Ximena Salazar

Understanding the HIV/AIDS Epidemic in Transgender Women of Lima, Peru: Results from a Sero-Epidemiologic Study Using Respondent Driven Sampling

In Latin America, transgender women (transwomen or male to female transgenders) have been included in MSM research but without addressing their specific needs in terms of the HIV/AIDS. We present results of the first seroepidemiologic study designed for transwomen in Peru. We conducted a study using respondent driven sampling to recruit transwomen from Lima. Our survey explored sociodemographic characteristics, gender enhancement procedures and sexual behavior. In addition, we conducted laboratory based HIV, genital herpes (HSV2) and syphilis testing. A total of 450 transwomen were recruited between April and July 2009. HIV prevalence was 30%, HSV2: 79% and syphilis: 23%. Sex-work was the main economic activity (64%). Gender enhancement procedures were reported by 70% of the population. Multivariable analysis showed HIV infection to be associated with being older than 35 recent, syphilis infection and HSV2 infection. Transwomen are the group most vulnerable to HIV/AIDS in Peru.ResumenEn Latinoamérica, las mujeres trans (personas trans de masculino a femenino) han sido incluídas en la investigación con población HSH sin abordar sus necesidades específicas en relación a la epidemia de VIH/SIDA. Presentamos los resultados del primer estudio sero-epidemiológico diseñado para mujeres trans en el Perú. Utilizamos un diseño transversal con respondent driven sampling (RDS). Las características socio-demográficas de la población, los procesos de transformación del cuerpo y las conductas sexuales fueron exploradas a través de una entrevista. Se realizaron pruebas de laboratorio para VIH, herpes genital (HSV2) y sífilis. Un total de 450 mujeres trans fueron enroladas en Lima entre abril y junio del 2009. La prevalencia de VIH encontrada fue de 30%, HSV2: 79% y sífilis: 23%. El trabajo sexual fue la principal actividad económica reportada (64%). Los procesos de modificación del cuerpo fueron reportados por el 70% de la población. El análisis mutivariable asoció la infección por VIH a una edad mayor a 35 años, la infección reciente por sífilis y la infección con HSV2. Este estudio muestra que las mujeres trans constituyen la población con mayor vulnerabilidad al VIH en el Perú.

Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations

This study examined pre-exposure prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, P < 0.001), followed by efficacy (21.4, P < 0.001) and potential side-effects (14.7, P < 0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of healthcare professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out.

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.

New populations at high risk of HIV / STIs in low-income urban coastal Peru.

The HIV epidemic in Peru is concentrated primarily among men who have sex with men. HIV interventions have focused exclusively on a narrowly defined group of MSM and FSW to the exclusion of other populations potentially at increased risk. Interventions targeting MSM and FSW are insufficient and there is evidence that focusing prevention efforts solely on these populations may ignore others that do not fall directly into these categories. This paper describes non-traditional, vulnerable populations within low-income neighborhoods. These populations were identified through the use of ethnographic and epidemiologic formative research methods and the results are reported in this publication. Although the traditional vulnerable groups are still in need of prevention efforts, this study provides evidence of previously unrecognized populations at increased risk that should also receive attention from HIV/STI prevention programs.

Vulnerability and sexual risks: Vagos and vaguitas in a low income town in Perú

Young people constitute a priority for sexual health research, policy and planning. Many studies, however, regard youth as a homogeneous group defined by developmental stages and their problems as inherent rather than factors resulting from structural vulnerability. Ethnographic data from this study provided strong evidence of the inappropriateness, in prevention interventions, of the concept of ‘young people’ as a group defined only by age and gender. When incorporating social resources and support into the analysis, specific segments of youth with diverse sexual practices and health seeking behaviours emerge. Thus, although most young people in urban areas show a similar level of HIV/STI knowledge, their exposure to risk varies according to their living conditions. Two population segments – “street guys” and “fast girls” – identified as vulnerable for sexual risk, are characterized. Both groups hang out on the streets, and most are involved in using alcohol and drugs, and/or practicing transactional sex. This study provided evidence for the need of various approaches according to level of poverty and social vulnerability in order to develop more effective HIV/AIDS and STI prevention programs to meet the needs of young men and women in low‐income areas.

HIV and Sexually Transmitted Infection Incidence and Associated Risk Factors Among High-Risk MSM and Male-to-Female Transgender Women in Lima Peru.

Background:Men who have sex with men (MSM) and male-to-female transgender women (TW) are at increased risk of HIV and sexually transmitted infections (STIs). We evaluated factors associated with incidence of HIV, HSV-2, and chlamydia and gonorrhea (anal and pharyngeal). Methods:We used data from the Comunidades Positivas trial with MSM/TW who have sex with men in Lima, Peru. Participants were asked about sexual risk behaviors and underwent HIV/STI testing at baseline and 9- and 18-month follow-ups. We used discrete time proportional hazards regression to calculate hazard ratios for variables associated with incidence of each STI. Results:Among 718 MSM/TW, HIV incidence was 3.6 cases per 100 person-years. HIV incidence was associated with having an incident STI adjusted hazard ratio (aHR) of 3.73. Unprotected receptive anal intercourse was associated with incident anal chlamydia (aHR 2.20). An increased number of sexual partners increased incident HSV-2 (aHR 3.15 for 6–14 partners and 3.97 for 15–46 partners compared with 0–2 partners). The risk of anal gonorrhea decreased with each sexually active year (aHR 0.94) and increased for unprotected compensated sex (aHR 2.36). The risk of pharyngeal gonorrhea also decreased with each year since sexual debut (aHR 0.95). The risk of anal chlamydia decreased with each sexually active year (aHR 0.96); the risk increased with reports of unprotected sex work (aHR 1.61) and unprotected receptive anal sex (aHR 2.63). All aHRs have P values <0.05. Conclusions:MSM/TW experience high incidence of HIV. Up-to-date prevalence and incidence information and identifying factors associated with infection can help develop a more effective combination prevention response.

Effect of a Community Popular Opinion Leader HIV/STI Intervention on Stigma in Urban, Coastal Peru

Evaluating interventions that reduce HIV stigma may help to craft effective stigma-reduction programs. This study evaluates the effects of a community popular opinion leader HIV/STI intervention on stigma in urban, coastal Peru. Mixed effects modeling was used to analyze data on 3,049 participants from the Peru site of the NIHM collaborative trial. Analyses looked at differences between the comparison and intervention groups on a stigma index from baseline to 12- and 24-month follow-up. Sub-analyses were conducted on heterosexual-identified men (esquineros), homosexual-identified men (homosexuales), and socially marginalized women (movidas). Compared to participants in the comparison group, intervention participants reported lower levels of stigma at 12- and 24-month follow-up. Similar results were found within esquineros and homosexuales. No significant differences were found within movidas. Findings suggest that interventions designed to normalize HIV prevention behaviors and HIV communication can reduce HIV-related stigma and change community norms.

Influencia del contexto sociocultural en la percepción del riesgo y la negociación de protección en hombres homosexuales pobres de la costa peruana

This paper focuses on risk, conceived not as an individual action, but considering its social dimension, analyzing the various forms in the socio-cultural context related to internalized homophobia and hegemonic gender norms that allow barriers to be constructed in risk perception. Such barriers hinder negotiation and protection among homosexual men that have adopted a female gender identity, living in low-income barrios of Lima and Trujillo, Peru. Risk perception is analyzed on the socio-cultural plane, allowing one to explain the limited negotiating capacity of this population, even though they have extensive knowledge of HIV/AIDS and its consequences.

Frequency, patterns, and preferences of lubricant use during anal intercourse within male sexual partnerships in Lima, Peru: Implications for a rectal microbicide HIV prevention intervention

Abstract Understanding current practices of lubricant use during anal intercourse can help to assess the contexts for the introduction of topical rectal microbicides as an HIV prevention tool for men who have sex with men (MSM). We used quantitative and qualitative methods to assess: current patterns of lubricant use; preferred characteristics of commercial lubricant formulations; and social and behavioral contexts of lubricant use within male sexual partnerships in Lima, Peru. Between 2007 and 2008, we conducted a quantitative behavioral survey with 547 MSM followed by qualitative individual and group interviews with 36 MSM from Lima, Peru. Approximately half of all participants in the quantitative survey (50.3%) reported using commercial lubricant during intercourse occasionally or consistently during the preceding two months, with lack of availability at the time of intercourse the most commonly reported reason for non-use. No clear preferences regarding the color, smell, taste, or viscosity of commercial lubricants were identified, and all participants who reported using a commercial lubricant used the same product (“Love-Lub”). In the qualitative analysis, participants characterized lubricant use as a sexual practice consistently controlled by the receptive partner, who typically obtained and applied lubricant independently, with or without the consent of the insertive partner. Quantitative findings supported this differential pattern of lubricant use, with men who reported sexual identities or roles consistent with receptive anal intercourse, including unprotected receptive intercourse, more likely to report lubricant use than MSM who claimed an exclusively insertive sexual role. Given the social, behavioral, and biological factors contributing to increased vulnerability for HIV and STI acquisition by the receptive partner in anal intercourse, delivery of a topical rectal microbicide as a lubricant formulation could provide an important HIV prevention resource for at-risk MSM in Lima, Peru.

‘Proyecto Orgullo’, an HIV prevention, empowerment and community mobilisation intervention for gay men and transgender women in Callao/Lima, Peru

ABSTRACT We used qualitative, quantitative, and observational methods to assess the feasibility, acceptability, and potential efficacy of Proyecto Orgullo (PO), a pilot community mobilisation intervention to decrease sexual risk, promote health-seeking behaviours, and facilitate personal and community empowerment among gay men (GM) and transgender women (TW) in Peru. PO was adapted from Mpowerment and Hermanos de Luna y Sol, two US interventions. PO included six interrelated core elements: (1) Self-reflection Small Group sessions; (2) Supporting peers in HIV prevention; (3) Mobilisation Activities addressing HIV, GM/TW issues, and community empowerment; (4) A Core Group (staff + GM/TW volunteers) designing/implementing those activities; (5) A Project Space; (6) Publicity. PO included specific components for TW, but promoted that GM/TW, who historically have not worked well together, collaborate for a common goal. We found that PO was embraced by GM/TW. PO positively influenced GM/TW’s HIV prevention beliefs, self-efficacy, and behaviours; provided social support and created community; facilitated individual and community empowerment; achieved that GM/TW collaborate; and established a functional Community Centre for socialising/conducting mobilisation activities. Community mobilisation strategies, lacking from HIV prevention efforts in Peru but considered key to HIV prevention, can help improve health-seeking behaviours and consolidate social norms supporting preventive behaviours among GM/TW.