Significant advances have been achieved in HIV prevention and care in recent years with expanded access to anti-retroviral therapy (ART) and the demonstrated effect of viral suppression on HIV transmission, or what is referred to treatment as prevention (TasP) (Cohen et al. 2016; Cohen et al. 2011; Yombi and Mertes 2018). Gaps exist in understanding how to optimize the potential of TasP among individuals from key populations living with HIV, including men who have sex with men (MSM) and transgender women (TW), especially in resource-constrained settings. There is also a need for greater understanding of how individuals from key populations navigate care and treatment systems to inform interventions that translate the biomedical advances of TasP to the reality of HIV clinics in low-and-middle-income countries in a sustainable manner.
The HIV epidemic in Guatemala is characterized as concentrated, with adult HIV prevalence at the national level estimated to be less than 1% (Miller et al. 2010), compared to 10.5% among MSM (Guardado Escobar et al. 2017). Late presentation due to missed opportunities for diagnosis has historically been a challenge to optimizing TasP (Meléndez et al. 2018), though improvements in early diagnosis have been made in recent years, including using innovative strategies such as navigation for linkage to care (Loya-Montiel et al. 2018; Barrington et al. 2016). While access to ART has improved dramatically during the last decade, in 2015 it was estimated that only 35% (18,325) of the 52,784 people living with HIV in Guatemala were engaged in HIV care and 31% (16,386) received anti-retroviral therapy (ART), which is provided to all people living with HIV free of charge by the government (Mejia 2015). These HIV continuum data are not available for specific key populations in Guatemala. The overall trend of high drop-off from diagnosis to engagement in care, however, highlights the need for interventions to strengthen the continuum of care to translate the biomedical advances in HIV treatment and prevention to the reality of HIV clinics in lowincome and middle-income countries.
While MSM experience a disproportionate burden of HIV in Guatemala, prior to this study, very little was known about their experiences navigating the HIV care and treatment system and how these experiences affect their HIV outcomes, in particular sustained viral suppression. In research exploring the social context of sexual health in general among MSM and TW in Guatemala City, barriers to accessing sexual health care in general included fear, cost, lack of social support, and the multiple, intersecting forms of stigma related to sexual and gender identity, socio-economic position, and involvement in sex work (Tucker et al. 2014; Boyce et al. 2012). In a qualitative study with both MSM and TW living with HIV in Guatemala City, Barrington et al (2016) again found that intersecting stigma and discrimination created fear of HIV testing and linkage to HIV care and barriers to knowledge about HIV. Retention-specific determinants included HIV clinic dynamics and limited employment opportunities, which affected economic stability. These multiple levels of factors driving linkage and retention in care and treatment require multi-level, integrated responses.