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Background Men who have sex with men (MSM) in Europe are most affected by HIV disparities. Complex systems theory proposes that many health behaviors and risks arise from numerous cascading and interacting processes. Our aim was to explore how stigmatizing policies at the European country-level create pathways to HIV risk and disparities among MSM in Europe. Methods We used data from the 2017 European Men Who Have Sex with Men Internet Survey (EMIS-2017). The anonymous online survey recruited 126,090 European MSM. We assessed condom use with steady &amp; non-steady partners as the outcome. Condom use was categorized from zero to 10 (10 or more partners). Abuse was scored zero to three and internalized homonegativity from zero to six. We used the International Gay and Lesbian Association's Rainbow Index as the main predictor, which ranks European countries' laws and policies regarding LGBTQ+ legal protections from zero (worst) to 100 (best). We used structural equation and multi-level modeling for analyses. Results The mean Rainbow Index score was 50.8 with a range from 6 to 88. The Rainbow Index scores were the highest in Western European (mean=62.5), then Central European (mean=45.9), then Eastern Europe (mean=21.4) (p &amp;lt; 0.000). Unadjusted regression models suggested that for every one-unit improvement in the Rainbow Index the number of condomless sexual acts with steady sexual partners was reduced [β=-0.0012, 95% CI (-0.0016, -0.0009)]. The unadjusted structural equation model showed that the relationship between the Rainbow Index and condom use with steady partners was mediated by 30% because of internalized homonegativity (p &amp;lt; 0.000). Conclusions The policy context influences HIV risk, especially through the policies' effects on condom use. HIV research and prevention efforts must recognize that structural determinants can shape people's risk for HIV and that the best individual and local efforts may be undermined by structural factors such as policies.

european journal of public health

Stigmatizing policies’ influence on HIV risk through their effect on internalized homonegativity and health behaviors among men who have sex with men in Europe