Cultural Scripts Surrounding Young People's Sexual & Romantic Relationships in the Western Highlands of Guatemala

Guatemala has one of the world's highest teenage pregnancy rates and 92% of young people report not using contraception for first sex. 

We conducted narrative-based thematic analysis of a sample of narratives (n = 40; 15 male-authored, 25 female-authored) on HIV and sexuality, submitted to a 2013 scriptwriting competition by young people aged 15-19 years from Guatemala's Western Highlands. Our objective was to identify dominant cultural scripts and narratives that deviated positively from that norm with a view to informing the development of educational curricula and communication materials promoting youth sexual and reproductive health. 

The narratives are characterised by romantic themes and melodramatic plotlines: three in four had tragic endings. Rigid gender norms and ideologies of enduring love make female characters blind to the potential consequences of unprotected sex and vulnerable to betrayal and abandonment. 

Unprotected sex is the norm, with contraception and sexually transmitted infection protection mentioned rarely. In the four positively deviant narratives, female and male characters' interaction is based on mutual respect, dialogue and genuine affection. 

The narratives reveal opportunities for action to increase sexual health knowledge and access to services and to challenge harmful cultural scripts, potentially by leveraging the positive value attached to romantic love by authors of both sexes.

Purchase full article at:   http://goo.gl/e6GhXs

By:  Singleton R1, Schroffel H1, Findlay T1, Winskell K1.

• 1 Hubert Department of Global Health , Rollins School of Public Health, Emory University , Atlanta, GA , USA. 
• Cult Health Sex. 2016 Mar 17:1-15. 

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Evidence of Increased STI/HIV-Related Risk Behavior among Male Perpetrators of Intimate Partner Violence in Guatemala

Intimate partner violence (IPV) is a significant public health problem with a demonstrated link to increased sexually transmitted infection (STI)/HIV-related risk and vulnerability. While IPV is an important issue in Central America, the link to STI/HIV risk has not been explored in this region. 

In this study, the relationship between emotional and physical/sexual IPV and the STI/HIV-related risk behaviors of sex worker patronage and infidelity is assessed among male IPV perpetrators using data from a national survey conducted in 2009 in Guatemala (n = 4773 married/partnered men). Bivariate associations between background characteristics and emotional and physical IPV perpetration were explored. Logistic regression models were run to test associations between IPV for each sexual risk behavior. Perpetration of emotional and physical/sexual IPV was more common among married/partnered men who were older than 24, had more education, lived in urban areas, or were in common law versus married unions. Reports of past-year emotional IPV perpetration increased as wealth quintile increased. After adjusting for demographics and other characteristics, physical/sexual IPV perpetration was associated with past-year infidelity (AOR 1.9, 95% CI: 1.1-3.6). Lifetime emotional IPV (AOR 1.4, 95% CI: 1.1-1.7) and physical/sexual IPV 1.6 (95% CI 1.2-2.0) were positively associated with a history of sex worker patronage. Endorsement of traditional gender role norms showed a marginally positive association with past-year infidelity in the adjusted model (AOR 1.3, 95% CI 1.0-1.8). 

The study findings from Guatemala reinforce the growing evidence globally that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and main partner infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who also face injury and psychological trauma. Integration of prevention and screening of IPV and STI/HIV prevention services should be adopted in Guatemala and other similar contexts.

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By:   Hembling J¹, Andrinopoulos K.

¹a Department of Global Health Systems and Development , Tulane School of Public Health and Tropical Medicine , New Orleans , LA , USA.

AIDS Care. 2014;26(11):1411-8. doi: 10.1080/09540121.2014.913766. Epub 2014 May 6.

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Ethnicity & HIV Risk Behaviour, Testing & Knowledge in Guatemala

OBJECTIVES:

To describe levels of risky sexual behaviour, HIV testing and HIV knowledge among men and women in Guatemala by ethnic group and to identify adjusted associations between ethnicity and these outcomes.

DESIGN:

Data on 16,205 women aged 15-49 and 6822 men aged 15-59 from the 2008-2009 Encuesta Nacional de Salud Materno Infantil were used to describe ethnic group differences in sexual behaviour, HIV knowledge and testing. We then controlled for age, education, wealth and other socio-demographic factors in a multivariate logistic regression model to examine the effects of ethnicity on outcomes related to age at sexual debut, number of lifetime sex partners, comprehensive HIV knowledge, HIV testing and lifetime sex worker patronage (men only).

RESULTS:

The data show low levels of risky sexual behaviour and low levels of HIV knowledge among indigenous women and men, compared to other respondents. Controlling for demographic factors, indigenous women were more likely than other women never to have been tested for HIV and to lack comprehensive HIV knowledge. They were less likely to report early sexual debut and three or more lifetime sexual partners. Indigenous men were more likely than other men to lack comprehensive HIV knowledge and demonstrated lower odds of early sexual debut, 10 or more lifetime sexual partners and sex worker patronage.

CONCLUSIONS:

The Mayan indigenous population in Guatemala, while broadly socially vulnerable, does not appear to be at elevated risk for HIV based on this analysis of selected risk factors. Nonetheless, low rates of HIV knowledge and testing may be cause for concern. Programmes working in indigenous communities should focus on HIV education and reducing barriers to testing. Further research into the factors that underlie ethnic self-identity and perceived ethnicity could help clarify the relative significance of these measures for HIV risk and other health outcomes.

Full article at:   http://goo.gl/Rxe4bb

By:   Taylor TM¹, Hembling J, Bertrand JT.

¹ Global Health Systems and Development , Tulane University , New Orleans , LA , USA.

Ethn Health. 2015;20(2):163-77. doi: 10.1080/13557858.2014.893562. Epub 2014 May 16.

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Scale-Up, Retention & HIV/STI Prevalence Trends among Female Sex Workers Attending VICITS Clinics in Guatemala

Since 2007, Guatemala integrated STI clinical service with an HIV prevention model into four existing public health clinics to prevent HIV infection, known as the VICITS strategy. We present the first assessment of VICITS scale-up, retention, HIV and STI prevalence trends, and risk factors associated with HIV infection among Female Sex Workers (FSW) attending VICITS clinics in Guatemala.

Demographic, behavioral and clinical data were collected using a standardized form. Data was analyzed by year and health center. HIV and STI prevalence were estimated from routine visits. Retention was estimated as the percent of new users attending VICITS clinics who returned for at least one follow-up visit to any VICITS clinic within 12 months. Separate multivariate logistic regression models were conducted to investigate factors associated with HIV infection and program retention.

During 2007-2011 5,682 FSW visited a VICITS clinic for the first-time. HIV prevalence varied from 0.4% to 5.8%, and chlamydia prevalence from 0% to 14.3%, across sites. Attending the Puerto Barrios clinic, having a current syphilis infection, working primarily on the street, and using the telephone or internet to contact clients were associated with HIV infection. The number of FSW accessing VICITS annually increased from 556 to 2,557 (361%) during the period. In 2011 retention varied across locations from 7.7% to 42.7%. Factors negatively impacting retention included current HIV diagnosis, having practiced sex work in another country, being born in Honduras, and attending Marco Antonio Foundation or Quetzaltenango clinic sites. Systematic time trends did not emerge, however 2008 and 2010 were characterized by reduced retention.

Our data show local differences in HIV prevalence and clinic attendance that can be used to prioritize prevention activities targeting FSW in Guatemala. VICITS achieved rapid scale-up; however, a better understanding of the causes of low return rates is urgently needed.

Below:  Number of active FSW attending VICITS clinics over time by clinic, Guatemala, 2007–2011

Risk factors associated with HIV infection among FSW attending VICITS clinics for the first time, Guatemala, 2007–2011 (N = 4,021).

Variable	OR (95% CI)	AOR (95% CI)
Age
18–24	1.00
25–34	1.09 (0.61–1.95)
≥35	2.10 (1.04–4.24)
Clinic
Zone 3	1.00	1.00
FMA	2.09 (1.06–4.10)	0.73 (0.31–1.71)
Puerto Barrios	4.58 (2.40–8.74)	4.52 (2.09–9.78)
Quetzaltenango	0.75 (0.18–3.15)	1.11 (0.26–1.71)
Highest level of education completed
<Primary	1.00	1.00
Primary	0.44 (0.24–0.81)	0.51 (0.28–0.93)
≥HS	0.54 (0.26–1.11)	0.73 (0.35–1.54)
Current syphilis infection	6.13 (2.13–17.59)	4.32 (1.46–12.81)
Sex work location
Strip club	1.00	1.00
Bar	2.42 (1.17–5.02)	1.37 (0.61–3.11)
Street	3.69 (1.67–8.18)	4.14 (1.60–10.69)
Brothels based at residential homes	0.94 (0.33–2.72)	1.01 (0.35–2.94)
Other (telephone or internet)	3.13 (1.15–8.54)	3.40 (1.11–10.38)

Full article at: http://goo.gl/49AN6S

By: Morales-Miranda S1, Jacobson JO1, Loya-Montiel I1, Mendizabal-Burastero R1, Galindo-Arandi C1, Flores C2, Chen SY3.

• 1Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
• 2National STI/HIV/AIDS Program, Ministry of Public Health, Guatemala City, Guatemala.
• 3Division of Global HIV/AIDS, Centers for Disease Control and Prevention - Central America Regional Office, Guatemala City, Guatemala. 

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The MANGUA Project: A Population-Based HIV Cohort in Guatemala

The MANGUA cohort is an ongoing multicenter, observational study of people living with HIV/AIDS in Guatemala. The cohort is based on the MANGUA application which is an electronic database to capture essential data from the medical records of HIV patients in care.

The cohort enrolls HIV-positive adults ≥16 years of age. A predefined set of sociodemographic, behavioral, clinical, and laboratory data are registered at entry to the cohort study.

As of October 1st, 2012, 21 697 patients had been included in the MANGUA cohort (median age: 33 years, 40.3% female). At enrollment 74.1% had signs of advanced HIV infection and only 56.3% had baseline CD4 cell counts. In the first 12 months after starting antiretroviral treatment 26.9% (n = 3938) of the patients were lost to the program.

The implementation of a cohort of HIV-positive patients in care in Guatemala is feasible and has provided national HIV indicators to monitor and evaluate the HIV epidemic. The identified percentages of late presenters and high rates of LTFU will help the Ministry to target their current efforts in improving access to diagnosis and care.

Below:  Number of UAIs and number of patients attended at each UAI by Guatemalan department

Below:  Spectrum of cART initiation in patients enrolled in MANGUA cohort

Full article at: http://goo.gl/yrPjAI

By: Juan Ignacio García, 1  Blanca Samayoa,  Meritxell Sabidó, 1  Luis Alberto Prieto, 1 Mikhail Nikiforov, 1 Rodolfo Pinzón,  Luis Roberto Santa Marina de León,  José Fernando Ortiz,  Ernesto Ponce,  Carlos Rodolfo Mejía, Eduardo Arathoon,  Jordi Casabona, 1  and The Mangua Cohort Study Group 1

²PhD Programme in Methodology of Biomedical Research and Public Health, Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Bellaterra, 08193 Catalonia, Spain

³Clínica Familiar Luis Ángel García, San Juan de Dios Hospital, Asociación de Salud Integral, 1001 Guatemala City, Guatemala

⁴TransLab, Department of Medical Sciences, University of Girona, Girona, 17004 Catalonia, Spain

⁵Infectious Diseases Clinic, Roosevelt Hospital, 1011 Guatemala City, Guatemala

⁶Juan José Ortega de Coatepeque National Hospital, Coatepeque, 09020 Quetzaltenango, Guatemala

⁷Hospital del Instituto Guatemalteco de Seguridad Social (IGSS), 1009 Guatemala City, Guatemala

⁸National Programme for Prevention and Control of STI and HIV/AIDS (PNS), 1011 Guatemala City, Guatemala

⁹CIBER Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain

¹⁰

1Fundació Sida i Societat, Technical Advisor Unit (UAT), Escuintla National Hospital, 5001 Escuintla, Guatemala

1Fundació Sida i Societat, Technical Advisor Unit (UAT), Escuintla National Hospital, 5001 Escuintla, Guatemala

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Is Violence Associated with Increased Risk Behavior among MSM? Evidence from A Population-Based Survey Conducted Across Nine Cities in Central America

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.

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.

MSM who experienced physical violence were more likely to be engaged in transactional sex, have multiple partners in the past 30 days, and have engaged in sex under the influence of alcohol or drugs. 

Both physical violence and psychological/verbal violence were also associated with reporting STI symptoms or diagnosis within the past 12 months. 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 and more likely to report engaging in sex under the influence of alcohol or drugs, as compared to those identifying as homosexual.

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.

Full article at: http://goo.gl/NX73bR

By: Wheeler J1, Anfinson K2, Valvert D3, Lungo S3.

• 1Population Services International, Washington, DC, USA
• 2Population Services International, Washington, DC, USA.
• 3Association PASMO, Guatemala City, Central America.

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Family Planning for Strangers: An Experiment on the Validity of Reported Contraceptive Use

Below:  Scatterplot for Reported Sterilization and TFR in Urban Latin American DHS data, 42 surveys from 15 countries, including OLS Regression Prediction Line (R2 = 0.14; p = 0.015).

Sterilization levels reported in the Dominican Republic appear well above what we would normally expect given prevailing patterns in the region. We suspect that the use of strangers as interviewers—the normative approach in data collection in both developed and developing country settings—may be partly responsible for this result, and may underlie a long history of bias in family planning data. We present findings from a field experiment conducted in a Dominican town in 2010, where interviewer assignment was randomized by level of preexisting level of familiarity between interviewer and respondent. In our data, sterilization use is higher when the interviewer is an outsider, as opposed to someone known to the respondent or from the same community. In addition, high sterilization use is correlated with a propensity of respondents to present themselves in a positive light to interviewers. These results call into question the routine use of strangers and outsiders as interviewers in demographic and health surveys.

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