Economic Precarity Shapes Engagement in Sex Work and HIV-Related Behaviors Among African Refugee Male Sex Workers in Italy: A Mixed-Methods Study

Abstract Background African refugee male sex workers (ARMSWs) in Europe experience overlapping forms of marginalization, including racism, legal precarity, and exclusion from formal labour markets, which collectively shape HIV vulnerability. However, little is known about how economic precarity drives engagement in sex work and HIV-related behaviors among ARMSWs in Italy. Methods We used a sequential exploratory mixed-methods design within the Refugee Initiative for Sexual Health (RIfESH). First, we conducted 20 in-depth interviews and 2 focus group discussions (n=15) with ARMSWs in Verona, Turin, and Milan to explore pathways into sex work, migration-stage experiences, and health-care access. Qualitative themes informed the development of a structured REDCap survey administered to 150 ARMSWs recruited through venue-based and snowball sampling. We used descriptive statistics and chi-square tests with Cramér’s V to examine associations between economic drivers (e.g., need for food, rent, and lack of other income) and sexual risk-taking, HIV service awareness, health-care discrimination, and reliance on traditional medicine. Integration occurred through side-by-side comparison and a joint display. Results Most participants (79%) relied on sex work as their sole income source, and 72% had entered sex work by age 25. Economic pressures related to rent, food, and having no other income were significantly associated with condomless sex, lower HIV service awareness, greater use of traditional medicine, and higher reports of hospital stigma and unmet health-care needs. Qualitative narratives showed how poverty, migration-stage coercion, racism, and client power constrained condom negotiation and access to care, often forcing participants to accept unsafe practices to survive. Conclusions Engagement in sex work among ARMSWs in Italy is primarily a survival response to structural exclusion rather than individual “risk-taking.” HIV prevention and care must be coupled with economic empowerment, anti-racist and stigma-free health services, and policies that recognize male refugee sex workers as a priority population.