ABSTRACT

OBJECTIVE:

To analyze the factors that increase the practice of condomless anal sex (CAS) among adolescent men who have sex with men (AMSM) and adolescent travestis and transgender women (ATGW) in three Brazilian state capitals.

METHODS:

PrEP1519 is a prospective, multicenter cohort study demonstrating the effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) among AMSM and ATGW aged from 15 to 19 years in three Brazilian state capitals. The analyses were performed with baseline cohort data, including 1,418 adolescents enrolled from 2019 to 2021. The outcome studied was CAS in the last six months, and the potentially associated factors were sociodemographic, behavioral, healthcare, and history of violence and discrimination. Descriptive, bivariate, and multivariate analyses were conducted. Adjusted prevalence ratios (aPRs) and 95% confidence intervals (95%CI) were estimated.

RESULTS:

Most of the participants were AMSM (91.5%), aged 18 to 19 years (75.9%), Black (40.5%), with secondary or higher education in progress (92.7%), with CAS during the first sexual intercourse (54.2%), sexual initiation before the age of 14 (43.4%), and history of group sex (24.6%) and transactional sex (14.6%). The prevalence of CAS in the last six months was 80.6% (95%CI 78.5%-82.6%). Adolescents who reported condomless first sexual intercourse (aPR: 1.18; 95%CI 1.10-1.25), use of psychoactive substances (aPR: 1.09; 95%CI 1.03-1.16), and transactional sex (aPR: 1.11; 95%CI 1.04-1.20) had a higher prevalence of CAS in the last six months. We also found that those aged 15 to 17 years had a higher prevalence of CAS than those aged 18 to 19 (aPR: 1.07; 95%CI 0.99-1.13).

CONCLUSIONS:

The prevalence of CAS was high among AMSM and ATGW, being associated with practices that may increase the risk of sexually transmitted infections (STIs). Therefore, it is recommended to strengthen sexual health programs for young people that address the issue of sexuality and STI prevention, as well as to expand access to preventive methods, such as condoms and PrEP.

DESCRIPTORS:
Men who have Sex with Men; Transgender Women; Adolescent; Condomless anal sex; HIV/AIDS; Sexually Transmitted Infections

INTRODUCTION

Adolescence is a phase of life characterized by physical, psychological, and cognitive changes and the expansion of social interactions. In this period, adolescents are faced with demands, challenges, and new experiences¹1 Bock AMB. A adolescência como construção social: estudo sobre livros destinados a pais e educadores. Psicol Esc Educ. 2007; 11(1): 63-76. https://doi.org/10.1590/S1413-85572007000100007
https://doi.org/10.1590/S1413-8557200700... . In this sense, sexual health education is recommended to promote information that improves quality of life²2 Silva AA, Gubert FA, Barbosa Filho VC, Freitas RWJF, Vieira-Meyer APGF, Pinheiro MTM, et al. Health promotion actions in the School Health Program in Ceará: nursing contributions. Rev Bras Enferm. 2021; 74(1): e20190769. https://doi.org/10.1590/0034-7167-2019-0769
https://doi.org/10.1590/0034-7167-2019-0... .

However, sexual health education for adolescents and youth remains a challenge for families and education and health systems, especially in low- and middle-income countries³3 Magno L, Marinho LFB, Zucchi EM, Amaral AMS, Lobo TCB, Paes HCS, et al. School-based sexual and reproductive health education for young people from low-income neighbourhoods in Northeastern Brazil: the role of communities, teachers, health providers, religious conservatism, and racial discrimination. Sex Educ. 2022; 23(4): 409-24. https://doi.org/10.1080/14681811.2022.2047017
https://doi.org/10.1080/14681811.2022.20... . Brazil, for example, has registered several obstacles in the conduct of sex education programs in schools in recent years, primarily due to social conservatism⁴4 Brandão ER, Cabral CS. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters. 2019; 27(2): 1669338. https://doi.org/10.1080/26410397.2019.1669338
https://doi.org/10.1080/26410397.2019.16... . A study conducted in Salvador, Bahia, from 2017 to 2018 highlighted weaknesses in the process of developing and integrating sexual health education activities in public schools, mainly by cause of the difficulty of dialogue between the health (i.e., Brazilian Family Health Strategy) and education (i.e., public schools) sectors within the scope of the Brazilian School Health Program (in Portuguese: Programa Saúde na Escola - PSE). Moreover, that study recorded experiences of racism and discrimination related to homosexuality experienced by adolescents in the school environment³3 Magno L, Marinho LFB, Zucchi EM, Amaral AMS, Lobo TCB, Paes HCS, et al. School-based sexual and reproductive health education for young people from low-income neighbourhoods in Northeastern Brazil: the role of communities, teachers, health providers, religious conservatism, and racial discrimination. Sex Educ. 2022; 23(4): 409-24. https://doi.org/10.1080/14681811.2022.2047017
https://doi.org/10.1080/14681811.2022.20... .

In this context, Brazil has registered an increase in the incidence rate of human immunodeficiency virus (HIV) among adolescents and young people⁵5 Brasil. Ministério da Saúde. Boletim Epidemiológico de HIV/Aids. Brasília, DF; 2022.. The Brazilian Ministry of Health also shows particular concern about men who have sex with men (MSM) and travestis and transgender women (TGW) as epidemiological surveillance studies have estimated high prevalence of HIV in these populations. For instance, two national surveys conducted among MSM recorded an increase in HIV prevalence, from 14.2% in 2009 to 18.4% in 2016⁶6 Kerr LRFS, Mota RS, Kendall C, Pinho AA, Mello MB, Guimarães MDC, et al. HIV among MSM in a large middle-income country. AIDS. 2013; 27(3): 427-35. https://doi.org/10.1097/QAD.0b013e32835ad504
https://doi.org/10.1097/QAD.0b013e32835a... ^{), (7}7 Kerr L, Kendall C, Guimarães MDC, Mota RS, Veras MA, Dourado I, et al. HIV prevalence among men who have sex with men in Brazil: Results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore). 2018; 97(1S): S9-15. https://doi.org/10.1097/MD.0000000000010573
https://doi.org/10.1097/MD.0000000000010... . Among TGW, HIV prevalence is disproportionately higher than that recorded among the general population (0.6%) from 2001 to 2021⁸8 Programa Conjunto das Nações Unidas sobre HIV/AIDS. In Danger: UNAIDS Global AIDS Update 2022. Geneva; 2022., with substantial regional and temporal differences: 9% from 2014 to 2016 and 24.3% from 2016 to 2017 in Salvador⁹9 Leite BO, Magno L, Soares F, MacCarthy S, Brignol S, Bastos FI, et al. HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies. BMC Public Health. 2022; 22:2120. https://doi.org/10.1186/s12889-022-14589-5
https://doi.org/10.1186/s12889-022-14589... and 31.2% from 2015 to 2016 in Rio de Janeiro¹⁰10 Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV. 2017; 4(4): e169-76. https://doi.org/10.1016/S2352-3018(17)30015-2.

To effectively reduce new HIV infections among more vulnerable populations, the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommends the promotion of combined prevention programs by integrating biomedical, behavioral, and structural intervention measures¹¹11 Programa Conjunto das Nações Unidas sobre HIV/AIDS. Fast-tracking combination prevention: towards reducing new HIV infections to fewer than 500 000 by 2020. Geneva; 2015.. In this context, condoms are considered one of the most effective methods in preventing both HIV transmission and other sexually transmitted infections (STIs).

It is estimated that condoms were responsible for reversing 117 million new HIV infections worldwide from 1990 to 2020¹²12 Programa Conjunto das Nações Unidas sobre HIV/AIDS. Global AIDS Update 2021: Confronting inequalities: Lessons for pandemic responses from 40 years of AIDS. Geneva; 2021.. However, the prevalence of inconsistent condom use has been high among young and adult MSM¹³13 Rocha GM, Kerr LRFS, Brito AM, Dourado I, Guimarães MDC. Unprotected receptive anal intercourse among men who have sex with men in Brazil. AIDS Behav. 2013; 17(4): 1288-95. https://doi.org/10.1007/s10461-012-0398-4
https://doi.org/10.1007/s10461-012-0398-... ^{), (14}14 Rocha GM, Guimarães MDC, Brito AM, Dourado I, Veras MA, Magno L, et al. High Rates of Unprotected Receptive Anal Intercourse and Their Correlates Among Young and Older MSM in Brazil. AIDS Behav. 2019; 24:938-50. https://doi.org/10.1007/s10461-019-02459-y
https://doi.org/10.1007/s10461-019-02459... . A study comparing sexual behaviors between two surveillance studies with MSM, using similar methods (that is, respondent-driven sampling [RDS]), estimated similar prevalences of unprotected receptive anal sex from 2009 to 2016: 35.2% and 36.4%, respectively. Nonetheless, when observing younger MSM aged 18 to 25 years, there is an increase in this prevalence: from 33.6% in 2009 to 41.8% in 2016¹⁵15 Guimarães MDC, Kendall C, Magno L, Rocha GM, Knauth DR, Leal AF, et al. Comparing HIV risk-related behaviors between 2 RDS national samples of MSM in Brazil, 2009 and 2016. Medicine (Baltimore). 2018; 97(1S): S62-8. https://doi.org/10.1097/MD.0000000000009079
https://doi.org/10.1097/MD.0000000000009... .

With TGW, the use of condoms in Brazil presents different proportions among the studies of the other regions investigated. A survey with travestis in the metropolitan area of Recife estimated that 87.3% of them had unprotected sex during their first sexual intercourse¹⁶16 Sousa PJ, Ferreira LOC, de Sá JB. Estudo descritivo da homofobia e vulnerabilidade ao HIV/Aids das travestis da Região Metropolitana do Recife, Brasil. Cienc Saude Coletiva. 2013; 18(8): 2239-51.. Moreover, in Salvador, two studies conducted with TGW found a prevalence of CAS of 73.4% in the last six months, from 2014 to 2016, and 74.8% in the previous thirty days, from 2016 to 2017⁹9 Leite BO, Magno L, Soares F, MacCarthy S, Brignol S, Bastos FI, et al. HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies. BMC Public Health. 2022; 22:2120. https://doi.org/10.1186/s12889-022-14589-5
https://doi.org/10.1186/s12889-022-14589... .

CAS is a practice that increases the risk of HIV infection when pre-exposure prophylaxis (PrEP) is not used, as well as other STIs¹⁷17 Baggaley RF, White RG, Boily MC. HIV transmission risk through anal intercourse: Systematic review, meta-analysis and implications for HIV prevention. Int J Epidemiol. 2010; 39(4): 1048-63. https://doi.org/10.1093/ije/dyq057
https://doi.org/10.1093/ije/dyq057... . Thus, understanding the explanatory factors of this behavior is important to develop intervention strategies for promoting sexual health and preventing HIV and other STIs. In 2009, Rocha et al.¹³13 Rocha GM, Kerr LRFS, Brito AM, Dourado I, Guimarães MDC. Unprotected receptive anal intercourse among men who have sex with men in Brazil. AIDS Behav. 2013; 17(4): 1288-95. https://doi.org/10.1007/s10461-012-0398-4
https://doi.org/10.1007/s10461-012-0398-... , for instance, in a study with MSM, showed that illicit drug use, stable or commercial partnership, and friends that did not encourage condom use were factors associated with unprotected receptive anal sex. In addition, another study of young adult MSM in 2016 showed that unprotected receptive anal sex was associated with commercial sex, moderate or high perceived risk of HIV infection, homosexual identity, and poor self-rated health status, whereas, for older adult MSM, this practice was associated with a history of sexual violence, sex with younger partners, having had more than six sexual partners, and unprotected first sexual intercourse. In the same study, for both groups, being married or having a stable union were also factors associated with unprotected receptive anal sex¹⁴14 Rocha GM, Guimarães MDC, Brito AM, Dourado I, Veras MA, Magno L, et al. High Rates of Unprotected Receptive Anal Intercourse and Their Correlates Among Young and Older MSM in Brazil. AIDS Behav. 2019; 24:938-50. https://doi.org/10.1007/s10461-019-02459-y
https://doi.org/10.1007/s10461-019-02459... .

Among the TGW, there are recurrent processes of stigmatization, discrimination, and violence in the Brazilian context, which can hinder the negotiation of condom use¹⁸18 Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study. PLoS One. 2018; 13(4): e0194306. https://doi.org/10.1371/journal.pone.0194306
https://doi.org/10.1371/journal.pone.019... . Moreover, trust in the partner, depressive symptoms, and excessive use of psychoactive substance in specific contexts can also make it challenging to decide on condom use¹⁹19 Jalil EM, Torres TS, Pereira CCA, Farias A, Brito JDU, Lacerda M, et al. High Rates of Sexualized Drug Use or Chemsex among Brazilian Transgender Women and Young Sexual and Gender Minorities. Int J Environ Res Public Health. 2022; 19(3): 1704. https://doi.org/10.3390/ijerph19031704
https://doi.org/10.3390/ijerph19031704... .

In Brazil, research on the factors associated with CAS among adolescent MSM (AMSM) and adolescent TGW (ATGW) is limited to adolescents in the general population. Thus, this study seeks to analyze the factors that increase the practice of CAS among AMSM and ATGW in three Brazilian state capitals.

METHODS

Study design and population

This cross-sectional study, which used baseline data from the PrEP1519 cohort, was conducted from February 2019 to November 2021 and adopted convenience sampling of AMSM and ATGW aged 15 to 19. PrEP1519 is the first cohort study demonstrating the effectiveness of daily oral PrEP among MSM and TGW in Latin America, conducted in three Brazilian capitals: Belo Horizonte, Salvador, and São Paulo. The study population was composed of adolescents, self-identified as MSM or TGW, who reported living, working, or frequenting social spaces in one of these cities and who reported sexual relations that increase the risk of HIV infection with transgender women, travestis, or cisgender men at some point in their lives²⁰20 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica. 2023; 39(Supl 1): e00143221. https://doi.org/10.1590/0102-311XEN143221
https://doi.org/10.1590/0102-311XEN14322... . Adolescents with mental health issues or who were under the influence of drugs that compromised their decision to participate or their ability to respond to the interview or to receive clinical care were excluded. Other details are described in the study by Dourado et al.²⁰20 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica. 2023; 39(Supl 1): e00143221. https://doi.org/10.1590/0102-311XEN143221
https://doi.org/10.1590/0102-311XEN14322... .

Data collection: recruitment and registration

Communication and demand strategies for PrEP were initiated in 2018 by mapping adolescent meeting places, such as schools and living spaces, as well as virtual platforms and partner search apps, such as Instagram, Facebook, WhatsApp, Grindr, and Badoo²⁰20 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica. 2023; 39(Supl 1): e00143221. https://doi.org/10.1590/0102-311XEN143221
https://doi.org/10.1590/0102-311XEN14322... . These strategies included information on sexual orientation and gender identity, sexual behavior, and HIV prevention, as well as the distribution of HIV self-testing, condoms, lubricants, and douching. In the case of online approaches, primarily implemented after the COVID-19 pandemic, prevention supplies were sent to participants by mail or distributed at PrEP services, according to participants’ preference and clinical assessment²¹21 Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 Pandemic: Continuing HIV Prevention Services for Adolescents Through Telemonitoring, Brazil. AIDS Behav. 2020; 24(7): 1994-9. https://doi.org/10.1007/s10461-020-02927-w
https://doi.org/10.1007/s10461-020-02927... . From mid-March 2020, in-person activities were adapted to online activities due to the COVID-19 pandemic²¹21 Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 Pandemic: Continuing HIV Prevention Services for Adolescents Through Telemonitoring, Brazil. AIDS Behav. 2020; 24(7): 1994-9. https://doi.org/10.1007/s10461-020-02927-w
https://doi.org/10.1007/s10461-020-02927... ⁾ and resumed following local health protocols.

Participants could be enrolled in one of two groups of the study: PrEP and non-PrEP, which included the option of receiving other exclusive HIV prevention methods (i.e., testing, counseling, lubricant, HIV self-testing, etc.). Those who chose to use PrEP were evaluated for clinical eligibility criteria by a physician or nurse and returned after 30 days and every 90 days after that for follow-up at PrEP services. Those who did not opt for PrEP were advised to adhere to other methods of combined prevention. Testing for HIV, hepatitis A, B, and C, syphilis, and other bacterial STIs was provided to all participants in the initial and subsequent visits²⁰20 Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saude Publica. 2023; 39(Supl 1): e00143221. https://doi.org/10.1590/0102-311XEN143221
https://doi.org/10.1590/0102-311XEN14322... .

Instruments

This study was conducted using a socio-behavioral survey applied by healthcare professionals, peer educators, or trained researchers at the time of the participant’s enrollment in the cohort baseline. Data were recorded on an electronic virtual platform.

Variables

The outcome variable was “condomless anal sex” (CAS). The question in the questionnaire refers to the practice of anal sex, insertive or receptive, without condom in the six months before the research, with casual or steady partners, and could be answered with yes or no.

The exposure variables were selected from the literature review and classified as follows:

Data analysis

A descriptive analysis was performed to estimate the prevalence of exposure and outcome variables. Additionally, the association between exposure variables and CAS was estimated using Pearson’s chi-square test and, when necessary, Fisher’s exact test, considering a statistical significance level of 5%. The variables that obtained a p-value<0.10 in this bivariate analysis were selected for multivariate analysis, which used a logistic regression model to estimate odds ratio for the association between the exposure variables and CAS. Subsequently, based on this logistic model, adjusted prevalence ratio (aPR) and 95% confidence intervals (95%CI) were estimated using the delta method, employing the adjrr command in the Stata statistical software version 14.0²²22 Kleinman LC, Norton EC. What’s the risk? A simple approach for estimating adjusted risk measures from nonlinear models including logistic regression. Health Serv Res. 2009; 44(1): 288-302. https://doi.org/10.1111/j.1475-6773.2008.00900.x
https://doi.org/10.1111/j.1475-6773.2008... ^{), (23}23 Norton EC, Miller MM, Kleinman LC. Computing adjusted risk ratios and risk differences in Stata. Stata J. 2013; 13(3): 492-509. https://doi.org/10.1177/1536867X1301300304
https://doi.org/10.1177/1536867X13013003... .

To choose the final model, the strategy of excluding variables was applied, initiating, one by one, the removal of less significant variables, i.e., with a p-value > 0.05. The exclusion of variables occurred in the following sequence: (i) having sexual intercourse at or before the age of 14; (ii) having used public services for care; and (iii) having experienced violence and discrimination based on gender identity and sexual orientation. The significance level of the p-value was 5%. The age variable was not statistically significant but was maintained in the final model due to its theoretical relevance. The model’s goodness of fit was analyzed using the Hosmer-Lemeshow test (p-value=0.64) and by examining the area under the ROC curve (AUC=0.65).

Ethical aspects

For this study, the formative research protocol was approved by the Research Ethics Committees (RECs) of the World Health Organization (WHO) (protocol identification: “FIOTEC-PrEP Adolescent study”), the Faculty of Medicine of the University of São Paulo (USP) (no. 70798017.3.0000.0065), the Institute of Collective Health of the Federal University of Bahia (UFBA) (no. 01691718.1.0000.5030), and the Federal University of Minas Gerais (UFMG) (no. 17750313.0.0000.5149). Participants were informed about the research objectives and their rights when participating in the study. Those aged 18 years or older signed an informed consent form, whereas those aged from 15 to 17 years signed an informed assent form. In each city, there was a specific court decision regarding signing the informed consent form by the adolescent’s parents or guardians. In São Paulo, there was a judicial authorization to waive the informed consent form; in Salvador, waiver occurred in situations in which there was loss of family ties or in cases of risk of violence for the adolescent; in Belo Horizonte, exemption was not granted and written authorization from parents or guardians was required²⁴24 Zucchi EM, Couto MT, Castellanos M, Dumont-Pena E, Ferraz D, Pinheiro TF, et al. Acceptability of daily pre-exposure prophylaxis among adolescent men who have sex with men, travestis and transgender women in Brazil: A qualitative study. PLoS One. 2021; 16(5): e0249293. https://doi.org/10.1371/journal.pone.0249293
https://doi.org/10.1371/journal.pone.024... .

RESULTS

A total of 1,418 adolescents were included in the study: most were AMSM (91.5%), aged 18 to 19 years (75.9%), Black (40.5%), and with secondary or higher education in progress (92.7%). More than one-third of the participants reported having their first sexual intercourse at age 14 or younger (43.4%), and more than half said they did not use a condom during that intercourse (54.2%). Most participants reported having a relationship with steady partners younger than or equal to their age (82.1%), and almost half reported using psychoactive substances in the last three months (47.2%). About a quarter reported having participated in group sex (24.6%), 14.6% said they had engaged in transactional sex, and 32.2% said they had suffered discrimination and violence based on gender identity and sexual orientation. Moreover, 83.5% reported using the public sector for medical follow-up, and 43.6% used the health center as the usual source of care when sick (Table 1).

The prevalence of CAS in the last six months was 80.6% (95%CI 78.5%-82.6%). In the bivariate analysis, the factors that were positively associated with the outcome of the study were: self-reported Pardo (Mixed-race - PR: 1.10; 95%CI 1.05-1.16); having started sexual life at the age of 14 years or less (PR: 1.08; 95%CI 1.03-1.14); not having used a condom during the first sexual intercourse (PR: 1.18; 95%CI 1.11-1.24), use of psychoactive substances (PR: 1.11; 95%CI 1.05-1.17); having engaged in transactional sex (PR: 1.14; 95%CI 1.07-1.20); having used the public sector as usual source of care (PR: 1.09; 95%CI 1.07-1.21); and having experienced discrimination and violence based on gender identity or sexual orientation (PR: 1.07; 95%CI 1.01-1.13) (Table 1).

In the multivariate analysis, the factors that remained associated with CAS after adjusting the model were: condomless in the first sexual intercourse (aPR: 1.18; 95%CI 1.10-1.25); use of psychoactive substances in the last three months (aPR: 1.09; 95%CI 1.03-1.16); and having engaged in transactional sex (aPR: 1.11; CI95% 1.04-1.20). We also found that those aged 15 to 17 years had a higher prevalence of CAS compared with those aged 18 to 19 years (aPR: 1.07; 95%CI 0.99-1.13), although, in this case, there was no statistical significance at p-value 5% (Table 2).

DISCUSSION

This study estimated a higher prevalence of CAS among AMSM and ATGW compared to adolescents in Brazil’s general population (66.2%)²⁵25 Felisbino-Mendes MS, Paula TF, Machado IE, Oliveira-Campos M, Malta DC. Analysis of sexual and reproductive health indicators of Brazilian adolescents, 2009, 2012 and 2015. Rev Bras Epidemiol. 2018; 21(Supl 1): e180013. https://doi.org/10.1590/1980-549720180013.supl.1
https://doi.org/10.1590/1980-54972018001... . Moreover, this prevalence was higher than that estimated in other studies among young and adult MSM and ATGW, such as the studies by Hentges et al.²⁶26 Hentges B, Knauth DR, Vigo A, Teixeira LB, Leal AF, Kendall C, et al. Inconsistent condom use with casual partners among men who have sex with men in Brazil: a cross-sectional study. Rev Bras Epidemiol. 2023; 26:e230019. https://doi.org/10.1590/1980-549720230019
https://doi.org/10.1590/1980-54972023001... ⁾ on inconsistent use of condoms with casual partners among MSM in Brazil, by Magno et al.¹⁸18 Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: A mixed methods study. PLoS One. 2018; 13(4): e0194306. https://doi.org/10.1371/journal.pone.0194306
https://doi.org/10.1371/journal.pone.019... ⁾ on unprotected receptive anal sex among adult transgender women in Salvador, and by Satcher et al.²⁷27 Satcher MF, Segura ER, Silva-Santisteban A, Sanchez J, Lama JR, Clark JL. Partner-level factors associated with insertive and receptive condomless anal intercourse among transgender women in Lima, Peru. AIDS Behav. 2017; 21(8): 2439-51. https://doi.org/10.1007/s10461-016-1503-x
https://doi.org/10.1007/s10461-016-1503-... ⁾ on unprotected insertive sex among transgender women in Peru. The high prevalence of CAS found in this study may indicate an inadequacy of condoms as a preventive method for this population, either due to decreasing information about the technique or due to the difficulty of consistent use caused by the sexual needs of this new generation.

CAS associated with the use of psychoactive substance and transactional sex may suggest a generational change related to the increase in sexual practices with a higher risk of STIs, as well as to the social vulnerability faced by this population. In this sense, it is necessary to consider other preventive methods, especially providing PrEP for HIV prevention, promoting testing and treatment of other STIs, and considering aspects of social vulnerability that hinder this population’s access to health supplies and services.

In this analysis, the age variable was not statistically significant. However, it was maintained in the final multivariate model due to its theoretical importance. For example, the studies by Queiroz et al.²⁸28 Queiroz AAFLN, Sousa AFL, Araújo TME, Brignol S, Reis RK, Fronteira I, et al. High rates of unprotected receptive anal sex and vulnerabilities to HIV infection among Brazilian men who have sex with men. Int J STD AIDS. 2021; 32(4): 368-77. https://doi.org/10.1177/0956462420968994
https://doi.org/10.1177/0956462420968994... ⁾ and Rocha et al.¹⁴14 Rocha GM, Guimarães MDC, Brito AM, Dourado I, Veras MA, Magno L, et al. High Rates of Unprotected Receptive Anal Intercourse and Their Correlates Among Young and Older MSM in Brazil. AIDS Behav. 2019; 24:938-50. https://doi.org/10.1007/s10461-019-02459-y
https://doi.org/10.1007/s10461-019-02459... ⁾ showed that younger adult MSM were more likely to report CAS than older adults. This can be explained by several factors, including issues related to stigma and discrimination, economic dependence that hinders access to condoms, and limitations of sexual health programs aimed at this specific group²⁹29 Alecrim DJD, Ceccato MGB, Dourado I, Kerr L, Brito AM, Guimarães MDC. Factors associated with exchanging sex for money in men who have sex with men in Brazil. Cienc Saude Coletiva. 2020; 25(3): 1025-39. https://doi.org/10.1590/1413-81232020253.18052018
https://doi.org/10.1590/1413-81232020253... .

This study also showed that the prevalence of CAS was higher among those who reported condomless sex during their first sexual intercourse compared with those who did the opposite. Condoms have been one of the most important technologies in combination with HIV prevention since the beginning of the AIDS pandemic and other STIs¹¹11 Programa Conjunto das Nações Unidas sobre HIV/AIDS. Fast-tracking combination prevention: towards reducing new HIV infections to fewer than 500 000 by 2020. Geneva; 2015.. Although young people know the importance of its use, correct and consistent use is still a challenge³⁰30 Gutierrez EB, Pinro VM, Basso CR, Spiassi AL, Lopez MEBR, Barros CRS. Fatores associados ao uso de preservativo em jovens - inquérito de base populacional. Rev Bras Epidemiol. 2019; 22:e190034. https://doi.org/10.1590/1980-549720190034
https://doi.org/10.1590/1980-54972019003... . Studies have shown that the onset of sexual life without a condom and the earlier onset of sexual life may be associated with decreased condom use during adulthood³¹31 Hugo TDO, Maier VT, Jansen K, Rodrigues CEG, Cruzeiro ALS, Ores LC, et al. Fatores associados à idade da primeira relação sexual em jovens: estudo de base populacional. Cad Saude Publica. 2011; 27(11): 2207-14. https://doi.org/10.1590/S0102-311X2011001100014
https://doi.org/10.1590/S0102-311X201100... .

Regarding psychoactive substances, this study showed a high prevalence of CAS among participants who reported consumption compared to those who did not. This finding corroborates the studies by Kapadia et al.³²32 Kapadia F, Latka MH, Hudson SM, Golub ET, Campbell JV, Bailey S, et al. Correlates of consistent condom use with main partners by partnership patterns among young adult male injection drug users from five US cities. Drug Alcohol Depend. 2007; 91(Supl 1): S56-63. https://doi.org/10.1016/j.drugalcdep.2007.01.004
https://doi.org/10.1016/j.drugalcdep.200... ⁾ and Sousa et al.³³33 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 Saude Publica. 2020; 36(12): e00202420. https://doi.org/10.1590/0102-311X00202420
https://doi.org/10.1590/0102-311X0020242... A systematic review with meta-analysis on the prevalence of psychoactive substance use among MSM in East and Southeast Asian countries also showed an association between drug use and condomless sex and HIV infection. The consumption of these substances may be motivated by recreation, intensification of sexual pleasure, and coping with social vulnerabilities³⁴34 Nevendorff L, Schroeder SE, Pedrana A, Bourne A, Stoové M. Prevalence of sexualized drug use and risk of HIV among sexually active MSM in East and South Asian countries: systematic review and meta-analysis. J Int AIDS Soc. 2023; 26(1): e26054. https://doi.org/10.1002/jia2.26054
https://doi.org/10.1002/jia2.26054... .

A higher prevalence of CAS was also found among the AMSM and ATGW, who reported transactional sex. Other studies conducted outside Brazil, such as those by Mgbako et al.³⁵35 Mgbako O, Park SH, Callander D, Brinker DA, Kuhner C, Carrico AW, et al. Transactional sex, condomless anal sex, and HIV risk among men who have sex with men. Int J STD AIDS. 2019; 30(8): 795-801. https://doi.org/10.1177/0956462418823411
https://doi.org/10.1177/0956462418823411... , Bórquez et al.³⁶36 Bórquez A, Guanira JV, Revill P, Caballero P, Silva-Santisteban A, Kelly S, et al. The impact and cost-effectiveness of combined HIV prevention scenarios among transgender women sex-workers in Lima, Peru: a mathematical modelling study. Lancet Public Health. 2019; 4(3): e127-36. https://doi.org/10.1016/S2468-2667(18)30236-6
https://doi.org/10.1016/S2468-2667(18)30... , and Beattie et al.³⁷37 Beattie TS, Kabuti R, Beksinska A, Babu H, Kung’u M, The Maisha Fiti Study Champions, et al. Violence across the Life Course and Implications for Intervention Design: Findings from the Maisha Fiti Study with Female Sex Workers in Nairobi, Kenya. Int J Environ Res Public Health. 2023; 20(11): 6046. https://doi.org/10.3390/ijerph20116046
https://doi.org/10.3390/ijerph20116046... , showed similar findings. According to the 2021 UNAIDS report on HIV and sex work, transactional sex is consensual sex between two adults involving the exchange of money or other favors³⁸38 Programa Conjunto das Nações Unidas sobre HIV/AIDS. HIV e trabalho sexual: série de fichas informativas sobre direitos humanos. Geneva; 2021.. In the Brazilian context, transactional sex is not appropriate for adolescents under 18 years of age, constituting a crime due to sexual exploitation and representing a significant violation of human rights³⁹39 Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [Internet]. 1990 jul. 16 [citado em 23 maio 2024]. Disponível em: Disponível em: https://www.planalto.gov.br/ccivil_03/leis/l8069.htm .
https://www.planalto.gov.br/ccivil_03/le... . Baral et al.⁴⁰40 Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, et al. Male sex workers: practices, contexts, and vulnerability for HIV acquisition and transmission. Lancet. 2015; 385(9964): 260-73. https://doi.org/10.1016/S0140-6736(14)60801-1
https://doi.org/10.1016/S0140-6736(14)60... , for example, showed that it is typical for the practice of transactional sex among adult MSM to begin when these men are still very young and is usually performed in contexts of sexual exploitation and violence. These contexts of vulnerability can lead to the worsening of depressive and anxiety symptoms, which, in turn, can interfere with the ability to negotiate the use of condoms in transactional sexual relations⁴¹41 Beyrer C, Crago AL, Bekker LG, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex work. Lancet. 2015; 385(9964): 287-301. https://doi.org/10.1016/S0140-6736(14)60933-8
https://doi.org/10.1016/S0140-6736(14)60... , increasing the vulnerability of this population to HIV infection³⁸38 Programa Conjunto das Nações Unidas sobre HIV/AIDS. HIV e trabalho sexual: série de fichas informativas sobre direitos humanos. Geneva; 2021..

Importantly, this research was conducted with AMSM and ATGW patients who were at high risk for HIV infection and other STIs and who sought a health service for the use of oral PrEP. Thus, the estimated high prevalence of CAS in the last six months may suggest that other prevention measures are preferred instead of condoms. On the other hand, it may also indicate the difficulty in accessing condoms faced by these young people, as well as the absence of sexual health education programs that promote the discussion of condom use among them. Therefore, it is recommended to strengthen sexual health education programs for young people that address the issue of sexuality and STI prevention, as well as to expand access to preventive methods, such as condoms and PrEP.

The main limitation of this study is that it was conducted with a hard-to-reach population using the convenience sampling technique, which, to a certain extent, may affect the sample size and analytical and statistical power of the sample in the three cities where the research was performed. Despite this, the study holds the advantage of covering adolescents at higher risk of HIV infection and who attend places of sociability, thus allowing a better understanding of the population groups that should be prioritized in public policies on HIV/AIDS.

ACKNOWLEDGMENTS

This project was made possible thanks to funding and support from UNITAID, a partner of the World Health Organization. UNITAID accelerates access to innovative health products and lays the groundwork for its expansion with countries and partners. We would like to thank the participants of this research who voluntarily collaborated. We extend our thanks to the work team of the PrEP1519 Project in all sites, non-governmental organizations, the Brazilian Ministry of Health via the Brazilian Department of Health and the Brazilian Department of Surveillance, Prevention and Control of Sexually Transmitted Diseases, HIV/AIDS, and Viral Hepatitis, including the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES - Coordination for the Improvement of Higher Education Personnel) Brazil for the master’s scholarship granted to the first author of this study.

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