Is the HIV epidemic stable among MSM in Mexico? HIV prevalence and risk behavior results from a nationally representative survey among men who have sex with men

Awareness, willingness to use pre-exposure prophylaxis, and use of post-exposure prophylaxis for HIV prevention among men who have sex with men in Mexico

BACKGROUND

Little is known about awareness and willingness to use or purchase HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Mexico.

METHODS

MSM in Mexico were recruited via advertisements on online social venues to participate in Encuesta de Sexo Entre Hombres, an online behavioral survey. Awareness of PrEP, willingness to take PrEP if available for free, willingness to purchase PrEP, awareness of post-exposure prophylaxis (PEP), and ever PEP use were assessed in descriptive and multivariate analyses.

RESULTS

Overall, 54.8% (4588/8376) of participants were aware of PrEP. Of those aware, 77.6% were willing to use PrEP if free and 52.6% were willing to purchase PrEP, generally at a maximum monthly cost of $500MXP. Both awareness of and willingness to use PrEP if free or for purchase were significantly greater among MSM who were younger, and varied by demographic, recent healthcare use, and behavioral risk factors. Only 8.2% had ever used PEP, which was highly associated with healthcare utilization.

CONCLUSIONS

About half of Mexican MSM were aware of PrEP. The majority of those aware were willing to use PrEP if available for free and many were willing to purchase PrEP at low cost. Leveraging demographic, recent healthcare use, and behavioral risk characteristics associated with awareness and willingness to use PrEP could be useful in designing future PrEP programs for MSM in Mexico. Expanding healthcare settings in which PEP is available may also support identifying candidates for PrEP and scaling up PrEP implementation.

Designing a Local Policy to Reduce HIV in Mexico City

The Joint United Nations Program on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (Joint United Nations Program on HIV/AIDS, UNAIDS) has recommended 90-90-90 goals to increase the number of patients who are aware of their status, on antiretroviral therapy, and have undetectable viral loads. Mexico City has made several achievements to aid in prevention, early diagnosis, and treatment; however, the incidence of HIV has not decreased over the past decade. This article reviews global initiatives that were successful in achieving some or all these metrics and provide a road map for Mexico to reach the desired goals.

Examining Geographical Differences in the HIV Care Continuum Among Men Who Have Sex with Men in Mexico

We analyzed data collected by the Encuesta de Sexo Entre Hombres study from 15,233 Mexican men who have sex with men (MSM) between May-July 2017 to examine differences in the HIV care continuum. Data were stratified into 6 geographical regions. Prevalence ratios assessed associations between region and care outcomes. Among participants never testing HIV positive (n = 13,583), 66.1% had ever been tested and 43.0% in the past year. Among HIV-positive persons (n = 1,650), 83.9% reported counseling post-diagnosis, 61.9% timely linkage to care, 42.4% timely CD4/viral load results, 38.2% timely access to antiretroviral therapy (ART), and 87.7% were currently on ART. The Ciudad de México /Estado de México region had significantly superior care continuum outcomes in ever and recent HIV testing, linkage to care, CD4/viral load results, and current ART use. Understanding geographical variations in HIV care for MSM in Mexico is one important step to inform efforts for ending HIV/AIDS by 2030 in Latin America.

High Prevalence of Syphilis and Syphilis/HIV Coinfection among Men Who Have Sex with Men Who Attend Meeting Places in Mexico

Men who have sex with men (MSM) are disproportionately affected by syphilis, HIV, and syphilis/HIV coinfection. Antiretroviral therapy (ART) prevents HIV transmission but does not impede the spread or acquisition of syphilis. Information about syphilis/HIV coinfection among MSM is scarce. We aimed to determine the prevalence of syphilis/HIV coinfection in a national sample of MSM who attend meeting places (such as movies, clubs, gay bars, saunas, shopping malls, and others referred to by the same MSM participants of the study) in Mexico to evaluate factors associated with syphilis, and to compare the prevalence rates of syphilis between the current survey and DGE data. We performed a laboratory diagnosis to determine the rates of syphilis and HIV among the included MSM. The national and regional prevalence of syphilis was calculated. HIV and coinfection prevalence were determined only for the survey. All prevalence rates included 95%CIs. Descriptive, bivariate, and multivariate analyses were performed. The national prevalence rates of syphilis, HIV, and coinfection were 15.2%, 10.2%, and 5.7%, respectively. The region with the highest prevalence rate was Mexico City (39.4%). The center region, minimal “goods” (i.e., a minimal number of material possessions such as a car or dryer, etc., which served as a proxy for low economic income level), use of “inhalant drugs”, “HIV infection”, “sexual intercourse” only with men, “rewarded sex”, and “youngest age at first sexual encounter or debut” were risk factors for syphilis. In general, regional prevalence of syphilis was higher in the survey (2013) and DGE data from 2019 than in the DGE data from 2013. Similar to other countries, Mexico needs to assess elements around not only syphilis and HIV infections but also syphilis/HIV coinfection, and preventive measures focusing on MSM are needed.

High Incidence, Reinfections, and Active Syphilis in Populations Attending a Specialized HIV Clinic in Mexico, a Dynamic Cohort Study

Syphilis, a sexually transmitted infection, has reemerged in many vulnerable groups around the world. The objective of the current study was to determine the prevalence and incidence of syphilis among people who attended a specialized HIV clinic in Mexico from 2011 to 2015. Databases from the laboratory were analyzed, and the following four groups were formed: people seeking HIV-1 voluntary counseling and testing (VCT), people in prison (PPr), people living with HIV (PLWH), and patients from primary care clinics (others). The diagnosis of syphilis was made using the reverse algorithm; antibody titers were examined to determine the stage of infection. Baseline data were analyzed and, with follow-up information, a retrospective dynamic cohort was formed. Factors associated with the seroprevalence of syphilis and active syphilis were evaluated by the chi-square test. Moreover, risk factors for the incidence of syphilis were described. A total of 81,863 baseline individuals were analyzed. The seroprevalence of syphilis was 9.9% in the VCT group, 8.2% in the PPr group, 37.0% in the PLWH group, and 8.7% in the others group; the prevalence of active syphilis was 1.7-13.1%. A total of 11,124 people were followed up. The incidence (cases per 100 person-years) was 3.5 among the VCT group, 16.0 among the PLWH group, and < 0.1 among both the PPr and others groups, respectively; moreover, the frequency of reinfections was 11.1-24.4%. The high prevalence and incidence of syphilis, active syphilis, and reinfections among men, transgender people, individuals aged 20-39 years, and people with a history of HIV or hepatitis B suggest that it is critical to improve prevention, diagnosis, and treatment measures to stop the reemergence of syphilis. There are also new factors such as methamphetamine use, group sex, or contacting partners over the internet that are associated with syphilis. In addition, HIV preexposure prophylaxis could contribute to the increased incidence of syphilis by providing false security in the prevention of STIs, thereby increasing risky sexual behaviors.

Patient sexuality disclosure experience and associations with clinical sexual health outcomes among HIV-negative men who have sex with men in Mexico

Many men who have sex with men (MSM) do not disclose their sexuality to their healthcare provider, despite potential health benefits. Data from the 2017 Encuesta de Sexo Entre Hombres online survey of 13,277 HIV-negative or unknown status MSM in Mexico were used to explore MSM patients' sexuality disclosure experience on sexual health outcomes using multivariable Poisson models with robust variance estimation to estimate adjusted prevalence ratios (aPR). Sexual health outcomes included Hepatitis B (HepB) and human papillomavirus (HPV) vaccination, and lifetime and past year HIV testing. Overall, 53.9% (n/N) disclosed their sexuality to their healthcare provider, and of those 6.4%, 62.9%, and 30.7% reported a negative, neutral, or positive disclosure experience, respectively. In comparison to no disclosure, neutral and positive disclosure experiences were associated with HepB vaccination (aPR[95% Confidence Interval (95% CI)] = 1.17[1.09, 1.25], p < 0.001; aPR[95% CI] = 1.35[1.25, 1.46], p < 0.001, respectively) and positive disclosure experiences were associated with HPV vaccination (aPR[95% CI] = 1.46[1.24, 1.71], p < 0.001). Those who disclosed their sexual behavior were more likely than those who did not disclose their sexual behavior to have received an HIV test in their lifetime (negative: aPR[95% CI] = 1.51[1.43, 1.60], p < 0.001; neutral: aPR[95% CI] = 1.61[1.56, 1.66], p < 0.001; positive: aPR[95% CI] = 1.64[1.58, 1.69], p < 0.001) and an HIV test in the past year (negative: aPR[95% CI] = 1.89[1.70, 2.10], p < 0.001; neutral: aPR[95% CI] = 2.09[1.98, 2.20], p < 0.001; positive: aPR[95% CI] = 2.24[2.12, 2.37], p < 0.001). There is a need to implement trainings for healthcare providers that focus on sexual health risk assessments and creating a space that encourages MSM patients and healthcare providers to discuss sexual health.

Identity and Relational Factors Associated with Sexual Role and Positioning for Anal Sex among Colombian Sexual Minority Men

This study aimed to identify Top, Bottom, and Versatile sexual role identities and anal sex behavior profiles using latent class analysis in a sample of 942 sexual minority men living in Bogotá. A Versatile-insertive and receptive class (52.2%) was the most prevalent of the four resulting classes, whereas the least common was a class (1.7%) that did not use labels and had a low probability of anal sex. We examined whether identity and relational factors (i.e., sexual orientation, LGBT collective identity, and partner type) were associated with profiles. Gay identity was associated with versatile and receptive classes and bisexual identity was associated with insertive and versatile classes. LGBT collective identity was associated with the class characterized by Bottom identity and receptive positioning. Partner type was not associated with class membership, but versatile behaviors were more common among encounters with a main partner. Models using data at different timescales offered consistent patterns of behavior between the last encounter and the past three months, though the versatile class in the three-month model split into two classes based on frequency of versatile positioning. Findings highlight the relationship between sexual identity and positioning and can inform interventions for sexual health education and identity development.

Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses

Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.

The Emergence of Hepatitis C Virus Genotype 4d Among Human Immunodeficiency Virus-Infected Patients in Mexico City: A Molecular Epidemiological Study

ABSTRACT

The recent detection of hepatitis C virus genotype 4 infection in human immunodeficiency virus-infected patients prompted performing molecular characterization of these isolates. All the Mexican isolates belonged to a subcluster within the 4d group and shared a common ancestor with a French isolate. The estimated timing of introduction in Mexico City was as recent as December 2015.

Factors Associated with Unprotected Anal Sex among Men Who Have Sex with Men in Mexico

The global prevalence of HIV is notably higher in men who have sex with men (MSM) compared with other male populations. Unprotected anal intercourse is the riskiest sexual behavior for HIV acquisition and/or transmission among this minority population. The purpose of the study was to identify if the syndemic of psychosocial stressors and experienced stigma are predictors of unprotected anal sex in Mexican MSM. A cross-sectional analytic study was carried out. It included adults residing in Manzanillo, Mexico, with oral/anal sex practices within the last year. Informed consent was given by 142 participants selected using snowball sampling. Collected data included sociodemographic characteristics, psychosocial stressors, experienced stigma, HIV knowledge, knowing a friend/acquaintance living with HIV/AIDS, and sexual risk behaviors. Adjusted logistic regression was used to identify predictors of unprotected anal sex within the last six months. Presence of syndemic of psychosocial stressors, drug use during sex, having friends/acquaintances with HIV/AIDS, and experiencing high stigma were positively associated; high level of HIV knowledge was negatively linked. Reducing psychosocial stressors and integrating stigma-mitigation strategies are key elements to reduce HIV transmission.

Metodología de una encuesta por internet para hombres que tienen sexo con hombres en México

OBJETIVO

Describir el diseño, implementación y el perfil de los participantes de la Encuesta de Sexo Entre Hombres (ES Entre Hombres). Material y métodos. ES Entre Hombres es una encuesta en línea no probabilística aplicada a nivel nacional a hombres de 18 años o más, que tienen sexo con hombres (HSH) y que usan internet. La población de estudio se reclutó a través de publicidad en diversos sitios de encuentro en línea y los cuestionarios se autoaplicaron con SurveyGizmo.

RESULTADOS

Durante 11 semanas se registró un total de 15 875 autoaplicaciones elegibles y completas de las 32 entidades del país. La mayoría de los participantes fueron jóvenes (<29 años; 65.7%) y personas que acceden a internet diariamente (94.3%). Conclusión. Las encuestas realizadas por internet para poblaciones como los HSH representan un método costoefectivo de estudio poblacional, ya que tienen el potencial de ahorrar recursos y alcanzar muestras grandes, lo que a la vez facilita la cobertura geográfica a un bajo costo.

Virologic failure in people living with HIV in 1st line ART: A 10-year Mexican population-based study

Background

In Mexico, the number of people living with HIV (PLWH) receiving antiretroviral therapy (ART) has increased in the last 20 years. The elimination of a CD4 threshold to initiate publicly funded ART was a major policy implemented in 2014. The study objective was to assess the determinants of Virologic Failure (VF) in Mexican PLWH on first-line ART between 2008 and 2017 and to evaluate the effects of changes following the 2014 policy.

Methods

A 10-year patient-level data analysis was conducted using the Mexican SALVAR database. The main outcome was the proportion of PLWH with VF. A multivariable logistic regression was conducted to identify the association between covariates and VF before and after the 2014 policy implementation.

Results

We found a lower proportion of people with VF in 2014–2017 compared with 2008–2013 (50% vs 33%, p<0.001). The multivariable analysis showed a reduction in the odds of virologic failure after 2014 (Odds ratio: 0.50 [95% CI: 0.48–0.51]). Place of treatment and level of deprivation were significant predictors of VF in during 2014–2017, but not before.

Conclusion

This study indicates that, by lowering threshold levels of CD4 required for treatment initiation in Mexico, a higher number of PLWH initiated treatment during 2014–2017, compared to 2008–2013 and the odds of VF were reduced.

Association Between Overt and Subtle Experiences of Discrimination and Violence and Mental Health in Homosexual and Bisexual Men in Mexico

The aim of this study was to determine whether the experiences of direct or subtle forms of discrimination and violence are associated with mental health in Mexican gay, homosexual, and bisexual (GHB) men. A cross-sectional survey was conducted online; the sample consisted of 4,827 GHB men. Ten forms of overt and subtle sexual orientation-based discrimination and violence (SO-DV) were assessed. Linear and logistic regression models were used to evaluate the association between SO-DV experiences and mental health outcomes. Physical violence was reported less frequently than the other forms of SO-DV. As the number of settings in which SO-DV were experienced increased, a stronger association with negative mental health outcomes was observed. Experiences of subtle SO-DV were associated with increased distress, lower vitality, and increased risk of suicidal ideation. Disapproval of gender nonconformity was associated with negative mental health outcomes independently of violence based on sexual orientation. Subtle forms of SO-DV are more common than direct and overt forms. Both types of SO-DV could negatively affect mental health. Studies investigating these negative experiences are required to gain an understanding of the health inequalities faced by non-heterosexual populations.

Patient characteristics and determinants of CD4 at diagnosis of HIV in Mexico from 2008 to 2017: a 10-year population-based study

BACKGROUND

In 2007-2012 the Mexican government launched the National HIV program and there was a major change in HIV policies implemented in 2013-2018, when efforts focused on prevention, increase in early diagnosis and timely treatment. Still, late HIV diagnosis is a major concern in Mexico due to its association with the development of AIDS development and mortality. Thus, the objectives of this study were to identify the determinants of late HIV diagnosis (i.e. CD4 count less than 200 cells/mm3) in Mexico from 2008 to 2017 and to evaluate the impact of the 2013-2017 National HIV program.

METHODS

Using patient level data from the SALVAR database, which includes 64% of the population receiving HIV care in Mexico, an adjusted logistic model was conducted. Main study outcomes were HIV late diagnosis which was defined as CD4 count less than 200 cells/mm3 at diagnosis.

RESULTS

The study included 106,830 individuals newly diagnosed with HIV and treated in Mexican public health facilities between 2008 and 2017 (mean age: 33 years old, 80% male). HIV late diagnosis decreased from 45 to 43% (P < 0.001) between 2008 and 2012 and 2013-2017 (i.e. before and after the implementation of the 2013-2017 policy). Multivariable logistic regressions indicated that being diagnosed between 2013 and 2017 (odds ratio [OR] = 0.96 [95% Confidence interval [CI] [0.93, 0.98]) or in health facilities specialized in HIV care (OR = 0.64 [95% CI 0.60, 0.69]) was associated with early diagnosis. Being male, older than 29 years old, diagnosed in Central East, the South region of Mexico or in high-marginalized locality increased the odds of a late diagnosis.

CONCLUSIONS

The results of this study indicate that the 2013-2017 National HIV program in Mexico has been marginally successful in decreasing the proportion of individuals with late HIV diagnosis in Mexico. We identified several predictors of late diagnosis which could help establishing health policies. The main determinants for late diagnosis were being male, older than 29 years old, and being diagnosed in a Hospital or National Institute.

Characteristics and growth of the genetic HIV transmission network of Mexico City during 2020

INTRODUCTION

Molecular surveillance systems could provide public health benefits to focus strategies to improve the HIV care continuum. Here, we infer the HIV genetic network of Mexico City in 2020, and identify actively growing clusters that could represent relevant targets for intervention.

METHODS

All new diagnoses, referrals from other institutions, as well as persons returning to care, enrolling at the largest HIV clinic in Mexico City were invited to participate in the study. The network was inferred from HIV pol sequences, using pairwise genetic distance methods, with a locally hosted, secure version of the HIV-TRACE tool: Seguro HIV-TRACE. Socio-demographic, clinical and behavioural metadata were overlaid across the network to design focused prevention interventions.

RESULTS

A total of 3168 HIV sequences from unique individuals were included. One thousand and one-hundred and fifty (36%) sequences formed 1361 links within 386 transmission clusters in the network. Cluster size varied from 2 to 14 (63% were dyads). After adjustment for covariates, lower age (adjusted odds ratio [aOR]: 0.37, p<0.001; >34 vs. <24 years), being a man who has sex with men (MSM) (aOR: 2.47, p = 0.004; MSM vs. cisgender women), having higher viral load (aOR: 1.28, p<0.001) and higher CD4+ T cell count (aOR: 1.80, p<0.001; ≥500 vs. <200 cells/mm3 ) remained associated with higher odds of clustering. Compared to MSM, cisgender women and heterosexual men had significantly lower education (none or any elementary: 59.1% and 54.2% vs. 16.6%, p<0.001) and socio-economic status (low income: 36.4% and 29.0% vs. 18.6%, p = 0.03) than MSM. We identified 10 (2.6%) clusters with constant growth, for prioritized intervention, that included intersecting sexual risk groups, highly connected nodes and bridge nodes between possible sub-clusters with high growth potential.

CONCLUSIONS

HIV transmission in Mexico City is strongly driven by young MSM with higher education level and recent infection. Nevertheless, leveraging network inference, we identified actively growing clusters that could be prioritized for focused intervention with demographic and risk characteristics that do not necessarily reflect the ones observed in the overall clustering population. Further studies evaluating different models to predict growing clusters are warranted. Focused interventions will have to consider structural and risk disparities between the MSM and the heterosexual populations.

The Prevalence of HIV Among Men Who Have Sex With Men (MSM) and Young MSM in Latin America and the Caribbean: A Systematic Review

Young men who have sex with men (YMSM) under 25 years old are among the few populations with increasing numbers of new HIV infections in parts of the world where HIV incidence is declining overall. In this systematic review, we synthesize the literature on HIV prevalence among MSM in Latin America and the Caribbean focusing on YMSM. Results were stratified according to study population sampling method used (probability and non-probability based). Forty-seven studies from 17 countries were published in the last 10 years. Among studies using probability-based sampling method (N = 21), HIV prevalence among MSM ranged from 1.2 to 32.6%. HIV prevalence tended to increase over time in studies sampling at different time points. HIV prevalence among YMSM exceeded 5.0% in more than a half of studies (51%; N = 22/43). Our review corroborates the high and potentially rising incidence of HIV among YMSM and characterizes the region's greatest challenge to ending the epidemic.

Regional disparity of HIV incidence and prevalence among men who have sex with men

BACKGROUND

HIV incidence can be estimated with cross-sectional studies using clinical, serological, and molecular data. Worldwide, HIV incidence data in only men who have sex with men (MSM) are scarce and principally focus on those with healthcare or under treatment. However, better estimates can be obtained through studies with national representativeness. The objective was to estimate the prevalence, incidence, and factors associated with acquiring HIV in a national sample of MSM who attend meeting places, considering geographical regions.

METHODS

A nationally representative survey of MSM attending meeting places was performed in Mexico. Participants answered a questionnaire, and a dried blood spot (DBS) was collected. Samples were classified as recent infections using an algorithm with HIV status, antiretroviral therapy, and the result of BED-EIA assay. Parameters were analysed considering regions and demographic and sexual behaviour characteristics.

RESULTS

The national HIV prevalence was 17.4% with regional differences; the highest prevalence (20.7%) was found in Mexico City, and the lowest prevalence was found in the West region (11.5%). The incidence was 9.4 per 100 p/y, with regional values from 6.2 to 13.2 for the Northeast and the Centre regions, respectively. Age, age at sexual debut, low wealth index, and rewarded sex were associated with HIV prevalence. Centre region, use of private clinics as health services, and having sex exclusively with men were associated with recent HIV infections.

CONCLUSIONS

The incidence and prevalence showed regional differences, suggesting a difference in the dynamics of HIV transmission; some regions have a greater case accumulation, and others have a greater rate of new infections. Understanding this dynamic will allow developing health programs focused on HIV prevention or treating people already living with HIV.

PrEP Awareness, Use, Intention to Use, and Information Source Among Geosocial Networking Application Users in Mexico in 2018-2019

Pre-exposure prophylaxis (PrEP) has limited availability across Latin America, though access is increasing. We explored PrEP uptake in Mexico via an online survey completed by Spanish-speaking, Hornet geosocial networking application (GSN app) users without HIV (n = 2020). Most (81.3%) had heard of PrEP, 3.5% were current users, and 34.2% intended to take PrEP within six months. Current PrEP use was associated with PrEP eligibility (aOR 26.07 [95%CI 13.05-52.09], p < 0.001), recent STI testing (aOR 3.79 [95%CI 1.10-13.11], p = 0.035), and recent chemsex (aOR 3.02 [95%CI 1.02-8.93], p = 0.046). Recent STI testing was associated with hearing about PrEP from a doctor (aOR 3.26 [95%CI 1.98-5.36], p < 0.001), and those who lived in large cities were less likely to have learned about PrEP via Hornet (aOR 0.52 [95%CI 0.32-0.85], p = 0.009). Interventions to increase PrEP uptake in Mexico should build upon existing health networks and utilize GSN apps for PrEP information dissemination, particularly in less populated areas.

Low socioeconomic status is associated with self-reported HIV positive status among young MSM in Brazil and Peru

BACKGROUND

Despite efforts to stop HIV epidemic in Latin America, new HIV cases continue to increase in the region especially among young MSM (YMSM). This study aims to assess if sociodemographic characteristics are associated with self-reported HIV positive status among YMSM from three Latin American countries.

METHODS

Cross-sectional web-based survey advertised on dating apps (Grindr and Hornet) and Facebook in Brazil, Mexico and Peru. For this analysis, we included YMSM aged 18-24 years who self-reported their HIV status. We used multivariable logistic regression models for each country separately to verify if sociodemographic characteristics (race, education and income) were associated with HIV self-reported status after adjusting for behavior characteristics (sexual attraction and steady partner).

RESULTS

Among 43,687 MSM who initiated the questionnaire, 27,318 (62.5%) reported their HIV status; 7001 (25.6%) of whom were YMSM. Most YMSM (83.4%) reported an HIV test in the past year, and 15.7% reported an HIV positive status in Peru, 8.4% in Mexico and 7.7% in Brazil. In adjusted models, low-income was associated with higher odds of self-reported HIV positive status in Brazil (aOR = 1.33, 95%CI: 1.01-1.75) and Peru (aOR = 1.56, 95%CI: 1.02-2.40), but not in Mexico. Lower education was associated with higher odds of self-reported HIV positive status only in Brazil (aOR = 1.35, 95%CI: 1.05-1.75).

CONCLUSIONS

In this large, cross-country study, self-reported HIV positive status among YMSM was high. Lower socioeconomic status was associated with higher odds of self-reported HIV positive status in Brazil and Peru. There is an urgent need for HIV prevention interventions targeting YMSM, and efforts to address low-income YMSM are especially needed in Peru and Brazil.

Women's Reaction to Opposite- and Same-Sex Infidelity in Three Cultures : Data from Canada, Samoa, and the Istmo Zapotec

Previous research indicates that Euro-American women are more upset by imagining their male partners committing homosexual infidelities than heterosexual ones. The present studies sought to replicate these findings and extend them to two non-Western cultures wherein masculine men frequently engage in sexual interactions with feminine third-gender males. Across six studies in three cultural locales (Canada, Samoa, and the Istmo Zapotec), women were asked to rate their degree of upset when imagining that their partner committed infidelity that was heterosexual in nature, as well as infidelity that was homosexual. In two Canadian undergraduate samples, women reported greater upset at imagining partner infidelity with a female, whereas a community sample of middle-aged women reported equal upset across infidelity types. Samoan women reported substantially less upset at the thought of partner infidelity with a third-gender male (fa'afafine) than with a female. Istmo Zapotec women reported equal upset toward infidelity with a female or a third-gender male (muxe), whereas a second Zapotec sample reported slightly greater upset at the thought of infidelity with a muxe. Results illustrate how cultural contexts moderate the degree to which same-sex infidelity scenarios are upsetting to women.

Profiles of Depressive Symptoms Among Men Who Have Sex With Men and Transgender Women During the COVID-19 Outbreak in Mexico: A Latent Class Analysis

The impact of the COVID-19 outbreak on mental health among HIV high-risk populations is not known. We assess the prevalence of depressive symptoms (DS) and explore the association with characteristics related to the COVID-19 pandemic. We conducted an online survey among 881 men who have sex with men (MSM) and transgender women (TGW) assessing the presence of DS using the Center for Epidemiological Studies Depression Scale (CESD-10); results were compared with previously self-reported DS and national data. We applied latent class analysis (LCA) to identify classes of participants with similar COVID-19 related characteristics. The overall prevalence of significant DS was 53.3%. By LCA posterior probabilities we identified three classes: (1) minimal impact of COVID-19 (54.1%), (2) objective risk for COVID-19 (41.5%), and (3) anxiety and economic stress caused by COVID-19 (4.4%). Multivariate logistic regression showed that compared with those in class one, the odds to have significant DS were almost five times higher for those in class three. Our findings suggest high levels of depression among MSM and TGW in Mexico during the COVID-19 pandemic and highlight the need for the provision of targeted psychological interventions to minimize the impacts of COVID-19 on the mental health.

Developing HIV assisted partner notification services tailored to Mexican key populations: a qualitative approach

Background

Assisted partner notification services (APNS) may increase HIV testing, early diagnosis, and treatment, but they are not formally implemented in Mexico, where the HIV epidemic is concentrated in men who have sex with men (MSM) and transwomen (TW). This study aimed to explore the awareness of and need for HIV partner notification, as well as to outline potential strategies for APNS based on identified barriers and facilitators.

Methods

We conducted semi-structured interviews to explore partner notification with MSM, TW, and counselors. Afterwards, brainstorm sessions were carried out to produce strategies for implementing APNS.

Results

Most participants reported experiences with informal partner notification and serostatus disclosure, but not with APNS. Only one counselor indicated assisting notification systematically. The main barriers for notifying or disclosing mentioned by both MSM and TW included fear of (violent) reactions, discrimination and lacking contact information of casual partners. Participants thought it was easier to inform a formal partner, conditional of being well informed about HIV. Given current stigma and lack of awareness, it was suggested that APNS should be preceded by HIV awareness efforts, and be provided by counselors or peers to mitigate potential rejection or violent reactions.

Conclusions

While APNS are not formally implemented in Mexico, all participants supported the service, indicating that APNS could potentially enhance early HIV diagnosis in Mexico. Strategies to implement such services need to be flexible addressing the individual needs of participants, guaranteeing the safety of more vulnerable participants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10612-3.

A comparison of the effectiveness of respondent-driven and venue-based sampling for identifying undiagnosed HIV infection among cisgender men who have sex with men and transgender women in Tijuana, Mexico

BACKGROUND

Efforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low- and middle-income countries (LMIC). We compared the effectiveness of respondent-driven sampling (RDS) and venue-based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico.

METHODS

Between March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing.

RESULTS

Of those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States.

CONCLUSIONS

Despite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC.

Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City

Background

Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City.

Methods

From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model.

Results

Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15–10.31], chlamydia (5.15; 95% CI: 2.58–9.34), gonorrhea (3.93; 95% CI: 1.88–7.83), syphilis (13.04; 95% CI: 8.24–19.94), hepatitis B (2.11; 95% CI: 0.53–4.89), hepatitis C (0.95; 95% CI: 0.00–3.16), any STI except HIV (30.99; 95% CI: 21.73–40.26), and any STI including HIV (50.08; 95% CI: 37.60–62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00–0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse.

Conclusions

Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.

Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

BACKGROUND

Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.

METHODS

We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.

RESULTS

All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries-apart from Ecuador-across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups-the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.

CONCLUSIONS

Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico

BACKGROUND

In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use.

METHODS

PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision.

RESULTS

At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment.

CONCLUSION

Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.

The HIV epidemic in Latin America: accomplishments and challenges on treatment and prevention

Purpose of review

To describe how countries in Latin America and the Caribbean are (or are not) meeting 2016 WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, that is, their progress on the adoption of ‘Treat All’ and of preexposure prophylaxis (PrEP) as an additional prevention tool for people at substantial risk of HIV infection.

Recent findings

The HIV epidemic in the region continues largely concentrated in vulnerable populations with MSM and transgender women (TGW) suffering the highest burden. On treatment, the challenges of late initiation as well as suboptimal adherence persist. On prevention, recent studies on PrEP willingness in key populations show promising results, meanwhile PrEP implementation projects as well as actual PrEP adoption by national health systems is expanding. A glimpse of real-world PrEP uptake is shown through Brazil's first-year experience of offering PrEP in multiple cities in all regions of the country.

Summary

In conclusion, accomplishments have been made though challenges for fully addressing the HIV epidemic persist. The impact of both treatment and PrEP will be limited by the availability and prompt use of all services, including HIV testing.

Hot, horny and healthy-online intervention to incentivize HIV and sexually transmitted infections (STI) testing among young Mexican MSM: a feasibility study

BACKGROUND

Encouraging Mexican men who have sex with men (MSM) to learn about and get tested for human immunodeficiency virus (HIV) is essential not only to initiate early treatment and reduce complications related to acquired immune deficiency syndrome (AIDS) but also to avoid new infections. HIV testing for MSM in Mexico remains a challenge, in part because of the stigma and discrimination they face in their daily lives and perceived discrimination in health care services. Thus, innovative approaches are needed to increase the uptake of health prevention services among this population. Games for health and gamification are now established approaches to achieving desired behavior change. Gamified interventions have been successfully deployed in various health domains, including HIV awareness, treatment, and prevention. The aim of this 2015 study was to develop a phone-based game and linked online platform with gamification elements to incentivize HIV and sexually transmitted infections (STI) testing, normalize asking partners about serostatus, and increase HIV and STI knowledge among young Mexican MSM. This paper describes its implementation process and feasibility assessment.

METHODS

The study consisted of three phases. The first phase was the formative research, which consisted of 6 focus groups and rapid prototyping to determine the most effective and appropriate design for the intervention. The second phase consisted of piloting and implementing the intervention over five weeks among 62 MSM, aged between 18 and 35 years old. Lastly, we assessed the feasibility of the intervention over three dimensions: acceptability, demand, and implementation. We conducted ten semi-structured interviews with participants and used a mixed-methods approach, including qualitative and quantitative evaluation methods.

RESULTS

Overall, the conceptual components of the intervention were perceived as acceptable, which leads us to believe that the formative phase captured our participants' needs and perceptions. However, we underestimated the complexity of the technical challenges involved. Participants' high standards and expectations of an interactive product based on their experience with industrially produced games impacted their patterns of use. Nevertheless, they perceived the platform as a good-quality information source. Gamification elements such as badges, points, and prizes were perceived as fun, exciting, and motivating, and 71% of participants engaged in at least one activity to earn points.

CONCLUSIONS

A game-based intervention, coupled with an online platform that incorporates gamification elements to motivate HIV and STI testing in young Mexican MSM is feasible. Successfully scaling such an intervention to a broader audience would require reducing the complexity of the intervention, working with a local technical partner to develop and implement a more efficient platform, improving the quality of the graphics, and a re-design of the point system.

Patterns of Sexual Behaviors in Young Men Who Have Sex With Men in Mexico

Recent research has documented the importance of understanding the multidimensional nature of sexual risk behavior. However, little is known about patterns of sexual behavior among men who have sex with men (MSM) in Mexico, men who are at greatest risk for HIV and sexually transmitted infections compared to other subpopulations in the country. This study applied latent class analysis to data from a large, HIV-negative sample of 18- to 25-year-old Mexican MSM recruited from a social and sexual networking website (N = 3,722) to uncover multidimensional patterns of sexual behaviors, partner factors, and protective behaviors, and examine how these were associated with health and well-being correlates. We selected a model with seven classes. The most common class included those who reported both insertive and receptive behaviors with more than one partner, but smaller groups of individuals were in classes marked by only insertive or receptive anal sex, romantic relationships, or sexual inactivity. Class membership differed by sexual orientation, age, depressive symptoms, alcohol problems, and self-acceptance, with individuals in a class marked by same-sex relationships generally reporting more positive outcomes. Findings suggest heterogeneity of behaviors among Mexican MSM and the possible efficacy of prevention messages tailored to individuals' specific patterns of sexual behavior.

Perceived barriers to pre-exposure prophylaxis use among HIV-negative men who have sex with men in Tijuana, Mexico: A latent class analysis

BACKGROUND

Given the slow uptake of PrEP among cisgender men who have sex with men (MSM) in high-income countries, efforts to roll-out PrEP in low- and middle-income countries (LMIC) should address barriers to PrEP use to facilitate its more rapid uptake. To inform PrEP programs in LMIC, we examined patterns of perceived barriers to PrEP use among HIV-negative MSM in Tijuana, Mexico.

METHODS

From 03/2016-09/2017, 364 MSM completed interviewer-administered surveys assessing perceived barriers to PrEP use across 4 domains: PrEP attribute, individual, interpersonal, and structural. Latent class analysis was performed to identify distinct classes with respect to perceived barriers to PrEP use. Multinomial logistic regression was used to identify factors associated with class membership.

RESULTS

We identified three classes characterized by (1) high levels of perceived barriers across domains (12%), (2) low levels of perceived barriers across domains (43%), and (3) perceived PrEP attribute barriers (i.e., side-effects and cost) (45%). Membership in the high level of perceived barriers class (vs. the low level of perceived barriers class) was positively associated with having a history of incarceration (AOR: 2.44; 95% CI: 1.04, 5.73) and negatively associated with more social support (AOR: 0.99; 95% CI: 0.98, 1.00). Membership in the perceived PrEP attribute barriers class was positively associated with having seen a healthcare provider in the past year (AOR: 2.78; 95% CI: 1.41, 5.45) and negatively associated with having any HIV-positive or status unknown partners (AOR: 0.56; 95% CI: 0.31, 1.01).

CONCLUSIONS

Since most participants were in either the low level of perceived barriers class or the perceived PrEP attribute barriers class, future PrEP uptake may be high among MSM in Tijuana. However, these findings suggest that achieving sufficient PrEP uptake and adherence among MSM in Tijuana may require a range of comprehensive HIV prevention interventions.

Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men

Background

HIV disproportionally affects key populations including men who have sex with men (MSM). HIV prevalence among MSM varies from 17% in Brazil and Mexico to 13% in Peru, whereas it is below 0.5% for the general population in each country. Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir is being implemented in the context of combination HIV prevention. Reports on willingness to use PrEP among MSM have started to emerge over the last few years. Previously reported factors associated with willingness to use PrEP include awareness, higher sexual risk behavior, and previous sexually transmitted infection.

Objective

This study aimed to evaluate the factors associated with willingness to use daily oral PrEP among MSM in 3 Latin American, middle-income countries (Brazil, Mexico, and Peru).

Methods

This Web-based, cross-sectional survey was advertised in 2 gay social network apps (Grindr and Hornet) used by MSM to find sexual partners and on Facebook during 2 months in 2018. Inclusion criteria were being 18 years or older, cisgender men, and HIV-negative by self-report. Eligible individuals answered questions on demographics, behavior, and PrEP (awareness, willingness to use, barriers, and facilitators). Multivariable logistic regression modeling was performed to assess the factors associated with willingness to use daily oral PrEP in each country.

Results

From a total sample of 43,687 individuals, 44.54% of MSM (19,457/43,687) were eligible and completed the Web-based survey—Brazil: 58.42% (11,367/19,457), Mexico: 30.50% (5934/19,457), and Peru: 11.08% (2156/19,457); median age was 28 years (interquartile range: 24-34), and almost half lived in large urban cities. Most participants were recruited on Grindr (69%, 13,349/19,457). Almost 20% (3862/19,352) had never tested for HIV, and condomless receptive anal sex was reported by 40% (7755/19,326) in the previous 6 months. Whereas 67.51% (13,110/19,376) would be eligible for PrEP, only 9.80% (1858/18,959) of participants had high HIV risk perception. PrEP awareness was reported by 64.92% (12,592/19,396); this was lower in Peru (46.60%, 1002/2156). Overall, willingness to use PrEP was reported by 64.23% (12,498/19,457); it was highest in Mexico (70%, 4158/5934) and lowest in Peru (58%, 1241/2156). In multivariate regression models adjusted for age, schooling, and income in each country, willingness to use PrEP was positively associated with PrEP awareness and PrEP facilitators (eg, free PrEP and HIV testing) and negatively associated with behavioral (eg, concerned by daily pill regimen) and belief barriers (eg, sexual partners may expect condomless sex).

Conclusions

In this first cross-country, Web-based survey in Latin America, willingness to use PrEP was found to be high and directly related to PrEP awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand. This study provides important information to support the implementation of PrEP in Brazil, Mexico, and Peru.

The role of sexual risk behaviors on PrEP awareness and interest among men who have sex with men in Latin America

In Latin America, men who have sex with men (MSM) remain disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool and has been FDA approved in the United States since 2012, but no Latin American state, with the recent exception of Brazil, has implemented PrEP guidelines. We carried out a multinational online survey of MSM in Latin America (n = 22698) in 2012 to assess whether MSM at highest risk of HIV acquisition (i.e., those engaging in condomless anal sex [CAS; n = 2606] and transactional sex [n = 1488]) had higher levels of awareness of PrEP, PrEP use and interest in participating in a PrEP trial. After adjusting for demographic and psychosocial characteristics including depressive symptoms, hazardous alcohol use, childhood sexual abuse, and sexual compulsivity, transactional sex and CAS were associated with increased PrEP awareness (aOR = 1.29, 95% CI: 1.05-1.59, p < .001 and aOR = 1.22, 95% CI: 1.11-1.34, p < .001, respectively) and PrEP trial interest (aOR = 1.45, 95% CI: 1.25-1.71, p < .001 and aOR = 1.74, 95% CI: 1.57-1.95, p < .001, respectively). Findings demonstrate substantial awareness of and interest in PrEP among MSM with behavioral risk factors for HIV in Latin America, suggesting that this region is primed for PrEP implementation, which has been slow.

Syndemic Vulnerability and Condomless Sex Among Incarcerated Men in Mexico City: A Latent Class Analysis

In order to address common statistical and population-based limitations in epidemiological literature applying syndemic theory, this study uses latent class analysis (LCA) to explore how health and social problems coalesce and shape sexual risk behaviors linked to HIV transmission in three Mexico City prisons. Among the studied male inmates, LCA identified four classes, defined by low syndemic risk (61.4%); marijuana (14.3%); depression, substances, and trauma (19.7%); and depression, substances, and marijuana (4.7%). In multinomial regression models, classes with a greater number of syndemic exposures were associated with increased odds of condomless anal sex during incarceration. In analyses stratified by pre-incarceration sexual risk behaviors, however, high syndemic burden classes were associated with condomless anal sex during incarceration differently. Overall, the study findings suggest that LCA has potential utility for syndemic analyses and highlight the need to attend to health and social adversities when addressing sexual risk behaviors and HIV transmission during incarceration.

The Relationship Between Psychological Temporal Perspective and HIV/STI Risk Behaviors Among Male Sex Workers in Mexico City

Men who have sex with men (MSM) face a disproportionate burden of HIV incidence and HIV prevalence, particularly young men who have sex with men. The aim of this article was to analyze the relation between a psychological temporal perspective and HIV/sexually transmitted infection (STI) risk behaviors among male sex workers (MSWs), a potentially highly present-oriented group of MSM. A total sample of 326 MSWs were included and responded to a validated psychological scale: the Zimbardo's Time Perspective Inventory; they also reported how frequently they engaged in protective behaviors against HIV and other STI risks behaviors, including condom use with casual and regular partners, as well as prior HIV testing. We adjusted structural equation models to analyze the relation between a psychological temporal perspective and HIV/STI risk behaviors. We found that orientation toward the past was correlated with decreased condom use with casual partners (β = - 0.18; CI_95% - 0.23, - 0.12). Future orientation was not associated with condom use with casual partners. Regarding condom use with regular partners, past and present orientation were related to lower likelihood of condom use (β = - 0.23; CI_95% - 0.29, - 0.17; β = - 0.11; CI_95% - 0.19, - 0.02), whereas future orientation increased the likelihood of condom use with regular partners (β = 0.40; CI_95% 0.31, 0.50). Time orientation (past, present, or future) did not predict the probability of having an HIV test. The design of HIV/STI prevention programs among vulnerable populations, such as MSM and MSWs, should consider specific time-frame mechanisms that can importantly affect sexual risk behavior decisions.

Prevalence of Drug Resistance Mutations in Protease, Reverse Transcriptase, and Integrase Genes of North Central Mexico HIV Isolates

This study set out to determine the frequency of antiretroviral drug resistance mutations in treatment-naive subjects of the north central Mexican state of San Luis Potosí. Mexican studies of antiretroviral drug resistance mutations have focused mainly on large metropolitan areas and border towns subjected to intense international migrations. This study set forth to describe the frequency of these mutations in a Mexican region less subjected to such migratory influences and more representative of smaller Mexican cities. Thirty-eight full-length pol sequences spanning the protease, reverse-transcriptase, and integrase-encoding regions were obtained from 42 treatment-naive human immunodeficiency virus (HIV)-infected subjects. Most exhibited subtype B homology, but CRF02_AG was also detected. Evidence of APOBEC3 hypermutation was seen in two samples. Calibrated population analysis revealed a surveillance drug resistance mutation prevalence of 4.9% for protease inhibitors, of 2.7% for nucleoside reverse transcriptase inhibitors, of 8.1% for non-nucleoside reverse transcriptase inhibitors, and an overall prevalence of 9.5%. This corresponds to an intermediate level of transmitted drug resistance according to the World Health Organization. The identification of integrase mutations suggests that transmitted drug mutations are being imported, as inhibitors targeting integrase have not been widely used in Mexico. Our results provide a greater understanding of HIV diversity in Mexico and highlight the way internal migrations allow HIV mutations and genetic features to permeate regions less subjected to international migrations. The implications of these findings will become more evident as Mexico hosts increased repatriations of migrants in the coming years.

Evaluation of HIV, STI and CD4 results among voluntary attendees at the HIV/AIDS program of Mexico City

Objective:

To describe results of HIV, sexually transmitted diseases (STI) and CD4 counts at the HIV-specialized Condesa Clinic (CC) in Mexico City.

Materials and methods:

Individuals who requested voluntary counseling and testing at CC were studied. We identified antibodies against HIV, syphilis, hepatitis C, and hepatitis B HBsAg. CD4 cell counts and viral load of HIV positive individuals were also obtained. Late HIV infection diagnosis was established if CD4 counts were lower than 200 cells/μL.

Results:

Global seroprevalence of HIV, syphilis, HBsAg, and anti HCV markers was of 20.1, 6, 1 and 1, respectively. Men displayed higher seroprevalence of infection markers than women. Among men, HIV infection was related to age and with all STI markers. Late HIV diagnosis was 31.8%. The risk of late HIV diagnosis was higher among women and it increased as age increased.

Conclusions:

Differences between genders regarding HIV and STIs prevalence as well as risk factors for HIV infection and late HIV diagnosis were observed.

Punto Seguro: A Randomized Controlled Pilot Using Conditional Economic Incentives to Reduce Sexually Transmitted Infection Risks in Mexico

Randomized controlled pilot evaluated effect of conditional economic incentives (CEIs) on number of sex partners, condom use, and incident sexually transmitted infections (STIs) among male sex workers in Mexico City. Incentives were contingent on testing free of new curable STIs and/or clinic attendance. We assessed outcomes for n = 227 participants at 6 and 12 months (during active phase with incentives), and then at 18 months (with incentives removed). We used intention-to-treat and inverse probability weighting for the analysis. During active phase, CEIs increased clinic visits (10-13 percentage points) and increased condom use (10-15 percentage points) for CEI groups relative to controls. The effect on condom use was not sustained once CEIs were removed. CEIs did not have an effect on number of partners or incident STIs. Conditional incentives for male sex workers can increase linkage to care and retention and reduce some HIV/STI risks such as condomless sex, while incentives are in place.

Correlates of condomless anal sex among men who have sex with men (MSM) in Tijuana, Mexico: The role of public sex venues

Condomless anal sex between male partners is the primary risk factor for HIV transmission among men who have sex with men (MSM). Correlates of condomless anal sex have been well-studied in developed countries, but they have received less attention in lower-to-middle income countries (LMIC), where MSM are often subject to stigma, discrimination, intolerance, and even the criminalization of same sex behavior. In Mexico, a LMIC where traditional views on homosexuality are common, HIV prevalence among MSM is high (16.9%), yet little research has been conducted on the correlates of condomless anal sex in this high-risk population. The present study examined correlates of condomless anal sex among 201 MSM recruited in Tijuana, Mexico, with a focus on the role of public sex venues in relation to sexual risk behavior. Eligibility requirements were: biologically male, 18 years of age or older, resident of Tijuana, and self-reported anal or oral sex with a male partner in the past year. Participants completed an interviewer-administered, demographic and psychosocial survey, and were tested for HIV and syphilis. A hierarchical multiple linear regression model was tested to identify correlates of condomless anal sex. Thirty-eight percent of participants (N = 76) reported condomless anal sex with a male partner in the past 2 months. Higher levels of condomless anal sex were associated with higher levels of depressive symptoms, greater sexual compulsivity, and more frequent seeking out of sex partners in a public venue in the past 2 months. In view of these findings, we recommend the development of multi-level, “combination” interventions, which in the Mexican context should include enhanced condom promotion and distribution, improved availability and access to mental health treatment and counseling services, and expanded HIV/STI testing in public venues.

Sociodemographic differences among HIV-positive and HIV-negative recently pregnant women in Mexico City: A case-control study

National HIV preventive programs in Mexico focus on high-risk groups that do not consider women, apart from prenatal screening. Nonetheless, the epidemic in women is growing, and there is a need to better understand sociodemographic factors in women living with HIV (WLH). We performed a case-control study in Mexico City, including HIV+ and HIV- women with a recent pregnancy to compare their sociodemographic characteristics and describe the circumstances of diagnosis in HIV+ women, as well as prenatal screening frequency in both groups. Fifty cases and 102 controls were interviewed. HIV+ women were more frequently the only economic support of the family (20% vs 0%, P < .0001). Thirty-eight percent of cases had their first pregnancy at ≤18 years, versus 16% of controls (odds ratio 2.47, 95% confidence interval 1.07-5.72, P = .03); 16% of cases had lived in the street; 6% reported transactional sex, versus none of the controls (P < .0001). In the multivariate analysis, there was strong evidence of an association between HIV infection and age at the time of the interview, history of sexually transmitted diseases, substance abuse, history of violence, and civil status. Only 6% of controls were tested for HIV during prenatal follow-up. WLH in this study faced important social vulnerability. Targeting women living in these social contexts might increase early diagnosis and could tailor HIV prevention strategies. Prenatal coverage needs to be improved and should represent a national priority.

Correlates of Sexual Violence Among Men Who Have Sex With Men in Tijuana, Mexico

Sexual violence among men who have sex with men (MSM) is prevalent in developing countries and is associated with increased HIV/STI risk. Despite high HIV prevalence (20 %) among MSM in Tijuana, Mexico, little attention has been paid to the occurrence of sexual violence in this high-risk group. The present study used a syndemic conditions framework to examine correlates of sexual violence victimization in a sample of 201 MSM surveyed in Tijuana, Mexico during 2012 and 2013. Participants were recruited through respondent-driven sampling and underwent a 2-h baseline interview and testing for HIV and syphilis. Sexual violence was defined as any incident during the past year in which the participant had been raped, sexually molested, or sexually harassed. The majority of participants self-identified as gay or bisexual, had never married, were employed, and had a high school education or greater. The average age was 29.7 years. Thirty-nine percent reported sexual violence in the past year. A hierarchical multiple linear regression model predicting more experiences of sexual violence was tested. In a final model, a higher number of experiences of sexual violence was associated with a history of childhood sexual abuse, more adult experiences of homophobia, more depression and hostility symptoms, and not living with a spouse or steady partner. The findings from this study support a model of co-occurring psychosocial factors that increase the likelihood of sexual violence experiences among MSM. Multi-level approaches to the prevention of childhood and adult experiences of sexual violence and homophobia are needed to avert the development of adverse mental and physical health outcomes associated with sexual violence victimization.

HIV testing practices and the potential role of HIV self-testing among men who have sex with men in Mexico

The objective of this study was to characterize HIV testing practices among men who have sex with men in Mexico and intention to use HIV self-testing. In 2012, members of one of the largest social/sexual networking websites for men who have sex with men in Latin America completed an anonymous online survey. This analysis was restricted to HIV-uninfected men who have sex with men residing in Mexico. Multivariable logistic regression models were fit to assess factors associated with HIV testing and intention to use a HIV self-test. Of 4537 respondents, 70.9% reported ever having a HIV test, of whom 75.5% reported testing at least yearly. The majority (94.3%) indicated that they would use a HIV home self-test if it were available. Participants identifying as bisexual less often reported ever HIV testing compared to those identifying as gay/homosexual (adjusted odds ratio = 0.52, 95% confidence interval: 0.44-0.62). Having a physical exam in the past year was associated with increased ever HIV testing (adjusted odds ratio = 4.35, 95% confidence interval: 3.73-5.07), but associated with decreased interest in HIV self-testing (adjusted odds ratio = 0.66, 95% confidence interval: 0.48-0.89). The high intention to use HIV home self-testing supports the use of this method as an acceptable alternative to clinic- or hospital-based HIV testing.

Late Diagnosis Due to Missed Opportunities and Inadequate Screening Strategies in HIV Infected Mexican Women

Late diagnosis of HIV remains a public health issue in Mexico. Most national programs target high-risk groups, not including women. More data on factors associated with late diagnosis and access to care in women are needed. In 2012-2013, Mexican women recently diagnosed with HIV were interviewed. Socio-cultural background, household-dynamics and clinical data were collected. Of 301 women, 49 % had <200 CD4 cells/mm³, 8 % were illiterate, 31 % had only primary school. Physical/sexual violence was reported by 47/30 %; 75 % acquired HIV from their stable partners. Prenatal HIV screening was not offered in 61 %; 40 % attended consultation for HIV-related symptoms without being tested for HIV. Seeking medical care ≥3 times before diagnosis was associated with baseline CD4 <200 cells/mm³ (adjusted OR 3.74, 95 % CI 1.88-7.45, p < 0.001). There were missed opportunities during prenatal screening and when symptomatic women seeked medical care. Primary care needs to be improved and new strategies implemented for early diagnosis in women.

Investigating HIV Infection and HIV Incidence Among Chinese Men Who Have Sex with Men with Recent Sexual Debut, Chongqing, China, 2011

HIV among men who have sex with men (MSM) with recent male-male sexual debut, such as within the past 5 years, may be a proxy for recent HIV infection. Using this definition, we explored factors associated with HIV infection in this group to understand the evolving HIV epidemic among MSM in Chongqing. We conducted a cross-sectional respondent-driven sampling survey among Chongqing MSM in 2011. Computer-assisted, self-administered questionnaires were used and blood specimens were collected for HIV and syphilis testing. Three hundred and ninety-one unique MSM were recruited of which 65.7 % (257) had their sexual debut with another man in the past 5 years. HIV prevalence among men with recent sexual debut was 18.7 % suggesting a possible HIV incidence of 3.7 %. Multivariable analysis among men with recent sexual debut suggests that lower education, having more than one male partner, and currently being infected with syphilis are associated with HIV among men with recent sexual debut. HIV prevalence is high among MSM with recent sexual debut in Chongqing, which may be a proxy a high incidence rate. HIV prevention efforts should focus on STD reduction among those MSM with lower educational attainment.

CD4 Counts at Entry to HIV Care in Mexico for Patients under the "Universal Antiretroviral Treatment Program for the Uninsured Population," 2007-2014

In Mexico, public health services have provided universal access to antiretroviral therapy (ART) since 2004. For individuals receiving HIV care in public healthcare facilities, the data are limited regarding CD4 T-lymphocyte counts (CD4e) at the time of entry into care. Relevant population-based estimates of CD4e are needed to inform strategies to maximize the impact of Mexico's national ART program, and may be applicable to other countries implementing universal HIV treatment programs. For this study, we retrospectively analyzed the CD4e of persons living with HIV and receiving care at state public health facilities from 2007 to 2014, comparing CD4e by demographic characteristics and the marginalization index of the state where treatment was provided, and assessing trends in CD4e over time. Our sample included 66,947 individuals who entered into HIV care between 2007 and 2014, of whom 79% were male. During the study period, the male-to-female ratio increased from 3.0 to 4.3, reflecting the country's HIV epidemic; the median age at entry decreased from 34 years to 32 years. Overall, 48.6% of individuals entered care with a CD4≤200 cells/μl, ranging from 42.2% in states with a very low marginalization index to 52.8% in states with a high marginalization index, and from 38.9% among individuals aged 18-29 to 56.5% among those older than 50. The adjusted geometric mean (95% confidence interval) CD4e increased among males from 135 (131,142) cells/μl in 2007 to 148 (143,155) cells/μl in 2014 (p-value<0.0001); no change was observed among women, with a geometric mean of 178 (171,186) and 171 (165,183) in 2007 and 2014, respectively. There have been important gains in access to HIV care and treatment; however, late entry into care remains an important barrier in achieving optimal outcomes of ART in Mexico. The geographic, socioeconomic, and demographic differences observed reflect important inequities in timely access to HIV prevention, care, and treatment services, and highlight the need to develop contextual and culturally appropriate prevention and HIV testing strategies and linkage programs.

HIV testing among men who have sex with men in Tijuana, Mexico: a cross-sectional study

OBJECTIVES

HIV testing is critical to the delivery of comprehensive HIV prevention and care services, yet coverage of sexual minorities by HIV testing programmes remains insufficient in many low- and middle-income countries, including Mexico. The objective of this study was to identify the prevalence and correlates of HIV testing among men who have sex with men (MSM) in Tijuana, Mexico.

METHODS

We conducted a cross-sectional study (2012-2013) among 189 MSM recruited via respondent-driven sampling (RDS). RDS-weighted logistic regression was used to identify correlates of prior HIV testing.

RESULTS

RDS-adjusted prevalence of prior and recent (≤ 12 months) HIV testing was 63.5% (95% CI 51.9% to 73.5%) and 36.8% (95% CI 25.4% to 46.4%), respectively. Prior HIV testing was positively associated with older age (adjusted OR (AOR)=1.09, 95% CI 1.04 to 1.15), being born in Tijuana (AOR=2.68, 95% CI 1.05 to 6.86), higher levels of education (AOR=2.65, 95% CI 1.08 to 6.53), identifying as homosexual or gay (AOR=3.73, 95% CI 1.48 to 9.42), being more 'out' about having sex with men (AOR=1.28, 95% CI:1.02 to 1.62), and a history of sexual abuse (AOR=3.24, 95% CI 1.06 to 9.86). Prior HIV testing was negatively associated with reporting more condomless anal intercourse acts (past 2 months) (AOR=0.95, 95% CI 0.92 to 0.98) and greater internalised homophobia (AOR=0.92, 95% CI 0.86 to 0.99).

CONCLUSIONS

Our findings indicate an urgent need for expanded HIV testing services for MSM in Tijuana. Innovative, non-stigmatising, confidential HIV testing interventions targeted at young, less educated, migrant and non-gay identifying MSM may facilitate HIV testing and timely linkage to HIV care and treatment within this population.

A tale of two epidemics: gender differences in socio-demographic characteristics and sexual behaviors among HIV positive individuals in Mexico City

BACKGROUND

To date, the HIV epidemic in Mexico has been concentrated mainly among men who have sex with men, butheterosexual transmission, particularly to women, is increasingly important. This study examine gender differences in socio-demographic characteristics and risk behaviors of HIV positive individuals in Mexico City.

METHODS

We analyzed data from a cross-sectional survey of 1,490 clinic patients (male:female ratio 8:1) with HIV inMexico City in 2010. We examined socio-demographic characteristics, risk behavior, and history of HIV infection.From multivariate non-linear probability (probit) models we calculated predicted probabilities by sex of several outcomes: marginalization, demographic and sexual risk behaviors.

RESULTS

Significant differences were found between men and women. Multivariate models suggest that women had lower schooling levels; were less likely to have been employed in the past month and earn more than the minimal wage; more likely to have children, to have been sexually abused, to never have used condoms and to report having been infected by a stable partner. Additionally, women were less likely to report having a partner with a history of migration to the USA and to have engaged in transactional sex.

CONCLUSION

Significant differences exist between men and women with HIV in Mexico City in terms of their socioeconomicand behavioral profiles, which translate into differences in terms of exposure to HIV infection. Women face social and economic vulnerability while men tend to have riskier sexual behavior. Gender issues must be approached in prevention and treatment efforts, using diverse methods to target those most vulnerable and at risk.

The HIV care continuum in Latin America: challenges and opportunities

Combination antiretroviral therapy (ART), also known as highly active antiretroviral therapy, provides clinical and immunological benefits for people living with HIV and is an effective strategy to prevent HIV transmission at the individual level. Early initiation of ART as part of a test and treat approach might decrease HIV transmission at the population level, but to do so the HIV continuum of care, from diagnosis to viral suppression, should be optimised. Access to ART has improved greatly in Latin America, and about 600,000 people are on treatment. However, health-care systems are deficient in different stages of the HIV continuum of care, and in some cases only a small proportion of individuals achieve the desired outcome of virological suppression. At present, data for most Latin American countries are not sufficient to build reliable metrics. Available data and estimates show that many people living with HIV in Latin America are unaware of their status, are diagnosed late, and enter into care late. Stigma, administrative barriers, and economic limitations seem to be important determinants of late diagnosis and failure to be linked to and retained in care. Policy makers need reliable data to optimise the HIV care continuum and improve individual-based and population-based outcomes of ART in Latin America.