Dear researchers,

We appreciate the interest in our publication and the comments on the content of the article, which we received with great esteem and consideration. Generally, the authors agree and reinforce the importance of our findings, but question two central points: (1) why our research, against the most recent literature, points to an increase in random sexual relations, and (2) whether the COVID-19 pandemic can truly affect the incidence of sexually transmitted infections (STIs) in high-risk/vulnerable groups.

Regarding the first question, we believe that the authors misunderstood our findings. In our study published in CSP ¹1. Sousa AFL, Queiroz AAFLN, Lima SVMA, Almeida PD, Oliveira LB, Chone JS, et al. Chemsex practice among men who have sex with men (MSM) during social isolation from COVID-19: multicentric online survey. Cad Saúde Pública 2020; 36:e00202420., we showed results regarding only individuals involved in chemsex, i.e., 920 people (38.9%) of the 2,361 men who have sex with men (MSM) included in the original survey. Although 95% of these individuals sought casual sex regardless of stay-at-home measures, frequency of sexual encounters as well as number of partners decreased, as we detailed in another publication ²2. Sousa AFL, Oliveira LB, Queiroz AAFLN, Carvalho HEF, Schneider G, Camargo ELS, et al. Casual sex among MSM during the period of sheltering in place to prevent the spread of COVID-19: results of national, online surveys in Brazil and Portugal. medRxiv 2020; 23 sep. https://www.medrxiv.org/content/10.1101/2020.06.07.20113142v2.
https://www.medrxiv.org/content/10.1101/... . The data from the general sample of that study show that the majority of MSM (75.9% in Brazil and 72.5% in Portugal) reported a decrease in the number of sexual partners during the pandemic. Thus, the problem itself is not just quantitative (increase or decrease in random encounters), but the fact that when the encounters occur, they seem to be permeated by unsafe sexual practices, increasing the vulnerability to exposure to STIs and SARS-CoV- 2 simultaneously (due to unknown partners, use of drugs, orgies, and use of ineffective prevention methods). The finding that 95% of chemical sex cases occurred with a casual partner reinforces the maintenance of behaviors and practices similar to the non-pandemic period, which are associated with higher turnover or number of sexual partners ³3. Carvalho HEF, Schneider G, Sousa AR, Camargo ELS, Nunes RV, Possani MA, et al . Suspected COVID-19 flu-like syndrome in men who have sex with men and have been involved in casual sex. Rev Bras Enferm 2020; 73 Suppl 2:e20200913..

Concerning the second question, we believe that the impact of the COVID-19 pandemic on STI incidence in high-risk or most vulnerable groups is notorious, as is the case of chemsex-practicing MSM. In a non-pandemic context, the practice of chemsex already increases exposure to STIs ⁴4. Evers YJ, Van Liere GAFS, Hoebe CJPA, Dukers-Muijrers NHTM. Chemsex among men who have sex with men living outside major cities and associations with sexually transmitted infections: a cross-sectional study in the Netherlands. PLoS One 2019; 14:e0216732., due to aspects such as diminished capacity for negotiating preventive methods, multiple partners, use of psychoactive substances, or even unorthodox contexts. A pandemic context, on the other hand, imposes physical and social distancing for preventing and controlling the new disease, such measures move bodies away and create barriers to sexual practice, which can increase access to psychoactive substances and also associated sexual practices, e.g., orgies that take place in “hidden” places. Facing the need to escape reality, individuals in our current context can lose focus on safe sex and prevention strategies.

In addition to the conditions already described by the authors in their letter, the male public’s distance from health services was aggravated, mostly due to the need to reorganize these services ⁵5. Operario D, King EJ, Gamarel KE. Prioritizing community partners and community HIV workers in the COVID-19 pandemic. AIDS Behav 2020; 24:2748-50.^,66. Kowalska JD, Skrzat-Klapaczynska A, Bursa D, Balayan T, Begovac J, Chkhartishvili N, et al. HIV care in times of the COVID-19 crisis: where are we now in Central and Eastern Europe? Int J Infect Dis 2020; 96:311-4. during the pandemic. This possibly impacted screening and diagnosis of STIs. Guidelines for social distancing and the needs of resource relocation during the COVID-19 pandemic have led to a significant disruption of sexual health clinics worldwide, which may mask STI incidence data, leading to a false sense of decrease ⁷7. Nagendra G, Carnevale C, Neu N, Cohall A, Zucker J. The potential impact and availability of sexual health services during the COVID-19 pandemic. Sex Transm Dis 2020; 47:434-6.^,88. Crane MA, Popovic A, Stolbach AI, Ghanem KG. Reporting of sexually transmitted infections during the COVID-19 pandemic. Sex Transm Infect 2020; sextrans-2020-054805..

Regarding the dispensing of medicines for HIV prevention and treatment, the fear of seeking hospitals to access medicines, tests, and other services ⁹9. Balestri R, Magnano M, Rizzoli L, Infusino SD, Urbani F, Rech G. STIs and the COVID-19 pandemic: the lockdown does not stop sexual infections. J Eur Acad Dermatol Venereol 2020; 34:e766-8. and getting infected with SARS-CoV-2 can be listed as a determinant impact of the pandemic on STI incidence ²2. Sousa AFL, Oliveira LB, Queiroz AAFLN, Carvalho HEF, Schneider G, Camargo ELS, et al. Casual sex among MSM during the period of sheltering in place to prevent the spread of COVID-19: results of national, online surveys in Brazil and Portugal. medRxiv 2020; 23 sep. https://www.medrxiv.org/content/10.1101/2020.06.07.20113142v2.
https://www.medrxiv.org/content/10.1101/... .

The discussion on vaccination among MSM is, in fact, interesting and should be considered more carefully when planning vaccination campaigns. The literature ¹⁰10. Queiroz AAFLN, de Sousa ÁFL, Matos MCB, de Araújo TME, Brignol S, Reis RK, et al. Factors associated with self-reported non-completion of the hepatitis B vaccine series in men who have sex with men in Brazil. BMC Infect Dis 2019; 19:335. indicates that the barriers to vaccine completeness in this group are strongly related to social and structural factors, which include non-welcoming environments in health services and a stigmatized minority self-perception, leading to neglect and consequently worse health outcomes ¹¹11. Cyrus K. Multiple minorities as multiply marginalized: applying the minority stress theory to LGBTQ people of color. J Gay Lesbian Ment Health 2017; 21:194-202..

Finally, we consider as inappropriate the description of the participants’ sexual practices as “bizarre”, which is an opinion that expresses judgment and reinforces a historical stigma; it should not have a place in academic and scientific literature. This fact even goes against the development of prevention and intervention measures suggested in the text. The heteronormative view of sexual practices marginalizes homosexuality and homoaffection and reinforces discrimination, as this perspective labels the practice of vaginal-heterosexual sex as “normal” and all the other sexual expressions as “not normal/bizarre”. In order to improve STI prevention, sexual rights must be guaranteed in the context of public health, and individual autonomy must be respected. We would have more gains in investing in prevention and harm reduction campaigns than in providing greater increased vulnerability of MSM based or focused on sexual practices.

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