Researchers from various academic fields have studied different life aspects of men who have sex with men (MSM) in the last decades. Arguably, their health issues are the most analysed, mainly because of their role in the AIDS epidemic history, which revealed not only its trigger HIV but also other opportunistic infections virtually unknown before. Nonetheless, their behaviours or attitudes are also of academic interest, particularly those that have health impacts, like adherence to therapies.Brazil, a country with almost 214 million people, has Latin American’s largest lesbian, gay, bisexual, transgender, queer and more (LGBTQ+) community with around 18 million people, of which several millions are men that have sex with men. This makes the biggest Portuguese speaking country, not only a nation where LGBTQ+ issues are socially relevant, but also a place that is both an interesting site to do research on those groups and a proving ground for new therapies or innovative health interventions.
The third greatest Western Hemisphere nation has been a pioneer in Latin America’s HIV/AIDS policies for both treatment and prevention. It spearheaded human rights-based prevention programs centred on behavioural and structural interventions and free access to daily oral antiretroviral medications (ARV): tenofovir diphosphate disoproxil fumarate in addition to emtricitabine. The leading example is the national policy allowing the use of ARV by HIV- individuals belonging to groups with the highest number of HIV cases in the country: men who have sex with men; trans people; sex workers; HIV- and HIV+ couples; aiming to reduce their risk of HIV infection in what is called pre-exposure prophylaxis (PrEP). This policy was made possible, since May 2017, by the support the Brazilian Ministry of Health has given to projects on the acceptability and feasibility of PrEP use in the country, since 2013.
The first trial of PrEP among MSM and transgender women vulnerable to HIV under real-world conditions in the Brazilian public health system was a 48-week demonstration study that assessed PrEP delivery at three referral centres for HIV prevention and care: Oswaldo Cruz Foundation in Rio de Janeiro, São Paulo’s University and DST and AIDS Reference and Training Centre. The 450 participants involved between the 1st April 2014 and July 8th, 2016 showed PrEP effectiveness as long as good drug adherence is maintained and people do not start having riskier sex. The researchers, wishing to catalyse the rest of the region to implement PrEP, used the success of that study to start a new one in 2017 involving México and Peru: the ImPrEP Study, with 7500 subjects.
With the onset of the COVID-19 pandemic came the lockdowns and social isolation measures. Within this challenging circumstance, many activities became extremely difficult or impossible to occur. However, researchers saw the opportunity to study the potential consequences of such context on the sexual behaviour of MSM. Having the experience of building up LGBTQ+ cohorts the previous projects demanded to obtain useful data – finding a statistically relevant number of suitable participants among those groups can be hard – a team of Brazilian and Portuguese scientists, decided to use it, seeking to measure those effects.
The Portuguese Institute of Hygiene and Tropical Medicine (IHMT-NOVA), in partnership with the University of São Paulo (USP), structured a macro-project called «40tena» – from the Portuguese «quarentena», i.e. quarantine, the period of isolation imposed on those who have had contact with the virus – derived from the cohort «ImPrEP Brazil/Portugal». An online multicentre survey was set-up to be conducted in Portugal and Brazil, carrying out behavioural follow-ups of MSM in both countries. This cross-cultural cohort study, started in 2020, focuses on investigating issues related to sexually transmitted infections (STIs) and MSM and is carried out in all 26 Brazilian states and the Federal District and 15 of the 18 districts of Portugal. Due to the COVID-19 pandemic, questions regarding this subject were added to the original project to analyse the sexual behaviours of the studied population during the confinement periods.
One of the behaviours analysed was casual sex with partners outside their homes during the period of sheltering in place for the COVID-19 pandemic. With recruitment done in April 2020, through meeting apps and Facebook, the online survey amassed a sample of 2361 MSM, being 1651 (69.9%) from Brazil and 710 (30.1%) from Portugal. The appraisal showed the pandemic had not stopped most of the MSM sample (53.0%) from finding sexual partners, with continued high-risk sexual behaviours, which could increase the likelihood of being infected by the SARS-CoV-2.
The results were published in the Int. J. Environ. Res. Public Health 2021, 18(6), 3266; under the title:
«Casual Sex among Men Who Have Sex with Men (MSM) during the Period of Sheltering in Place to Prevent the Spread of COVID-19»
That team, comprised of Brazilian and Portuguese scientists, included two from GHTM:
Alvaro Francisco Lopes de Sousa, Inês Fronteira.
Meanwhile, the scientific team, using the same sample, went one-step further and decided to delve into the hidden world of chemical sex or sex under the influence of drugs, commonly called chemsex, an association between the words chemical and sex. For this practice, only 920 (38.9%) people were eligible, meaning: «reported engaging in chemsex practice»; being 777 (84.5%) from Brazil and 143 (15.5%) from Portugal. Their answers showed the practice of chemsex in Brazil (69.9%) was higher than in Portugal (30.1%) more than twice, and almost all of them (95%) had casual partners. Group sex was described by 31.4% and sex without a condom by 47.6%.
The research team, realising that chemsex probability was more than 50 times higher with casual encounters, hypothesised that such behaviour might be related to the following of PrEP and the adoption of supposedly protective measures for COVID-19, which gave to those individuals a false safety sense. In fact, PrEP users were more likely to be involved in chemsex, and a relevant amount of MSM (21.8%) even considered the former a defensive approach against SARS-Cov-2. Maybe surprisingly, checking for symptoms was also mentioned, in spite the fact that the overwhelming majority of infected people do not show any. Moreover, during the incubation time or the time after the end of visible disease signs it is possible to infect others. In addition, the statistics obtained confirmed the lack of adherence by MSM to policies restricting movements to enforce social distancing, following the general attitude of the Brazilian population despite being one of the top countries in terms of COVID-19 cases and deaths.
The findings show how important are compelling campaigns aiming MSM, in order to reduce health ignorance, namely in the sexual realm, and to enlighten them about healthy living habits.
The results were published in the Cadernos de Saúde Pública, 2020, 36(12); under the title:
«Chemsex practice among men who have sex with men (MSM) during social isolation from COVID-19: multicentric online survey»;
and the research team members belonging to GHTM were:
Álvaro Francisco Lopes de Sousa, Inês Fronteira, Jeremias Salomão Chone, Sónia Dias.
The research team conducted another survey in Portugal in May 2020, in the same 15 districts when the country was under restrictive sanitary measures – social distancing, isolation and mandatory quarantine – imposing home confinement and avoidance of any interactions with people outside one’s household bubble as much as possible. The cultural divergence from Brazil, both in terms of the Portuguese population’s attitudes towards movements’ limitation and chemsex practice, justified a separate analysis. Using internet social networks, dating apps and snowball sampling it was possible to enrol 1301 MSM for the survey.
The conclusions were parallel to those from Brazil, but with lower numbers:
- chemsex was acknowledged by 20.2% (n=263) of the participants, all of whom (n=263) reported casual sex;
- approximately 30% (n=356) of the participants used pre-exposure prophylaxis (PrEP/Truvada) against Human Immunodeficiency Vírus (HIV), with many believing it would also protect against COVID-19;
- group sex, with 2 or more people simultaneously, stood out as conferring a 28 times greater chance of engaging in chemsex;
- risky behaviours were also more common with chemsex;
- MSM checked for COVID-19 symptoms;
- negative tests gave a false sense of safety.
When comparing to a previous Portuguese survey, chemsex practice increased from 9.2% to 20.2%. Could this be caused because of the pandemic, as a way to «relax and escape from reality», or is it a trend, regardless?
The results of this groundbreaking study reveal that it is impossible to ignore the role of sexual and loving relationships and activities on the adherence to social distancing measures and the magnitude of the pandemic itself, especially among socially marginalised groups such as MSM. Therefore, governmental messages recommending preventive measures against the COVID-19 should explicitly target sexual behaviours and its consequences for the pandemic worsening.
The results were published in Revista Latino-Americana de Enfermagem, 29, under the title:
and the study GHTM’s authors were:
Ahmed Nabil Shaaban, Álvaro Francisco Lopes Sousa, Inês Fronteira, Jeremias Salomão Chone, Maria do Rosário Oliveira Martins.
The overwhelming majority of scientific studies is overlooked by the media. However, considering that the Brazilian LGBTQ+ community is one of World’s biggest, being its social situation a contentious matter, particularly under Bolsonaro Presidency, the string of studies mentioned above caught the attention of the «Folha de São Paulo» newspaper. Two journalists of Brazil’s most important newspaper wrote a piece with interviews to chemsex users and health professionals, which included Álvaro Francisco Lopes Sousa, PhD, responsible for the research. The article was published in 28 August 2021:
e.g. «Sex on drugs, chemsex attracts users and accumulates risks».
GHTM’S RESEARCHERS INVOLVED IN THE ABOVE STUDIES