The LAMIS-2018 was the first survey to describe the SDU phenomenon in a large population of gay men and other MSM from LA countries, addressing multiple aspects of the psycho-socio-sexual health in 18 countries of the region. Literature has revealed that gay men may be more prone to excessive alcohol consumption and drug use than the general male population [41], in part due to the discrimination and stigma experienced by sexual minorities, which have been associated with increased alcohol and drug use [42]. This study revealed high percentage of alcohol consumption and dependence (90.1% and 21.2%, respectively), which exceeded the levels reported by the WHO for the general population of the American region. Considering that the abuse of most illegal drugs, including methamphetamine, cannabis, cocaine, heroin, and polydrugs, generally occur in conjunction with alcohol, intervention strategies should not exclude legal drugs in their communication aspects, especially considering the risks associated with polydrug use and the interaction between PS [43]. Cannabis was predominantly used by the surveyed population. This observation was consistent with the previously observed trend in the region [2, 18]. The highest prevalence of cannabis use was observed in Chile (49.9%), which is the leading LA country in terms of cannabis consumption and drug abuse/dependence rates [44]. Consumption of synthetic drugs was registered at a low extent in the studied population; however, the use of synthetic cannabinoids have become increasingly common [45]. Ecstasy is the second most commonly used synthetic drug, which has experienced a global boom owing to cultural influence among the young population [46]. The use of injectable drugs was reported by a low proportion of the participants, which was in accordance with the evidence found for the general population of the region in previous reports [21] and research papers [47]. However, it is necessary to constantly monitor the use of injectable drugs in the sexual context, as the practice of slamsex has been increasing in other regions along with the corresponding risks for infection transmission by parenteral route while sharing the injection material [25].

The prevalence of SDU (last 12 months) in this study was relatively similar to that reported in the EMIS-2017 conducted in the European region (13.6% vs. 10.4%) ([35]; however, the prevalence in this study was lower than the reported prevalence in an investigation carried out in Mexico (23.9%) [48], though there are certain differences in the definition of the phenomenon that hinders the comparability of the studies. Chile had the highest prevalence of SDU (24.2%), exceeding the general prevalence by almost 10 points (13.6%). The prevalence of SDU with multiple partners and the proportion of preferring private homes for such encounters was similar to that reported by the EMIS-2017 study (6.6% vs. 6.7%); the increased use of private homes for group sexual encounters is attributable to the use of mobile dating applications [49]. In group encounters, a predominance of the cannabis-poppers-Viagra triad was observed, which are associated with the sexual context in MSM and heterosexual population as these drugs can facilitate penetrative practices and prolong the sexual intercourse [50, 51]. It was found that people who practiced SDU had higher educational qualifications than the other respondents of the study (72.5% vs. 66.2%), as opposed to the general prejudice of marginality historically associated with drug use [52]. High proportion of sexual behaviors that can increase exposure to HIV/STIs and of HIV diagnosis among people who practiced SDU observed in this study are in line with the literature. It has been reported that a higher prevalence of HIV/STIs and greater tendency to develop sexual behaviors that render them more vulnerable to STIs are seen in a segment of people who use drugs to enhance and prolong their sexual relations [53, 54]. It is important to mention the case of Mexico where a remarkable difference was observed in the self-reported HIV diagnosis among people who practiced SDU and those who did not (31% vs. 13.1%), suggesting a possible relationship between drug use and a higher prevalence of HIV; similar observation was made in the general population of the region [55]. Similarly, the self-reported HIV diagnosis in Chile was 28.1% among those who practiced SDU, indicating the re-emergence of HIV in this country, wich presents the highest increase in the number of cases in the last 10 years within the LA region [56, 57]. This phenomenon is directly related to the lack of preventive public policies [58].

This research revealed a low prevalence of PrEP use among those who practiced SDU (3.3%) and non-users (1.3%). This observation is in contrast with the phenomenon observed in other regions such as the UK, wherein usage rates exceed 20% [59], and France, where programs have been implemented at a national level to deliver PrEP services to the groups who are most likely at risk of HIV infection [60]. However, it is necessary to consider that PrEP has only recently been available in LA, and mainly linked to studies conducted in key populations, such as the “ImPrEP Project”, that addressed strategic aspects for the implementation of PrEP in integrated public health services in Brazil, Mexico, and Peru [61]. In Chile, a pilot study on the implementation of PrEP as a public health policy has been conducted in some regions of the country since 2019, but it does not identify people who practice SDU as a target group [62] despite the fact that PrEP has become a feasible strategy for HIV prevention in these population [63, 64].

People who practiced SDU reported high levels of satisfaction with their sexual life, which is consistent with the increased sexual enjoyment and less anxiety reported by people who use drugs in the sexual context [65]. On the other hand, payment in exchange for sex with men was high among people who practiced SDU than the other respondents (13.4% vs. 6.7%), indicating that the phenomenon of transactional sex is frequently observed in gay men, other MSM and trans women in relation with alcohol and drugs consumption and psychosocial factors, so these people constitute a particularly vulnerable group that needs to be prioritized while developing intervention strategies [66]. Another differential aspect observed in this study was the higher prevalence of severe anxiety/depression symptoms in people who practiced SDU, which in line with multiple studies that have revealed a greater susceptibility to depression, anxiety and/or drug dependence in MSM who practice SDU [67]. The impact of the phenomena of stigma and persistent homophobia in LA region can also affect the mental health of these population [68], as evidenced by the high percentages of intimidation (52.6%) and homophobic insults (34.4%) reported by people practicing SDU, especially considering that these experiences of homophobic bullying have been described as a risk factor for increased substance use in young adults, especially among victims with depressive symptoms [69]. On the other hand, the higher levels of perceived social support among those who reported drug use in the sexual context, as well as a lower internalized homonegativity, could be related to the fact that those who have an active social life, who attend parties and who are in permanent connection with their peers through the use of social networks or dating applications, could be more inclined to experiment with practices such as drug use during their sexual encounters [70]. Drug use can be a creative or experimental response of people and not necessarily a problem in all cases [71].