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MSM AND TRANS
PEOPLE IN ESTONIA
Tallinn, 2024
POPULATION SIZE,
INTERNAL HOMOPHOBIA,
INVOLVEMENT IN HIV PROGRAMS
AND SATISFACTION WITH THEM
Maksym Kasianczuk
Kostyantyn Dumchev
Latšin Aliev
Sagib Kulbaev
Lukas Andrijauskas
Gleb Kuznetsov
Paavo Ulmanis
www.ehpv.ee
Kasianczuk, M. et al. MSM and Trans People in Estonia: Population Size, Inter-
nal Homophobia, Involvement in HIV Programs and Satisfaction with Them /
M. Kasianczuk (Institute of Sociology of NAS of Ukraine), K. Dumchev (Ukrain-
ian Institute on Public Health Policy), L. Alijev, S. Kulbaev, L. Andrijauskas,
G. Kuznetsov, P. Ulmanis (Estonian Network of People Living with HIV). — Tal-
linn, 2024. — 70 p.
ISBN 978-9916-4-2421-6 (pdf)
Contributions of the authors: MK — development of the protocol and research tools, preparation of the first ver-
sion of the Report, KD — composition of the sections on the ethical review in the Protocol and the Report, consult-
ing on the topics of PrEP and the cascade of HIV services, LA — general management of the research project, SK,
LA and GK — data collection during the field phase of the study, PU — recommendations, interpretation of data on
chemsex
Reviewers: Ivan Тitar, PhD, Chief Specialist in Scientific Research, Center for Public Health of the Ministry of
Health of Ukraine; Kristi Rüütel, PhD, Senior Researcher, National Institute for Health Development of Estonia
The Study was carried out by the Estonian Network of People Living with HIV as part of the “MSM Checkpoint”
Project
The design of the cover: Iana Levman
1
LIST OF TABLES ........................................................................................................................................ 2
LIST OF FIGURES ...................................................................................................................................... 3
ACKNOWLEDGMENTS .............................................................................................................................. 4
GLOSSARY ................................................................................................................................................. 4
MAIN RESULTS .......................................................................................................................................... 6
RECOMMENDATIONS TO STAKEHOLDERS .......................................................................................... 9
RESEARCH TEAMS AND INSTITUTIONS ........................................................................................................... 9
LGBTI ORGANIZATIONS ............................................................................................................................ 10
HIV SERVICE ORGANIZATIONS AND GOVERNMENT INSTITUTIONS .................................................................... 10
VOLUNTEERS AND COMMUNITY MEMBERS .................................................................................................. 12
1 BACKGROUND .............................................................................................................................. 13
2 METHODOLOGY ............................................................................................................................ 20
3 RESULTS AND DISCUSSION ........................................................................................................ 25
3.1 SOCIO-DEMOGRAPHICS AND SEXUALITY OF RESPONDENTS ..................................................................... 25
3.2 EXPERIENCES OF STIGMA AND DISCRIMINATION ..................................................................................... 33
3.3 INTERNAL HOMOPHOBIA ...................................................................................................................... 35
3.4 HIV KNOWLEDGE, TESTING EXPERIENCE AND SATISFACTION ................................................................... 39
3.5 AWARENESS OF PREP, TAKING PREP, AND SATISFACTION WITH A DOCTOR ............................................. 45
3.6 CASCADE OF HIV SERVICES ................................................................................................................ 50
3.7 SERVICES USED ................................................................................................................................. 51
3.8 POPULATION SIZE ESTIMATION ............................................................................................................. 56
CONCLUSIONS AND LIMITATIONS ....................................................................................................... 60
REFERENCES ........................................................................................................................................... 63
2
List of tables
Table 1 GAM Indicators ........................................................................................... 9
Table 2 Data about studies of Estonian MSM in the context of HIV ..................... 15
Table 3 The number of changes in identity documents due to the changed gender
marker by year according to the Estonian Ministry of the Interior ........................ 16
Table 4 Demographics of respondents .................................................................... 26
Table 5 Substances used by MSM and trans people ............................................... 29
Table 6 Reasons for dissatisfaction with sexual life ............................................... 32
Table 7 Negative life experience related to homo-/bisexual orientation or
homosexual behavior .............................................................................................. 33
Table 8 Links between external and internal stigma .............................................. 36
Table 9 Results of the regression analysis of links between demographics and the
level of internal homophobia .................................................................................. 37
Table 10 Knowledge of basic facts about HIV ....................................................... 40
Table 11 HIV testing .............................................................................................. 42
Table 12 Results of the regression analysis of links between social-demographic
variables and HIV testing ....................................................................................... 43
Table 13 Experience of using PrEP among HIV-negative respondents, who have
ever heard of it ........................................................................................................ 46
3
Table 14 Readiness to join PrEP programs taking into account existing restrictions
................................................................................................................................ 48
Table 15 Results of the regression analysis of links between social-economic
variables and willingness to participate in PrEP program ...................................... 49
Table 16 Ways of communication of respondents with other homo- and bisexual
men as well as trans-people .................................................................................... 52
Table 17 Compilation of data from all available sources and point estimates of the
number of MSM in Estonia .................................................................................... 57
List of figures
Figure 1 MSM PSEs in Estonia .............................................................................. 17
Figure 2 Attractiveness of different genders and sexual experience of МSМ and
trans people ............................................................................................................. 27
Figure 3 Indicator of external stigma related to sexual orientation in groups of
MSM and trans people in Estonia with different languages of communication;
scale from 0 (no stigma) to 11 (stigma is expressed to the most extent in hostile
actions of others) ..................................................................................................... 35
Figure 4 Levels of internal homophobia among Estonian MSM with different
languages of communication; scale from 1 (no internal homophobia) to 7
(maximum internal homophobia) ........................................................................... 36
Figure 5 Distribution of МSМ and trans people according to the level of their
awareness of basic facts about HIV ........................................................................ 41
Figure 6 Popularity of current and desired places for HIV testing ......................... 44
4
Figure 7 Obtaining consensus estimates of the population of MSM and trans
people in Estonia using the Bayesian approach ...................................................... 59
Figure 8 Changes in the number of adult men in Estonia according to the data of
the Statistics Estonia (https://www.stat.ee) ............................................................. 59
Acknowledgments
Alvar Ameljushenko, Imbi Arro, Miroslav Bingel, Mart Kalvet, Eeva Koplimets,
Raul Lindemann, Sasha Milyakina, Indrek Niibo, Heino Nurk, Liisi Raidna, Marju
Sammul, Keio Soomelt, Maksim Drozhzhin, Alla Zakharchuk, Jekaterina
Smirnova
Glossary
AIDS — acquired immunodeficiency syndrome
ART — antiretroviral therapy
Body positivity — acceptance of oneself and other people’s bodies as they exist
Chemsex — the use of psychoactive substances before or during sexual intercourse
CI — confidence interval
CS — convenience sample
EHPV — Eesti HIV-positiivsete võrgustik — Estonian Network of People Living
with HIV
5
GAM — The Global AIDS Monitoring (2024) — the system of standard indicators
that enables to assess the progress of different countries in their fight against
the HIV epidemic
HIV — human immunodeficiency virus
LGBTI — lesbian, gay, bisexual, trans and intersex people
MSM — men who have sex with men
N — sample size from which the percentage is calculated
NGO — non-governmental and non-profit organization
OR — odds ratio
p-value — the probability of obtaining test results at least as extreme as the result
actually observed, under the assumption that the null hypothesis; p-values <
0.05 are generally considered to indicate that the nature of observed data dis-
tribution is non-random
Peer consultant — a person, who has the same personal experience as the people
he/she advises and has undergone a special training
PLHIV — people living with HIV
PrEP — pre-exposure prophylaxis
PSE — population size estimation
RDS — respondent driven sample
6
Main results
A cross-sectional pilot study with a convenience sample based on quantitative meth-
odology. The resulting sample (314 people) exceeded the coverage of previous stud-
ies of MSM due to the active involvement of the community.
In the sample, Estonian-, Russian-, and English-speaking MSM and trans-people
were respectively represented by 39, 47, and 14%. The average age was 36 [35–37]
years. 98% were cis men. 65% stated that to them only men are sexually attractive.
About half (48%) have had sexual experience only with men.
Chemsex is popular among respondents (55% have used certain substances before
or during sex during the last 6 months). Erection stimulation drugs are more popular
among Estonian-speaking respondents. Half (47%) have experience in using several
different substances during chemsex, and the most common are combinations of ei-
ther poppers and erectile stimulants or poppers and cannabis.
40% are dissatisfied with their sexual life. The main reasons named were lack of a
permanent relationship, small number of partners and/or the need for greater fre-
quency of meetings, difficulties in relationships with the permanent partner as well
as various psychological and social problems (including the distance between part-
ners, rejection, stigma, and noncompliance with “beauty standards”).
The indicator of external stigma (2.6 [2.3–2.9] points out of 11) is not high, mean-
while it is significantly higher among Russian-speaking (2.9 [2.4–3.4]) MSM and
trans people than among Estonian-speaking (2.0 [1.6–2.4]). Due to their sexual ori-
entation, gender identity or sexual behaviour, participants of the study most often
experienced insults, gossip and comments in their family and health care settings.
7
The level of internalised homophobia is close to the minimum value (2.9 [2.8–3.0]
on a scale from 1 to 7), however, in Estonia, it is higher among Russian-speaking
MSM (3.2 [3.0–3.4]), than among Estonian-speaking MSM (2.8 [2.6–3.0]). Moreo-
ver, predominantly heterosexual orientation and dissatisfaction with one's sexual life
were associated with high levels of internal homophobia.
Half (54%) correctly answered all 7 questions regarding basic facts about HIV.
88% have been tested for HIV at least once in their lives and 67% in the last year.
The odds to have been tested for HIV in the last year among respondents aged 25+
is four times higher compared to younger respondents. The odds are eight times
higher among the respondents, who know all basic facts about HIV compared to the
ones, who do not. The prevalent heterosexual experience is associated with the odds
of being tested four times higher compared to those with prevalent homosexual ex-
perience. Respondents, who took psychoactive substances before or during sex,
were five times less likely to be tested for HIV in the last year compared to those,
who did not engage in chemsex.
Most respondents are tested for HIV in medical settings (78%) and prefer to continue
doing it there (70% of all tested). Satisfaction with communication with a health care
worker during the last test was high (4.4 [4.3–4.5] on a 5-point scale).
76% of respondents without HIV-positive status have ever heard of PrEP. Of these,
66% have never used PrEP mainly due to their certitude that there is no risk to be
infected with HIV, lack of knowledge where to get the medication and other reasons,
the most probable of which may be the lack of medication in pharmacies during the
period of the field (only 26% among these without HIV-positive status used PrEP).
Respondents are also discouraged by the cost of PrEP because it is substantially
higher than generics available abroad.
8
Only one third (29%) of those, who do not use pre-exposure prophylaxis, are ready
to use it under the current conditions in Estonia. Respondents aged 25 years and
older were four times more likely to participate in PrEP compared to younger re-
spondents. The odds of receiving PrEP among Russian-speaking respondents, was
half the rate of Estonian- or English-speaking ones. Similarly, one-point increase in
internal homophobia halved the odds of participating in PrEP.
PrEP was prescribed to 90% of users and their satisfaction with communication with
a doctor averaged 4.4 [4.1–4.8] on a five-point scale.
Out of the two most well-known mobile dating apps for MSM and trans people in
Estonia, Grindr is more popular (62%).
One third used the IHA.ee (35%) and Romeo.com (39%) during the last year. Both
sites are more popular among Estonian-speaking than among Russian-speaking par-
ticipants. Bluesystem.world (12%) is popular among the Russian-speaking and un-
known to the Estonian-speaking respondents.
The popularity of the LGBTI-oriented business is comparable to online dating (“X-
Baar” 37%, “Hello Bar” and “Bar Sveta” 31% each). The most frequently mentioned
LGBTI events were Tallinn Pride (22%), LGBTI film screenings at Q-Space (13%)
and visiting the Festheart Film Festival (11%).
In Table 1 presented the calculated GAM indicators, based on the study results.
9
Table 1 GAM Indicators
1.2B
MSM PSE a)
9,898 [9,628–10,166] b)
1.3B
HIV prevalence among MSM a)
8%
1.4B
HIV testing coverage and status awareness among
MSM a)
67%
1.11
HIV-negative MSM a) who have ever received PrEP
34%
2.1
MSM a) living with HIV who know their HIV status
87%
2.2
MSM a) living with HIV on antiretroviral therapy
100%
2.3
MSM a) living with HIV who have suppressed viral
loads
82%
6.5B
Stigma and discrimination experienced by MSM within
their lives a)
53%
Notes: a) incl. trans-people; b) 2.0 [1.9–2.1]% among men aged 18+
Recommendations to stakeholders
Research teams and institutions
Nothing about us is without us. LGBTI community (including trans and intersex
people) should be fully involved at all stages of planning and implementation of
research and programs aimed at LGBTI people.
Each study involving LGBTI people should include separate sets of questions related
to experiences of trans and intersex people.
Separate research should be conducted to analyse experiences of bisexual men and
their partners.
10
A qualitative study of reasons for lower popularity of erection stimulants among
Russian-speaking MSM and trans people in Estonia should be carried out.
LGBTI organizations
Proactive involvement in funding, planning, and implementation of LGBTI- and
MSM-focused research and programs should be secured.
Services should be designed considering the large number of bisexual people (in-
cluding those, who do not consider themselves to be a part of the LGBTI community
but have experience of same-sex sexual contacts).
During implementation of sexual health programs, attention should be paid to chem-
sex practices and minimization of their harmful consequences.
When conducting events aimed at LGBTI people, promotion of body-positive mes-
sages, counteracting stigmatization of certain subgroups in the LGBTI community,
whilst during individual consultations, activities concerning stereotypical perception
of gender and sexuality should be envisaged.
When documenting cases of stigma, discrimination, and hate crimes, analysis of
cases based on the language or nationality of the victims, should be performed.
Awareness campaigns aimed at combating stigmatization, discrimination and hate
crimes, considering their unequal intensity and specificity in Estonian- and Russian-
speaking groups, should be run.
HIV service organizations and government institutions
Awareness-raising programs to inform MSM and trans people about modes of trans-
mission, methods of prophylaxis (both pre- and post-exposure) and treatment of
11
HIV, as well as counteracting individual and group stigmatization of people living
with HIV should be expanded.
The range of opportunities for voluntary HIV testing and counselling for MSM and
trans people, including self-testing, dispensing tests by mail and remote consulta-
tions should be expanded. The specificities of bisexual people, who do not identify
with the LGBTI community, but have experience of same-sex sexual contacts should
be considered.
The index testing framework should be scaled up. The service of letters, which in-
clude message templates and offers to come for anonymous and free of charge test-
ing in cases of new seroconversion should be suggested to contact persons.
Peer consultants, who can work with people at private sex parties, including where
chemsex is practiced, should be trained.
Greater availability of pre-exposure prophylaxis medications drugs, including re-
duction of their cost and over-the-counter sales, with opportunity to receive online
consultation on their use should be lobbied for. Even though Estonia has the national
guidance on PrEP, it can be prescribed half price only by infectious diseases doctors
in a few cities, but it could be expanded to other specialists, e.g. general practitioners,
STI doctors, etc.
Implement programs with proven effectiveness and impact not only at the
individual level, but throughout the whole gay and trans communities, e.g.
PROMISE for HIP (https://www.cdc.gov/hiv/effective-interventions/treat/promise-
for-hip/index.html) or d-up: Defend Yourself! (https://www.cdc.gov/hiv/effective-
interventions/prevent/d-up/index.html).
12
When designing PrEP programs, specifics associated with the language or national-
ity of participants as well as presence of medium and high levels of internal homo-
phobia should be considered.
Negotiations with the most popular online and offline dating services about publish-
ing advertisements of services for MSM and trans people should be conducted.
Volunteers and community members
Own experience in HIV prevention and control should be shared with others as much
as possible, including personal stories, habits, addictions, patterns, side effects, im-
pressions of contacts with a doctor and other health-care personnel, etc. The personal
example of familiar people helps to better remove psychological barriers compared
to brochures and cold scientific arguments.
Active involvement in debate with critics, deniers, and peddlers of misinformation
about HIV and PrEP should take place. During periods of supply disruptions, the
approach to filling issued prescriptions should be reasonable, unwise purchase of
drugs for future use should be avoided. When purchasing PrEP in pharmacies, the
quantity of the drug remaining on sale should be checked. When purchasing several
packages, be sure to leave at least one on sale for the emergency needs of other
community members.
Tabooing and stigmatizing the topics of sexual health and HIV should be avoided.
13
1 Background
Estonia is a country in Northern Europe with more developed economy compared
to other post-Soviet countries.[1] Estonia is characterized by a low level of corruption
and high public confidence in the legislative, executive, and judicial powers.[2] The
population of the country is 1.3 million and the estimated population size of MSM
in 2021 was 9,909 [6,279–14,243].[3] It is also the only country in Eastern Europe
and Central Asia where same-sex couples have the right to enter a civil partnership
[4] and gender-neutral marriage.[5] The country has its own anti-discriminatory legis-
lation [6] and during 2022–2023, there was an active public discussion about the in-
troduction of criminal liability for hate speech. In 2021, Estonia ranked 23rd out of
49 countries included in the Rainbow Index of the ILGA-Europe and was highest in
the ranking among other countries of the region.
Data on the attitude of Estonian society towards LGBTI people can be obtained from
several independent sources, e.g. CRONOS studies,[7,8] ESS [9–17] including regular
surveys ordered by the Center for Human Rights.[18] In addition, several other data
were obtained by the Liberal Citizen Foundation (https://salk.ee). The analysis of
these data allows to assert that the attitude of Estonian society towards LGBTI peo-
ple is improving, while the processes happen at different pace in the Estonian- and
Russian-speaking communities (the Russian-speaking community demonstrates sig-
nificantly more conservative position).[19] At the same time, the Estonian-speaking
majority is not homogeneous. On one hand, there is a more socially active part of it,
and on the other — those who consider nationality to be a citizenship, not an eth-
nic/kin category.
As a high-level income country, Estonia has not received the Global Fund funding
since 2004. NGO activities, as a rule, are supported from local sources (state and
14
local authorities, trust funds, private donations, volunteer work, etc.), although
LGBTI community projects can be supported from abroad.
Estonia has a developed LGBTI infrastructure, which includes regular cultural
events (Rakvere Film Festival, Baltic Pride, etc.), NGOs, initiative groups, LGBTI-
oriented businesses, which include nightclubs and informal meeting places (i.e. pri-
vate sex parties, nudist gay beaches in Tallinn, Tartu and Pärnu). According to the
pan-European study (https://fra.europa.eu/en/data-and-maps/2020/lgbti-survey-
data-explorer), Estonia ranked seventh among 28 European Union countries on the
participation of LGBTI people in activities of LGBTI organizations.
The literature on Estonian LGBTI people is very scarce and mainly relates to the
context of MSM and HIV.[20,21] As demonstrated in Table 2, except for the 2010
EMIS survey, studies of MSM in Estonia were based on small samples (less than
250 people) and covered mainly Tallinn. Trans people did not participate in studies
until 2017.
The situation in Estonia regarding the empirical population size estimates (PSE) is
not optimistic (Figure 1). The first one was published in 2013,[22] although the data
on which it was based had been collected in 2009. For more than ten years, the esti-
mates were not updated. Only 2023 saw a new estimate based on the data of 2021.[3]
The data of the two studies (2000 [23] and 2020 [24]) were neither known in HIV ser-
vices, nor used in planning of the public health policy.
15
Table 2 Data about studies of Estonian MSM in the context of HIV
Yea r
Name and methodology
Sample size
2004
HIV/AIDS-iga seotud teadmised ja käitumine gay-
internetilehekülgi külastavate meeste seas (CS)
312 [25]
2005
HIV/AIDS-iga seotud teadmised ja käitumine gay-in-
ternetilehekülgi külastavate MSM-ide seas (CS)
232 [26]
2007
HIV-iga seotud teadmised ja käitumine gay-internetile-
hekülgi külastavate MSM-ide seas (CS)
361 [27]
2007
HIV-nakkuse levimus ja riskikäitumine meestega
seksivate meeste seas Tallinnas ja Harjumaal: Pilootu-
urimus uuritava poolt juhitud kaasamise meetodil
(RDS)
59 [28]
2010
Еuropean internet survey of МSМ (CS)
500
[29]
2013
Meeste tervise heaks (CS)
228 [30]
2016
Meeste terviSEKS (CS)
223
[31]
2017
ECOM Study of internalized homonegativity (CS)
62 [32]
2017
Еuropean internet survey of МSМ (CS)
212
[33]
2022
HIVi levimus ja riskikäitumine meestega seksivate
meeste hulgas Tallinnas ja Harjumaal (RDS)
163 [34]
16
The PSE of transgender people in Estonia is unknown,[35] although the survey data
from 2020 (0.96% of population aged 18+) [24] are available. Estonian authorities
(Department of Statistics / Statistikaamet
1
, Health Department / Terviseamet
2
) re-
ported that they did not have any information regarding the number of trans people.
The number of changes in identity documents due to the changed gender marker was
reported by the Ministry of the Interior / Siseministeerium (Table 3), most gender
change data is registered at the Tallinn Family Status Office / Tallinna Perekon-
naseisuametis
3
.
Table 3 The number of changes in identity documents due to the changed gen-
der marker by year according to the Estonian Ministry of the Interior
Year
Number of changed documents
2019
22
2020
15
2021
9
2022
23
2023
25
1
Official reply dated 12.03.2024 to inquiry of EHPV
2
Official reply dated 14.03.2024 to inquiry of EHPV
3
Official reply dated 09.04.2024 to inquiry of EHPV
17
Figure 1 MSM PSEs in Estonia
Note: the figure is based on data [3,22,24,28]; the dotted vertical line indicates the minimum of 1%
of adult men recommended by WHO [36]
The following brief overview of the existing HIV services for MSM in Estonia is
based on the UNAIDS country report.[37]
HIV testing is voluntary and can be carried out only with the informed consent of an
individual. Any physician can recommend HIV testing based on indication, risk as-
sessment or patient request. Blood testing for HIV is carried out only in health care
settings. If there is an indication for testing, a general practitioner or infectious dis-
ease specialist will test patients with health insurance free of charge. People without
insurance may have other options, for instance, testing provided free of charge at
anonymous testing sites.
Patients with the positive result are referred to an infectious disease specialist for
observation, treatment, and counseling. No formal referral is required. HIV-related
health services, including antiretroviral therapy (ART), are free for all patients. Pa-
18
tients receiving ART usually need to visit the clinic once a month to get drugs dis-
pensed. Several non-governmental organizations provide consultations for people
living with HIV and their loved ones on social, psychological, and legal issues, treat-
ment adherence, HIV prevention, etc.
Condoms are sold everywhere. In many places and organizations, i.e. youth coun-
seling centers, anonymous HIV testing sites, syringe exchange programs, infectious
diseases clinics, drop-in centers, etc., they are distributed free of charge.
The efficacy of the pre-exposure prophylaxis (PrEP) is well known [38] and lots of
EU countries provided reimbursed PrEP.[39] In Estonia, PrEP has been officially
available since the beginning of 2020. It is prescribed by an infectious disease spe-
cialist,[40] to whom a referral from a family doctor is de facto required. Some family
physicians have been trained to manage PrEP users and are authorized to prescribe
PrEP, but the number is small. PrEP is available from pharmacies and reimbursed
by 50–75% if a person has national health insurance.
According to data from Tervisekassa / Estonian Health Insurance Fund, in 2023,
infectious disease specialists issued 1,246 prescriptions for PrEP, of which 1,028
were filled
4
. Ravimiamet / Department of Medicines based on the data reported by
Tervisekassa
5
informed that in 2023, PrEP in Estonia was received by 236 people.
There are three clinics for MSM that provide free counseling and testing for sexually
transmitted infections. In most cases, treatment is also conditionally free of charge
4
Official reply dated 16.02.2024 to inquiry of EHPV
5
Official reply dated 23.02.2024 to inquiry of EHPV
19
(MSM-patient doesn’t pay neither for a visit nor for testing; necessary medicine ex-
cept HIV-therapy must be acquired by patients from any drugstore, price will depend
on patient’s insurance status and treatment coverage line. In some cases, i.e. obvi-
ously high risk of non-treatment — social situation, low level of self-confidence etc.
— necessary medicine is offered by the clinic onsite).
The purpose of the study is to assess the availability and acceptability of existing
services (such as HIV testing and pre-exposure prophylaxis), as well as to identify
unmet needs of MSM and trans people related to sexual health, stigma and discrim-
ination, update estimates of the population of MSM and create the HIV treatment
cascade.
20
2 Methodology
The cross-sectional pilot study was based on the quantitative methodology. Initially,
it was planned to use the online questionnaire and involve at least 150 people from
Tallinn, Tartu, and Narva. However, during the field phase (from 19.12.2023 to
2.1.2024), it became clear that respondents from all over Estonia also took part in
the survey. Most of the sample (71%) were people who filled out the questionnaire
without coming to the EHPV offices.
The online questionnaire was available in three main everyday languages — Esto-
nian, English, and Russian.
The criteria for inclusion in the sample were age (18 years and older), self-identifi-
cation as a man who had had experience of sexual relations with men or identifica-
tion as a homo-, bisexual or trans person. The informed consent to participate in the
survey was also required. If a person completing the online questionnaire did not
meet the inclusion criteria, their responses were excluded from analysis (5 women
and 4 completely heterosexual men, who had sexual interest only in women and
sexual experience only with women).
The questionnaire covered the following topics: socio-demographic characteristics,
awareness of HIV and pre-exposure prophylaxis (EMIS 2017 [33]), experience in
HIV testing (including GAM indicators [41] 1.3B, 1.4B), use of pre-exposure prophy-
laxis (for HIV-negative people, including GAM indicator 1.11), assessment of ex-
perience in HIV testing and use of pre-exposure prophylaxis, willingness for HIV
testing and use of pre-exposure prophylaxis, HIV treatment cascade (GAM indica-
tors 2.1–2.3), cases of experiencing stigma and discrimination related to sexual ori-
entation (GAM 6.5B), including those in health care settings, internalized ho-
21
monegativity scale,[42] alcohol consumption (EMIS 2017 [33]), substances used dur-
ing chemsex (survey of Hornet users “COVID-19 and disparities among Gay, Bi,
and Trans people”), use of services in LGBTI- and MSM-oriented organizations (in-
cluding population size estimates, GAM indicator 1.2B).
The questionnaire was pretested in Estonian, Russian and English languages on
29.08.2023 with three EHPV clients in Tallinn.
The questionnaire was created with GoogleForms, filling the questionnaire in took
10 to 15 min in average. It was not possible to pause answering the questions. The
informed consenting process did not differ between those who were recruited on-
line and on-site.
Participants were invited both by social workers of the EHPV and through adver-
tisements published on online social networks, in particular, Romeo, IHA, Grindr,
Telegram channel “Eesti kutid”, Facebook group “Kõik mehed on head” etc., as well
as with the help of Estonian LGBTI NGOs. People in EHPV sites were not specifi-
cally recruited, EHPV personnel proposed clients to fill the questionnaire during
EHPV activities (in local computer or client’s mobile gadget).
There are no incentives for participation in the study.
Data processing. After completing the field phase, the database was checked for
compliance with the inclusion criteria. The questionnaires, which did not meet the
criteria were excluded. The analytical database was supplemented with calculated
variables (HIV knowledge scale; PrEP readiness scale; external stigma scale; inter-
nal homophobia scale).
Considering both Estonia as a whole and its LGBTI community are clearly divided
by the language, presented results provide not only one-dimensional distributions,
22
but also their breakdown into Estonian- and Russian-speaking subsamples (the Eng-
lish-speaking part is represented mainly by students at the University of Tartu and
is not enough for analysis, N = 43).
The significance of differences in nominal variables was tested using the chi-squared
test and differences were considered significant at p < 0.05. The significance of dif-
ferences in scale variables was established through comparison of CIs.
Associations between key variables (internal homophobia, HIV testing coverage,
willingness to take PrEP) and other characteristics of respondents were established
using multivariate regression analysis (linear and binary logistic regressions). The
initial model included external stigma scales, language, age, sexual orientation and
sexual experience, consumption of alcohol, chemsex, knowledge of basic facts about
HIV, etc.; significant variables were selected with the backward algorithm.
Population size estimation. There is a wide range of PSE methods.[43] More reliable
data can be obtained by combining several estimates into a consensus value.[44] Tak-
ing into account the existing possibilities in Estonia, we have selected different op-
tions of the multiplier method, which is used in case there is quantitative information
from at least two independent sources, it is known that the measured groups overlap,
and the size of this overlap can be assessed. The first source, for example, a list of
organizations, which are in contact with members of the assessed group (statistical
reporting, program information and other databases), the second source being infor-
mation received directly from representatives of the assessed group about their con-
tact with this organization.
The research team sent letters to Estonian LGBTI organizations asking about the
number of cis men and trans people, who had taken part in the organization’s events
in 2023. Answers were received from MTÜ SevenBow, MTÜ Vikerlased, VEK
23
LGBT, MTÜ Peemoti Raamatud, MTÜ Karuelu, GeiKristlaste Kogu, LGBT Ühing,
although some of the letters did not contain necessary data.
Information on the number of viewers of LGBTI movies (MTÜ Q-Space) was ob-
tained from the website https://www.q-space.ee and adjusted for the share of men.
Dating sites for MSM and trans people in Estonia were also monitored. The infor-
mation from personnel of such sites (bars, nightclubs) was collected.
The formulae (1–3) were used to obtain point estimates:
! = # ⋅ !
"
(1)
where P is estimated size of the group, I — number of members in the assessed group according
to the independent source, N — survey sample, n — number of respondents, who mentioned
their affiliation to the independent source
%&'
(
!
)
=!⋅$⋅
(
!&"
)
⋅
(
$&"
)
"!
(2)
95% CI:
! ± 1.96 ⋅
/
%&'
(
!
) (3)
The PSE data was summarized using the Bayesian approach in the Triangulator li-
brary (https://fellstat.github.io/triangulator/). All calculations were performed in the
statistical programming environment R.[45]
Ethics. Project implementers and individuals were trained to guarantee the confi-
dentiality of information received. Before answering the survey questions, partici-
24
pants were provided information about the study (including the principle of com-
pletely voluntary participation and possibility to stop completing the survey at any
time without any sanctions) and were asked to confirm their consent to participation.
No information was collected that could identify a respondent.
The study protocol was approved by the Ethics Committee of the Ukrainian Institute
of Public Health Policy
6
by Decision No. 27–23/IRB dated 5.12.2023.
6
The principal and co-researchers are employees of Ukrainian institutions; the IRB of the Ukrainian Institute of
Public Health Policy is officially registered as the Board for consideration of international researches in the Office
of Human Research Protection of the U.S. Department of Health and Human Services: IRB #00007612, FWA
#00029648
25
3 Results and discussion
3.1 Socio-demographics and sexuality of respondents
The total of 323 questionnaires (314 valid ones) were collected between 19.12.2023
and 1.2.2024, two thirds of which (71%) were completed by respondents outside the
EHPV offices in Tallinn, Tartu, and Narva. It should be noted that the resulting sam-
ple was larger than in most of the previous studies of MSM (Table 2) and covered
the entire territory of Estonia due to the active involvement of the community in the
process of recruiting respondents.
Estonian- and Russian-speaking people in the sample were respectively represented
by 39 and 47% (Table 4), the average age of respondents was 36 years and did not
differ languages-wise, the vast majority (98%) were cis gender men.
This composition differs from the results of previous studies (both offline [34] and
online [33]), in which the ratio of Estonian and Russian speakers generally reflects
the ratio of speakers of these languages in the general population of the country. The
average age of the respondents coincides with the data.[34]
Unlike recent studies, in which men, who considered only men as sexually attractive,
accounted for about 80%, in this sample this proportion is lower (65%). Meanwhile
there are correspondingly more bisexuals (sexual orientation and sexual behavior do
not coincide — there are more behaviorally bisexual men than respondents, who
indicated the sexual attractiveness of both women and men). The high prevalence of
bisexuality was also recorded in early Internet studies of Estonian MSM.[25–27]
26
Table 4 Demographics of respondents
Variable
% or mean,
N = 314
Where a questionnaire filled
Tallinn office of EHPV
10
Tartu office of EHPV
8
Narva office of EHPV
11
Out of the offices
71
Selected language
Estonian
39
Russian
47
English
14
Age, years, mean and 95% CI
36 [35–37]
Gender
Male
98
Transgender person: MtF
1
Transgender person: FtM
1
Two-thirds (65%, Figure 2) are sexually attracted only to men, while one third of
respondents demonstrate some form of bisexuality. About half (48%) have had sex-
ual experience only with men. Differences between sexual orientation and experi-
ence are statistically significant. Sexual orientation and experience do not differ
among respondents with different languages (p = 0.66 and 0.19 respectively).
27
Figure 2 Attractiveness of different genders and sexual experience of МSМ
and trans people
Note: significance of differences p < 0.001, N = 314
28
Features of sexual behavior, in addition to the already noted widely spread relation-
ships with people of both sexes, include the significant popularity of chemsex (55%
have used certain drugs before or during sex in the last 6 months, Table 5). Before
or during the sexual intercourse, respondents most frequently used poppers, erection
stimulants (such as Viagra ®) and natural or synthetic cannabinoids. Differences by
language were recorded only in the use of erection stimulants — they are less pop-
ular in the Russian-speaking population.
Approximately half of the respondents have experience in using several substances
during chemsex. The most popular is the combination of poppers and erection stim-
ulants or poppers and cannabis.
Just under two thirds (60%) had consumed alcohol during the past week. Previous
studies have also documented relatively high levels of alcohol consumption, e.g.
48% of MSM surveyed in 2004 drinking alcohol once a week or more often.[25]
Previous studies documented the widespread prevalence of poppers and other sub-
stances among Estonian MSM during chemsex (32% — poppers, 18% — erection
stimulants during the last contact with a casual partner within one year [33], 50% —
poppers throughout the year among MSM in Harju County [34]).
Although the most common indication for erection stimulants is impotence and psy-
chological causes of erectile dysfunction, the use of such drugs during chemsex (ev-
idenced by their frequent combination with poppers) aims at maintaining the erec-
tion during long-lasting sex marathons (for example, at private parties). The higher
frequency of use among Estonian-speaking respondents can be explained by greater
popularity of such private sex parties among them. Income gap between the two
29
language groups
7
noted country-wide is unlikely to play a significant role, since
more expensive simultaneous use of substances is the same among Estonian and
Russian speakers.
Table 5 Substances used by MSM and trans people
Variable
%
All
N = 314
Est.
N = 122
Rus.
N = 149
Which of the following substances have you used before or during sex
within the last 6 months?
I have not used any of the substances listed below
45
43
48
Poppers
37
40
33
Viagra®, Cialis®, or other ED medications*
22
29
15
Extasy (E, XTC, MDMA)
11
13
8
Cannabis (hashish, marihuana, weed)
20
21
19
Methamphetamine (ice, crystal, Tina)
4
2
5
GHB / GBL (liquid E, Gina)
5
8
3
Heroin (fentanyls, nitazenes, Oxy)
1
1
1
Mephedrone (4-MMC, meow-meow)
3
2
1
Continued on the next page
7
According to the data of the Department of Statistics for 2022, 18% of Estonians earned income in the lowest quin-
tile and 23% in the highest, while among non-Estonians the same figures were respectively 25% and 12%
(https://andmed.stat.ee/et/stat/sotsiaalelu__sissetulek/ST04)
30
Continuation of Table 5
Variable
%
All
N = 314
Est.
N = 122
Rus.
N = 149
Cocaine / crack
7
8
5
Amphetamine (speeds)
8
7
8
Use of several substances during chemsex, N = 169
1 substance
53
44
59
2 substances
21
26
18
3+ substances
26
29
23
The signif. of difference btw Estonian- and Russian-speakers
p = 0.465
When was the last time you drank alcohol?
Never
6
2
9
During the last 24 hours
27
35
22
During the last 7 days
33
29
34
During the last 4 weeks
19
21
16
More than a month ago
15
13
19
The signif. of difference btw Estonian- and Russian-speakers
p = 0.065
Note: * difference between Estonian- and Russian-speaking subsamples is statistically signifi-
cant, p < 0.05
Over one third of the respondents (40%) indicated that they were dissatisfied with
their sexual life (no differences between the respondents from different language
groups). The main provided reasons were (Table 6):
31
I. desire for a permanent relationship
II. small number of partners and/or the need for greater intensity of meetings
(in some cases, absence of couple sex): “I have a permanent partner.
There could be more sex with him, but there could also be more with oth-
ers”, “I would like a more open relationship, we don’t have sex very of-
ten anymore”, “just jerking off under Amphetamine”
III. difficulties in relationship with a partner: “I lack sufficiently frequent
sexual intimacy with a regular partner”, “for 6 weeks, my wife, my part-
ners and my love conspired and continuously kept me sexually unsatis-
fied”
IV. various psychological and social problems:
a) physical distance between the respondent and his partners: “I have a boy-
friend, but I can’t be with him. I live in Valga and he lives in Tallinn”
b) rejection and stigma: “Estonians don’t like foreigners”, “who needs an
HIV-positive alcoholic?”, “I haven’t had any sex since I fled Russia. Almost
2 years”
c) noncompliance with “beauty standards” which are common among homo-
sexual and bisexual men (e.g. young, thin/athletic): “I don’t consider myself
handsome, I’m always rejected, it seems like no one wants me”, “obviously,
I’m already past the age of attractiveness”, “depression interferes with my
sex life and although I’m an attractive man, after 40 it’s harder to cause in-
terest of sexual partners”
d) mental health problems and side effects of medications: “I can’t find a suit-
able partner, and if I choose for fun, I feel remorse”, “the antidepressant
drug I take kills libido”, “I would like to be normal (straight), and not a
freak with low self-esteem”
e) absence of conditions for a date: “I don’t have much time for dating, I’m
married and work”, “I don’t have own space to be together with someone”
32
f) discrepancy between reality and expectations: “most of attractive men are
emotionally cowards and/or immature”, “people don’t share photos online;
when they write to you, they finally send a photo of 20 pixels in size and with
sunglasses, although from countries, where sometimes there is even a death
penalty for gay sex, you get at least three clear, normal photos at once. Our
society is advanced and safe, but photos are shared only at gunpoint”, “my
problem is that I really would like to have an ‘unforgettable sex’, but my
roommate does not want intercourse several times a day and today I treat
him more like a good friend (i.e. when I think about him, I don’t shake all
over)”, “anal doesn’t give as much pleasure as it seems, or is it my fault”.
Table 6 Reasons for dissatisfaction with sexual life
Responses
Too few sexual partners
16
I would like permanent relationship
12
I do not have sex at all
8
Issues with permanent relationship
5
Geographical distance
5
Stigma and exclusion from local communities
5
Depression / mental health issues
5
Noncompliance with “beauty standards”
4
Inflated expectations
4
I fear HIV and STIs
3
No time / place
2
I’d like to have more intensive sex with current partner
2
Other reasons
4
33
3.2 Experiences of stigma and discrimination
Most frequently, respondents experienced stigmatization due to their sexual orien-
tation, gender identity, or sexual behavior (Table 7) i.e. insults, gossip and comments
in their families and in healthcare settings. Prejudices were less often expressed in
the form of physical violence. It should be noted that Russian-speaking MSM suffer
from stigma more than Estonian-speaking MSM.
Indicator of external stigma (2.6 points out of 11, Figure 3) is not high, although it
is significantly higher among Russian-speaking MSM and trans people, who took
part in the study, compared to Estonian-speaking ones. These differences can be
related to the attitude towards homosexuality existing in different counties. [30]
Table 7 Negative life experience related to homo-/bisexual orientation or ho-
mosexual behavior
Statement
%
All
N = 314
Est.
N = 122
Rus.
N = 149
You were not invited to meetings, where your
family traditionally gathers*
11
6
15
Family members have made comments to you or
gossiped about you
33
31
31
Continued on the next page
34
Continuation of Table 7
Statement
%
All
N = 314
Est.
N = 122
Rus.
N = 149
Your friends have avoided you
23
23
23
You have been afraid to go to medical institu-
tions*
28
19
34
You felt that you were treated poorly*
18
10
21
You have heard health care workers talking
about you*
15
9
19
The police have refused to protect you
6
7
8
You have been afraid in public places
28
21
32
You have been insulted
47
44
48
You have been blackmailed
17
12
20
You have been physically harmed (e.g. pushed,
hit, choked)*
21
11
27
You have been forced to have sex against your
will
10
10
11
Stigma experienced by MSM and trans people
(GAM 6.5B)
53
48
56
Notes: The table shows the percentage of affirmative answers to the question “Have you ever
found yourself in such situations because you are attracted to men or have had sex with them?”;
*differences between Estonian- and Russian-speaking samples are statistically significant,
p < 0.05
35
Figure 3 Indicator of external stigma related to sexual orientation in groups of
MSM and trans people in Estonia with different languages of communication;
scale from 0 (no stigma) to 11 (stigma is expressed to the most extent in hostile
actions of others)
3.3 Internal homophobia
Short scale of internalized homonegativity [42] consisted of eight statements. Re-
spondents rated their concordance with each of the statements with a score from 1
(completely disagree) to 7 (completely agree). The scale describes the rejection of
one’s homo- or bisexuality (the higher the score, the higher the internal homopho-
bia). Cronbach’s alpha is 0.79.
As can be seen from Figure 4, rejection of homosexuality among Russian-speaking
MSM is significantly higher than among Estonian-speaking respondents. The level
of internal homophobia (both in general and in individual language groups) is close
to the minimum value.
36
Figure 4 Levels of internal homophobia among Estonian MSM with different
languages of communication; scale from 1 (no internal homophobia) to 7
(maximum internal homophobia)
Negative life experiences in connection with sexual orientation or homosexual be-
havior did not reveal significant links with the internal stigma of the respondents
(CIs intersect, Table 8).
Table 8 Links between external and internal stigma
Level of internal homophobia
Index of external stigma, mean and 95% CI
low (1–3.5), N = 227
2.6 [2.2–2.9]
high (3.5–7), N = 87
2.5 [2.0–3.1]
Socio-demographic factors associated with internal homophobia are presented in
Table 9. The significance of the intersection indicates that the level of rejection of
one’s own homosexuality is impacted not only by the factors indicated in the table.
37
Language, sexual orientation, and satisfaction of respondents with sexual life asso-
ciated with internal homophobia are:
• belonging to Russian-speaking and predominantly heterosexual men is asso-
ciated with a higher level of rejection of one’s own homosexuality;
• Satisfaction with the quality of sexual life is associated with lower levels of
internal homophobia.
Table 9 Results of the regression analysis of links between demographics and
the level of internal homophobia
Variable
Index
p
Intersection of the regression line with the axis of
internal homophobia
3.2
< 0.001
Language of the respondent — Russian (ref = Es-
tonian + English)
0.5
< 0.001
Sexually attractive for the respondent (ref = only men)
Mostly men, but sometimes women, too
0.3
0.078
Both men and women to similar extent
0.4
0.079
Mostly women, but sometimes men, too
1.2
< 0.001
Only women
1.3
0.094
In general, are you satisfied with your sex life?
— Yes (ref = no)
- 0.5
< 0.001
Note: Adj. R2 = 0.135 at p < 0.001
38
The minority stress model [46] suggests that persistent stressors, i.e., repeated hostil-
ity and bullying due to minority individual’s failure to conform to cultural expecta-
tions of the majority, are associated with incidental health problems, both mental
and physical. People from persecuted minorities internalize negative attitudes of the
majority towards their minority through the process of socialization and treat them-
selves with shame, contempt, and similar feelings.[47] In case of homo- and bisexu-
ality, internalized homophobia is shaped, i.e. internal reflection of the existing ex-
ternal stigma of homosexuality.[48,49]
Although the results of our study do not confirm the association of experiences of
bullying and violence with higher levels of internal homophobia (Table 8), the pres-
ence of such a link cannot be denied both because of the relatively small sample and
because of the generally low values of the presumed independent (2.6 points out of
11, Figure 3) and dependent (2.9 points out of 7, Figure 4) variables.
Many studies of internalized homophobia are dedicated to its connections with al-
cohol and use of psychoactive substances.[50,51] Our data, however, do not show such
a link in either bivariate distributions or multivariate analyses, probably due to gen-
erally low values of internalized homophobia, which require larger samples.
Higher values of internal homophobia are associated with a respondent’s Russian
language and heterosexual orientation (Table 9).
Population surveys constantly record differences between the Estonian- and Rus-
sian-speaking parts of the Estonian society in their attitudes towards homosexuality
and LGBTI people.[7–18] Meanwhile, the attitude of the Russian-speaking population
was and remains systematically worse than that of the Estonian-speaking population.
Since, according to the minority stress model, internalized homophobia is shaped
39
under the impact of homophobic attitudes of the society,[46] higher rates of internal-
ized homophobia among Russian-speaking MSM in this and previous studies [30]
look consistent.
Differences in levels of internalized homophobia between homosexual and hetero-
sexual people were recorded previous studies of MSM in Estonia.[30,32,33,52,53]
3.4 HIV knowledge, testing experience and satisfaction
The awareness of HIV in terms of separate facts was high (75% and above, Table
10). However, significantly fewer respondents — about half of the survey partici-
pants — are familiar with all the seven statements. At the same time, Figure 5 shows
that the vast majority (80%) knows at least five facts out of the seven listed. There
is no difference in the level of basic knowledge between the two language groups.
Two thirds (67%) of MSM and trans people were tested for HIV within one year
prior to the survey, 88% — at least once in their lives (Table 11). In general, 8%
know their HIV+ status, all of them receive ARV and 82% have reached, according
to them, an undetectable viral load.
Factors related to HIV testing are provided in Table 12:
• the 25+ years old group has fourfold higher odds to be tested compared to
younger people. Among those, who know all the basic facts about HIV, these
chances are eight times higher than among those, who do not know;
• having predominantly heterosexual experience is associated with fourfold
lower odds of being tested compared to those with predominantly homosexual
experience. Using chemsex is related to fivefold lower odds of being tested
compared to those, who do not use such substances.
40
Table 10 Knowledge of basic facts about HIV
Statement
%
All
N = 314
Est.
N = 122
Rus.
N = 149
The HIV virus leads to AIDS
89
88
87
It’s not possible to determine whether a person is
infected with HIV based on a person’s ap-
pearance
83
82
80
There are medical tests that can indicate whether a
person is infected with HIV
92
92
87
If you are infected with HIV, it may take several
weeks for the test to show the presence of
the virus
76
75
76
There is currently no way to cure HIV infection
75
77
70
There are medications for HIV infection to mini-
mize its impact on health
85
86
79
Effective HIV treatment reduces the risk of HIV
transmission
79
80
73
Index of knowledge (% respondents, who know
all basic facts)
56
56
54
The signif. of differences btw Estonian- and Russian-speakers
p = 0.917
Note: the table includes the responses “Yes, I have already known that”
41
Figure 5 Distribution of МSМ and trans people according to the level of their
awareness of basic facts about HIV
Respondent’s language, internalized homophobia and negative life experiences re-
lated to sexual orientation or homosexual behavior did not show significant links
with testing.
Popularity of places of the last and desired HIV testing (Figure 6) — most of them
are tested in medical facilities (including anonymous sites) and prefer to continue
doing it there.
Most of the answers in the “other” category relate to the willingness to self-testing:
“Doing a rapid test at home is most convenient. Unfortunately, they must be ordered
online,” however, the cost of such tests is quite high (30–40 € if this is a blood-test
and even higher if this is a saliva-test). In case of testing in medical institutions,
respondents would like to receive the result and support remotely: “SMS / Call, if
positive.”
42
Table 11 HIV testing
Variable
%
All
N = 134
Est.
N = 122
Rus.
N = 149
HIV testing coverage within the past 12 months (GAM 1.4B)
In the last 6 months
49
67
50
41
In the last year (not earlier than 6 months ago)
18
13
22
More than a year ago
21
23
25
No, I have never been tested for HIV
12
14
12
The signif. of differences btw Estonian- and Russian-speakers
p = 0.213
Satisfaction with communication with medical
professional during the last test 1 (very
bad) to 5 (very good), points, mean and 95%
CI, N = 277
4.4 [4.3–4.5]
HIV-status (self-declaration) (GAM 1.3B)
HIV-negative person
71
73
63
HIV-positive person
8
5
13
I do not know
5
6
5
I do not want to answer
4
3
6
The signif. of differences btw Estonian- and Russian-speakers
p = 0.213
Recipients of ART-therapy (among those, who know about their HIV+ status,
N = 26) (GAM 2.2 and 2.3)
Yes, I have an undetectable viral load
82
Yes, I’ve not yet reached an undetectable viral load
14
Yes, I don’t know / don’t remember what my viral
load is
4
No, I’m not taking them / I don’t want to answer
0
43
Table 12 Results of the regression analysis of links between social-demo-
graphic variables and HIV testing
Variable
OR [95% CI]
AOR [95% CI]
p
Age — 25+ years (ref = by 25)
3.50 [1.67–7.36]
3.88 [1.62–9.30]
0.003
Sexual partners of the respondent (ref = only men)
Mostly men, but sometimes
women, too
2.17 [0.83–5.71]
1.92 [0.66–5.54]
0.231
Both men and women to similar
extent
0.42 [0.16–1.12]
0.67 [0.20–2.20]
0.508
Mostly women, but sometimes
men, too
0.38 [0.13–1.10]
0.24 [0.07–0.80]
0.020
Only women
0.13 [0.01–2.14]
0.55 [0.03–11.2]
0.701
Chemsex during last 6 months
— Yes (ref = no)
0.27 [0.12–0.57]
0.19 [0.08–0.45]
< 0.001
Basic knowledge about HIV —
Knows (ref = no)
6.71 [2.85–15.8]
7.86 [3.08–20.0]
< 0.001
Note: the case was considered with the combination of answers “tested in the last 6 months”, “in
the last year”, “more than a year ago”, N = 314; AOR — Adjusted Odds Ratio
44
Figure 6 Popularity of current and desired places for HIV testing
Note: the significance of differences p = 0.105, N = 277
The obtained results do not differ from those of the previous studies, for instance,
according to the results of a biobehavioural study of MSM in Harju County,[34] 90%
of MSM were tested for HIV at least once during their lifetime. Thus, we can con-
clude that the accessibility and acceptability of testing are high, which is confirmed
by high satisfaction with communicating with a healthcare personnel during the last
test (average of 4.4 points on a five-point scale).
However, there is still a potential to increase testing coverage. Some respondents
would prefer to be tested at home, which suggests that self-testing (alternatively with
remote pre- and post-test counselling) could be a perspective direction for develop-
ing services. In addition, the data in Table 12 shows that the uncovered subgroups
of MSM and trans people are a) those under the age of 25, b) those, who identify
themselves as rather heterosexual, and c) those, engaged in chemsex.
It is noted in the literature that HIV testing is directly associated with lower self-
homonegativity,[50] but our data do not show such a link (Table 12). Hypothetically,
45
this can be explained by the generally low level of internalized homophobia and the
high quality of provided medical services, including confidentiality.
Overall, 8% of respondents know about their HIV-positive status and another 4%
refused to answer. Considering the existing HIV stigma in society,[54] it can be as-
sumed that the true prevalence of HIV among MSM and trans people in Estonia
ranges from 8 to 12%. This data is consistent with the previous biobehavioural study
of MSM in Harju County (6.7 [3.4–11.8]%).[34]
3.5 Awareness of PrEP, taking PrEP, and satisfaction with a
doctor
Three quarters of respondents without HIV-positive status (76%, N = 288) have ever
heard of PrEP, two thirds (68%) of them have never used pre-exposure prophylaxis
(Table 13). The respondents cited three main reasons for not using PrEP: their own
belief that there is no risk of HIV infection (25%), not knowing where to get the
medicines (22%) and something that was not included in the list of answers (20%).
It can be assumed that the “other” option presumes the chronic lack of PrEP drugs
on sale in Estonian pharmacies from the summer of 2023 to the end of January 2024
(the period, during which the field phase of the study was carried out). Moreover, in
their answers, the respondents pointed out the question about the reasons for dissat-
isfaction with their own sex life and the problem related to the cost of PrEP: “since
PrEP is expensive in Estonia even at half price, you can order it from India for
10 €”, “I am too careful and would like to get PrEP just in case, but I don’t know
how, and since it costs money, I simply don’t have sex.”
46
Table 13 Experience of using PrEP among HIV-negative respondents, who
have ever heard of it
Variable
%
All
N = 220
Est.
N = 92
Rus.
N = 88
PrEP was used within last 12 months (GAM 1.11)
Yes, I have used PrEP and I am still using it
23
34
22
18
Yes, I have used PrEP, but I am not using it now
11
11
11
No, I have never used it
65
67
69
I do not want to answer
1
1
1
The signif. of differences btw Estonian- and Russian-speakers
p = 0.682
How did you get PrEP the last time? (among users, N = 50)
A doctor prescribed it for me
90
It was given to me by a friend
4
I got it in another way
6
Rating satisfaction of communication with a
doctor with your last PrEP prescription
among those, to whom PrEP was prescribed
by a doctor, N = 45, from 1 (very bad) to 5
(very well), points, mean and 95% CI
4.4 [4.1–4.8]
Why are you not taking PrEP? (among those, who have never used PrEP,
N = 170)
I am embarrassed to talk about it with a doctor
11
I do not think I am at risk of contracting HIV
25
It is not available where I live
2
I do not know where to get the drugs
22
Continued on the next page
47
Continuation of Table 13
Variable
%
All
N = 220
Est.
N = 92
Rus.
N = 88
I am worried about side-effects
10
I do not have enough money
5
Another reason
20
Willingness to participate in the pre-exposure prophylaxis program is determined
both by understanding of its usefulness, including one’s own risks and by the exist-
ing conditions in the country (i.e. the cost of drugs) (Table 14). Of all individual
factors that determine willingness to use PrEP, the most significant is the desire to
reduce the risk of HIV infection (for 84% of respondents, this could be a reason to
take PrEP). In general, only one third of respondents (29%) are willing to use PrEP
under the existing conditions.
Table 15 lists factors associated with willingness to participate in the PrEP program:
• the 25+ year old group has fourfold higher odds of participation compared to
younger respondents;
• belonging to the group of Russian-speaking respondents reduces the chances
of being ready to participate in the program by half, compared to the Estonian-
or English-speaking groups;
• an increase by one point in internalized homophobia also reduces the odds of
participation in PrEP by half.
48
Table 14 Readiness to join PrEP programs taking into account existing re-
strictions
Statement
%
The drug can protect a person from HIV infection
84
To obtain the drug, you need a doctor’s prescription
53
To receive the drug in Estonia, you need to partially pay for it
55
A person who starts taking the drug needs to take an HIV test every 3
months
55
A person who starts taking the drug should still use a condom every
time they have sexual intercourse
58
Willingness to participate in PrEP (% of respondents, who answered
“Yes” to all 7 statements)
29
Note: the table shows the ratio of answers “Yes” to the question “Would you be willing to partic-
ipate in the PrEP program, if you knew that ...?” among HIV-negative people not taking PrEP,
N = 170
In most cases (90%), the ones, who took PrEP, received it by prescription and their
satisfaction with communication with doctor was very high (4.4 points on a five-
point scale, Table 13).
49
Table 15 Results of the regression analysis of links between social-economic
variables and willingness to participate in PrEP program
Variable
OR [95% CI]
AOR [95% CI]
p
Age — 25+ years (ref = by 25)
0.88 [0.38–2.02]
0.67 [0.27–1.68]
0.399
Language of communication of
the respondent — Rus-
sian (ref = Estonian +
English)
0.37 [0.18–0.77]
0.42 [0.20–0.90]
0.022
Scale of internal homophobia
0.53 [0.37–0.77]
0.54 [0.37–0.80]
< 0.001
Note: the case in the analysis was the answer “Yes” to all questions specified in Table 14 among
HIV-negative respondents not taking PrEP, N = 169; AOR — Adjusted Odds Ratio
Factors determining willingness to participate in the PrEP program among those,
who have ever heard of PrEP (76% of HIV-negative), play an important role in scal-
ing up this program (Table 13). Only one third (29% of HIV-negative people, who
have not previously used PrEP) are ready to participate in the PrEP program under
all the existing conditions (including the need to obtain a prescription and pay be-
tween half and a quarter of the cost of the medications).
The main reasons for not using PrEP were personal belief in the absence of the risk
of HIV infection (25%) and lack of knowledge of where to get the medications
(22%). Analysis of socio-demographic factors also reflected (Table 15) that young,
Russian-speaking persons, who are less knowledgeable about basic facts about HIV,
use pre-exposure prophylaxis significantly less. Perhaps the main reason is linked
with both linguistic and geographical isolation of young residents of North-Eastern
Estonia.
50
Likewise, it is important to note that internal homophobia is also significantly asso-
ciated with less willingness to participate in PrEP and the minority stress model sug-
gests the influence of anti-LGBTI environment in the society. In the study, there was
no connection between bullying based on sexual orientation and gender identity as
well as the level of internal homophobia (Table 8), meanwhile, there are no argu-
ments to deny such a connection. Thus, both educational work with the wider society
towards overcoming prejudice and provision of psychological services for both
MSM and trans people could help to implement PrEP.
3.6 Cascade of HIV services
The cascade of HIV services visualizing the 90-90-90 goals (90% of HIV+ know
their status, 90% of those, who know their status, are receiving ARV and 90% of
those receiving ARV have achieved an undetectable viral load) can be indirectly
derived from the obtained results: if 13% have never been tested for HIV, then as-
suming the even distribution of testing coverage, 87% of HIV+ know their status
(GAM 2.1, conservative estimate). All those, who know their status, are receiving
ARV (GAM 2.2), 82% of whom achieved a self-reported undetectable viral load
(GAM 2.3).
Extrapolating enables to estimate that (100 – 87) + (87 * 0.18) = 29% of HIV-
positive MSM or in absolute figures 9,909 * 0.067 * 0.29 = 192 people (approxi-
mately 2% of MSM in Estonia in general) have a detectable viral load and can trans-
mit HIV to a partner through unprotected sex (i.e. without a condom or PrEP with
the partner). Part of them (13 * 100 / 29 = 45%) are aware of their status, which may
increase the likelihood of using a condom or PrEP, but some are not.
51
3.7 Services used
As stated in Section 1, Estonia has the developed LGBTI infrastructure, including
cultural events, public organizations, initiative groups, LGBTI businesses and infor-
mal meeting places. At the same time, this infrastructure (except for online dating)
is concentrated in Tallinn and Tartu, while MSM and trans people from other regions
are forced to either use only online opportunities or travel to these two cities: “My
regular partners live 150 km. from me. And in a godforsaken village in the middle
of the forest, I don’t have any sex except masturbation”, “I can’t find a partner. I
live far from cultural centres”. This entire infrastructure covers groups of different
languages and ages. Systematization of this information is necessary for estimating
numbers (see Section 3.8) and planning HIV interventions.
As can be seen from Table 16, of the two most well-known mobile dating apps for
MSM and trans people in Estonia, Grindr is more popular (62% of respondents have
their profiles). Both Estonian- and Russian-speaking participants of the sample use
Grindr and Hornet equally.
Over the past year, one third of respondents have used the websites of IHA.ee (a
local Estonian erotic site for both straight and LGBTI people, operating since 2007
without changing the interface) and Romeo.com (an international gay/bi/ trans-da-
ting, operating since 2009, but acquired the function of searching for partners by
their geoposition). Both sites are significantly more popular among the Estonian-
speaking respondents than among the Russian-speaking. In contrast, Bluesys-
tem.world, also an old Russian-language site, aimed at homosexual men and being
in operation with minimal interface changes since 2004, is generally justifiably pop-
ular among the Russian-speaking respondents and practically unknown to the Esto-
nian-speaking.
52
Table 16 Ways of communication of respondents with other homo- and bisex-
ual men as well as trans-people
%
All
N = 134
Est.
N = 122
Rus.
N = 139
Do you have your profile in Grindr or Hornet?
Yes, only on Hornet
3
1
6
Yes, only on Grindr
35
40
36
Yes, on both Hornet and Grindr
27
23
17
No, I do not use these apps
32
35
31
I do not want to answer
4
1
10
The signif. of diff. btw Estonian- and Russian-speakers
p = 0.241
During the last year, how have you communicated/met online with other gay
or bisexual men?
Bluesystem*
12
4
20
IHA*
35
52
28
Romeo*
39
48
32
Facebook group «Kõik mehed on head»*
11
16
7
Continued on the next page
53
Continuation of Table 16
%
All,
N = 134
Est.,
N = 122
Rus.,
N = 139
Facebook group «LGBT virtuaalne kogu-
kond»
13
16
11
Telegram channel «Eesti kutid»*
19
27
13
Listed below are active LGBT and MSM organizations in Estonia. Have you
used the services of such organizations over the past year?
MTÜ Peemoti Raamatud (Tartu)
5
6
3
MTÜ SEKY (Tallinn)
1
1
1
Eesti LGBT Ühing (Tallinn)
12
13
11
Geikristlaste Kogu (Tallinn)
5
7
4
ВЕК ЛГБТ (Narva)*
7
0
15
You have participated in the Rakvere LGBT
Film Festival (MTÜ SevenBow)
11
11
10
MTÜ Karuelu
3
5
2
You have participated at a Pride march in Tal-
linn (MTÜ Tallinn Pride)
22
14
22
Continued on the next page
54
Continuation of Table 16
%
All
N = 134
Est.
N = 122
Rus.
N = 139
You have sung in the choir Vikerlased (MTÜ
Vikerlased, Tallinn)
6
7
5
MTÜ Tartu LGBT+*
4
8
1
You have attended screenings of LGBT films
at the Film Museum in Tallinn (MTÜ
Q-Space)*
13
5
19
MTÜ Eesti Transinimeste Ühing (Tallinn)
2
0
4
Have you visited the porn cinema in the sex shop “Sex max” (Tartu mnt 62,
Tallinn) over the past year?
Yes
23
30
17
No
75
69
79
I do not want to answer
2
2
4
The sign. of diff. btw Estonian- and Russian-speakers
p = 0.019
Continued on the next page
55
Continuation of Table 16
%
All,
N = 134
Est.,
N = 122
Rus.,
N = 139
The respondents visited the listed night clubs over the past year
X-baar (Tallinn)
37
39
31
69 (Tallinn)
29
30
29
9/11 (Tallinn)
19
21
16
Bar Sveta (Tallinn)
31
27
32
Hello Bar (Tallinn)
31
29
28
Note: * the differences between the Estonian- and Russian-speaking subsamples are statistically
significant, p < 0.05
Online social networks such as Facebook and, more recently, Telegram messenger
are also used for internal communication of LGBTI communities corresponding
through virtual groups / channels. Two Facebook groups and currently the largest
Telegram group for MSM in Estonia were selected for the purposes of this study.
Although generally their popularity is not high, they allow to reach predominantly
Estonian-speaking homo- and bisexual men.
Participation in LGBTI organizations events is not very popular among the sur-
veyed. The most frequently mentioned events were Pride in Tallinn (22%), LGBTI
film screenings at the Q-Space organization (13%) and visiting the Festheart Film
56
Festival (11%). At the same time, there are also differences in the Estonian- and
Russian-speaking parts of the sample. Thus, Q-Space events are significantly more
popular among Russian-speaking respondents than among Estonian-speaking, while
Tartu LGBT+ is more visited by Estonian-speaking survey participants. The data
obtained do not contradict with the results of the 2019 pan-European study
(https://fra.europa.eu/en/data-and-maps/2020/lgbti-survey-data-explorer), accord-
ing to which 21% LGBTI people in Estonia responded positively to the question
“Are you involved in one or more LGBTI people’s organizations?”
LGBTI-oriented businesses (nightclubs, bars and porn cinemas) are concentrated in
Tallinn and rival online dating in popularity. Visitors to nightclubs and bars did not
differ in language background, while one of the porn cinemas
8
was more popular
among Estonian-speaking respondents than Russian-speaking.
3.8 Population size estimation
As mentioned in Section 3.6, the service data covers both Estonian- and Russian-
speaking populations, as well as those residing outside Tallinn, Tartu, and Narva.
Thus, they can be used to generally estimate the population of MSM in Estonia
(GAM 1.2B).
All obtained data and calculations are provided in Table 17. The point values of the
population estimate have a 30-fold range, with the smallest value (513) and the lower
limit of its CI (460) being greater than the number of EHPV clients tested for HIV
8
There are two porn cinemas: one in Tallinn and one in Tartu
57
in Estonia in 2023 (i.e., the actual number of MSM and trans people from an inde-
pendent source), allowing all point estimates to be included in the calculation of the
consensus value (Figure 7).
The resulting consensus estimate for the number of MSM and transgender people is
9,892 [9,628–10,172] people or 2.0 [1.9–2.1]% of men aged 18+ (according to
https://www.stat.ee at the end of 2023).
The estimated number of MSM and trans people has increased by 7% since 2009
(9,195 [22] and 9,898, respectively). The change in the number of adult men in the
country (difference between 2009 and 2023) is 5% (Figure 8). Thus, the numbers of
MSM and trans people in Estonia generally reflect the increase in the male popula-
tion of the country. However, it is worth noting that due to the larger sample size
and more source data used, the accuracy of the new estimate has increased by ap-
proximately ten times compared to the 2021 estimate.
Table 17 Compilation of data from all available sources and point estimates of
the number of MSM in Estonia
Independent source
I
N
n
P
95% CI
lower
upper
Bluesystem
538 a)
314
36
4,693
3,299
6,086
IHA
2,040 a)
314
108
5,931
5,049
6,813
Romeo
1,416 a)
314
118
3,768
3,254
4,282
Facebook group “Kõik mehed
on head”
216 b)
314
34
1,995
1,414
2,576
Continued on the next page
58
Continuation of Table 17
Independent source
I
N
n
P
95% CI
lower
upper
Facebook group “LGBT virtu-
aalne kogukond”
1,600 a)
314
41
12,254
8,801
15,706
Telegram channel “Eesti
kutid”
203 a)
314
58
1,099
883
1315
Grindr
483 a)
314
193
786
732
839
Hornet
160 a)
314
98
513
460
565
TallinnPride
2,333 g)
314
68
10,775
8,541
13,008
Festheart
673 b)
314
38
5,557
3,948
7,166
GeiKrislaste Kogu
55 b)
314
14
1,234
688
1,779
Karuelu
225 b)
314
10
7,065
2,853
11,277
Peemoti Raamatud
816 b)
314
15
17,082
8,724
25,439
Q-Spice
825 d)
314
42
6,168
4,476
7,859
X-baar
2,950 e)
314
112
8,271
7,066
9,476
Hello Bar
1,000 e)
314
31
10,129
6,797
13,461
МSМ on PrEP
236 z)
314
74
1,001
836
1,167
Notes: designations I, N, n, P are used in accordance with formulas (1–3); a) monitoring during
the field stage; b) information received upon request to the relevant organizations / groups;
g) information from Eesti LGBT Ühing considering demographic characteristics; d) information
from the site of the organization adjusted for demographic characteristics; e) information from an
interview with a bartender; z) information received upon a request to Ravimiamet.
59
Figure 7 Obtaining consensus estimates of the population of MSM and trans
people in Estonia using the Bayesian approach
On the figure: Prior — value of previous population estimates [3] (9,909 [6,279–14,243]); Con-
sensus — the resulting new population estimate based on a combination of point values and their
95% CI (solid horizontal lines) considering the expert assessment of the reliability of each indi-
vidual value (punctual horizontal lines)
Figure 8 Changes in the number of adult men in Estonia according to the data
of the Statistics Estonia (https://www.stat.ee)
60
Conclusions and limitations
The purpose of the study was to assess the accessibility and acceptability of existing
services, as well as to identify some of the unmet needs of MSM and trans people,
including those related to stigma and discrimination, to update the estimate of the
number of MSM and to build a cascade of HIV treatment. Therefore, 314 people,
mostly cis men aged 18 years or older, living in Estonia, were interviewed between
December 2023 and January 2024.
It has been demonstrated that the availability and acceptability of HIV testing is
high, as is satisfaction with communication with a health worker at the last test. At
the same time, there is potential to increase testing coverage (including self-testing)
among young MSM and trans people, as well as those men who do not identify with
the LGBT community and engage in same-sex sexual activity.
Between 8 and 12% are HIV positive and know their status, all are receiving ART,
82% have achieved an undetectable viral load.
Most of those, who took PrEP medications received them by prescriptions and their
satisfaction with the communication with their physicians was high.
Although knowledge about PrEP is widespread among HIV-negative MSM and
trans people, most of them have never taken PrEP and are not ready to use it under
the current conditions. Willingness is lower among young people, Russian-speaking
people as well as among respondents with higher levels of internal homophobia.
Respectively, currently the use of PrEP in Estonia is low.
External and internal stigma related to homosexual orientation or homosexual be-
havior is small, but there are significant differences between groups of MSM and
trans people with different languages of communication: Russian speakers have a
61
higher feeling of stigmatization than Estonian and English speakers. Study partici-
pants most often encountered insults, gossip, and comments in their families and in
medical institutions. Heterosexual orientation and dissatisfaction with one’s sexual
life were primarily associated with high levels of internal homophobia. Internal
stigma was associated with willingness to participate in the PrEP program.
In general, the unmet needs of survey participants are related to:
• issues in own sex life;
• availability and cost of PrEP medications;
• with the feeling of insecurity due to various manifestations of stigma in the
subgroup of Russian-speaking and mostly heterosexual respondents.
The HIV treatment cascade was created and a number of other GAM indicators were
obtained for country to report to UNAIDS.
An independent estimate of the number of MSM and trans people in Estonia was
carried out using the significantly larger number of information sources than in the
previous studies. It is shown that the number of MSM in Estonia is 9,892 [9,628–
10,172] people or 2.0 [1.9–2.1]% of men aged 18+ and changes in the numbers of
MSM and trans people over time reflect the growth of the male population in the
country.
The presented results have several limitations due to the methodology used to obtain
them, specifically:
• cross-sectional design of the study does not allow the determined statistical
relationships to be interpreted in terms of cause and effect;
• the structure of a convenience sample limits the possibility of generalizing the
data to the entire population (which is especially true for trans people). The
relatively small number of respondents (314 people) restricted our ability to
62
see the links between external stigma known from the scientific literature and
internal homophobia, as well as between internal homophobia and alcohol
consumption;
• the questionnaire did not provide a separate set of questions assigned to trans
and intersex people and in the set about sexual orientation and experience
there was no option “no sexual experience,” which could reduce the interest
of the trans population in this study;
• the online form of the questionnaire resulted in a small number of considered
topics, which focused on HIV-related issues and, except for aspects of chem-
sex, did not touch upon common sexual practices in communities, including
high-risk (such as sex without a condom or fisting).
63
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