Contextualising sexual health practices among lesbian and bisexual women in Jamaica: a multi-methods study.

Limited research has examined lesbian and bisexual women's sexual health practices in the Caribbean, where lesbian and bisexual women experience sexual stigma that may reduce sexual healthcare utilisation. We conducted a sequential multi-method research study, including semi-structured individual interviews (n = 20) and a focus group (n = 5) followed by a cross-sectional survey (n = 205) with lesbian and bisexual women in Kingston, Montego Bay, and Ocho Rios, Jamaica. Binary logistic analyses and ordinal logistic regression were conducted to estimate the odds ratios for social-ecological factors associated with lifetime STI testing, sex work involvement, and the last time of STI testing. Over half of participants reported a lifetime STI test and of these, 6.1% reported an STI diagnosis. One-fifth of the sample reported ever selling sex. Directed content analysis of women's narratives highlighted that stigma and discrimination from healthcare providers, in combination with low perceived STI risk, limited STI testing access and safer sex practices. Participants described how safer sex self-efficacy increased their safer sex practices. Quantitative results revealed that a longer time since last STI test was positively associated with depression, sexual stigma, and forced sex, and negatively associated with residential location, perceived STI risk, safer sex self-efficacy, and LGBT connectedness. Selling sex was associated with perceived STI risk, relationship status, sexual stigma, food insecurity, and forced sex. Sexual health practices among lesbian and bisexual women in Jamaica are associated with intrapersonal, interpersonal, and structural factors, underscoring the urgent need for multi-level interventions to improve sexual health and advance sexual rights among lesbian and bisexual women in Jamaica.

Factors associated with sexually transmissible infection testing practices among men who have sex with men in Jamaica: results from a cross-sectional, tablet-based survey.

Background Men who have sex with men (MSM) are at elevated risk for sexually transmissible infection (STI) acquisition globally. Yet, limited research has explored STI testing practices among MSM in contexts where same-sex practices are criminalised, such as in Jamaica. METHODS: A cross-sectional, tablet-based survey with MSM in Kingston, Ocho Rios and Montego Bay, Jamaica, was conducted. Multivariable logistic regression analyses were conducted to determine the adjusted risk ratio for lifetime STI testing and lifetime STI diagnosis. Multinomial logistic regression analyses were conducted to determine the relative odds of having had an STI test 3-5 months ago and 6-12 months ago in comparison with <3 months ago. RESULTS: Three-quarters (74.8%) of the 556 participants reported receiving an STI test (44% <3 months ago; 32% 3-5 months ago; 13% 6-12 months ago; 10% >12 months ago); 12.1% reported ever receiving an STI diagnosis. In adjusted multivariable analyses, STI testing was associated with sociodemographic (education, location), individual (depression, perceived risk), social (relationship status, sexual stigma) and structural (healthcare provider access) factors. In multinomial analysis, reporting a less recent STI test (>3 months ago) versus <3 months ago was associated with increased likelihood of sexual stigma and food insecurity. Lifetime STI diagnosis was associated with sociodemographic (location), individual (HIV infection) and social (lower social support) factors. CONCLUSIONS: Findings document associations between structural factors and delayed timing of STI testing. Further research is necessary to explore how to address social ecological factors in sexual health interventions with MSM in Jamaica.

Pathways From Sexual Stigma to Inconsistent Condom Use and Condom Breakage and Slippage Among MSM in Jamaica.

BACKGROUND: HIV prevalence among men who have sex with men (MSM) in Jamaica, where same sex practices are criminalized, is among the Caribbean's highest. Sexual stigma, the devaluation, mistreatment, and reduced power afforded to sexual minorities, is a distal driver of HIV vulnerabilities. The mechanisms accounting for associations between sexual stigma and condom use outcomes are underexplored. We examined pathways from sexual stigma to condom use and condom breakage and/or slippage among MSM in Jamaica. METHODS: We conducted a cross-sectional survey with a chain-referral sample of MSM (n = 556) in Kingston, Montego Bay, and Ocho Rios. Structural equation modeling using weighted least squares estimation methods was conducted to test the direct effects of sexual stigma on inconsistent condom use and condom breakage/slippage, and the indirect effects through depression, sexual abuse history, and condom use self-efficacy, adjusting for sociodemographic factors. RESULTS: One-fifth of participants (21%; 90/422) who had engaged in anal sex reported inconsistent condom use, and 38% (155/410) reported condom breakage/slippage during the previous 4 weeks. The relationship between sexual stigma and inconsistent condom use was mediated by the combination effect of sexual abuse history, condom use self-efficacy, and depression. The relationship between sexual stigma and condom breakage and slippage was mediated by the combination effect of condom use self-efficacy and sexual abuse history. CONCLUSIONS: Sexual stigma is associated with negative condom use outcomes in Jamaican MSM, mediated by psychosocial factors. Multilevel social ecological approaches to the HIV prevention cascade can inform interventions at individual, interpersonal, community, and systemic levels.

Factors Associated With Syphilis Testing and a History of Syphilis Infection Among a Sample of Transgender Women in Jamaica.

BACKGROUND: Globally, social inequalities contribute to elevated sexually transmitted infections (STIs) rates among transgender women. High syphilis prevalence has been documented among transgender women in Latin America. Little is known, however, of syphilis testing uptake among transgender women in Jamaica, where homosexuality is criminalized. The study objective was to understand factors associated with opting-in for syphilis testing and a syphilis infection history among transgender women in Jamaica. METHODS: We conducted a cross-sectional tablet-based survey of 137 transgender women between March and November 2015 in Jamaica. Bivariate analyses were used to assess differences across sociodemographic, intrapersonal, interpersonal, and structural factors based on syphilis infection history. We conducted univariable and multivariable logistic regression to determine the odds ratio for opting-in for syphilis testing for all factors associated with testing uptake at a P value of less than 0.05 in bivariate analyses, controlling for sociodemographic characteristics. RESULTS: Among 137 participants, 83 (60.6%) opted in for syphilis screening and 8 (9.6%) had positive rapid test results. One quarter of participants (n = 26; 25.2%) reported being HIV positive. Opting-in for syphilis testing was associated with the following: 1 health (HIV-positive serostatus: adjusted odds ratio [AOR], 4.33; 95% confidence interval [CI], 1.31-14.26), 1 intrapersonal (perceived STI risk: AOR, 1.58; 95% CI, 1.04-2.40), 1 interpersonal (childhood sexual abuse: AOR, 2.80; 95% CI, 1.03-7.62), and 1 structural (incarceration: AOR, 0.27; 95% CI, 0.11-0.71) factor. CONCLUSIONS: This study identified factors (HIV-positive serostatus, perceived STI risk, childhood sexual abuse, no incarceration history) associated with syphilis testing uptake among transgender women. Findings can inform multilevel STI testing, prevention, and care strategies tailored for transgender women in Jamaica.

Social-ecological factors associated with selling sex among men who have sex with men in Jamaica: results from a cross-sectional tablet-based survey.

BACKGROUND: Globally, men who have sex with men (MSM) experience social marginalization and criminalization that increase HIV vulnerability by constraining access to HIV prevention and care. People who sell sex also experience criminalization, rights violations, and violence, which elevate HIV exposure. MSM who sell sex may experience intersectional stigma and intensified social marginalization, yet have largely been overlooked in epidemiological and social HIV research. In Jamaica, where same sex practices and sex work are criminalized, scant research has investigated sex selling among MSM, including associations with HIV vulnerability. OBJECTIVE: We aimed to examine social ecological factors associated with selling sex among MSM in Jamaica, including exchanging sex for money, shelter, food, transportation, or drugs/alcohol (past 12 months). METHODS: We conducted a cross-sectional survey with a peer-driven sample of MSM in Kingston, Ocho Rios, and Montego Bay. Multivariable logistic regression analyses were conducted to estimate intrapersonal/individual, interpersonal/social, and structural factors associated with selling sex. RESULTS: Among 556 MSM, one-third (n = 182; 32.7%) reported selling sex. In the final multivariable model, correlates of selling sex included: individual/intrapersonal (lower safer sex self-efficacy [AOR: 0.85, 95% CI: 0.77, 0.94]), interpersonal/social (concurrent partnerships [AOR: 5.52, 95% CI: 1.56, 19.53], a higher need for social support [AOR: 1.08, 95% CI: 1.03, 1.12], lifetime forced sex [AOR: 2.74, 95% 1.65, 4.55]) and structural-level factors (sexual stigma [AOR: 1.09, 95% CI: 1.04, 1.15], food insecurity [AOR: 2.38, 95% CI: 1.41, 4.02], housing insecurity [AOR: 1.94, 95% CI: 1.16, 3.26], no regular healthcare provider [AOR: 2.72, 95% CI: 1.60, 4.64]). CONCLUSIONS: This study highlights social ecological correlates of selling sex among MSM in Jamaica, in particular elevated stigma and economic insecurity. Findings suggest that MSM in Jamaica who sell sex experience intensified social and structural HIV vulnerabilities that should be addressed in multi-level interventions to promote health and human rights.

Social-ecological factors associated with HIV infection among men who have sex with men in Jamaica.

In Jamaica, where homosexuality is criminalized, scant research has examined associations between sexual stigma and HIV infection. The study objective was to examine correlates of HIV infection among men who have sex with men (MSM) in Jamaica. We conducted a cross-sectional tablet-based survey with MSM in Jamaica using chain referral sampling. We assessed socio-demographic, individual, social, and structural factors associated with HIV infection. A logit-link model, fit using backwards-stepwise regression, was used to estimate a final multivariable model. Among 498 participants (median age: 24, interquartile range: 22-28), 67 (13.5%) were HIV-positive. In the multivariable model, HIV infection was associated with increased odds of socio-demographic (older age, odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.10]; residing in Kingston versus Ocho Rios [OR: 6.99, 95% CI 2.54-19.26]), individual (poor/fair versus excellent/good self-rated health [OR: 4.55, 95% CI: 1.81-11.42], sexually transmitted infection [STI] history [OR: 3.67, 95% CI: 1.61-8.38]), and structural (enacted sexual stigma [OR: 1.08, 95% CI: 1.01-1.15], having a health care provider [OR: 2.23, 95% CI: 1.06-4.66]) factors. This is among the first studies to demonstrate associations between sexual stigma and HIV infection in Jamaica. Findings underscore the need to integrate STI testing in the HIV care continuum and to address stigma and regional differences among MSM in Jamaica.

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study.

INTRODUCTION: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV-related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica. METHODS: We implemented a community-based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18-30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in-depth individual semi-structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community-based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes. RESULTS: Participant narratives revealed social-ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV-related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT-friendly clinics that peers would discover they were getting tested. HIV-related stigma contributed to fear of testing HIV-positive; this intersected with the stigma of HIV as a "gay" disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake. CONCLUSION: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV-related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

Factors associated with sex work involvement among transgender women in Jamaica: a cross-sectional study.

INTRODUCTION: Transgender women are disproportionately impacted by HIV. Transgender women involved in sex work may experience exacerbated violence, social exclusion, and HIV vulnerabilities, in comparison with non-sex work-involved transgender women. Scant research has investigated sex work among transgender women in the Caribbean, including Jamaica, where transgender women report pervasive violence. The study objective was to examine factors associated with sex work involvement among transgender women in Jamaica. METHODS: In 2015, we implemented a cross-sectional survey using modified peer-driven recruitment with transgender women in Kingston and Ocho Rios, Jamaica, in collaboration with a local community-based AIDS service organization. We conducted multivariable logistic regression analyses to identify factors associated with paid sex and transactional sex. Exchanging oral, anal or vaginal sex for money only was categorized as paid sex. Exchanging sex for survival needs (food, accommodation, transportation), drugs or alcohol, or for money along with survival needs and/or drugs/alcohol, was categorized as transactional sex. RESULTS: Among 137 transgender women (mean age: 24.0 [SD: 4.5]), two-thirds reported living in the Kingston area. Overall, 25.2% reported being HIV-positive. Approximately half (n = 71; 51.82%) reported any sex work involvement, this included sex in exchange for: money (n = 64; 47.06%); survival needs (n = 27; 19.85%); and drugs/alcohol (n = 6; 4.41%). In multivariable analyses, paid sex and transactional sex were both associated with: intrapersonal (depression), interpersonal (lower social support, forced sex, childhood sexual abuse, intimate partner violence, multiple partners/polyamory), and structural (transgender stigma, unemployment) factors. Participants reporting transactional sex also reported increased odds of incarceration perceived to be due to transgender identity, forced sex, homelessness, and lower resilience, in comparison with participants reporting no sex work involvement. CONCLUSION: Findings reveal high HIV infection rates among transgender women in Jamaica. Sex work-involved participants experience social and structural drivers of HIV, including violence, stigma, and unemployment. Transgender women involved in transactional sex also experience high rates of incarceration, forced sex and homelessness in comparison with non-sex workers. Taken together, these findings suggest that social ecological factors elevate HIV exposure among sex work-involved transgender women in Jamaica. Findings can inform interventions to advance human rights and HIV prevention and care cascades with transgender women in Jamaica.

Prevalence and Correlates of HIV Infection and HIV Testing Among Transgender Women in Jamaica.

Transgender women are overrepresented in the Caribbean HIV epidemic. The study objective was to examine correlates of HIV infection and HIV testing among transgender women in Jamaica. We implemented a cross-sectional survey with transgender women in Kingston and Ocho Rios, Jamaica. We conducted multivariable logistic regression to identify factors associated with HIV testing and HIV infection. Among 137 transgender women [mean age 24.0; standard deviation (SD) 5.5], three-quarters (n = 103, 75.7%) had received an HIV test. Of these, one-quarter (n = 26, 25.2%) were HIV positive. In multivariable analyses, HIV testing was associated with: perceived HIV risk [adjusted odds ratio (AOR) 2.42, confidence interval (CI) 1.36-4.28], depression (AOR 1.34, CI 1.01-1.77), forced sex (AOR 3.83, CI 1.42-10.35), physical abuse (AOR 4.11, CI 1.44-11.72), perceived transgender stigma (AOR 1.23, 1.06-1.42), having a healthcare provider (AOR 5.89, CI 1.46-23.77), and lower HIV-related stigma (AOR 0.96, CI 0.92-0.99), incarceration (AOR 0.28, CI 0.10-0.78), and drug use (AOR 0.74, CI 0.58-0.95). HIV infection was associated with the following: homelessness (AOR 5.94, CI 1.27-27.74), perceived HIV risk (AOR 1.67, CI 1.02-2.72), depression (AOR 1.39, CI 1.06-1.82), STI history (AOR 56.79, CI 5.12-630.33), perceived (AOR 1.26, CI 1.06-1.51) and enacted (AOR 1.16, CI 1.04-1.29) transgender stigma, forced sex (AOR 4.14, CI 1.49-11.51), physical abuse (AOR 3.75, CI 1.39-10.12), and lower self-rated health (AOR 0.55, CI 0.30-0.98) and social support (AOR 0.79, CI 0.64-0.97). Transgender women in Jamaica experience high HIV infection rates and suboptimal HIV testing. Combination HIV prevention approaches should address transgender women's social and structural vulnerabilities.