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Averting HIV and AIDS epidemic in Nicaragua: Studies of prevalence, knowledge, attitudes, and behavior
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (International Maternal and Reproductive Health and Migration)
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to obtain an understanding of the dynamics of the HIV epidemic by estimating prevalence and exploring the relationship between HIV-related knowledge, attitudes, behavior, and HIV status in Nicaragua. Structured questionnaires were administered to adults from a health and demographic surveillance system in León, Nicaragua (Papers I–III). In-depth interviews and a survey were conducted among men who have sex with men (MSM, Paper IV). Blood sampling for HIV was carried out among 2,204 men and women (Paper I). Bivariate and multivariate analyses, including adjusted prevalence ratio (Papers I, II, IV), factor analysis, Cronbach’s alpha, and hierarchical regression analysis (Paper III) were performed. Thematic analysis was used with qualitative data (Paper IV).

The prevalence of HIV in the general population was 0.35% (95% CI, 0.17–0.73). Those who have taken a HIV test were more likely to be females, younger, living in an urban setting, have a higher level of education, be married or cohabiting, and have no religious affiliation. HIV-related knowledge was lower among members of the general population than among MSM. Unprotected sex was reported more times with regular partners than with casual partners. Findings suggested that consistency of condom use and emotional attachment (steady relations) were inversely related. Stigma and discrimination were reported high in the general population; they appeared to be negatively associated with HIV-related knowledge, self-perception of HIV risk, HIV testing, and willingness to disclose HIV status in the event of being HIV-positive. Findings demonstrated an increasing tolerance towards same-sex attractions. MSM have a better understanding of HIV transmission than men and women of the general population. Although seven out of ten MSM and six out of ten women were concerned about becoming infected with HIV, inconsistent condom use was common.

This study confirmed that Nicaragua has a low prevalence but high risk for HIV infection and transmission. Results underscore that social, behavioral, and cultural factors contribute to retard progress in achieving the Millennium Development Goals on reducing gender inequality and combating HIV/AIDS. Addressing these challenges depends not only on successful behavior change interventions, but requires a culturally gender-appropriate strategy.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 67 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 847
Keyword [en]
HIV-related knowledge, vulnerability, risk behaviors, stigma, discrimination, men who have sex with men, gender, sexuality, Nicaragua
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science; Social Medicine
URN: urn:nbn:se:uu:diva-186673ISBN: 978-91-554-8553-5 (print)OAI: diva2:572900
Public defence
2013-01-16, Room IX, plan 2, Uppsala University Main Building, Biskopsgatan 3, Uppsala, 09:15 (English)
Available from: 2012-12-21 Created: 2012-11-29 Last updated: 2013-04-02Bibliographically approved
List of papers
1. HIV community prevalence and testing practices in León, Nicaragua
Open this publication in new window or tab >>HIV community prevalence and testing practices in León, Nicaragua
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Our objective was to determine the HIV prevalence, testing practices, and HIV-related behaviors in a general population sample in the municipality of Leon, Nicaragua. We performed a cross-sectional community-based study of 2,204 males and females ages 18 to 69, from a health and demographic surveillance system. A behavior survey and blood sampling for HIV were also carried out. Seven of 1,960 individuals who provided biological samples (0.35%; CI 0.18–0.67) were HIV positive. The predicted prevalence of HIV among non-participants was about 11% higher than the observed prevalence but it was not significantly different. The major obstacle to HIV testing seemed to be the fear of being diagnosed HIV positive. This is the first study to determine HIV prevalence among the general population in Nicaragua. Our findings confirmed that this population has a low prevalence but high risk for HIV infection. Prevention strategies are essential to maintain this figure.

HIV, prevalence, testing, health demographic surveillance system, Nicaragua
National Category
Medical and Health Sciences
Research subject
Caring Sciences in Medical Sciences
urn:nbn:se:uu:diva-185571 (URN)
Available from: 2012-11-28 Created: 2012-11-26 Last updated: 2013-04-02
2. Assessing knowledge, attitudes, and behaviors related to HIV and AIDS in Nicaragua: A community-level perspective
Open this publication in new window or tab >>Assessing knowledge, attitudes, and behaviors related to HIV and AIDS in Nicaragua: A community-level perspective
2013 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 4, no 1, 37-44 p.Article in journal (Refereed) Published
Abstract [en]


Nicaragua's HIV epidemic is concentrated among men who have sex with men.Nevertheless, the increasing number of HIV cases among heterosexuals, high levels of poverty andmigration rates, and incomplete epidemiological data suggest the need to improve the understanding of the epidemic.


To examine the prevalence of HIV-related knowledge, attitudes, and sexual rsik-taking behaviors, and their predictors among the adult population.


A community-based cross-sectional survey was conducted in 2009 among 520 participants ages 15 to 49 from an ongoing Health and Demographic Surveillance System in Nicaragua. Bivariate analysis and adjusted prevalence ratios were use to examine factors associated with HIV-related knowledge, attitudes, and sexual behavior.


Contributing factors for risk-taking behaviors included cognitive, psychosocial, and emotional elements. Insufficient knowledge affecting the accurate assessment of HIV risk were low educational level, poverty, and rural origin, especially among females. Recognizing risk was not sufficient to promote safer sex: 90% of the females and 70% of the males who reported being sexually active in the past year did not use condoms during their last sexual encounter. Inconsistent condom use among men was associated with older age, long-term relationships, and lack of awareness about acquiring HIV infection.


Interventions to reduce social-structural contextual factors in Nicaragua are needed so that individuals may adopt and maintain HIV risk reduction strategies. Increased gender-specific HIV education and skills-building programs need to be implemented. Sensitive mass media messages may also increase the knowledge of HIV and AIDS, and serve to encourage protective attitudes and behaviors.

HIV/AIDS-related knowledge, attitudes, behaviors, adult population, gender, Nicaragua
National Category
Medical and Health Sciences
Research subject
Social Medicine
urn:nbn:se:uu:diva-185012 (URN)10.1016/j.srhc.2012.11.001 (DOI)000316091000008 ()
Available from: 2012-11-26 Created: 2012-11-17 Last updated: 2017-12-07Bibliographically approved
3. Measuring HIV- and AIDS-related stigma and discrimination in Nicaragua: Results from a community-based study
Open this publication in new window or tab >>Measuring HIV- and AIDS-related stigma and discrimination in Nicaragua: Results from a community-based study
2013 (English)In: AIDS Education and Prevention, ISSN 0899-9546, E-ISSN 1943-2755, Vol. 25, no 2, 164-178 p.Article in journal (Refereed) Published
Abstract [en]

Psychometric properties of external HIV-related stigma and discrimination scales and their predictors were investigated. A cross-sectional community-based study was carried out among 520 participants using an ongoing health and demographic surveillance system in León, Nicaragua. Participants completed an 18-item HIV stigma scale and 19 HIV and AIDS discrimination-related statements. A factor analysis found that 15 of the 18 items in the stigma scale and 18 of the 19 items in the discrimination scale loaded clearly into five- and four-factor structures, respectively. Overall Cronbach’s alpha of .81 for the HIV stigma scale and .91 for the HIV discrimination scale provided evidence of internal consistency. Hierarchical multiple linear regression analysis identified that females, rural residents, people with insufficient HIV-related transmission knowledge, those not tested for HIV, those reporting an elevated self-perception of HIV risk, and those unwilling to disclose their HIV status were associated with higher stigmatizing attitudes and higher discriminatory actions towards HIV-positive people. This is the first community-based study in Nicaragua that demonstrates that overall HIV stigma and discrimination scales were reliable and valid in a community-based sample comprised of men and women of reproductive age. Stigma and discrimination were reported high in the general population, especially among sub-groups. The findings in the current study suggest Community-based strategies, including the monitoring of stigma and discrimination, and designing and implementing stigma reduction interventions, are greatly needed to reduce inequities and increase acceptance of persons with HIV.

AIDS-related stigma; discrimination, scale construction, community-based, Nicaragua
National Category
Medical and Health Sciences
Research subject
Social Medicine
urn:nbn:se:uu:diva-185568 (URN)10.1521/aeap.2013.25.2.164 (DOI)000316922100007 ()
Available from: 2012-11-26 Created: 2012-11-26 Last updated: 2017-12-07Bibliographically approved
4. Sexuality and Risk Behavior among Men Who have Sex with Men in León, Nicaragua: A Mixed Methods Approach
Open this publication in new window or tab >>Sexuality and Risk Behavior among Men Who have Sex with Men in León, Nicaragua: A Mixed Methods Approach
2012 (English)In: Journal of Sexual Medicine, ISSN 1743-6095, E-ISSN 1743-6109, Vol. 9, no 6, 1634-1648 p.Article in journal (Refereed) Published
Abstract [en]


HIV prevalence among men who have sex with men (MSM) is 38 times higher than among the general population in Nicaragua. There are little data about the sexuality and sexual behaviors of MSM. It is essential to gain a better understanding of this understudied population.


The nature of sexual relationships among MSM, their reasons for engaging in risky sexual behaviors, and the sociocultural context in Leon, Nicaragua, were investigated through in-depth interviews. Our findings resulted in a structured overview of sociodemographic characteristics and HIV-related knowledge, attitudes, and risk behaviors.


Fifteen participants recruited by purposive sampling completed an in-depth interview that was then thematically analyzed. An additional 104 participants were surveyed by means of an interviewer-administered questionnaire.

Main Outcome Measures.

The in-depth interview guide and the survey covered topics related to sociodemographics, childhood, social and sexual relationships, knowledge and attitudes toward HIV and AIDS, identity, and networks.


The resulting ecological model explored sexuality and behaviors in four categories. It showed that despite a homophobic and heterosexist society, there is an increasing gay community and greater social acceptance of homosexuality. Nevertheless, interpersonal and intrapersonal factors continue to negatively influence MSM behavior. Quantitative findings demonstrate a satisfactory understanding of HIV transmission among this population, 75% of whom reported concerns of becoming infected with HIV in the future. Approximately one-half claimed that they always used condoms when having sex with men, but only one-third of the time with women, indicating inconsistent condom use. Negative attitudes toward HIV/AIDS were seldom heard.


This study is the first mixed methods approach in a Nicaraguan context that shows the interrelations among sex, sexuality, and identity at various levels of MSM life, and how they influence the sexual risk behaviors of individuals. Engaging in unprotected sex and postponing HIV testing are seen as cognitive dissonances.

Sexuality, Sexual Behavior, MSM, HIV Vulnerability, Nicaragua
National Category
Medical and Health Sciences
Research subject
Social Medicine
urn:nbn:se:uu:diva-177243 (URN)10.1111/j.1743-6109.2012.02713.x (DOI)000304710400015 ()
Available from: 2012-07-05 Created: 2012-07-04 Last updated: 2017-12-07Bibliographically approved

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