Age biases in a large HIV and sexual behaviour-related internet survey among MSM

Abstract

Background: Behavioural data from MSM are usually collected in non-representative convenience samples, increasingly on the internet. Epidemiological data from such samples might be useful for comparisons between countries, but are subject to unknown participation biases.

Methods: Self-reported HIV diagnoses from participants of the European MSM Internet Survey (EMIS) living in the Czech Republic, Germany, The Netherlands, Portugal, Sweden and the United Kingdom were compared with surveillance data, for both the overall diagnosed prevalence and for new diagnoses made in 2009. Country level prevalence and new diagnoses rates per 100 MSM were calculated based on an assumed MSM population size of 3% of the adult male population. Survey-surveillance discrepancies (SSD) for survey participation, diagnosed HIV prevalence and new HIV diagnoses were determined as ratios of proportions. Results are calculated and presented by 5-year age groups for MSM aged 15-64.

Results: Surveillance derived estimates of diagnosed HIV prevalence among MSM aged 15-64 ranged from 0.63% in the Czech Republic to 4.93% in The Netherlands. New HIV diagnoses rates ranged between 0.10 per 100 MSM in the Czech Republic and 0.48 per 100 in The Netherlands. Self-reported rates from EMIS were consistently higher, with prevalence ranging from 2.68% in the Czech Republic to 12.72% in The Netherlands, and new HIV diagnoses rates from 0.36 per 100 in Sweden to 1.44 per 100 in The Netherlands. Across age groups, the survey surveillance discrepancies (SSD) for new HIV diagnoses were between 1.93 in UK and 5.95 in the Czech Republic, and for diagnosed prevalence between 1.80 in Germany and 4.26 in the Czech Republic.Internet samples of MSM were skewed towards younger age groups when compared to an age distribution of the general adult male population. Survey-surveillance discrepancies (SSD) for EMIS participation were inverse u-shaped across the age range. The two HIV-related SSD were u- or j-shaped with higher values for the very young and for older MSM. The highest discrepancies between survey and surveillance data regarding HIV-prevalence were observed in the oldest age group in Sweden and the youngest age group in Portugal.

Conclusion: Internet samples are biased towards a lower median age because younger men are over-represented on MSM dating websites and therefore may be more likely to be recruited into surveys. Men diagnosed with HIV were over-represented in the internet survey, and increasingly so in the older age groups. A similar effect was observed in the age groups younger than 25 years. Self-reported peak prevalence and peak HIV diagnoses rates are often shifted to higher age groups in internet samples compared to surveillance data. Adjustment for age-effects on online accessibility should be considered when linking data from internet surveys with surveillance data.

Figure 1

Survey-surveillance discrepancy curves for EMIS participation (=proportion of EMIS respondents per age group/ proportion of male adults per age group) for six EMIS countries: Czech Republic (CZ), Germany (DE), The Netherlands (NL), Portugal (PT), Sweden (SE), United Kingdom (UK).

Figure 2

2^nd order polynomic trendline curves for survey-surveillance discrepancies between self-reported HIV prevalence in EMIS and diagnosed HIV prevalence based on surveillance data (self-reported HIV prevalence per 5-year age group in EMIS/ diagnosed prevalence per age group in the MSM population).

Figure 3

2^nd order polynomic trendline curves for survey-surveillance discrepancies between self-reported new HIV diagnosis in 2009 in EMIS and surveillance data for 2009 (=number of HIV infections diagnosed in 2009 per 100 EMIS participants/ number of newly diagnosed HIV infections in 2009 per 100 MSM by 5-year age group).

Figure 4

Relationship between the SSD for EMIS participation and the SSD for new HIV diagnoses, taking Germany as example.

Figure 5

Self-reported median number of non-steady sexual partners per age group in the German EMIS sample (SSD-adjusted*), stratified by self-reported HIV status: correlation with EMIS age distribution. * Reported median partner numbers were divided by the age group-related SSD factor.

Figure 6

Changes of newly diagnosed HIV infections among MSM in Germany between 2001–2003 and 2010–2012. Figure 6a: Proportional increase by population size of the place of residency Figure 6b: Proportional increase by age group.