Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation.

BACKGROUND: Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks. METHODS: PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage. RESULTS: Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10). CONCLUSIONS: PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

Is violence associated with increased risk behavior among MSM? Evidence from a population-based survey conducted across nine cities in Central America.

BACKGROUND/OBJECTIVE: There is a dearth of research examining the linkages between violence and HIV risk behavior among men who have sex with men (MSM), including those who identify as transgender women (TW), particularly in Central America where violence is widespread. In this paper, we use population-based survey results to independently examine the correlations between physical, emotional and sexual violence and HIV risk behavior among MSM populations in five countries in Central America. DESIGN: As part of USAID's Combination Prevention for HIV program in Central America, PASMO conducted population based surveys using respondent-driven sampling (RDS) in nine cities in Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama. Initial seeds were recruited using the following criteria: individuals who represented subgroups of MSM by self-identification (homosexual vs. heterosexual or bisexual vs. transgender), social economic strata, and by sex work practices. This study examines the association between violence and 1) HIV risk behaviors relevant to the study populations; 2) protective behaviors; and 3) reported STIs. Individualized RDS estimator weights for each outcome variable were calculated using RDSAT software, and logistic regression analysis was used to determine associations between different forms of violence and the outcome variables. RESULTS: MSM who experienced physical violence were more likely to be engaged in transactional sex (OR: 1.76 [1.42-2.18]), have multiple partners in the past 30 days (OR: 1.37 [1.09-1.71]), and have engaged in sex under the influence of alcohol or drugs (OR: 1.51 [1.24-1.83]). Both physical violence and psychological/verbal violence were also associated with reporting STI symptoms or diagnosis within the past 12 months (OR: 1.72 [1.34-2.21] and 1.80 [1.45-2.23]). The effects of violence on the outcomes were observed after controlling for other risk factors. Transgender women were 3.9 times more likely to report engaging in transactional sex. Respondents who were heterosexual, bisexual, or transgender were also more likely to both report multiple partnerships (OR: 1.44 [1.07-1.96], 1.99 [1.67-2.38], 1.79 [1.37-2.33], respectively) and more likely to report engaging in sex under the influence of alcohol or drugs (OR: 1.52 [1.15-2.01], 1.38 [1.17-1.63], 1.47 [1.16-1.87], respectively), as compared to those identifying as homosexual. CONCLUSION: Violence experienced by MSM and TW is widespread in Central America. The experience of violence is shown in this study to be independently associated with risk behaviors for HIV infections. Further research and studies are needed to identify the effects violence has on HIV risk behavior among this under-researched population to improve targeted HIV prevention interventions.