AIDS and Behavior, Vol. 4, No. 1, 2000 HIV Infection, Syphilis, and Behavioral Risks in Brazilian Male Sex Workers Joa ˜ o Luiz Grandi, 1 Samuel Goihman, 2 Mirtes Ueda, 3 and George W. Rutherford 4,5 Received Jan. 26, 1999; revised June 9, 1999; accepted June 28, 1999 To describe the epidemiology of HIV and syphilis infection and sexual practices among male sex workers, we studied 434 transvestites and 96 ‘‘hustlers’’ recruited by peers in the metropolitan area of Sa ˜ o Paulo, Brazil, from 1992 to 1998. Participants were young adults with low education levels who had recently immigrated to Sa ˜ o Paulo and supported themselves primarily through sex work. The prevalence of HIV infection among transvestites and hustlers was 40% and 22% respectively, and the prevalence of current or past syphilis was 43% and 27%, respectively. Infection was associated more with gender performance and duration of sex work than to recent unsafe sexual practices or recent condom use. As opposed to hustlers, whose clients came primarily from Sa ˜ o Paulo and were homosexual, transvestites were more likely to have foreign and heterosexual clients. HIV and syphilis among sex workers are urgent public health problems that require continuous prevention programs for male sex workers and their clients. KEY WORDS: HIV; male sex workers; transvestites; risk factors; syphilis; transgender; Brazil. INTRODUCTION Although female sex work has been shown to be an important epidemiological factor in the spread of HIV infection in the developing world (McKega- ney, 1994), few studies have examined risk-taking among male sex workers in the developing world (Cortes et al., 1989; Perlongher, 1987; Suleiman et al., 1989; Veronesi et al., 1989). Thus, prevention pro- grams that seek to halt the spread of HIV infection among male sex workers and their clients must oper- 1 Reference and Training Center for STD/AIDS and Unicsul Uni- versity, Sa ˜ o Paulo, Brazil. 2 Federal University of Sa ˜ o Paulo, EPM-UNIFESP, Sa ˜ o Paulo, Brazil. 3 Instituto Adolfo Lutz Central Laboratory, HIV/AIDS Study Group, Sa ˜ o Paulo, Brazil. 4 Center for AIDS Prevention Studies, AIDS Research Institute, University of California, San Francisco, San Francisco, California. 5 Correspondence should be addressed to George W. Rutherford, M.D., Center for AIDS Prevention Studies, AIDS Research Insti- tute, University of California, San Francisco, 74 New Montgomery Street, Suite 508, San Francisco, California 94105; e-mail: grutherford@psg.ucsf.edu 129 1090-7165/00/0300-0129$18.00/0  2000 Plenum Publishing Corporation ate without benefit of sound behavioral or epidemio- logical data. Gender performance by male sex workers is an important variable for understanding high-risk sex between these men and their clients. Male transves- tites or transsexuals who look like women when they engage in sex work serve clients who are primarily heterosexual. Previous authors have commented ex- tensively on transvestite society in Brazil (Denizart, 1997; Parker, 1993; Silva, 1993; Silva and Florentino, 1996). Male hustlers, on the other hand, emphasize their masculine appeal when they work and primarily have sex with male homosexuals. Thus, while both groups are, strictly speaking, men who have sex with men and both groups may engage in very similar sexual risk behaviors, they attract male clients from very different populations. This important difference can result in very different patterns of HIV spread within a community. The few published papers reporting data on risk behaviors of male sex workers in the developing world have emphasized rates of unprotected anal sex and identified the predictors of engaging in high-risk