A cross-sectional study of knowledge of sex partner serostatus among high-risk Peruvian men who have sex with men and transgender women: implications for HIV prevention

Knowledge of sex partner HIV serostatus can influence perception of sexual risk and may inform harm-reduction strategies for men who have sex with men (MSM) and transgendered women (TW) [1]. Currently little is known about partnership dynamics in Peruvian MSM and TW, including whether they discuss HIV testing, serostatus, or risk-reduction behaviors. In order to develop an initial understanding of communication about serostatus between Peruvian MSM and TW sex partners, we analyzed data from the 2008 HIV Sentinel Surveillance Survey of Peruvian MSM and TW to assess for factors associated with having knowledge of a sex partner’s HIV serostatus, and whether or not this knowledge or the partner’s serostatus itself is associated with unprotected anal intercourse (UAI) with that partner.

Knowledge of a partner’s HIV serostatus is uncommon among high-risk MSM and TW in Peru. The rate of knowledge of partner serostatus ranged from 8.3% for exchange sex partners to 32.6% for stable partners, much lower than that found in previous studies of MSM populations in the U.S. and Australia, which have reported knowledge of partner serostatus ranging from 15.6% for casual partners [3] to 86.3% for stable partners [4]. Of partners whose serostatus was known, only 5.7% were reported HIV-positive, a level far below the actual HIV prevalence rate of 9.6-30.0% among MSM and TW in Peru [2, 5–8]. These results suggest that some MSM and TW are unaware that one or more of their partners is HIV-positive. The implication of HIV-positive persons reporting their HIV status to their sex partners as negative or unknown, whether intentional or not, is that the ability of sex partners to effectively utilize seroadaptive and self-protective behaviors may be diminished.

Knowledge of partner serostatus was dependent on both the type and length of partnership in our multivariate analysis. Our results indicate that even among partners qualitatively categorized as casual, those who have known each other for a longer period of time were more likely to share information about HIV serostatus. At the same time, some long-term partners may be considered “casual” and therefore less likely to communicate about HIV serostatus than “stable” partners who have known each other for a shorter period of time. Previous research on partner notification in high-risk Peruvian men and women has similarly demonstrated a decreased likelihood to notify casual as compared to stable partners after being recently diagnosed with HIV [9]. HIV-related stigma underlies accounts of “fear” and “embarrasment” and is a commonly reported reason for failure to discuss HIV with MSM partners [10–13]. A greater sense of intimacy, trust and/or mutual reponsibility found in stable and longer-term partnerships may help to overcome stigma and promote communication about serostatus.

Exchange sex partnerships were also associated with a decreased likelihood of knowledge of partner serostatus. Exchange sex in Peru often occurs in low-income areas where the social and economic vulnerabilities of both homosexual and marginalized heterosexual men can result in a power differential which hinders communication and negotiation of sexual risk [14]. Future prevention research may include behavioral interventions with a focus on building communication skills, offering social support, and emphasizing the importance of initiating discussions about HIV testing, serostatus, and safer sex, specifically with casual or new partners and during exchange sex [15].

Neither knowledge of a partner’s HIV test result nor the serostatus itself was significantly associated with UAI with that partner. Although results seemed to indicate a pattern of protective behavior with HIV-positive partners, the association was not statistically significant. The lack of association with partner serostatus may have been due to insufficient power since this part of the analysis could only be conducted with the 230 partners whose serostatus was known. The lack of association between unprotected intercourse and knowledge of partner serostatus corroborates results from a study of Latino gay men in the U.S. which also found no association between knowledge of partner serostatus and likelihood of engaging in UAI [16]. Knowledge of partner serostatus alone may not be sufficient to prompt a change in sexual behavior; condom use or safer sex strategies may need to be discussed in addition to sharing serostatus in order to increase the rate of protected sex [16–18].

There are a number of limitations in our study. First, all data were self-reported and therefore subject to recall and social desirability bias. Second, this study recruited a convenience-based sample of high-risk MSM in three cities and may not represent the Peruvian MSM and TW population as a whole. Although large samples representing a diverse range of MSM subcultures were included, men who participated in this study consisted mainly of those who visited socialization venues where study recruitment was conducted and who voluntarily accepted participation. MSM at higher risk for HIV and/or STI acquisition may have been more willing to participate or selected for in this survey based on eligibility criteria.

Other major limitations of our study may be attributed to its design as a secondary analysis. The outcome measure was based on a single question asking for the partner’s most recent HIV test result and was not suited to adequately evaluate the complex dynamics of partner communication about HIV testing and serostatus. It is likely that some of the participants had inaccurate or uncertain knowledge of their partner’s serostatus [19], and the veracity of the partner’s testing history and serostatus could not be determined without directly validating this information with each partner. Future studies should ask specific questions about what Peruvian MSM and TW discuss with their partners regarding HIV and safer sex, how often, when in relation sexual intercourse, where, who initiates, and how verbal discussion is initiated. Furthermore, it would be ideal to evaluate communication bi-directionally, asking not only what the participant knows about his partner, but also if he shared any information about his own sexual or HIV history with this partner.

Our analysis adds to the literature on communication about HIV status among MSM and TW, and also highlights the need for further research on this topic in Peru. The lack of adequate data on the accuracy and use of personally disclosed information regarding partner HIV serostatus mandates caution in the use of serodisclosure or serosorting as an isolated prevention measure. Further research should explore the contexts and practices of partner communication, their effect on sexual behavior, and interventions to promote discussion of HIV testing and serostatus as an HIV prevention strategy among MSM and TW.

The study protocol and written informed consents were approved by the Asociación Civil Impacta Salud y Educación Institutional Bioethics Committee and U.S. Naval Medical Research Unit Six (NAMRU-6) Institutional Review Board in compliance with all applicable federal regulations governing the protection of human subjects.

Silvia M. Montano is an employee of the U.S. Government. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that Copyright protection under this title is not available for any work of the U.S. Government. Title 17 U.S.C. 101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person's official duties.

The opinions and assertions contained in this manuscript are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, the U.S. Government or of any of the other organizations listed.