Behavioral and structural drivers of HIV in men who have sex with men in Belize: a mixed-methods study

To estimate the prevalence of human immunodeficiency virus (HIV) in men who have sex with men (MSM) in Belize and identify behavioral and structural factors associated with infection.

This mixed-methods study was a secondary analysis of data from the 2024 Integrated Biological and Behavioral Surveillance Survey. A total of 490 MSM were recruited using respondent-driven sampling. Data were collected using a structured behavioral questionnaire administered via computer-assisted self-interview. Qualitative data were collected through key informant interviews and focus group discussions.

HIV prevalence was 11.0%. Condom use was inconsistent: 70.4% reported consistent use, while 16.1% never used condoms. Transactional sex was common (18.8% received payment and 22.0% paid for sex). Condom use was higher in respondents who paid for sex (84.3%) than in those who were paid (64.1%). HIV testing was moderate: 74.5% had ever tested, but only 42.0% were tested in the past year and 6.5% had self-tested. Awareness of pre-exposure prophylaxis and post-exposure prophylaxis was low (8.6% and 8.4%, respectively). Among respondents who were aware, < 20% had used prophylaxis in the past 6 months. Substance use was prevalent (high alcohol risk 56.7% and cannabis use 41.4%) and 50.4% engaged in risky sex under intoxication. Depression risk was 46.1%. Qualitative findings identified three themes: individual factors, health system factors, and stigma.

MSM in Belize face a high HIV burden driven by behavioral and structural factors. Interventions should prioritize condom promotion, pre-exposure prophylaxis scale-up, mental health support, substance use prevention, and stigma reduction.