Data gap: Why are gay, bi and trans men at high risk of HIV in Estonia?

“There’s a slur I won’t mention here, but I hear people using it on the street all the time, more than I ever heard it in my hometown,” says an American immigrant in Tallinn, who identifies as a cisgender male, gay, and an immigrant, and wanted to remain unnamed.

“Maybe it hasn’t been directed at me, but its frequent use makes me uneasy and a bit nervous. So, I think that’s maybe also part of why I decided to go to the sexual health clinic and not use a regular provider. Not because I’ve had a bad experience with the regular provider, but because I don’t want to have a negative experience”.

This is a snapshot of the relationship between Estonian healthcare providers offering HIV testing and the community whose sexual behavior is considered one of the most vulnerable groups to HIV.

Clinically referred to as MSM (man having sex with man), which includes different genders and sexual identities – gay, trans and bisexual – is closely linked to sexual behavior, which is why regular medical check-ups and preventative resources are important.

A new study “MSM and Trans People in Estonia“, published in May, included 314 MSMs and is the first of its kind in Estonia. Maksym Kasianczuk, an independent researcher and the study’s co-author, says: “The availability of data is a big problem, and this problem is also due to the old school thinking in Estonian public health policy.”

“For example, providing free testing and precaution methods is a great effort, but if you do not have a study on what is the reason why people do not take up the free testing or precaution methods…,” he says, adding: “I would rather like to ask why there is no research on the stigmatization of MSM after 2010?”

The study says 53 percent of MSMs have experienced stigma due to their sexual orientation such as insults, gossip and comments in their family and health care settings. Additionally, stigma was found to be “significantly higher” among the Russian-speaking community than among Estonian and English-speaking people living in Estonia.

Beyond the facts and figures, how are MSM faring in Estonia? Why does the highest vulnerability for HIV-positive cases lie within this community, and how are they recorded in Estonian official data?

The community and its complexity

If you keep an eye on social media, especially Facebook, and click the ‘Like’ button on pages such as the Estonian LGBT Association, Q Space, Baltic Pride or X-Baar, Hello Bar and Hunger Bar etc., its easy to find activities, engagement and calls to action in Estonia’s gay, trans, and bisexual communities. Especially during June – Pride Month.

However, in-person events are concentrated in larger cities, such as Tallinn and Tartu. For many, the only choice is to keep a low profile, to remain invisible, in their fight against fear.

Gleb Kuznetsov, who works as an MSM peer counselor for an NGO in Ida-Viru County, paints a similar picture. “Here in the community, people are afraid to be open as homosexuals. Russia is close, and that also affects the situation. Homosexuality is a stigma here,” he said.

Estonia’s MSM population totals 9,909, according to the National Institute for Health Development’s 2023 report “Men who have sex with men population size estimation in Estonia.”

 

This group faces “a higher vulnerability to HIV during receptive anal intercourse compared to vaginal intercourse. The lining of the rectum is more prone to tears, making it easier for the virus to enter the bloodstream,” the U.S. Centers for Disease Control and Prevention (CDC) explains. This is one of the primary reasons why individuals who identify as gay, trans or bisexual are framed in the clinical term MSM.

But until now, there has been no report published by the Health Board or the National Institute for Health Development (TAI) that provides detailed insights into the sexual behaviors and psychological impact on MSM in Estonia.

The newly published “MSM and Trans People in Estonia” written by the Estonian HIV Positive Network-EHPV states that 55 percent of respondents have used substances, such as “poppers and erectile stimulants or poppers and cannabis” before or during sexual intercourse, and 40 percent express dissatisfaction with their sex life.

The report elaborates on the reasons behind this dissatisfaction: “Lack of a permanent relationship, a small number of partners, or the need for greater frequency of meetings; difficulties in relationships with a permanent partner; as well as various psychological and social problems, including distance between partners, rejection, stigma and noncompliance with ‘beauty standards.'”

It says, this reality leads to several sexual behaviors including a higher number of concurrent partners, substance use and less consistent use of protection during sex.

Of those who participated in the study, 88 percent had been tested for HIV at least once in their lives and 67 percent in the last year. Over 25s were four times more likely to have been tested during the last year.

Data gap

In total, the TAI Center for Health and Wellbeing said there are around 7,000 people in Estonia who have received an HIV-positive diagnosis.

It is hard to give an exact figure because until 2009 the confirmation of HIV tests was anonymous, says Alyona Kurbatova, head of the center.

“Estonia is among the first in Europe in terms of infections, but there is definitely no pandemic and the number of infections has stabilized,” Kurbatova says. “Unfortunately, Estonian data is very incomplete, perhaps 80 percent of newly infected people we don’t know the route of spread.”

This is one of the biggest problems when talking about HIV and the LGBT+ and MSM communities.

“However, it can be said that there is a known proportion of MSM among the cases related to Estonia’s 6.4 percent,” Kurbatova says.

Two reports, Kasianczuk’s and another recently published by the National Institute both put the figure at between 6-8 percent.

Data from the Health Board shows 69 new cases have been recorded in 2024, but there is no specific breakdown for MSM. Trans people were not included in the research until 2017.

Are precautions really accessible and available?

While the access and availability of treatment and facilities are appreciated by individuals living with HIV, prevention is more complicated. In line with the European Center for Disease Prevention and Control, Estonia approves condoms and PrEP (Pre-Exposure Prophylaxis) tablets as preventive measures against HIV transmission among MSM.

Condoms are free and available everywhere at regular and sexual health specialized centers. In addition to government health providers, some non-governmental organizations and associations, such as EHPV, Convictus, VekLGBT, and the LGBT association, also offer free condoms, testing, lubricants and self-support counseling. However, they do not provide PrEP, as it is solely managed by the government authority.

The journey to obtaining PrEP tablets is long. Kerstin Aimla, an HIV/HCV co-infection specialist at Tartu University Clinic, explains: “PrEP has been available in Estonia at a 50 percent discount since April 1, 2020, if prescribed by an infectious disease specialist or ID. If a person has health insurance and is referred to an infectious disease doctor, they can get tested and then receive a prescription for PrEP. We have very strict rules regarding how to follow our patients.”

But for some, the start of the process is also the end. An anonymous MSM says: “If you know that your family doctor knows not only your parents but also your neighbors, or if you know that your family doctor is homophobic, how can it be possible to ask him or her for PrEP?”

Researcher Maksym Kasianczuk says there is a high demand for the drug and highlights the Estonian Health Insurance Fund’s 2023 data. “You can see that in the last year [2023], 269 people received PrEP, while PrEP prescriptions were prescribed 2,390 times.”

He added: “This clearly shows that the demand is much higher than the number of recipients. If we look at the HIV-positive rate of MSM of 6 to 8 percent, about 92 percent of people in the community have no HIV viral load. These 92 percent need PrEP to protect themselves from HIV. And it is the responsibility of the state to make PrEP available. And it should also be available at an affordable price, because now it costs €51 without a prescription and €27 with a prescription and discount. That sucks!”