Application of the “syndemics” theory to explain unprotected sex and transactional sex: A crosssectional study in men who have sex with men (MSM), transgender women, and non-MSM in Colombia

Abstract

Introduction: Men who have sex with men (MSM) and transgender women (TW) in Colombia are highly affected by HIV. To improve understanding of the role of HIV risk behaviors in HIV acquisition, we used the syndemic framework, a useful concept to inform prevention efforts.Objective: To examine the effect of four psychosocial conditions, namely, forced sex, history of childhood sexual abuse, frequent alcohol use, and illicit drug use on unprotected sex and the synergistic effects (“syndemic” effects) of these conditions on HIV risk behavior.Materials and methods: We enrolled a total of 812 males (54.7% men who have sex with men, MSM; 7.3% transgender women, and 38% non-MSM). The participants were recruited from neighborhoods of low socioeconomic status through free HIV-counseling and -testing campaigns. We performed Poisson regression analysis to test the associations and interactions between the four psychosocial conditions and unprotected sex with regular, occasional, and transactional partners. To test the “syndemic” model, we assessed additive and multiplicative interactions.Results: The prevalence of any psychosocial condition was 94.9% in transgender women, 60.1% in MSM, and 72.2% in non-MSM. A higher likelihood of transactional sex was associated in MSM (prevalence ratio (PR)=7.41, p<0.001) and non-MSM (PR=2.18, p< 0.001) with three or all four conditions compared to those with one condition. Additive interactions were present for all combinations of psychosocial problems on transactional sex n MSM. No cumulative effect or additive interaction was observed in transgender women.Conclusions: Our study highlights the need for bundled mental health programs addressing childhood sexual abuse, illicit drug use, and frequent alcohol use with other HIV prevention programs.

Substance Use, Mental Health Problems, and Physical and Sexual Violence Additively Increase HIV Risk Between Male Sex Workers and Their Male Clients in Northeastern United States

“…The limited number of published studies specific to male sex workers that have examined syndemics in relation to sexual risk have relied on cross-sectional data. [9][10][11] Despite this expanding evidence, research is needed to examine the syndemic production of HIV risk behavior longitudinally among this group.…”

Factors associated with transactional sex among a cohort of gay, bisexual, and other men who have sex with men in Vancouver, Canada

“…However, the use of substances may lead to decreased inhibitions and participation in sexual behaviours which are associated with higher levels of STI and HIV transmission. 31 As such, a syndemic approach 10,15 is needed in order to better understand and support the needs of those who report polysubstance use and/or chemsex and also engage in transactional sex.…”

“…loneliness, cognitive escape, sensation seeking), and behavioural HIV and STI risk, which are associated with transactional sex. [10][11][12][13][14][15] In a large, multisite US study of 8411 GBM, 7% reported transactional sex and those who did so were more likely to identify as Black, be living in poverty, use substances, report condomless anal sex (CAS) with multiple partners, and be living with HIV (both aware and unaware of their status). 14 Likewise, in a longitudinal study of 722 US GBM living with HIV, 8% reported recent transactional sex, and results from this study indicated that transactional sex was associated with Black (vs White) race, younger age, lower income, and increased levels of intimate partner violence, substance use, and depression.…”

“…Further, it has been shown that the more syndemic factors GBM had, the more likely they were to also report recent transactional sex. 10,15 As such, research among GBM needs to consider a variety of psychosocial, behavioural, and physical and mental health factors to develop a better understanding of the true scope of transactional sex.…”

HIV incidence and risk factors among transgender women and cisgender men who have sex with men in two cities of China: a prospective cohort study

“…And compared with cis-MSM, transgender women were 2.2 times more likely to be infected with HIV [ 12 ]. A range of factors may contribute to increased risk of HIV infection among transgender women including the effects of social stigma and discrimination, the preference to be the receptive partner in anal sex to affirm their gender identity, the involvement in commercial sex, and other risky behaviors [ 13 , 14 ].…”