Inconsistent use of male condoms among HIV-negative men who have sex with other men

Objective: to analyze the factors associated with inconsistent use of male condoms among HIV-negative men who have sex with other men. Method: a cross-sectional, analytical and nationwide study conducted online in all the Brazilian regions in 2020, via networks and in dating websites. Inconsistent condom use was defined as occasional use or as never using it. Descriptive statistical analyses were performed, as well as association and binary logistic regression tests. Results: inconsistent condom use was reported by 1,222 (85%) of all 1,438 participants. The “homosexuals” (ORAdj: 2.03; 95% CI: 1.14-3.59; p=0.016), “having a fixed partner” (ORAdj: 2.19; 95% CI: 1.55-3.09; p<0.001), “oral sex” (ORAdj: 2.41; 95% CI: 1.31-4.43; p=0.005), “insertive anal” (ORAdj: 1.98; 95% CI: 1.10-3.58; p=0.023) and “STI diagnosis” (ORAdj: 1.59; 95% CI: 1.13-2.24; p=0.007) variables were independently associated with inconsistent use of male condoms. The “receiving advice on HIV test from a friend” (ORAdj: 0.71; 95% CI: 0.52-0.96; p=0.028) and “sex worker” (ORAdj: 0.26; 95% CI: 0.11-0.60; p=0.002) variables were protective factors. Conclusion: the variables under study pointed to a strong relationship between steady partners and increased trust and low adherence to condom use, corroborating other studies.


Introduction
Inconsistent use of male condoms is understood as occasionally or never using them in sexual relations (1) and is reported in the international literature as an important focus of prevention actions among Men who have Sex with other Men (MSMs), given the high risk of acquiring and transmitting the Human Immunodeficiency Virus (HIV) and other Sexually Transmitted Infections (STIs) (2) .
Despite the prevention efforts and scientific advances, particularly in recent decades, which have enabled increased availability and incorporation of prevention methods, MSMs are disproportionately affected by infection with HIV and other STIs (3)(4)(5)(6) . Consequently, use of male condoms is still a protagonist in the context of preventing HIV and other STIs in this specific population group. In addition, inconsistent condom use promotes a search for other preventive methods such as Post-Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP).
Intrinsic factors such as unplanned sexual practices and consumption of alcohol and other drugs, in addition to the relationship with the sex partner, delineate how the prevention methods are used (7) .
Advances in the prevention methods have added options to devise a broader prevention plan, which is known as combined prevention disclosed in campaigns promoted by the Brazilian Ministry of Health, which is the combination in the use of two or more methods (8) .
In addition to that, these advances seek to comply with what has been established by UNAIDS (United Nations Joint Program on HIV/AIDS) known as the 90 -90 -90 Goal, of which Brazil is a signatory and has signed commitments to diagnose, offer treatment and promote viral suppression of 90% of the population by 2030 (9)(10) .
The risk to acquire HIV is the result of a combination of socio-structural, behavioral and biological factors.
Despite the biomedical advances in terms of prevention, the number of new cases is increasing. The Latin American region presents profound and generalized inequalities that lead to social and structural barriers affecting access to health services, particularly among the key populations.
The new infection cases in this region have increased by 21% and 44% among gay individuals and other MSMs since 2010 (9) .
Brazil is a country with significant estimates regarding the epidemic by the HIV infection, with nearly 1.5 million AIDS cases notified up to the end of 2020 (1,11) . The epidemic in the country is concentrated in key populations (sex workers and their clientele, gay people and other men who have sex with men, drug users and trans individuals) (9) with HIV prevalence of 0.4% in the general population (12) and of 18.4% among MSMs (8) .
Consequently, MSMs are considered a priority for HIV prevention as a result of vulnerabilities for acquiring and transmitting the infection (13) .
MSMs represent a category of interest for research studies related to the prevention of HIV and other STIs and encompass an extremely wide range of sexual orientations and gender identities.
Sexual orientation and gender identity are considered as social determinants of health in the public policies.
Sexual orientation refers to the ability for emotional, affective or sexual attraction to people of the same gender, different genders or more than one type of gender. Currently, the visibility guidelines, even by the LGBTQIAP+ (Lesbian, Gay, Bisexual, Transvestite, Transgender, Transsexual, Queer or non-binary, Intersex, Asexual, Pansexual, and +, which corresponds to other denominations not included in the acronym) acronym, are as follows: asexual (a person who does not feel any sexual attraction regardless of the sex/gender of the other), bisexual (a person who relates to both sexes/ gender), gay (a cisgender or transgender male person who relates to other male people), heterosexual (a person who relates to other people of the gender opposite to their own), homosexual (a person who is attracted to people of the same sex/gender as their own), lesbian (a cis or trans person who relates to other cis or trans women), pansexual (people who develop attraction to other people's gender identity or sexual orientation) (14) .
Gender identity is a particular internal experience corresponding or not to the sex attributed at a person's birth, including self-perception of the body and gender expressions (way of dressing, behaviors, mannerisms, etc.). Some examples of gender identity are as follows: agender (a person who does not identify with or does not feel belonging to any gender), cisgender (people who are not transgender and identify in all respects with the gender assigned at birth), non-binary (people who consider malefemale binarism as limiting), transgender (people who transition between genders), transsexual (a person who has a different gender identity than the sex assigned at birth) and queer (people whose sexual orientation is not exclusively heterosexual and who question binarism) (14) . In turn, among the MSM population, in addition to the aspects linked to information and substance use (7) , living with more diverse sexual networks contributes to risky sexual behaviors such as multiple sexual partners and unprotected sex (7,16) . Unprotected anal sex is the greatest risk factor for sexual HIV transmission among MSMs (17) . Studies conducted with MSMs in low-, middleand high-income countries show high rates of unprotected anal sex (18) . However, risk exposure occurs when there is not a wider prevention plan with different methods, both biomedical and barrier.
When used consistently, male condoms offer very high protection against HIV and other STIs (16) . However, consistent use among MSMs is low and unsatisfactory for prevention (19)(20) . Although a number of Brazilian studies have documented inconsistent use of male condoms, they were conducted with very specific population groups, not including MSMs in a more direct way (1,21) . Consequently, there is lack of studies with national samples about factors associated with inconsistent use of male condoms among Brazilian MSMs. Given the above, the objective of this article was to analyze the factors associated with inconsistent use of male condoms among HIV-negative men who have sex with other men.

Study design
A cross-sectional, analytical and nationwide study conducted by means of online data collection in all the Brazilian regions, guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool (22) .

Data collection setting
Convenience sampling was used and data collection occurred by making the online questionnaire available in virtual environments such as Instagram, Facebook, Twitter, WhatsApp groups, Telegram and dating apps for MSMs.
The questionnaire was hosted in SurveyMonkey. All the Brazilian regions were reached by means of this strategy.

Period
The data were collected between April and May 2020.

Population
Men who have sex with other men from all the Brazilian regions were eligible for the study. This group includes people with different sexual orientations and gender identities, which allows greater scope to understand the variables under analysis.

Selection criteria
The participants should meet the established inclusion criteria to take part in the study: being aged 18 years or older, identifying themselves as males, having

Definition of the sample
The study was conducted in all the Brazilian regions by means of convenience sampling. In total, the online questionnaire was accessed 1,830 times and, after refining the database, a total of 1,438 MSMs were reached who met the inclusion criteria and answered the questionnaire in full.

Study variables
Descriptive statistics (frequency) were used to analyze the following variables: sociodemographic characterization: years of study; gender; sexual orientation; steady sexual partner; alcohol use; smoking; use of other drugs; multiple partners; most frequent sexual practice; history of HIV testing and counseling; sources of information on HIV prevention; previous diagnosis of Sexually Transmitted Infection; being a sex worker and PrEP use.
The dependent variable was "inconsistent condom use" and was assessed in a dichotomous way (Yes/No).
Inconsistent use was defined as the action of occasionally or never using condoms, in the form of an explanatory note in the upper part of the variable in the questionnaire (1) .

Instruments used for data collection
The questionnaire containing the study variables was divided into three parts: the first one contained the research title, the invitation to participate, the inclusion criteria and the Informed Consent Form with the following options: "I read the terms and I agree to take part in the research" and "I read the terms and I do not agree to take part in the research". The participants had access to the questionnaire if they selected the option agreeing to take part in the research and, if not, the invitation was closed and the SurveyMonkey platform directed access to a closing and thank you page. The second part of the questionnaire contained questions related to characterization of the sample and the third part was targeted to sexual behaviors.

Data treatment and analysis
Binary logistic regression analysis was used to assess the influence of the independent variables on inconsistent use of male condoms. For statistical significance, p<0.05 was considered for inclusion of the independent variables in the regression model, resorting to the "enter" model. In addition, the "bootstrapping" procedure was performed (considering 1,000 resamples from the existing sample; 95% Confidence Interval and Corrected and Accelerated Adjustment, CAA) (23) to adjust the model. The odds ratios were calculated: Unadjusted Odds Ratio (OR Unad ) and Adjusted Odds Ratio (OR Adj ). A 95% Confidence Interval and a 5% (α=0.05) significance level were considered. All the analyses were performed in the Statistical Package for the Social Sciences (SPSS) software, version 20.0.

Results
The study participants were 1,438 MSMs: 915 (63.6%) were aged between 18 and 28 years old, 1,156 (80,4%) had more than 11 years of study, 1,263 (87.8%) were cisgender and 1,190 (82.8%) were homosexuals. Regarding use of male condoms, it was observed that 1,222 (85%) reported inconsistent use. Table 1 shows the relationship of the characterization variables corresponding to the men who have sex with other men with inconsistent use of male condoms. This is the initial association before performing the regression model, which showed that, in the association of the variables, "years of study", "gender", "sexual orientation", "steady sex partner", "frequent sexual practice", "advice on HIV test from a friend", "STI diagnosis" and "sex worker" were those that resulted in statistically significant values (p-value<0.05) in relation to inconsistent use of male condoms among MSMs.

Discussion
This study identified that the factors associated according to data from the Brazilian Ministry of Health (24) .
Male condoms are still a relevant strategy incorporated in a broader prevention plan and encourage research studies on risk management and pleasure promotion (7,25) , as the method remains included in the group of preventive strategies used, combined prevention (26) .
Sexual orientation also exerted an influence on condom use. Preliminary results of a study presented at the International Congress on Health whose objective was to evaluate sexual habits and orientation in Brazilian men identified that 52.47% of the homosexual men reported that they did not use condoms in all their sexual relations (27) . The high risk for inconsistent condom use among homosexuals is already pointed out in other studies as a result of the decrease in the perception of risk by HIV due to the improvement in quality of life and other factors, such as the technological advances that favor access to platforms with specific content with unprotected sex images for MSMs (28) . Cultural advances on the concept of homosexuality, in addition to enabling more social acceptance, allowed it to be more evident in the public sphere; therefore, people who assume homosexual sexual practices are considered potential targets of preventive measures (29) .
Regarding steady partners and inconsistent condom use, a number of studies have already brought about the perception of unprotected sex in heterosexual relationships as a promoter of romance, trust and support for stability of the couple (27) . In addition, male condoms interfere with penile erection and with the perception of sexual pleasure, and there are reports of allergies to their material (30) . In turn, among MSMs, a Chinese study conducted with 343 participants found that more than 50% of the sexual intercourses were without condoms.
In the aforementioned study, it was also reported that trust and intimacy in the relationship with a steady partner were positively associated with having unprotected anal sex, representing important obstacles in the prevention of HIV infection (18) .
The results presented in the current study also indicated that the most frequent sexual practices associated with inconsistent condom use were oral sex and insertive anal sex, which corroborates the results of other studies (18,(28)(29)(30) . In fact, low adherence to consistent use of male condoms is pointed out as one of the main practices of vulnerabilities among the gay population and is justified by discomfort, decreased pleasure, lower perception of contracting HIV and lack of knowledge (31) .
It was also found that having been diagnosed with an STI was a factor associated with inconsistent use of male condoms. Therefore, despite the benefits of condom use, the MSM population does not seem to associate consistent use with protection against other infections (31) .
In relation to sex workers, knowledge about HIV and AIDS is substantial, even with difficulties accessing health services and vulnerabilities negotiating use in sexual relations (32) . Male sex work is wide in terms of possibilities and condom use can be subjected to bargaining and changes in the prices of services, with consequent influences on health care (33) . Although in this study variables such as alcohol use, drug use and having accessed information in printed materials and on the Internet were not statistically significant, they variables pointed out in other studies as related to inconsistent condom use (28) . Therefore, they need to be interpreted carefully because they influence adherence to the prevention practices.
This study presented results referring to a specific group with regard to sexual orientations. Reported by most of the interviewees, homosexuality confers health professionals the responsibility of improving contact with MSMs, reducing the likely manifestations of possible sexual preconceptions. Targeted educational interventions encourage improvements in prevention according to the sexual behavior of a given population (35) . When analyzing the factors associated with inconsistent condom use by Brazilian MSMs, the need for health care directed to sexual health is evidenced. The probable lack of training in some regions can curb complete and equitable care anamnesis (36) .

Conclusion
The variable under study pointed to a strong relationship between steady partners and increased trust