Integrating Cognitive-behavioural Therapy for Social Anxiety Disorder With HIV Risk Reduction Counselling for HIV-negative Gay and Bisexual Men Who Are at High Risk for HIV: A Randomized Controlled Trial.

Gay, bisexual, and other men who have sex with men (MSM) continue to bear a disproportionate burden of the sexually transmitted infections (STI), such as HIV in Canada, largely attributable to efficient transmission during condomless anal sex (CAS). Despite overall declines in HIV incidence since 2005, HIV incidence among MSM remains stable. In 2016, MSM accounted for 52.5% of new HIV diagnoses in Canada, compared with 56.8% in 2014. MSM also represent over half of all prevalent HIV cases. The HIV epidemic among MSM has failed to decline despite biomedically-driven efforts to reduce infectiousness through the proliferation of antiretroviral Treatment as Prevention, and the emergence of HIV Pre-Exposure Prophylaxis (PrEP) to reduce HIV susceptibility. The epidemiologic data underscore the need for efficacious interventions for reducing sexual risk behaviour among MSM. The Public Health Agency of Canada (PHAC) has therefore identified MSM as a high priority population to reach with prevention initiatives.

Social anxiety is a risk factor for CAS among MSM. It is typically defined as the experience of fear of and apprehension about being evaluated in interpersonal situations, including romantic or sexual relationships. Social anxiety is higher among gay men and other sexual minority populations than among heterosexuals on both dimensional measures and categorical measures, with recent studies reporting the prevalence of social anxiety disorders among MSM as 22.3-22.9%.

Social anxiety predicts risky sex among MSM. Research suggests a direct relation between social anxiety and CAS among MSM. Social anxiety was associated with a greater proportion of receptive and insertive CAS even after adjusting for condom use negotiation, depression, and club drug use. Social anxiety may also increase substance use in sexual situations, which is another risk factor for HIV among MSM. However, no studies have examined the efficacy of social anxiety treatment on CAS among MSM. Social anxiety is highly modifiable via cognitive-behavioural therapy (CBT).

Fears of being sexually rejected by one's partner fully accounted for the association between social anxiety at baseline and CAS at 6-month follow-up. This study is consistent with previous findings that 32% of gay men reported being less likely to use condoms when they were concerned their partner would react negatively. Substance use may be another mediator. Social anxiety is also a risk factor for later alcohol use and other substance use problems in clinical and nonclinical samples, including among MSM. Substance use tends to follow social anxiety disorder because alcohol and other substances are used to self-medicate anxiety symptoms in social situations. Alcohol and substance use in sexual situations is a relatively consistent risk factor for CAS among Canadian MSM, as well as higher HIV incidence. Due to consistent data linking substance use to HIV risks, it has been suggested that incorporating alcohol and substance use treatment into sexual risk reduction counselling may increase the efficacy of HIV prevention efforts for MSM. Social anxiety may have a specific relationship with substance use in creating risk for HIV and other STIs.

The present study will provide efficacy data for a novel and innovative STI/HIV prevention intervention for MSM. This intervention, called Sexual Confidence, builds upon empirically supported treatments for social anxiety, including social anxiety-related substance use, by adding risk reduction counselling to reduce STI/HIV sexual risk behaviour.