Since the emergence of HIV and the AIDS pandemic, sex workers were considered a highly vulnerable group ¹ because of their high-risk exposure to acquire these infections compared to adult non-sex workers. ² Across the globe, approximately 8% of the newly HIV cases are reported among sex workers. ³ Of serious concern are male sex workers (MSW) who are at more HIV risk than female sex workers (FSW). Receptive anal intercourse and insertive anal intercourse are considerably at higher risk of HIV transmission than vaginal sex. ⁴ Further, MSW are greatly affected by other sexually transmitted infections (STIs). ^{5 – 7} In response to AIDS and the concurrent increase in HIV prevention research, numerous interventions that aimed at decreasing the risk of infection have been conducted to reduce the practice of condomless sex. ^{8 – 11} After decades, there is still a debate about the success of these interventions - while some authors claim that new infections are yet associated to an inconsistent use of condoms, ^{12 , 13} others argue that MSW are using them more regularly, for either insertive anal sex or receptive anal sex. ^{14 – 16}

A large number of sex workers in Europe are migrants who are living and working in disadvantaged circumstances, facing isolation and social exclusion. ^{17 – 19} Moreover, migrant sex workers are extremely exposed to HIV and STIs due to their overlapping risks ^{3 , 6 , 20} and structural inequalities that can create difficulties to use health services for HIV prevention, testing and treatment ^{17 , 21 , 22} in some European countries. For example, it has been reported that male street sex workers, in particular illegal migrants in Germany, have lack of access to health care services due to their socio-legal position. ²³ This is a significant aspect as non-European sex workers who are highly mobile in Europe ¹⁹ and are under different migration status, ²⁴ can be impacted by the legislation and internal policies of each country that determines their access to the health care services. ¹⁷ In the United Kingdom, an important proportion of the sex work population is represented by male migrant sex workers (MMSW) who mostly work indoors in London. ^{25 – 27} Reports show that they are mainly from Europe, Latin America and the Caribbean countries. ^{26 , 28} Epidemiological and qualitative research have demonstrated that these migrants utilize national health care services (NHS), including sexual health clinics. In this manner, they can be tested for HIV and other STIs, receive counselling, adequate information, and a provision of condoms and lubricants. ^{24 , 29} However, a study using national data demonstrated that although the use of sexual health clinics does not vary between British MSW and MMSW, the latter group seem to be more exposed to HIV and chlamydia infections. ²⁹

This paper explores the risk perception and condomless sex experiences of MMSW with commercial and non-commercial sexual partners, as discrepancies have been reported in the use of condom according to the type of sexual partner, ^{14 , 16 , 30 – 32} and the sexual role performed during the act. ²⁷ In this manner, this paper aims to contribute to lessons learnt and recommendations for future educational interventions for this highly vulnerable group. This paper is pertinent in an era when the role of behavioral interventions is evolving with the advent of efficient alternatives of prevention such as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Despite of the efficacy demonstrated by the PrEP scheme, it requires high adherence to the treatment, strict laboratory monitoring, ³³ and more importantly, the use of supplementary methods of prevention such as the use of condoms to further reduce the HIV risk, and specifically for protection against other STI; since PrEP only protects against HIV. ³⁴

This study has used the theory of planned behaviour to explore the risk perception and condomless sex experiences of 25 male migrant sex workers with commercial and non-commercial sexual partners. Unlike other research, ³⁹ the participants of this study knew the risks of HIV and other STIs, self-reported risk adverse, and consistently declared their position against condomless sex in their online adverts. However, despite their perception of safer sex as a norm and their intention of using condoms with clients, they revealed that condomless sex was a frequent practice. ^{40 – 42} In accordance with this, the participants exposed an unfavourable attitude towards condoms due to displeasure, concerns of losing clients that reject condoms, and issues affecting their sexual response and performance. The latter, not so often acknowledged, highlights the importance of male sexual arousal in this type of work. ⁴³ In addressing past events of condomless sex with clients, this study identified a perceived behavioural control among participants that made this high-risk decision based on signs of physical evidence for HIV and other STIs in clients, assessing client’s social and sexual risk characteristics, and performing sexual practices that they considered 'low risk', to lessen the risk of transmission. These practices, that indicate a self-protective behaviour, demonstrate the persistence of inaccurate information about HIV and other STIs. ^{15 , 44 – 47} In addition, this study identified factors that made the participants lose their perceived control and drove them to condomless anal sex. One of main factors was the use of recreational drugs with clients. ^{48 – 50} Authors describe the use of drugs with clients as a social aspect of their occupation, ⁵¹ while improving their performance. ⁵² Further, some argue that this is a difficult aspect to avoid with clients who are regular drug users. ⁴⁹ Another interlinked factor was feeling sexually attracted to clients that implied opting for personal pleasure over a professional perspective. ^{53 , 54} A third factor was the precarious situation that made participants to accept the financial reward offered by clients. ^{55 – 58} Similar to other studies, ^{55 , 58} physical domination and verbal violence perpetrated by clients was the other aspects facilitating condomless experience, which validates MSW's vulnerability regardless of the situation. ⁵⁹

Within the context of private life, this study found that differences in the perspective of condomless sex was related to the type of non-commercial sexual partner. As such, most of participants dismissed the use of condoms with formal partners as they were emotionally attached to these relationships. Participants also said that they agreed not to use condoms when they both were HIV negative and keep this practice strictly among themselves. Although condomless sex with formal partners was perceived as a safer practice, some participants had episodes of STIs that were associated to these sexual partners. Besides, it is worth noting that in line with other studies ^{43 , 60} few participants reported a consistent use of condoms with formal partners when they were HIV-serodiscordant. Regarding condomless sex practice with casual sexual partners, participants said that it was more frequent with these sexual partners than with their clients. They connected this practice to strong sexual arousal and the use of drugs and alcohol. Drug use mainly initiates sexual interaction between gay and bisexuals, ^{40 , 61} and more importantly, ^{62 , 63} it facilitates sexual acts. ^{64 , 65} Of serious concern is that these substances affect the perception and response to risk, directing the behaviour to high-risk sexual practices, ⁶⁶ and consequently, increase the possibility of contracting HIV and other STIs. ^{67 , 68} This finding suggests the use of recreational drugs and attraction to the client are significant factors that intersected both private and sex work experiences of the study participants, and reinforce claims that condomless sex with casual partners can be a predictor of condomless sex with clients. ⁵³ Additionally, these results support the perspective that the type of sexual partner chosen in the MSW’s personal life can also be a risk factor. ^{40 , 61}

Overall, participants that experienced condomless sex visited sexual health clinics to have screening tests for HIV and other STIs, as they felt exposed to contracting these infections. The most concern and anxiety was expressed for HIV, therefore almost all participants had requested for post-exposure prophylaxis (PEP) to reduce their chances of contracting this infection. ^{69 , 70} Some had received PEP more than twice in the past 12 months. Few admitted to not continuing with their PEP treatment due to the adverse effects. These findings raise concerns of possible seroconversions when considering the poor medication adherence. ⁷¹ It is relevant to mention that nearly the whole group of participants (22/25) had been diagnosed with one or more STIs including HIV ( Table 1).

Participants experienced condomless sex with commercial sexual partners as risk-taking decision that intuitively triggered a set of risk reduction practices, which may not work effectively as they were based upon misinformation. Condomless sex with clients also occurred in a context of perceived loss of control with recreational drug use, experiencing precarious conditions, physical domination and verbal violence perpetrated by clients. These findings challenge claims that recreational drugs are not problematic among male escorts, ^{72 – 74} that they work in safer environments, obtain higher earnings, and can control work conditions. ^{73 , 75 , 76} In addition, condomless sex with non-commercial sexual partners was also a common practice, but clearly differentiated by the meanings attached to formal and casual partners. More importantly, this study found that the use of recreational drugs and attraction to the client are significant factors that intersected private and sex work experiences.

The findings suggest the need to reinforce educational interventions to deliver appropriate information about the transmissibility of HIV and other STIs, improve skills of self-control, strengthen the risk-reduction counselling for those requesting PEP, and the use of condoms for those who decide to take pre-PEP as the best action to secure its success. Likewise, emphasising the relevance of training healthcare professionals to identify MMSW who use recreational drugs, and to facilitate their referral to programmes of harm reduction in substance use and mental health services. Finally, the identification of other subgroups among MMSW such as those whose partners are also sex workers, have a HIV serodiscordant partner, tend to have condomless sex with casual sex partners, and are experiencing difficult-living or working conditions, can allow for tailoring behavioural interventions.