In the present study, results on sexual behavior from the PCAP-2013 and the PNS-2019 were compared for two purposes: to check the comparability of the two surveys and to investigate improvements in sexual behavior indicators.
In Brazil, since the PNS is a broad population-based household survey, conducted with a probabilistic sample of the Brazilian population in all stages, it is considered the gold standard of national health surveys (14). Although the PCAP selection of individuals in the final stage (households) obeys a quota system, the comparison of the PCAP-2013 and the PNS-2013 distributions of individuals by sociodemographic characteristics showed minor differences for most of the study variables. Significant differences were found for the distributions by age-group, educational level, and skin color. Comparison of the two PNS editions showed significant differences for the same sociodemographic variables. As the PCAP-2013 was weighted according to the 2010 Demographic Census, and weighting of both PNS databases was based on natural expansion factors, these findings represent the aging of the Brazilian population from 2010 to 2019 and the improvement in Brazilians’ educational level (19).
Variations in PNS race/skin color proportions from 2013 to 2019 have been discussed before and have been attributed to changes in the self-identification of skin color (20). However, the underestimation of the proportion of white people in the PCAP-2013 is most likely due to a statistical estimation problem, as this variable was not included in the survey post-stratification procedure (21).
Estimating the size and understanding diversity of homosexuality are essential for the development of inclusive policies and services (22). To date, research on this topic is still scarce in Brazil. In 2019, the PNS has included the question of sexual orientation by self-declaration for the first time. The comparison with the PCAP-2013 direct questions about who they currently have sex with (men, women, or women and men) showed lower prevalence estimates of homosexuality based on sexual orientation self- declaration, for males and females, even though this questionnaire module is self-completed by the participants in both surveys.
It is well-known that sexual minorities experience stigma and discrimination worldwide (23–25). In Brazil, the underestimation of MSM and WSW size estimates based on the self-declared sexual orientation suggests that gay and bisexual communities experience various psychological challenges related to their sexuality and gender identity disclosure (26). A qualitative study in Fortaleza, Brazil, indicated that MSM avoided seeking health care services due to a fear of being stigmatized and discriminated against. Furthermore, when they sought out health care, they tended to demonstrate masculine behavior so as not to be identified by their sexual orientation (27).
For some specific population groups, the MSM size estimates showed even greater differences between the PNS-2019 and the PCAP-2013 estimates. Findings revealed that men with incomplete fundamental schooling, living with a partner, residents in the North, aged 35 years and over, and living in the rural area or in cities other than state capitals were more likely not to reveal their sexual orientation. These results reinforce the importance of monitoring sexual orientation by self-declaration to continuously improve the quality of this information at subnational levels.
Identifying factors associated with the nondisclosure of sexual orientation is crucial for the development of interventions to strengthen protection from stigma and discrimination, as well as improve healthcare access among MSM. A survey in Germany showed that respondents who had never tested for HIV were more likely to live in a city with less than 100,000 inhabitants and to be less open about their sexual orientation to their primary care provider (28). In addition to less frequently testing for HIV, stigma in healthcare services is a barrier to HIV pre-exposure prophylaxis (PrEP) (29). Interest in PrEP is lower among MSM who are not open about their sexual orientation and opportunities in reducing new HIV infections are therefore lost (30, 31).
The indicator “condom use at last recent sexual intercourse” has the advantage of being questioned in the same way in both surveys. At the national level, no significant difference was found in the PNS-2019 when compared to the PCAP-2013, indicating that there is no general improvement in this behavior. However, the comparative analysis by sociodemographic variables showed significant increases for younger age groups (18–24 and 25–34 years), for MSM, and for those who do not live with a partner. These results show a greater awareness concerning HIV risk exposure in the most at risk population groups, suggesting that prevention actions focused on key populations have been successful (32).
However, although condom use is key to HIV prevention if used consistently and correctly, there are various barriers to regular condom use. The PNS-2019 data showed that the main reason for not having used a condom at last sexual intercourse was trusting the sexual partner. The second reason most cited was the aversion to using a condom, more frequently cited among people with a low educational level. A recent systematic review revealed that the MSM population believes that not using condoms represents mutual trust and loyalty between sexual partners, while condom use is a symbol of distrust or suspicion regarding the partner’s HIV status (33).
Prejudice and stigma against sexual minorities in Brazil are expressed by the excess of violence experienced by people who declare themselves to be homosexual/bisexual. MSM and WSW showed 3-fold greater odds of having suffered at least one type of violence (verbal, physical, or sexual) in the last 12 months prior to the survey than did heterosexual men and women. The most impressive results were found for sexual violence among MSM and WSW. Prevalence of having ever suffered sexual violence among MSM was 18.1%, with 10-fold greater odds than heterosexual men, while among WSW, this prevalence was 25.6%, with 3-fold greater odds than heterosexual women. In a biological and behavioral surveys among MSM conducted in nine Brazilian cities (2009), prevalence of having experienced sexual violence at least once in lifetime was approximately 16%, with discrimination due to sexual orientation being the strongest determinant of sexual violence (34).
A limitation of the PNS-2019 is the absence of questions about periodic HIV testing. As the current policy in Brazil is to provide antiretroviral therapy to all HIV patients immediately after diagnosis, the PCAP module on HIV testing (When? Where? Why? Why not?) is of utmost importance in tracking spatial and temporal trends of HIV diagnosis and should also be included in the PNS. Moreover, the reasons for having experienced discrimination or having been treated worse in the health services, addressed only in the PNS- 2013 (35), could have further contributed to this discussion (36).
An additional limitation of this study lies in the difficulty to estimate the size of sexual and gender minorities. Although the estimate of MSM size in the PCAP is similar to that of Joint United Nations Program on HIV/AIDS, UNAIDS for Latin America (15), and is in line with the international standards in countries that do not prohibit homosexuality (16, 17), it is possible that the size of the MSM population is still underestimated (37, 38).