Santiago Aguilera-Mijares

HIV prevention efforts in Mexico often overlook heterosexual-identified men who have sex with men (H-MSM), a subgroup at elevated risk for HIV. Using data from the 2021-2022 National Survey on Sexual and Gender Diversity (ENDISEG), we examined condomless sex among cisgender MSM, categorizing participants by sexual identity (heterosexual vs. gay, bisexual, or other non-heterosexual), sexual behavior (only male partners vs. both male and female), and their combinations: H-MSM, H-MSMW, GB+MSM, and GB+MSMW. Among cisgender men, 3.9% (n = 775) reported a male sexual partner in the past year, and 41% of them identified as heterosexual. Condomless sex was reported by 63.8% of MSM overall and was most common among H-MSM (74.4%). Probit regression analysis showed significantly lower probabilities of condomless sex among H-MSMW (-19.8%), GB+MSM (-14.8%), and GB+MSMW (-15.9%) compared to H-MSM. Additional risk factors included older age, lower education, and depression. These findings underscore the limitations of considering MSM as one group and reveal a sizable, high-risk subgroup that may be missed by current HIV programs. Effective prevention strategies must integrate sexual identity and behavior and be adapted to Mexico's sociocultural context. Identity-sensitive approaches, particularly for H-MSM and H-MSMW, are essential to reduce HIV transmission in this population.

Background/Objectives: Transgender women in Mexico face a high HIV prevalence, yet they remain insufficiently engaged in pre-exposure prophylaxis (PrEP). This study aimed to evaluate willingness to use HIV pre-exposure prophylaxis (PrEP) and its connection to risk behaviors among transgender women in Mexico. Methods: In 2021, a cross-sectional study was conducted among Mexican transgender women to assess HIV risk factors and willingness to use PrEP. We used Latent Class Analysis to cluster participants with similar HIV risk behaviors, and multivariable logistic regression to identify covariates of willingness to use PrEP. Results: Among 266 transgender women, 40% were aware of PrEP, yet 78% reported willingness to use it after a brief introduction. Only 25% of the participants perceived themselves at high HIV risk. Through Latent Class Analysis, three classes were identified: 1) transactional sex with lower risk (10%); 2) no transactional sex with higher risk (25%); and 3) transactional sex with higher risk (65%), with reported willingness to use PrEP at 61%, 66% and 85%, respectively. In the multivariable model, belonging to class 3 (vs class 1) was associated with higher willingness to use PrEP (aOR:3.3; CI:1.2–9.5). Conclusions: Willingness to use PrEP aligned with HIV risk in those with a higher risk (class 3) and lower risk (class 1), but not in those at higher risk despite not reporting transactional sex (class 2). Therefore, not all who could benefit from PrEP may want it. Strategies are needed to promote PrEP’s awareness and willingness to use considering the needs of transgender women subgroups.

This study aimed to evaluate the interest in event-driven PrEP (ED-PrEP) among men who have sex with men (MSM) using daily PrEP in Mexico's PrEP demonstration project between 2019 and 2020. We compared participants interested or not in ED-PrEP during their first-month visit and identified associated factors. Of 1,021 MSM attending their first-month visit, 7% had previous knowledge of ED-PrEP, but 40% were interested in ED-PrEP. However, over 50% perceived the scheme as less protective than daily PrEP. Having doubts about ED-PrEP's level of protection was related to less interest in the scheme (aOR = 0.11; CI = 0.07-0.18), just like reporting perceived barriers such as having frequent sex (aOR = 0.06; CI = 0.03-0.14), unplanned sex (aOR = 0.17; CI = 0.11-0.27), forgetting the medicine (aOR = 0.06; CI = 0.03-0.12), or difficulty carrying the medicine (aOR = 0.13; CI = 0.07-0.25). Finally, reporting not taking PrEP for >20 days in the last month (aOR = 0.05; CI = 0.01-0.27) diminished interest in ED-PrEP. In conclusion, few MSM daily PrEP users knew about ED-PrEP yet many were interested in it, suggesting the importance of awareness campaigns regarding ED-PrEP's effectiveness. The lack of interest in ED-PrEP among participants with poor adherence to daily PrEP indicates that they might prefer long-acting PrEP or HIV prevention strategies without medication.

Background: Telemedicine, which involves utilising technologies for remote health care delivery, proved useful to continue offering certain health services during the coronavirus disease 2019 (COVID-19) lockdown. However, the extent of its effectiveness in delivering pre-exposure prophylaxis services for HIV prevention remains underexplored from the viewpoint of health care providers. Therefore, this study aimed to assess the experiences of health care professionals in Mexico who utilised telemedicine for delivering pre-exposure prophylaxis services during the COVID-19 contingency. Methods: A qualitative study was performed: 15 virtual interviews with health care professionals were conducted, transcribed and coded in ATLAS.ti. Results: The results indicate that telemedicine effectively mitigated COVID-19 exposure, facilitated users’ access to pre-exposure prophylaxis counselling, minimised waiting times and enhanced health care professionals’ perceived control during sessions. While implementing remote services, certain organisational challenges, which were somewhat latent before the pandemic, became more apparent: colleagues recognised the necessity for more formal communication channels to disseminate information effectively. Additionally, there was a recognised need for electronic patient files to streamline data-sharing processes. An optimal approach would involve a blend of face-to-face and virtual services, contingent upon the availability of essential infrastructure, well-defined implementation protocols and comprehensive training programs. Conclusions: Telemedicine streamlined certain processes, garnered positive acceptance from healthcare professionals and holds promise as a valuable post-pandemic tool for improving retention among pre-exposure prophylaxis users.

Objectives: Screening tools in which participants self-report sexual behaviors can identify people at risk of HIV acquisition for enrollment in preexposure prophylaxis (PrEP). We compared enrollment outcomes (ie, receiving PrEP vs being excluded by a counselor or declining PrEP) in Mexico’s PrEP demonstration project and evaluated the validity of a 4-criteria PrEP eligibility tool in which participants self-reported risk behavior—having condomless anal sex, transactional sex, a partner living with HIV, or a sexually transmitted infection—as compared with PrEP eligibility assessed by a counselor. Methods: We recruited men who have sex with men and transwomen who were offered PrEP services in Mexico. We characterized participants according to enrollment outcome and identified underlying factors through logistic regression analyses. We calculated the sensitivity and specificity of the self-reported risk criteria, using the counselor’s risk assessment as the point of reference. Results: Of 2460 participants, 2323 (94%) had risk criteria of HIV acquisition according to the 4-criteria tool; 1701 (73%) received PrEP, 247 (11%) were excluded by a counselor, and 351 (15%) declined PrEP despite being considered eligible by the counselor. Participants who were excluded or who declined PrEP were less likely to report HIV risk behaviors than those who received PrEP, and participants who declined PrEP were more likely to be transwomen (vs men who have sex with men) and aged ≤25 years (vs >25 y). The 4-criteria risk tool had high sensitivity (98.6%) and low specificity (29.8%). Conclusion: The screening tool identified most participants at risk of HIV acquisition, but counselors’ assessment helped refine the decision for enrollment in PrEP by excluding those with low risk. Public health strategies are needed to enhance enrollment in PrEP among some groups.

In 2018, 24% of Mexican men living with HIV were disengaged from HIV care, which impedes their use of antiretroviral treatment (ART). To identify HIV care disengagement and/or ART discontinuation factors using an ecological framework, we conducted 22 semi-structured interviews with men who have sex with men from the HIV state clinic of Tabasco, Mexico. HIV care disengagement was attributed to interpersonal, organizational, and community factors, whereas ART discontinuation was attributed to intrapersonal and interpersonal factors. Intrapersonal factors were burden of ART, substance use, mental health problems, and feeling well or ill. Interpersonal factors included family stigma or support, and partner discouragement. Factors at the organizational level were HIV care-related: inconvenient follow-ups, negative provider interactions, and reentry obstacles; and work-related: absences, work stigma, and travel. Community factors were social stigma and economic means. Interventions should target multiple levels of interdependent factors, distinguishing between HIV care disengagement and ART discontinuation factors.