In Peru, there are few studies on male sex workers (MSWs), and existing studies explore limited subgroups or offer limited information about MSWs' perspectives. This study provides in-depth perspectives from 40 MSWs who work in downtown Lima (Cercado) and in surrounding urban neighborhoods (non-Cercado) through interviews on their identities, lives, and HIV/STI (sexually transmitted infection) risks and vulnerabilities. Findings are that entry into sex work links economy and affection, particularly among Cercado MSWs. Continued sex work cements this link, making it difficult to exit sex work and establish goals. Ties between economics and affections influence MSWs' perceived HIV/STI risks, vulnerabilities, and prevention practices. Although Cercado MSWs report higher HIV/STI risks and vulnerabilities than non-Cercado peers, they report fewer prevention practices given inability to buy condoms and acceptance of client offers of higher payment, especially clients they feel affection for. MSWs need support to strengthen their self-perceptions and define and pursue their goals in order to improve their HIV/STI prevention practices, health, and well-being.

Background

In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care.

Methods

This cross-sectional continuous observation time motion study took place from July - September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection.

Results

Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors.

Conclusions

The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Objective

This study describes the pregnancy and birth outcomes at two hospitals in Lima, Peru. The data collection and analysis is intended to inform patients, providers, and policy makers on Peru's progress toward achieving the Millennium Development Goals and to help set priorities for action and further research.

Methods

Data were collected retrospectively from a sample of 237 women who delivered between December 2012 and September 2013 at the Instituto Nacional Materno Perinatal or the Hospital Nacional Arzobispo Loayza. The outcomes were recorded by a trained mid-wife through telephone interviews with patients and by review of hospital records. Associations between participant demographic characteristics and pregnancy outcomes were tested with Chi-squared, Fisher's exact, or Student's t-test.

Results

Over 37% of women experienced at least one maternal or perinatal complication, and the most frequent were hypertension/preeclampsia and macrosomia. The women in our sample had a cesarean section rate of 50.2%.

Conclusion

Maternal and perinatal complications are not uncommon among women in the lower socioeconomic strata of Lima. Also, the high cesarean rate underpins the need for a more comprehensive understanding of the indications for cesarean section deliveries, which could help reduce the number of unnecessary procedures and preventable complications.

Background

Patient-reported measures attempt to quantify the value health services provide to users. Satisfaction is a common summative measure, but often has limited utility in identifying poor quality care. We compared satisfaction and the net promoter score (NPS), which was developed to help businesses quantify consumer sentiment, in a nationally representative survey in Peru. We aimed to compare NPS and satisfaction as individual ratings of care, assess the relationship of patient-reported experience ratings to these outcome measures and consider the utility of these measures as indicators of facility performance based on reliability within facilities and capacity to discriminate between facilities.

Methods

We analysed the 2016 National Survey on User Satisfaction of Health Services, a cross-sectional outpatient exit survey. We assessed ratings by patient characteristics and compared the distributions of satisfaction and NPS categories. We tested the association of patient-reported experience measures with each outcome using multilevel ordinal logistic regression. We used intraclass correlation (ICC) from these models to predict minimum sample for reliable assessment and compared patient-reported experience measures in facilities with average satisfaction but below or above average NPS.

Results

13 434 individuals rated services at 184 facilities. Satisfaction (74% satisfied) and NPS (17% reported at least 9 out of 10) were largely concordant within individuals but weakly correlated (0.37). Ratings varied by individual factors such as age and visit purpose. Most domains of patient-reported experience were associated with both outcomes. Adjusted ICC was higher for NPS (0.26 vs 0.11), requiring a minimum of 7 (vs 20) respondents for adequate reliability. Within the 70% of facilities classified as average based on satisfaction, NPS-based classification revealed systematic differences in patient-reported experience measures.

Conclusion

While satisfaction and NPS were broadly similar at an individual level, this evidence suggests NPS may be useful for benchmarking facility performance as part of national efforts in Peru and throughout Latin America to identify deficits in health service quality.

Objectives

To describe the sociodemographic and sex work characteristics, recent sexual practices, HIV risk perception and testing history, and HIV and syphilis prevalence of Cercado (downtown) and non-Cercado (close urban) male sex workers (MSWs) in Lima, Peru.

Methods

Eighty-nine MSWs completed a self-administered survey and participated in HIV and syphilis testing.

Results

Cercado MSWs had significantly lower median weekly earnings than non-Cercado MSWs (US$43 vs US$72, p=0.04). Most non-Cercado MSWs (81%) reported only insertive anal intercourse with male/transgender partners, while Cercado MSWs primarily reported only insertive (52%) or insertive and receptive (45%) anal intercourse (p=0.03). Consistent condom use was low with insertive and receptive anal intercourse in both subgroups. Among MSWs with recent female partners, condom use with the last partner was lower among Cercado versus non-Cercado MSWs for vaginal sex (37% vs 65%, p=0.04) and anal sex (27% vs 80%, p=0.01). More Cercado than non-Cercado MSWs (57% vs 42%) perceived high HIV risk (p=0.05) and Cercado MSWs had a much higher prevalence than non-Cercado MSWs of HIV (23% vs 4%, p=0.04) and syphilis (22% vs 0%, p=0.02) infections.

Conclusions

MSWs in Lima are diverse and Cercado MSWs are 'just getting by,' engaging in more risk behaviours, and more likely to have HIV/STIs. Future research should identify, describe and carry out HIV/STI testing with broader groups of MSWs and their client and non-client partners. Prevention efforts should provide HIV/STI risk reduction education for MSWs and related subgroups who are currently not targeted such as female partners.

Objectives –

To determine the socio-demographics, sexual practices, and HIV prevalence of male sex workers (MSWs), transwomen sex workers (TSWs), and their male clients in Lima, Peru.

Methods –

Following ethnographic mapping of sex work venues, we revisited randomly selected venues to survey MSWs, TSWs and their clients.

Results –

MSWs and TSW clients are more educated than MSW clients and TSWs. Only 50% of TSW clients have received HIV testing. Self-reported HIV positivity is highest among MSW clients and TSWs.

Conclusion –

Notable differences exist between MSWs and TSWs and their clients that can affect the health of these groups and warrant intervention.

HIV disproportionately affects men who have sex with men and transwomen in Latin America. Globally, efforts to map, enumerate, and describe male and transwomen sex workers (MTSWs) are limited. We mapped and described venue- and non-venue-based MTSWs and enumerated venuebased MTSWs in Lima, Peru's capital. With venue-based MTSWs, we identified and described the venues, SWs, and clients and enumerated the SWs. With non-venue-based MTSWs, we described SW offerings and SWs. Male SWs (MSWs) are concentrated downtown, with many moving online. Transwomen SWs (TSWs) are spread across metropolitan Lima, with fewer online. At venues, there are more TSWs than MSWs, TSWs reported more HIV and sexual risk behaviors, and MSWs had more female partners. Non-venue-based MSWs used condoms less than venue-based MSWs. Results support systematic efforts to describe hard-to-reach MTSWs and their different types of partners, all of whom have unique, differing needs for HIV/ STI education, prevention, testing, and care services.

Violence experience can increase HIV risk behaviors; however, literature is scarce on violence among male sex workers (MSWs) globally. In 2014, 210 Peruvian MSWs (median age 24.9) were interviewed about their experience of physical, emotional, and sexual violence and condom use with non-paying intimate partners and clients and were tested for HIV. Multivariable models examined relationships between violence in the past 6 months, condomless anal intercourse (CLAI) in the past 3 months and HIV infection. HIV infection (24 %), CLAI (43 %), being a violence victim (42 %) and perpetrator (39 %) were common. In separate multivariable models, being a violence victim [adjusted prevalence ratio aPR = 1.49 (95 % CI 1.09-2.03)] and perpetrator [aPR = 1.39 (1.03-1.87)] were associated with CLAI. Further, being a victim [aPR = 1.65 (1.04-2.62)] was associated with HIV infection. Violence, which was significantly associated with CLAI and HIV infection, is common among Peruvian MSWs, reinforcing the importance of violence awareness and prevention as HIV risk-reduction strategies.