Sex work, syndemic conditions and condomless anal intercourse among men who have sex with men who engage in sex work in Latin America.

Background In Latin American countries and Suriname, sexual transmission is one of the most common modes of HIV transmission, and men who have sex with men (MSM) who engage in sex work constitute a key population. Methods In a sample of MSM (N =53,166) from the Latin American Internet Survey (2018) across 18 countries, we examined how sex work engagement is associated with syndemic conditions (multidrug use, homophobic abuse, depression/anxiety, alcohol dependency (CAGE alcohol questionnaire) and internalised homonegativity) and condomless anal intercourse with non-steady male partners using separate logistic regressions. We then used a structural equation model to determine if and how syndemic conditions mediate the relationship between sex work engagement and non-steady male partners. Results We found that getting paid for sex was associated with less condom use for anal intercourse with non-steady male partners and particular syndemic conditions, such as multidrug use, homophobic abuse and alcohol dependency. In our structural equation model, the results showed that the direct relationship between sex work engagement and non-steady male partners was positive and significant, and syndemic conditions partially mediated this relationship. Conclusion Our results highlight the continuing need for including MSM who engage in sex work and those who experience syndemic conditions in the prevention strategies targeted to MSM in Latin America and Suriname, to prevent the transmission of HIV.

Factors associated with PrEP knowledge and intention to use PrEP among HIV-negative men and trans women sex workers in Spain.

Lack of data regarding knowledge and intention to use pre-exposure prophylaxis (PrEP) among sex workers exists in Spain. We conducted a cross-sectional analysis based on data from SexCohort study, which included male (MSW) and trans women sex workers (TWSW), aged ≥18 and recruited in two community-based centres in Barcelona, Spain. Of 116 TWSW and 79 MSW, 49.1% and 58.2% had factual knowledge of PrEP, and 40.3% and 70.1% had the intention to use PrEP, respectively. In the multivariable analyses, we found that education and condomless anal sex with stable partners were associated with PrEP knowledge. Regarding intention to use PrEP, TWSW were less likely than MSW to report an intention to use it (aOR = 0.35, 95% CI: 0.16-0.74). Furthermore, intention to use PrEP was associated with being foreign-born, practicing chemsex, and visiting a medical service in the last 12 months. The results of this study inform future trans-specific guidance for PrEP to be effectively implemented in Spain.

Syndemic conditions and quality of life in the PISCIS Cohort of people living with HIV in Catalonia and the Balearic Islands: a cross sectional study.

BACKGROUND: People living with HIV (PLWH) face structural and psychosocial factors that affect health-related quality of life (HRQoL). We aimed to evaluate how syndemic conditions affected HRQoL in PLWH. METHODS: A cross-sectional survey was conducted among 861 PLWH, to determine whether syndemic conditions (monthly income; sexual satisfaction; depressive symptoms; social role satisfaction; social isolation; cognitive function; nicotine dependence; perception of stigma) have an effect on HRQoL. A linear regression model and measures of Additive Interaction (AI) were used to determine the effects of syndemic conditions on HRQoL, controlling for other risk factors. RESULTS: Overall, the most frequently observed were stigma perception (56.9%), poor cognitive function (50.6%) and the perception of social isolation (51.6%). The presence of depressive symptoms was the risk factor most associated with worse Physical Health (PH) (B 3.93, 2.71-5.15) and Mental Health (MH) (B 5.08, 3.81-6.34) in linear regression model. Specifically, an interaction was observed between poor cognitive function and poor satisfaction with social role on worse PH and MH (AI 2.08, 0.14-4.02; AI 2.69, 0.15-5.22, respectively); and low income and perception of stigma (AI 2.98, 0.26-5.71), low income and perception of social isolation (AI 2.79, 0.27-5.32), and low income and poor satisfaction with social role (AI 3.45, 0.99-5.91) on MH. CONCLUSION: These findings provide evidence that syndemic factors impact HRQoL. HIV prevention programs should screen and address co-occurring health problems to improve patient-centered health care and outcomes.

Impact of the COVID-19 Health Crisis on Trans Women and Cis Men Sex Workers in Spain.

The objective of the study was to describe the impact of the COVID-19 pandemic on sex workers in accessing health and social services. A qualitative study was conducted using semi-structured interviews with 29 participants in Barcelona, Spain. Data were analyzed using thematic analysis. Four themes were identified: (1) impact of COVID-19 on physical/mental health, (2) barriers and facilitators to health/social service access, (3) health decision-making, and (4) suggestions for future pandemic situations. Barriers to accessing health services were structural. Non-governmental organization support was the main facilitating factor. A person-centered, intersectional approach is suggested for future practice, considering co-occurring syndemic factors.

Syndemic Conditions and Their Association with HIV/STI Sexual Risk Behaviors Among Transgender Women and Cisgender Men Sex Workers in Catalonia: The SexCohort Project.

BACKGROUND: Transgender women and cisgender men sex workers are vulnerable to HIV and sexually transmitted infections (STIs). This study aimed to explore in depth the prevalence of syndemic conditions and their association with the sexual risk behaviors for HIV/STI acquisition in cis men and trans women sex workers in Barcelona (Catalonia, Spain). METHOD: We conducted a study between 2014 and 2018 to determine whether syndemic conditions (frequent alcohol consumption and polydrug use (> 2) during sex with clients; experience of violence; and lack of healthcare access) are associated with HIV/STI sexual risk behaviors. A "syndemic index" was calculated based on the cumulative number of syndemic conditions (0 to 4). RESULTS: In the last year (2018), 78.8% of cisgender men and 68.1% of transgender women reported at least one syndemic condition. The most prevalent syndemic factor in both cisgender men and transgender women was violence (38.8% and 43.6% respectively). In multivariable analysis, an association was found between condomless anal sex and violence (aOR = 1.81), and frequent alcohol consumption and violence with reporting > 10 clients/week (aOR = 2.73 and 1.88, respectively). The higher the number of syndemic factors, the greater probability of having > 10 clients/week and reporting condomless anal sex with clients. CONCLUSION: Psychosocial conditions have a syndemic effect on risky sexual behaviors highlighting the need for a more holistic approach to HIV/STI prevention targeting these populations.

High Hepatitis B Prevalence and Vaccination Needs Among Transgender Women and Men Sex Workers in Barcelona, Spain.

Background: Transgender women sex workers (TWSWs) and men sex workers (MSWs) are especially vulnerable to acquiring hepatitis B virus (HBV) infection. We aimed to describe HBV prevalence (hepatitis B surface antigen [HBsAg] and core antibody [HBcAb]) and associated risk factors for HBV exposure (HBcAb), to assess vaccination status and risk factors for no prior vaccination, and to compare HBV prevalence and vaccination status between TWSWs and MSWs. Methods: The SexCohort study was advertised to TWSWs and MSWs through several communication channels. At cohort entry through 2 community-based organizations in Barcelona, the study population was screened for HBV and other sexually transmitted infections, and an epidemiological questionnaire was administered (n = 271). Results: Overall, 93.0% of participants were migrants, mostly from South and Central American countries. HBsAg prevalence was 1.9% (TWSWs, 2.4%; vs MSWs, 0.9%; P = .42), and previous exposure to HBV was 31.8% (TWSWs, 38.5%; vs MSWs, 20.8%; P = .002). Over 5 years of sex work (adjusted odds ratio [aOR], 9.35), prior exposure to Treponema pallidum (aOR, 3.49), and treatment with anxiolytic drugs (aOR, 3.23) were associated with HBV exposure. Overall, 33.7% of participants exhibited immunity from vaccination (TWSWs, 30.8%; vs MSWs, 38.61%; P < .001), while 34.4% were candidates to HBV vaccination (TWSWs, 30.8%; vs MSWs, 40.6%; P < .001). Never having been on pre-exposure prophylaxis for HIV (odds ratio [OR], 4.23) and non-Spanish origin (OR, 5.00) were associated with no prior HBV vaccination. Conclusions: There is a need to reinforce screening and vaccination programs aimed at TWSWs and MSWs as integrated services offered at the community centers commonly accessed by these populations.

Determinants of Depressive Symptoms in People Living with HIV: Findings from a Population-Based Study with a Gender Perspective.

Depressive symptoms are common among people living with HIV (PLWH). The aim of this study was to identify the determinants of depressive symptoms in PLWH in Spain. A total of 1060 PLWH participated in this cross-sectional study and completed the Patient Health Questionnaire-9. The odds ratios for the presence of depressive symptoms were analyzed in a multivariable logistic regression model, including sociodemographic data, comorbidities, health-related behaviors, and social-environment-related variables. We found an overall prevalence of depressive symptoms of 21.42%; by subgroup, namely men, women, and transgender persons, prevalence was 18.13%, 32.81%, and 37.14%, respectively. Moreover, social isolation (OR = 1.05 [CI, 1.02-1.08]) and poor physical and mental quality of life (OR = 1.06 [CI, 1.02-1.09] and OR = 1.13 [CI, 1.09-1.17], respectively) were associated with depressive symptoms. As protective factors, we identified serodisclosure to more people (vs. none; OR = 0.39 [CI, 0.17-0.87]), satisfaction with social roles (OR = 0.86 [CI, 0.79-0.94]), better cognitive function (OR = 0.92 [CI, 0.89-0.95]), and sexualized drug use once in a lifetime (OR = 0.52 [CI, 0.29-0.93]). This study showed a high prevalence of depressive symptoms in PLWH, especially among women and transgender people. The association between psychosocial variables and depressive symptoms highlights the multidimensionality of the problem and identifies areas for intervention. This study found that the management of mental health issues is an area that needs to be improved and tailored to specific groups, with the aim of enhancing the well-being of PLWH.