The Association between Incarceration and Transactional Sex among HIV-infected Young Men Who Have Sex with Men in the United States

Transactional Sex, HIV, and Bacterial STIs Among U.S. Men Who have Sex with Men

INTRODUCTION

Men who have sex with men (MSM) and are engaged in transactional sex (MSM-TS) experience complex social and structural vulnerabilities that increase their HIV risk. This study aimed to estimate the prevalence of TS and associations between TS and sexually transmitted infection (STI) outcomes among cisgender MSM in the U.S.

METHODS

Using 2017-2021 data from an online survey of U.S. MSM, characteristics of MSM-TS were summarized, and adjusted prevalence ratios (aPRs) calculated for the associations between past-year TS and bacterial STI diagnosis, HIV status, and either antiretroviral or pre-exposure prophylaxis use. Analyses were conducted in 2023.

RESULTS

TS prevalence was 3.7% (n=1,848/49,539). Compared to other MSM, MSM-TS more commonly reported homelessness, being uninsured, condomless anal sex with partners of any HIV status and condomless anal sex with serodifferent partners, and illicit drug use. TS was associated with increased HIV (aPR 1.44, 95% CI 1.25-1.66) and bacterial STI prevalence (aPR 2.40, 95% CI=2.09-2.52) and lower antiretroviral therapy use (among MSM living with HIV; PR 0.92, 95% CI=0.87-0.97).

CONCLUSIONS

Structural and behavioral risks converged among U.S. MSM engaging in TS leading to greater HIV and bacterial STI prevalence in this group. HIV interventions for U.S. MSM-TS should address individual as well as structural risks, including poverty and housing instability.

Transactional sex and its associated factors among gay, bisexual and other men who have sex with men in Nepal

Background Transactional sex, which involves the exchange of sex for money, goods or other items of value, has been associated with adverse health outcomes, such as HIV and other sexually transmitted infections, mental health challenges, and substance use. Although transactional sex has been extensively studied globally among cisgender and transgender women, there is a lack of comprehensive understanding regarding its prevalence and correlates among gay, bisexual and other men who have sex with men (GBMSM), particularly in Nepal. Thus, this study aimed to examine the prevalence of transactional sex and its associated factors among GBMSM in Nepal. Methods A cross-sectional survey was conducted among GBMSM in Kathmandu Valley, Nepal, between October and December 2022 (N =250). We collected information on participants' sociodemographic characteristics, sexual and other behavioural characteristics, and their engagement in transactional sex. Bivariate and multivariate logistic regression analyses were performed to determine the factors associated with transactional sex. Results The average age of participants was 27.5years (s.d. 8.9). Overall, 16.4% reported engaging in transactional sex within the past 6months. Participants with more financial dependants (aOR: 1.2, 95% CI: 1.0-1.5) and those who had experienced police detention (aOR: 4.8, 95% CI: 1.1-19.6) were more likely to engage in transactional sex. In contrast, GBMSM who reported engaging in condomless sex were less likely to engage in transactional sex (aOR: 0.02, 95% CI: 0.06-0.1). Conclusions The study findings underscore a noteworthy prevalence of transactional sex and associated socioeconomic and behavioural factors among GBMSM in Nepal. These results underscore the need for targeted interventions addressing both economic vulnerabilities and legal interactions to reduce transactional sex and its associated risks in this high-risk group.

History of Incarceration is Associated with Unmet Socioeconomic Needs and Structural Discrimination among Young Black Sexual Minority Men (SMM) in the United States

There is a dearth of research on incarceration among young Black sexual minority men (SMM). The current study aimed to assess the prevalence and association between unmet socioeconomic and structural needs and history of incarceration among young Black SMM. Between 2009 and 2015, young Black SMM (N = 1,774) in Dallas and Houston Texas were recruited to participate in an annual, venue-based, cross-sectional survey. We found that 26% of the sample reported any lifetime history of incarceration. Additionally, participants with unmet socioeconomic and structural needs (unemployment, homelessness, financial insecurity and limited educational attainment) were more likely to have a history of incarceration. It is imperative that interventions are developed to address the basic, social, and economic needs of young Black SMM with a history of incarceration or who are at risk for incarceration.

Structural-Level Racial-, Sexual Orientation-, and HIV-Related Discrimination and Subsequent Criminal Justice Involvement Among Young, Black, Men Who Have Sex With Men in North Carolina

Multiple aspects of Black young men who have sex with men's (YMSM) identities cause them to be differentially targeted for arrest and incarceration. However, limited research has explored structural drivers of Black YMSM' criminal justice involvement, particularly co-occurring forms of discrimination. This article examines the temporal relationship between perceived racial discrimination, perceived sexual orientation discrimination, and community-level HIV discrimination and criminal justice involvement among Black YMSM in North Carolina. The study followed 465 Black YMSM from November 2013 to October 2016 who were recruited for a randomized controlled trial to test an internet-based intervention for Black YMSM living with, and at risk for HIV; participants completed online surveys at baseline, 3, 6, and 12 months. Logistic regression was used to explore the relationship between the three predictors at baseline (i.e., perceived racism and sexual orientation discrimination and community-level HIV discrimination) and criminal justice involvement at follow-up. All three predictor variables were significantly associated with subsequent criminal justice involvement in separate regression models that adjusted for other covariates: HIV discrimination (aOR = 1.06 [1.01-1.11]), perceived sexual orientation discrimination (aOR = 1.12 [1.00-1.27]), and perceived racism (aOR = 1.26 [1.12-1.42]). Perceived racism remained significant in the model with all three predictors (aOR = 1.29 [1.07-1.55]). Racism did not modify the relationship between HIV discrimination and perceived sexual orientation discrimination and criminal justice involvement. This study expands existing research by exploring racism as a structural driver of criminal justice involvement; we subsequently examined whether racism modified the effect of the two other predictors. It also contributes to research on co-occurring discrimination by examining their impact on an underrepresented population.

Interest in Sex Work-Related Resources Among Gay, Bisexual, and Other Men Who Have Sex with Men Engaged in Sex Work

Introduction

Practicing sex work can present considerable risks to an individual's sexual health and overall well-being. Though resources tailored for sex workers can help mitigate such risks, little is known about male sex workers' interest in them.

Methods

From 2018 to 2020, we conducted in-depth telephone interviews with 180 U.S. men who engaged in sex work with clients met online. We inquired about what sex work-related resources they were aware of or had used, the specific content of resources they would want, and whether they would use such resources or not.

Results

Few participants had used sex work-related resources, but many had found material related to sex work through organizations and online media. While some participants expressed interest in resources to help make their engagement in sex work safer and more profitable, others were interested in resources that would help them address the conditions that had led them to sex work in the first place. Participants also discussed some barriers to resource utilization such as low perceived need, privacy concerns, and low credibility of the material.

Conclusions & Policy Implications

Results show that there is substantial interest in sex work-related resources among men engaged in the practice. However, programs should carefully consider potential barriers to utilization when developing these resources.

Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland

BACKGROUND

Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men's selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland.

METHODS

Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors.

RESULTS

Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97-0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81-7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05-3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02-3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex.

CONCLUSIONS

Synergistic sources of social and structural marginalization-from sexuality to hunger, homelessness, and injection drug use-are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.

Characterization of Risk Factors Among Individuals with a History of Incarceration Presenting to a Sexually Transmitted Infections Clinic: Implications for HIV and STI Prevention and Care

More than 2 million people are incarcerated in the United States with many millions more processed through correctional facilities annually. Communities impacted by incarceration are also disproportionately impacted by the HIV and sexually transmitted infection (STI) epidemics. However, relatively little is known about the behaviors that place individuals with a history of incarceration at risk for HIV/STI acquisition. We utilized clinical data from patients presenting to an STI clinic located in Providence, Rhode Island. A latent class analysis was conducted on reported HIV acquisition risk behavior and STI testing results on a total of 1129 encounters where a history of incarceration was reported. A total of three classes were identified. Class 1 (N = 187, 11%), more frequently reported 10+ sexual partners (45%), an STI diagnosis (48%) and sex while intoxicated (86%) in the past year as well as identifying as a man who has sex with other men (60%). Class 2 (N = 57, 5%) was more likely to report giving (53%) and receiving (44%) money/drugs for sex in the past year as well as a history of injecting drugs (61%) and using methamphetamine (60%). Class 3 (N = 885, 78%) most frequently reported 0-2 sexual partners (48%), identified as Black (27%), Hispanic/Latino (69%) and a man who only has sex with women (80%). Class 1 had significantly higher odds ratio (1.8, 95% confidence interval = 1.3-2.5) of testing HIV/STI positive. The results provide important insights into risk subgroups for those with a history of incarceration at risk of HIV/STI acquisition.

Ecological and Syndemic Predictors of Drug Use During Sex and Transactional Sex among U.S. Black Men Who Have Sex with Men: A Secondary Data Analysis from the HPTN 061 Study

Threats to sexual health among U.S. Black men who have sex with men (MSM) may manifest in a context of social adverse experiences. Situational sex is one such context, which we characterize as sexual behaviors driven either by a desire to cultivate a specific sexual experience or attributable to social vulnerability. Two characterizations of situational sex explored in this study were drug use during sex and transactional sex. Guided by ecological and syndemic frameworks, we conducted a secondary data analysis of social conditions and sexual behaviors among a prospective cohort of Black MSM from the HIV Prevention Trial Network (HPTN) 061 study. Using structural equation modeling, this analysis examined the indirect effect of syndemic factors (substance use, depression, violence exposure) in the relationship between ecological constructs (anti-Black/homophobic stigma, childhood violence, and economic vulnerability) and situational sex (drug use during sex, transactional sex). Model fit indices, CFI (.870) and SRMR (.091), demonstrated reasonable fit. Significant indirect effects emerged via substance use for economic vulnerability (indirect effect = .181, 95% CI [.078, .294]) and anti-Black/homophobic violence and stigma (indirect effect = .061, 95% CI [.008, .121]) on drug use during sex; as well as on transactional sex (economic vulnerability indirect effect = .059, 95% CI [.018, .121] and anti-Black/homophobic stigma and violence indirect effect = .020, 95% CI [.003, .051]). Findings implicate the need for social and fiscal intervention to address upstream, ecological, and syndemic factors that influence inherent vulnerability of situational sex and overall threats to sexual health among Black MSM.

Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S

Black men who have sex with men (MSM) engaged in sex work (BMSM-SW) experience elevated HIV and sexually transmitted infection (STI) prevalence. Further, BMSM-SW have been shown to have higher rates of syndemic psychosocial health conditions which contribute to HIV risk behavior and incidence, and poorer care outcomes than other groups of men who have sex with men. However, syndemic perspectives have not been applied to understanding past-year STI burden among BMSM-SW in the U.S. Sexually active Black MSM ≥ 18 years old were recruited from Black Pride events in six U.S. cities (n = 4421) between 2014 and 2017. Multivariable logistic regressions assessed correlates of past-year sex work engagement; whether BMSM-SW had higher odds of syndemic conditions; and whether BMSM-SW had higher odds of self-reported, past-year STI diagnoses. Structural equation models assessed relationships between sex work engagement, syndemic conditions, and STI controlled for sociodemographics and number of sexual partners. A total of 254 (5.7%) Black MSM reported past-year sex work, of whom 45.3% were HIV positive. BMSM-SW were significantly more likely to be Hispanic, to report past-year bisexual behavior, and to report annual income < $10,000. In multivariable models, BMSM-SW were significantly more likely to report intimate partner violence, assault victimization, polydrug use, and depression symptoms; they were also more likely to report past-year gonorrhea, chlamydia, and syphilis. Syndemic conditions mediated the relationship between past-year sex work and past-year STI burden, constituting a significant indirect effect. BMSM-SW in the U.S. face severe biopsychosocial health disparities. Interventions developed for BMSM engaged in sex work are lacking. Our results suggest that interventions containing safer sex work education and sex-positive biobehavioral HIV/STI prevention alongside substance use, mental health, employment, and education components will be most effective.

Lifetime Burden of Incarceration and Violence, Internalized Homophobia, and HIV/STI Risk Among Black Men Who Have Sex with Men in the HPTN 061 Study

Black men who have sex with men (BMSM) have disproportionate HIV/STI acquisition risk. Incarceration may increase exposure to violence and exacerbate psychosocial vulnerabilities, including internalized homophobia, which are associated with HIV/STI acquisition risk. Using data from HIV Prevention Trials Network 061 (N = 1553), we estimated adjusted prevalence ratios (APR) and 95% confidence intervals (CIs) for associations between lifetime burden of incarceration and HIV/STI risk outcomes. We measured associations between incarceration and HIV/STI risk outcomes with hypothesized mediators of recent violence victimization and internalized homophobia. Compared to those never incarcerated, those with 3-9 or ≥ 10 incarcerations had approximately 10% higher prevalence of multiple partnerships. Incarceration burden was associated with selling sex (1-2 incarcerations: APR: 1.52, 95% CI 1.14-2.03; 3-9: APR: 1.77, 95% CI 1.35-2.33; ≥ 10: APR: 1.85, 95% CI 1.37-2.51) and buying sex (≥ 10 incarcerations APR: 1.80, 95% CI 1.18-2.75). Compared to never incarcerated, 1-2 incarcerations appeared to be associated with current chlamydia (APR: 1.47, 95% CI 0.98-2.20) and 3-9 incarcerations appeared to be associated with current syphilis (APR: 1.46, 95% CI 0.92-2.30). Incarceration was independently associated with violence, which in turn was a correlate of transactional sex. Longitudinal research is warranted to clarify the role of incarceration in violence and HIV/STI risk in this population.

Brief Report: Associations Between Self-Reported Substance Use Behaviors and PrEP Acceptance and Adherence Among Black MSM in the HPTN 073 Study

BACKGROUND

Pre-exposure prophylaxis (PrEP) is efficacious for HIV prevention. Black men who have sex with men (MSM) accounted for the largest proportion of new HIV diagnoses in the United States relative to other racial/ethnic groups. Black MSM who use substances are at an increased risk for HIV infection and are ideal candidates for PrEP, but barriers to maintaining PrEP adherence remain a concern. We assessed whether substance use behaviors are associated with initiation and adherence to PrEP among a sample of black MSM in the United States.

METHODS

Data for this analysis come from the HIV Prevention Trails Network Study 073 (HPTN 073). Substance use behaviors-including alcohol, marijuana, poppers (ie, alkyl nitrites), and stimulants (ie, methamphetamine/cocaine use) including use of these substances before/during condomless anal intercourse (CAI)-were assessed longitudinally through self-report. PrEP adherence was assessed by pharmacological testing in blood. Generalized estimating equations were used to evaluate association between substance use behaviors and PrEP initiation and adherence.

RESULTS

Among 226 HIV-negative black MSM, the majority (60%) were 25+ years of age. Most of the substance use behaviors were not significantly associated with PrEP initiation or adherence. However, stimulant use before/during CAI was significantly associated with lower odds of PrEP adherence (adjusted odds ratio = 0.21, 95% confidence interval = 0.07 to 0.61; P = <0.01).

CONCLUSIONS

These findings suggest that PrEP adherence is feasible among black MSM who use substances. However, black MSM who engage in stimulant use before/during CAI may present a unique group for additional study and support with enhanced behavioral health and support services.

Association between Recent Criminal Justice Involvement and Transactional Sex among African American Men Who Have Sex with Men in Baltimore

Non-Hispanic Black/African American men who have sex with men (AAMSM) have been disproportionately affected by criminal justice (CJ) involvement and HIV. One potential pathway between CJ involvement and high HIV prevalence and incidence among AAMSM is through risky sexual behavior. The goal of this study was to explore the association between recent CJ involvement, i.e., having been arrested and/or in prison/jail in the past 6 months, and transactional sex in a sample of AAMSM in Baltimore. We analyzed the baseline data of 396 AAMSM from a pilot behavioral HIV intervention conducted in Baltimore, MD, between October 2012 and November 2015. A multivariate logistic regression model was conducted to explore the association between recent CJ involvement and transactional sex. A total of 65 (16%) participants reported recent CJ involvement, and 116 (29%) reported transactional sex in the past 90 days. After adjusting for age, education, employment, sexual identity, HIV status, and drug use, recent CJ involvement was significantly associated with transactional sex (AOR 3.31; 95% CI 1.72; 5.70). Being 24-40 years (AOR 2.73; 95% CI 1.17, 6.33) or over 40 years older (AOR 3.80; 95% CI 1.61, 8.98) vs. younger and using drugs (AOR 4.47; 95% CI 2.43, 8.23) also remained independently associated with recent transactional sex. Findings of the current study contribute to the literature on the association between recent history of CJ involvement and transactional sex among AAMSM. More evidence-based HIV prevention interventions for people involved in the CJ system who are at high risk for contracting HIV, particularly racial and sexual minorities such as AAMSM, are urgently needed.