title: Is violence associated with increased risk behavior among MSM? Evidence from a population-based survey conducted across nine cities in Central America.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  MSM who experienced physical violence were more likely to be engaged in transactional sex (OR: 1.76 [1.42-2.18]), have multiple partners in the past 30 days (OR: 1.37 [1.09-1.71]), and have engaged in sex under the influence of alcohol or drugs (OR: 1.51 [1.24-1.83]). Both physical violence and psychological/verbal violence were also associated with reporting STI symptoms or diagnosis within the past 12 months (OR: 1.72 [1.34-2.21] and 1.80 [1.45-2.23]). 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 (OR: 1.44 [1.07-1.96], 1.99 [1.67-2.38], 1.79 [1.37-2.33], respectively) and more likely to report engaging in sex under the influence of alcohol or drugs (OR: 1.52 [1.15-2.01], 1.38 [1.17-1.63], 1.47 [1.16-1.87], respectively), as compared to those identifying as homosexual.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Population Services International, Washington, DC, USA; jwheeler@psi.org.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Wheeler
authors.affiliation: Population Services International, Washington, DC, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Anfinson
authors.affiliation: Association PASMO, Guatemala City, Central America.
authors.forename: Dennis
authors.initials: D
authors.lastname: Valvert
authors.affiliation: Association PASMO, Guatemala City, Central America.
authors.forename: Susana
authors.initials: S
authors.lastname: Lungo
mesh_terms: D000328:Adult; D001727:Bisexuality; D002489:Central America; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D018451:Homosexuality, Male; D006801:Humans; D008297:Male; D012307:Risk Factors; D012309:Risk-Taking; D012725:Sexual Behavior; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D063106:Transgender Persons; D014505:Urban Population; D014754:Violence / Q000706:statistics & numerical data*; D005260:Female
keywords: Central America; HIV; HIV risk; IPV; MARPS; MSM; key populations; transgender women; violence