Transactional sex and its associated factors among gay, bisexual and other men who have sex with men in Nepal
Md. Safaet Hossain Sujan
A , Kiran Paudel A B , Kamal Gautam A , Antoine Khati A , Jeffrey Wickersham C , Manisha Dhakal D , Toan Ha E and Roman Shrestha A C *
A
B
C
D
E
Abstract
Transactional sex, which involves the exchange of sex for money, goods or other items of value, has been associated with adverse health outcomes, such as HIV and other sexually transmitted infections, mental health challenges, and substance use. Although transactional sex has been extensively studied globally among cisgender and transgender women, there is a lack of comprehensive understanding regarding its prevalence and correlates among gay, bisexual and other men who have sex with men (GBMSM), particularly in Nepal. Thus, this study aimed to examine the prevalence of transactional sex and its associated factors among GBMSM in Nepal.
A cross-sectional survey was conducted among GBMSM in Kathmandu Valley, Nepal, between October and December 2022 (N = 250). We collected information on participants’ sociodemographic characteristics, sexual and other behavioural characteristics, and their engagement in transactional sex. Bivariate and multivariate logistic regression analyses were performed to determine the factors associated with transactional sex.
The average age of participants was 27.5 years (s.d. 8.9). Overall, 16.4% reported engaging in transactional sex within the past 6 months. Participants with more financial dependants (aOR: 1.2, 95% CI: 1.0–1.5) and those who had experienced police detention (aOR: 4.8, 95% CI: 1.1–19.6) were more likely to engage in transactional sex. In contrast, GBMSM who reported engaging in condomless sex were less likely to engage in transactional sex (aOR: 0.02, 95% CI: 0.06–0.1).
The study findings underscore a noteworthy prevalence of transactional sex and associated socioeconomic and behavioural factors among GBMSM in Nepal. These results underscore the need for targeted interventions addressing both economic vulnerabilities and legal interactions to reduce transactional sex and its associated risks in this high-risk group.
Keywords: bisexual and other men who have sex with men, condomless sex, gay, HIV, Nepal, respondent driven sampling, sexual risk behavior, sexually transmitted infections, transactional sex.
Introduction
Globally, gay, bisexual and other men who have sex with men (GBMSM) have higher odds of acquiring HIV, syphilis and other sexually transmitted infections (STIs).1–3 Potential risk factors for acquiring STIs among GBMSM include high-risk sexual behaviour, such as condomless sex, multiple sex partners and sex with a partner with unknown HIV serostatus or an unsuppressed viral load.3
Transactional sex (i.e. buying or selling sex) is typically done for material benefit; this might include money exchange, drugs, accommodation, food or other goods for sex.4 Transactional sex among GBMSM has a global prevalence of 17.4%,5 and the prevalence of it in high-income countries is estimated to be 16–20%.6,7
Evidence suggests a strong link between transactional sex and increased risk behaviours among GBMSM, including higher rates of substance use8,9 and engagement in chemsex.10 In addition, multiple anal sex partners, condomless sex, living with HIV and being unaware of HIV status11 are other characteristics of GBMSM who engage in transactional sex.8 Moreover, GBMSM who engage in transactional sex frequently report abuse and attack from their counterparts or intimate partner violence,9,12 healthcare barriers,13 and are prone to socioeconomic or psychosocial problems, such as financial hardship, housing instability and mental health challenges.14
Previous studies on transactional sex have primarily focused on cisgender and female sex workers, yielding inconclusive results.8 Few studies have been conducted assessing this phenomenon among GBMSM in the South Asian region,5 particularly in Nepal, where no such research has been undertaken. GBMSM in Nepal are mostly hidden,15 and their engagement in transactional sex has mainly gone unnoticed.16 Understanding the health-related needs and behavioural aspects of GBMSM engaging in transactional sex in Nepal is essential for future HIV and STI prevention initiatives. Thus, we aimed to investigate the prevalence of transactional sex and its associated factors among GBMSM in Nepal.
Methods
Study design
This study is part of a larger population-based HIV/AIDS bio-behavioural survey conducted between October and December 2022 in the Kathmandu Valley, Nepal.17 The Kathmandu Valley, which encompasses Kathmandu, Bhaktapur and Lalitpur districts, is one of Nepal’s major metropolitan areas, with a population of over 2.5 million.16 People of various castes and ethnicities, mostly from the Newar, Brahmin, Chhetri and Thakuri communities, have come to this valley from various regions of the nation. A total of 250 MSM were enrolled in this study. The eligibility criteria included: (1) self-identified gay and bisexual men; (2) ≥18 years of age; (3) currently living in the Kathmandu Valley, Nepal; and (4) comfortable in Nepali or English languages.
Participant recruitment and study procedures
Respondent-driven sampling was utilised to recruit participants. The respondent-driven sampling technique is a unique sampling approach that leverages social networks to address typically hard-to-reach groups.18,19 First, we selected five GBMSM ‘seeds’ based on recommendations from LGBTQ-led community-based organisations, such as Blue Diamond Society, which is an organisation that works for the GBMSM welfare and rights in Nepal. Second, we distributed five recruitment vouchers to each of the potential participants. Finally, we gave each participant five tickets to recruit their friends.17 Participants were interviewed in person by trained research assistants utilising Qualtrics.20 The face-to-face interviews were held in a private room, each lasting approximately 40 min. The participants were compensated 1000 Nepali Rupees (~USD 8) for participating in the study. In addition, those who recruited five eligible peers received 500 Nepali Rupees (~USD 4) for each successful recruitment.
Measures
The transactional sex was assessed using a single-item question: ‘Have you engaged in sex work in the last 6 months, which involves exchanging sexual services for money, goods or a place to stay?’ A binary response (yes, no) was utilised to define the variable.
Participants were asked to report their age, sexual orientation, education and financial dependants.
Participants were further asked about their engagement in condomless sex (yes/no); drug use (yes/no); STI diagnosis (yes/no); HIV status (positive/negative); detention by the police, placed in lock-up or imprisonment (yes/no); denied employment opportunities (yes/no); verbally abused (yes/no); physically abused (yes/no); and sexually abused (yes/no).
Statistical analysis
The statistical software SPSS v25 was utilised to perform data analysis. The data were summarised using descriptive statistics, which included frequency and percentages for categorical variables, and mean and standard deviation for continuous variables. We evaluated the unadjusted relationship between the outcome variable (i.e. transactional sex) and the covariates using bivariate analysis. The multivariate regression model included significant variables from the bivariate analysis (P-value <0.05). We employed multivariable logistic regression analysis to establish the statistically significant relationship between the covariates and the outcome variable. Diagnostic plots were also incorporated to assess model fit and assumptions. The adjusted odds ratio was calculated at 95% CI in the present study, and a P-value <0.05 was considered statistically significant.21
Ethics
Institutional Research Ethics and Human Involvement Guidelines (Helsinki Declaration) were followed throughout the study. All participants provided informed consent before participating in the study. Nepal Health Research Council, Kathmandu, and the University of Connecticut’s ethical review board approved the study protocol.
Results
Participant characteristics
The participants were young, with a mean age of 27.5 years (s.d. 8.9 years). Overall, 16.4% of participants reported having engaged in transactional sex within the past 6 months. Overall, 13.6% of participants engaged in condomless sex. Of the participants, 28.0% reported drug use, 4.4% were HIV -positive and 20.8% experienced police detention (Table 1).
| Variables | Frequency (n) and percentages (%) | ||
|---|---|---|---|
| Age (years) | Mean (s.d.) | 27.5 (8.9) | |
| Sexual orientation | |||
| Gay | 158 (63.2) | ||
| Bisexual | 90 (36.0) | ||
| Other men who have sex with men | 2 (0.8) | ||
| Education | |||
| Up to Grade 10 | 105 (42.0) | ||
| Higher secondary and above | 145 (58.0) | ||
| Financial dependants | |||
| Mean (s.d.) | 2 (2.1) | ||
| Engagement in transactional sex in the past 6 months | |||
| No | 209 (83.6) | ||
| Yes | 41 (16.4) | ||
| Engagement in condomless sex in the past 6 months | |||
| No | 216 (86.4) | ||
| Yes | 34 (13.6) | ||
| Drug use | |||
| No | 180 (72.0) | ||
| Yes | 70 (28.0) | ||
| STIs diagnosis | |||
| No | 217 (86.8) | ||
| Yes | 33 (13.2) | ||
| HIV status | |||
| Negative | 239 (95.5) | ||
| Positive | 11 (4.5) | ||
| Detained by police or placed in lock-up | |||
| No | 198 (79.2) | ||
| Yes | 52 (20.8) | ||
| Denied employment opportunities | |||
| No | 210 (84.0) | ||
| Yes | 40 (16.0) | ||
| Verbally abused | |||
| No | 203 (81.2) | ||
| Yes | 47 (18.8) | ||
| Physically abused | |||
| No | 209 (83.6) | ||
| Yes | 41 (16.4) | ||
| Sexually abused | |||
| No | 221 (88.4) | ||
| Yes | 29 (11.6) | ||
Associations between participants’ engagement in transactional sex with other covariates (N = 250)
Individuals who have more financial dependants (aOR: 1.2, 95% CI: 1.0–1.5) and experienced police detention (aOR: 4.8, 95% CI: 1.1–19.6) were more likely to have engaged in transactional sex. Conversely, MSM who reported to have engaged in condomless sex (aOR: 0.2, 95% CI: 0.06–0.1) were less likely to engage in transactional sex (Table 2).
| Variables | Crude OR (95% CI) | Adjusted OR (95% CI) | P-value | ||
|---|---|---|---|---|---|
| Age (years) | Mean (s.d.) | 1.7 (0.9–3.5) | 1.3 (0.6–3.2) | 0.840 | |
| Sexual orientation | |||||
| Gay | 5.1 (1.9–13.6) | 1.9 (0.4–8.6) | 0.372 | ||
| Bisexual | Ref. | Ref. | |||
| Education | |||||
| Up to Grade 10 | 1.9 (1.0–3.9) | 1.5 (0.4–5.5) | 0.541 | ||
| Higher secondary and above | Ref. | Ref. | |||
| Financial dependents | |||||
| Mean (s.d.) | 2.1 (1.3–3.2) | 1.2 (1.0–1.5) | 0.021* | ||
| Engagement in condomless sex in the past 6 months | |||||
| No | Ref. | Ref. | <0.01** | ||
| Yes | 0.02 (0.01–0.05) | 0.02 (0.06–0.1) | |||
| Drug use | |||||
| No | Ref. | Ref. | 0.098 | ||
| Yes | 0.3 (0.1–0.8) | 0.2 (0.1–1.2) | |||
| STIs diagnosis | |||||
| No | 0.2 (0.1–0.5) | 0.2 (0.1–1.3) | 0.107 | ||
| Yes | Ref. | Ref. | |||
| HIV status | |||||
| Negative | Ref. | Ref. | 0.415 | ||
| Positive | 4.6 (1.3–16.2) | 2.4 (0.2–22.2) | |||
| Detained by police or placed in lock-up | |||||
| No | Ref. | Ref. | 0.040 * | ||
| Yes | 14.1 (6.5–30.6) | 4.8 (1.1–19.6) | |||
| Denied employment opportunity | |||||
| No | 0.3 (0.1–0.8) | 0.8 (0.2–3.4) | 0.850 | ||
| Yes | Ref. | Ref. | |||
| Verbally abused | |||||
| No | 0.1 (0.02–0.1) | 0.5 (0.1–5.1) | 0.595 | ||
| Yes | Ref. | Ref. | |||
| Physically abused | |||||
| No | 0.1 (0.02–0.1) | 0.9 (0.1–10.5) | 0.958 | ||
| Yes | Ref. | Ref. | |||
| Sexually abused | |||||
| No | 0.1 (0.02–0.1) | 0.3 (0.1–2.3) | 0.246 | ||
| Yes | Ref. | Ref. | |||
OR, odds ratio.
Bold data indicates significance: *P < 0.05; **P < 0.01.
Discussion
Our study revealed that a notable proportion of GBMSM in Kathmandu Valley, Nepal, engaged in transactional sex in the past 6 months, suggesting an elevated risk of HIV and other STIs among this group.
In support of the above findings, prior studies conducted in the South Asian region have reported similar occurrences among GBMSM,22,23 and the rate of transactional sex here ranges from 7.0 to 48.0%.22,24,25 Factors that influence transactional sex engagement among GBMSM are diverse and region-specific,26 and its prevalence in our study is comparatively lower than in some South Asian countries. Higher levels of stigma and discrimination against GBMSM in Nepal17 might have discouraged the participants from engaging in transactional sex due to fear of exposure or social repercussions. In addition, adequate peer groups or community support networks in Nepal27 might have provided financial and emotional support, reducing the reliance on such work for survival. Furthermore, our study only assessed the participant’s past 6 months of engagement in transactional sex, whereas others might have examined their past 12 months or ever engagement in it, which might have affected our results.
Our study also showed that GBMSM who have more family members financially dependent on them were more likely to engage in transactional sex. Aligning with our findings, a recent study showed that GBMSM who were insecure about family maintenance, such as food and home, tended to be more likely to engage in transactional sex.28 Another study reported that homeless people or people with no social support were likelier to engage in transactional sex.29 Additionally, research revealed that motivations and justifications for transactional sex are generally material-related, such as trading sex for money, food, shelter and paying debts.30 Because Nepal is a low- and middle-income country and GBMSM are highly stigmatised, finding a job is more difficult for the GBMSM than their general counterparts, which may facilitate them to engage in transactional sex as an easy method of supporting their family. A recent study showed that food insecurity is highly prevalent among this group in Nepal,17 which could be another reason for their engagement in transactional sex. Moreover, in the past decade, Nepal experienced a massive earthquake,31 and the COVID-19 pandemic,32 which is also responsible for enormous job loss,33 leading more people to such type of work to feed their families. Opening more job opportunities and vocational training, particularly focusing on GBMSM in Nepal, could discourage them from engaging in transactional sex.
Interestingly, our study showed that GBMSM who were engaged in transactional sex were less likely to practice condomless sex. This finding is in contrast to findings from existing studies, which have shown that GBMSM sex workers were more likely to engage in condomless sex.34,35 Evidence suggests a link between increased engagement in transactional sex and condomless sex by GBMSM and a heightened risk of HIV acquisition.5 Studies revealed that motivation and information, such as self-worth, HIV prevention knowledge, power dynamics in the relationship, social vulnerabilities, comfort with condom use, and interpersonal issues like trust and intimacy, played a crucial role in determining condom use during anal sex.36,37 Prioritising self-worth, such as protective behaviours during sex work, can help in negotiating condom use.38 A recent study conducted with the same demographic in Nepal revealed a high level of condom usage among GBMSM,16 referring to adequate HIV prevention knowledge being highly prevalent among this group, which might have affected our findings. However, more research is necessary to obtain a deeper understanding of the complex interplay of transactional sex and potential motivations for condom use within this population.
Furthermore, our study also showed that GBMSM who were detained by police were more likely to engage in transactional sex. In line with our present findings, a recent study indicated that GBMSM incarcerated by police were more likely to report engagement in transactional sex.39 Abuse, violence and police detention of sex workers remain widespread,40 and GBMSM sex workers mostly face it. Although transactional sex is not criminalised in Nepal, most GBMSM sex workers experience detention by law enforcement authorities,41 and the common reasons are diverse (i.e. engaging in unaccepted sexual activities outside, gathering in a grey area and defaming public morality).39 Research has shown that police detention leads to a range of negative consequences, such as limited access to essential commodities, employment, housing and health care.42,43 Transactional sex is often a consequence of economic instability. As most GBMSM are engaged in transactional sex as a means of earning their livelihood or items of value, police detention failed to prevent the repetition of this practice. We advocate developing a new, quick training program for law enforcement professionals to understand better GBMSM sexual behaviour and their involvement in transactional sex.
Strengths and limitations
The present study had several strengths. This study is among the first to report on the prevalence of transactional sex engagement among GBMSM in Nepal. In addition, we used the respondent-driven sampling technique to recruit this hidden group to estimate a more accurate prevalence. Despite its strengths, this study had some limitations that should be considered. First, our study was cross-sectional; hence, it can not establish a causal relationship between variables. Second, because of the sensitive nature of the subjects, such as sexual behaviour and stigmatisation, this study mostly depended on self-reported data, which is susceptible to recall bias or misreporting. Third, the findings might not be generalisable for all GBMSM in Nepal, as we only recruited GBMSM from Kathmandu Valley, Nepal. Finally, our study directs to future longitudinal studies among this group to assess the lifetime prevalence of transactional sex among this high-risk group and which factors lead them to transactional sex.
Conclusion
The present study uncovered a concerning prevalence of transactional sex among GBMSM in Nepal. Our findings emphasise the importance of the economic empowerment of GBMSM through skill development and microfinance. The results suggest the need for enhanced legal protections to prevent police harassment and exploitation of GBMSM. In addition, expanding access to HIV prevention resources, such as PrEP and counselling services tailored to the needs of GBMSM, can help reduce the risks associated with transactional sex and can make an LGBTQ-friendly community, which may help to prevent transactional sex practice among this demographic.
Data availability
Data from this study may be obtained from the corresponding author upon reasonable request.
Declaration of funding
We acknowledge financial support from a career development award from the National Institute on Drug Abuse (K01 DA051346) to Dr Roman Shrestha. The funders had no role in study design, data collection, analysis, manuscript preparation or the decision to publish.
Author contributions
RS designed and conducted the study. MSHS and RS performed the statistical analysis. MSHS prepared the initial draft of the manuscript with the subsequent assistance of RS, KP, KG and AT. All authors critically reviewed the manuscript and provided insightful feedback. RS supervised the study. All authors read, reviewed and agreed to the last version of the manuscript.
Acknowledgements
We are grateful to every participant for giving their time and effort to make the study succeed.
References
1 Chow EPF, Grulich AE, Fairley CK. Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV. Lancet HIV 2019; 6(6): e396-e405.
| Crossref | Google Scholar | PubMed |
2 Marcus U, Veras M, Casabona J, et al. Comparison of the burden of self-reported bacterial sexually transmitted infections among men having sex with men across 68 countries on four continents. BMC Public Health 2023; 23(1): 1008.
| Crossref | Google Scholar |
3 Mayer KH. Sexually transmitted diseases in men who have sex with men. Clin Infect Dis 2011; 53(suppl. 3): S79-S83.
| Crossref | Google Scholar |
4 Bamgboye EA, Badru T, Bamgboye A. Transactional sex between men and its implications on HIV and sexually transmitted infections in Nigeria. J Sex Transm Dis 2017; 2017: 1-7.
| Crossref | Google Scholar |
5 Oldenburg CE, Perez-Brumer AG, Reisner SL, Mimiaga MJ. Transactional sex and the HIV epidemic among men who have sex with men (MSM): results from a systematic review and meta-analysis. AIDS Behav 2015; 19(12): 2177-2183.
| Crossref | Google Scholar | PubMed |
6 Weber AE, Craib KJP, Chan K, et al. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol 2001; 30: 1449-1454.
| Google Scholar |
7 Prestage G, Jin F, Bavinton B, Hurley M. Sex workers and their clients among australian gay and bisexual men. AIDS Behav 2014; 18(7): 1293-1301.
| Crossref | Google Scholar | PubMed |
8 Javanbakht M, Ragsdale A, Shoptaw S, Gorbach PM. Transactional sex among men who have sex with men: differences by substance use and HIV status. J Urban Health 2019; 96(3): 429-441.
| Crossref | Google Scholar | PubMed |
9 Meunier É, Siegel K, Sundelson AE, Hirshfield S, Schrimshaw EW. Interest in sex work-related resources among gay, bisexual, and other men who have sex with men engaged in sex work. Sex Res Soc Policy 2022; 19(4): 1904-1919.
| Crossref | Google Scholar | PubMed |
10 Wang H, Jonas KJ, Guadamuz TE. Chemsex and chemsex associated substance use among men who have sex with men in Asia: a systematic review and meta-analysis. Drug Alcohol Depend 2023; 243: 109741.
| Crossref | Google Scholar |
11 Nerlander LM, Hess KL, Sionean C, et al. Exchange sex and HIV infection among men who have sex with men: 20 US cities, 2011. AIDS Behav 2017; 21(8): 2283-2294.
| Crossref | Google Scholar |
12 Balaji AB, Bowles KE, Hess KL, et al. Association between enacted stigma and HIV-related risk behavior among MSM, national HIV behavioral surveillance system, 2011. AIDS Behav 2017; 21(1): 227-237.
| Crossref | Google Scholar | PubMed |
13 Gomes A, Nicholas C, Donastorg Y, et al. Barriers and opportunities for sexual health services for key populations in the Dominican Republic: provider, government, and community-leader perspectives. Lancet Glob Health 2016; 4: S36.
| Crossref | Google Scholar |
14 Chandler CJ, Meunier É, Eaton LA, et al. Syndemic health disparities and sexually transmitted infection burden among black men who have sex with men engaged in sex work in the U.S. Arch Sex Behav 2021; 50(4): 1627-1640.
| Crossref | Google Scholar | PubMed |
15 Montgomery JP, Mokotoff ED, Gentry AC, Blair JM. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care 2003; 15(6): 829-837.
| Crossref | Google Scholar |
16 Mishra SR, Khanal V. Sexual behaviors among men who have sex with men: a quantitative cross sectional study in Kathmandu Valley, Nepal. HIV AIDS 2013; 5: 81-88.
| Crossref | Google Scholar | PubMed |
17 Paudel K, Bhandari P, Gautam K, et al. Mediating role of food insecurity in the relationship between perceived MSM related stigma and depressive symptoms among men who have sex with men in Nepal. PLoS ONE 2024; 19(1): e0296097.
| Crossref | Google Scholar |
18 Heckathorn DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl 1997; 44: 174-199.
| Crossref | Google Scholar |
19 Schonlau M, Liebau E, Berlin D. Respondent-driven sampling. Stata J 2012; 12: 72-93 Available at http://www.respondentdrivensampling.org.
| Google Scholar |
20 Molnar A. SMARTRIQS: a simple method allowing real-time respondent interaction in qualtrics surveys. J Behav Exp Finance 2019; 22: 161-169.
| Crossref | Google Scholar |
21 Tasnim R, Islam MS, Sujan MSH, Sikder MT, Potenza MN. Suicidal ideation among Bangladeshi university students early during the COVID-19 pandemic: prevalence estimates and correlates. Child Youth Serv Rev 2020; 119: 105703.
| Crossref | Google Scholar |
22 Weir BW, Dun C, Wirtz AL, et al. Transactional sex, HIV and health among young cisgender men and transgender women who have sex with men in Thailand. Ann Epidemiol 2022; 72: 1-8.
| Crossref | Google Scholar | PubMed |
23 Mimiaga MJ, Reisner SL, Closson EF, et al. Self-perceived HIV risk and the use of risk reduction strategies among men who engage in transactional sex with other men in Ho Chi Minh City, Vietnam. AIDS Care 2013; 25(8): 1039-1044.
| Crossref | Google Scholar |
24 Zhao J, Cai W-D, Gan Y-X, et al. A comparison of HIV infection and related risk factors between money boys and noncommercial men who have sex with men in Shenzhen, China. Sex Transm Dis 2012; 39(12): 942-948.
| Crossref | Google Scholar | PubMed |
25 Brahmam GNV, Kodavalla V, Rajkumar H, et al. Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India. AIDS 2008; 22(Suppl 5): S45-S57.
| Crossref | Google Scholar |
26 Oldenburg CE, Perez-Brumer AG, Reisner SL, et al. Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis. PLoS ONE 2014; 9(7): e103549.
| Crossref | Google Scholar |
27 Deuba K, Ekström AM, Shrestha R, Ionita G, Bhatta L, Karki DK. Psychosocial health problems associated with increased HIV risk behavior among men who have sex with men in Nepal: a cross-sectional survey. PLoS ONE 2013; 8(3): e58099.
| Crossref | Google Scholar | PubMed |
28 Logie CH, Lacombe-Duncan A, Kenny KS, et al. Social-ecological factors associated with selling sex among men who have sex with men in Jamaica: results from a cross-sectional tablet-based survey. Glob Health Action 2018; 11(1): 1424614.
| Crossref | Google Scholar |
29 Logie CH, Wang Y, Lacombe-Duncan A, et al. Factors associated with sex work involvement among transgender women in Jamaica: a cross-sectional study. J Int AIDS Soc 2017; 20(1): 21422.
| Crossref | Google Scholar |
30 Berg RC, Schmidt AJ, Weatherburn P. Transactional sex: supply and demand among european men who have sex with men (MSM) in the context of local laws. Int J Sex Health 2015; 27(3): 286-302.
| Crossref | Google Scholar | PubMed |
31 Ansary M, Hamidul Bari Q. Characteristics and consequence of Nepal earthquake 2015: a review. J Geotech Eng 2015; 46: 114-120.
| Crossref | Google Scholar |
32 Pandey BD, Ngwe Tun MM, Pandey K, et al. How an outbreak of COVID-19 circulated widely in nepal: a chronological analysis of the national response to an unprecedented pandemic. Life 2022; 12(7): 1087.
| Crossref | Google Scholar |
33 Sharma K, Banstola A, Parajuli RR. Assessment of COVID-19 pandemic in Nepal: a lockdown scenario analysis. Front Public Health 2021; 9: 599280.
| Crossref | Google Scholar | PubMed |
34 Mgbako O, Park SH, Callander D, et al. Transactional sex, condomless anal sex, and HIV risk among men who have sex with men. Int J STD AIDS 2019; 30(8): 795-801.
| Crossref | Google Scholar | PubMed |
35 Siegel K, Cabán M, Brown-Bradley CJ, Schrimshaw EW. Condomless anal sex between male sex workers and clients in the age of hookup apps. AIDS Behav 2023; 28: 1077-1092.
| Crossref | Google Scholar |
36 Jiang H, Chen X, Li J, Tan Z, Cheng W, Yang Y. Predictors of condom use behavior among men who have sex with men in China using a modified information-motivation-behavioral skills (IMB) model. BMC Public Health 2019; 19(1): 261.
| Crossref | Google Scholar |
37 Shen Y, Zhang C, Valimaki MA, et al. Why do men who have sex with men practice condomless sex? A systematic review and meta-synthesis. BMC Infect Dis 2022; 22(1): 850.
| Crossref | Google Scholar |
38 Siegler AJ, Voux Ad, Phaswana-Mafuya N, et al. Elements of condom-use decision making among South African men who have sex with men. J Int Assoc Provid AIDS Care 2014; 13(5): 414-423.
| Crossref | Google Scholar | PubMed |
39 Philbin MM, Kinnard EN, Tanner AE, et al. The association between incarceration and transactional sex among HIV-infected young men who have sex with men in the United States. J Urban Health 2018; 95(4): 576-583.
| Crossref | Google Scholar | PubMed |
40 Stenersen MR, Thomas K, McKee S. Police harassment and violence against transgender & gender diverse sex workers in the United States. J Homosex 2022; 71: 828-840.
| Crossref | Google Scholar |
41 Tanaka M. Advocating sex workers’ rights by identity-based associations in Nepal. Asian J Law Soc 2020; 7(2): 265-274.
| Crossref | Google Scholar |
42 Dale SK, Bogart LM, Galvan FH, Wagner GJ, Pantalone DW, Klein DJ. Discrimination and hate crimes in the context of neighborhood poverty and stressors among HIV-positive African-American men who have sex with men. J Community Health 2016; 41(3): 574-583.
| Crossref | Google Scholar | PubMed |
43 Feelemyer JP, Duncan DT, Remch M, et al. Associations between police harassment and distrust in and reduced access to healthcare among Black sexual minority men: a longitudinal analysis of HPTN 061. PLoS ONE 2023; 18(8): e0290378.
| Crossref | Google Scholar |
