Impact of Structural Factors On HIV/STI Vulnerability Among Indigenous Men Who Have Sex With Men in Guatemala

Purpose: By the end of 2011, MSM in Latin America were at substantially increased risk for HIV infection in virtually every study conducted. One study found that MSM in South and Central America were 33 times more likely to be infected with HIV than the general population. Guatemala is in the subregion most affected by the HIV epidemic in Latin America, as Central America suffered generalized epidemics at the turn of the century. The HIV epidemic in Guatemala is currently concentrated among MSM and it is estimated at 18.3%. Common to populations heavily affected by HIV, and other sexually transmitted infections (STIs), is exposure to structural factors that increase their vulnerability to disease acquisition. Structural factors include social, political, economic, and environmental factors that operate at different ecosocial levels (i.e. individual, interpersonal, and community) and shape the risks for HIV/STI infection. We present data examining structural factors associated with increased HIV/STI vulnerability among indigenous MSM near the Guatemala/Mexico border.

Methods: Throughout 2010-12, we purposively recruited indigenous MSM. The study took place throughout the Guatemalan highlands, in towns near the Guatemala/Mexico border, an area of heavy international migration toward the United States. Semi-structured in-depth interviews were conducted with indigenous men, who consented to voluntarily participate in the study. We interviewed 20 men from five different ethnic groups.

Results: The qualitative data revealed a complex set of structural factors that give rise to environments of risk, where the health of indigenous MSM is constantly challenged. Extreme poverty, lack of educational and employment opportunities, lack of health services in indigenous villages, and increasing discrimination impel people to migrate to larger cities. Participants saw migration to Guatemalan cities, as well as Mexico and the U.S. as an escape from oppressive forces in the community. In the city, however, participants were often exposed to risky settings where substance abuse and unprotected sex, including transactional sex, are common.

Conclusions and Implications: This study found that the combination of poverty, lack of educational and employment opportunities, stigma and discrimination, cultural beliefs related to health and sexual behaviors, and people mobility and mixing along border regions of Guatemala give rise to environments of risk where HIV/STI prevention knowledge is minimal and the opportunities for disease transmission are abundant. The findings provide important insights, not only into the contextual circumstances in which marginalized populations struggle for health and wellness, but also into factors that may be amenable to HIV/STI prevention strategies that are culturally and contextually grounded in the local situation. For indigenous MSM, current HIV prevention efforts are unlikely to be effective if the structural factors that increase their vulnerability for diseases are not addressed. Multi-level, combination prevention strategies that integrate empirically based interventions with traditional indigenous knowledge have the potential to not only reduce vulnerability to HIV/STI transmission, but also alter the nature of the social structures that affect indigenous people's health.