Transactional Sex Among Men Who Have Sex With Men in Latin America: Economic, Sociodemographic, and Psychosocial Factors

摘要

Objectives. We assessed factors associated with engagement in transactional sex among men who have sex with men recruited from one of the largest Internet sites for men seeking social or sexual interactions with other men in Latin America. Methods. We constructed multilevel logistic regression models to analyze factors associated with engagement in transactional sex in 17 Latin American countries in 2012. Results. Of 24?051 respondents, 1732 (7.2%) reported being paid for sexual intercourse in the past 12 months. In a multivariable model, higher country-level unemployment was associated with increased odds of transactional sex (adjusted odds ratio [AOR]?=?1.07 per 1% increase in unemployment; 95% confidence interval [CI]?=?1.00, 1.13). Individual or interpersonal factors associated with increased odds of engagement in transactional sex included self-reported HIV (AOR?=?1.33; 95% CI?=?1.04, 1.69) or sexually transmitted infection (AOR?=?1.33; 95% CI?=?1.11, 1.59), childhood sexual abuse history (AOR?=?1.75; 95% CI?=?1.48, 2.06), intimate partner violence (past 5 years, AOR?=?1.68; 95% CI?=?1.45, 1.95), and sexual compulsivity (AOR?=?1.77; 95% CI?=?1.49, 2.11). Conclusions. Structural-level economic interventions and those that address individual and interpersonal factors may improve HIV prevention efforts among men who have sex with men who engage in transactional sex. In Latin America, the HIV epidemic is driven by sexual transmission and is highly concentrated in men who have sex with men (MSM). 1,2 MSM in Latin America have 30 times greater odds of HIV infection than do men in the general population. 1 Although much of the literature has focused on HIV risk in MSM, limited research in Latin America has specifically assessed the associated risk characteristics of men who engage in transactional sex. 2–10 Transactional sex, defined as the exchange of sexual intercourse for money or goods, is associated with increased vulnerability to HIV among women. 11 Some men who engage in transactional sex may be engaged in regular sex work (in which transactional sex is a primary income source and individuals self-identify as sex workers); however, these men may also occasionally engage in transactional sex. There are likely important differences between men who engage in sex work and those who engage in occasional transactional sex. Some studies have shown an increased prevalence of HIV among MSM who report engagement in sex work compared with those who do not, 3–5,12 and some evidence suggests that men engaged in sex work have higher HIV prevalence than do those who engage in transactional sex informally. 5 Men who engage in transactional sex may have increased vulnerability to HIV via an increased burden of psychosocial morbidities, reduced power and condom use negotiation, and stigma and discrimination. 6,13,14 Men who engage in transactional sex may also face a disproportionate burden of psychosocial factors, including a history of childhood sexual abuse (CSA), intimate partner violence (IPV), substance use, and depression, which can lead to increased sexual risk for HIV. 15,16 These factors and others may differ depending on the type or frequency of transactional sex men are involved in. Factors beyond those at the individual level may affect vulnerability to HIV infection. The political economy of health theory provides a framework in which to consider how unequal distribution of resources, wealth, and power can affect health. Structural drivers of the HIV/AIDS epidemic, which include social, economic, and political factors, contribute to social inequities. 17–19 Recent research has pointed to the importance of these factors in HIV transmission and acquisition among vulnerable groups. 11,18,20 In particular, urban unemployment has been implicated as a driver of the sex work industry among female sex workers as well as HIV infection among injection drug users in Eastern Europe. 21,22 Latin America is a rapidly urbanizing area of the world, 23 and country-level unemployment there may be a particularly salient structural driver of the transactional sex market among MSM and may have implications for the HIV epidemic. Even when employment opportunities are available, the inability to access them because of discrimination on the basis of sexual orientation could lead to engagement in transactional sex. Legal protections against employment discrimination may therefore result in decreased engagement in transactional sex. The emergence of the Internet and mobile apps as popular venues for MSM to meet social and sexual partners provides a novel framework within which to assess factors associated with transactional sex. We have documented the prevalence of engagement in transactional sex and assessed which individual and interpersonal factors and whether employment-related factors are associated with transactional sex among a large sample of MSM in 17 Latin American countries who are users of one of the largest Internet s