Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland

Background Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men’s selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland. Methods Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors. Results Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97–0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81–7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05–3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02–3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex. Conclusions Synergistic sources of social and structural marginalization—from sexuality to hunger, homelessness, and injection drug use—are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.