Substance Use and HIV Risk Among African Refugee and Migrant Sex Workers in Italy: A Mixed-Methods Study Informed by Syndemic Theory.

Substance use is a recognized driver of HIV vulnerability among sex workers, yet little is known about how behavioral patterns intersect with structural exclusion for African male and gender-diverse refugee and migrant sex workers in Italy. Informed by syndemic theory, we conducted a sequential mixed-methods study in partnership with a community-based organization in Northern Italy. The qualitative strand included 20 in-depth interviews and two focus group discussions exploring experiences of substance use, stigma, and healthcare engagement. The quantitative strand comprised a structured survey of 150 participants assessing changes in substance use before and after entering sex work and its associations with HIV-related outcomes. Participants reported significantly higher substance use after entering sex work than before entering sex work, with increases observed for both substance types. Logistic regression and chi-square analyses revealed distinct patterns by substance type: injection-related substance use was associated with a lower likelihood of HIV testing, reduced enjoyment of sex work, reduced healthcare engagement, alongside higher STI diagnosis and testing. Non-injection use was linked to greater HIV service awareness, higher odds of disclosure, and higher STI diagnosis and testing. Chi-square tests indicated that escalating tobacco, alcohol, and drug use were associated with increased HIV testing, higher reports of healthcare stigma, immigration-related barriers, and reduced voluntary healthcare access. Qualitative findings contextualized these patterns, highlighting how stigma, financial precarity, and institutional exclusion shaped substance use trajectories and HIV risk. Integrated analysis underscores the need for interventions addressing structural discrimination and immigration-related barriers alongside behavioral HIV prevention for refugee sex workers.