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

ABSTRACT Objective: 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. Methods: 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. Results: 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. Conclusion: 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.