Arch Sex Behav (2015) 44:357–365 DOI 10.1007/s10508-014-0357-4


Unprotected Sexual Practices Among Men Who Have Sex with Women and Men Who Have Sex with Men Living with HIV/AIDS in Rio de Janeiro Renata Siqueira Julio • Ruth Khalili Friedman • Cynthia B. Cunha • Raquel Brandini De Boni • Sandra Wagner Cardoso • Thiago Torres Carla Almeida Alves • Cristiane Castro • Nilo Martinez Fernandes • Valdilea G. Veloso • Beatriz Grinsztejn

Received: 4 December 2013 / Revised: 19 March 2014 / Accepted: 26 May 2014 / Published online: 16 October 2014  Springer Science+Business Media New York 2014

Abstract Combined antiretroviral therapy is now acknowledged for preventing new HIV infections, besides decreasing mortality and morbidity. However, in many Latin America countries the epidemic is still driven by unprotected sexual intercourse. This study aims to describe sexual practices related to HIV/STD and to evaluate factors associated to unprotected sex among men who have sex with women (MSW) and men who have sex with men (MSM) under care at a reference center for HIV in Rio de Janeiro, Brazil. A cross-sectional study, nested in a Brazilian clinical cohort, evaluated the sexual practices of 404 sexually active HIV-positive MSW and men who have MSM. Approximately 30 % of them reported unprotected sexual practices during the 6 months prior to the interview. Most frequent risky practices reported were unprotected vaginal sex among MSW and unprotected receptive anal sex among MSM. Factors increasing the chance of unprotected sexual practices among MSW were the partner’s desire of becoming pregnant (OR 2.81; CI 95 %: 1.36–5.95). To have received comments about excessive consumption of alcohol (OR 2.43; CI 95 %: 1.01–5.83), illicit drug use (OR 4.41; CI 95 %: 1.75–11.60) and lived in marital situation (OR 2.10; CI 95 %: 1.09–4.08) were significantly associated with unsafe sexual practices among MSM. The results highlight that health care of men living with HIV, as well as the prevention strategies, must consider the

R. S. Julio Superintendeˆncia Regional de Sau´de de Varginha/Centro Universita´rio do Sul de Minas, Varginha, Minas Gerais, Brazil R. K. Friedman  C. B. Cunha  R. B. De Boni (&)  S. W. Cardoso  T. Torres  C. A. Alves  C. Castro  N. M. Fernandes  V. G. Veloso  B. Grinsztejn Instituto de Pesquisa Clı´nica Evandro Chagas/FIOCRUZ, Avenida Brasil 4365, Rio de Janeiro 21040-360, Brazil e-mail: [email protected]

particularities of sexual behavior practiced by people who differ in sexual orientation. Keywords HIV/AIDS  Unprotected sexual behavior  MSM  MSW

Introduction HIV/AIDS remain a public health problem with an estimated 2.3 million new infections worldwide each year (UNAIDS, 2013). Although combined antiretroviral therapy (cART) has reduced mortality and prevented new cases (Cohen et al., 2011; Mocroft et al., 2003), in most Latin America countries the epidemic is still mainly driven by unprotected sexual practices (De Boni, Veloso, & Grinsztejn, 2014).The knowledge of HIV serostatus may allow individuals to take measures to reduce or eliminate the risk of transmission and reinfection, but it may not be enough to prevent sexual risk behavior following HIV diagnosis. For instance, some studies have indicated an increase in risky sexual activity among men who sex with men (MSM) following the use of cART (Courtenay-Quirk et al., 2008; Eisele et al., 2008), with increases in the incidence of sexually transmitted infections (Desquilbet et al., 2002; Kerani et al., 2007; Mayer, 2011; Van de Ven, Kippax, Knox, Prestage, & Crawford, 1999). However, there is still controversy about the association of cART use over unprotected sexual intercourse. Recent data from HPTN 052 suggest that heterosexual discordant couples under cART diminish unprotected sexual behavior over the time (Mayer et al., 2013). Factors that have been associated with sexual risk behavior among HIV-positive MSM have been the most comprehensively studied and include complex interactions of use of alcohol and drugs (Lim et al., 2012; Mansergh et al., 2008;



Purcell et al., 2006; Semple, Strathdee, Zians, & Patterson, 2011), inconsistent disclosure of HIV serostatus to sex partners (Hart & Williamson, 2005; Morin et al., 2007; Parsons, Kutnick, Halkitis, Punzalan, & Carbonari, 2005), perceived responsibility to protect partners from HIV infection (Wolitiski, Bailey, O’Leary, Gomez, & Parsons, 2003), and beliefs about transmission risks (Benotsch, Kalichman, & Pinkerton 2001). Less is known about unsafe sex among HIV-positive men who have sex with women (MSW). Some variables that have been found as associated factors are to be in a stable relationship, to be young, to exchange sex for money, to have multiple sexual partners, serosorting, to be on cART for more than 6 months, and to have an undetectable viral load (Aidala et al., 2006; Golin et al., 2009; Seng et al., 2011). ‘‘Prevention for Positives’’ programs are behavioral and biomedical interventions aimed to protect the health of HIVinfected individuals, by reducing their chance of infection by other pathogens, as well as aimed to engage them in efforts to decrease HIV transmission (Fisher, Smith, & Lenz, 2010). Designing and implementing such programs require that the trends on this population behavior are understood. As there are few Brazilian studies on the risky sexual behavior of men living with HIV/AIDS (Guimara˜es et al., 2008; Scanavino, 2011), evidence coming from epidemiological studies is warranted in order to plan, implement, and evaluate programs that promote the health of HIV-infected men. Thus the purpose of this study was to describe sexual behavior practices related to HIV/STD and to analyze the factors associated to unprotected sexual practices among MSW and MSM under care at a reference center for HIV in Rio de Janeiro, Brazil.

Method This was a cross-sectional study nested in the IPEC clinical cohort, described elsewhere (Grinsztejn et al., 2009). The Instituto de Pesquisa Clı´nica Evandro Chagas—IPEC-FIOCRUZ—is a major referral Centre for HIV/AIDS care and research in Rio de Janeiro and its metropolitan area. Since 1986, over 5,000 HIV-infected individuals have received care at the institution. In January 2008 there were 1,500 HIVinfected men under active follow-up at the clinic. Participants The study population consisted of men with HIV/AIDS under follow-up at IPEC between January 15, 2008, to April 30, 2009, with age over 18 years, diagnosed with HIV infection at least 6 months prior to the interview and sexually active within the 6 months prior to the interview. Men were invited to participate in the study while waiting for a routine appointment and results from this convenience sample are reported. Exclusion criteria


Arch Sex Behav (2015) 44:357–365

were any neurocognitive impairment that precluded the interview and refusal to participate. Participants were considered as MSM if they had a sexual male partner(s) in the past 6 months. MSW were defined as those having only female partner(s) in the last 6 months. Individuals who reported male and female sexual partners in the last 6 months were excluded.

Measures Sociodemographic variables evaluated were as follows: age; ethnicity (self-reported); schooling; relationship status; monthly family income; and per capita monthly family income [reported as minimum wage (MW)]. The household income per capita was obtained by dividing family income by the number of people living on this income. Alcohol and drug use was accessed for the 6 months preceding the interview and included questions about the use of drugs to stimulate erection; use of illicit drugs such as marijuana, cocaine/crack, inhaled substances or injected drug use; and whether anyone commented that the interviewee had consumed excessive amounts of alcohol. Sexual behavior in the 6 months preceding the interview included questions on the number of sexual partners (partners with whom oral sex, vaginal and/or anal intercourse were reported); number of new sexual partners; disclosure of HIVpositive status; HIV status of sexual partner(s) (participant perception about partners HIV status based or not on any available HIV test result). Clinical and laboratory variables were considered as the time elapsed since HIV diagnosis and time since the last AIDS-related illness (months), CD4? T cell count at the time of interview (cells/mm3), viral load at the time of interview (copies/IU), and use of cART for at least 7 months preceding the interview. CD4? T cell count and viral load data were taken from the tests conducted nearest to the interview date (12 months before and up to 3 months after interview). Categories were guided by the definition of AIDS from the CDC1993, in terms of immunological parameters. Reproductive health variables were assessed only for MSW and included: desire to have children in the 6 months preceding the interview, the presence of a female partner who wanted to become pregnant and the absence/low risk of pregnancy in the last 6 months (vasectomy or sexual partner with history of tubal ligation, hysterectomy and/or menopause or consistent use of oral/injectable contraceptives, intrauterine devices or diaphragms). Sexual practices were accessed for the 6 months preceding the interview and included questions about anal insertive and receptive intercourse, vaginal intercourse and insertive oral sex with semen exposure.

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Unprotected sexual practice was the main outcome of the study and it was defined as composite measure including: anal insertive and/or anal receptive and/or vaginal intercourse without condoms (or not using condoms for the entire time of intercourse) and/or insertive oral sex with partner’s exposure to semen. Data Management and Analysis A database was generated based on the Teleform program for Windows, version 6.1, Cardiff Software, Inc. The software R 2.9.1 (R Development Core Team) was used to generate all analysis. Characteristics and proportions of men who reported unprotected sexual practices were compared among MSW and MSM using the chi square test. Bivariate analysis to test the association of unprotected sexual practices and sociodemographics, alcohol and drug use, sexual behavior, clinical/laboratory and reproductive health were performed independently for MSW and MSM. Logistic regression models were used to identify factors associated with unprotected sexual practices for each group. Variables with p values\0.10 at the bivariate analysis were selected, assessed for multicollinearity using generalized collinearity diagnostics (GVIF) and entered in the initial multivariate model. Covariates with the highest p values in the Wald test were sequentially removed and those with statistical significance at 5 % (p\0.05) remained in the final models. Though schooling was borderline significant in the model for MSM (p = 0.06), it was kept in the final model given its clinical relevance. Ethics The study was approved by the IPEC-FIOCRUZ IRB (CAE 056/2007) and all study participants signed an informed consent form. After the interview, counseling was provided and condoms were offered.

Results Five hundred and thirty-two men were approached and 76 reported not having sex in the 6 months prior to the interview. Forty men (7.5 %) declined to participate and the main reason for refusal was limited time availability. The final sample included 404 men, 211 (52.23 %) were MSM and 193 (47.77 %) reported having had only female partners (MSW). Twelve men reported having sex with male and female partners and were excluded. The participant’s characteristics are presented in Table 1. Median age was 39 years (IQR, 33–46) and there was no significant difference in the proportion of MSW and MSM who were older than 40 years (p = 0.334). Compared to MSW,


a higher proportion of MSM reported to have a white skin color (p = 0.002), to have more than 8 years of education (p\0.001) and to receive more than 1 MW per capita income (p = 0.001). MSW more frequently lived with a partner in the past 6 months (p\0.001). Regarding alcohol and drug use, approximately 15 % of men reported having received comments on their excessive consumption of alcoholic beverages and 12 % have used illicit drugs, with no significant difference between groups. The most frequent illicit drugs used were marijuana (9.9 %) and inhaled cocaine (6.4 %), with no significant difference between the groups. No significant differences on drug use for erection were reported by MSW and MSM (7.9 vs. 9.4 %; p = 0.58). There was no report of injecting drug use. MSM more frequently had more than one sexual partner compared to MSW (51.2 vs. 18.1 %, respectively); 52.1 and 15.5 % of MSM and MSW reported having had new sexual partners within the 6 months preceding the interview, respectively. A higher proportion of MSW reported having had serodiscordant HIV sexual partner (50.3 %) while most of MSM reported having had unknown HIV sexual partner (56.9 %) (p\0.001). The median elapsed time between the HIV infection diagnosis and the date of the interview was 62.3 months (IQR, 21.1–139.5). MSW had been aware of their diagnosis for a shorter period of time (median 44.7 months; IQR, 17.8– 118.5) compared to MSM (median 78.5; IQR, 24.9–145.6; Kruskal–Wallis test p = 0.007). The median duration of cART use was 40.1 months (IQR, 11.7–112.3), and was lower in MSW (median 28.1; IQR 10.8–95.4) compared to MSM (median 58.8; IQR, 14.8–124.1; Kruskal–Wallis test p = 0.017). Overall 277 (68.6 %)of men were using cART for at least 7 months at the time of interview and the median CD4? T cell counts was 392.0 cells/mm3 (IQR, 260.0–544.0). Among individuals under cART, 78.3 % had an undetectable HIV viral load and there was no difference among MSW and MSM. Sixty-seven MSW(34.7 %), reported the desire of having children and 32.6 % (n = 63) reported their partner’s desire to conceive. Most of them (58.5 %, n = 113/193), reported a low likelihood of the partner becoming pregnant due to the use of effective contraceptive methods or other definitive procedures to avoid pregnancy (hysterectomy or vasectomy). The sexual practices reported by MSW and MSM in the 6 months preceding the interview are described in Table 2. Insertive oral sex was a frequent sexual practice among MSM (82.0 %), while less than half of MSW reported this practice (43.0 %). As expected, vaginal sex was reported by almost the total of MSW (99.5 %). Insertive or receptive anal sex was reported by 93.8 % of MSM; 14.2 % (n = 30) and 21.8 % (n = 46) reported having had only insertive anal sex and only receptive anal sex, respectively.



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Table 1 Characteristics of HIV-positive MSW and MSM who received care at IPEC-FIOCRUZ, January 2008–April 2009 Total (N = 404)

MSW (N = 193)

MSM (N = 211)


Age C 40 years

195 (48.3)

98 (50.8)

97 (46.0)


Race/ethnicity: non-white

234 (57.9)

128 (66.3)

106 (50.2)



Schooling[8 years

293 (72.5)

110 (57.0)

183 (86.7)


Income[1 MW per capita

248 (63.6)

78 (41.7)

170 (83.7)


Lived in marital situation (past 6 months)

225 (55.7)

146 (75.6)

79 (37.4)


Alcohol and drug use in the past 6 months Excessive alcohol consumption

62 (15.3)

32 (16.6)

30 (14.2)


Illicit drug use

49 (12.3)

23 (12.1)

26 (12.5)


Drug use for erection

35 (8.7)

15 (7.9)

20 (9.5)



261 (64.6)

158 (81.9)

103 (48.8)

2 or more

143 (35.4)

35 (18.1)

108 (51.2)


264 (65.3)

163 (84.5)

101 (47.9)

1 or more

140 (34.7)

30 (15.5)

110 (52.1)

Disclosure of HIV-positive status

239 (59.3)

151 (78.6)

88 (41.7)

\0.001 \0.001

Sexual behavior in the past 6 months \0.001

Number of sexual partners


Number of new sexual partners

HIV status of sexual partner(s) Negative

155 (38.4)

97 (50.3)

58 (27.5)


78 (19.3)

45 (23.3)

33 (15.6)

171 (42.3)

51 (26.4)

120 (56.9)

Time elapsed since HIV diagnosis C 12 months

343 (85.1)

159 (82.8)

184 (87.2)


Use of cART for at least 7 months preceding the interview

277 (68.6)

129 (66.8)

148 (70.1)


Undetectable viral load at the time of interview (copies/IU)a

216 (78.3)

102 (79.7)

114 (77.0)


CD4 ? C200 at the time of interview (cels/mm3)

351 (87.1)

157 (81.3)

194 (92.4)


Never had a disease

209 (51.7)

94 (48.7)

115 (54.5)

\12 ms

56 (13.9)

34 (17.6)

22 (10.4)

[12 ms

139 (34.4)

65 (33.7)

74 (35.1)

Unknown Clinical characteristics

Time since last AIDS-related disease (months)


* Chi square for the comparison of MSW (men who have sex with women) and MSM (men who have sex with men) a

Among individuals under cART for at least 7 months

Insertive anal sex was reported by 24.9 % of MSW. Unprotected vaginal sex was the most frequent unprotected sex reported by MSW (23.3 %), while unprotected receptive anal sex was the most frequent unprotected sex among MSM (20.4 %). MSM more frequently exposed sexual partners to oral contact with semen (p\0.001) and throughout insertive anal sex (p\0.001) compared to MSW. The results of the multivariate models predicting unprotected sexual practices for MSW and MSM are shown in Table 3. For MSW, having a serodiscordant partner led to 80 % less chance of having unprotected sexual practices compared to men in sero-


concordant relationships (OR 0.20; p = 0.001). MSW whose partners wished to become pregnant in the past 6 months of the interview were 2.81 times more likely to have unprotected sex compared to those whose partners did not wish to become pregnant (OR 2.81; p = 0.006). A longer time interval since HIV infection diagnosis was associated with a 72 % reduction in unprotected sex in this group (OR 0.28; p = 0.005). The factors that remained significantly associated with unprotected sexual practices among MSM were to be older than 40 years (OR 0.41; CI 95 %: 0.21–0.80), excessive alcohol consumption (OR 2.43; CI 95 %: 1.01–5.83), illicit drug

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Table 2 Sexual practices among HIV-positive MSW and MSM under care at IPEC-FIOCRUZ, 2008–2009 Total (N = 404)

MSW (N = 193)

MSM (N = 211)

256 (63.4)

83 (43.0)

173 (82.0)

Sexual practices Insertive oral sex Vaginal sex

192 (47.5)

192 (99.5)

Insertive anal sex

200 (49.5)

48 (24.9)

152 (72.0)

Receptive anal sex

168 (41.6)

168 (79.6)

16 (8.3)

32 (15.2)

Unprotected sexual practices Insertive oral sex

48 (11.9)

Vaginal sex

45 (11.1)

45 (23.3)

Insertive anal sex

41 (10.1)

11 (5.7)

30 (14.2)

Receptive anal sex

43 (10.6)

43 (20.4)

use (OR 4.41; CI 95 %: 1.75–11.6), and marital status (OR 2.10; CI 95 %: 1.09–4.08).

Discussion Our results show that MSW and MSM under care at IPEC had different demographical and behavioral characteristics. MSM were more frequently white, with higher education and income compared to MSW. They have also reported a higher number of sexual partners, new sexual partners and partners unaware of their HIV serostatus. Such differences in the number of partners and new sexual partners may be related to differences in the partnership formation patterns between the groups. In the study conducted by Glick et al. (2012), by the age of 30, half of MSW reported that the latest partnership started before 5 years from the

study, while among MSM this proportion was only 11 %. Other possibility that could be further evaluated is compulsive sexual behavior (CSB) which seems to be more prevalent among MSM (Grov, Parsons, & Bimbi, 2010; Kelly, Bimbi, Nanin, Izienicki, & Parsons, 2009). To the best of our knowledge, there is only one study evaluating CSB among men in Brazil. Scanavino et al. (2013) did not find a significant difference in the Sexual Compulsivity Scale scores between MSW and MSM, but the later reported a higher frequency of multiple sexual partners. There was no difference on the prevalence of alcohol and/ or illicit drugs use between MSW and MSM, but its use was associated with unprotected sexual practices only among MSM. Several studies conducted with MSM have found positive associations between sexual risk behavior for HIV transmission and the excessive consumption of alcoholic beverages (Bruce, Kahana, Harper, Fernandez, & The ATN, 2013; Sander et al., 2013) and illicit drug use before or during intercourse (Durham et al., 2013). Actually, these associations are disturbing since alcohol abuse is a public health problem in Brazil (Schmidt et al., 2011) and there are few health services providing comprehensive care for substance use disorders to HIV-infected individuals. Thus, results point to the need of careful and structured substance use screening, as well as integrated treatment of substance dependence/ abuse. In this study, we have included individuals with different stages of treatment (around 70 % were in stable use of cART, i.g. cART for at least 7 months) and, regardless of being MSW or MSM, most of them had undetectable viral load, high CD4 levels and absence of opportunistic diseases during the study time frame. We cannot infer about possible changes in sexual behavior related to cART, but neither cART nor undetectable viral load were associated with unprotected sexual practices,

Table 3 Factors associated with unprotected sexual practices among HIV-positive MSW and MSM after logistic regression MSW



Unadjusted OR (IC 95 %)

Adjusted OR (IC 95 %)

Unadjusted OR (IC 95 %)

Adjusted OR (IC 95 %)

Age: C 40 years

0.57 (0.30–1.07)

0.41 (0.22–0.76)

0.41 (0.21–0.80)

Schooling: B 8 years

1.08 (0.57–2.04)

2.24 (0.99–5.05)

2.34 (0.95–5.72)

Lived in marital situation (past 6 months) Excessive alcohol consumption

2.24 (1.01–5.51) 1.70 (0.75–3.74)

– –

2.13 (1.17–3.89) 2.69 (1.22–5.96)

2.10 (1.09–4.08) 2.43 (1.01–5.83)

Illicit drug use

0.88 (0.30–2.25)

4.60 (1.98–11.16)

4.41 (1.75–11.6)

HIV serodiscordant sexual partner (last 6 months)

0.26 (0.12–0.56)

0.20 (0.08-0.46)

0.49 (0.20–1.21)

Unknown HIV sexual partner (in last 6 months)

0.48 (0.20–1.10)

0.52 (0.20-1.28)

0.56 (0.25–1.25)

Partner’s desire of having children(last 6 months)

2.41 (1.25–4.66)

2.81 (1.36–5.95)

– –

Time elapsed since HIV diagnosis C 12 months

0.33 (0.15–0.73)

0.28 (0.11–0.67)

0.62 (0.28–1.45)

Use of cART for at least 7 months

0.56 (0.29–1.09)

0.62 (0.33–1.15)

Time since the last AIDS-related illness\12 months

2.04 (0.89–4.66)

0.82 (0.30–2.09)


Variables where univariate analysis had p[0.10 in both groups are not shown. There were three missing observations among MSM



in accordance with previous international results (Crepaz et al., 2009). A substantial number of men engaged in unprotected sexual practices. Unprotected vaginal sex practiced by MSW (23.3 %) and unprotected receptive anal sex practiced by MSM (20.2 %), such as sexual practices that are exclusively realized by each of the groups, contributed with the higher proportion of sexual risk behavior. Our results also showed that insertive oral sex with partner exposure to semen (MSW: 8.3 % vs. MSM: 15.2 %) and unprotected insertive anal sex (MSW 5.7 % vs. MSM: 14.2 %), e.g., sexual practices common to both groups, should be considered in prevention programs. Although oral sex with exposure to semen is a practice considered as having less risk of HIV transmission compared to unprotected anal sex (Page-Shafer et al., 2002; Varghese, Maher, Peterman, Branson, & Steketee, 2002), this practice was included in the outcome of the present study. The exact risk of HIV transmission per act remains uncertain, but current guidelines for post-exposure prophylaxis (PEP) still recommend PEP for individuals presenting such risk whenever the partner is HIV-positive (Benn, Fisher, & Kulasegaram, 2011; New York State Department of Health AIDS Institute, 2013; Smith et al., 2005). Including oral sex with exposure to semen has slightly increased the prevalence of unprotected sexual practices in our study, because most individuals also reported other unprotected practices. However, there is so little data on sexual behavior of HIV-positive men from Brazil, that we consider that a comprehensive understanding is pivotal for future interventions. The high frequency of unprotected sexual practices constitutes a public health challenge due to the potential of increasing HIV transmissibility, including drug-resistant strains of the virus (Chin-Hong et al., 2005; Stolte, de Wit, van Eeden, Coutinho, & Dukers, 2004. The frequency of unprotected anal sex among MSW and MSM was 5.7 and 23.3 %, respectively. Among MSM, unprotected receptive anal sex (20.4 %), which represents the practice with higher risk for HIV acquisition (Baggaley, White, & Boily, 2010), occurred more frequently than unprotected insertive anal sex (14.2 %), but most individuals (around 80 %) reported both practices. The differences in sexual practices may be associated with role—identities, as described by Clark et al. (2013), which may have implications for the understanding of social and sexual networks, as well as the behaviors of individuals. Unfortunately, the present study did not investigate the construct of gender identity (such as heterosexual, homosexual/gay, transsexual or bisexual) and it is not possible to make any inference on how this perception impacts the frequency of unprotected sex and other sexual practices. We acknowledge that sexual identity is a crucial concept to investigate in HIV research, especially because transgender women are one of the most at risk populations for HIV (Baral et al., 2013) and future studies must address this issue. Furthermore, our sample was too small to analyze the sexual behavior and unprotected sexual practices of men report-


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ing male and female partners (MSMW—12 men or 5.7 % of MSM). The frequency of MSMW presented herein was much lower than found among MSM from Africa (34 %), although the results are not completely comparable because the African study also included HIV-negative/unknown status MSM (Beyrer et al., 2010). According to the results presented by Dodge et al. (2013), MSMW may have a similar range of sexual practices with both men and women. They also reported less frequently receptive than insertive anal sex, which was different than observed for MSM at our study. Thus, including MSMW either in the MSW or MSM group would be controversial, and future studies should be conducted to evaluate sexual practices and risk of HIV infection among this specific population in Brazil. The factors associated with unprotected sexual practices were different between MSW and MSM. Half of MSW reported having serodiscordant partners and sexual risk behavior was less common among them. This could result from the increased concern about the sexual transmission of HIV to their partners (Morin et al., 2007). Of note, 30 % of HIV transmissions in HPTN 052 and in the Partners PREP study were unlinked, pointing out that there is a substantial risk of HIV transmission/ acquisition outside the stable couple relationship. Our results also indicate a need for comprehensive prevention strategies targeting couples living with HIV/AIDS, combining ART treatment expansion for all HIV-infected individuals engaged in a serodiscordant relationship regardless of CD4 counts and also pre-exposure prophylaxis for the seronegative partner as needed. About 30 % of MSW reported the partner’s desire of pregnancy, and this was associated with a higher likelihood of unprotected sexual intercourse. The issues of reproductive couples living with HIV/AIDS are becoming increasingly relevant in the current context due to the expansion of cART (Delvaux & No¨stlinger, 2007). Longer survival and an increased quality of life give these couples the opportunity to bear and nurture children. Therefore, counseling for the prevention of HIV transmission or acquisition of new viral strains should also take into account the couple’s desire for children. In March 2005, the Brazilian Ministry of Health launched its National Policy on Sexual and Reproductive Rights, which introduced assisted reproduction in the National Health System—SUS. However, few resources are available to assist human reproduction ensuring a lower risk of horizontal transmission of HIV. The factors associated with unprotected sexual practices among MSM were to have less than 40 years old, to have lived in marital situation and to have used alcohol and/or drugs. The association between age and sexual risk behavior for HIV transmission among MSM may be related with higher sexual activity among the youngest. Unlike MSW, only 37.4 % of all MSM lived in marital union, which led to increased chance of unprotected sexual practices in 2.10 times in this last group. This result is similar to recent international (Halkitis et al., 2013) and national data including HIV-positive (Guimara˜es

Arch Sex Behav (2015) 44:357–365

et al., 2008) and HIV-negative (Rocha, Kerr, de Brito, Dourado, & Guimara˜es, 2013) MSM, and it is plausible that a stable relationship does not favor the use of condoms during sexual intercourse, especially when the partner is seroconcordant (Marks et al., 1994). Given the current profile of HIV epidemics in the country, disproportionally affecting MSM (Barbosa, Szwarcwald, Pascom, & Souza, 2009; de Castro et al., 2010; Malta et al., 2010; Ministe´rio da Saude Brasil, 2012), a comprehensive understanding of sexual behavior may contribute for the development and implementation of targeted interventions for prevention among this population. As stated in the Beyrer et al. (2012) review, MSM are a vulnerable population who needs to have also actions directed to mental health and against stigma. Besides, HIV-negative MSM may need a better understanding and access to alternative prevention strategies such as post-exposure and preexposure prophylaxis to HIV (Liu et al., 2008; Mimiaga, Case, Johnson, Safren, & Mayer, 2009) Limitations of this study include its convenience sample, which precludes generalizing the results. However, it is plausible that our results constitute factors associated with unprotected sexual practices among men with HIV/AIDS in Brazil, and they should be investigated in services providing HIV care. Besides, alcohol and drug consumption were measured with non-standardized instruments, and diagnostics of abuse or dependence cannot be inferred. Further studies are necessary in Brazil to address this question, especially among MSM. Despite such limitations, the study shows interesting particularities on the factors associated with unprotected sexual practices among MSW and MSM indicating that targeted strategies for prevention of HIV transmission need to be designed for these two groups.

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AIDS in Rio de Janeiro.

Combined antiretroviral therapy is now acknowledged for preventing new HIV infections, besides decreasing mortality and morbidity. However, in many La...
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