In the United States, HIV prevalence among men who have ever engaged in transactional sex is estimated to be 20 percent, and men who engage in transactional sex with other men (i.e., sex in exchange for money, gifts, or favors) have been shown to have both increased HIV prevalence and incidence compared to other men who have sex with men (MSM).
[Photo: Dr. Katie Brooks Biello]
Pre-exposure prophylaxis (PrEP), a daily oral antiretroviral pill taken by HIV uninfected, at-risk individuals, is an efficacious HIV prevention tool. However, the same factors that put MSM at risk for HIV may present challenges to PrEP uptake and adherence. Barriers to PrEP uptake and adherence have been examined among MSM, and include cost, perceived efficacy, concerns about side effects and not wanting to take a daily pill. However, studies examining barriers to PrEP initiation and adherence are limited among sub-groups of high-risk MSM who may benefit from it the most, including those who are dependent on alcohol/drugs and those who engage in transactional sex. Understanding perceptions of PrEP and its use among MSM with different risk profiles is necessary for the development of contextually relevant PrEP promotion strategies targeted to unique sub-groups of MSM.
This study by Dr. Katie Brooks Biello, assistant professor of behavioral and social sciences and epidemiology, a secondary data analysis of a sample of substance-dependent MSM with a high prevalence of recent transactional sex, compared high-risk MSM who engage in transactional sex to those who do not engage in transactional sex across a wide range of multilevel, perceived barriers to PrEP use.
In this sample of substance-dependent MSM, over 20 percent of participants reported being paid for sex with a man in the past three months. Importantly, participants who reported engagement in transactional sex were less likely to identify as gay, more likely to identify as a racial minority, reported lower socioeconomic status and were more likely to be dependent on stimulants, suggesting that traditional messages and interventions for MSM, particularly those who identify as gay, that do not account for these complex risk factors may not be appropriate or effective for this subgroup.
Unique perceived barriers to PrEP use existed for MSM who recently engaged in transactional sex, primarily based on concerns that PrEP would adversely affect primary and casual partner perceptions. These barriers differed from MSM not engaged in transactional sex, but with high sexual and substance use risk, despite adjustment for potential socioeconomic confounders (e.g., income, education, insurance) and substance used (i.e., stimulants vs. alcohol). Future research is needed to confirm these findings given that PrEP has become more widely available; however, this study suggests that assessing recent transactional sex among MSM who could benefit from PrEP and providing culturally relevant interventions for these subgroups may help to address unique barriers to PrEP uptake and potentially adherence.
The study was published June in AIDS and Behavior.