Abstract
Hispanic immigrant/migrant men who have sex with men (MSM) should be at higher risk for sexually transmitted infections/human immunodeficiency virus (STIs/HIV) given individual-level factors associated with the migration process that have been theorised to increase susceptibility to STIs/HIV among migrant populations. However, relatively little is known if these individual level factors are actually associated with the STI prevalence among this population. During 2005–2007, 2576 men and women foreign-born Hispanics were surveyed at three community-based organisations offering services to immigrant/migrant communities in the US. We analysed demographic characteristics, sexual risk behaviours, migration patterns, and factors associated with STI diagnoses (syphilis, chlamydia, and gonorrhoea) in the past 12 months among Hispanic immigrant/migrant MSM. Of 1482 Hispanic immigrant/migrant men surveyed who reported having sex in the past 12 months, 353 (24%) reported sex with a man, and of these, 302 answered questions regarding whether or not they had been diagnosed with a bacterial STI in the past year. Of these 302 men, 25% reported being married; 42% self-identified as being heterosexual and 20% as bisexual. Twenty-nine (9.6%) men reported that they had received an STI diagnosis in the past year. In the multivariate logistic regression model, men who reported receiving money or goods for sex had increased odds of a self-reported STI diagnosis. The prevalence of bacterial STIs among Hispanic immigrant/migrant MSM is lower than the prevalence of bacterial STIs among other MSM in the United States. Nevertheless, receiving money or goods for sex was significantly associated with a self-reported STI diagnosis among Hispanic immigrant/migrant MSM. It is important to understand factors contributing to participation in exchange sex among this population. HIV/STI prevention interventions tailored to non-gay identifying MSM are important for Hispanic immigrant/migrant MSM.
Background
Bacterial sexually transmitted infections (STIs) such as syphilis, chlamydia, and gonorrhoea can pose serious health complications and in some cases be life threatening. Infection with each of these bacterial STIs has been identified as a risk factor for infection with the human immunodeficiency virus (HIV).1,2 Reducing the negative impact of these STIs in communities nationwide is an objective of public health partners at the national, state, and local levels. Certain populations are disproportionately affected by STIs. In 2014, the Centers for Disease Control and Prevention (CDC) published that reported rates of syphilis, chlamydia, and gonorrhoea among Hispanics were all twice as high as among non-Hispanic white ethnicities. 3
Hispanic immigrants (those permanently relocating to the United States [US]) and migrants (those in the US temporarily) account for 53% of the total Hispanic adult population in the US 4 and 6.5% of the total US population. 5 There are no national estimates of bacterial STI diagnoses for Hispanic immigrants, but studies among Hispanic immigrant men in the US in the last 10 years have reported a prevalence of syphilis infection ranging from 0% to 2%,6–10 prevalence of chlamydia infection ranging from 1.2% to 3.5%,6,7,9–11 and prevalence of gonorrhoea infection ranging from 0% to 0.5%.6,9–11 Risk factors associated with a bacterial STI identified in these studies have been few because of the low number of participants diagnosed with an STI. However, Brammeier et al. 9 reported that the majority of participants in their study did not use any methods to protect themselves against STIs, Rhodes et al. 8 reported low levels of STIs/HIV knowledge among participants, and Kissinger et al. 6 reported that all participants in their study diagnosed with chlamydia reported inconsistent condom use.
Estimates of the prevalence of STIs among Hispanic immigrant/migrant men who have sex with men (MSM) are not currently available even though MSM in general and Hispanic MSM in particular have been substantially affected by some bacterial STIs. 3 The exposure to at least one of these bacterial STIs (syphilis) has been highly associated with HIV infection among MSM nationwide. 12 Hispanic immigrant/migrant MSM should be at a higher risk for STI/HIV infection than other MSM populations in the US given individual-level factors associated with the migration process theorised to increase susceptibility to STI/HIV infections among migrant populations. 13 These individual-level factors include lack of personal resources to cope with continuous stressful changes due to migration, as well as behavioural factors such as the lack of use of HIV prevention services because of economic or psychosocial barriers, and increased levels of unsafe sexual behaviours due to disruption of pre-existing sexual networks. Yet, relatively little is known as to whether these or other individual-level factors associated with the migration process are actually associated with STI infections among Hispanic immigrant/migrant MSM, making it challenging to develop STI/HIV prevention interventions targeting this population.
The purpose of this analysis is to report migration practices, use of HIV testing services, and sexual risk behaviours among Hispanic immigrant/migrant MSM and examine the associations between these individual-level factors and infection with a self-reported bacterial STIs among a sample of Hispanic immigrant/migrant MSM recruited from five US states.
Methods
CDC’s 2003 Advancing HIV Prevention (AHP) initiative was conceived to reduce barriers to early HIV diagnosis and increase participation in HIV-related services by racial/ethnic minorities and hard-to-reach populations by funding a series of demonstration projects. 14 Methods of the demonstration project targeting migrants and recent immigrant communities have been reported elsewhere, 15 but briefly, the demonstration project to reach migrants and recent immigrants was intended to reduce the barriers to early HIV diagnosis by funding three community-based organisations (CBOs) to conduct rapid HIV testing among these populations between March 2005 and February 2007 in five US states (Georgia, Connecticut, Wisconsin, Minnesota, and South Dakota).
Recruitment efforts took place in a range of non-traditional outreach settings, with recruitment strategies which included focusing on clients currently utilising the services of the CBO, outreach to a range of settings frequented by the intended population, and partnerships with existing clinical sites that served migrants and recent immigrants. Persons who agreed to HIV testing were asked to participate in a face-to-face survey conducted by trained outreach workers that collected information in Spanish or English on participants’ socio-demographic characteristics, immigration history, past HIV/STI risk behaviours, and history of bacterial STIs diagnosis. Ultimately, 2576 men and women who identified as foreign-born Hispanic migrants and recent immigrants were surveyed. All participants provided written informed consent for HIV testing as required by state and local laws. This demonstration project was determined by CDC to be a public health program activity and review by CDC’s Institutional Review Board was not required.
For this analysis our sample was restricted to foreign-born Hispanic migrant and recent immigrant MSM who reported having sex with a man in the preceding 12 months, and reported whether or not they received in the past 12 months a diagnosis of a bacterial STI (syphilis, chlamydia, and/or gonorrhoea) by a medical provider. MSM who reported having sex with a man in the preceding 12 months and also reported sex with women were also included in the analysis.
Outcome variable
To assess bacterial STI diagnosis, our analysis focused on participants’ responses to the question: In the past 12 months, has a doctor, nurse, or other health care provider told you that you had any of the following sexually transmitted diseases (STDs)? For this analysis, a self-reported bacterial STI diagnosis was defined as a diagnosis of syphilis, chlamydia, or gonorrhoea. A single variable (yes/no) was created that captured whether a participant had received a diagnosis of at least one of these three bacterial STIs.
Covariates
Socio-demographic, migration-related, and HIV/STI risk factors were included in the bivariate analyses. Socio-demographic factors included: age (14–25, 26–35, 36–45, 46 and over), education (less than high school, high school, more than high school), marital status (married, divorced/widowed/separated, single), country/region of birth (Mexico, Central America, South America), spoken English language fluency (very well/well, not well/not at all), and sexual orientation (heterosexual, bisexual, homosexual/gay).
Migration-related factors included: state where participant was recruited for the interview (GA, CT, WI, MN, SD), length of time since arriving in the US (less than five years, five to 10 years, more than 10 years), number of moves for work in the past two years (0, 1, 2 or more), and reasons for migration based on where men intended to live long-term. Men who intended to return to their country of origin or another country to reside permanently were defined as labor migrants (or migrants); men who intended to stay in the US to reside permanently were defined as immigrants. This classification of migrants and immigrants is not based on legal status in the US but has been used by other researchers to look at multilevel determinants affecting HIV/STI risk among labor migrants throughout the world. 16
Finally, HIV/STI risk behaviours reported by men during the past 12 months selected for the analysis included: the number of sexual partners for vaginal or anal sex (1, 2–5, 6–10, more than 10); sex while high on drugs or alcohol (yes/no); receptive unprotected (without a condom) anal intercourse in the past 12 months (yes/no); sex with anonymous partner in the past 12 months (yes/no); gave someone money or goods for sex in the past 12 months (yes/no); received money or goods in exchange for sex in the past 12 months (yes/no); and previous HIV test (never tested, tested past 12 months, tested more than 12 months ago).
Analysis
Bivariate analyses were performed using Chi square or Fisher’s exact test (when the expected value in any of the cells was below 10). Factors associated at p < 0.10 with a self-reported bacterial STI diagnosis in the past 12 months in bivariate analyses were included in a multivariate logistic regression model. The final multivariate logistic regression model included all variables that were adjusted for in the model, and estimated adjusted odds ratios (aOR) for all variables in the model, including 95% confidence intervals (CI) for these variables. Data were analysed using SAS software version 9.2 (SAS Corporation, Cary, NC).
Results
Of 1482 Hispanic immigrant/migrant men surveyed who reported having sex in the past 12 months, 353 (24%) reported sex with a man. Of these, 302 men answered questions regarding whether or not they had been diagnosed with a bacterial STI (syphilis, chlamydia, or gonorrhoea) in the past 12 months.
Of these 302 Hispanic immigrant/migrant MSM, 38% were younger than 26 years of age, 75% had less than a high school diploma, 83% reported not speaking English well or at all, 25% reported being married, 42% self-identified as being heterosexual, and 20% self-identified as bisexual.
Seventy-nine percent of these participants reported being born in Mexico, 57% reported having arrived in the US less than five years previously, 45% had moved or migrated more than once in the past two years because of work, and 83% were classified as migrants (i.e. intended to return to their countries of origin to live long-term).
Demographic, migration, and sex risk characteristics associated with a self-reported bacterial STI diagnosis among Hispanic migrant men who had sex with other men in the past 12 months, Georgia, Connecticut, Wisconsin, Minnesota, and South Dakota, 2005–2007.
p < 0.10.
CBO, community-based organisation. Totals may not add to 100% due to missing values.
Twenty-nine participants (9.6%) reported that they received a bacterial STI diagnosis in the past year. Three men (1%) reported receiving a syphilis diagnosis, 21 men (7%) reported receiving a diagnosis of gonorrhoea, and six men (2%) reported receiving a diagnosis of chlamydia (one man reported being diagnosed with both gonorrhoea and syphilis). Only 38% of participants reported ever testing for HIV.
Bivariate analyses
In bivariate analyses, only marital status, number of sexual partners in the past 12 months, and receiving money or goods for sex were significantly associated at p < 0.10 with reporting a bacterial STI diagnosis (Table 1).
Multivariate analysis
Multivariate logistic regression model assessing risk factors for a self-reported bacterial STI diagnosis among Hispanic migrant men who had sex with other men in the past 12 months, Georgia, Connecticut, Wisconsin, Minnesota, and South Dakota, 2005–2007.
aOR: adjusted odds ratio; CI: confidence interval; STI: sexually transmitted infection.
Only variables associated at p < 0.10 with the outcome variable in the bivariate analyses were entered in the multivariate logistic regression model.
Syphilis, gonorrhoea, and/or chlamydia
Discussion
Findings from our sample of Hispanic immigrant/migrant MSM in five states indicate that self-report of a diagnosis of a bacterial STI infection in the previous 12 months by a medical provider was associated with receiving money or goods for sex. Almost 10% of participants reported a diagnosis of a bacterial STI infection in the previous 12 months. No significant difference in self-report of a diagnosis of a bacterial STI infection in the previous 12 months was noted between immigrant and migrant men.
Project activities took place in states not considered to be the traditional states in which Hispanic immigrants have settled over the years (e.g. California, New Mexico, Florida, Arizona, etc.), but as noted by some researchers, migration patterns among Hispanic immigrants have changed in the past decade. States like Georgia, where the majority of our participants were recruited, are now considered ‘rapid growth states’ in terms of Hispanic migration.17,18 Among our sample of Hispanic immigrant/migrant MSM living in Georgia and the four other states included in this analysis, the prevalence of self-reported bacterial STIs ranged from 1% (syphilis) to 7% (gonorrhoea), similar to or slightly higher than what has been reported in previous studies among other Hispanic migrant men,6–10 but much higher than what has been reported for Hispanic men in general. Yet, as high as this prevalence is, it is lower than the prevalence of bacterial STIs among MSM in the US reported by CDC from data from several STI clinics across the nation. 3 This difference indicates a window of opportunity to reach Hispanic immigrant/migrant MSM living in these ‘rapid growth states’ with STI/HIV testing and prevention initiatives that are culturally and linguistically appropriate. Considering that a significant number of these men reported multiple sexual partners as well as sexual risk behaviours such as unprotected receptive anal sex and sex in exchange for money or goods that may place them at risk for STIs and HIV, focusing efforts on developing effective campaigns for these men may protect them from the STI and HIV epidemics that have occurred among MSM in other parts of the country.3,12 Adding to the urgency of this effort is that a majority of these men reported that they had never been tested for HIV, highlighting their low perception of risk and the absence of effective HIV/STI testing and prevention campaigns directed towards this population.
Receiving money or goods for sex in the past 12 months was significantly associated with a self-reported STI diagnosis in the past year, controlling for other factors such as marital status and number of sexual partners. Although several studies have reported that exchanging money or goods for sex with a female sex worker is a common HIV/STI risk behaviour among Hispanic immigrant/migrant men,6–8,19–22 far fewer studies have reported the risks associated with Hispanic immigrant/migrant men receiving money or goods for sex. Denner and colleagues 23 reported that 39% of the migrant and marginally housed men in their study who reported sex with other men also reported engaging in sex work. Galvan and colleagues 24 reported that among their sample of 450 Hispanic day laborers in Los Angeles, California, 171 (38%) reported being solicited for sex by another man while seeking work, and of those solicited, 9.4% had sex with their solicitors. Although our survey did not ask participants why they engaged in sexual activities with other men in exchange for money of goods, Galvan reported that 88% of men in their sample who agreed to having sex after being solicited, did so due to economic need, and/or drug dependency. In another study exploring structural level factors shaping high-risk behaviours that could lead to HIV infection among Mexican migrants, Sanchez and colleagues 7 reported that among Mexican migrant men in their study there was an increase after migration in the odds of exchanging sex for money, food, shelter, protection, and drugs. Furthermore, Sanchez noted that in the absence of effective interventions targeting this population, there could be an increase in HIV cases among Hispanic immigrant/migrant men in future years that could impact both sides of the United States/Mexico border. Given the association reported in our current analysis between exchanging sex for money or goods and a self-reported STI diagnosis among Hispanic immigrant/migrant MSM, more work is needed to understand additional individual and structural factors contributing to participation in exchange sex among this population.
Our analysis also indicated that a majority (62%) of the men who reported having sex with other men did not self-identify as homosexual/gay (42% self-identified as heterosexual and 20% as bisexual). Other studies have noted this discrepancy between self-reported sexual orientation and sexual behaviour among Hispanic men. Zellner and colleagues 25 reported that among the 80 participants in their sample of Hispanic men who reported lifetime history of anal intercourse with a male partner, 38% identified as heterosexual, 18% identified as bisexual, and 40% identified as gay MSM. Furthermore, Zellner reported that Hispanic heterosexual men who reported sex with both men and women were more likely to report a history of STIs. Galvan and colleagues 24 reported that of the men who reported receiving money or goods for sex in their study, 75% and 19%, respectively, identified themselves as heterosexual and bisexual (none identified as gay). STI/HIV prevention interventions tailored to non-gay identified MSM are important for the Hispanic immigrant/migrant male population.
Prevention efforts should focus on reaching Hispanic immigrant/migrant MSM at venues where they feel comfortable interacting with health care professionals. Recruitment strategies used by the demonstration project were highly effective in reaching this hidden population and included recruiting men at CBOs providing services to Hispanic immigrants, outreach in a range of settings frequented by the target population, and partnerships with existing clinical sites that serve migrants and recent immigrants. Sanchez and colleagues 7 utilised venue-based sampling to select sites at which to enroll participants for their study, while Galvan and colleagues 24 utilised the internet to select sites that specifically discussed where to find Latino day laborers for potential sexual encounters.
Limitations
Our findings are subject to at least four limitations: first, men in our study were not randomly selected but were recruited from a small number of CBOs in states that are not among those states where the majority of Hispanics settle. This recruitment strategy underscores that our findings are not representative of all Hispanic immigrant/migrant MSM in either the US or the states in which the demonstration project was conducted. Additionally, data were self-reported by participants and may be subject to social desirability and/or recall bias. That the data are self-reported is particularly important to take into consideration when interpreting self-reported STI diagnosis frequency reported in our study. Nonetheless, studies that have assessed self-reports of gonorrhoea, chlamydia, and syphilis infection history have found self-reports to have high reliability, excellent specificity, and moderate sensitivity.26,27 Data were collected 8–10 years ago meaning that frequency of STIs, HIV testing, and migration patterns may have changed since then. Finally, data in this analysis are cross sectional so no causal inference can be made from the study findings.
Our analysis contributes to understanding the HIV/STI risks that Hispanic immigrants and migrants face by describing the prevalence of self-reported bacterial STIs and examining individual-level factors associated with self-reported bacterial STI diagnoses in sexually active Hispanic immigrant/migrant MSM. With high rates of HIV/STI diagnoses among MSM in the US, the comparatively low levels of bacterial STIs reported by participants in our study indicate a window of opportunity to intervene with this population. Yet, previous analysis in the US indicates that immigrant populations are more than likely infected with HIV after immigration, 28 making the need for intervening with Hispanic immigrant/migrant MSM more urgent. The fact that a significant proportion of these men do not identify themselves as homosexual/gay poses a challenge for designing interventions that address the specific individual and structural-level factors that place these men at risk. This also highlights the importance of clarifying the relationship between sexual self-identity and potential risk behaviours in order to incorporate these insights into approaches for preventing HIV/STI infection among Hispanic immigrants and migrants.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.