were living with HIV within their social networks, they did so to be able to openly talk about their concerns, share experiences, and receive mental support. However, (anticipated) lack of social support influenced the acceptance of the HIV diagnosis. Persons who had little social support, found it more difficult to accept their HIV status. As a result, they continued to keep their HIV diagnosis secretely and thus could not benefit from social support to better cope with their diagnosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“From the age of 12, I have always had a pretty closed ‘world of living’... No one knows, no I carry it all by myself... It is very hard to live with. I have everything, I have my own house, I have a car. I am not rich, but I have everything. But tomorrow, if they would say that there is a cure for HIV, they can have everything from me, I would even want to live on the street. I find it terribly hard to have”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 10, hMSW\u003c/p\u003e\n\u003cp\u003eOften only sex partner(s) who were considered as ‘life partner(s)’ of ‘regular sex partner(s) were included in the social networks. In those cases, participants always informed their regular sex partner(s) about the HIV diagnosis, yet only after a few sexual interactions. Only one individual had shared his HIV status with casual sex partners. The following quote illustrates commonly mentioned reasons for non-disclosure to casual sex partners.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A casual sex contact should not know that. I take my medication. I am undetectable. I hope it stays that way. That reassures me so why should I tell?”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 2, gMSM\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHIV stigma\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnticipated HIV-stigma could be identified as an important factor for non-disclosure to persons placed more distant from the ego in their social network. With network members belonging to the closer social network, participants often would not disclose HIV because they did not want to unnecessarily worry family members, or they wanted to protect them from negative reactions. Only few participants shared their HIV diagnosis with their professional network or with less good friends.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Because I believe the more people know the more likely it is that someday someone will react badly. And that will have an impact on my children. I don't expect that now, but I don't want to take that risk. That's a very conscious decision”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 6, hMSW\u003c/p\u003e\n\u003cp\u003eEspecially heterosexuals and bMSM kept themselves from sharing their diagnosis with persons within the social network because of feelings of both anticipated and internalized HIV stigma:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think for my friends HIV is still linked to prostitution, homosexuality and drugs. If I did not have HIV myself, I might think like that too”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 6, hMSW\u003c/p\u003e\n\u003cp\u003eAlso, feelings of internalized homophobia determined non-disclosure of HIV:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Besides those few persons, no one knows about my HIV because I am also afraid to be confronted with that stigma. I am not a person like in the clichés of unsafe behavior and decadence etc. I like to go out and dance. I also took drugs, xtc, coke and alcohol from time to time, but never to the extent that I led a normless life, quite the contrary. No, the problem is that if I tell my friends or family that I am HIV positive than I will be stigmatized as gay. I am not gay because I do not like men, I only have sex with men”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant 13,hMSM\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePeer distribution of HIV self-sampling kits\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, nine participants accepted a total of 38 self-sampling kits for distribution, with each participant taking between one to five kits. Only four participants actually distributed the kits (N=11) within their networks. Participants who did not distribute the HIV self-sampling kits reported reluctance to disclose their HIV status, as distributing the kits would have demanded such disclosure. Additionally, they said to be unaware of individuals who could benefit from HIV self-sampling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants who did accept the kits for distribution (all gMSM), were those who reported to have experienced less difficulties to disclose their HIV status. One participant gave three kits to his children and one participant gave three kits to persons who visited the pharmacy in which he was employed. Another participant gave one of the five kits to someone who knew the participant’s HIV status and attempted to distribute the remaining kits to others in his network. However, they were not accepted due to their low perceived need (e.g. recipients already getting tested occasionally or having fewer sexual contacts). The last participant shared four kits among his sex partners. Nobody reported negative experiences when distributing the kits. Reasons for not distributing the remaining kits were the loss of the kits, forgetting it, or finding it too challenging to promote. One participant could not be reached for follow-up. None of the distributed tests were returned and thus no further analysis could be performed.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis egocentric SNA study aimed to better understand how the social and sexual networks of people with a new HIV diagnosis may have influenced their sexual risk taking and HIV preventive behavior leading to their HIV acquisition. The participants\u0026rsquo; networks varied widely in size, ranging from 1 to 14 alters, of which on average six were included in the sociograms. Alters were placed on the sociogram based on emotional closeness. Friends, family members and steady partners were considered the closest, HIV physicians and FPs had a significant role as confidants and trustful resources. gMSM participants typically discussed sexual health with friends of similar sexual orientation or their sex partners, who influenced HIV prevention decisions. Family members, although deemed influential by the participants, were generally not approached for discussions about sexuality. gMSM participants often had a clear distinction between their homosexual friends and straight friends. In contrast, heterosexual participants reported more homogeneous networks, with less distinction between different types of friends. Interestingly, the participants who did not identify themselves as homosexual, but were men who had sex with men displayed diverse network structures, including both male sex partners as female life partners. Anonymous or casual sex partners were often mentioned in the narratives but were not considered emotionally close enough to be included in the sociogram, despite participants indicating that these partners were often their primary source of information about sexual health.\u003c/p\u003e\n\u003cp\u003eWe found a clear difference in preventive behavior between heterosexual and homosexual participants. Most importantly, the heterosexuals (hMSW and hWSM) and bi- and heterosexual-identifying MSM (bMSM or hMSM) participants generally did not identify themselves as vulnerable to HIV and hence did not engage in prevention strategies. This may be due to HIV prevention messages predominantly targeting gMSM. This became evident among hMSM and bMSM. Apparently, they are not reached by targeted and/or community-based prevention messages because they do not identify themselves as gay or homosexual. The relative absence of general HIV awareness raising campaigns in Belgium during recent years may have resulted in this group being left behind. Additionally, the bi-or heterosexual-identifying MSM participants described having sexual relationships in high-risk settings such as saunas and public spaces. There, the prevailing social norm discouraged condom use and discussions about sexual health and prevention methods. Previous research found that the majority of participants with a recent HIV infection have engaged in high-risk behavior and were aware of their risk-taking. \u003csup\u003e4 \u0026nbsp;\u003c/sup\u003eOur data complements these quantitative findings for the group of gMSM, and further demonstrates that condom use often depended on rare explicit requests. Participants attributed condomless sex to a to lack of communication and group dynamics even when they had planned to use a condom. Some participants intended to use condoms but forgot or chose not to with trusted partners to increase emotional closeness and intimacy, a phenomenon that literature has established as motivation for condomless sex \u003csup\u003e20\u003c/sup\u003e. In addition, gMSM participants often had acquired HIV in the context of sexualized drug use, which is consistent with other studies in Belgium \u003csup\u003e21,22\u003c/sup\u003e and internationally \u003csup\u003e23\u0026ndash;25\u003c/sup\u003e. This adds to the existing literature that sexual risk-taking can be partially influenced by community beliefs regarding treatment and risk perception, and may be encouraged in certain social environments \u003csup\u003e9\u003c/sup\u003e. The interviews conducted with hMSM and bMSM bring to our attention a discrepancy between sexual identity and sexual behavior. Despite ample international literature on sexual fluidity \u003csup\u003e26\u003c/sup\u003e, this group remains largely hidden and misunderstood. This could be partly due to persistent societal norms on the hetero-homosexual binary, and ideas of masculinity, which makes this group less prone to speak out \u003csup\u003e26\u003c/sup\u003e, even in a country with a comparatively high rainbow index of 78,48% \u003csup\u003e2\u003c/sup\u003e(compared to the European Union countries with 50,61%) \u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAwareness of biomedical HIV prevention methods, such as PrEP was higher among gMSM participants compared to the other participants, which is in line with previous studies investigating the knowledge of PrEP among PrEP eligible persons \u003csup\u003e28\u0026ndash;30\u003c/sup\u003e. A recent French study comparing data from 2014 with 2021 data, demonstrated that the community context of declining condom use and increased rates of STIs in the era of biomedical prevention including treatment as PEP and PrEP, may have changed sexual behavior of newly diagnosed MSM towards more inconsistent condom use while having lower number of partners than in 2014 \u003csup\u003e31\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThis could be partly due to community-based prevention efforts targeting gay-identifying MSM. HIV prevention and sexual health promotion, have been well established for men who identify as gay. Greater efforts are needed to increase knowledge among those who do not identify as part of this category and were therefore excluded from receiving relevant prevention messages. However, caution is needed in interpreting this finding, as some participants were diagnosed in 2018, only shortly after PrEP became reimbursed and subsequently more widely used in 2017. The latter could also explain low knowledge and awareness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFPs often played an important role in the social networks of participants. Therefore, we recommend that they be (even) more involved in HIV prevention. Sexual health and screening for STIs and HIV, should be discussed on a regular basis by FPs, as it is a key preventive measure to reducing HIV transmissions \u003csup\u003e32,33\u003c/sup\u003e. Consistent with previous findings \u003csup\u003e34,35\u003c/sup\u003e, also in the domain of other chronic diseases \u003csup\u003e36,37\u003c/sup\u003e, participants in this study preferred that discussing sexual health should be initiated by the FPs, rather than leaving it to patients to talk about their concerns or ask specific questions. There is a need for proper sexual health counselling and STI testing with all patients during FPs\u0026rsquo; consultations, not only with the most \u0026lsquo;at risk groups\u0026rsquo;. It should be an integral component of any routine health check in order to prevent and treat STIs while contributing to the normalization of HIV and Belgian guidelines for primary care already exist \u003csup\u003e38\u003c/sup\u003e. Evidence shows that FPs recognize the increased difficulties of accurately establishing person\u0026rsquo;s sexual risk \u003csup\u003e35\u003c/sup\u003e. Furthermore, awareness of P(r)EP should be raised among family physicians and discussed with patients \u003csup\u003e39,40\u003c/sup\u003e. Both factors may result in targeting the unknown risk groups by promoting P(r)EP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings revealed that HIV disclosure was challenging for most participants, and occurred primarily to those closest in their social networks to gain support and reduce fear of transmission. Participants who have (a) sex partner(s) that was/were considered as \u0026lsquo;life partner(s)\u0026rsquo; of \u0026lsquo;regular\u0026rsquo; sex partner(s) always informed them about the HIV diagnosis, yet only after a few sexual interactions. The HIV status was never disclosed to casual sex partner(s), except for one participant. These findings are in line with the \u0026lsquo;Model of HIV disclosure\u0026rsquo; \u003csup\u003e41\u003c/sup\u003e, which showed that disclosure of one\u0026rsquo;s HIV status is associated with one\u0026rsquo;s social and sexual relationships and its strengths \u003csup\u003e41\u003c/sup\u003e. Furthermore, anticipated HIV stigma remained high, similar as in a Belgian study \u003csup\u003e42\u003c/sup\u003e in which 85% of participants indicated to be careful about to whom they disclosed their status out of fear of rejection. Positively, in our study, HIV discrimination was absent within participants\u0026rsquo; networks. Though, internalized stigma and fear of negative reactions influenced non-disclosure, especially among heterosexual and bisexual individuals. As HIV related stigma is associated with decreased quality of life and poorer mental health \u003csup\u003e43\u0026ndash;45\u003c/sup\u003e specific interventions are needed to increase awareness of the general population about the low risk of HIV transmission among people living with HIV (PLWH) who are on effective treatment. Moreover, trainings that focus on social empowerment in PLHIV may decrease anticipated stigma \u003csup\u003e46\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the separated network structure apparent in our data, we may ask how effective a network approach to HIV prevention may be in the Belgian context. Indeed; peer distribution of HIV self-sampling kits was limited, with participants hesitant to disclose their HIV status, especially to casual sex partners. This may have resulted in the low acceptance of peer distribution of self-sampling kits. Additionally, the general lack of communication about HIV and sexual health, mainly in the social/sexual networks of heterosexual and bisexual identifying MSM, made it difficult for participants to identify those in need of testing. As a result, distributing HIV self-sampling kits among the social networks \u003cem\u003eof newly diagnosed persons\u003c/em\u003e living with HIV is not likely to be successful, based on our data. Intervention research should investigate its potential among different MSM communities who do not struggle with HIV disclosure. Literature suggests that a network-based strategy for HIV self-test distribution is a promising intervention to increase testing uptake and reduce undiagnosed infections among key populations (such as MSM, people who use drugs, and sex workers. \u003csup\u003e47,48\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhile this study provides valuable insights into the role of social and sexual networks in HIV prevention behavior, several limitations must be considered when interpreting the findings. Firstly, due to our recruitment strategy and study setup, participant demographics do not fully correspond to the diversity of transmission groups reported in the Belgian HIV surveillance: only one woman and only two participants in the young age-group from 20-29 years were included. Although six participants were born abroad, none had a Sub-Saharan African background, limiting our insights into the social networks of these most vulnerable groups. Due to these limitations, we could not reach data saturation, considered as a common quality criteria in qualitative research. We acknowledge the limited transferability of our findings to the population of all people with a new HIV diagnosis in Belgium. Further studies using more targeted recruitment, focusing on specific key populations such as migrants, (Sub-Saharan African) women, and young people, are needed. Secondly, although participants were recruited soon after their HIV diagnosis, they could have been living with HIV for almost four years by the time of their interview, increasing the likelihood of recall bias as discussions primarily focused on the period around their diagnosis. Thirdly, all interviewers were white, heterosexual women, whereas all, except one participant were men, mainly gMSM. Although the interviewers emphasized rapport-building, encouraged an open communication and emphasized pseudonymity , interviewer bias cannot be completely ruled out. Participants may have hesitated to disclose all relevant information due to lesser affinity with the interviewer or due to social desirability. Finally, the ego-centric network approach is limited as it only provides insights from the participant\u0026rsquo;s perspective and cannot visualize the complete social network.\u003c/p\u003e\n\u003cp\u003eThe study, however, generated several important theoretical insights of how social and sexual networks do or do not influence individual HIV prevention behaviour, and subsequently also HIV acquisition. These insights lead to several recommendations for HIV prevention and sexual health promotion\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIn addition to tailored messaging, sexual health promotion and HIV prevention should be inclusive and mainstreamed to ensure that those who do not identify with the current key population approach, but still are vulnerable to HIV are reached with effective prevention messages.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIn addition, sexualized drug use should be addressed to enable people to maintain in control of their sexual health risks.\u003c/li\u003e\n \u003cli\u003eInformation on PrEP and PEP should be more widely disseminated among the general population. Simultaneously, HIV stigma and intersecting forms of stigma, such as homophobia, as well as internalized homonegativity should also be addressed\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFPs should discuss sexual health, STIs/HIV testing and prevention measures such as P(r)EP with \u003cem\u003eall\u003c/em\u003e patients as it remains a cornerstone of prevention efforts in sexual health care.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAt the level of individual patient support and counseling, encouraging HIV disclosure and open communication among the social and sexual networks of newly diagnosed HIV persons may result in a higher success rate of the distribution of HIV self-sampling kits.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis egocentric SNA study has provided valuable insights into the social and sexual networks of people newly diagnosed with HIV. The findings underscore the need for inclusive and comprehensive HIV prevention strategies that reach beyond the current key populations, emphasizing the importance of PrEP and PEP promotion among the general population and FPs.\u003c/p\u003e\n\u003cp\u003eTo enhance HIV prevention efforts, it is crucial to involve FPs more actively in discussing sexual health and HIV testing with all patients, irrespective of their perceived risk. Encouraging open communication and HIV disclosure within social and sexual networks remains vital for improving the quality of life and mental health of people living with HIV and can potentially increase the success of distributing HIV self-sampling kits. Furthermore, future efforts should aim to address low HIV risk perception and the influence of sexualized drug use to help individuals better manage their sexual health risks.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eMSM\u0026nbsp; \u0026nbsp;Men who have sex with men\u003c/p\u003e\n\u003cp\u003ePrEP\u0026nbsp; \u0026nbsp;HIV Pre-Exposure Prophylaxis\u003c/p\u003e\n\u003cp\u003eSTI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sexually Transmitted Infection\u003c/p\u003e\n\u003cp\u003eSNA\u0026nbsp; \u0026nbsp;\u0026nbsp;Social Network Analysis\u003c/p\u003e\n\u003cp\u003ePEP\u0026nbsp; \u0026nbsp; \u0026nbsp;Post-Exposure Prophylaxis\u003c/p\u003e\n\u003cp\u003ePLHIV\u0026nbsp;People living with HIV\u003c/p\u003e\n\u003cp\u003egMSM\u0026nbsp;Gay-identified men who have sex with men\u003c/p\u003e\n\u003cp\u003ehMSW\u0026nbsp;Hetero-identified men who have sex with women\u003c/p\u003e\n\u003cp\u003ehMSM\u0026nbsp;Hetero-identified men who has sex with men\u003c/p\u003e\n\u003cp\u003ehWSM\u0026nbsp;Hetero-identified women who have sex with men\u003c/p\u003e\n\u003cp\u003ebMSM\u0026nbsp;Bisexual-identified men who have sex with men\u003c/p\u003e\n\u003cp\u003eFP \u0026nbsp; \u0026nbsp; \u0026nbsp; Family physician\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of the Institute of Tropical Medicine Antwerp (1181/17). Written or oral informed consent for participation was obtained from all individual participants prior to participation by the respective researcher. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants signed an informed consent sheet for participation, which also informed them that pseudonymized data may be published. No information that could personally identify study participants has been included in this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this article are not readily publicly available because they contain information that could compromise the privacy of our research participants. A list of condensed meaning units or codes could be made available upon reasonable request to the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was financed by Gilead Sciences.\u0026nbsp;The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEVL\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, data collection, formal analysis, writing \u0026ndash; original draft, writing \u0026ndash; review \u0026amp; editing, visualization and project administration \u003cstrong\u003eCVB\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, data collection, formal analysis, writing \u0026ndash; original draft, writing \u0026ndash; review \u0026amp; editing, funding acquisition and project administration \u003cstrong\u003eAR\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, data collection, writing \u0026ndash; review \u0026amp; editing, project administration \u003cstrong\u003eJDB\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, writing \u0026ndash; review \u0026amp; editing \u003cstrong\u003eCV\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, writing \u0026ndash; review \u0026amp; editing \u003cstrong\u003eCN\u0026nbsp;\u003c/strong\u003eConceptualization, methodology, writing \u0026ndash; review \u0026amp; editing, supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors want to thank Gilead Sciences for financial support, Prof. Dr. Steven Callens for acquiring funding and all study participants for their contribution.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eECDC, WHO. 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Eur J Gen Pract 2012;18(3):181\u0026ndash;186.\u003c/li\u003e\n\u003cli\u003eBarnhoorn PC, Prins IC, Zuurveen HR, et al. Let\u0026rsquo;s talk about sex: exploring factors influencing the discussion of sexual health among chronically Ill patients in general practice. BMC Primary Care 2022;23(1):49.\u003c/li\u003e\n\u003cli\u003eWoodbridge M, Dowell A, Gray L. \u0026ldquo;He said he had been out doing the traffic\u0026rdquo;: general practitioner perceptions of sexually transmitted infection and HIV testing strategies for men. J Prim Health Care 2015;7(1):50\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eBijlsma-Rutte A, Braamse AMJ, van Oppen P, et al. Screening for sexual dissatisfaction among people with type 2 diabetes in primary care. J Diabetes Complications 2017;31(11):1614\u0026ndash;1619.\u003c/li\u003e\n\u003cli\u003eZhou ES, Nekhlyudov L, Bober SL. The primary health care physician and the cancer patient: tips and strategies for managing sexual health. Transl Androl Urol 2015;4(2):218.\u003c/li\u003e\n\u003cli\u003eJespers V, Stordeur S, Desomer A, et al. SEXUALLY TRANSMITTED INFECTIONS IN PRIMARY CARE CONSULTATIONS: DEVELOPMENT OF AN ONLINE TOOL TO GUIDE HEALTHCARE PRACTITIONERS. n.d.\u003c/li\u003e\n\u003cli\u003eVanhamel J, Reyniers T, Wouters E, et al. How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?\u0026ndash;An Online Qualitative Study in Flanders, Belgium. Front Med (Lausanne) 2022;9; doi: 10.3389/fmed.2022.828695.\u003c/li\u003e\n\u003cli\u003eLions C, Laroche H, Mora M, et al. Missed opportunities for HIV pre‐exposure prophylaxis among people with recent HIV infection: The French ANRS 95041 OMaPrEP study. HIV Med 2023;24(2):191\u0026ndash;201.\u003c/li\u003e\n\u003cli\u003eBairan A, Taylor GAJ, Blake BJ, et al. A model of HIV disclosure: Disclosure and types of social relationships. J Am Assoc Nurse Pract 2007;19(5):242\u0026ndash;250.\u003c/li\u003e\n\u003cli\u003eScheerder G, Van den Eynde S, Reyntiens P, et al. Quality of life in people living with HIV: An exploratory cross-sectional survey in Belgium. AIDS Education and Prevention 2021;33(3):249\u0026ndash;264.\u003c/li\u003e\n\u003cli\u003eLogie C, Gadalla TM. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care 2009;21(6):742\u0026ndash;753.\u003c/li\u003e\n\u003cli\u003eRueda S, Mitra S, Chen S, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ Open 2016;6(7):e011453.\u003c/li\u003e\n\u003cli\u003eStutterheim SE, Bos AER, Schaalma HP. HIV-Related Stigma in the Netherlands. Aids Fonds; 2008.\u003c/li\u003e\n\u003cli\u003ePantelic M, Steinert JI, Park J, et al. \u0026lsquo;Management of a spoiled identity\u0026rsquo;: systematic review of interventions to address self-stigma among people living with and affected by HIV. BMJ Glob Health 2019;4(2):e001285.\u003c/li\u003e\n\u003cli\u003eHu S, Jing F, Fan C, et al. Social network strategies to distribute HIV self‐testing kits: a global systematic review and network meta‐analysis. J Int AIDS Soc 2024;27(7):e26342.\u003c/li\u003e\n\u003cli\u003eLightfoot MA, Campbell CK, Moss N, et al. Using a social network strategy to distribute HIV self-test kits to African American and Latino MSM. JAIDS Journal of Acquired Immune Deficiency Syndromes 2018;79(1):38\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eAnonymous. People First Charter. n.d.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e We subscribe the People First Charter \u003csup\u003e49\u003c/sup\u003e and we agree that it is best to avoid abbreviations when referring to people. However, we will have to resort to the aforementioned abbreviations for the sake of readability within this paper.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e ILGA-Europe\u0026rsquo;s Rainbow Map annually ranks 49 European countries on a scale between 0% (gross violations of human rights, discrimination) and 100% (respect of human rights, full equality) on the basis of laws and policies that have a direct impact on LGBTI people\u0026rsquo;s human rights.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV, Social Network Analysis, behavior, prevention","lastPublishedDoi":"10.21203/rs.3.rs-4985105/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4985105/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA better understanding of HIV transmission dynamics is needed to further reduce the number of new HIV diagnoses in Belgium. As environmental and social context play an important role in explaining HIV acquisition despite the availability of effective HIV prevention, this study investigated the role of social and sexual networks in HIV prevention and risk behavior among people newly diagnosed with HIV, including their perceptions of how they acquired HIV and their ability to disclose their HIV status.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e This qualitative study used an ego-centric social network approach, through in-depth interviews generating sociograms of social and sexual networks with 20 participants newly diagnosed with HIV.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFriends, family members, regular sex partners and HIV physicians were placed closest to the ego on the sociogram. Self-identified gay men did not consider their casual sex partners as emotionally close enough to be included in the sociogram, even though these partners were often participants\u0026rsquo; primary source of information about sexual health. HIV acquisition among this group was often attributed to increased sexual risk-taking under influence of drugs. Heterosexual and bisexual men who have sex with men (MSM), who had more diverse networks, often did not consider themselves at risk for HIV. Awareness of PrEP was higher among gay-identified MSM than among heterosexuals and heterosexual MSM, partly attributed to community-based prevention efforts. Most participants only disclosed HIV to those closest to them, and the anticipated and perceived lack of social support influenced HIV acceptance. Feelings of internalized HIV stigma and homophobia prevented HIV disclosure, especially among heterosexuals and heterosexual and bisexual MSM.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study revealed important differences in the networks of gay-identified MSM, heterosexuals and hetero- and bisexual identified MSM influencing sexual risk taking and prevention behavior. Future prevention initiatives should be inclusive and mainstreamed to ensure to also address those who do not identify as the established transmission groups. Awareness of biomedical prevention should be raised in the general population, providing a base on which more tailored promotion can be built. Involving family physicians and social empowering people living with HIV may help to decrease (anticipated) HIV stigma.\u003c/p\u003e","manuscriptTitle":"Social and sexual networks of newly diagnosed people living with HIV: a qualitative social network analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-18 08:33:35","doi":"10.21203/rs.3.rs-4985105/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-02T16:28:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-30T04:31:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-30T04:31:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-08-27T14:02:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cb625bd-467d-4481-b3ce-5329df4babb6","owner":[],"postedDate":"October 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:01:37+00:00","versionOfRecord":{"articleIdentity":"rs-4985105","link":"https://doi.org/10.1186/s12889-025-21708-5","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-02-15 15:57:33","publishedOnDateReadable":"February 15th, 2025"},"versionCreatedAt":"2024-10-18 08:33:35","video":"","vorDoi":"10.1186/s12889-025-21708-5","vorDoiUrl":"https://doi.org/10.1186/s12889-025-21708-5","workflowStages":[]},"version":"v1","identity":"rs-4985105","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4985105","identity":"rs-4985105","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}