Participation of men who have sex with men in non-governmental organizations in Belo Horizonte , 2007-2009 *

The aim of this study was to describe and analyze the participation of men who have sex with men (MSM) in NGOs. This is a cross-sectional study with 265 MSM in Belo Horizonte in 2007-2009. The sampling technique RDS (Respondent Driven Sampling) was used to contact populations considered difficult to be reached. The results indicate that among the participants, 72.7% have sufficient knowledge about the transmission of sexually transmitted diseases (STDs) and HIV. High proportions of alcohol drinking for more than twice a week (62.6%) and of irregular condom use in receptive or insertive anal intercourse (40.5% and 43.9%, respectively) were found. It was also observed that 40.6% felt they were discriminated against due to sexual orientation and the proportion of those who suffered sexual, verbal or physical violence due to sexual orientation was high (67.2%). The participation of MSM in NGOs in Belo Horizonte can be considered low (17.3%). The following variables were statistically associated with higher participation in NGOs: non-white skin color, being in a common-law union, feeling discriminated against because of sexual orientation, a history of sexual, physical or verbal violence, receiving free condoms in the last 12 months, having been tested for syphilis, perceiving to be under risk of becoming infected with HIV, and having a history of STD in the last 12 months. NGOs should strive for specific awareness to encourage greater participation, regular condom use, and prevention of transmission of HIV and other STDs.


Este trabalho descreve e analisa a participação de homens que fazem sexo com homens (HSH) em organizações não governamentais (ONGs). Trata-se de estudo de corte transversal com 271 HSHs em Belo Horizonte nos anos 2007-2009. Utilizou-se a técnica amostral
Respondent Driven Sampling (RDS), usada para contatar populações de difícil acesso.Verificou-se que 72,7% dos participantes tinham conhecimentos suficientes sobre a transmissão das doenças sexualmente transmissíveis (DST) e vírus da imunodeficiência humana (HIV).Foram verificadas altas proporções de consumo de álcool mais de duas vezes por semana (62,6%) e uso irregular de preservativo no sexo anal receptivo e insertivo (40,5 e 43,9%,  respectivamente).Observou-se que 40,6% sentiram-se discriminados pela orientação sexual e foi alta a proporção dos que tiveram história de ter sofrido agressão sexual, física ou verbal pela orientação sexual (67,2%).A participação de HSH em ONGs em Belo Horizonte pode ser considerada baixa (17,3%).As seguintes variáveis estiveram estatisticamente associadas a mais participação em ONG: estar em união estável, sentir-se discriminado pela orientação sexual; história de ter sofrido agressão sexual, física ou verbal; receber Participação de homens que fazem sexo com homens em organizações não governamentais em Belo Horizonte,  2007 a 2009  Participation of men who have sex with men in non-governmental organizations in Belo Horizonte, 2007-2009   zed, which can lead to lack of access and fewer visits to public health services 16,18 to obtain care or information on prevention, diagnosis or treatment of HIV and other STDs.Participation in non-governmental organizations (NGOs) thus becomes an important component of comprehensive healthcare for this population. 17he pioneer nature of the first NGOs created by homosexual rights groups in the fight against the epidemic of HIV/AIDS in Brazil 19 is undeniable.These NGO/ AIDS deserve attention as they were responsible for implementing the first prevention measures and for presenting demands to the government for the implementation of AIDS programs, with political activism and interventions to reduce the stigma associated with the disease.They have established a network that enables direct access to healthcare by the communities and most affected groups, as is the case with prevention and in the fight against several discrimination situations. 17he NGOs aimed at fighting HIV/AIDS are essential participants in the process of developing public health policies.They also encourage changes in behavior and are not dedicated to financial profit. 20heir importance also lies on the fact that they are familiar with the issues of the target-population and are closer to the realities they seek to improve. 20,21he importance of studying the participation of MSM in NGOs relates to the fact that these organizations provide for diffusion of knowledge on HIV/AIDS among that population, having contributed to disseminating information about the risk of negative behavior and about the means of individual contagion by HIV. 22he participation of the target population in the NGO/AIDS is important for them to achieve their goals fully as organizations.In fact, participation is not merely an individual act but a collective one, a defense of social rights. 23It is from participation that broad representation can arise and community determination be created.Changes in behavior can only be accomplished with effective participation, a necessary condition to acquire the tools to exert social pressure with the purpose of obtaining respect, equality and influence the future of an organization. 23articipation is an achievement and must be faced as an act of expression and democracy, for the proposition of ideas and approaches to be followed. 24or this viewpoint, participation provides members of NGOs with conditions to acquire the ability to improve their health and take control of their lives, in order to seek solutions for their own health concerns, individually and collectively. 25NGO projects are edu-preservativos gratuitos nos últimos 12 meses, história de testagem prévia para sífilis, relatar chance moderada a alta de se infectar pelo HIV; e história de DST nos últimos 12 meses.As ONGs devem se empenhar em relação à sensibilização específica da população de HSH, com base na sua participação na disseminação de informação e conhecimentos, com vistas a estimular nessa população empenho, uso regular de preservativo e a prevenção em relação à transmissão de HIV e de outras DSTs.

INTRODUCTION
Acquired immunodeficiency syndrome (AIDS) is a major issue in public health,¹ having to this day affected over 60 million people, half of which are already deceased.Over the past 20 years, the epidemic of human immunodeficiency virus (HIV)/AIDS has achieved catastrophic proportions.¹ The global prevalence of HIV infection among men who have sex with men (MSM) is very high when compared to other populations. 2,3In Vietnam and in Jamaica, HIV prevalence in the general population and in the MSM population are of 0.53 and 9.0% 2 and of 1.6 and of 32% 3 , respectively.HIV was the first agent to be associated with diseases that specifically affect MSM. 4 This is also noticed in Brazil. 5he growing rates of infection among MSM in Brazil and in other counties can be attributed to biological, behavioral and/or sociocultural factors. 5In Brazil, the prevalence of HIV infection in the population from 15 to 49 years old is estimated at 0.6%. 6Among female sex workers, injection drug users (IDU), and MSM, it is at 5.1 7 , 5.9 8 and 10.5%, respectively.The high prevalence of HIV infection among MSM indicates that global prevention efforts have not been sufficiently expanded and strengthened to contain the spread of the infection in this population. 9,10SM present high-risk behaviors when compared to the general population.2][13][14][15] There is evidence that the practice of passive unprotected anal sex involves much higher risks for infection with HIV than any other sexual practice. 16s a result of the epidemic being associated with specific sexual behavior, MSM suffer a higher degree of prejudice, homophobia and stigmatization. 17Because of the consequences of discrimination and from fear of public exposure, the MSM population is marginali-Participation of men who have sex with men in non-governmental organizations in Belo Horizonte, 2007-2009 questionnaire, be willing to invite peers to participate in the study, accept and sign the informed consent form, and be under the influence of no drugs, alcohol included, at the moment of the interview. 9fter signing the informed consent to participate in the research, each recruit answered a semi-structured interview with questions on social and demographic information, behavior, knowledge about HIV/STD, attitudes and sexual practices, his social network and the type of relationship with the persons recruited.They were given then pre-test advice and were invited to perform quick tests for HIV and syphilis 9 .Those who agreed were tested, given post-test advice and, in cases when the test was positive, referred to medical care units.
The study was approved by the CONEP (register number 14494), by the Committee of Ethics in Research of Universidade Federal do Ceará (COMEPE), number 202/07, and by the Belo Horizonte Health Office(number 062/2007).

Explanatory variables and event
The event of interest in the analysis was membership or taking parti in any organized group, social movement or NGO that promotes lesbian, gay, bisexual, and transgender (LGBT) rights and citizenship, here defined as participation in an NGO.
For this analysis the following characteristics were assessed as explanatory variables for participation in an NGO: age, education level, skin color, marital status, individual income in the previous month (in Brazilian Real), sexual identity, use of alcohol, use of illegal drugs in the previous six months, regular partner in the previous six months, use of condom for passive anal sex with any type of partner in the previous six months, use of condom for active anal sex with any type of partner in the previous six months, feeling discriminated because of sexual orientation, history of being victim of verbal, sexual or physical aggression, being given free condoms in the previous 12 months, having been tested for HIV, having been tested for syphilis, considering oneself under risk of being infected by HIV, STD history in the previous 12 months, and knowledge about contagions by STD/HIV.
For the non-white skin group we considered the following skin color options: black, yellow, brown, mulatto, mixed or indigenous.Consistent usage of condom was defined as always using condom in all sexual intercourses.For the aggression variable, we cational, with workshops conducted by facilitators to promote discussion and reflection about the realities in the societies participants live as well as the situations they encounter.With this incentive to autonomy, they are encouraged to act as the main subjects and manage their own health and lives. 26ew studies have assessed the participation of MSM in NGOs, in the world and in Brazil.This study seeks to describe and analyze the participation of MSM in NGOs in Belo Horizonte, from 2007 to 2009.It is our purpose to contribute in the creation of public policies articulated with those organizations for the prevention of HIV and other STDs.

Population and outline
This is a cross-sectional study that seeks to monitor the prevalence of HIV and syphilis infections among the MSM population, as well as knowledge, attitudes, and sexual practices of this population.This information is intended to be sourced in policies for the prevention and care of this population.The fieldwork was developed between from November 2007 and July 2009. 9he Respondent Driven Sampling (RDS) technique was used to recruit people from the MSM network.This is a chain sampling technique used to contact difficult to access populations that carries out recruitment through referrals by the respondents themselves, not by the researchers. 27he first respondents of the research (called seeds) were selected by choosing individuals from a given group.Initially, these were individuals who participated in an NGO.Each seed was given three vouchers and told to recruit other eligible members.As expected in this methodology, recruitment by the RDS technique gives incentives for participation 27 , in this case reimbursement for expenses with transport, for which respondents received R$10.00 per new volunteer recruited, up to three, as specified.The eligibility criteria for the project stated that subjects must: live in Belo Horizonte; not have taken part in the same research before; have had at least one sexual intercourse (oral or anal sex) with a man in the previous 12 months, present a valid voucher to participate in the study, accept the terms and conditions of the study, which include answering a structured Participation of men who have sex with men in non-governmental organizations in Belo Horizonte, 2007-2009 40.6% of the participants felt discrimination against because of their sexual orientation, and 67.2% of them reported stories of sexual, physical or verbal aggression for the same reason.Lectures or workshops on STD in the previous 12 months were attended to by 97.0 and 1.5% of the individuals in the health services and in NGOs, respectively (Table 1).
We found that 86.6 and 8.2% of the participants in this study received educational material on STD in the previous 12 months at a healthcare service and at NGOs, respectively; 72.7% of them scored a minimum of nine out of ten statements on STD/AIDS.74.2% had been previously tested for HIV and 33.6% reported having been previously tested for syphilis (Table 1).considered that if the individual had suffered verbal, physical or sexual aggression, this would be considered as a positive answer to the variable.For previous STD orientation, we considered positive those who received at least one piece of orientation regarding such diseases.Adequate knowledge on STD/HIV was considered positive for those who scored nine out of ten in the specific questions.

Data analysis
The starting point for data analysis was the data from the baseline interview.Descriptive analysis was performed, which included study population descriptions and frequency distribution for the variables.Differences in proportions was assessed by Pearson's chi-square test.The magnitude of association between explanatory variables and participation in NGOs was estimated by odds ratio (OR), with a 95% confidence interval (95% CI).The significance level considered was 0.05.Softwares SAS System version 9.0 (SAS Inst, Cary, United States) and Paradox 11.0 Corel Corporation were used for data analysis and storage, respectively.

Descriptive analysis
There were 274 participants in this study, all of them from Belo Horizonte.Three were excluded (1.1%) because there was no information about participation in NGOs.
We observed that 66.9 and 62.6% of the participants in the study had not used illegal drugs in the six months previous to the study or drank alcohol more than twice a week, respectively.A total of 69.1% participants had regular sex partners in the previous six months; and irregular use of condoms for passive and active anal sex was practiced by 43.9 and 43.9% of respondents, respectively (Table 1).To be continued …

Univariate analysis
The proportion of MSM participating in NGOs in Belo Horizonte was higher among men under the age of 24 years (19.6%),non-white (21.1%), under common law marriage (32.4%), with 11 years of schooling or less (21.6%) and income higher than R$500.00(18.6%).Those who identified themselves as bisexual/heterosexual, who consumed alcohol at least twice a week and who used illegal drugs in the previous six months showed a higher proportion of participation in NGOs.The same occurred among those with a regular partner in the previous six months (18.8%), who reported irregular use of condom in passive anal sex (18.4%) or in active anal sex (20.3%).A high participation in NGOs was found among those who reported having been victims of discrimination because of sexual orientation (29.1%) or who reported a history of victimhood in verbal, sexual or physical aggression (21.4%).The participation of MSM who were given condoms in the previous 12 months, were tested for HIV or syphilis, reported history of STD in the previous 12 months, presented insufficient knowledge on HIV, and reported moderate to high risk of being infected by HIV was more substantial (Table 2).Although there is currently no other published study describing the participation of MSM in NGOs, the percentage found in this study can be considered low, especially because of the investment in organizations that promote the prevention of HIV/AIDS and other STDs in vulnerable in groups Brazil 28 .This outcome could be explained, at least in part, by the fact that not all MSM in this social network knew about the importance of participating in NGOs or about the existence of many of these organizations, despite these being widely publicized in public events.The first participants in that MSM social network were members of NGOs working on gay rights and those of people living with AIDS; however, those seeds were not efficient in recruiting other participants.][31] Even though the majority (72.7%) of participants had more than 12 years of schooling, the MSM parti-Univariate analysis showed that the following characteristics were statistically associated with participation in NGOs (p<0.05):being under common law marriage (OR=2.64;95%CI: 1.19-5.89),feeling discriminated against due to sexual orientation (OR=3.99;95%CI: 2.04-7.82),having suffered verbal, sexual or physical aggression (OR=2.76;95%CI: 1.23-6.20),having been given free condoms in the previous 12 months (OR=3.67;95%CI: 1.26-10.67),having been tested for syphilis (OR=1.98;95%CI: 1.04-3.75),reporting moderate to high risk of being infected by HIV (OR=3.05;95%CI: 1.56-5.95),and history of STD in the previous 12 months (OR=2.37;95%CI: 1.17-4.81)(Table 2).

DISCUSSION
The Participation of men who have sex with men in non-governmental organizations in Belo Horizonte, 2007-2009   given less attention by the media and by healthcare professionals, despite being an important indicator of risk behavior.Many authors [39][40][41] note that a significant part of the population still associates sexual orientation with HIV/AIDS dissemination and other deviant behavior, with a consequent increase in discrimination against MSM.In Brazil, cases of violence, torture and even murder have been motivated by the desire to exterminate this population subgroup 41 We discovered the troubling association between having felt discriminated against because of sexual orientation and history of sexual, physical or verbal aggression for the same reason and their participation in NGOs.
It is likely that because the government is perceived to be absent or negligent in preventing violence and discrimination, NGOs play the role of catalysts, refuge, and legal support to MSM who have been victims of violence.Over 60% of the participants of NGOs in Brazil described cases of discrimination in all areas of their lives, including school, work, healthcare services, their own neighborhood, public transportation, police departments, and very frequent physical aggression in nightclubs and on the streets at night. 39hat is why anti-discrimination and anti-violence campaigns must be conducted, with the use of posters, advertisement, debates, lectures in public places, among others, in order to sensitize society to need prevent this serious public health issue.Increased participation of MSM in NGOs can contribute to raising awareness on the importance of preventing HIV/STD transmission by spreading knowledge on high-risk practice, encouraging the use of condom and adoption of safe sexual practices.NGOs must serve as a privileged space for prevention and for spreading knowledge more broadly, including close cooperation with public healthcare services throughout the country.They must work together with all sectors and with the media so as to give visibility to the issue of discrimination and disseminate information about the illegal nature of all forms of prejudice and violence based on sexual orientation.

ACKNOWLEDGEMENT
This study was only possible because of the financial support of the National Department of STD, AIDS and Viral Hepatitis of the Ministry of Health and the United Nations Educational, Scientific, and Cultural Organization (UNESCO), as well the participation of cipating in this social network exhibited high-risk sexual behavior, considering the high proportion who reported irregular use of condom in passive anal sex (40.5%) as well as in active (43.9%).In a similar study conducted in Canada 32 , 69.0% of participants reported using condom every time with their partners, while in Juarez 33 , Mexico, the use of condoms in passive and active anal sex was at 60.7 and 52.2%, respectively.
This study showed that, although the "being given free condoms" variable is associated with the participation in NGOs, "being under risk of infection by HIV" and "having history of STD in the previous 12 months" were also associated with that participation.Some MSM intentionally engage in the practice of unprotected sex because they find condoms artificial, and not because of lack of access and/or lack of knowledge about risk of infection.These participants are driven by the sensation during sexual contact and trust on the advancement of medicine 32 , considerably increasing their risk of contagion.
A study carried out in New York 34 adds that many MSM use condoms inconsistently because they see HIV/AIDS as a disease already conquered by medical advances or because they trust their partners.In another study made in the United States 35 , it was found that 66% of the respondents involved in unprotected anal sex and MSM who practice active anal sex tended to engage more in unprotected sex than those practicing passive anal sex.
Findings related to factors such as insufficient knowledge about STD/HIV transmission (27.3% of the sample in this study) and thinking that there is no/little risk of getting infected by HIV (68.3%) indicate that MSM have low perception of their increased risk.The success of antiretroviral therapy in promoting better quality of life, the reduction of mortality by AIDS, and longer life expectancy may have altered how they perceive the risks associated with HIV.Perception of low risk can lead to practice of unprotected sex and to inconsistent use of condoms. 36These findings are corroborated by a research made in Vietnam, in which 30% of MSM knew of the high risk of transmission of HIV in this population. 37he proportion of participants who reported having been tested for HIV in the previous six months was very high when compared to the results of another study with MSM conducted in the United States (74.7% versus 44.0%, respectively). 38However, the number of anti-syphilis testing was low (31.6%).That may be partially explained by the fact that syphilis is a curable disease and that it has been misguidedly the Group for Research in Epidemiology and Health Evaluation (Grupo de Pesquisas em Epidemiologia e Avaliação em Saúde -GPEAS) of the Department of Social and Preventive Medicine at Universidade Federal de Minas Gerais School of Medicine.

Table 1 -
Descriptive analysis of the sociodemographic and behavioral variables related to service, knowledge, and perception.Participation of men who have sex with men in NGOs in Belo Horizonte, 2007-2009 (N = 271)

Table 1 -
Descriptive analysis of the sociodemographic and behavioral variables related to service, knowledge, and perception.Participation of men who have sex with men in NGOs in Belo Horizonte, 2007-2009 (N = 271) Use of condom in active anal sex in the past 6 months

Table 1 -
Descriptive analysis of the sociodemographic and behavioral variables related to service, knowledge, and perception.Participation of men who have sex with men in NGOs in Belo Horizonte, 2007-2009 (N = 271)

Table 2 -
Univariate analysis of sociodemographic and behavioral variables related to service, perception, and knowledge.Participation of men who have sex with men in NGOs in Belo Horizonte, 2007-2009 (N = 265) Use of condom in passive anal sex in the past 6 months Participation of men who have sex with men in non-governmental organizations in Belo Horizonte, 2007-2009 History of having suffered sexual, physical, or verbal aggression because of sexual orientation

Table 2 -
present work aimed at describing and analyzing the participation of MSM in NGOs in Belo Horizonte, from 2007 to 2009.Results revealed a low proportion (17.3%) of MSM participating in NGOs.Univariate analysis of sociodemographic and behavioral variables related to service, perception, and knowledge.Participation of men who have sex with men in NGOs in Belo Horizonte, 2007-2009 (N = 265) …continued 1 Proportion of participation in NGOs in relation to each category of the variables.