AIDS Care, 2016

Vol. 28, No. 1, 112–118, http://dx.doi.org/10.1080/09540121.2015.1069789

Substance use and sexual risk behaviors among Peruvian MSM social media users
Sean D. Younga*, Roch A. Nianogob, ChingChe J. Chiua, Lucho Menachoc and Jerome Galeac

a
Department of Family Medicine, University of California-Los Angeles (UCLA), 10880 Wilshire Blvd, Suite 1800, Los Angeles,
CA, USA; bDepartment of Epidemiology, University of California-Los Angeles (UCLA), 10833 Le Conte Avenue, Los Angeles,
CA 90095, USA; cEpicentro Gay Mens’ Community Center, Jr. Jaén 250A, Barranco, Lima 15063, Peru
(Received 10 January 2015; accepted 26 June 2015)

Peru is experiencing a concentrated HIV epidemic among men who have sex with men (MSM). Substance use
(alcohol and drug use) has been found to be associated with HIV-related sexual risk behaviors. A recent surge in
the number of social media users in Peru has enabled these technologies to be potential tools for reaching HIV
at-risk individuals. This study sought to assess the relationship between substance use and sexual risk behaviors
among Peruvian MSM who use social media. A total of 556 Peruvian MSM Facebook users (ages 18–59) were
recruited to complete a 92-item survey on demographics, sexual risk behaviors, and substance use. We performed
a logistic regression of various sexual risk behaviors (e.g., unprotected sex, casual sex) on substance abuse,
including alcohol, adjusting for potential covariates. Drinking more than five alcoholic drinks a day in the past
three months was associated with an increased odds of having unprotected sex (vaginal and anal) (aOR: 1.52;
95% CL: 1.01, 2.28), casual sex (1.75; 1.17, 2.62), and sex with unknown persons (1.82; 1.23, 2.71). Drug use
was not significantly associated with sexual risk behaviors. Among Peruvian MSM social media users, findings
suggest that alcohol use was associated with increased HIV-related sexual risk behaviors.
Keywords: men who have sex with men (MSM); Peru; HIV; substance use; sexual risk behavior

Introduction
2007). While drug use is not as common (Ludford
Peru is experiencing a concentrated HIV epidemic that et al., 2013), drug use (e.g., marijuana, amphetamines,
disproportionately impacts men who have sex with poppers, and methamphetamines) has been associated
men (MSM) (Curioso & Kurth, 2007; Tabet et al., with UAI (receptive and insertive) (Celentano et al.,
2002). It has been estimated that the prevalence of 2006; Ludford et al., 2013; Stueve, O’Donnell,
HIV among Peruvian MSM is above 12% (Noriega Duran, San Doval, & Geier, 2002), having multiple
et al., 2012), and this is particularly salient in large sexual partners (Ludford et al., 2013), having sex
urban areas, such as Lima (Sanchez et al., 2007). with someone of unknown HIV status (Colfax et al.,
Sexual risk behaviors (e.g., unprotected sexual inter- 2004, 2005), engaging in sex work (Ludford et al.,
course) are a major mode of HIV transmission 2013), and seroconversion (Chesney, Barrett, & Stall,
among MSM, particularly unprotected anal inter- 1998). Although limited research has focused on this
course (UAI). Studies have shown that MSM are topic in Peru, alcohol use is highly prevalent in Peru,
more likely to practice UAI (both insertive and recep- especially among men (Gálvez-Buccollini, Paz-
tive), have more sexual partners, and engage in a Soldán, Herrera, DeLea, & Gilman, 2009).
greater frequency of transactional sexual encounters Social media use is rapidly increasing among Peru-
in comparison to exclusively heterosexual men (Clark vians (Chase, 2013; New Media and Peru’s Youth and
et al., 2007, 2008). Young Adults, 2009). In the USA, these technologies
In the USA, an important factor that has been have been shown to facilitate sexual risk (Young, Sze-
found to be associated with sexual risk behaviors is keres, & Coates, 2013) as well as to provide the ability
substance use, including alcohol and drug use. for HIV prevention interventions to reach a large
Among MSM, over 60% had an alcohol use disorder number of HIV at-risk individuals (Young, Cumber-
(Ludford et al., 2013), and alcohol use was associated land, et al., 2013). In Peru, 76% of youth (young
with increased odds of having unprotected insertive adults, ages 15–29) and 60% of adults report using
and receptive intercourse by 20% and 50%, respect- social media in the past month (New Media and
ively (Celentano et al., 2006). Some studies further Peru’s Youth and Young Adults, 2009). In 2011,
suggest that alcohol use is related to increased odds there were more than 8 million Peruvian Facebook
of serodiscordent UAI (Colfax et al., 2004), and ulti- users, and the penetration rate was 28.1% (Social Net-
mately HIV seroconversion (Fisher, Bang, & Kapiga, working, 2013). Because social media sites allow users

*Corresponding author. Email: [email protected]

© 2015 Taylor & Francis

to communicate with each other without face-to-face and a phone number. Next, a study staff member con-
contact, these technologies might be especially useful tacted the potential participant to explain the study
methods for reaching MSM heavily affected by objectives, procedures, and consent process. Interested
stigma who do not visit physical (in-person) health participants were sent an email with a link to an online
centers. Studying the newly growing group of Peruvian informed consent form which they were asked to read
social media users at high risk for HIV would help to and complete to confirm their study participation.
improve the understanding of HIV epidemiology in Next, participants were required to connect to a Face-
Peru and develop interventions that are better tailored book “fan page” created for the study before receiving
to the needs of this growing group. However, no known the baseline survey. The creation of a fan page allowed
work has studied the epidemiological profiles (includ- us to increase data quality: All participant profiles
ing sexual and drug-related risk behaviors) among Per- were checked in an attempt to ensure they were
uvian MSM social media users to better understand unique Facebook profiles, for example, by checking
their needs and associated risks. The aim of this for no duplications in names and checking the
study was to assess the relationship between substance number of friends in an attempt to see whether they
use and sexual risk behaviors among Peruvian MSM had created a fake profile for study participation.
social media users. These methods have been recommended in previous
research guidelines on using social media for HIV pre-
vention (Young, 2012). Participants received a baseline
Materials and methods survey deployed via an online survey website. Gift
cards valued at US $10 for a local supermarket were
Participants completed consent online and over the
provided after completion of the baseline survey.
phone to join in the study. The study coordinator assisted
participants during the consent process by being avail-
able to answer study-related questions on the phone
and/or by email, as well as documenting consent after Measurements
participants consented. Written consent was not We collected information on demographics, including
obtained as this study was designed to use online recruit- area of origin, sex (male or transgender woman),
ment methods to maximize reach and reduce barriers sexual orientation, age, race, current marital/partner-
associated with in-person recruitment visits (e.g., ship status, current work situation, and income from
reduce participant time spent traveling to the clinic, stig- last month. To assess sexual risk, we adapted items
matization associated with face-to-face involvement in a from the Sexual Acquisition and Transmission of
HIV-related study, etc.). Institutional review boards at HIV Cooperative Agreement Program HIV study
Epicentro (Lima, Peru) and the University of California, (Shoptaw et al., 2009). Participants were asked if
Los Angeles, reviewed and approved the study protocol, they had had casual sexual partners, sex with
including the consent procedure. unknown persons, unprotected sex (vaginal, unpro-
tected receptive anal, and unprotected insertive anal
sex), and oral sex in the past three months. In addition,
Study population and participants participants were asked about their frequency of using
A total of 556 MSM aged 18–59 who use social media alcohol or drugs while having sex (response choices
(Facebook) were recruited online. We recruited partici- included never, less than half of the time during sex,
pants who: (1) were male, (2) reported having had sex about half of the time, at almost every sexual encoun-
with a man in the past 12 months, (3) were 18 years of ter, and all the time). Lastly, participants reported their
age or older, (4) reported living in the Lima Metropo- use of alcohol (number of days a week, on average, that
litan area, and (5) had a social media account. they had more than five alcoholic drinks), and use of
drugs within the past three months. The following
drugs were included in the study: marijuana, meth-
Recruitment, informed consent, and enrollment amphetamines, crack, powder cocaine, heroin,
ecstasy, poppers, inhalation drugs, sedatives, opiates,
From January to June 2012, participants were
club drugs, and hallucinogens.
recruited via the Internet (e.g., website banner adver-
tisements, email, Facebook) to complete an online
anonymous survey. We used banner ads to recruit par-
ticipants on three of the major Peruvian gay websites: Statistical analysis
gayperu.com, peruesgay.com, and perugay.com, as We performed a logistic regression of various sexual
well as Facebook. Banner ads redirected participants risk behaviors on alcohol consumption and drug use,
to a form, in which they provided an email address adjusting for age, education, income, and race.
114 S.D. Young et al.

Alcohol consumption was defined as having more than Table 1. Socio-demographic characteristics among a sample
five whole (i.e., an 8-ounce glass of wine, a 12-ounce of Peruvian MSM social media users, Greater Lima, Peru
glass of beer, or a 1-ounce shot) alcoholic drinks. (n = 556).
Sexual risk behaviors (binary) included insertive Total
unprotected anal sex, receptive unprotected anal sex,
casual sex, oral sex, sex with unknown persons, and n %
sex while being buzzed on alcohol. Crude and adjusted
Area of origin
odds ratios were used to estimate the association Latin America 551 99.10
between substance abuse and sexual risk behaviors Europe 4 0.72
among MSM. Analyses were conducted using SAS Asia 1 0.18
software version 9.3 (SAS Institute Inc. Cary, NC) Age
and the PROC LOGISTIC procedure. 18–29 339 61.52
30–39 150 27.22
40–49 54 9.80
50–59 8 1.45
Results Gender
Male 552 99.28
Demographics (Table 1) Trans-woman 4 0.72
Most participants originated from South America Sexual orientation
(99%) and all resided in Lima, Peru. Participants Gay 424 77.09
were relatively young, with a median age of 27 (Inter- Bisexual 106 19.27
quartile range: 23–33). Ninety-nine percent identified Heterosexual 6 1.09
I am asking myself 14 2.55
as male, 77% described their sexual orientation as
Race/ethnicity
gay, and 20% described themselves as bisexual. Indigenous 6 1.13
About 37% of the participants went to an institute or White 104 19.62
specialized school and 27% had some college edu- Black 12 2.26
cation. About 58% had a full-time job and 38% had Mixed race (mestizo) 370 69.81
an income lower than $286 US. Eighty percent of the Asian 9 1.70
sample were never married. Other 29 5.47
Education completed
Up to high school 42 7.55
University/Technical non-graduates 251 45.15
Substance abuse (Table 2) University/Technical graduates 263 47.30
Current marital/partnership status
The prevalence of drug use and marijuana use in the Single (never married) 443 79.68
past three months was, respectively, 16% and 10%. Married/domestic partnership 9 1.62
Half of the sample reported drinking more than five Living with a partner 44 7.91
whole alcoholic drinks a day at least once a week. Separated 4 0.72
Divorced 2 0.36
Other/dating 54 9.71
Current work situation
Sexual risk behaviors (Table 3) Handicapped 2 0.37
Unemployed 39 7.18
Over 60% of participants reported having had casual
I take care of my home 9 1.66
sex in the past three months, while 57% reported Part-time job 100 18.42
having had sex with unknown persons. The prevalence Full-time job 312 57.46
of unprotected sex (anal and vaginal) was approxi- Student 80 14.73
mately 50%. Ninety percent had oral sex in the past Retired 1 0.18
three months. Thirty-six percent reported having had Income in the last month (US dollars)
unprotected insertive anal sex and 36% also reported Less than U$ 286 195 38.09
having had unprotected receptive anal sex. Over 20% U$ 286–573 183 35.74
reported having had sex while buzzed on alcohol and US$ 573–1145 86 16.80
7% reported having had sex while high on drugs. U$ 1145–1908 35 6.84
More than U$ 1908 13 2.54
About 13% of the sample had been told by a care pro-
vider that they were HIV positive.
 AIDS Care 115

Table 2. Substance abuse and alcohol consumption among Table 3. Sexual behaviors (in the last three months) among
Peruvian MSM (n = 556). Peruvian MSM (n = 556).

Total* Total*

n % n %

Drugs (in the past three months) Had casual sexual partners
Marijuana 55 9.89 Yes 309 63.32
Methamphetamines 1 0.18 No 179 36.68
Crack 0 0.00 Had sex with unknown persons
Powder cocaine 18 3.24 Yes 280 57.38
Heroin 0 0.00 No 208 42.62
Ecstasy 6 1.08 Had unprotected sex (vaginal or anal)
Poppers 23 4.14 Yes 246 53.02
Inhalation drugs 0 0.00 No 218 46.98
Sedatives 15 2.70 Had oral sex
Club drugs 4 0.72 Yes 428 90.30
Opiates 4 0.72 No 46 9.70
Hallucinogen 5 0.90 Had anal sex
None 453 81.47 Insertive unprotected
Refuse to answer 8 1.44 Yes 170 36.25
Drugs (categorized) in the past three months No 299 63.75
Any drug 87 16.11 Receptive unprotected
No drugs 453 83.89 Yes 170 36.25
Drink > 5 whole alcoholic drinks No 299 63.75
the same day High or buzzed on alcohol while having sex?
Yes 283 50.99 Never 390 70.78
No 272 49.01 Less than half of the times 132 23.96
About half of the times 18 3.27
Note: The * in the table signify analysis that excluded missing values.
Almost all the time 10 1.81
Always 1 0.18
Sexual risk behaviors and substance abuse (Table 4) High or using drugs while having sex?
Drinking more than five whole alcoholic drink a day Never 511 92.57
was associated with increased odds of having receptive Less than half of the times 29 5.25
unprotected anal sex, casual sex, sex with unknown About half of the times 6 1.09
Almost all the time 6 1.09
persons, unprotected sex, and having sex while buzzed
Ever been told by a care provider that you have
on alcohol in both the crude and adjusted models,
HIV/AIDS?
while alcohol use was associated with insertive unpro- Yes 69 12.90
tected anal sex and oral sex in the crude model online. No 466 87.10
Using drugs in the past three months was not associated Exchange Sex for food, money, drugs, or a
with an increased likelihood of sexual risk behaviors. place?
Yes 45 9.22
No 443 90.78
Discussion Note: The * in the table signify analysis that excluded missing values.
To the best of our knowledge, this is the first study to
assess the association between drug and alcohol use excessive alcohol intake was associated with heigh-
(substance use) and sexual risk behaviors among Peru- tened risk of HIV (Celentano et al., 2006; Colfax
vian MSM social media users. Similar to the high rates et al., 2004; Ludford et al., 2013). However, unlike a
of alcohol use among MSM found in other studies, study outside Peru (Fisher et al., 2007), we did not
half of the participants in the sample reported aver- find associations between alcohol use and being HIV
aging more than five drinks a day at least once a positive among this Peruvian sample. In the USA,
week (Ludford et al., 2013). We found that drinking drug use has been found to be associated with unpro-
more than five whole alcoholic drinks in a day was tected insertive or receptive anal intercourse, being
associated with 52%, 75%, and 82% increased odds HIV positive, engaging in sex work, sex with multiple
for unprotected sex, casual sex, and sex with partners, and sex with people with unknown status
unknown persons, respectively. Therefore, similar to (Celentano et al., 2006; Chesney et al., 1998;
other studies in Peru and the USA, we found that Ludford et al., 2013; Stueve et al., 2002). Among this
116 S.D. Young et al.

Table 4. Association between substance abuse (in the past three months), alcohol consumption, and sexual behaviors among
Peruvian MSM.

Alcohol (Yes vs. No) Drugs (Yes vs. No)

P- P- P- P-
cORa 95% CL value aORb 95% CL value cORc 95% CL value aOR 95% CL value

Oral sex
Yes 1.88 1.01, 3.50 0.05 1.78 0.91, 3.50 0.09 0.92 0.41, 2.07 0.85 0.69 0.29, 1.64 0.40
No 1.0 – 1.0 – 1.0 – 1.0 –
Insertive unprotected
anal sex
Yes 1.49 1.02, 2.19 0.04 1.45 0.96, 2.20 0.07 0.89 0.53, 1.48 0.65 0.92 0.53, 1.60 0.78
No 1.0 – 1.0 – 1.0 – 1.0 –
Receptive unprotected
anal sex
Yes 1.26 0.86, 1.83 0.24 1.34 0.88, 2.03 0.17 1.12 0.68, 1.84 0.65 1.16 0.67, 2.00 0.60
No 1.0 – 1.0 – 1.0 – 1.0 –
Casual sex
Yes 1.7 1.18, 2.47 0.02 1.75 1.17, 2.62 0.01 1.45 0.86, 2.44 0.16 1.66 0.94, 2.96 0.08
No 1.0 – 1.0 – 1.0 – 1.0 –
Sex with unknown
persons
Yes 1.63 1.13, 2.33 0.02 1.82 1.23, 2.71 <0.01 0.91 0.56, 1.47 0.70 1.01 0.60, 1.71 0.97
No 1.0 – 1.0 – 1.0 – 1.0 –
Unprotected sex
Yes 1.47 1.02, 2.12 0.04 1.52 1.01, 2.28 0.04 1.12 0.70, 1.81 0.66 1.11 0.65, 1.90 0.71
No 1.0 – 1.0 – 1.0 – 1.0 –
Having sex while buzzed
on alcohol
Yes 6.07 3.94, 9.40 <.01 5.95 3.77, 9.97 <.01 – – – – – –
No 1.0 – – – – – – –
HIV status
Positive 0.55 0.32, 0.92 0.02 0.52 0.31, 0.97 0.04 0.67 0.31, 1.45 0.31 0.81 0.36, 1.83 0.61
Negative 1.0 – 1.0 – 1.0 – 1.0 –
a
OR: Odds ratio.
b
aOR: adjusted OR. They were generated by the simultaneous entry of covariates (race, age, education, income, and drugs/alcohol) in a logistic
model.
c
cOR: Crude OR.

Peruvian sample, we did not observe associations In order to successfully and effectively tailor HIV
between drug use and sexual risk behaviors. interventions for substance users, research is needed
There are a few limitations to the study. This study is to further understand the social and psychological
cross-sectional, limiting the ability to determine causal- context and predictors of substance use. For
ity. Second, the proportion of participants using differ- example, personality traits, such as sensation seeking,
ent types of drugs was low (<5%), with the exception of have been found to influence the link between sub-
marijuana use (approximately 10%). To overcome this stance use and sexual risk behaviors (Kalichman,
problem, we combined all drug use into one dichoto- Heckman, & Kelly, 1996; Newcomb, Clerkin, & Mus-
mized measure (general drug use in the past three tanski, 2011). Moreover, in some studies, MSM have
months), making it difficult for us to distinguish the described substance use as a coping mechanism for
effects of different drugs on sexual risk behaviors, dealing with institutional and individual-level HIV
such as injection drugs, sex-enhancing drugs, and inha- and gay-related discrimination (Celentano et al.,
lants. These factors might account for the null findings 2006). For example, studies have shown heterosexual-
between drug use and sexual risk behaviors. Finally, the identified men often live a double life between their
study did not assess the frequency or the quantity of girlfriends/wives and casual sexual encounters with
drug use that might reveal a dose–response relationship other men (Caceres, 2002), and might seek a substance
with sexual risk behaviors (Colfax et al., 2005). to achieve disinhibition or sexual pleasure (Celentano
 AIDS Care 117

et al., 2006; Gálvez-Buccollini et al., 2009). Given the Colfax, G., Vittinghoff, E., Husnik, M. J., McKirnan, D.,
dire consequences of substance use, it is vital for future Buchbinder, S., Koblin, B., … Mayer, K. (2004).
HIV programs targeting Peruvian MSM to take these Substance use and sexual risk: A participant-and
individual and social factors into consideration when episode-level analysis among a cohort of men who
have sex with men. American Journal of Epidemiology,
addressing the intertwining epidemics of substance
159(10), 1002–1012.
use and HIV.
Curioso, W. H., & Kurth, A. E. (2007). Access, use and per-
ceptions regarding Internet, cell phones and PDAs as a
Acknowledgements means for health promotion for people living with HIV
in Peru. BMC Medical Informatics and Decision
The authors want to thank the researchers at the Center for Making, 7(1), 24. doi:10.1186/1472-6947-7-24
Digital Behavior (CDB) at the University of California, Los Fisher, J. C., Bang, H., & Kapiga, S. H. (2007). The
Angles (UCLA), for the input in this study. association between HIV infection and alcohol
use: A systematic review and meta-analysis of
African studies. Sexually Transmitted Diseases, 34
Disclosure statement (11), 856–863.
No potential conflict of interest was reported by the authors. Gálvez-Buccollini, J. A., Paz-Soldán, V. A., Herrera, P. M.,
DeLea, S., & Gilman, R. H. (2009). Gender differences
in sex-related alcohol expectancies in young adults from
Funding a peri-urban area in Lima, Peru. Revista Panamericana
de Salud Pública, 25(6), 499–505.
This work was supported by the National Institute of Mental Kalichman, S. C., Heckman, T., & Kelly, J. A. (1996).
Health (NIMH) under Grant K01 MH 090884 (Young). Sensation seeking as an explanation for the association
between substance use and HIV-related risky sexual be-
havior. Archives of Sexual Behavior, 25(2), 141–154.
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