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BMC Public Health. 2019 May 21;19(1):617. doi: 10.1186/s12889-019-6956-1.

Homophobia and heteronormativity as dimensions of stigma that influence sexual risk behaviors among men who have sex with men (MSM) and women (MSMW) in Lima, Peru: a mixed-methods analysis.

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Columbia Mailman School of Public Health, Department of Sociomedical Sciences, 722 West 168th St., New York, NY, 10032, USA.
College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
South American Program in HIV Prevention Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
Francis I Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA.
Centro de Investigaciones Tecnologicas y Biomedicas Universidad Nacional de San Marcos, Lima, Peru.
Asociación Civil Impacta Salud y Educación, Lima, Peru.



Stigma differentially influences HIV and STI care among MSM, especially regarding partner notification practices. Recognizing the heterogeneous behaviors/identities within the category "MSM," we used mixed-methods to assess sexual risk behaviors among men who have sex with men only (MSMO) and behaviorally bisexual MSM (MSMW) with HIV and/or other STIs.


MSMO/MSMW recently diagnosed (< 30 days) with HIV, syphilis, urethritis, or proctitis completed a cross-sectional survey assessing sexual risk behaviors, anticipated disclosure, and sexual partnership characteristics (n = 332). Multivariable generalized estimating equation models assessed characteristics associated with female compared to male partners in the last three partnerships. Follow-up qualitative interviews (n = 30) probed partner-specific experiences (e.g., acts and disclosure).


Among all participants, 13.9% (n = 46) described at least one of their last three sex partners as female (MSMW). MSMW (mean age of 31.8) reported a mean of 3.5 partners (SD = 4.5) in the past 3 months and MSMO (mean age 30.6) reported a mean of 4.6 partners (SD = 9.7) in the past 3 months. MSMW were more likely to report unprotected insertive anal sex (77.9%) than MSMO (43.1%; p < 0.01). Cisgender female partners were associated with condomless insertive sex in the last 3 months (aPR: 3.97, 95%CI: 1.98-8.00) and classification as a "primary" partnership (2.10, 1.34-3.31), and with lower prevalence of recent HIV diagnosis (0.26, 0.11-0.61). Planned notification of HIV/STI diagnoses was less common for female than for male partners (0.52, 0.31-0.85). Narratives illustrate internal (e.g., women as 'true' partners) and community-level processes (e.g., discrimination due to exposure of same-sex behavior) that position homosexual behavior and bisexual identity as divergent processes of deviance and generate vulnerability within sexual networks.


MSMW recently diagnosed with HIV/STI in Peru report varying partnership characteristics, with different partner-specific risk contexts and prevention needs. Descriptions highlight how behaviorally bisexual partnerships cut across traditional risk group boundaries and suggest that HIV/STI prevention strategies must address diverse, partnership-specific risks.


Human immunodeficiency virus (HIV); Men who have sex with men and women (MSMW); Partner notification; Sexually transmitted infections (STIs); Social determinants of health

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