Abstract

This study aimed to analyze the association between sociodemographic, programmatic and contextual factors and the receipt of money in exchange for sex among men who have sex with men (MSM). This is a multicenter, cross-sectional study conducted in ten Brazilian cities between 2008 and 2009. Adult MSM recruited through the Respondent Driven Sampling (RDS) were interviewed. Weighted Odds Ratio (ORw) was obtained through logistic regression, retaining the variables associated with the event (p < 0.05) in the final model. Of the total sample, 33.3% reported receiving money in exchange for sex in the last 12 months before the interview. The variables that were independently associated with the event were age less than or equal to 25 years, lower education, lower social classes, previous history of syphilis, using sites or services to find sexual partners in the previous month, very high risk behavior, using illicit drugs in the previous six months, self-identifying as heterosexual or bisexual, having suffered physical violence due to sexual orientation and having suicidal thoughts always or most of the time. It was observed that MSM who received money in exchange for sex had greater socioeconomic, programmatic and contextual vulnerability, potentially increasing the risk of HIV infection than the other MSM in the sample.

Key words
Men who have sex with men; Commercial sex; HIV

Introduction

HIV infection has a high prevalence among men who have sex with men (MSM) in Brazil, representing 14.2%¹1 Kerr LS, Mota RS, Kendall C. Pinho AA, Mello MB, Guimarães MDC, Dourado I, Brito AM, Benzaken A, McFarland W, Rutherford G. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435. compared to 0.6% in the general Brazilian adult population²2 Brasil. Ministério da Saúde (MS). Boletim Epidemiológico AIDS e DST. Brasília: MS; 2015.. When compared to the infection rate among heterosexual men, the ratio is 13 times higher among MSM residing in Brazil¹1 Kerr LS, Mota RS, Kendall C. Pinho AA, Mello MB, Guimarães MDC, Dourado I, Brito AM, Benzaken A, McFarland W, Rutherford G. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.^,33 Brasil. Ministério da Saúde (MS). Pesquisa de conhecimento, atitudes e práticas na população brasileira. Brasília: MS; 2011.^,44 Barbosa Junior A, Szwarcwald CL, Pascom AR, Souza Júnior PB. Tendências da epidemia de AIDS entre subgrupos sob maior risco no Brasil, 1980-2004. Cad Saude Publica 2009; 24(4):727-737.. Several studies have consistently drawn the attention to the high prevalence of HIV infection among sexually exploitable MSM, with varying estimates of 14%-31% in the U.S.⁵5 Reisner SL, Mimiaga MJ, Mayer KH, Tinsley JP, Safren SA. Tricks of the trade: sexual health behaviors, the context of HIV risk, and potential prevention intervention strategies for male sex workers. J LGBT Health Res 2008; 4(4):195-209.^,66 Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sex Transm Dis 2006; 33(4):228-234., 4.1%-24.4% in South America⁷7 Montano SM, Sanchez JL, Laguna-Torres A, Cuchi P, Avila MM, Weissenbacher M, Serra M, Viñoles J, Russi JC, Aguayo N, Galeano AH, Gianella A, Andrade R, Arredondo A, Ramirez E, Acosta ME, Alava A, Montoya O, Guevara A, Manrique H, Sanchez JL, Lama JR, de la Hoz F, Sanchez GI, Ayala C, Pacheco ME, Carrion G, Chauca G, Perez JJ, Negrete M, Russell KL, Bautista CT, Olson JG, Watts DM, Birx DL, Carr JK; South American HIV Molecular Surveillance Working Group. Prevalences, genotypes, and risk factors for HIV transmission in South America. J Acquir Immune Defic Syndr 2005; 40(1):57-64.

8 Lama JR, Lucchetti A, Suarez L, Laguna-Torres VA, Guanira JV, PunM, Montano SM, Celum CL, Carr JK, Sanchez J, Bautista CT, Sanchez JL. Association of herpes simplex virus type 2 infection and syphilis with human immunodeficiency virus infection among men who have sex with men in Peru. J Infect Dis 2006; 194(10):1459-1466.

9 Valderrama MBM, Carcamo C, Garcia P, Bernabe A, Cotrina A, Chiappe M, Guerra C, Gonzales M, Garnett G, Espinosa B, Gadea N, Montano S, Nieto M, Holmes K. High HIV and syphilis prevalence among male commercial sex workers from the Peruvian Amazon. International AIDS Conference; 2008; Mexico City, Mexico.

10 Bayer AM, Garvich M, Diaz DA, Sanchez H, Garcia PJ, Coates TJ. When Sex Work Becomes Your Everything: The Complex Linkages Between Economy and Affection Among Male Sex Workers in Peru. Am J Mens Health 2014; 8(5):373-386.^-1111 Ramos Farias MS, Garcia MN, Reynaga E, Romero M, Vaulet ML, Fermepin MR, Toscano MF, Rey J, Marone R, Squiquera L, González JV, Basiletti J, Picconi MA, Pando MA, Avila MM. First report on sexually transmitted infections among trans (male to female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis 2011; 15(9):e635-640. and 3.1%-13.0% in Brazil¹²12 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.^,1313 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457..

Sex work is defined as the sale of consensual sexual services by adults in exchange for money, goods or objects¹⁴14 Joint United Nations Programme on HIV/AIDS (UNAIDS). Technical guidance for Global Fund HIV proposals Round 11. New York: UNAIDS; 2011., and this may occur regularly or occasionally and, according to the country’s legislation, formally or informally¹⁵15 Joint United Nations Programme on HIV/AIDS (UNAIDS). Sex work and HIV/AIDS. Technical Update. Geneva: UNAIDS. 2002.^,1616 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.. Due to the association of sex work with a professional practice with low social acceptability and carrying with it characteristics and social signs that are often stigmatized, MSM describe the sex for money exchange as an occasional activity to temporarily support or pay for an expensive goods, and do not identify themselves as sex workers¹¹11 Ramos Farias MS, Garcia MN, Reynaga E, Romero M, Vaulet ML, Fermepin MR, Toscano MF, Rey J, Marone R, Squiquera L, González JV, Basiletti J, Picconi MA, Pando MA, Avila MM. First report on sexually transmitted infections among trans (male to female transvestites, transsexuals, or transgender) and male sex workers in Argentina: high HIV, HPV, HBV, and syphilis prevalence. Int J Infect Dis 2011; 15(9):e635-640.^,1616 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.^,1717 Caceres CF, Bayer AM, Gomero A, Grenfell P, Salazar X. Men who sell sex in Peru: evolving technological and sexual cultures. Aggleton P, Parker R, editors. Men Who Sell Sex: Global Perspectives. London: Taylor and Francis; 2015.. Besides, there is a growing tendency for sex work to be no longer based on street-related experiences and shifting to the field of the Internet, which makes it more difficult to identify these people as part of a homogeneous social group¹⁸18 Mimiaga MJ, Reisner SL, Tinsley JP, Mayer KH, Safren SA. Street workers and internet escorts: contextual and psychosocial factors surrounding HIV risk behavior among men who engage in sex work with other men. J Urban Health 2009; 86(1):54-66..

The most common factors associated with the initiation of men into sex work are economic factors, such as absolute poverty, family abandonment, and those associated with difficult access to the formal labor market, such as low schooling and professional qualification¹²12 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.^,1919 Rigoletto RN. Um olhar sobre a prostituição masculina. In: XII CLASES; 2004; Santiago.

20 Santos MA. Prostituição Masculina e Vulnerabilidade às DSTS/AIDS. Texto Contexto Enferm 2011; 20(1):76-84.^-2121 Abreu W. O submundo da prostituição, vadiagem e jogo do bicho. 16ª ed. Rio de Janeiro: Record; 1998.. MSM who receive money in exchange for sex may be more vulnerable to sexually transmitted diseases (STDs) because of factors not only related to the high number of sexual partners but also because of their involvement in practices and situations associated with low socioeconomic status and risk sexual intercourse, such as drug use and inconsistent use of condoms²²22 Passos AD, Figueiredo JF. Risk factors for sexually transmited diseases in prostitutes and transvestites in Ribeirão Preto (SP), Brazil. Rev Panam Salud Publica 2004; 16(2):95-101.. A recent systematic review indicates an association between the exchange of sex for money and a higher risk of HIV infection among MSM from different countries¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273..

The National Plan to Fight Against AIDS and STD Epidemic among Gays, MSM, and Transvestites²³23 Brasil. Ministério da Saúde (MS). Plano nacional de enfrentamento da epidemia de AIDS e das DST entre gays, HSH e travestis. Brasília: MS; 2007. makes no mention of MSM who received money in exchange for sex, evidencing the silencing of health actions aimed at this segment, which only appear implicitly in the subcategory “other men who have sex with men”. This invisibility reveals an explicit limitation of the public power in adapting, appropriately, with contextualized prevention actions to the complexity of the sexual networks between these men¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.. HIV/AIDS vulnerability factors among MSM who received money in exchange for sex should not be considered as isolated problems, but indeed convincing examples of the need for comprehensive HIV responses that address the needs of this diverse and complex group²⁴24 Padilla MB, Guilamo-Ramos V, Bouris A, Reyes AM. HIV/AIDS and tourism in the Caribbean: an ecological systems perspective. Am J Public Health 2010; 100(1):70-77.^,2525 Liu H, Liu H, Cai Y, Rhodes AG, Hong F. Money boys, HIV risks, and the associations between norms and safer sex: a respondent-driven sampling study in Shenzhen, China. AIDS Behav 2009; 13(4):652-662.. Following a new epidemiological surveillance strategy, information on populations most vulnerable to HIV/AIDS should be periodically investigated to build an information framework on the dynamics of the epidemic over time²⁶26 Brasil. Ministério da Saúde (MS). 'UNGASS - HIV/Aids, Resposta Brasileira 2008-2009. Relatório de Progresso do País. Brasilia: MS; 2010..

Although evidence indicates that the exchange of sex for money among MSM is potentially related to sociodemographic, programmatic and contextual factors, the studies of national coverage that approach the subject are limited. Moreover, a large part of the studies with this population does not clearly identify those who receive or pay for sex, and the former are potentially at greater risk¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.. The conceptions, values and practices that organize the construction of masculinity, the adoption of representations and understandings about the sexual practices they adopt, which hinder the perception of vulnerability to STDs and HIV/AIDS, gender vulnerability, low level of knowledge about STDs and behavioral risks or individual-related risk, the difficulty of negotiating preventive practices with clients, among others, are factors that may be related to the lower admission or acceptance (appropriation) of the risk experienced, which leads to the difficulty in awareness, behavioral change and risk minimization²⁰20 Santos MA. Prostituição Masculina e Vulnerabilidade às DSTS/AIDS. Texto Contexto Enferm 2011; 20(1):76-84.. Besides the vulnerability factors directly linked to STDs and HIV/AIDS, other factors are quite frequent, such as exposure to potential violence, stigmatization of sex work and homosexuality, which affect MSM who receive money in exchange for sex²⁰20 Santos MA. Prostituição Masculina e Vulnerabilidade às DSTS/AIDS. Texto Contexto Enferm 2011; 20(1):76-84..

This study is shown in this context and which aims to analyze the association between sociodemographic, programmatic and contextual factors and the exchange of sex for money between men who have sex with men in ten Brazilian cities in 2009 and 2010, with emphasis on receiving money. The information obtained with this national survey could contribute to increasing actions and measures for the prevention of HIV infection and health promotion in Brazil, until then poorly emphatic for this population.

Methods

This a cross-sectional study, part of a nationwide study carried out between 2008 and 2009, with MSM residing in ten Brazilian cities, aimed at estimating the prevalence of HIV and syphilis infection and assessing knowledge on HIV/AIDS, attitudes and sexual practices of this population. Methodological details of the study are available in Kerr et al.¹1 Kerr LS, Mota RS, Kendall C. Pinho AA, Mello MB, Guimarães MDC, Dourado I, Brito AM, Benzaken A, McFarland W, Rutherford G. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.. The Respondent-Driven Sampling (RDS) was used to recruit the participating MSM, a chain sampling method used with difficult-to-reach populations²⁷27 Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl 1997; 44(2):174-199.. We calculated the sample by city to provide independent estimates, which returned 250 to 350 MSM in each city of the study¹1 Kerr LS, Mota RS, Kendall C. Pinho AA, Mello MB, Guimarães MDC, Dourado I, Brito AM, Benzaken A, McFarland W, Rutherford G. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.. Thus, 3,746 MSM were recruited in the cities of Manaus, Recife, Salvador, Belo Horizonte, Rio de Janeiro, Santos, Curitiba, Itajaí, Brasilia and Campo Grande.

A formative research was conducted using qualitative methods to adjust logistics and research protocols²⁸28 Kerr LRFS. Comportamento, atitudes, práticas e prevalência de HIV e sífilis entre homens que fazem sexo com homens (HSH) em 10 cidades brasileiras [relatório]. Brasília: Ministério da Saúde (MS); 2009.. After selecting the MSM of the initial sample of the target population, called “seeds”, the MSM received three numbered coupons and guidelines on the survey to invite three MSM from their social network. A management system controlled the coupons. Participants selected as “seeds” who attended the research sites with the valid coupon (identification number and expiry date) and met the inclusion criteria were the first sampling wave. This process was repeated with their guests until the sample reached the desired size in each city.

MSM aged 18 years or over and residents of selected municipalities were invited to participate in the study. Those meeting the following inclusion criteria were eligible: 1. Having had at least one sexual intercourse with a man in the last 12 months; 2. Accepting the conditions to participate in the study, which include responding to a structured questionnaire, signing the Informed Consent Form, and being willing to invite their peers to participate in the study; 3. Submitting a valid coupon. Participants identified as transvestites or transgender were excluded. The research was conducted following Resolution Nº 466/12 National Council of Health - Ministry of Health. The project was approved by the National Commission for Research Ethics (CONEP nº 14.494 - Opinion Nº 116/2008), by the Research Ethics Committee of the Federal University of Ceará (COMEPE/UFC Nº 202/07) and by the health services of the participating cities¹1 Kerr LS, Mota RS, Kendall C. Pinho AA, Mello MB, Guimarães MDC, Dourado I, Brito AM, Benzaken A, McFarland W, Rutherford G. HIV among MSM in a large middle-income country. AIDS 2013; 27(3):427-435.^,2828 Kerr LRFS. Comportamento, atitudes, práticas e prevalência de HIV e sífilis entre homens que fazem sexo com homens (HSH) em 10 cidades brasileiras [relatório]. Brasília: Ministério da Saúde (MS); 2009..

The event of interest was having received money in exchange for sex in the last 12 months before the interview, considering positive answers to the question asked during the interview: “In the last 12 months, did you receive money in exchange for sex?”

The potential association variables were organized into the following three blocks: 1. Sociodemographic (age, schooling, social class, skin color/ethnicity, marital status, and employment status at the time of interview); 2. Programmatic (knowledge about HIV transmission, prior HIV testing, positive serology for HIV, prior syphilis testing, history of syphilis, positive serology for syphilis and, in the last 12 months before the interview, having STD history, receiving STD counseling, receiving free condoms and lubricating gel; 3. Contextual, subdivided into: 3.a. Behavioral (gender of first sexual partner, age at first sexual intercourse, number of partners last six months, condom use in all sexual intercourse in the last 12 months, using sites/services to find partners last month, sexual intercourse with participants of potential guests’ network, sexual intercourse under the effect of any drug last six months, self-perceived risk of becoming infected with HIV, risk behavior score for the last 12 months, frequency of alcohol use, use of illicit drugs in the last six months; 3.b related to sexual orientation - sexual self-identity, discrimination based on sexual orientation, having suffered verbal, physical violence and sexual violence; and 3.c related to mental health - feeling tense/worried, sleeping problems, feeling fear and panic, feeling sad/depressed, having suicidal thoughts. Knowledge about HIV transmission was measured through 10 questions about HIV transmission and prevention and was considered sufficient knowledge when the participant answered eight or more questions²⁹29 Rocha GM. Comportamento sexual de risco entre homens que fazem sexo com outros homens no Brasil [tese]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014.. The HIV risk behavior score was calculated from information on the number of male partners and use of condoms in anal intercourse in the past 12 months with fixed, casual, and commercial partners. The final score was calculated by adding the results obtained, ranging from 0-48 points, with high values indicating a higher degree of risky sexual behavior. This score was categorized as low and medium risk (0-8 points) and high risk (9 points or +)²⁹29 Rocha GM. Comportamento sexual de risco entre homens que fazem sexo com outros homens no Brasil [tese]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014..

The RDS data were weighted according to the size of the social network and the proportion of MSM in each city related to the total sample, based on the method used for RDS by Szwarcwald et al.³⁰30 Szwarcwald CL, Souza JRPRB, Damacena GN, Barbosa Júnior A, Kendall C. Analysis of Data Collected by RDS Among Sex Workers in 10 Brazilian Cities, 2009: Estimation of the Prevalence of HIV, Variance and Design Effect. J Acquir Imune Defic Syndr 2011; 57(Supl. 3):S129-S135.. The magnitude of the association between the explanatory variables and the event was estimated by the weighted Odds Ratio (OR_w) with a 95% confidence interval (95% CI). Logistic regression was used for the association analysis.

The multivariate analysis was initially performed separately for each block, for the following characteristics: 1. sociodemographic; 2. programmatic; 3.a. behavioral; 3.b. related to sexual orientation; 3.c. related to mental health. For each block, the modeling started with variables statistically associated with the event in the univariate analysis, considering a p-value < 0.20. The explanatory variables were deleted sequentially within each block, and only those statistically associated with the event, considering a p-value < 0.10, remained in the intermediate models. The final modeling started with the statistically significant variables (p < 0.10) in each intermediate model, followed by sequential deletion. Only those associated with the event with p < 0.05 remained in the final model. The analyses were performed using SAS software^® (SAS Inst., Cary, USA).

Results

In total, 3,859 MSM were recruited from the ten Brazilian cities. Of these, 3,749 had information available on commercial sex and were included in this analysis. Of this group, 1,146 (33.3%) reported having received money in exchange for sex in the 12 months before the interviews. More than half of the sample consisted of MSM over the age of 25 (58.4%), with more than eight years of study (58.6%), belonging to the lower economic classes (C-D-E), and most of them were non-white (83.2%), single or living alone (84.4%). Approximately 30% were not working at the time of the interview (Table 1).

Regarding the program variables, knowledge about HIV prevention and transmission was insufficient, for 42.3% of respondents. About half of the individuals (48.4%) had already been tested for HIV in their lifetime, and 12.6% were positive in the HIV serological test performed in the research. On the other hand, only a quarter (25.7%) had already had a diagnostic test for syphilis, and 7.7% had a previous history of syphilis, both in their lifetime. In the serological test for syphilis carried out in the research, 14.6% were positive. A large proportion (72.4%) received condoms for free in the previous 12 months, and only 45.5% of them received lubricating gel during the same period (Table 1).

Among the contextual variables, concerning sexual behavior, the first sexual intercourse was with a female partner in 52.9% of the respondents, and almost half (46.9%) started sexual activity aged 14 years or less. In the 12 months before the interview, about a quarter of the participants (24.5%) reported having had more than five sexual partners. Regarding drug use, 42.8% reported using some illicit drug during the six months before the interview. About 20% of MSM interviewed were classified as having high HIV risk behavior.

Regarding sexual orientation, approximately 39% identified themselves as bisexual or heterosexual, and 43.3% and 13.4% suffered verbal and physical violence due to sexual orientation, respectively, with sexual violence reported by 15.0%.

Concerning mental health, they reported that during the six months before the interview they always or most often felt tense or worried (74.1%), sad or depressed (54.2%), had sleeping problems (42.5%) and fear or panic (22.2%). Also, 11.0% of participants reported having suicidal thoughts always or most of the time.

The bivariate analysis indicated that most of the variables had a statistically significant association with the event (Table 2).

In the final logistic regression model, the following were independently associated with receiving money in exchange for sex 12 months prior to the interview (Table 3): being young (age less than or equal to 25 years) (OR_w = 2.04); having lower educational level (OR_w = 3.58); being of lower social classes (C-D-E) (OR_w = 2.35); having previous history of syphilis (OR_w = 1.60); having had first sexual intercourse with a woman (OR_w = 2.32) and aged less than or equal to 14 (OR_w = 1.78); having had sexual intercourse with more than five partners in the six months prior to the interview (OR_w = 3.27); using sites or services to find sexual partners in the month prior to the interview (OR_w = 1.27); having sex with the possible invitees to the study (OR_w = 1.25); having very high risk behavior (OR_w = 2.76); using illicit drugs in the six months prior to the interview (OR_w = 1.89); self-identifying as heterosexual or bisexual (OR_w = 2.49); having suffered physical violence (OR_w = 1.38) and not having suffered verbal violence (OR_w = 0.66) due to sexual orientation and having suicidal thoughts always or most of the time (OR_w = 2.71).

Discussion

The results indicate a high proportion (33.3%) of receiving money in exchange for sex in the year before the interview among the population of MSM in Brazil. The results found in this study are within the range of the reported proportion in the national and international literature. Internationally, a substantial variation is observed between the results found, from 16% to 63%, which can be attributed to the different characteristics of the target population, the overlapping of vulnerability factors and differences in recruitment, among others³¹31 Myers T, Allman D, Xu K, Remis RS, Aguinaldo J, Burchell A, Calzavara L, Swantee C. The prevalence and correlates of hepatitis C virus (HCV) infection and HCV-HIV co-infection in a community sample of gay and bisexual men. Int J Infect Dis 2009; 13(6):730-739.

32 Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30(6):1449-1454.

33 Gorbach PM, Murphy R, Weiss RE, Hucks-Ortiz C, Shoptaw S. Bridging sexual boundaries: men who have sex with men and women in a street-based sample in Los Angeles. J Urban Health 2009; 86(Supl. 1):63-76.

34 Newman PA, Rhodes F, Weiss RE. Correlates of sex trading among drug-using men who have sex whit men. Am J Public Health 2004; 94(11):1998-2003.^-3535 Nerlander LM, Hess KL, Sionean C, Rose CE, Thorson A, Broz D, Paz-Bailey G. Exchange Sex and HIV Infection Among Men Who Have Sex with Men: 20 US Cities, 2011. AIDS Behav 2016; 21(8):2283-2294.. In Brazil, in the city of Campinas, 14.8% of MSM received money in exchange for sex in the previous two months¹³13 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.. Thus, the comparison between the results found should be cautious, as they are mostly limited to local studies and subpopulations of MSM of greater social vulnerability, such as drug users, people living in the streets and the unemployed. Thus, methodological differences can influence the result found because methodologies in which the recruitment is carried out by the participant based on financial incentive can result in greater participation of those interested in this incentive. Another critical factor is the definition of the time bracket for sexual practice in exchange for money before the interview, in the previous 12 months in this study and up to two months in Tun et al.¹³13 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457..

In this study, MSM who received money in exchange for sex showed essential differences in sociodemographic issues when compared to other MSM. MSM who received money in exchange for sex had lower schooling, lower social classes, and lower probability of being employed at the time of the interview. These results are consistent with other studies conducted in Brazil and other countries⁶6 Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sex Transm Dis 2006; 33(4):228-234.^,1212 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.^,1313 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.^,3232 Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30(6):1449-1454.. In this sample, following the international trend, MSM who received money in exchange for sex show greater social marginalization when compared to other MSM. The marginalization of this group can lead to human rights violations resulting in substantial barriers to their access to prevention information and health services for the prevention and treatment of HIV infection³⁶36 Beyrer C, Crago AL, Bekker LG, Butler J, Shannon K, Kerrigan D, Strathdee SA. An action agenda for HIV and sex workers. Lancet 2014; 6736(15):1-14..

The positive association between receiving money in exchange for sex and being younger (age less than or equal to 25 years) is also described by other studies⁶6 Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sex Transm Dis 2006; 33(4):228-234.^,1212 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.^,3232 Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30(6):1449-1454.^,3737 Kelly JA, Amirkhanian YA, Mcauliffe TL, Dyatlov RV, Granskaya J, Borodkina OI. HIV risk behavior and risk-related characteristics of young Russian men who exchange sex for money or valuables from other men. AIDS Education and Prevention 2001; 13(2):175-88.. Despite the ethical complexities involved in research involving young people and adolescents, resulting in few studies with this population, many MSM who received money in exchange for sex in different countries report having started sex work in adolescence, sometimes in coercive or forceful³⁸38 Ballester-Arnal R, Gil-Llario MD, Salmeron-Sanchez P, Gimenez-Garcia C. HIV prevention interventions for young male commercial sex workers. Current HIV/AIDS reports 2014; 11(1):72-80. conditions due to the economic factor or family abandonment¹⁹19 Rigoletto RN. Um olhar sobre a prostituição masculina. In: XII CLASES; 2004; Santiago.. The high prevalence of HIV infection observed among MSM in adolescence and youth may suggest that the vulnerability factors present during adolescence are related to infection¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.. In this study, a significant proportion of MSM who received money in exchange for sex reported first sexual intercourse up to 14 years old and with female partners. Despite the increased use of condoms in the first sexual intercourse among young people aged 16-19 years in Brazil, sexual activity without a condom has grown among young people who started their sexual life before the age of 14³⁹39 Paiva V, Calazans G, Venturi G, Dias R. Idade e uso de preservativos na iniciação sexual de adolescentes brasileiros. Rev Saude Publica 2008; 42(Supl 1):45-53.. Also, late sexual first sexual intercourse, i.e., over 17 years of age for boys, is vital for the determination of the subsequent use of condoms⁴⁰40 Teixeira AMFB, Knauth DR, Fachel JMG, Leal AF. Adolescentes e uso de preservativos: as escolhas de jovens de três capitais brasileiras na iniciação e na última relação sexual. Cad Saude Publica 2006; 22(7):1385-1396.. The earlier the onset of sexual activity among members of the MSM population, the higher the likelihood of this individual having risk sexual behavior for HIV infection in adulthood²⁹29 Rocha GM. Comportamento sexual de risco entre homens que fazem sexo com outros homens no Brasil [tese]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014..

In recent years, the use of the Internet and geosocial network applications for phones with the aim of finding sexual partners has gained prominence among MSM worldwide⁴¹41 Beymer MR, Weiss RE, Bolan RK, Rudy ET, Bourque LB, Rodriguez JP. Sex on demand: geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles County. Sex Transm Infect 2014; 90(7):567-572.^,4242 Grosskopf NA, Levasseur MT, Glaser DB. Use of the internet and mobile-based "apps" for sex-seeking among men who have sex with men in New York City. Am J Mens Health 2014; 8(6):510-520.. Also, specific spaces of socialization among members of the MSM population are available, such as bars and nightclubs characterized as LGBT or “gay-friendly”, squares, parks, saunas, among others. In this study, having received money in exchange for sex was positively associated with using places or services to find sex partners in the previous month. Thus, we note that a trend of sex work is also related to experiences in the field of internet and geosocial network applications, besides those already usually identified¹⁸18 Mimiaga MJ, Reisner SL, Tinsley JP, Mayer KH, Safren SA. Street workers and internet escorts: contextual and psychosocial factors surrounding HIV risk behavior among men who engage in sex work with other men. J Urban Health 2009; 86(1):54-66..

This study evidenced that MSM who received money in exchange for sex reported a higher frequency of having a very high-risk behavior for HIV infection when compared to other MSM. These results probably indicate a high number of sexual partnerships that can be fixed, casual and commercial, and inconsistent use of condoms in anal intercourse with these partners in the previous 12 months²⁹29 Rocha GM. Comportamento sexual de risco entre homens que fazem sexo com outros homens no Brasil [tese]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014.. Literature¹²12 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.^,1313 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.^,4343 Mattson CL, Campbell D, Karabatsos G, et al. Scaling sexual behavior or 'sexual risk propensity' among men at risk for HIV in Kisumu, Kenia. AIDS Behav 2010; 14(1):162-172. reports that high-risk behavior has been shown to be related to HIV infection and syphilis, in isolation or by coinfection. Differently from that found in the literature¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273., the results of this study did not show an association between serological positivity for HIV and syphilis with the exchange of sex for money. That is, although they are more exposed to several factors that are vulnerable to HIV and syphilis than the others, there is no statistical difference for HIV infection and syphilis among MSM who received money in exchange for sex and the other MSM in the sample. It should be emphasized that, in this study, there was a significant number of participants who did not perform the serological test for HIV at the time of the interview, possibly generating a bias in the measurement of this variable.

It is known that, as a consequence of sociocultural factors, stigma, discrimination, and violence, the MSM population may be at higher risk of developing mental disorders such as anxiety and depression⁴⁴44 Nguyen, HM. Understanding Male Sex Work: A Literature Review. J Subst Abuse Alcohol 2017; 5(1):1054.. Moreover, the international literature points out that some types of mental disorders are associated with higher risk sexual behavior in MSM⁴⁵45 Safren SA, Thomas BE, Mimiaga MJ, Chandrasekaran V, Menon S, Swaminathan S, Mayer KH. Depressive symptoms and human immunodeficiency virus risk behavior among men who have sex with men in Chennai, India. Psychology, Health and Medicine 2009; 14(6):705-715.^,4646 Safren SA, Reisner SL, Herrick A, Mimiaga MJ, Stall RD. Mental health and HIV risk in men who have sex with men. J Acquir Immune Defic Syndr 2010; 55(Supl.):S74-S77.. Moreover, high rates of depression and other mental disorders are reported in different countries¹⁶16 Baral SD, Friedman MR, Geibel S. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385(9964):260-273.^,3232 Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30(6):1449-1454.^,4747 Goldsamt LA, Clatts MC, Giang LM, Yu G. Prevalence and behavioral correlates of depression and anxiety among male sex workers in Vietnam. Intern J Sex Health 2014; 27(2):145-155. among MSM who received money in exchange for sex. Depression and hopelessness are associated with suicidal thoughts, which are considered a risk factor for effective suicide⁴⁸48 Borges VR, Werlang BSG. Estudo de ideação suicida em adolescentes de 15 a 19 anos. Estudos de Psicologia (Natal) 2006; 11(3):345-351.. In consonance with the literature, this study found an independent association between suicidal thoughts and the receipt of money in exchange for sex, which may express a higher vulnerability of this population to self-destructive behaviors.

Thus, we highlight the importance of prevention programs aimed at providing MSM, especially those who have received money in exchange for sex, humanized care, a reception, active listening and psychological and therapeutic counseling through the health services to prevent them from developing suicidal behaviors and thoughts or adopting self-destructive conducts.

The positive association between self-identification as heterosexual or bisexual with the exchange of sex for money among Brazilian MSM is also reported in the national and international literature¹³13 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.^,4949 Ross MW, Timpson SC, Williams ML, Amos C, Bowen A. Stigma consciousness concerns related to drug use and sexuality in a sample of street-based male sex workers. Int J Sex Health 2007; 19(2):57-65.. Identification as heterosexual or bisexual among MSM who received money in exchange for sex may be associated with less receptive anal sexual practices than their gay peers and is thus an essential factor to consider for HIV transmission⁵⁰50 Elifson KW, Boles J, Sweat M. Risk factors associated with HIV infection among male prostitutes. Am J Public Health 1993; 83(1):79-83.^,5151 Boles J, Elifson KW. Sexual identity and HIV: The male prostitute. The Journal of Sex Research 1994; 31:39-46.. On the other hand, it is believed that the association between receiving money in exchange for sex and mental disorders can be mediated by sexual identity due to the identity conflict of those who identify as heterosexual or bisexual and the stigma of sex work between men being related to homosexuality⁵²52 Bar-Johnson M, Weiss P. Mental health and sexual identity in a sample of male sex workers in the Czech Republic. Med Sci Monit 2014; 20:1682-1686..

The use of illicit drugs in the six months before the interview was positively associated with the exchange of sex for money by MSM. This result is consistent with the national and international literature¹³13 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.^,3232 Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30(6):1449-1454.^,4949 Ross MW, Timpson SC, Williams ML, Amos C, Bowen A. Stigma consciousness concerns related to drug use and sexuality in a sample of street-based male sex workers. Int J Sex Health 2007; 19(2):57-65.. In general, the use of illicit drugs by MSM is more significant than that estimated for the general Brazilian population, and this difference is more pronounced among MSM who received money in exchange for sex¹³13 Tun W, Mello M, Pinho A, Chinaglia M, Diaz J. Sexual risk behaviours and HIV seroprevalence among male sex workers who have sex with men and non-sex workers in Campinas, Brazil. Sex Transm Infect 2008; 84(6):455-457.. The greater involvement with drug use is high among MSM who received money in exchange for sex and may be related to the stigma, discrimination, and violence that these people endure⁴⁹49 Ross MW, Timpson SC, Williams ML, Amos C, Bowen A. Stigma consciousness concerns related to drug use and sexuality in a sample of street-based male sex workers. Int J Sex Health 2007; 19(2):57-65.. Also, the environments in which MSM seek commercial sex partners due to marginalization are often favorable to alcohol and illicit drug use¹²12 Chao GF. Prostituição masculina, HIV/AIDS: estudo epidemiológico em municípios do Ceará [dissertação]. Fortaleza: Universidade Federal do Ceará; 2008.. Another critical factor is that receiving money in exchange for sex may be the result of the economic need of many drug users⁵³53 Van Den Hoek JAR, Coutinho RA, Van Haastrecht HJA, Van Zadelhoff AW, Goudsmit J. Prevalence and risk factors of HIV infections among drug users and drug-using prostitutes in Amsterdam. AIDS 1988; 2(1):55-60..

In this study, having suffered physical violence due to sexual orientation was positively associated with the receipt of money in exchange for sex for MSM. Violence due to sexual orientation is an essential indicator of vulnerability, as it intimidates, humiliates and entails social isolation, restricting the places and times of circulation in the public space, as well as access to health services, as a way of preserving themselves from assault or bullying.

This study has some limitations. This is a cross-sectional study with a single sample of Brazilian MSM obtained from ten cities from different states, with different sociocultural, geographic and epidemiological contexts that may not necessarily be representative of the entire Brazilian MSM population, and the RDS sampling technique is potentially subject to selection bias. Thus, people recruited in the sample of each city may show different characteristics. However, theoretically, when the sample reaches a steady state after successive waves of recruitment, the estimates obtained through the RDS are robust and tend to minimize this bias²⁷27 Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl 1997; 44(2):174-199.. The characteristics of the sample can also be influenced by homophilia, that is, individuals with specific characteristics may tend to recruit pairs with similar characteristics⁵⁴54 Gile KJ, Handcock MS. Respondent-driven sampling: as assessment of current methodology. Sociol Methodol 2010; 40(1):285-327.. However, this method stands out because it reaches hard-to-reach populations, avoiding results based only on samples of convenience. Finally, although the combined analysis of the ten independent samples does not certify that the results found are representative of the Brazilian MSM population, the pooled data provide a more robust sample with higher statistical power and are more suitable for the general purpose of surveillance monitoring at the national level, as initially proposed. Despite these limitations, the high proportion of MSM who exchanged sex for money and their associated factors shown in this study is of very relevant in the context of public health, regarding the prevention of HIV infection and health promotion in this population.

As shown in this study, a large number of MSM reported having exchanged sex for money the year before the interview. The results are in agreement with findings in the national and international literature, confirming the hypothesis that MSM who received money in exchange for sex have greater socioeconomic, programmatic and behavioral vulnerability potentially increasing the risk of HIV infection than other MSM in the sample.

The sociodemographic and behavioral risk characteristics, including the use of illicit drugs by this population, require the development of specific intervention strategies that take into account the whole social dynamics of this group, focusing on the perspective of human rights and fight against prejudice, stigma and homophobic violence. As a result, it is necessary to consider the vulnerability factors in the construction of policies to prevent HIV infection and health promotion for MSM who received money in exchange for sex, also concerning the collection of information of higher quality about this population. Besides the new approaches, such as increased HIV testing, the use of HIV pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), the use of rectal microbicides, actions to cope with stigma and discrimination are essential instruments in reducing the incidence of HIV infections and, consequently, on the course of the epidemic. Among these, the debate on the regulation of sex work, advertising actions directed to this segment and the promotion of the social inclusion of this population are highlighted in coping with the expanded HIV epidemic.

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