ORIGINAL STUDY Unsafe Sexual Behaviors Among HIV-Positive Men and Women in Honduras: The Role of Discrimination, Condom Access, and Gender Gabriela Paz-Bailey, MD, MSc, PhD,*† Virginia Isern Fernandez, MD, MSc,‡ Sonia Morales Miranda, MSc,* Jerry O. Jacobson, PhD,§ Suyapa Mendoza, MPH,¶ Mayte A. Paredes, MD,¶ Damien C. Danaval, PhD, David Mabey, MD,‡ and Edgar Monterroso, MD, MPH** Background: We conducted a study among HIV-positive men and women in Honduras to describe demographics, HIV risk behaviors and sexually transmitted infection prevalence, and identify correlates of unsafe sex. Methods: Participants were recruited from HIV clinics and nongov- ernmental organizations in Tegucigalpa and San Pedro Sula, Honduras in a cross-sectional study in 2006. We used audio-assisted computer inter- views on demographics; behaviors in the past 12 months, 6 months, and 30 days; and access to care. Assays performed included herpes (HSV-2 Herpes Select), syphilis (rapid plasma reagin [RPR] and Treponema pal- lidum particle agglutination assay [TPPA]) serology, and other sexually transmitted infections by polymerase chain reaction (PCR). Bivariate and multivariate analyses were conducted to assess variables associated with unprotected sex across all partner types in the past 12 months. Results: Of 810 participants, 400 were from Tegucigalpa and 410 from San Pedro Sula; 367 (45%) were men. Mean age was 37 years (interquartile range: 31– 43). Consistent condom use for men and women was below 60% for all partner types. In multivariate analysis, unprotected sex was more likely among women (odds ratio [OR]: 1.9, 95% confidence interval [CI]: 1.2–3.1, P = 0.007), those with HIV diagnoses within the past year (OR: 2.0, 95% CI: 1.1–3.7, P = 0.016), those reporting difficulty accessing condoms (OR: 2.6, 95% CI: 1.4 – 4.7, P = 0.003), and those reporting discrimination (OR: 1.8, 95% CI: 1.1–3.0, P = 0.016). Conclusions: Programs targeting HIV-positive patients need to address gender-based disparities, improve condom access and use, and help establish a protective legal and policy environment free of stigma and discrimination. W orldwide there have been dramatic gains achieved in increasing access to highly-active antiretroviral therapy (HAART) for people with HIV in low- and middle-income countries—from 0.3 million individuals on treatment in 2002 to 5.3 million people in 2009. 1–4 Based on recent findings on the impact of antiretroviral treatment to prevent HIV transmission, 5 broadening treatment access continues to be a public health priority, which will have the potential to bring more individuals with HIV within the reach of additional health care, support, and prevention services. Antiretroviral treatment for prevention will have to be complemented with other successful strategies. 6 The World Health Organization released new guidelines for integrating prevention as a routine part of HIV management in resource-limited settings which reaffirms prevention for people with HIV as an international priority for HIV control. 4 Little is known about the profiles of people with HIV in most areas where HAART has become available. Information is scarce outside the context of controlled trials or from regions other than Africa. 7–9 Relatively high levels of sexual activity (84%) and recent unprotected sex (25%–39%) have been reported in studies among men in Brazil and men and women at selected HIV treatment centers in urban areas of Brazil and Argentina. 10,11 Although two-thirds of the estimated 1.7 million people with HIV in Latin America live in the largest countries (Ar- From the *Center for Health Studies, Del Valle University, Guatemala City, Guatemala; †Tephinet, Inc, Atlanta, GA; ‡London School of Hygiene and Tropical Medicine, London, United Kingdom; §Pan American Health Organization, Bogota, Colombia; ¶Ministry of Health, Tegucigalpa, Honduras; Division of STD Prevention, Cen- ters for Disease Control and Prevention, Atlanta, GA; and **Global AIDS Program, Centers for Disease Control and Prevention, At- lanta, GA The authors thank the Department of Health of Honduras for leading this study and providing permission to use government health facilities. The authors also thank the staff at the participating hospitals; the study participants who made this survey possible; Ron Ballard, Celine Taboy, and Lisa Steele for processing the specimens at the Centers for Disease Control and Prevention STD Laboratory and providing technical advice; the United States Agency for International Development office in Honduras and the Centers for Disease Control and Prevention for funding the study; Kelly Stewart from United States Agency for International Devel- opment for her advice and support; and Dr. Armando Medina and Sandra Nun ˜ez for sharing data from the national information sys- tem on HIV-positive in care. Supported by funds from the United States Agency for International Development office in Honduras and the Centers for Disease Con- trol and Prevention and the Network for Research and Training in Tropical Diseases in Central America (NeTropica) under the proj- ect No. 06-R-2010. The findings and conclusions in this paper are those of the authors and do not necessarily represent those of the Centers for Disease Con- trol and Prevention. G.P.B. conceived and designed the study protocol, supervised data collection, drafted the manuscript and participated in data analysis. V.I.F. conducted data analysis, participated in the preparation of the manuscript and interpretation of findings. S.M.M., S.M., M.P. participated in the study design and conducted data collection. J.J. helped conceptualize the analysis and participated in manuscript preparation and review. D.D. participated in preparing the study flow and conducted all laboratory testing. D.M. and E.M. supervised dif- ferent aspects of the study. All authors helped to conceptualize ideas, interpret findings, and review drafts of the manuscript. All authors have read and approved the final version of the manuscript. Correspondence: Gabriela Paz-Bailey, MD, MSc, PhD, 1600 Clifton Road, Atlanta GA, 30333, MS E46. E-mail: gmb5@cdc.gov. Received for publication March 9, 2011, and accepted August 8, 2011. DOI: 10.1097/OLQ.0b013e318231cf2d Copyright © 2012 American Sexually Transmitted Diseases Association All rights reserved. Sexually Transmitted Diseases ● Volume 39, Number 1, January 2012 35