Article Text
Abstract
Objectives: To compare population-based prevalence estimates of sexual risk behaviours and HIV seroprevalence of male sex workers who have sex with men (MSM) and those not engaged in sex work in Campinas, Brazil.
Methods: MSM (n = 658) were recruited for a cross-sectional study through respondent-driven sampling. Audio-assisted computer self-interview was used to collect information on sexual behaviours and HIV testing (optional) was performed. Population-based prevalence estimates with 95% CI of characteristics and behaviours of MSM sex workers and non-sex workers are reported.
Results: One-quarter reported ever receiving payment for sex and 14.8% (95% CI 11.1 to 19.0) had been paid in the previous 2 months; most exclusively with men. MSM sex workers were significantly more likely than non-sex workers to report being transgendered (40.5% vs 8.1%), to practise unprotected receptive (22.4% vs 4.6%) and insertive (20.5% vs 5.0%) anal intercourse with ⩾2 male partners and to have unprotected vaginal sex with women (22.7% vs 5.6%). MSM sex workers experienced significantly greater rates of psychological abuse (80.9% vs 58.4%) and physical abuse (48.2% vs 15.2%).
Conclusions: MSM sex workers have higher sexual risk behaviours as well as social vulnerabilities than the general population of MSM. HIV/sexually transmitted infection prevention efforts should be targeted to this riskier subgroup. Programmes should be transgender sensitive, should recognise that MSM sex workers have sex with men and women and address other factors that influence risk, such as homophobic abuse.
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Male sex workers who have sex with men (MSM) may have behaviours and vulnerabilities that increase their HIV risk. However, little is known about this population in Brazil. A cross-sectional survey was used to determine population-based estimates of sexual risk behaviours and HIV seroprevalence of MSM sex workers and non-sex workers.
METHODS
The study was conducted in Campinas because of a collaborative history with the municipal AIDS programme, a supportive local gay/lesbian organisation and it is a large metropolitan area in São Paulo state, which has the highest number of reported AIDS cases.1
Sample
Between October 2005 and October 2006, 658 MSM were recruited for an HIV behavioural survey and optional HIV testing, through respondent-driven sampling.2 Recruitment started with 10 initial seed participants with the subsequent addition of 20 seeds to boost recruitment. Seeds were asked to recruit three MSM peers from their personal network; eligibility criteria included living in the metropolitan Campinas area, being 14 years of age or older and having had oral/anal sex with a man within the last 6 months. Following informed consent, a blood sample was collected and tested using the Determine HIV 1/2 test (Abbott Japan, Tokyo, Japan) and Rapid Check HIV 1&2 (NDI, UFES—Universidade Federal do Espírito Santo, Vitória, Brazil). The Uni-Gold HIV test (Trinity Biotech, Bray, Ireland) and Teste Rápido HIV-1/2 Bio-Manguinhos (Fundacão Oswaldo Cruz, Rio de Janeiro, Brazil) were used for discordant results.
Analysis
MSM sex workers were defined as someone receiving money, drugs or gifts in exchange for sex in the 2 months before the survey. Population-based estimates and 95% CI of characteristics, behaviours, and HIV seroprevalence of MSM sex workers and those not engaged in sex work were calculated in RDSAT (RDS AnalysisTool) 5.6, which provides weights for network size and recruitment patterns. The study was approved by the Population Council Institutional Review Board, the State University of Campinas Ethics Committee and Comissão Nacional de Ética em Pesquisa/Brazil.
RESULTS
Of the 658 participating MSM, 93.0% (95% CI 90.0 to 96.0) reported being sexually active in the previous 2 months. One quarter reported ever receiving payment for sex and 14.8% (95% CI 11.1 to 19.0) were paid in the previous 2 months almost exclusively with men. MSM sex workers and non-sex workers were similar in age and marital status (table 1) but sex workers were significantly less educated and were more likely to be mullato–brown than white. MSM sex workers were significantly less likely to self-report their sexual orientation as homosexual and more likely to report being transgendered than non-sex workers.
Sex workers were more likely to have had unprotected receptive anal intercourse (22.4% vs 4.6%) and unprotected insertive anal intercourse (20.5% vs 5.0%) with two or more male partners and unprotected anal or vaginal intercourse with women (22.7% vs 5.6%) than non-sex workers. Approximately 60% of both groups had ever tested for HIV; however, only half were tested in the last year. MSM sex workers were significantly more likely to have reported using any drugs in the past 6 months (56.4% vs 27.1%), experienced psychological and physical abuse and abuse from police in the past 12 months than non-sex workers. Injection drug use was not common among all MSM (<1%).
Key messages
MSM sex workers were more likely to identify as transgender and less likely to be gay identified. This suggests that HIV/STI prevention efforts should be designed to ensure that efforts are transgender sensitive and not aimed solely at gay-identified MSM.
HIV prevention programmes, particularly those targeting MSM sex workers, must address not only sexual risk reduction, but other factors that influence risk, such as homophobic abuse shown to be associated with high-risk sexual practices.
There were overall low HIV testing rates among MSM; this suggests a need to intensify HIV testing efforts for MSM and MSM sex workers alike.
DISCUSSION
This study revealed a surprisingly high number of MSM sex workers among MSM and they have higher sexual risk behaviours and social vulnerabilities. The increased likelihood of MSM sex workers identifying as transgendered and the lower proportion who are non-gay identified has major implications for HIV/STI prevention efforts. Non-traditional outreach efforts should be designed to ensure that efforts are transgender sensitive and not aimed solely at self-identified MSM.3 4 In addition, efforts to increase provider capacity to address transgender health issues related to HIV transmission are needed. Additional research to obtain a better understanding of factors that influence bisexual behaviours among MSM sex workers are also needed.
There were higher rates of drug use in MSM sex workers than non-sex workers. These rates are much higher than the estimated 19% among the Brazilian general population of ever use of illicit drugs.5 Given that injection drug use was rare in this population, the MSM population appears to be a separate high-risk group from injection drug users. Although HIV testing rates were similar between sex workers and non-sex workers, the low overall testing rates suggest a need to intensify HIV testing efforts for MSM and MSM sex workers alike. Finally, HIV prevention programmes for MSM, especially those targeting sex workers, must address not only sexual risk reduction but other factors that influence risk, such as homophobic abuse shown to be associated with high-risk sexual practices.6–8
Acknowledgments
This study was a collaborative effort between the National STD/AIDS Program of Brazil, the USAID Mission in Brazil, CDC/Global AIDS Program, the STD/AIDS Program of Campinas, the Reference Centre for Gays, Lesbians, Transsexuals, Transvestites, and Bisexuals (GLTTB) of Campinas and the Municipal Laboratory of Campinas. The authors acknowledge Alex Carballo-Diéguez from Columbia University, Keith Sabin, Aristides Barbosa Junior and Suzanne Westman of the CDC/Global AIDS Program for their technical support, Lee Ann Jones for her assistance in drafting the original report and Scott Kellerman for his editorial suggestions and critical review of the manuscript drafts. The authors are especially grateful to the committed project staff in Campinas and the MSM participants for their time and effort.
Footnotes
Funding: This study was supported by the President’s Emergency Plan for AIDS Relief and the generous support of the American people through the United States Agency for International Development (USAID) through the Population Council’s Horizons Program under the terms of cooperative agreement no HRN-A-00-97-00012-00. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States government.
Competing interests: None.
Ethics approval: The study was approved by the Population Council Institutional Review Board, the State University of Campinas Ethics Committee and Comissão Nacional de Ética em Pesquisa/Brazil.
Contributors: MdM and JD led the conception and design of the research study. AP and MdM oversaw the operations of the field data collection. MC, AP, WT, MdM and JD conducted the analysis and participated in the data interpretation. WT participated in the protocol development and was the main author responsible for the writing and final editing of the manuscript. All authors approved the final version of the submitted manuscript.