Amaya Perez-Brumer

Individual- and Structural-Level Risk Factors for Suicide Attempts Among Transgender Adults

This study assessed individual (ie, internalized transphobia) and structural forms of stigma as risk factors for suicide attempts among transgender adults. Internalized transphobia was assessed through a 26-item scale including four dimensions: pride, passing, alienation, and shame. State-level structural stigma was operationalized as a composite index, including density of same-sex couples; proportion of Gay–Straight Alliances per public high school; 5 policies related to sexual orientation discrimination; and aggregated public opinion toward homosexuality. Multivariable logistic generalized estimating equation models assessed associations of interest among an online sample of transgender adults (N = 1,229) representing 48 states and the District of Columbia. Lower levels of structural stigma were associated with fewer lifetime suicide attempts (AOR 0.96, 95% CI 0.92–0.997), and a higher score on the internalized transphobia scale was associated with greater lifetime suicide attempts (AOR 1.18, 95% CI 1.04–1.33). Addressing stigma at multiple levels is necessary to reduce the vulnerability of suicide attempts among transgender adults.

State-level structural sexual stigma and Hiv prevention in a national online sample of Hiv-uninfected Msm in the United States

Background:Stigmatizing social environments (of which ‘structural stigma’ is one component) negatively affect health-related outcomes. However, few studies have examined structural stigma related to sexual minority status as a risk factor for HIV outcomes among MSM. Methods:In August 2013, members of a large MSM social and sexual networking site in the United States completed a survey about HIV-prevention practices. A previously validated composite index provided values for state-level structural stigma, including density of same-sex couples, proportion of public high schools with Gay-Straight Alliances, state laws protecting sexual minorities, and public opinion toward homosexuality. Multivariable logistic generalized estimating equations assessed the relationship between structural stigma and condomless anal intercourse, use and awareness of antiretroviral-based HIV-prevention strategies (i.e. pre and postexposure prophylaxis, or PEP and PrEP), and comfort discussing male–male sex with primary care providers. Results:Among the 4098 HIV-uninfected MSM, lower state-level structural stigma was associated with decreased odds of condomless anal intercourse [adjusted odds ratio (aOR) 0.97 per one unit increase in structural stigma score, 95% confidence interval (CI) 0.94–0.99], increased odds of awareness of PEP (aOR 1.06, 95% CI 1.02–1.09), and PrEP (aOR 1.06, 95% CI 1.02–1.10), having taken PEP (aOR 1.15, 95% CI 1.05–1.26) and PrEP (aOR 1.21, 95% CI 1.01–1.44), and comfort discussing male–male sex with providers (aOR 1.08, 95% CI 1.05–1.11), after adjusting for social and state-level confounders. Conclusion:MSM living in more stigmatizing environments had decreased use of antiretroviral-based HIV-prevention strategies compared to those in less stigmatizing environments. Legal reforms protecting sexual minorities should be evaluated as structural interventions that could reduce HIV risk among MSM.

Moderno love: sexual role-based identities and HIV/STI prevention among men who have sex with men in Lima Peru.

Role-based sexual identities structure male same-sex partnerships and influence HIV/STI epidemiology among MSM in Latin America. We explored shifting relationships between sexual roles, identities and practices among MSM in Lima, Peru, and implications for HIV/STI prevention. Patterns of HIV/STI epidemiology reflected differential risks for transmission within role-based partnerships with relatively low prevalences of HIV, syphilis, and HSV-2 but higher prevalences of urethral gonorrhea/chlamydia among activo MSM compared with moderno and pasivo participants. Qualitative analysis of how MSM in Peru integrate sexual identities, roles, and practices identified four key themes: pasivo role as a gay approximation of cultural femininity; activo role as a heterosexual consolidation of masculinity; moderno role as a masculine reconceptualization of gay identity; and role-based identities as social determinants of partnership, network, and community formation. The concept of role-based sexual identities provides a framework for HIV prevention for Latin American MSM that integrates sexual identities, practices, partnerships, and networks.ResumenLas identidades basadas en roles sexuales forman la estructura de las relaciones de pareja e influyen en la epidemiología del VIH/ITS entre HSH en América Latina. Se exploró la relación cambiante entre roles, identidades, y practicas sexuales en HSH en Lima, Perú y las implicaciones para la prevención del VIH. Los patrones epidemiológicos del VIH/ITS mostraron diferencias en riesgos de transmisión en parejas definidas por roles sexuales con una prevalencia relativamente baja de VIH, sífilis, y HSV-2, pero una prevalencia alta de gonorrea/clamidia uretral en HSH activos en comparación a modernos y pasivos. El análisis cualitativo de como los HSH en el Perú integran sus identidades, roles y practicas identificó cuatro ejes temáticos: El rol pasivo como una aproximación gay de la feminidad cultural; el rol activo como una consolidación heterosexual de la masculinidad; el rol moderno como una reconceptualización masculina de la identidad gay; y las identidades basadas en roles sexuales como determinantes de la formación de parejas, redes, y comunidades. El concepto de identidades sexuales basadas en roles sexuales ofrece un marco analítico para la prevención del VIH entre HSH Latinoamericanos que puede integrar las identidades, prácticas, parejas, y redes sexuales.

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.

Despite the efficacy of pre‐exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real‐world settings outside of clinical trials.

Poverty matters: contextualizing the syndemic condition of psychological factors and newly diagnosed HIV infection in the United States.

Background:‘Syndemic factors’, defined as co-occurring psychological conditions including major depressive disorder, substance and alcohol use, and intimate partner violence, have been shown to increase HIV incidence among MSM in the United States. However, this relationship has not been well characterized in the general population, particularly in the context of poverty. Design:Prospective cohort study including a nationally-representative sample of 34 427 men and women in the National Epidemiologic Survey on Alcohol and Related Conditions wave 1 (2001–2002) and wave 2 (2004–2005). Methods:Weighted multivariable logistic regression models were used to assess the association between syndemic factors and newly diagnosed HIV infection, and to assess how living below the poverty line (based on 2001 US Poverty Guidelines) modified this relationship. Results:The proportion of participants reporting new HIV diagnosis in the past year was 0.22%, increasing from 0.19% among individuals with no syndemic factor to 5.1% among those with four syndemic factors. Adjusting for potentially confounding factors, each additional syndemic factor was associated with a 47% increase in odds of HIV infection [adjusted odds ratio (aOR) 1.47, 95% confidence interval (CI) 1.30–1.65]. The effect of syndemic factors was stronger among individuals living below federal poverty guidelines (aOR 1.96, 95% CI 1.57–2.44) compared to those living above poverty guidelines (aOR 1.21, 95% CI 1.07–1.36). Conclusions:Among the US general population, the association between co-occurring syndemic factors and incident HIV infection was stronger in the setting of poverty. Mental health interventions, particularly in socioeconomically disadvantaged areas, should be considered to reduce transmission of HIV.

Prevalence of HIV, STIs, and Risk Behaviors in a Cross-Sectional Community- and Clinic-Based Sample of Men Who Have Sex with Men (MSM) in Lima, Peru

Background Further research is necessary to understand the factors contributing to the high prevalence of HIV/STIs among men who have sex with men (MSM) in Peru. We compared HIV/STI prevalence and risk factors between two non-probability samples of MSM, one passively enrolled from an STI clinic and the other actively enrolled from community venues surrounding the clinic in Lima, Peru. Methods A total of 560 self-identified MSM were enrolled between May-December, 2007. 438 subjects enrolled from a municipal STI clinic and 122 subjects enrolled during community outreach visits. All participants underwent screening for HIV, syphilis, HSV-2, gonorrhoea, and chlamydia and completed a survey assessing their history of HIV/STIs, prior HIV testing, and sexual behavior. Results HIV prevalence was significantly higher among MSM enrolled from the clinic, with previously undiagnosed HIV identified in 9.1% compared with 2.6% of community participants. 15.4 % of all MSM screened were infected with ≥1 curable STI, 7.4% with early syphilis (RPR≥1∶16) and 5.5% with urethral gonorrhoea and/or chlamydia. No significant differences between populations were reported in prevalence of STIs, number of male sex partners, history of unprotected anal intercourse, or alcohol and/or drug use prior to sex. Exchange of sex for money or goods was reported by 33.5% of MSM enrolled from the clinic and 21.2% of MSM from the community (p = 0.01). Conclusions Our data demonstrate that the prevalence of HIV and STIs, including syphilis, gonorrhoea, and chlamydia are extremely high among MSM enrolled from both clinic and community venues in urban Peru. New strategies are needed to address differences in HIV/STI epidemiology between clinic- and community-enrolled samples of MSM.

Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis.

Background Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts. Methods We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004–2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men. Findings Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5). Conclusions The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.

Social, structural, behavioral and clinical factors influencing retention in Pre-Exposure Prophylaxis (PrEP) care in Mississippi

Pre-exposure prophylaxis (PrEP) is a biomedical intervention that can reduce rates of HIV transmission when taken once daily by HIV-negative individuals. Little is understood about PrEP uptake and retention in care among the populations most heavily impacted by the HIV epidemic, particularly among young men who have sex with men (YMSM) in the Deep South. Therefore, this study explored the structural, social, behavioral, and clinical factors that affect PrEP use and retention in care among YMSM in Jackson, Mississippi. Thirty MSM who were prescribed PrEP at an outpatient primary care clinic were interviewed and included 23 men who had been retained in PrEP care and seven who had not been retained. The mean age of participants was 26.6 years. Most (23) participants were African American. Major factors affecting PrEP use and retention in PrEP care included 1) structural factors such as cost and access to financial assistance for medications and clinical services; 2) social factors such as stigma and relationship status; 3) behavioral factors including sexual risk behaviors; and 4) clinical factors such as perceived and actual side effects. Many participants also discussed the positive spillover effects of PrEP use and reported that PrEP had a positive impact on their health. Four of the seven individuals who had not been retained re-enrolled in PrEP care after completing their interviews, suggesting that case management and ongoing outreach can enhance retention in PrEP care. Interventions to enhance retention in PrEP care among MSM in the Deep South will be most effective if they address the complex structural, social, clinical, and behavioral factors that influence PrEP uptake and retention in PrEP care.

The risk of stable partnerships: Associations between partnership characteristics and unprotected anal intercourse among men who have sex with men and transgender women recently diagnosed with HIV and/or STI in Lima, Peru

Background Partnership type is an important factor associated with unprotected anal intercourse (UAI) and subsequent risk for HIV and sexually transmitted infections (STI). We examined the association of partnership type with UAI among men who have sex with men (MSM) and male-to-female transgender women (TGW) in Lima, Peru, recently diagnosed with HIV and/or STI. Methods We report data from a cross-sectional analysis of MSM and TGW recently diagnosed with HIV and/or STI in Lima, Peru between 2011 and 2012. We surveyed participants regarding UAI with up to their three most recent sexual partners according to partner type. Multivariable Generalized Estimate Equating (GEE) models with Poisson distribution were used to estimate prevalence ratios (PR) for UAI according to partner type. Results Among 339 MSM and TGW recently diagnosed with HIV and/or STI (mean age: 30.6 years, SD 9.0), 65.5% self-identified as homosexual/gay, 16.0% as bisexual, 15.2% as male-to-female transgender, and 3.3% as heterosexual. Participants provided information on 893 recent male or TGW partners with whom they had engaged in insertive or receptive anal intercourse: 28.9% stable partners, 56.4% non-stable/non-transactional partners (i.e. casual or anonymous), and 14.7% transactional partners (i.e. transactional sex client or sex worker). Unprotected anal intercourse was reported with 41.3% of all partners. In multivariable analysis, factors associated with UAI included partnership type (non-stable/non-transactional partner APR 0.73, [95% CI 0.59–0.91], transactional partner APR 0.53 [0.36–0.78], p<0.05) and the number of previous sexual encounters with the partner (>10 encounters APR 1.43 [1.06–1.92], p<0.05). Conclusion UAI was more commonly reported for stable partners and in partnerships with >10 sexual encounters, suggesting UAI is more prevalent in partnerships with a greater degree of interpersonal commitment. Further research assessing partner-level factors and behavior is critical for improving HIV and/or STI prevention efforts among Peruvian MSM and TGW.

Leveraging social capital: Multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru

Introduction: In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community‐level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.