Behavioral and structural drivers of HIV in men who have sex with men in Belize: a mixed-methods study

ABSTRACT

Objective:

To estimate the prevalence of human immunodeficiency virus (HIV) in men who have sex with men (MSM) in Belize and identify behavioral and structural factors associated with infection.

Methods:

This mixed-methods study was a secondary analysis of data from the 2024 Integrated Biological and Behavioral Surveillance Survey. A total of 490 MSM were recruited using respondent-driven sampling. Data were collected using a structured behavioral questionnaire administered via computer-assisted self-interview. Qualitative data were collected through key informant interviews and focus group discussions.

Results:

HIV prevalence was 11.0%. Condom use was inconsistent: 70.4% reported consistent use, while 16.1% never used condoms. Transactional sex was common (18.8% received payment and 22.0% paid for sex). Condom use was higher in respondents who paid for sex (84.3%) than in those who were paid (64.1%). HIV testing was moderate: 74.5% had ever tested, but only 42.0% were tested in the past year and 6.5% had self-tested. Awareness of pre-exposure prophylaxis and post-exposure prophylaxis was low (8.6% and 8.4%, respectively). Among respondents who were aware, < 20% had used prophylaxis in the past 6 months. Substance use was prevalent (high alcohol risk 56.7% and cannabis use 41.4%) and 50.4% engaged in risky sex under intoxication. Depression risk was 46.1%. Qualitative findings identified three themes: individual factors, health system factors, and stigma.

Conclusion:

MSM in Belize face a high HIV burden driven by behavioral and structural factors. Interventions should prioritize condom promotion, pre-exposure prophylaxis scale-up, mental health support, substance use prevention, and stigma reduction.

Human immunodeficiency virus (HIV) remains a major public health challenge in Latin America and the Caribbean. In 2019, an estimated 2.5 million people were living with HIV in the region, with more than 133 000 new infections reported, including about 22 500 in individuals aged 15–24 years (1). The epidemic is concentrated in key populations, particularly men who have sex with men (MSM), female sex workers, and transgender women. While HIV prevalence in the general adult population remains relatively low – 0.4% in Latin America and 1.1% in the Caribbean – the prevalence in MSM is substantially higher, estimated at 12.6% and 4.5%, respectively (2). In 2022, key populations and their sexual partners accounted for nearly half of new HIV infections in the Caribbean (3).

HIV risk in MSM reflects both behavioral and structural determinants, including condomless anal intercourse, multiple sexual partnerships, stigma, discrimination, and socioeconomic vulnerability, which limit access to prevention and care services (3). Despite the 2017 recommendations of the World Health Organization (WHO) on effective prevention strategies such as pre-exposure prophylaxis (PrEP) and HIV self-testing, regional declines in HIV incidence have been modest, with infections rising in younger key populations (4).

Belize exemplifies these challenges. With an HIV prevalence of 1.3%, Belize has the highest HIV burden in Central America (5). The epidemic is concentrated in MSM and transgender women, and progress toward the 95–95–95 targets for 2025 of the Joint United Nations Programme on HIV/AIDS (UNAIDS) is still insufficient (6, 7). This study aimed to estimate the prevalence of HIV in MSM in Belize and identify the risk factors associated with HIV infection using data from the 2024 Integrated Biological and Behavioral Surveillance Survey (8).

METHODS

Study design

This exploratory study used a mixed-methods approach, integrating both quantitative and qualitative data. The study was secondary analysis of the data collected from the 2024 Integrated Biological and Behavioral Surveillance Survey among MSM in Belize. The analysis aimed to determine the prevalence of HIV and associated factors in MSM in Belize.

Study population and sampling

Eligible participants were biologically male, aged 18 years or older, and reporting anal sex with another man in the past 12 months. Respondent-driven sampling was used to recruit 490 MSM, using peer referral to reach a hidden population lacking formal sampling frames. Recruitment began with purposively selected “seeds” (selected directly by the research team, with the seeds then identifying other participants) and continued through successive waves. Respondent-driven sampling weights were applied to generate population-representative estimates using participants’ self-reported personal network sizes. Weights were calculated using RDS Analyst version 4.0, with convergence achieved after six recruitment waves (9).

Study sites

Participants were recruited from Belize City and Orange Walk, as these sites were identified as having substantial MSM populations and met methodological assumptions for implementation of respondent-driven sampling.

Data collection

Quantitative data were collected using a structured behavioral questionnaire administered via audio computer-assisted self-interview. The questionnaire assessed sociodemographic characteristics, sexual risk behaviors, alcohol and drug use, HIV knowledge, stigma and discrimination, mental health, uptake of HIV prevention methods (PrEP and post-exposure prophylaxis (PEP)), and access to HIV-related services.

Depression risk was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D 20) (10), with scores ≥ 16 indicating increased risk of depression. Alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT) (11), which yields scores ranging from 0 to 40. Scores of 0–7 indicate low risk of alcohol disorder, 8–15 moderate risk, 16–19 high risk, and ≥ 20 possible alcohol dependence.

All participants were tested for HIV according to national testing processes. Positive results were confirmed by a second rapid diagnostic test and, if discordant, by an enzyme-linked immunosorbent assay (ELISA). Participants received post-test counseling and those testing positive were referred for HIV care and treatment. Data collection occurred between June 2024 and March 2025.

Qualitative data were collected through semi-structured key informant interviews with 30 MSM, 10 representatives of nongovernmental organizations that provide MSM-focused services, and four health professionals from the national HIV program, as well as two focus group discussions with MSM.

Data analysis

Quantitative data were analyzed in STATA 19 (StataCorp, College Station, TX, USA) using univariate and bivariate analyses with chi-squared tests. Qualitative data were analyzed thematically using ATLAS.ti, version 9 (Lumivero, LLC, Burlington, MA, USA).

Ethical approval

Ethical approval for the study was obtained from the Ethics Review Board of the Ministry of Health and Wellness in Belize (GEN/147/01/24). Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study.

RESULTS

The results are presented in two sections. Section 1 provides findings from quantitative data, while section 2 focuses on insights from the qualitative data.

Quantitative data

A total of 490 MSM responded to the survey.

Sociodemographic characteristics and sexual history. Table 1 shows that most respondents (78.8%) were aged 25 years and older, with a median age of 32.5 years. The age group 30–34 years represented the largest proportion (18.4%). Educational attainment was generally low to moderate: 38.8% had primary education, 35.7% secondary education, and 16.1% post-secondary education. Most respondents (85.1%) reported some form of employment however, income levels were low. Only 11.8% earned 3000 Belize dollars (Belize $; US$ 1500) or more monthly and more than half (60.6%) earned less than Belize $ 1600 monthly.

TABLE 1. Sociodemographic characteristics and sexual history of the respondents.

Variable	No. (%), n=490
Age in years
18–24	104 (21.2)
25–29	88 (18.0)
30–34	90 (18.4)
35–39	53 (10.8)
40–44	63 (12.9)
45–49	42 (8.5)
50–69	50 (10.2)
Level of education
No formal	46 (9.4)
Primary	190 (38.8)
Secondary	175 (35.7)
Post secondary	79 (16.1)
Employment status
Yes	417 (85.1)
No	73 (14.9)
Monthly income, in Belize dollars
< 650	84 (17.1)
651–1599	213 (43.5)
1600–2999	135 (27.6)
≥ 3000	58 (11.8 )
Marital status
Single	369 (75.3)
Married	31 (6.3)
Common law partner	51 (10.4)
Divorced/separated/widowed	39 (8.0)
Age at first anal sex, years
< 15	166 (33.9)
15–19	207 (42.2)
≥ 20	117 (23.9
Had anal sex in the past 6 months
Yes	268 (54.7)
No	222 (45.3)
Frequency of condom use in the past 6 months
Always	345 (70.4)
Sometimes	66 (13.5)
Never	79 (16.1)
Received money or goods in exchange for anal sex in the past 6 months
Yes	92 (18.8)
No	398 (81.2)
Used condoms when received money or goods for anal sex in the past 6 months (n = 92)
Yes	59 (64.1)
No	33 (35.9)
Ever received money or goods from a man in exchange for anal sex
Yes	162 (33.1)
No	328 (66.9)
Paid money or goods for anal sex in the past 6 months
Yes	108 (22.0)
No	382 (88.0)
Used condoms when paid for anal sex in the past 6 months (n = 108)
Yes	91 (84.3)
No	17 (15.7)
Had sex with a woman in the past 6 months (n = 291a)
Yes	245 (84.2)
No	46 (15.8)

^aThe number of respondents who reported ever having sex with a woman.

Source: Prepared by the authors based on the study data.

The greatest percentage of respondents (42.3%) reported first anal sex at age 15–19 years, while 33.8% reported having first anal sex younger than 15 years; the median age was 16.5 years. More than half (54.4%) of the respondents had had anal sex in the 6 months preceding the survey. Consistent condom use was reported by 70.4%, whereas 16.1% reported never using condoms.

Transactional sex was reported by a substantial proportion of respondents: 33.1% had ever received money or goods in exchange for anal sex and 18.8% had done so in the past 6 months. Condom use among those receiving money or goods was 64.1%. Conversely, 22.0% of respondents reported paying for anal sex in the past 6 months and condom use in this group was higher (84.3%).

Additionally, 84.2% of respondents reported having sex with a woman in the past 6 months.

Knowledge and practices related to HIV. Table 2 presents respondents’ knowledge and practices regarding HIV. Overall knowledge of HIV transmission and prevention was high, with 92.2% demonstrating good knowledge. Nearly three quarters (74.5%) had ever been tested for HIV and received counseling, although only 42.0% had tested in the previous 12 months. HIV self-testing was rare (6.5%). The majority of respondents (70.0%) reported knowing their HIV status.

TABLE 2. HIV knowledge and practices of respondents.

Variable	No. (%), n=490
Have good knowledge of HIV transmissiona
Yes	452 (92.2)
No	38 (7.8)
Ever had an HIV test
Yes	365 (74.5)
No	125 (25.5)
Ever self-tested for HIV
Yes	32 (6.5)
No	458 (93.5)
Had an HIV test in the past 12 months
Yes	206 (42.0)
No	284 (58.0)
Know HIV status
Yesb	343 (70.0)
No	147 (30.0)
Result of last HIV test of those knowing their HIV status (n = 343)
Positive	10 (2.9)
Negative	333 (97.1)
Took antiretroviral treatment in the past 12 months (n = 10)
Yes	7 (70.0)
No	3 (30.0)
Had viral load test in the past 12 months (n = 10)
Yes	6 (60.0)
No	4 (40.0)
HIV result during study
Positive	54 (11.0)
Negative	436 (89.0)
Syphilis result during study
Positive	56 (11.4)
Negative	434 (88.6)

HIV, human immunodeficiency virus.

^aAssessed using 10 knowledge questions on facts and myths of HIV transmission and methods of protection. The average score is reported.

^b“Know HIV status” refers to the result of their most recent HIV test, which may have been done more than 12 months ago.

Source: Prepared by the authors based on the study data.

Among those who said they knew their status, 3.0% reported being HIV-positive. However, study-administered testing identified 11.0% as HIV-positive, indicating that 81.5% of HIV-positive respondents were previously unaware of their infection. Of those who reported being HIV-positive, 70.0% had taken antiretroviral therapy (ART) and 60.0% had undergone viral load testing in the past 12 months. Notably, 7.5% of respondents who previously tested HIV-negative were newly diagnosed with HIV during the study. As regards other sexually transmitted infection (STIs), syphilis prevalence was 11.4%.

Knowledge and use of PEP and PrEP. Figure 1 shows the awareness and use of HIV prevention methods (PEP and PrEP) among respondents. Awareness of biomedical HIV prevention strategies was low. Only 8.6% had heard of PEP and 8.4% of PrEP. Uptake among the respondents who were aware of these methods was limited: 14.3% had used PEP and 19.5% had used PrEP in the past 6 months. At the time of the study, only 14.6% of the respondents who were aware of PrEP were currently using it.

FIGURE 1. Knowledge and use of post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP).

Risk factors and risky behaviors. Table 3 shows that more than half of the respondents (56.7%) were at high risk of alcohol abuse based on AUDIT, while 14.9% were at moderate risk. Cannabis use in the previous 6 months was reported by 41.4%. Risky sexual practices were common: 50.4% of respondents reported anal sex under the influence of alcohol or other substances in the past 6 months. Mental health screening revealed a high burden of psychological distress: 46.1% of respondents were at risk for depression according to the Center for Epidemiologic Studies Depression Scale.

TABLE 3. Risk factors for HIV infection and risky behavior among respondents (n=490).

Risk factor	No. (%), n=490
Risk of alcohol abusea
Low	139 (28.4)
Moderate	73 (14.9)
High	278 (56.7)
Use of cannabis in the past 6 months
Yes	203 (41.4)
No	287 (58.6)
Had anal sex while intoxicated with alcohol or other drugs in the past 6 months
Yes	247 (50.4)
No	243 (49.6)
Risk of depressionb
Not at risk	264 (53.9)
At risk	226 (46.1)

HIV, human immunodeficiency virus.

^aBased on the Alcohol Use Disorders Identification Test (11).

^bBased on the Center for Epidemiologic Studies Depression Scale (10).

Source: Prepared by the authors based on the study data.

Association between age, HIV preventive practices, and risk behaviors. Younger respondents (< 25 years) were significantly more likely to report receiving HIV preventive interventions than those aged 25 years and above (9.6% versus 3.6%; χ² = 6.31, P = 0.012) (Table 4). In contrast, older respondents were significantly more likely to know their HIV status (75.6% versus 61.5%; χ² = 8.21, P = 0.004).

TABLE 4. Association between age and paid sex, and HIV prevention characteristics, bivariate analysis.

HIV prevention characteristic	No.		χ2 (P)
	< 25 years	≥ 25 years
Received HIV preventive intervention			6.31 (0.012*)
Yes	10	14
No	94	372
Know HIV status			8.21 (0.004*)
Yes	64	292
No	40	94
Used condom with most recent male partners			0.48 (0.59)
Yes	80	287
No	22	95
HIV status			2.16 (0.141)
Positive	4	31
Negative	100	355
	Received money or goods for anal sex	Paid money or goods for anal sex
Condom use			10.74 (0.0015*)
Yes	59	91
No	33	17

HIV, human immunodeficiency virus.

^*Significant.

Source: Prepared by the authors based on the study data.

Although condom use at last anal sex was slightly higher among younger participants, the difference was not statistically significant. HIV prevalence was higher in respondents aged 25 years and older, but this difference was also not statistically significant.

A significant association was seen between condom use and the type of transactional sex: 84.2% of respondents who paid for sex reported condom use compared with 64.1% of those who received money or goods for sex (χ² = 10.74, P = 0.0015).

Qualitative findings

Three main themes emerged from the key informant interviews and focus groups discussions: individual factors, health system factors, and stigma.

Theme 1: individual factors. Respondents generally had good knowledge of HIV transmission and prevention, attributed to the efforts of peer educators and community leaders. However, awareness of PEP and PrEP was limited. Mental health challenges, including depression, anxiety, and suicidal ideation, were frequently reported, particularly among respondents living with HIV. Some described discontinuing ART due to emotional distress.

I work as an activist with the LGBT community… I raise awareness about HIV care, I do outreach for testing… I know most of them have good knowledge on HIV prevention and treatment (key informant, Belize City; 40–44 years).

We receive messages on the need for us to know our HIV status; the earlier something is discovered, the easier treatment and care will be (focus group discussion participant, Belize City;18–24years).

Most of us have good knowledge about HIV, but limited knowledge on PEP and PrEP because of limited awareness (focus group discussion participant, Orange Walk; 25–29 years).

I have stopped taking my drugs because of my emotional problem. I went through depression… I just wanted to die… I ate rat poison, I tried to cut my wrists. (focus group discussion participant, Belize City; 35–39years).

Theme 2: health system factors. Distrust of health care providers, especially in public facilities, was a major barrier to service uptake. Participants reported breaches of confidentiality and judgmental attitudes, discouraging HIV testing and continued care. Limited access to mental health services, especially outside urban areas, further compounded these challenges, with many respondents reporting a lack of culturally competent counseling services.

There was a person who is HIV positive and the doctor treating him told his friend… I can never trust those health workers (key informant, Belize City; 25–29 years).

Personally, I wouldn’t go to the polyclinic… Private service or NGO offices are better if one can afford it (focus group discussion participant, Orange Walk; 18–24 years).

All the mental health services are in the city. If you live outside of town, you are basically on your own, unless you have money to travel and pay privately (focus group discussion participant, Orange Walk; 25–29 years).

Most counsellors don’t understand the kind of stress we deal with as gay men. You end up explaining your life instead of getting help (key informant, Belize City; 40–44 years).

Theme 3: stigma. Stigma emerged as a pervasive barrier across the continuum of HIV care. Participants reported discriminatory treatment by health care workers, including those in HIV-related services, which negatively affected willingness to seek testing, treatment, and mental health support.

I once went to the clinic and didn’t like the way the nurse talked to me… She told me, ‘Oh you have AIDS!’ Like that… I felt stigmatized (focus group discussion participant, Belize City; 30–34 years).

There is stigma even among people who work for organizations with infected people, for example, those who do testing in the laboratory (focus group discussion participant, Orange Walk; 35–39years).

DISCUSSION

This study assessed HIV prevalence in MSM in Belize and examined behavioral and structural factors associated with infection. The findings demonstrate a persistent concentrated HIV epidemic among MSM, driven by high-risk sexual practices, substance use, mental health challenges, and limited access to prevention services within a context of stigma and discrimination

HIV prevalence

HIV prevalence among MSM in this study was 11.0%, markedly higher than the national adult prevalence of 1.3%, confirming a concentrated epidemic (7). This figure reflects a modest improvement from the 13.9% reported in the 2012 Integrated Biological and Behavioral Surveillance Survey, yet it is still higher than the Caribbean average (4.5%) and slightly lower than that of Latin America (12.6%) (7). The prevalence of HIV in MSM varies widely in the region, from over 30% in Trinidad and Tobago to 5–6% in Guyana, Suriname, and Cuba. The prevalence is often higher in settings that criminalize same-sex behavior (12, 13). Globally, the HIV prevalence in MSM is 4.5 times higher than the general population, and is influenced by behavioral and structural factors (14). In this study, the prevalence was lower in MSM younger than 25 years (3.8%) than in those aged 25 years and older (8.0%), although the difference was not statistically significant. This finding reflects cumulative exposure risks and delayed diagnosis among older MSM (15).

Condom use

Condom use is a central HIV prevention strategy during anal intercourse, yet inconsistent use persists among MSM across partner types (16). In this study, 70.4% of respondents who reported anal sex in the past 6 months indicated consistent condom use, while 16.1% reported never using condoms. Condom use differed by context: 84.3% among MSM who paid for sex compared with 64.1% among those who received payment for sex.

These findings are consistent with regional estimates from Latin America and the Caribbean, where condom use among MSM averages at 63%, with substantial variability between countries (12, 17). Condom use at last anal sex was slightly higher among MSM younger than 25 years compared with older participants, although many studies report lower condom use in younger MSM – particularly those with steady partners (12, 17). Consistent with existing evidence, engagement in transactional sex was associated with lower condom use, which underscore the role of power asymmetries and economic vulnerability in shaping HIV risk (18).

Transactional sex

Transactional sex remains a key driver of HIV vulnerability among MSM (19). In this study, 33.1% of respondents reported ever receiving money or goods in exchange for anal sex, while 22.0% reported paying for sex in the past 6 months. Condom use differed substantially by role, reflecting unequal negotiating power: 64.1% of respondents receiving payment for sex used condoms compared with 84.3% among those paying for sex. This disparity highlights the socioeconomic determinants of HIV risk and the heightened vulnerability associated with economic dependence.

HIV and STI testing

Despite recommendations for annual or more frequent HIV testing among sexually active MSM, testing coverage remains inadequate in many settings (20, 21). In this study, only 42.0% of respondents reported HIV testing in the previous 12 months, which is slightly lower than the 48% and 46.2% reported in Mexico and Brazil (22, 23).

HIV self-testing, recommended by WHO as an additional strategy to accelerate reaching UNAIDS targets, was rarely used in this study. Only 6.5% of respondents reported ever self-testing, which is lower than global pooled estimates of 8% (24). Uptake remains limited in Latin America and the Caribbean despite availability, which may reflect persistent barriers including stigma, low awareness, and concerns about post-test counseling and linkage to care (25).

Syphilis prevalence was 11.4%, considerably higher than earlier estimates among MSM in Belize of less than 1% and consistent with the pooled prevalence of 14.5% reported for Latin America and the Caribbean (26). Syphilis disproportionately affects MSM and is closely associated with HIV co-infection, and is sustained by structural barriers to prevention and care (27). These findings underscore the importance of routine, frequent syphilis screening and integration of STI services into HIV and PrEP programs.

Substance use and mental health

Sexualized use of alcohol and drugs (use of substances before or during sexual activity) is common in MSM and is strongly associated with HIV risk (28). In this study, more than half of respondents were in the high-risk category on the AUDIT, while 50.4% reported anal sex while intoxicated or while using cannabis or other substances in the past 6 months. Comparable patterns have been reported across Latin America and the Caribbean, with wide country-level variation (29).

Substance use is closely linked to transactional sex and psychosocial stressors, including depression and intimate partner violence, which further increase vulnerability to HIV and other STIs (30). Mental health problems were evident among the respondents of this study: 46.1% were at high risk of depression. The qualitative findings corroborated these results, including reports of severe psychological distress and a prior suicide attempt.

Globally, depression and anxiety are disproportionately prevalent in MSM, driven by stigma, discrimination, social exclusion, HIV status, and socioeconomic disadvantage (31). These mental health challenges contribute to increased sexual risk-taking and reduced engagement with HIV prevention and care services (32). Integration of mental health screening and psychosocial support within HIV services is therefore crucial.

Access to PEP and PrEP and stigma

PEP and PrEP are core biomedical HIV prevention strategies worldwide. Belize has approved daily oral PrEP for key populations, including MSM, yet awareness and uptake are still very low (33). In this study, awareness of PEP and PrEP was similarly limited: 8.6% and 8.4%, respectively, far lower than levels reported in other Latin America and the Caribbean countries. For example, in Brazil and Mexico, awareness of PEP was 54.5% and 39.2%, respectively, and awareness of PrEP was 46.5% and 54.8%, respectively (34). Of those who were aware, few were current users, well below the UNAIDS target of 50% coverage for MSM (1, 3). Limited awareness, inadequate counseling, stigma, and low health care engagement are key barriers to the use of these strategies, underscoring the need for PEP and PrEP integration into HIV testing services (33, 34).

Stigma further constrained access to care as reported in the study where participants reported stigmatizing experiences in health care settings. This result is consistent with findings from multiple regions showing that discrimination and insufficient provider training discourage MSM from seeking services (35). Targeted provider training and MSM-friendly services are essential to improving HIV prevention outcomes.

Strength and limitations of the study

Respondent-driven sampling enabled access to a hard-to-reach population and improved representativeness. Integrating quantitative and qualitative data strengthened interpretation and validity of the findings. Limitations included potential selection and self-report biases and a cross-sectional design. Nonetheless, the findings provide important evidence to inform targeted HIV prevention and care strategies among MSM in Belize.

Conclusion

HIV prevalence in MSM in Belize remains high at 11.0%, far exceeding the national average. Persistent risk behaviors, such as inconsistent condom use, multiple partners, transactional sex, substance use, and low uptake of PrEP and PEP, are compounded by stigma, discrimination, and unmet mental health needs. Integrated, MSM-centered interventions that expand stigma-free care, testing, prevention awareness, mental health services, and harm reduction are essential to accelerate progress toward the UNAIDS 95-95-95 targets.

Data availability:

Data are available on request.

Declaration of artificial intelligence (AI) use:

The authors declare that AI tools were not used beyond basic text editing (e.g., spell-checking using Microsoft Copilot).

Disclaimer:

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization and the World Health Organization.