title: Sexuality and risk behavior among men who have sex with men in León, Nicaragua: a mixed methods approach.
abstract: BACKGROUND
  HIV prevalence among men who have sex with men (MSM) is 38 times higher than among the general population in Nicaragua. There are little data about the sexuality and sexual behaviors of MSM. It is essential to gain a better understanding of this understudied population.
  
  
  OBJECTIVE
  The nature of sexual relationships among MSM, their reasons for engaging in risky sexual behaviors, and the sociocultural context in León, Nicaragua, were investigated through in-depth interviews. Our findings resulted in a structured overview of sociodemographic characteristics and HIV-related knowledge, attitudes, and risk behaviors.
  
  
  METHODS
  Fifteen participants recruited by purposive sampling completed an in-depth interview that was then thematically analyzed. An additional 104 participants were surveyed by means of an interviewer-administered questionnaire.
  
  
  METHODS
  The in-depth interview guide and the survey covered topics related to sociodemographics, childhood, social and sexual relationships, knowledge and attitudes toward HIV and AIDS, identity, and networks.
  
  
  RESULTS
  The resulting ecological model explored sexuality and behaviors in four categories. It showed that despite a homophobic and heterosexist society, there is an increasing gay community and greater social acceptance of homosexuality. Nevertheless, interpersonal and intrapersonal factors continue to negatively influence MSM behavior. Quantitative findings demonstrate a satisfactory understanding of HIV transmission among this population, 75% of whom reported concerns of becoming infected with HIV in the future. Approximately one-half claimed that they always used condoms when having sex with men, but only one-third of the time with women, indicating inconsistent condom use. Negative attitudes toward HIV/AIDS were seldom heard.
  
  
  CONCLUSIONS
  This study is the first mixed methods approach in a Nicaraguan context that shows the interrelations among sex, sexuality, and identity at various levels of MSM life, and how they influence the sexual risk behaviors of individuals. Engaging in unprotected sex and postponing HIV testing are seen as cognitive dissonances.
authors.affiliation: Department of Women's and Children's Health, Uppsala University, Sweden. william.ugarte@kbh.uu.se
authors.forename: William J
authors.initials: WJ
authors.lastname: Ugarte Guevara
authors.forename: Eliette
authors.initials: E
authors.lastname: Valladares Cardoza
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000293:Adolescent; D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data; D015658:HIV Infections / Q000517:prevention & control*; D007722:Health Knowledge, Attitudes, Practice; D006306:Health Surveys; D018451:Homosexuality, Male / Q000523:psychology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009527:Nicaragua; D012309:Risk-Taking; D021841:Safe Sex / Q000523:psychology; D012725:Sexual Behavior; D012944:Social Support