alexa Male Sex Workers in Lisbon, Portugal: A Pilot Study of Demographics, Sexual Behavior, and HIV Prevalence | Open Access Journals
ISSN 2155-6113
Journal of AIDS & Clinical Research
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Male Sex Workers in Lisbon, Portugal: A Pilot Study of Demographics, Sexual Behavior, and HIV Prevalence

Henrique Pereira1,2,3*, Inês Gonçalves3, Isabel Borges3, Justino Filho3, Natália Cerqueira3 and Maria Eugénia Saraiva3

1University of Beira Interior, Portugal

2Research Unit of Psychology and Health, UIPES-ISPA/IU, Portugal

3Portuguese Leagueagainst AIDS, Liga Portuguesa contra a SIDA, Portugal

*Corresponding Author:
Henrique Pereira
University of Beira Interior
Portugal
Tel: +351914572131
E-mail: [email protected]

Received date: July 02, 2014; Accepted date: August 27, 2014; Published date: September 06, 2014

Citation: Pereira H, Gonçalves I, Borges I, Filho J, Cerqueira N, et al. (2014) Male Sex Workers in Lisbon, Portugal: A Pilot Study of Demographics, Sexual Behavior, and HIV Prevalence. J AIDS Clin Res 5:342. doi:10.4172/2155-6113.1000342

Copyright: © 2014 Pereira H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of AIDS & Clinical Research

Abstract

Background: HIV transmission among men who have sex with men (MSM) is a major concern in Portugal. Little is known, however, about HIV transmission among male sex workers (MSW) who have sex with male clients. This study aimed to investigate the prevalence of HIV infection and risk behaviors among MSW in Lisbon, Portugal. Materials and Methods: A cross-sectional study was conducted using outreach sampling among MSW in Lisbon. Behavioral and serological data on HIV was collected. Results: In total, 143 MSW were recruited for the survey (mean age=28.26, SD=5.96). The prevalence of HIV among these workers was 8.4%. 86% of the MSW self-identified as gay or bisexual. More than 75% were Brazilian immigrants, and 94.4% worked indoors (apartments). Consistent condom use was high (95%) for anal sex with clients, but much lower (63.6%) for anal sex with partners. In addition, 21.7% had not been tested for HIV in the previous year. Self-identified gay MSW had been tested for HIV more often in the previous year than self-identified bisexual or heterosexual MSW (p=0.020). This was also the case with MSW who said that they were versatile (p=0.026), when compared with men who said that they had receptive or insertive anal intercourse. The data suggests that the most salient risks for MSW include professional isolation, inconsistent HIV testing, limited perceived HIV risk, and suboptimal levels of condom use in sexual relationships with partners.

Keywords

Male sex work; Lisbon, Portugal; MSM; HIV

Introduction

HIV transmission among men who have sex with men (MSM) is a major concern in Portugal, since MSM remain one of the most at risk groups for HIV transmission [1,2]. However, little is known about HIV transmission and sexual practices among male sex workers (MSW) who work with male clients in Portugal, particularly in Lisbon. Male sex workers (MSW) are thought to be at an increased risk of sexually transmitted infections (STIs), since some STIs are more prevalent and reinfections are more common among MSWs than in other groups of men, including MSM [3,4].

It has been demonstrated that entry into the sex work industry is linked to economic and emotional factors, making it difficult to exit sex work and establish goals. Additionally, links between economics and beliefs influence MSWs’ perceived HIV/STI risks, vulnerability, and prevention practices [5]. The current social and economic circumstances in Portugal, shaped by the financial crisis and the growing acceptance of same-sex forms of sexual recognition, including same-sex marriage, [6] have been accompanied by an increase indifferent forms of sex work. The proliferation of sex work was in part an adaptive response to the loss of previous income, but was also facilitated by changing social norms that increased the supply side for sex work. This has occurred mainly in Lisbon, the capital of Portugal, where prostitution was decriminalized in 1983, but there is still a political void concerning sex work, as there is no professional recognition by the state [7]. Despite this, sex work in general, and male sex work in particular, is strongly socially reproved [8]. This stigma may partially explain why so little information is known, relegating MSW in Portugal to an invisible place in society and leaving them vulnerable to discrimination.

According to the European Centre for Disease Prevention and Control [9], HIV prevalence among MSW in Portugal is 13.5%, one of the highest rates in Western Europe. Another Portuguese study concerning MSW indicated a rate of 5% [10], reflecting the need for more accurate studies of this population.

Regarding the socio-demographic characterization of MSW, few studies exist that give an accurate idea of their social profile. Most studies look for determinants of entrance into the sex industry, such as personality characteristics, alcohol and drug abuse, lack of job opportunities, academic problems, depression, and violence [11]. These studies also focus on the professional consequences of sex work, such as: professional isolation, threats to personal safety, limited perceived HIV risk, and sub-optimal levels of condom use [12]. Previous studies have also examined other general determinants, such as family factors, sexual and criminal history, and current life situation, sexual practices with clients, financial gain, sexual orientation, and early sexual experiences [13]. Furthermore, the majorities of MSW are generally young and are working in the sex industry for the first time after immigrating to the city where they do their sex work [14].

When it comes to understanding sexual behavior among MSW most studies are inconclusive. Results vary widely, as some studies have found that condom use is inconsistent for receptive and insertive anal intercourse, especially when associated with lower education, fear of HIV infection, and a history of sexually transmitted infections [15]. However, other studies have demonstrated that around 87% to 100% of MSW consistently use condoms for anal intercourse with their clients [4,9].

Therefore, HIV infection in MSW needs to be understood in conjunction with its psychosocial correlates and sexual practices. This research was conducted as there are no prior studies that have examined MSW in Lisbon, Portugal, who are at an especially high risk for HIV infection. While MSW are an important population to characterize, they are also a challenging group to identify and follow in Portugal, rendering this study even more pertinent.

Methods

Participants and procedures

A total of 143 MSW participated in this research. Participants were generally young with the majority being under the age of 28 (mean age=28.26, SD=5.96). Only 21% of the participants are originally from Portugal. The majority was Brazilian immigrants, and the vast majority of recruited MSW engaged in sex work indoors (94.4%). About 68% reported being unemployed and sex work was their primary source of income. Financial reasons or the lack of better employment opportunities were cited as the primary reasons for their entry into sex work. See Table 1 for more information on demographic characteristics of the sample.

    Frequency Percent
Age 18-27 74 51.7
  28-43 69 48.3
Sexual orientation Gay 73 51.0
  Bisexual 50 35.0
  Heterosexual 20 14.0
Nationality Portuguese 30 21.0
  Brazilian 108 75.5
  Other 5 3.5
Marital Status Single 116 81.1
  Married to another man 10 7.0
  Married to a woman 8 5.6
  Separated from a woman 6 4.2
  Civil union with a woman 1 0.7
  Civil union with a man 2 1.4
Education 4 years of school 8 5.6
  6 years of school 14 9.8
  9 years of school 38 26.6
  12 years of school 64 44.8
  University 19 13.3
Job Student 8 5.6
  Employed 29 20.3
  Unemployed 97 67.8
  No occupation 6 4.2
  Students and employed 3 2.1
Sex role Insertive 49 34.3
  Receptive 5 3.5
  Versatile 89 62.2
Venue Indoor (apartment) 135 94.4
  Outdoor (street) 1 0.7
  Other 2 1.4
  Street and apartment 5 3.5

Table 1: Demographic characteristics (n=143).

The research was part an outreach program called “Encontros (In) Seguros” ((Un) Safe Encounters) which was aimed at preventing HIV and other STIs in MSW. Encontros (In) Seguros was conducted by the Portuguese League against AIDS (Liga Portuguesa Contra a SIDA), a non-governmental organization committed to expanding HIV prevention efforts in Portugal. Participants were recruited through team visits to indoor sex work facilities, namely apartments, where the opportunity was taken to distribute information, condoms, and lubricant gel. Rapid HIV tests were made available by the team to control the serostatus of all participants. This outreach program took place between 2011 and 2013.

Materials

Demographic characteristics: Data on participants’ age, sexual orientation, nationality, marital status, educational attainment, employment, sex role, and the venue where sex work was conducted (indoor or outdoor) were collected. For the purpose of data analysis, all variables were grouped into several categories.

HIV history and testing: a short-form questionnaire regarding HIV testing history (prior to rapid testing) was used. It included 2 questions: “How often do you test for HIV?” (Never tested; every 3 months; every 6 months; once a year; every 2 years or more), and “Have you had an HIV test in the previous year?”(Yes or no). Rapid HIV testing was done using commercially available and legally approved rapid test kitsin Portugal.

Ethical approval

This study was approved by the scientific and ethical committees of the Research Unit of Health and Psychology (UIPES-ISPA, Institute of Applied Psychology in Portugal) and the Portuguese League against AIDS (Liga Portuguesa contra a SIDA).

Results

HIV related Sexual behavior with clients

Most participants said that they worked on a daily basis, having 4 clients a day (average number of daily clients=4.08; SD=2.27), and 82.5% have exclusively male clients. Table 2 shows that nearly 70% of MSW say that they use condoms in oral sex, and 95.1% in anal sex. 2.1% said that they didn’t use a condom with a client in the last sexual relation, and 4.2% said that they didn’t discuss the use of condom when a client refused to use one.

    Frequency Percent
Gender of client Men 118 82.5
  Women 3 2.1
  Couples 1 0.7
Condom use in oral sex Never 5 3.5
  Rarely 7 4.9
  Almost always 26 18.2
  Always 100 69.9
  Doesn’t apply 5 3.5
Condom use in anal sex Never 1 0.7
  Rarely 1 0.7
  Almost always 3 2.1
  Always 136 95.1
  Doesn’t apply 2 1.4
Condom use in vaginal sex Never 2 1.4
  Rarely 1 0.7
  Almost always 4 2.8
  Always 62 43.4
  Doesn’t apply 74 51.7
Used a condom with the last client Yes 140 97.9
  No 3 2.1
Discuss the use of condom when a client refuses Yes 137 95.8
  No 6 4.2

Table 2: Results for HIV related sexual behavior with clients.

HIV related Sexual behavior with partners

Table 3 shows the results for sexual behaviors with their partners. A plurality of respondents (44.8%) said that they had sex with only one sexual partner, 68.5% of whom were male. Nearly 20% said that they never use condoms for anal sex with their partners, and 47% never use condoms for oral sex. Results also show that 32.2% did not use a condom in their last sexual relationship, and 21% did not use a condom for anal sex.

    Frequency Percent
Sexual activity with partners No sexual activity 48 33.6
  One sexual partner 64 44.8
  Several sexual partners 31 21.6
Gender of partners Female 29 20.3
  Male 98 68.5
  Transgender 2 1.4
  Female and male 14 9.8
Condom use in oral sex Never 67 46.9
  Rarely 13 9.1
  Almost always 26 18.2
  Always 34 23.8
  Doesn’t apply 3 2.1
Condom use in anal sex Never 28 19.5
  Rarely 7 4.9
  Almost always 11 7.7
  Always 91 63.6
  Doesn’t apply 6 4.2
Condom use in vaginal sex Never 20 14.0
  Rarely 4 2.8
  Almost always 5 3.5
  Always 36 25.2
  Doesn’t apply 78 54.5
Used a condom in the last sexual relationship with a partner Yes 94 65.7
  No 46 32.2
  Doesn’t apply 3 2.1
Used a condom in the last anal sexual relationship with a partner Yes 95 66.4
  No 30 21
  Doesn’t apply 18 12.6

Table 3: Results for HIV related sexual behavior with partners.

HIV history

Regarding HIV history, the majority said that they were tested every 6 months or once a year (39.2% and 32.9% respectively). Nevertheless, 9.1% of all MSW said that they had never been tested, and 21.7% of participants had not been tested during the past year. Results of HIV rapid testing showed that the prevalence of HIV infection was 8.4% (Table 4).

    Frequency Percent
HIV testing Never tested 13 9.1
  Every 3 months 17 11.9
  Every 6 months 56 39.2
  Once a year 47 32.9
  Every 2 years or more 10 7.0
HIV test in the previous year Yes 112 78.3
  No 31 21.7
HIV result Positive 12 8.4
  Negative 131 91.6

Table 4: Results for HIV related sexual behavior with partners.

When comparing HIV testing patterns and results by sexual orientation and sexual position, results show that self-identified gay MSW have been tested for HIV more frequently over the previous year than bisexual and heterosexual self-identified MSW, and that this difference was statistically significant (p=0.020). Yet, no differences were found regarding the relationship between sexual orientation and HIV serostatus (Table 5). When comparing HIV testing patterns and HIV results by sexual positions, our results indicate that MSW who said that they were versatile were tested much more often over the previous year than those who said that had insertive or receptive anal intercourse, and that this difference was also significant (p=0.026). No statistical differences were found between sexual positions and HIV serostatus results despite the fact that more HIV positive MSW were versatile (Table 6).

  Sexual Orientation Χ2(df) p
Gay Bisexual Heterosexual
HIV test over the past year       9.09(2) 0.020*
        Yes 43.7% 26.8% 7.7%
        No 7.0% 8.5% 6.3%
Total 50.7% 35.2% 14.1%
HIV Result       0.377(2) 0.823.
Positive 4.2% 1.7% 0.8%
Negative 50.0% 33.3% 10.0%
Total 54.2% 35.0% 10.8%

Table 5: Results for HIV testing and HIV serostatus by sexual orientations (n=143).

  Sexual Position Χ2 (df) p
Insertive Receptive Versatile
HIV test over the past year       7.332(2) 0.026*
        Yes 22.5% 2.8% 52.8%
        No 12.0% 0.7% 9.2%
        Total 34.5% 3.5% 62.0%
HIV Result       5.169(2) 0.075
        Positive   0.8% 5.8%
        Negative 29.2% 2.5% 61.7%
        Total 29.2% 3.3% 67.5%

Table 6: Results for HIV testing and HIV serostatusby sexual position (n=143).

Discussion

The main objective of this study was to assess the prevalence of HIV and behavioral circumstances in a sample of 143 MSW using outreach team members of the (UN) Safe Encounters project. In this study, HIV prevalence was found to be 8.4%, and MSW reported low levels of HIV risk behavior when having sex with their clients; however, this was not the case for sexual practices with their partners. Given the background of HIV prevalence in this group, MSW are at high risk of acquiring and transmitting HIV. Risk factors included inconsistent condom use with their partners during receptive anal, oral and vaginal intercourse. Studies have demonstrated that having a condom available at all times increases the likelihood of its use when sexual intercourse occurs [16,17]. Alternatively, possession of a condom may be an indicator of being better informed and of the willingness to use a condom when necessary. In our study MSW were more likely to carry a condom at the time of the survey, because condoms, as well as support and information regarding HIV and AIDS, were made available by the team. This finding demonstrates the importance of targeting MSW venues more often with outreach activities, especially the distribution of condoms and information. Other studies of MSWs confirm higher levels of condom use than among other at-riskgroups [18].

This study also found that the majority of MSW working in Lisbon were Brazilian immigrants who live away from their family or from their primary sources of social and emotional support. Additionally, they were more likely to use condoms inconsistently when having anal intercourse [19]. As it has been suggested, it is possible that men living away from their families have lower social support levels and fewer financial means to negotiate condom use effectively with partners, particularly if there is an obligation to support their extended families at home [20].

Being versatile during anal intercourse (or being both receptive and insertive) with a partner was found to be associated with inconsistent condom use among MSW. The decreased control versatile partners have over condom use compared with exclusively insertive or receptive partners may contribute to this risk, thus making versatile MSW test more for HIV. Moreover, versatile MSW were more likely to be HIV positive than MSW who said that they had exclusively insertive or receptive anal sex. Therefore, programs aiming to increase consistent condom use in MSM and MSW should address the responsibilities of both partners in anal intercourse and should include strategies for increased condom negotiation skills and the ability to carry out safer sexual scripts with partners to effectively negotiate condom use [21,22]. In light of the group-specific risk factors highlighted in the analysis, this information can beused to design HIV prevention messages that are applicable to MSM in general and various at risk subgroups.

Low levels of consistent condom use among MSW reflect recent trends in condom use among the broader population of MSM. Because MSM and MSW are more likely to be infected with HIV in Portugal [23,24], the epidemic has the potential to spread further in this population. These epidemiologic factors combined with the difficulty of reaching this target population signify the need for HIV prevention initiatives specific to MSW.

Our study demonstrated high levels of consistent condom use with clients among MSW; however, it had its limitations. Importantly, the risk behaviors of our sample may not be representative of the total population of MSW since participants were recruited from venues (apartments) where men socialize and find clients, in addition to having access to outreach and prevention materials such as condoms and lubricant. Levels of consistent condom use and risk behavior may be overestimated because MSW who gather in indoor venues may have higher risk profiles. The fact that measure used has not been validated, but was created for the study, is also a potential limitation of the study. At the same time, this is done in other qualitative/community-based participatory research as the measures are made specifically for the community group under study and meant to be representative of their specific and unique characteristics and behaviors. On the other hand, participants in our study may have over-reported the use of condoms, because they may be aware that this is the normative response.

The HIV epidemic has not been well controlled among MSM in Portugal [20]. The consistent condom use with clients among a large percentage of MSW, but the inconsistent condom use with partners, suggests that the spread of HIV will not decrease until we observe widescale behavioral change among these groups, especially within romantic relationships with partners. Future studies may consider assessing the partners of MSWs to obtain additional dada on this topic.

Finally, qualitative studies to increase and deepen our understanding of the reasons that MSW in Portugal cite for not using condoms consistently are also urgently needed. To maximize efficacy, HIV prevention campaigns must be able to consistently have access to and adequately monitor this invisible population of MSW.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 12168
  • [From(publication date):
    September-2014 - Nov 20, 2017]
  • Breakdown by view type
  • HTML page views : 8387
  • PDF downloads : 3781
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords