G Paz-Bailey

Facilitating access to sexual health services for men who have sex with men and male-to-female transgender persons in Guatemala City

The purpose of this study was to identify barriers to accessing sexual health services among gay, bisexual and heterosexual-identifying men who have sex with men and male-to-female transgender persons in Guatemala City, to inform the development of high quality and population-friendly services. In-depth, semi-structured interviews were conducted with 29 purposively sampled individuals, including 8 transgender, 16 gay/bisexual and 5 heterosexual-identifying participants. Topical codes were applied to the data using software Atlas.ti™ to compare data between sub-groups. Analysis revealed that public clinics were most commonly used due to their lower cost and greater accessibility, but many participants experienced discrimination, violation of confidentiality and distrust of these services. Transgender and gay/bisexual-identifying participants preferred clinics where they felt a sense of belonging, while heterosexual-identifying participants preferred clinics unassociated with the men who have sex with men community. The most prominent barriers to sexual health services included fear of discrimination, fear of having HIV, cost and lack of social support. Findings highlight the need to strengthen existing public sexually transmitted infection clinics so that they address the multiple layers of stigma and discrimination that men who have sex with men and transgender persons experience.

Understanding Social and Sexual Networks of Sexual Minority Men and Transgender Women in Guatemala City to Improve HIV Prevention Efforts

Sexual minority men and transgender women are disproportionately affected by HIV in Guatemala. Innovative prevention strategies are urgently needed to address these disparities. While social network approaches are frequently used to reach sexual minorities, little is known about the unique network characteristics among sub-groups. We conducted in-depth qualitative interviews with 13 gay-identifying men, eight non-gay-identifying men who have sex with men (MSM) and eight transgender women in Guatemala City. Using narrative and thematic coding procedures, we identified distinct patterns in the size, composition, and overlap between social and sexual networks across groups. Gay-identifying men had the largest, most supportive social networks, predominantly comprising family. For both non-gay-identifying MSM and transgender women, friends and sex clients provided more support. Transgender women reported the smallest social networks, least social support, and the most discrimination. HIV prevention efforts should be tailored to the specific sexual minority population and engage with strong ties.

P1-S2.55 High incidence of HIV and low HIV prevention coverage among men who have sex with men in Managua, Nicaragua

Background High rates of HIV and sexually transmitted infections (STI) are found in men who have sex with men (MSM) in Nicaragua. This study investigated HIV, STI, and risk behaviours in MSM. Methods From 9/2009 to 2/2010, MSM 18 years or older who gave written informed consent and reported having anal sex with a man in the last year were recruited using respondent-driven sampling in Managua. The survey process included audio computer assisted survey instruments (ACASI) and face-to-face interviews followed by STI counselling and specimen collection for HIV (Uni-Gold Recombigen®, Determine®, HIV Elisa and Western Blot), HSV-2 (Elisa IgG Focus® Technology, Inc), and syphilis testing (RPR/TPPA). Gonorrhoea, Chlamydia, Mycoplasma genitalium and Trichomonas were tested by PCR. The BED IgG capture enzyme immunoassay was applied to HIV positive specimens to detect recently-acquired HIV infections, used to estimate HIV incidence. Population proportions and 95% CIs were calculated and adjusted for RDS-sampling weights. Incidence estimates were adjusted using a locally-established false-recent rate for the assay. Data analyses were conducted in STATA 9.0 and RDSAT 6.1. Results Respondents self-identified as bisexual (50%), gay (41%), heterosexual (1%) or transgender (8%). In the last year, 34.5% had one or more stable partner and 66% had occasional partners. Sex with women during lifetime was reported by 66% and 40% in the last year. Consistent condom use (last 30 days) was reported at 31% with stable male partner, 12%, with stable female partner, 38% with occasional partner, and 38% with clients. Condom use in last sex was 62%. Overall, 36% had received peer-driven outreach for HIV prevention and 64% had been tested for HIV in the last year. HIV prevalence in Managua was determined to be 7.5% (CI 4.5% to 11%), incidence 2.9% (CI 0.2% to 5.6%). Herpes simplex 2 was the most prevalent STI at 39.9% (CI 34.4% to 46%) see Abstract P1-S2.55 Table 1. Conclusions The 2003 Multicentric Study found a similar prevalence in Managua among MSM at 9.4% (CI 5.3% to 14.8%). Condom use is low with all types of partners, but lowest with female partners. The populations high HIV incidence, coupled with low access to education, underlines the urgency of enhancing prevention activities among this population. Stronger strategies are needed to ensure that prevention, care, and treatment interventions reach this population. Abstract P1-S2.55 Table 1 HIV and STI prevalence, men who have sex with men, ECVC Nicaragua, 2009 Managua N n % (95% CI) HIV 639 50 7.5 (4.5 to 11.1) Herpes simplex tipo 2 632 293 39.9 (34.4 to 46.0) Syphilis 641 52 6.6 (3.9 to 9.3) Active syphilis 641 26 2.9 (1.3 to 4.7) Neisseria gonorrhoeae 512 15 2.6 (0.8 to 4.7)  N gonorrhoeae (urine) 643 3 1.0 (0 to 2.1) N gonorrhoeae (rectal swab) 511 12 1.4 (0.4 to 2.6) Chlamydia trachomatis 516 29 4.3 (2.2 to 6.2) C trachomatis (urine) 643 11 1.5 (0.5 to 2.9) C trachomatis (rectal swab) 511 18 2.3 (1.0 to 3.7) Lymphogranuloma venereum 511 4 0.7 (0 to 1.5) Mycoplasma genitalium 643 16 2.4 (1.1 to 3.9) Trichomonas vaginalis 643 4 0.7 (0.1 to 1.4) HIV or any STI* 530 147 24.9 (18.9 to 29.7) Any STI 526 110 17.6 (12.5 to 21.6) * Including HIV, Syphilis, Chlamydia, Gonorrhoea, Mycoplasma genitalium or Trichomonas.

P1-S4.08 Population size estimates for men who have sex with men in Guatemala City using time location sampling and respondent driven sampling

Background Men who have sex with men (MSM) are highly vulnerable to HIV infection, but this population can be particularly difficult to reach in Central America due to stigma and violence. Knowing the size of populations at high risk for HIV and sexually transmitted infections (STI) is critical for informing prevention, care, and treatment programs. Simple approaches are needed to provide baseline estimates of the population size of MSM in Guatemala to advocate for appropriate resource allocation and programming. We compared population size estimates of MSM and transgender persons using capture-recapture linked to two differentsurveys that were developed concurrently using different sampling methodologies. Methods Capture recapture methods for estimating population size were integrated into two probability-based surveys using respondent driven sampling (RDS) and time-location sampling (TLS); conducted simultaneously among MSM in Guatemala City from October to December 2010. Key chains were used as uUnique objects in the form ofand study key chains were distributed approximately 1-month prior to the surveys in venues known to be frequented by MSM. Duplicate participation was avoided by using the same team to distribute the key chains and administering a set of questions before handing the object. Participants in the RDS and TLS surveys were asked, as part of the study interview, whether they had received the key chain. We assigned the number of key chains distributed in venues as the first capture and the proportion of participants that reported receiving the key chain in the RDS or TLS survey as the second capture. By applying standardised formulas for estimating population size using capture-recapture methods, we estimated the number of MSM in Guatemala City and 95% CIs around this estimate, adjusted for RDS and TLS sampling design. Results A total of 2128 key chains were distributed in the first capture. Of the 501 MSM interviewed in the RDS survey, 200 (RDS adjusted, 23.4%) had received the key chain. Thus the RDS adjusted estimated population size of MSM in Guatemala City was 9,190 (95% CI 7765 to 10 616). Of the 504 MSM interviewed in the TLS survey, 193 (TLS adjusted, 32.1%) had received the key chain. The TLS adjusted estimated number of MSM was 6620 (95% CI 5813 to 7427). Conclusions Estimates of MSM population size using the TLS survey resulted in a significantly lower estimate than that obtained through RDS survey, probably due to the fact that TLS targets MSM who attend venues. The estimate obtained through RDS may better reflect the size of the larger MSM population in Guatemala City, since this itRDS reaches MSM attending and not attending publicmeeting venues. Integrating capture-recapture methods in probability-based surveys among MSM is a simple and fast approach for providing the population sizes needed to inform and evaluate programs for MSM in Guatemala.

P5-S6.17 Facilitating access to sexual health services for men who have sex with men (MSM) and transgender persons in Guatemala city

Background Men who have sex with men (MSM) and transgender persons are disproportionately affected by sexually transmitted infections (STIs), including HIV, in Guatemala. Access to integrated sexual health prevention and treatment services is limited. The purpose of this study was to identify barriers to accessing sexual health services among gay, bisexual, and non-gay identified MSM and male-to-female transgender persons in Guatemala City to inform the development of high quality and population-friendly services that are sensitive to the needs of this population. Methods Semi-structured in-depth interviews were conducted with 27 purposively sampled participants, including 7 transgender, 11 gay, 5 bisexual, and 4 non-gay-identified participants, in Guatemala City. Interview topics included experiences with sexual health services, perceived barriers to access, social and sexual network characteristics, and HIV risk behaviours. Topical codes were developed based on readings of interview transcripts and codes were applied to the data using the qualitative software Atlas.ti. Data were compared between study sub-groups using thematic matrices and analytic memos. Results Across all participants, public clinics were the most commonly used sexual health services due to their lower cost and greater accessibility, but many participants provided examples of discrimination, violation of confidentiality, and distrust in the quality of services offered. Transgender and gay participants preferred clinics where they felt a sense of belonging while non-gay identified participants preferred clinics that were not associated with the MSM community. The most prominent barriers to sexual health services described by participants included fear of discrimination related to sexual identity and/or behaviour, fear of having HIV and the associated stigmatisation, cost, and lack of social support. Conclusions Findings highlight the need to strengthen and expand existing public STI clinics to improve access to services among MSM and transgender populations in Guatemala City. These services must address the multiple layers of stigma and discrimination that MSM and transgender persons experience related to identity, behaviour, and STI/HIV. Insights from this study are currently being applied to the implementation of two public clinics in Guatemala City that seek to provide a discrete, non-judgemental environment where individuals can seek affordable services without fear.