Sexual risk behaviors among young migrants and key populations in Sweden

Sammanfattning: Background: The approximate number of young migrants (aged 15 to 24 years) is almost 32 million globally. In Sweden, in 2022, nearly 2.5% of all citizens were foreign-born aged 15-24. Previous research has shown that young migrants are at increased risk of engaging in sexual risk behaviors, including sexual minorities, such as men who have sex with men (MSM). In addition, migrants can suffer from poor health due to their migration journey and postmigration living circumstances. The aim of this thesis is to assess the prevalence of sexual risk behaviors and the sociodemographic factors that can influence the sexual risk behaviors among young foreign-born key populations who are at risk for HIV in Sweden. Additionally, to assess the prevalence of sexual risk behavior transactional sex among MSM and foreign-born MSM living in Sweden. Methods: Four papers were completed using data from two cross-sectional surveys: one from a migrant SRHR study conducted in Sweden during 2017-2018 (Papers I and II) and another from the European Men who have sex with men Internet Survey (EMIS) conducted in 2017 (Papers III and IV). In Paper I, 1563 participants aged between 15 and 25 years (56% male, 44% female) were eligible to participate in the assessment of sexual risk behavior prevalence, and in paper II, 976 (54% male, 46% female) participants to assess the prevalence of poor mental health. Descriptive, bivariate and multivariable logistic regression analyses were performed to estimate the relationship between sexual risk behavior and demographic and migrationrelated variables (Paper I). In paper II, we assess the association between mental health, sexual risk behavior, willingness to take risks, and demographic and migration-related variables. In the EMIS–2017 papers, 4443 MSM participants reporting to live in Sweden are included to assess the prevalence of engaging in transactional sex. Descriptive, bivariate and multivariable logistic regression analyses were performed to estimate the prevalence of transactional sex and the relationship between transactional sex and demographic and migration-related variables (paper III) and HIV status (paper IV). Results: In paper I, the overall prevalence of sexual risk behaviors in the past year was 33% (n=536). Condomless sex was the most prevalent sexual risk behavior, with increased odds among those coming from the Americas and Europe (compared to Syria) and coming to Sweden to live with a family (compared to those arriving as asylum seekers/refugees), including younger age and living longer in Sweden. Belonging to Islam decreased the odds. Increased odds for engaging in sex under drug influence were among young migrants born in Europe or a MENA country and those who came to Sweden to work or study, while age decreased the odds. Young migrants who came to work or study and lived longer in Sweden had increased odds of engaging in exchanging sex for money or goods. In paper II, 59% of participants reported poor mental health. Participants who reported living 4 and 5 years in Sweden had increased odds of poor mental health outcomes compared to those who lived in Sweden for less than one year. Living alone or with friends they had known earlier (compared to those living with family), being female, coming from Syria, engaging in sexual risk behaviors, and the willingness to take risks increased the odds of reporting poor mental health. Being highly educated, born in Asia, Europe, or Africa, and coming to live with family (compared to coming as an asylum seeker/refugee) decreased the odds of poor mental health. In paper III, we observe that the overall prevalence of engaging in selling sex ever was 13.2% (16% in foreign-born and 12.7% in Swedish-born) and 5.9% in the previous five years (8.4% foreign-born and 5.4% Swedish-born) among participants. Increased odds of selling sex were observed among those who were younger, reporting to struggle on their current income, being foreign-born, not defining their sexual orientation, and reporting to had sex with a woman in the previous 12 months. Low levels of outness decreased the odds of selling sex among Swedishborn MSM, contrary to foreign-born MSM, where higher levels of outness increased the odds of selling sex. Prevalence of buying sex ever was 10.8% (11.6% in foreignborn and 10.7% in Swedish-born) and 6.7% in the previous five years (6.9% foreignborn and 6.6% in Swedish-born). Factors increasing the odds of buying sex were higher education and not having a current partner, while younger age, low level of outness and defining as bisexual (compared to gay/homosexual) decreased the odds, including years of living in Sweden among foreign-born MSM. In paper IV, 5.4% of participants reported living with HIV (8.8% foreign-born and 4.8% Swedish-born). In the overall sample, the factors for increasing odds of reporting living with HIV were buying and selling sex in the past five years, being foreign-born, and really struggling with current income. Factors decreasing the odds for reporting living with HIV were younger age (up to 34 years compared to 65 and above), low levels of outness, always using a condom, including with a non-steady partner , and one to five sexual partners in the previous 12 months. Factor decreasing the odds among foreign-born MSM were 20-39 years old, higher education, living comfortably, always using a condom in the past 12 months and years lived in Sweden. Among Swedish-born MSM, low levels of outness, having one partner, and using a condom always and with a non-steady partner in the past 12 months (compared to never using a condom) were decreasing the odds. Conclusions: One in three young migrants aged 15-25 years living in Sweden reported engaging in sexual risk behavior, predominantly in condomless sex. Those who engage in sexual risk behavior also have increased odds of poor mental health. We observe that foreign-born MSM participants living in Sweden had a higher prevalence of transactional sex engagement than their Swedish-born MSM peers. Transactional sex remains a risk factor for living with HIV among MSM, particularly among foreign-born. Socio-demographic characteristics and migration influence young migrants’ sexual risk behavior. These findings can inform the design of social, economic, and political programs that aim promote safer sexual behaviors among young migrants. These findings can also benefit future targeting and tailoring of HIV prevention and testing programs reaching MSM and meeting the various needs of different MSM subpopulations.