Abstract
Risk perception and health behaviors result from individual-level factors influenced by specific partnership contexts. We explored individual- and partner-level factors associated with partner-specific perceptions of HIV/STI risk among 372 HIV/STI-positive MSM and transgender women (TW) in Lima, Peru. Generalized estimating equations (GEE) explored participants’ perception of their three most recent partner(s) as a likely source of their HIV/STI diagnosis. Homosexual/gay (PR = 2.07; 95% CI 1.19-3.61) or transgender (PR = 2.84; 95% CI 1.48-5.44) partners were more likely to be considered a source of infection than heterosexual partners. Compared to heterosexual respondents, gay and TW respondents were less likely to associate their partner with HIV/STI infection, suggesting a cultural link between gay or TW identity and perceived HIV/STI risk. Our findings demonstrate a need for health promotion messages tailored to high-risk MSM partnerships addressing how perceived HIV/STI risk aligns or conflicts with actual transmission risks in sexual partnerships and networks.
Keywords: HIV, STI, MSM, Perceived Risk, Transgender
INTRODUCTION
Men who have sex with men (MSM) and male-to-female transgender women (TW) in Peru are disproportionately affected by the HIV epidemic (1). HIV prevalence among Peruvian MSM has been estimated at 11-22% and 30% among TW as compared to a 0.4% HIV prevalence in the general population (1-6). Ulcerative STIs, such as HSV-2 and syphilis, are also common among MSM and TW and contribute to HIV transmission (2, 4, 7, 8). Though factors underlying the disproportionate burden of disease within MSM and TW are numerous and complex, the high frequency of condomless anal intercourse (CAI) is a key contributing factor (2, 9). Since sexual risk assessments and subsequent risk reduction behaviors occur at both the dyadic and the individual level (i.e., not only as individual patterns of behavior, but also as partnership-specific constructs), it is important to delineate how perceptions of risk and actual HIV and STI transmission differ according to partnership context.
Previous studies have demonstrated that partnership type and other dyadic characteristics inform perceptions of risk for HIV and STI acquisition and influence sexual risk behaviors (10-14). While MSM are more likely to participate in condomless intercourse in the context of stable partnerships, CAI has also been reported in many casual partnerships in the United States and Latin America (15, 16). Other partner-level characteristics associated with perceived risk for HIV and STI and decisions concerning condom use include: knowledge of the partner's sexual history, trust, degree of familiarity with the partner, and prior disclosure of HIV serostatus (11, 12, 17). While previous research in Peru has described associations between partnership type and CAI, information concerning individuals’ perceptions of partner-level risks for HIV and STI and their impact on sexual risk behavior is limited.
Cultural constructions of sexuality and epidemiologic patterns of disease prevalence also influence MSM and TW's perceptions of HIV and STI vulnerability. As outlined in previous research, HIV/STI prevalence varies between subpopulations of MSM and TW, with higher frequencies of HIV, syphilis, and rectal STIs observed among gay-identified pasivo and moderno men and TW who engage in receptive anal intercourse compared with heterosexual-identified MSM who are primarily insertive, or activo, during intercourse (18). Qualitative evidence from the same sample suggested that differences in STI prevalence coincided with cultural constructions of sexuality and gender that defined gay-identified MSM and TW as carriers of disease. However, the same study found a high prevalence of HIV and other STIs among non-gay identified activo MSM, suggesting that cultural ideologies linking gay or transgender identity with HIV and STI risk are incomplete at best, and insufficient for accurate assessments of partner-level risk for disease transmission.
In order to further explore the question of how partnership characteristics influence individuals’ estimations of HIV/STI risk, we examined the association between sexual identity and perceived partner-specific risk of HIV/STI transmission in a group of MSM and TW in Peru recently diagnosed with HIV and/or STI. Improved understanding of how individuals diagnosed with HIV/STI perceive their likelihood of having acquired and/or transmitted the infection with their recent sexual partners can help to define both individual and dyadic factors associated with HIV and STI risk perceptions and contribute to a better understanding of how social and cultural constructions of vulnerability define individual- and partner-level frameworks for harm reduction practices. In order to develop targeted, context-specific public health interventions for MSM and TW in Latin America, we assessed individual- and partner-level factors associated with the perceived source of infection among MSM and TW in Peru recently diagnosed with HIV and STI.
METHODS
Study Setting, Design and Population
As part of a larger cross-sectional study assessing partner notification beliefs and practices among MSM and TW in Lima, Peru, we conducted a secondary analysis of the association between sexual orientation/gender identity and perceived source of infection among MSM and TW recently diagnosed with HIV and/or STI.
The study methods have been previously described (19). Briefly, between January 2011 to January 2012, 397 MSM and TW newly diagnosed with HIV and/or STI completed a survey of attitudes, beliefs, and anticipated practices related to partner notification. Enrollment was limited to individuals assigned male sex at birth ≥18 years of age who reported oral or anal intercourse with a male or TW partner during the previous year and who had been diagnosed with HIV and/or STI (syphilis, genital ulcer disease, genital herpes, proctitis, and/or urethritis) within the previous 30 days. All participants received 10 Nuevos Soles (approximately $4.00 USD) as compensation for their transportation costs.
Written informed consent was obtained from all participants prior to enrollment. The study protocol was reviewed and approved by the Office of Human Research Participant Protection (OHRPP) at the University of California, Los Angeles (UCLA) (G10-03-036-01) and the Comite Institucional de Bioética at Asociación Civil Impacta Salud y Educación (0104-2010-CE).
Demographics
Participants were asked about their age, education, sexual orientation/gender identity, specific STI diagnosed (which was later grouped into three categories), sexual role, and sexual practices both as an aggregate of behavior in the past three months and individually with each of their most recent partners (to a maximum of three partners).
Partnership-level variables
Questions specific to the three most recent sexual contacts included each partner's perceived sexual orientation/gender identity, partnership type, length of the partnership, whether the participant considered the partner a likely source of their HIV/STI, and whether the participant considered themselves to be a likely source of infection for the partner. Due to the small number of female partners reported, we excluded female partnerships from our analysis (n=42), giving a sample of 993 total partners reported. Respondents were asked to classify each recent partner as stable, casual, anonymous, commercial (client), or commercial (sex worker). For our analysis, we reclassified partnerships into three categories: stable, casual (casual and anonymous) and commercial (commercial sex client or worker). Respondents were asked if they practiced receptive and/or insertive CAI with each partner, and we then dichotomized this variable into partnerships with any CAI (either insertive and/or receptive) and partnerships without any CAI. Respondents were also asked to classify their own sexual role as well as the perceived role of their partner(s) as activo (insertive), pasivo (receptive), or moderno (versatile) or “Does Not Apply” (18).
Perception of Partner-Specific STI Risk
The primary outcome for our analysis was whether the participant described their recent partner(s) as a likely source of their recently diagnosed infection. For each of the most recent partners (up to a maximum of three partners), participants were asked “Do you think it is likely that this partner infected you (i.e., that they were the source of your infection)?” Possible responses included: “Yes, I am sure that this person was the source of my infection”, “Yes, this person probably was the source of my infection”, “No, this person probably was not the source of my infection”, “No, this person definitely was not the source of my infection”, or “I don't know”. For our analysis, we dichotomized the outcome as “Likely” or “I don't know/Unlikely”. Participants were also asked to estimate their likelihood of having infected each of their most recent partners (to a maximum of three partners) with the STI diagnosed, repeating the same response options and categorizations described above.
Data Analysis
We assessed associations between sexual orientation/gender identity and perceived HIV/STI risk at both the individual-level (e.g., participant) and the dyadic-level (e.g., partnership). Cluster-adjusted chi square tests were used to assess respondent-level factors (age, education, sexual orientation/gender identity, sexual role, STI diagnosis) and partnership-level factors (partner sexual orientation/gender identity, partner sexual role, partnership type, CAI) with the primary outcome, using the respondent as the cluster and partnership-level factors as units within the cluster.
We used generalized estimating equations (GEEs) to model the association between the main predictor (sexual orientation/gender identity) as well as other respondent- and partnership-level covariates with perceived risk of HIV/STI transmission among each of the respondent's reported partners (up to a maximum of three partnerships reported per participant). As each respondent could report data on up to 3 partnerships and the main outcome (perception) was measured at the partnership-level, GEEs were used to account for the correlated data structure in this study (20). Given that condom use within the partnership was likely to influence perceptions surrounding risk of HIV/STI acquisition and transmission, we controlled for CAI in multivariable analysis. Our final multivariable model adjusted for both participant-level (age, education, sexual orientation/gender identity, specific HIV /STI diagnosis) and partnership-level factors (partner sexual orientation/gender identity, partner type, and CAI with the partner). We created an additional multivariable model, with the same participant- and partnership-level factors as predictors, using respondent's self-perception as the actual source of infection for each of their reported partnerships as the main outcome. While sexual orientation/gender identity and sexual role of the participant were associated with perceived source of infection in the bivariate analysis, we excluded participant and partner's sexual role from the multivariable models due to the conceptual overlap between sexual role and sexual orientation/gender identity in this context (18). Crude and adjusted prevalence ratios (PR) with 95% confidence intervals were calculated using GEEs with a Poisson distribution family for the primary outcome, a logarithmic link function, exchangeable working correlation matrix and robust standard errors (21). All data analyses were conducted using Stata 12.0 (Stata Corporation, College Station, TX).
RESULTS
Participant characteristics
We analyzed data from 372 participants, with most participants (85.2%) providing data on three recent sexual partners. The mean age of respondents was 30.6 years (SD 8.9), with 133 (35.9%) completing high school and 154 (41.5%) reporting some level of higher education (university or technical school). The majority of respondents self-identified as homosexual/gay (66.6%), followed by bisexual (15.6%), TW (14.5%), and heterosexual (3.3%). The most common diagnoses among respondents were STI (non-HIV) (52.2%), HIV and STI co-infection (25.8%), followed by only HIV (22%). Participant characteristics are reported in Table 1.
Table 1.
Participant- and partnership-level characteristics of MSM and TW recently diagnosed with HIV and/or STI; Lima, Peru, 2011.
| No. | % | |
|---|---|---|
| Respondent characteristics (n = 372)a | ||
| Education | ||
| Less than high school | 84 | 22.6 |
| Completed high school | 133 | 35.9 |
| Higher educationb | 154 | 41.5 |
| Sexual orientation/gender identity | ||
| Heterosexual | 12 | 3.3 |
| Bisexual | 57 | 15.6 |
| Homosexual | 243 | 66.6 |
| Transgender | 53 | 14.5 |
| Sexual role | ||
| Activo (insertive) | 52 | 14.1 |
| Pasivo (receptive) | 140 | 37.9 |
| Moderno (versatile) | 177 | 48.0 |
| Partnership characteristics (n = 993)c | ||
| Partner sexual orientation/gender identity | ||
| Heterosexual | 124 | 13.7 |
| Bisexual | 372 | 41.0 |
| Homosexual | 386 | 42.6 |
| Transgender | 24 | 2.7 |
| Partner sexual role | ||
| Activo (insertive) | 500 | 52.2 |
| Pasivo (receptive) | 148 | 15.5 |
| Moderno (versatile) | 310 | 32.4 |
| Partnership type | ||
| Stable | 298 | 31.3 |
| Casual | 524 | 55.0 |
| Commercial | 131 | 13.7 |
Some variables do not total 372 due to missing data
Received some post-secondary education (e.g., university or technical school)
Some variables do not total 993 due to missing data
Partnership characteristics
Of 993 partnerships reported, 524 (55.0%) were casual and 298 (31.3%) were with stable partners. Most participants described their partner's sexual orientation as bisexual (41.0%) or homosexual/gay (42.6%), and reported CAI in 335 (41.2%) of all partnerships. Among all recent partners, 26.0% (CI 22.9%-29.4%) were perceived as a likely source of STI transmission. In contrast, participants believed themselves likely to have transmitted an STI to their partners in only 159 (16%) partnerships. Partnership characteristics are reported in Table 1.
Perceived infection source
In bivariate analysis (Table 2), respondent factors significantly associated with perceiving a recent partner as a likely source of HIV and/or STI were self-reported sexual orientation/gender identity and sexual role (p<0.05). Prior to adjusting for selected individual- and partnership-level variables, respondents who reported their sexual role as pasivo (receptive) (PR crude = 0.54; CI 0.38-0.77) or moderno (versatile) (PR crude = 0.58; CI 0.42-0.81) were significantly less likely to consider their partner as a source of infection as compared with respondents who reported an activo (insertive) sexual role. Partner-level factors associated with perceived HIV/STI risk included: partner sexual orientation/gender identity, partnership type, and history of CAI with the partner. Compared to partners who endorsed an activo sexual role during intercourse, moderno-identified partners were more likely to be perceived as the source of infection (PR crude = 1.44; CI 1.03-2.01). Compared to stable partnerships, commercial partnerships were significantly less likely to be considered sources of infection (PR crude = 0.43; CI 0.26-0.70). Respondent age, education, STI diagnosis, and partner sexual role were not significantly associated with perception of the partner as being the source of HIV and/or STI in bivariate analysis.
Table 2.
Participant- and partnership-level characteristics associated with perception of sexual partner as the source of transmitted infection among MSM and TW recently diagnosed with HIV and/or STI; Lima, Peru, 2011.
| Characteristics | Partner perceived as source of infection (n=258) n (%) | Partner not perceived as source of infection (n=735) n (%) | pa |
|---|---|---|---|
| Age (years) mean; sd | 30.8 ; 0.8 | 30.3 ; 0.5 | 0.55 |
| Education | |||
| Less than high school | 47 (20.4) | 184 (79.6) | 0.11 |
| Completed high school | 86 (25.4) | 253 (74.6) | |
| Higher educationb | 125 (29.8) | 295 (70.2) | |
| Respondent sexual orientation/gender identity | |||
| Heterosexual | 13 (68.4) | 6 (31.6) | <0.05 |
| Bisexual | 44 (31.7) | 95 (68.3) | |
| Homosexual | 170 (25.6) | 495 (74.4) | |
| Transgender | 26 (17.1) | 126 (82.9) | |
| Respondent sexual role during intercourse | |||
| Activo (insertive) | 48 (41.0) | 69 (59.0) | <0.05 |
| Pasivo (receptive) | 91 (23.1) | 303 (76.9) | |
| Moderno (versatile) | 117 (24.5) | 360 (75.5) | |
| STI diagnosis | |||
| Any non-HIV STI | 135 (26.6) | 373 (73.4) | 0.23 |
| HIV | 47 (20.8) | 179 (79.2) | |
| HIV plus any other STI | 76 (29.3) | 183 (70.7) | |
| Partner sexual orientation/gender identity | |||
| Heterosexual | 18 (14.5) | 106 (85.5) | <0.05 |
| Bisexual | 82 (22.0) | 290 (78.0) | |
| Homosexual | 126 (32.6) | 260 (67.4) | |
| Transgender | 13 (54.2) | 11 (45.8) | |
| Partner sexual role | |||
| Activo (insertive) | 116 (23.2) | 384 (76.8) | 0.08 |
| Pasivo (receptive) | 50 (33.8) | 98 (66.2) | |
| Moderno (versatile) | 88 (28.4) | 222 (71.6) | |
| Partnership type | |||
| Stable | 98 (32.9) | 200 (67.1) | <0.05 |
| Casual | 136 (26.0) | 388 (74.0) | |
| Commercial | 18 (13.7) | 113 (86.3) | |
| Unprotected anal intercourse | |||
| Yes | 137 (40.9) | 198 (59.1) | <0.05 |
| No | 75 (15.7) | 403 (84.3) | |
Cluster-adjusted chi-square analysis
Received some post-secondary education (e.g., university or technical school)
Of the 993 partnerships reported, 159 participants considered themselves likely to have infected their partner with HIV/STI. Perceived likelihood of infecting partners was lower in commercial partnerships (compared to stable partnerships) and in partnerships where CAI was practiced. In multivariable models (see Table 3), both CAI and participant/partner sexual orientation/gender identity were significantly associated with perceived HIV/STI source. Compared to heterosexual-identified respondents, bisexual (PR = 0.52; CI 0.30-0.90), homosexual (PR = 0.47; CI 0.31-0.73), and TW (PR = 0.37; CI 0.19-0.70) respondents were significantly less likely to consider their partner a likely source of their infection. Additionally, partners who were identified as gay (PR = 2.07; CI 1.19-3.61) and TW (PR = 2.84; CI 1.48-5.44) were significantly more likely to be perceived as a source of infection compared to heterosexual male partners. CAI within a partnership was independently associated with perception of the partner as the source of infection (PR = 3.2; CI 2.28-4.46) while partnership type, type of HIV/STI diagnosis, education level, and respondent age were not significantly associated.
Table 3.
Participant- and partner-level characteristics associated with perception of the partner as a likely HIV/STI source among recently diagnosed MSM/TW; Lima, Peru, 2011.
| Characteristics | Crude Prevalence Ratio (n = 993) | 95% CI | P | Adjusted Prevalence Ratioa (n = 743) | 95% CI | P |
|---|---|---|---|---|---|---|
| Age (years) | 1.00 | 0.99-1.02 | 0.64 | 1.00 | 0.99-1.02 | 0.91 |
| Education | ||||||
| Less than high school | Ref | - | - | Ref | - | - |
| Completed high school | 1.25 | 0.85-1.83 | 0.26 | 0.88 | 0.60-1.30 | 0.53 |
| Higher educationb | 1.42 | 0.98-2.05 | 0.06 | 1.00 | 0.69-1.44 | 0.99 |
| Respondent sexual orientation/gender identity | ||||||
| Heterosexual | Ref | - | - | Ref | - | - |
| Bisexual | 0.51 | 0.32-0.81 | <0.05 | 0.52 | 0.30-0.90 | <0.05 |
| Homosexual | 0.40 | 0.27-0.59 | <0.05 | 0.47 | 0.31-0.73 | <0.05 |
| Transgender | 0.26 | 0.15-0.46 | <0.05 | 0.37 | 0.19-0.70 | <0.05 |
| STI diagnosis | ||||||
| Any non-HIV STI | Ref | - | - | Ref | - | - |
| HIV | 0.80 | 0.56-1.13 | 0.20 | 0.82 | 0.56-1.21 | 0.32 |
| HIV plus any other STI | 1.06 | 0.78-1.46 | 0.70 | 0.95 | 0.69-1.30 | 0.75 |
| Partner sexual orientation/gender identity | ||||||
| Heterosexual | Ref | - | - | Ref | - | - |
| Bisexual | 1.53 | 0.94-2.50 | 0.08 | 1.49 | 0.85-2.61 | 0.16 |
| Homosexual | 2.33 | 1.46-3.70 | <0.05 | 2.07 | 1.19-3.61 | <0.05 |
| Transgender | 3.71 | 2.02-6.80 | <0.05 | 2.84 | 1.48-5.44 | <0.05 |
| Partnership type | ||||||
| Stable | Ref | - | - | Ref | - | - |
| Casual | 0.83 | 0.64-1.07 | 0.16 | 1.05 | 0.77-1.42 | 0.77 |
| Commercial | 0.43 | 0.26-0.70 | <0.05 | 0.71 | 0.44-1.16 | 0.17 |
| Unprotected anal intercourse | 2.93 | 2.17-3.97 | <0.05 | 3.2 | 2.28-4.46 | <0.05 |
Adjusted for all variables included in table
Received some post-secondary education (e.g., University or technical school)
Note: Bold indicates statistical significance
DISCUSSION
Our findings highlight that self-reported gay men and transgender women in Peru were less likely to perceive their partner (irrelevant of partner sexual orientation/gender identity) as a source of infection when compared with self-described heterosexual MSM. Similarly, partners described as gay or transgender were more likely to be perceived as a source of infection compared to heterosexual male partners. While CAI was associated with perceived HIV and STI acquisition and transmission risk in a partnership, the link between sexual identity and perceived source of HIV and STI transmission remained significant even after controlling for partner-specific CAI. Jointly, these results suggest that sexual orientation/gender identity significantly impact risk perceptions in MSM and TW partnerships at both the individual- and dyadic-level and influence use of health protective behaviors within specific partnership contexts.
As noted in previous studies, CAI was associated with perceived likelihood of HIV/STI transmission to and from the partner, independent of education, age, partnership type and sexual orientation/gender identity of partner/respondent. Given the well-documented association between CAI and HIV/STI risk, the increased perceived risk of HIV and STI acquisition from partnerships where CAI was practiced is not surprising, though the high reported frequency of CAI is of public health concern in a sample where all respondents had recently tested positive for HIV/STI. Despite the fact that CAI was associated with increased bidirectional risk perception, CAI was reported in 41.2% of partnerships, consistent with previous research in Peru where CAI was reported in 35.2%-55.1% of MSM/TW partnerships (2, 3, 15, 22). The high frequency of CAI reported in this sample of high-risk MSM and TW underscores the need for public health interventions that are tailored to the needs of this group and highlights the potential importance of alternative biomedical prevention interventions (such as pre-exposure prophylaxis, rectal microbicides, test and treat, and STI control) in addition to condom use promotion.
Independent of CAI, sexual orientation/gender identity of both the individual and the partner were important predictors of perceived HIV and STI source. Partners described as gay or TW were significantly more likely to be considered a source of participants’ recently acquired infection. Perceived likelihood of having acquired HIV and/or STI from a TW partner was almost 3-fold greater than from heterosexual male partners. At the same time, respondents who identified as part of a sexual minority (e.g., gay, bisexual) were less likely to consider their recent partners probable sources of infection. Among our sample, TW were least likely to perceive their partners as the likely STI source, followed by gay, and then bisexual respondents. Our findings highlight a latent cultural logic that associates identification as transgender or homosexual/gay with HIV/STI risk and as a result (inaccurately) defines non-gay identified MSM as lower risk than other, gay-identified male and TW partners (6, 18). As all MSM included in this study were recently diagnosed with HIV/STI and therefore objectively at “high-risk” for HIV and STI acquisition, and despite the fact that only a minority of participants regarded themselves as such, this flawed logic reflects a lack of congruency between perceptions of HIV and STI risk and actual likelihood of disease transmission underlying their common failure to take appropriate health prevention measures. Because of the assumption that they represent a low-risk for HIV and STI to themselves and their partners, regardless of their actual sexual behavior, heterosexual MSM often fail to receive important public health messages and continue to engage in sexual practices that increase HIV/STI transmission risk for themselves and their partner(s), whether male, female or transgender.
The lower likelihood that the partners of gay-identified and TW would be considered a likely HIV/STI source may be due to a complex interaction of individual- and partnership-level factors. The assumption among gay and TW participants that their heterosexual-identified partners are unlikely to be sources of HIV/STI is an obvious corollary of the cultural link between gay men/TW and sexually transmitted disease. This cultural logic could have a profound effect on partner risk perception whereby gay MSM and TW always consider themselves to be the “risky partner,” regardless of their actual HIV or STI status, leading them to minimize their likelihood of acquiring HIV or STI during unprotected intercourse with a non-gay identified male partner.
Complex issues of trust, vulnerability, and sexual risk behavior are also likely to be at play in these differences in partner-specific HIV/STI risk perception. Prior studies in Latin America have identified partnership status and commitment in a partnership as important determinants of partner-specific condom use. At the same time, previous studies with gay-identified MSM and TW have described their prioritization of intimacy and long-term partnerships, in contrast to the description of male sexual partners as transient sexual contacts commonly articulated by heterosexual- and bisexual-identified MSM (18, 23-26). As a result, by minimizing potential risks of HIV/STI acquisition within what they regard as committed partnerships, gay men and TW are often led to further increase their vulnerability to HIV/STI acquisition with high-risk sexual partners. To address this problem, public health efforts need to de-link social constructions of sexual orientation/gender identity from cultural concepts of HIV/STI risk, emphasizing the primacy of sexual practices and sexual networks in defining risk for HIV and STI transmission, and recognizing how nuances of identity and behavior may influence an individual's perceived susceptibility to HIV/STIs in a specific partnership context.
Some limitations of this study need to be considered when interpreting our data. First, there is an inherent bias in secondary analysis of self-reported data from a cross-sectional study. Since enrollment was limited to individuals diagnosed with HIV and/or STI within the last 30 days, and participants were recruited through convenience sampling methods, our findings cannot be generalized to the entire MSM and TW population in Peru or elsewhere. However, by limiting eligibility to individuals with a recent HIV or STI diagnosis, our study was designed to address HIV/STI risk in a subpopulation of MSM and TW at high risk for future HIV infection and/or transmission, a group that is a priority for prevention efforts. Another potential limitation of our study is that our results are based on participant reports of the sexual orientation and gender identity of their partners rather than collecting this information directly from the partners. However, as the primary focus of our analysis was on the perception of risk, including respondents’ perceptions of their partners’ sexual orientation/gender identity was an important component of our analysis. While our survey used commonly accepted classifications of sexual identity for MSM and TW in Peru at the time it was originally written, we were unable to assess the differential effects of gender and sexual orientation among TW, as the survey did not collect that information.
Our findings suggest the need for health promotion efforts that promote recognition of the potential for HIV/STI risk among non-gay identified MSM by increasing their knowledge of how behaviors and networks, not identities and communities, structure HIV/STI transmission, and influence partner-specific HIV and STI risk. While the findings from our study suggest that differences in social and cultural contexts of risk perception vary according to participants’ and partners’ sexual orientation/gender identity, it is important to stress that transmission dynamics within partnerships are influenced by individual behavioral decision-making processes, partner-level sexual interactions, population-level patterns of HIV/STI prevalence, and sexual network structure. More research is needed to understand how sexual orientation/gender identity and risk perceptions vary between different partnership contexts in order to improve understanding of partner- and network-specific patterns of risk behavior and disease transmission and to inform future health promotion efforts among MSM and TW in Latin America.
ACKNOWEDGEMENTS
The authors would like to thank the staff at Asociación Civil Impacta Salud y Educación and the CERITS Alberto Barton for their help in completing the study. We would also like to thank the participants of this study for sharing their lives with us. Research funding was provided by NIH grant K23 MH084611.
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