Condom use and reported diagnosis of STI in cisgender men, according to sexual orientation: an analysis based on the 2019 Brazilian National Health SurveyAbstract
This study investigated condom use and the reported diagnosis of sexually transmitted infections (STIs) in men, aged 18 to 59 years, according their sexual orientation, based on data from the 2019 Brazilian National Health Survey (NHS). A total of 30,512 subjects were analyzed. Crude and adjusted Poisson regression models, with robust variance, were used to investigate the association between sexual orientation and condom use in the last 12 months and, during the last sexual encounter, as well as the reported diagnosis of STIs. Although in crude analyses, homosexual and bisexual men reported more condom use in the last 12 months and during the most recent sexual encounter, after adjusting for the variable of living with a partner in the models, these associations lost statistical significance. The reported STI diagnosis, however, remained more prevalent in homosexual and bisexual men, even after adjustments (aPR 4.69; 95% CI 2.76-7.99). Public policies for STI/HIV/AIDS prevention should shift from a logic of risky practices to the analysis of a broader context, including different types of relationships, their temporalities, and negotiations.
Keywords:
sexual and gender minorities; condoms; sexually transmitted diseases; men’s health
Resumo
Este estudo investigou o uso de preservativo e o relato de diagnóstico de infecções sexualmente transmissíveis (IST) em homens de 18 a 59 anos, segundo orientação sexual, a partir dos dados da Pesquisa Nacional de Saúde 2019. Foram analisados 30.512 sujeitos. Modelos de regressão de Poisson, com variância robusta, brutos e ajustados foram utilizados para investigar a associação entre orientação sexual e uso de preservativo nos últimos 12 meses e, na última relação, e o relato de diagnóstico de IST. Embora nas análises brutas homens homo e bissexuais fizessem mais uso de camisinha, nos últimos 12 meses e na última relação sexual, após ajuste para a variável morar com companheiro/a, essas associações perderam significância estatística. O relato de diagnóstico de IST, no entanto, manteve-se mais prevalente em homo e bissexuais, mesmo após ajustes (aRP 4,69; IC95% 2,76-7,99). As políticas públicas de prevenção de IST/HIV/Aids devem passar de uma lógica de práticas de risco para a análise de um contexto mais amplo, que inclua os diferentes tipos de relacionamento, suas temporalidades e negociações.
Palavras-chave:
minorias sexuais e de gênero; preservativos; infecções sexualmente transmissíveis; saúde do homem
Resumen
Este estudio investigó el uso de condón y el diagnóstico reportado de infecciones de transmisión sexual (ITS) en hombres de 18 a 59 años, según orientación sexual, con base en datos de la Encuesta Nacional de Salud de 2019. Se analizaron 30.512 sujetos. Se utilizaron modelos de regresión de Poisson con, varianza, robusta y ajustada para investigar la asociación entre la orientación sexual y el uso del condón en los últimos 12 meses y, en la última relación, y el reporte del diagnóstico de ITS. Aunque en los análisis crudos los hombres homo y bisexuales usaron más condón en los últimos 12 meses y en la última relación sexual, estas asociaciones perdieron significación estadística después del ajuste por la variable convivencia. Sin embargo, el diagnóstico informado de ITS siguió siendo más prevalente en hombres homosexuales y bisexuales, incluso después de los ajustes (aRP 4,69; IC 95% 2,76-7,99). Las políticas públicas de prevención de ITS/VIH/SIDA deben transitar de una lógica de prácticas de riesgo al análisis de un contexto más amplio, que incluya diferentes tipos de relaciones, sus temporalidades y negociaciones.
Palabras clave:
Minorías sexuales y de género; Condones; Infecciones de transmisión sexual; la salud de los hombres
Introduction
Historically, prevention actions against HIV/AIDS and other sexually transmitted infections (STIs) have focused primarily on men who identify themselves as homosexual, bisexual and other men who have sex with men (MSM)1. In 2022, this population accounted for 55.3% of all new sexually transmitted HIV/AIDS infections in men1 and, in 2016, had a much higher prevalence of syphilis than that reported in the general population2. Those who identify as heterosexual, as they are not understood as a key population, were thus subsumed into the “general population” category, for which there are no specific prevention policies and actions3. However, in 2022, they accounted for 27.7% of all new cases of HIV/AIDS1.
The more frequent diagnosis of STI/HIV/AIDS by homosexual/bisexual men, as well as the invisibility of heterosexuals in prevention policies and actions, contrast with what the literature has been indicating about condom use. Although studies investigating condom use by homosexual/bisexual men and heterosexual men use very different methodologies, which limits their comparability, they have indicated that homosexual/bisexual men use condoms more and more consistently than do heterosexual men4-7, especially when in relationships with other men8 (in the case of men who have sex with men and women). However, this use varies according to the type of partnership (which is more frequent with commercial partners9 than with casual10 and steady4,8 partners, respectively) and the type of practice evaluated (more frequent in vaginal than in anal sex11 and more frequent in insertive than in receptive anal intercourse8,12).
It is worth noting that most studies on the occurrence of STIs/HIV/AIDS and condom use conducted with homosexual and bisexual men in Brazil are restricted to convenience samples8,13 or probabilistic samples with limited potential for generalization6,9,10,14,15. There are few studies designed with methodologies that allow for comparisons between homosexual/bisexual men and heterosexual men4,16,17. And those that collect data on sexual orientation are even scarcer (most investigate sexual practices, using the MSM category18). In this sense, the 2019 National Health Survey (NHS 2019) is the only survey with a representative sample of the Brazilian population that has investigated sexual orientation17,19,20. This study, therefore, aimed to investigate condom use and reported STI diagnoses in cisgender men, aged 18 to 59 years, according to sexual orientation, comparing homosexual/bisexual men with heterosexual men, based on data from the 2019 NHS.
Methods
Study population and sampling
This work was a cross-sectional study using data from the 2019 NHS, a population-based survey conducted by the Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics (IBGE). The respondent population consisted of adults, aged 18 years or over, living in urban or rural areas, excluding special census tracts or those with a low population19.
The cluster sampling plan was divided into three stages: 1) the primary sampling units (unidades primárias de amostragem - UPA) were the census tracts or composition of tracts, selected by simple random sampling, maintaining the stratification of the National Household Sample Survey (Pesquisa Nacional de Amostra por Domicílio - PNAD); 2) a fixed number of permanent private households was selected in each UPA; 3) a resident (aged 15 years or over) was selected with equiprobability from the list of eligible residents to respond to the individual interview. Details on the sampling are available in Stopa et al., 202019.
The interview process involved interviewers, supervisors, and coordinators trained by IBGE, between August 2019 and March 2020. The interviews were conducted using mobile collection devices. Upon arriving at the selected household and explaining the study objectives to the residents, the interviewer filled out a list of all individuals residing in the household, regardless of whether or not they agreed to participate in the research; identified the resident who would provide information on the household questionnaires and on all residents of the household; and randomly selected one resident, aged 15 years or over, to respond to the individual interview (to be scheduled)19.
In the 2019 NHS, 108,525 households were visited and 94,114 individual interviews were conducted, with a non-response rate of 6.4%. Those selected between 15 and 17 years of age did not answer the questions contained in the “Sexual activity” module (n=2,317). Those who refused to respond to the individual interviews (n=1,189), those selected who could not be found (n=1,664), and those to whom the questionnaire was not applicable (n=412) were excluded from this analysis. Only men were included (n=41,662). Due to the lack of detail, those with any other orientation (n=16), those who did not know their sexual orientation (n=358), and those who refused to answer this question (n=757) were excluded. Thus, of the 40,531 men who declared themselves heterosexual, homosexual, or bisexual, 30,512 were between 18 and 59 years of age. Of this total, 423 had not had sexual relations up until the time of the interview, resulting in a final analysis of 30,089 people (Figure 1).
Answer variables
The frequency of condom use in the last 12 months was assessed by asking the question “In the last twelve months, when you had sexual relations, how often did you use a condom?”, whose response options were always, sometimes, never, refused to answer, and not applicable. A total of 27,063 men responded to this question (of the 30,089 analyzed, 29,206 answered the question about having had relations in the last 12 months, 1,872 were excluded because they had not had relations in the last 12 months, and 271 because they did not know/did not remember). For the analysis of association with the explanatory variable, this variable was recategorized as sometimes/none (characterizing inconsistent condom use) and always (consistent use of the input). Condom use during the last sexual intercourse in the last 12 months was assessed by the question “During the most recent sexual intercourse you had in the last twelve months, did you use a male or female condom?”, whose response options were male condom, female condom, did not use any, does not know/does not remember, refused to answer, and not applicable. In this case, male condom and female condom were grouped into the “yes” answer, while “did not use any” remained as the “no” category; the other answers were considered missing. A total of 12,494 subjects answered this question (that is, of the 27,063 who answered the previous question, 14,569 were excluded because they had not used a condom at all in the last year).
Finally, the reported STI diagnosis was assessed using the question “In the last 12 months, has a doctor diagnosed you with a sexually transmitted disease/infection?”, the answer options for which were yes, no and not applicable. To this question, 30,512 men responded (including those who had not had sexual intercourse in the last 12 months). Absences, refusals, and non-responses were treated as losses and subjects in these categories were excluded from the analyses.
Explicative variable
Information on sexual orientation was collected through the question “What is your sexual orientation?” The spontaneous response was then categorized by the interviewer as: heterosexual, homosexual, bisexual, other (specify). If there was no spontaneous response, the options were read aloud, followed, if necessary, by the meaning of each alternative, according to the information in the manual and research training.
Covariables
In addition to sexual orientation, other explanatory variables were analyzed, such as age (mean and age range, categorized as 18-29 years, 30-44 years, and 45-59 years); self-reported race/skin color (white, black, yellow, brown, Indigenous); living with a partner (yes and no); education (incomplete elementary school or equivalent, complete elementary school/incomplete high school or equivalent, complete high school/incomplete higher education or equivalent, complete higher education/postgraduate studies); sexual violence, through the question of whether or not they had ever been threatened or forced to have sexual relations or any other sexual acts against their will (yes and no); health status (very good/good and fair/poor/very poor); and when they last saw a doctor (up to one year, more than one up to three years, more than three years).
Statistical analysis
Descriptive analysis was stratified by sexual orientation, and all data were presented as relative frequency and 95% confidence interval (95% CI), considering the sample design and weights. For categorical variables, differences between groups were assessed by the chi-square test. Age was additionally described as mean and 95% CI, and differences between groups were assessed by Student’s t-test (Tables 1 and 2).
A Poisson regression model with unadjusted robust variance was used to assess the association between sexual orientation and each response variable: condom use in sexual intercourse in the last 12 months, condom use in the last sexual intercourse in the last 12 months, and reported STI diagnosis in the last 12 months (model 1). Sequential adjustments were made for age and race/skin color (model 2); cohabitation, education, and sexual violence (model 3); and health status and use of health services (model 4). The results were expressed as Prevalence Ratio (PR) and 95% CI. The analyses were performed using the survey command from the Stata 16.0 software (Stata Corporation, College Station, TX), and considered the effects of complex sampling and sampling weights.
Ethical aspects
The 2019 NHS was approved by the National Research Ethics Commission (CONEP)/National Health Council (CNS), logged under opinion no. 3,529,376, dated 08/23/2019. All procedures followed the recommendations of CNS Resolution 466 of 2012, and consent was obtained before each interview.
Results
Homosexual and bisexual men were younger (55.5% were between 18 and 29 years of age, the same situation as 28.0% of heterosexual men; mean age 31.0 vs. 38.1 years); lived less frequently with a partner (22.6% vs. 67.1%); had higher education (69.6% had completed high school or more, compared to 35.6%); reported having suffered more sexual violence (6.5 % vs. 0.8%); and were in better health (81.5% vs. 23.3%) than heterosexual men. There were no statistically significant differences between groups regarding race/skin color and time since the last medical consultation (Table 1).
Always using a bed in the last 12 months (56.3% vs. 25.7%) and having used it in the last intercourse in the last 12 months (80.5% vs. 41.1%) was more common among homosexual/bisexual men when compared to heterosexual men. Having been diagnosed with an STI in the last 12 months (6.0% vs. 0.5%) was also more common (Table 2).
Table 3 shows that, in the crude analysis, being homosexual or bisexual was associated with always using a condom in the last 12 months (PR 1.78; 95% CI 1.58-2.01) and with having used this input in the last intercourse in the last 12 months (PR 1.66; 95% CI 1.53-1.81). These associations also remained after the inclusion of age and race/skin color in the models (model 2). However, in model 3 (for both response variables), the association became statistically insignificant after the introduction of the variable “lives with a partner” in the model. It is worth noting that, among those who identified themselves as homosexual and bisexual, 37.9% (95% CI 26.4%-51.0%) of those who lived with a partner and 62.4% (95% CI 53.1%-70.9%) of those who did not live with a partner used condoms consistently, the same situation as 13.4% (95% CI 12.6%-14.3%) and 57.0% (95% CI 54.9%-59.2%) of heterosexuals, respectively. The association between sexual orientation and reported STI diagnosis remained significant even after adjustments, with homosexual and bisexual men showing a higher prevalence of reported STI diagnosis in the last year than heterosexual men (crude model: PR 8.88; 95% CI 5.54-14.24; model 4: aPR 4.69; 95% CI 2.76-7.99).
Discussion
Our findings indicate that, in the 12 months preceding the 2019 NHS, homosexual and bisexual men, aged 18 to 59 years, used condoms more consistently, including at their last sexual intercourse, but also reported more STI diagnoses than heterosexual men in the same age group. Although the literature has consistently indicated more frequent and consistent condom use by homosexual and bisexual men than by heterosexual men4-7,17, our results show that, after adjusting for cohabitation with a partner, the difference in condom use between the two groups becomes statistically insignificant. In other words, the greater condom use among homosexual and bisexual men is partially explained by the fact that they live less frequently with a partner when compared to heterosexual men.
Previous studies4,9,10,17,21 conducted with both men in general and MSMs indicate that condom use is less frequent in more stable and long-lasting relationships. According to the 2013 PCAP, among men in general, aged 15 to 64 years, who were sexually active in the 12 months prior to the survey, 44.6% used a condom during their last sexual intercourse, a percentage that reached 72.5% when the relationship was with a casual partner. Condom use in all relationships in the last 12 months prior to the survey with any type of partner was reported by only 27.5%, ranging from 22.1% for those with a steady partner to 60.9% for those with casual partners4. In the 2019 NHS, only 25% (95% CI 74.0-75.9%) of all men, in general, married or living together, used a condom in their last intercourse, the same situation as 73.1% (95% CI 71.5%-74.8%) of men who did not live together21. In the 2016 RDS MSM, in turn, while three-quarters of the interviewees used condoms consistently with commercial partners9, less than 50% used the input consistently with casual partners10.
In this context, it is important to consider that individuals, based on the collective learning of how to deal with STIs, manage their risk, trying to balance their needs and the risk of exposure22, without this necessarily meaning abandonment or disinterest in prevention23. Having sexual relations without using a condom with a partner when living together can symbolize greater commitment, intimacy, and emotional involvement of the partners in the relationship24. In the international literature, this non-use of condoms with a stable primary partner and its use with occasional partners has been called negotiated safety25. In addition, the dimension of pleasure and desire can also imply a less frequent use of condoms26. In this same sense, negotiations, changes, and intermittency are important in a certain risk management of sexual partnerships27, generating agreements and contracts that can usually be relevant in the use or not of condoms. The analysis of the length of the relationship, which could help in understanding this association between living together and condom use, is not available in the NHS.
Interventions and support groups to discuss the negotiation involved in condom use may be important to increase condom use26. Likewise, the use of biomedical and/or behavioral strategies, such as treatment as prevention, post-exposure prophylaxis, counseling and testing, and seroadaptation may be used as alternatives in risk management22,26,28.
Our findings also indicate that homosexual and bisexual men reported more STI diagnoses in the 12 months preceding the survey than did heterosexual men, which is consistent with the literature. In this sense, the 2013 PCAP indicated that 9.9% of all sexually active men, aged 15 to 64 years (regardless of sexual orientation), had some symptom that could indicate STI throughout their lives4. This contrasts with data from the 2016 RDS MSM, which indicated that nearly 20.0% of the MSM interviewed had some type of STI symptom in the year prior to the survey, and which pointed to a self-reported lifetime prevalence of STIs of 27.8%, with emphasis on syphilis (52.1%), HIV/AIDS (27.5%), and gonorrhea (23.4%)2. The comparison of surveys with different time periods (2013 and 2016), samples (representative population of Brazil and MSM from specific networks), and questions (STI symptoms in general vs. measured prevalence), such as the PCAP 2013 and the RDS MSM 2016 is an important limitation, due to the lack of national studies that investigate both groups simultaneously. Furthermore, in Brazil, it is worth noting that, although the HIV/AIDS epidemic has changed significantly over its course, it is still concentrated in groups with certain sexual practices, such as MSM29. Studies that analyzed the trajectory of the HIV/AIDS epidemic28 showed that stigma and prejudice are permanent factors, which are related to increased vulnerabilities and are linked to health care and risk management in sexual practices29.
This higher frequency of reported STI diagnoses in the final year prior to the survey may also be partially due to an overtesting of homosexual and bisexual men, since heterosexuals are invisible in policies and programs aimed at testing and preventing STIs/HIV/AIDS and do not perceive themselves as being at risk30. In this sense, a survey conducted in Campo Grande, Curitiba, and Florianópolis in 2019 indicated that more than 80% of MSM in the three cities had already tested for HIV throughout their lives and more than 50% of them had tested in the last year prior to the survey16. This contrasts with data from PCAP 2013, which indicate that, among sexually active men, aged 15 to 64 years (regardless of sexual orientation), only 27.3% had tested at least once in their lifetime4.
It is important to highlight some limitations of the present study. The way sexual orientation was surveyed in the NHS (by spontaneous self-declaration and recategorized by the interviewer as heterosexual, homosexual, bisexual, other (specify) and, in case of no response, reading of the alternatives followed by an explanation) may have resulted in an underreporting of homosexuals/bisexuals, reducing the magnitude of the observed association measures. Considering the high frequency of prejudice and discrimination in Brazilian society, these data should always be contextualized. In addition to sexual orientation, another variable that may have suffered information bias was the reporting of STI diagnosis (asked through the question “In the last 12 months, has a doctor diagnosed you with a sexually transmitted disease/infection?”). Besides being an unspecific question (making it impossible to investigate which STI it was), it restricted the response to only those who had a diagnosis provided by a doctor.
However, despite the limitations, our findings are important, as the NHS was the first national study with a representative sample of the adult population to investigate sexual orientation, and not sexual practices20. In the health area, the concept of MSM is commonly used, which, although it has historical importance, especially in the context of the shift in the focus of preventive actions from risk groups to risky behaviors, does not contemplate the diversity of gender identities and sexual orientations that it attempts to encompass, with their preventive behaviors and different prevalences of STI/HIV/AIDS, and reveals the centrality of sex and genitalia in the elaboration of public policies18.
Although it is essential to have public health policies that historically vulnerable target groups that have been excluded from the health system, such as gay and bisexual men, our findings indicate that STI/HIV/AIDS prevention strategies should be recontemplated in order to move from a logic of risky practices to the analysis of a broader context, which includes, for example, the different types of relationships, their temporalities, and negotiations. Considering the broader context, particularly the forms and types of relationships, the negotiations involved in them, and the timing of these negotiations, suggests a promising path for new research that can make the dynamic understanding of the growing rates of HIV and other STI infections among gay and bisexual men even more complex. With regard to consistent condom use among heterosexual men, our results reinforce what the literature has already indicated3, that the absence of public policies aimed at preventing STI/HIV/AIDS among this group reduces their opportunities for a timely diagnosis and makes them more exposed to the risk of new infections.
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