text:
Q: Which is more wet: 'moist' or 'damp'? Which contains more liquid, something that is moist or something that is damp?
Context of question:
This question was asked to a young friend of mine in her high school freshman English class. It was a bonus question on a test she was taking. My thoughts after looking at the definitions in my copy of Merriam Webster's was that both were perfect synonyms and that neither truly quantified the amount of liquid within an item.
As I thought on it a little more, I figured this would be a good question to ask on this site to see what those with more knowledge of the language would come up with.

A: damp:
slightly wet, often in an unpleasant way:
moist:
slightly wet, especially in a way that is pleasant or suitable
The same soil would be moist and damp at the same time: moist for planting seeds, and damp for sitting on.
This is the Word Choice note given by Longman Dictionary:

WORD CHOICE:
damp, moist, humid
Use damp especially to say that something is slightly wet in an unpleasant way:
  • The room was cold and damp.
Use moist to say that something is slightly wet in a pleasant way or in the way it should be:
  • She took a mouthful of the delicious moist cake.
  • rich, moist soil
Use humid to talk about the weather or the air when it is slightly wet and makes you feel uncomfortable:
  • the hot humid atmosphere of a greenhouse

Source: Longman Dictionary

A: The word "moist" has a visceral effect that is not shared with "damp".
Moist and damp object have, as noted in dictionaries "slight wetness", and to this extent they are synonymous. However "moist" also has a meaning in medicine of "Marked by fluid discharge". You could describe some something in with liquid on the surface as "moist".
While the dictionaries note that dampness is unpleasant,  moistness has been called the most hated word, especially among younger people. This seems to be a recent development, with older people happy to describe a cake as moist, with a positive sense.  However moistness seems to have picked up sexual connotations and senses of rankness, that have made the word one to be avoided, when a relatively neutral term such as damp is available. There are words with a negative sense that dont carry the same visceral impact, such as "soggy".
As an aside, the word "rank", meaning foetid or gross, went through a similar change in meaning, changing from luxuriant, to overripe to its modern meaning. Moist may develop in the same way.

A: Dictionary definitions and other literary analyses aside, my personal connotative impression finds damp as just slightly wetter than moist.
Specifically, a damp washcloth will tend to leave a small puddle behind when picked up, and probably drip as well; a moist washcloth will do neither, but the moisture can still be felt by touch. Add a little more water to the moist washcloth and it will become damp.

A: As a counterpoint to the definitions that appear in Fard's answer (by way of Longman's Dictionary, I offer these definitions from Merriam-Webster's Eleventh Collegiate Dictionary (2003):

damp adj. {ME, black damp, fr. MD or MLG, vapor; akin to OHG damph vapor} (1590) 1 a archaic : being confused, bewildered, or shocked : STUPEFIED b : DEPRESSED, DULL 2 : slightly or moderately wet : MOIST {a damp towel} also : HUMID {damp weather}
...
moist adj. {ME moiste, fr. AF, perh. fr. VL muscidus, alter. of L mucidus slimy, fr. mucus nasal mucus} (14c) 1 : slightly or moderately wet : DAMP 2 : TEARFUL 3 : characterized by high humidity

The Eleventh Collegiate also includes this usage note under the entry for wet:

DAMP implies a slight or moderate absorption and often connotes an unpleasant degree of moisture {clothes will mildew if stored in a damp place}. ... MOIST applies to what is slightly damp or not felt as dry {treat the injury with moist heat}.

So the main entries for the two words give the relevant definition of damp as "slightly or moderately wet : MOIST" and the relevant definition of moist as "slightly or moderately wet : DAMP." Those are about as close to interchangeable definitions as you can find in Merriam-Webster. The usage note comparing the two words does note that some senses of damp involve unpleasant or uncomfortable settings, but it doesn't draw a sharp, categorical contrast between unpleasant wet (damp) and pleasant or suitable wet (moist).
In U.S. usage a damp towel is neither more nor less pleasant than a moist towel—and many other instances exist where damp and moist might be used interchangeably without significantly different connotations. UK usage may be different, but for the United States I don't think that a definite difference in wetness is implicitly understood as between damp and moist.

A: The Oxford English Dictionary has as one of its definitions for damp

To make moist or humid, to wet as steam, vapour, mist, or dew does; to moisten.

The Oxford English Dictionary also has as one of its definitions of moist as:

Of a season, climate, etc.: Wet; rainy; having some rain; having a considerable rainfall.

So perhaps moist is wetter as having a considerable rainfall is much wetter than mist or dew
And further more, it defines moisten (which damp is defined as doing) as:

To make or render moist, damp, or wet; to wet superficially or moderately

So that seems to prove damp is only wet superficially or moderately where as moist can be much more so.

A: The OED Online, in an entry for 'moist' updated for the third edition, September 2002, addresses the issue directly, if somewhat hesitantly:

A. adj. 1. a. Slightly wet, imbued with moisture; containing liquid in a state of suspension or absorption; not dry; damp, humid.
In many contexts now differing from damp by having a neutral (sometimes, esp. with reference to the texture of food, good) rather than a negative sense, and in connoting a lesser degree of wetness. In early use the word had a wider application.

(Bold emphasis mine.)
The note concerning the greater degree of wetness connoted ("in many contexts") by 'moist' was added in the 2002 update. The note in the second edition (1989) was

Now differing from damp in having no tendency to imply either an undesirable or a merely temporary or casual condition. In early use the word had a wider application.

The three historical quotes from the 1900s given for the cited definition of 'moist' are from a US author (1901), an Australian author (1972), and the Toronto Star (Canadian, 1993). These quotes have no explicit bearing on the aforementioned observation concerning the "lesser degree of wetness" connoted by 'moist'.

A: In my opinion, the degree of wetness is the same for damp and moist: appropriate to cause the word's use. In my experience, fathering two girls, I used damp to describe a moist diaper and wet to describe a much soggier one. When wiping the kitchen counter with a damp cloth, I had to first moisten it. I know the technical answer has been given, and I don't disagree with it; but usage develops our choice.

A: Well, though their definitions do not make clear a difference in degree, damp notes unpleasantness, which, more often that not, would have more liquid that a pleasant amount. The words themselves, however, do not differentiate.

A: Looking at this question denotatively, the words both define to (more or less) "slightly wet".
Given this we must then determine the question to be answered connotatively. When we look at the usage of the action to dampen and the usage of the action to moisten, then often times dampening something (such as a towel) would require more water than to moisten something (such as the mouth).
However, given that this is more of a gray area question, it is much more likely the professor was looking for a stance and defense to show critical thinking than an ultimatum.

A: The answer from fard covers all formal aspects for the answer. It also supports my thoughts:
I would use damp in contexts describing solid matter. eg a towel, whereas I would use moist in contexts describing gaseous matter. e.g. air.
With that, from a Physics's point of view I would say damp is more wet.


text:
package org.apache.activemq.artemis.tests.integration.cluster.failover;

import java.util.Arrays;
import java.util.concurrent.CountDownLatch;
import java.util.concurrent.TimeUnit;

import org.apache.activemq.artemis.api.core.ActiveMQException;
import org.apache.activemq.artemis.api.core.Interceptor;
import org.apache.activemq.artemis.api.core.TransportConfiguration;
import org.apache.activemq.artemis.core.protocol.core.Packet;
import org.apache.activemq.artemis.core.protocol.core.impl.PacketImpl;
import org.apache.activemq.artemis.spi.core.protocol.RemotingConnection;
import org.apache.activemq.artemis.tests.util.TransportConfigurationUtils;
import org.junit.Before;
import org.junit.Test;

public class BackupAuthenticationTest extends FailoverTestBase {

   private static CountDownLatch latch;

   @Override
   @Before
   public void setUp() throws Exception {
      startBackupServer = false;
      latch = new CountDownLatch(1);
      super.setUp();
   }

   @Test
   public void testPasswordSetting() throws Exception {
      waitForServerToStart(liveServer.getServer());
      backupServer.start();
      assertTrue(latch.await(5, TimeUnit.SECONDS));
      /*
       * can't intercept the message at the backup, so we intercept the registration message at the
       * live.
       */
      Thread.sleep(2000);
      assertFalse("backup should have stopped", backupServer.isStarted());
      backupConfig.setClusterPassword(CLUSTER_PASSWORD);
      backupServer.start();
      waitForRemoteBackup(null, 5, true, backupServer.getServer());
   }

   @Override
   protected void createConfigs() throws Exception {
      createReplicatedConfigs();
      backupConfig.setClusterPassword("crocodile");
      liveConfig.setIncomingInterceptorClassNames(Arrays.asList(NotifyingInterceptor.class.getName()));
      backupConfig.setSecurityEnabled(true);
      liveConfig.setSecurityEnabled(true);
   }

   @Override
   protected TransportConfiguration getAcceptorTransportConfiguration(boolean live) {
      return TransportConfigurationUtils.getInVMAcceptor(live);
   }

   @Override
   protected TransportConfiguration getConnectorTransportConfiguration(boolean live) {
      return TransportConfigurationUtils.getInVMConnector(live);
   }

   public static final class NotifyingInterceptor implements Interceptor {

      @Override
      public boolean intercept(Packet packet, RemotingConnection connection) throws ActiveMQException {
         if (packet.getType() == PacketImpl.BACKUP_REGISTRATION) {
            latch.countDown();
         } else if (packet.getType() == PacketImpl.CLUSTER_CONNECT) {
            latch.countDown();
         }
         return true;
      }
   }
}

redpajama_set_name: RedPajamaGithub


Shades of pink and purple are never going to go out of style, keeping classic colors together with a toned down cake design – something you are not going to one day wake up to, flip through your wedding album and ask yourself, "What was I thinking".
Honestly, I would like to see a little more creativity in the cake here, especially if it's for a wedding or some such life changing event, but the image does serve a good starting point.
We have lots of other very cute idea that will match with the colors here, check out the wedding venues posts to help put something together.


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Taking the expected design elements of hard contemporary and putting a decidedly feminine curve into the mix make the Lyric Collection a unique addition to your new bedroom design. With each curve comes a new twist satin nickel hardware accents the glossy white or dark espresso or brownish gray finish, bowfront case pieces feature ball bearing drawer glides, and compliment the padded sleigh headboard and footboard, while a round, contemporary mirror reflects the modern designs that you have selected. A final unique addition to the collection is the glass-topped night stand that furthers the contemporary feel.


text:
Survival Solar Charger and Power Bank
5 ( 1 reviews)
Never, ever run out of juice for your electronic devices with this compact and portable solar charger and power bank
On the back, is a glow-in-the-dark skull so that you can find the charger in low-light situations
It has a powerful 1.2 W monocrystalline solar panel that will charge the li-polymer battery, which has an 10,000 mAh capacity
It features two USB outputs and a micro-USB input, along with a micro-USB charging cable, that can be used to charge the power bank
The splash-resistant (IPX4) and shock-proof charger is made of silica gel and ABS/PC material with a rubber paint surface process
The 5 3/4" x 2 3/4" electronic device charger and power bank also features an emergency LED light and comes with a survival lanyard
The Skull 10,000 mAh Solar Charger And Power Bank will make sure that you never run out of juice for all of your electronic devices no matter where you are! You can use the charger to charge iPhones, iPads, Android phones, GPS devices, cameras and more. It features a powerful 1.2 W monocrystalline solar panel that will charge the Li-Polymer battery and it also has capacity LED indicators. The skull-themed splash-resistant (IPX4), shock and dust-proof charger is made of environmentally friendly silica gel and ABS/PC material with a black rubber paint surface process. On the back, is a glow-in-the-dark skull so that you can find the charger in low-light situations. It has hidden dual USB/micro charging ports and an emergency LED light, plus, a built-in compass on the back. The attached paracord survival lanyard has a fire striker. Just attach the solar charger to your gear and go!
36 BK5681
Never Run Out of Power
Customer Reviews | Average Rating: 5.00 out of 5
Steven Dane
Nice to have when I go into Chewaumegan/Nicolet National Forest. Middle of Nowhere. Hut!
Showing 1 out of 1

redpajama_set_name: RedPajamaCommonCrawl


Attorneys for the two Hungarian students who were killed in the collision accident in July 2010 between a tugboat pushed barge and a stranded tourist Duck Boat, have released a new video of the event that they say contains disturbing details of what actually happened.
Attorney Robert Mongeluzzi explains that the video clearly shows the duck boat's captain jumping ship off the bow moments before the crash, while the rest of the 35 passengers were left still struggling to put on their life jackets. He states the boat's crew could have taken advantage of the 11:46 minutes before the crash while they were sitting there out of commission to warn them of a pending crash and to put on jackets, instead of the :45 second warning the crew actually gave the passengers.
Mongeluzzi states that they didn't have enough time to get on the jackets before the barge struck the boat and submerged it under its hull along with the passengers, including his clients who did not make it.
Mongeluzzi plans on using the video in the upcoming trial.


text:
Newport County legislators consider highs and lows of pot legalization
Derek Gomes Daily News staff writer
Local legislators are split over Gov. Gina Raimondo's proposal to legalize recreational marijuana for the state to recoup money from the societal costs it will bear as recreational pot shops open in Massachusetts.
All the legislators who spoke with The Daily News, even those who voiced support for the move, expressed concern about the repercussions tied to legalization: Greater access to the drug for children, motorists operating under the influence and federal contractors whose employees must pass a drug test to get a security clearance.
Rep. Lauren Carson, D-Newport, who said she "fundamentally supports" legalization, noted the strain that Rhode Island communities on the Massachusetts border will face because of the legalization divide. "We have a recreational pot shop 200 feet across the street from Tiverton," she said. "What kind of onus are we putting on the Tiverton community, Tiverton police?"
"We're totally surrounded," Rep. John "Jay" Edwards, D-Tiverton, said. "I have a facility in Massachusetts that's a stone's throw from the border of my town."
Northeast Alternatives, which is located on William S. Canning Boulevard on the border of Tiverton and Fall River, is set to begin recreational marijuana sales Sunday.
"We have to face this thing," Carson added. "And if Connecticut legalizes it, we will be surrounded by legalization."
Along with Carson and Edwards, Sen. Dawn Euer, D-Newport, voiced conditional support for legalization.
Sens. Louis DiPalma, D-Newport, and James Seveney, D-Portsmouth, along with Reps. Dennis Canario, D-Portsmouth, and Susan Donovan, D-Bristol, said they either have serious concerns about or are outright opposed to the move.
And the rest of the Newport County legislative delegation, Reps. Marvin Abney, D-Newport; Terri Cortvriend, D-Portsmouth; and Deborah Ruggiero, D-Jamestown, said they need more information about the proposal. Sen. Walter Felag, D-Warren, could not be reached for comment Thursday. His district includes a portion of Tiverton.
"There are more questions than answers," Ruggiero said. "To say what's your position, it's a really complicated issue that warrants time" and debate about the public safety and public health angles related to legalization.
Raimondo announced her proposal in an interview with The Providence Journal earlier this week. Highlights of the plan are:
•Her fiscal 2020 budget proposal would set aside $3.5 million to establish the regulatory framework for recreational sales.
•The product would be taxed at about 17 percent.
•Twenty-five percent of gross revenue would be split between the state Department of Health, Department of Public Safety and Department of Business Regulation. An additional 15 percent would be disbursed to the state's cities and towns. The rest would go into the state's general fund.
•The first three recreational shops would likely be the state's existing three medical marijuana dispensaries, including Greenleaf Compassionate Care Center in Portsmouth.
•Individuals would be barred from growing recreational marijuana at home.
•Edibles cannot contain more than 5 milligrams of THC.
Canario said he does not know how the state can afford to establish a regulatory framework for recreational marijuana when the state faces a possible $200 million deficit in the coming fiscal year.
"You don't just legalize marijuana and the money starts rolling in," he said. "You have to put money in place, funds in place, in order to implement a program like this. You could be talking serious money — in the millions. … The governor laid out some pretty nice things the other night [during the State of the State address] in terms of education, but this is all going to take money and I want to know where this money is going to come."
DiPalma and Seveney stressed that marijuana use can negatively affect a child's development and that employees of federal contractors, many of which call Aquidneck Island home, must pass a drug test.
"A positive hit for drugs, be it THC or whatever, you're out of a job," Seveney said. "They'll yank your clearance. And in the defense business if you don't have a security clearance, you don't have a job."
"I don't believe it's the right policy," DiPalma said. "Regardless of the money and what our neighboring states are doing … if it's not the right policy, it's not the right thing to do."
Donovan, whose district includes northwestern Portsmouth, cited concerns about the lack of a test that police officers can administer to motorists to determine whether they are under the influence of marijuana. "Science has not caught up with that yet," she said. "That's my big concern."
Euer, who said she wants to hear from all sides on the matter, compared the ineffectiveness of alcohol prohibition to a ban on recreational marijuana. "Prohibition doesn't work," she said. "That's why we move to regulate it."
If recreational marijuana is legalized, she wants legislators to consider a process for those convicted of marijuana possession to have the charge expunged.
"We're going to suffer costs because of what's going on in Massachusetts and Connecticut," Edwards said. "We have to legalize on our own."
He cautioned against moving too quickly with legalization, saying it would take about one year to implement the regulatory system after the legislature approves legalization. "This stuff does not happen overnight," he said.
Just because Massachusetts has started legal recreational sales is not a reason to "rush into it," Abney said. "We need to take a look at how that will affect us and fit us."
Cortvriend, who said her focus at the outset of the legislative session has been rules reform, said she will turn her attention to the legalization question.
"We should not jump into something just because the next state did it," Canario said. "There has been no planning. There's been none of that. There has to be really a lot of planning before event thinking about going forward with this."
dgomes@newportri.com


text:
Hoeven Hosts Army Corps Chief in Minot for Signing of Chief's Report, Visit to Review Region's Flood Protection Project
MINOT, N.D. - Senator John Hoeven today marked the signing of the Chief's report for comprehensive flood protection in the Souris River Valley by U.S. Army Corps of Engineers (USACE) Chief Lt. Gen. Todd Semonite. Hoeven hosted Semonite in Minot for the signing ceremony and to review the region's project. This comes as a result of the senator's efforts to finalize the report, necessary to allow the project to receive federal authorization and funding for phase 4. Hoeven also leveraged the occasi… Continue Reading
Hoeven to Host Agriculture Secretary Perdue in North Dakota on Saturday, April 27
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Hoeven Announces More than $15.6 Million in Funding to Support Affordable Housing in North Dakota
WASHINGTON - Senator John Hoeven, a member of the Senate Transportation, Housing and Urban Development and Related Agencies Appropriations Committee, today announced that the U.S. Department of Housing and Urban Development (HUD) has awarded more than $15.6 million in funding to support affordable, quality housing in North Dakota. Details of the funding are as follows: Community Development Block (CDBG) Grants - The funds will help provide quality housing and expand economic opportunities for l… Continue Reading
FSA Implements Hoeven's Capital for Farmers and Ranchers Act to Increase Limits for Ownership and Operating Loans
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Hoeven Convenes Agriculture Appropriations Committee Hearing with USDA Secretary Perdue
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Hoeven Statement on Confirmation of David Bernhardt as Interior Secretary
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Hoeven Secures Senate Confirmation for Drew Wrigley to Serve as U.S. Attorney for North Dakota
WASHINGTON - Senator John Hoeven today issued the following statement after the Senate confirmed former Lt. Governor Drew Wrigley to again serve as U.S. Attorney for North Dakota. "We've worked very hard on it, and I'm pleased that we've been able to get confirmation for Drew Wrigley as U.S. Attorney," said Hoeven. "He served in this role before. He did an outstanding job, and I know he will do a great job again for our state in that capacity." Wrigley served as Lt. Governor of North Dakota f… Continue Reading
Hoeven and Shaheen Introduce Legislation to Improve FAA Hiring of Air Traffic Controllers
WASHINGTON - Senators John Hoeven (R-N.D.) and Jeanne Shaheen (D-N.H.) today introduced the Air Traffic Controller (ATC) Hiring Reform Act of 2019, legislation to help improve the Federal Aviation Administration (FAA) hiring process for air traffic controllers. The bill would ensure the agency is able to prioritize the hiring of veterans and graduates of FAA Certified Collegiate Training Initiative (CTI) schools, candidates who have a statistically lower attrition rate during qualification train… Continue Reading
Hoeven, Boozman Introduce Legislation to Improve Access to Education Benefits for National Guard and Reserve
WASHINGTON - Senators John Hoeven (R-N.D.) and John Boozman (R-Ark.), members of the Senate Defense Appropriations Committee, this week introduced the Montgomery GI Bill Parity Act, legislation that would enable members of the Guard and Reserve to concurrently use GI Bill benefts and Federal Tuition Assistance (FTA) programs to fund their education. "Our legislation is all about supporting our Guard and Reserve members and ensuring they receive the benefits that they have earned," said Senator… Continue Reading
Hoeven: FEMA Approves Ward County's Plan to Protect Rice Lake Homes, Infrastructure from Flooding & Erosion
WASHINGTON, D.C. - Senator John Hoeven today announced that the Federal Emergency Management Agency (FEMA) has approved Ward County's plan to protect homes and community infrastructure at Rice Lake from the threat of flooding and erosion. Last week, Hoeven secured a commitment from FEMA Acting Administrator Peter Gaynor to provide a timely response to Ward County and pressed for a positive outcome. Hoeven also wrote to the FEMA Region 8 office last month in order to help secure its approval for … Continue Reading
Hoeven: Ag Secretary Perdue Approves Bipartisan Request to Issue Livestock Disaster Payments
WASHINGTON - Senator John Hoeven, chairman of the Senate Agriculture Appropriations Committee and a member of the Agriculture Committee, today announced that U.S. Department of Agriculture (USDA) Secretary Sonny Perdue has approved his request, made with a bipartisan group of senators led by Senator John Thune (R-S.D.), for USDA to provide immediate Livestock Indemnity Program (LIP) assistance to agriculture producers. Severe weather events this year in the Plains, Rocky Mountains, Mississippi V… Continue Reading
Hoeven Announces More Than $20.2 Million to Help North Dakota Tribes Develop and Operate Affordable Housing
WASHINGTON - Senator John Hoeven, chairman of the Senate Committee on Indian Affairs and a member of the Senate Transportation, Housing and Urban Development Subcommittee on Appropriations, today announced that the U.S. Department of Housing and Urban Development (HUD) has awarded more than $20.2 million to four tribes in North Dakota. The funds are awarded through HUD's Indian Housing Block Grant (IHBG) program and will help the tribes develop and operate low-income housing. Details are as foll… Continue Reading
Hoeven Invites Secretary Carson to North Dakota to Review Innovative Efforts to Combat Homelessness
WASHINGTON - At a recent hearing of the Senate Transportation, Housing and Urban Development Appropriations Committee, Senator John Hoeven invited Ben Carson, Secretary of U.S. Department of Housing and Urban Development (HUD), to visit North Dakota and review two innovative efforts in the state to combat homelessness: The LaGrave on First project in Grand Forks. The Tribal HUD-Veterans Affairs Supportive Housing (VASH) program at the Turtle Mountain Indian Reservation. "We have some trul… Continue Reading
Hoeven Statement on Designation of Iran Islamic Revolutionary Guard Corps as a Foreign Terrorist Organization
WASHINGTON - Senator John Hoeven today issued the following statement regarding the Administration's plan to designate Iran's Islamic Revolutionary Guard Corps as a Foreign Terrorist Organization. "Iran has long been a force of destabilization, violence and terrorism in the region, and this designation will ensure that we hold Iran's Islamic Revolutionary Guard Corps accountable for its role in promoting and supporting terrorism, not only in the Middle East but around the globe," said Hoeven. "… Continue Reading
Hoeven Meets with National Guard Bureau Chief to Outline Legislation to Improve Guard Benefits, Need for New Facility in Fargo for 119th Wing Operations
WASHINGTON - Senator John Hoeven, a member of the Senate Defense Appropriations Committee, recently met with National Guard Bureau Chief General Joseph L. Lengyel and secured his commitment to support legislation to expand health care and education eligibility and benefits for National Guardsmen and Reservists. The senator also outlined the need for a new operations facility for the 119th Wing in Fargo to support the unit's mission. The senator has been specifically working to: Extend eligibi… Continue Reading
Hoeven Meets with Corps Northwestern Division Commander to Ensure Corps Prevents Missouri River Flooding in ND
WASHINGTON - Senator John Hoeven this week met with the Brigadier General D. Peter Helmlinger, the Northwestern Division Commander for the U.S. Army Corps of Engineers, to discuss the Corps' flood management plan for the Missouri River and to press the Corps to carefully monitor snowmelt and take actions to prevent flooding in North Dakota. General Helmlinger oversees the Corps' Omaha District, along with four other districts. "I met with Brigadier General Helmlinger, who leads the Northwest Di… Continue Reading
Hoeven Secures Commitment from Secretary Perry to Visit North Dakota & See Work of UND's EERC, Red Trail Energy & Project Tundra
WASHINGTON, D.C. - At a hearing of the Senate Energy and Natural Resources (ENR) Committee this week, Senator John Hoeven secured a commitment from Energy Secretary Rick Perry to come to North Dakota and learn firsthand about the work of the University of North Dakota's (UND) Energy and Environmental Research Center (EERC) and its partners to develop carbon capture and sequestration (CCS) technologies for both traditional and renewable energy resources, including: Project Tundra, a post-comb… Continue Reading
Hoeven: SkyWest to Restore Early Morning Flights from Devils Lake, Jamestown to Denver
WASHINGTON - Senator John Hoeven today announced that SkyWest Airlines, flying for United Airlines, will restore the longstanding early morning flight schedule from Devils Lake and Jamestown to Denver starting June 1. The flight will depart Devils Lake at 5:00 a.m. and Jamestown at 6:30 a.m. on its way to Denver. Hoeven worked with SkyWest and United Airlines to restore the previous flight schedule, which allows for a much greater availability of connecting flights for travelers from the two com… Continue Reading
Hoeven Advancing Ward County's Efforts to Prevent Flooding and Erosion at Rice Lake
WASHINGTON, D.C. - At a hearing of the Senate Homeland Security Appropriations Committee this week, Senator John Hoeven secured a commitment from Federal Emergency Management Agency (FEMA) Acting Administrator Peter Gaynor to provide a timely response to Ward County as it works to prevent flood and erosion risks at Rice Lake. The county is in the process of acquiring and demolishing a home using Pre-Disaster Mitigation (PDM) grant funding from FEMA, with plans to elevate the property to prevent … Continue Reading
Hoeven: Lance Yohe Nomination for IJC Approved by Committee, Moves to Full Senate for Consideration
WASHINGTON - Senator John Hoeven today issued the following statement after the Senate Foreign Relations Committee approved the nomination of Lance Yohe to serve on the International Joint Commission (IJC) - U.S. Section. His nomination now moves to the full Senate for consideration. "Water rights are central to our quality of life and economy, especially in western states like North Dakota," said Hoeven. "Lance Yohe is uniquely qualified to serve on the IJC and will help ensure our state and n… Continue Reading


What's a Worldview? –Why do different people believe so many different things? What are the main questions that every human being asks, and how do we seek answers? What makes Christianity unique among the many worldviews? How do we interact with others who do not share the same worldview as us?
All About the Bible– Students will learn about the Bible's origins and uniqueness among religious texts, and will also look at the evidence as to why we think it is trustworthy. We will also discuss the basic rules for interpreting and studying the Bible, which the students will practice all year.
Personal Finance– We will learn the basics of financial management as a single person and within a family. Debt, saving, home ownership, giving, buying and methods for budgeting will be discussed and practiced.
Individual Assessment– This is a practical component to the year. Students will undergo assessments for skills, gifting, and interests that can begin to narrow the focus toward a future vocation. Students will learn a lot about themselves and how they interact with others.
Media Filtering– We will assess the messages in all forms of media. Everything we watch, read, and listen to has a message, and a Christian must be able to recognize and interpret it. We will study the perspectives and worldviews found in media, and compare them to the Bible's teachings.
A Christian View of Work– Work will always be a part of our lives, and we should seek to glorify God in how we approach our vocation. Much of this course is experiential, as our staff members work alongside each student and deliver feedback, challenges and encouragement.
The Local Church– Students will attend a local church, and serve alongside its members throughout the year. We will discuss their positive and negative experiences in church, and prepare them to find and serve in a church in the future.
Foundations of Christian Leadership– Students will learn the theories and practices related to ministry and spiritual leadership.
Life skills– In addition to the above classes, students will learn a variety of practical things. These will include everyday skills such as cooking (both personal and hosting a group), time management, basic auto care, running a chainsaw, and many more unique and interesting skills and hobbies.
Elective– College application/financial aid applications for students preparing for college.


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Sexual assault lawsuit against former Vancouver 2010 chief thrown out
By Daniel Etchells
A sexual assault case against John Furlong, the former President and chief executive of Vancouver 2010, has been thrown out by British Columbia Supreme Court Justice Miriam Gropper.
Grace Jessie West filed a lawsuit in 2013 alleging that Furlong had sexually assaulted her when he was teaching at Immaculata Roman Catholic Elementary School in Burns Lake, British Columbia, in 1969 and 1970.
But Justice Gropper has ruled that the claims submitted by West were bogus, citing school records which indicated she never attended the school and was actually a pupil at St Joseph's School in Smithers.
During a court testimony, West was unable to name the school she attended where she alleges the abuse occurred.
"On the basis of that evidence and there being no evidence to the contrary, I must find that Ms. West did not attend Immaculata in 1969 to 1970," Justice Gropper wrote in a ruling.
West is one of three people to have alleged Furlong had verbally and physically abused them, claims he has slammed as "completely unfounded" and "horrible, heartless lies and innuendo".
John Furlong (right) was the President and chief executive of Vancouver 2010
©Getty Images
With police unable to find any evidence, Beverly Abraham withdrew her lawsuit against Furlong last month, claiming it was causing her too much stress, while an unidentified man's legal action is also being questioned as court documents suggest he too attended a different school at the time of the alleged abuse.
The man's lawsuit, for which no application has yet been made for dismissal, is scheduled to begin on March 30.
The allegations against Furlong first came to light in September 2012, when freelance journalist Laura Robinson wrote an article for the Georgia Straight newspaper, quoting several people who claimed to have been verbally and physically abused while being taught by Furlong in Burns Lake and Prince George, in the late 1960s and early 1970s.
Furlong, now the executive chair of Major League Soccer club Vancouver Whitecaps, filed a defamation lawsuit against the publication and Robinson, although he later dropped the claims against the newspaper.
Robinson, in turn, filed a defamation lawsuit against Furlong.
February 2015: Furlong lawyers attempt to have sexual assault lawsuit thrown out
December 2013: Furlong challenged to prove he can pay legal cases if loses libel case
October 2013: Furlong breaks silence on "completely unfounded" abuse allegations
September 2013: Third abuse lawsuit filed against Furlong as he defends himself in court
July 2013: Civil suits against former Vancouver 2010 chief claims of sexual abuse


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HIV/AIDS/STI Prevention and Care (642) Descriptive Epidemiology and Population Size Estimates (65) LGBTQ Issues (329)
Published on 17.6.2019 in Vol 5 , No 2 (2019) :Apr-Jun
Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/13771, first published February 21, 2019 .
Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men
Thiago Silva Torres 1 ; Kelika A Konda 2 ; E Hamid Vega-Ramirez 3, 4 ; Oliver A Elorreaga 2 ; Dulce Diaz-Sosa 3, 4 ; Brenda Hoagland 1 ; Steven Diaz 5 ; Cristina Pimenta 6 ; Marcos Benedetti 1 ; Hugo Lopez-Gatell 7 ; Rebeca Robles-Garcia 4 ; Beatriz Grinsztejn 1 ; Carlos Caceres 2 ; Valdilea G Veloso 1 ; ImPrEP Study Group 1, 2, 3
Thiago Silva Torres1*, PhD ;
Kelika A Konda2*, PhD ;
E Hamid Vega-Ramirez3,4*, MD, MSc ;
Oliver A Elorreaga2, MSc ;
Dulce Diaz-Sosa3,4, PsyD ;
Brenda Hoagland1, MD, PhD ;
Steven Diaz5, MD ;
Cristina Pimenta6, PhD ;
Marcos Benedetti1, MSc ;
Hugo Lopez-Gatell7, PhD ;
Rebeca Robles-Garcia4, PhD ;
Beatriz Grinsztejn1, MD, PhD ;
Carlos Caceres2, MD, PhD ;
Valdilea G Veloso1, MD, PhD ;
ImPrEP Study Group1,2,3
1Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI/Fiocruz), Rio de Janeiro, Brazil
2Centro de Investigación Interdisciplinaria en Sexualidad Sida y Sociedad, UPCH, Lima, Peru
3Condesa & Condesa-Iztapalapa Specialized Clinics, Mexico City, Mexico
4National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
5Center for Prevention and Comprehensive Healthcare for HIV/AIDS of Mexico City, Mexico City, Mexico
6Brazilian Ministry of Health, Brasília, Brazil
7National Institute of Public Health, Mexico City, Mexico
Thiago Silva Torres, PhD
Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI/Fiocruz)
Av Brasil 4365 Manguinhos
Rio de Janeiro, 21040-900
Fax:55 38659679
Email: thiago.torres@ini.fiocruz.br
Background: HIV disproportionally affects key populations including men who have sex with men (MSM). HIV prevalence among MSM varies from 17% in Brazil and Mexico to 13% in Peru, whereas it is below 0.5% for the general population in each country. Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir is being implemented in the context of combination HIV prevention. Reports on willingness to use PrEP among MSM have started to emerge over the last few years. Previously reported factors associated with willingness to use PrEP include awareness, higher sexual risk behavior, and previous sexually transmitted infection.
Objective: This study aimed to evaluate the factors associated with willingness to use daily oral PrEP among MSM in 3 Latin American, middle-income countries (Brazil, Mexico, and Peru).
Methods: This Web-based, cross-sectional survey was advertised in 2 gay social network apps (Grindr and Hornet) used by MSM to find sexual partners and on Facebook during 2 months in 2018. Inclusion criteria were being 18 years or older, cisgender men, and HIV-negative by self-report. Eligible individuals answered questions on demographics, behavior, and PrEP (awareness, willingness to use, barriers, and facilitators). Multivariable logistic regression modeling was performed to assess the factors associated with willingness to use daily oral PrEP in each country.
Results: From a total sample of 43,687 individuals, 44.54% of MSM (19,457/43,687) were eligible and completed the Web-based survey—Brazil: 58.42% (11,367/19,457), Mexico: 30.50% (5934/19,457), and Peru: 11.08% (2156/19,457); median age was 28 years (interquartile range: 24-34), and almost half lived in large urban cities. Most participants were recruited on Grindr (69%, 13,349/19,457). Almost 20% (3862/19,352) had never tested for HIV, and condomless receptive anal sex was reported by 40% (7755/19,326) in the previous 6 months. Whereas 67.51% (13,110/19,376) would be eligible for PrEP, only 9.80% (1858/18,959) of participants had high HIV risk perception. PrEP awareness was reported by 64.92% (12,592/19,396); this was lower in Peru (46.60%, 1002/2156). Overall, willingness to use PrEP was reported by 64.23% (12,498/19,457); it was highest in Mexico (70%, 4158/5934) and lowest in Peru (58%, 1241/2156). In multivariate regression models adjusted for age, schooling, and income in each country, willingness to use PrEP was positively associated with PrEP awareness and PrEP facilitators (eg, free PrEP and HIV testing) and negatively associated with behavioral (eg, concerned by daily pill regimen) and belief barriers (eg, sexual partners may expect condomless sex).
Conclusions: In this first cross-country, Web-based survey in Latin America, willingness to use PrEP was found to be high and directly related to PrEP awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand. This study provides important information to support the implementation of PrEP in Brazil, Mexico, and Peru.
pre-exposure prophylaxis; men who have sex with men; prevention; Latin America; surveys and questionnaires
HIV continues to be a major health problem worldwide. The Latin American region has the fourth largest number of individuals living with HIV (1.8 million accumulated cases) and is fifth with regard to new HIV infections (96,000). About 90% of new HIV infections in 2016 in Latin America occurred in 10 countries, including Brazil (49%), Mexico (13%), and Peru (4%) [1]. In this region, HIV disproportionally affects key populations, and these are primarily gay, bisexual, and other men who have sex with men (MSM) and transgender women [2]. HIV prevalence among MSM varies from 17% in Brazil [3] and Mexico [4] to 13% in Peru [5], whereas it is below 0.5% for the general population in each country [6-8]. This continuing burden highlights the need for a more energetic, integrated, and strategic focus on combination HIV prevention among this population.
Pre-exposure prophylaxis (PrEP) with daily oral emtricitabine/tenofovir (FTC/TDF) is an effective biomedical prevention strategy to reduce HIV acquisition among MSM [9-12]. PrEP guidelines were first published in 2012 by the US Centers for Disease Control and Prevention [13], followed by the World Health Organization (WHO) in 2014 [14], and in 2017, by the Brazilian Ministry of Health (MoH) [15]. PrEP is being implemented by public health services in Brazil [16], and it is being considered for implementation in Mexico and Peru, even though neither country has issued guidance with regard to PrEP.
Reports on PrEP awareness, willingness to use, and acceptability among MSM have started to emerge over the last few years. Few MSM were aware of PrEP (<50%) in 11 studies in low- and middle-income countries [17]. Willingness to use PrEP among MSM varies by country and time, ranging from 32% to 92% [18], suggesting a diversity of factors associated with willingness to use PrEP. Previously reported factors associated with willingness to use PrEP included the following: awareness, low cost of PrEP, higher sexual risk, previous sexually transmitted infection (STI), and unwillingness to use condoms [19]. However, these factors may vary according to the characteristics of the region or country and may change rapidly. Recent reports of awareness and willingness to use PrEP among MSM are available for Brazil [20-22], but no information was captured after the availability of PrEP in the public health system. Conversely, no recent reports are available for either Mexico or Peru.
The Implementation PrEP Project (ImPrEP) is the first transnational project in Latin America aiming to generate evidence on the feasibility, acceptability, and cost-effectiveness of PrEP among key populations (MSM and transgender people) specific to the cultural contexts and health systems in Brazil, Mexico, and Peru. Within ImPrEP, several studies are being conducted, including a PrEP demonstration study with 7500 MSM and transgender people in these countries. The results of ImPrEP [23] will permit stakeholders to evaluate and incorporate PrEP as part of combination HIV prevention within their countries. The data presented herein are from a formative survey conducted for ImPrEP, with the aim to better understand the characteristics, sexual behavior, and the knowledge and opinions regarding PrEP among MSM.
This study evaluated the factors associated with willingness to use PrEP among MSM in Brazil, Mexico, and Peru.
This was a cross-sectional, Web-based survey for MSM from 3 countries in Latin America: Brazil, Mexico, and Peru. Individuals who met the eligibility criteria (age ≥18 years, cisgender men, and HIV uninfected by self-report) and provided informed consent were directed to the Web-based questionnaire.
The questionnaire was conducted using SurveyGizmo in Brazil and SurveyMonkey in Mexico and Peru. The project was advertised on 2 geosocial networking apps for sexual encounters among men (Hornet and Grindr) and Facebook social media. On Facebook, advertisements focused toward male gender, country (Brazil, Mexico, or Peru), and related interests, applying keywords frequently used by gay and bisexual population, for instance, gay pride, gay community, and homophobia. Hornet users received 2 inbox messages with a link to the survey, and Grindr users received pop-up advertisements, 1 per week for 2 months. The advertisements were launched in March for Brazil and Peru and in June for Mexico, all in 2018. The questionnaire remained open for 2 months in each country. The informed consent stated clearly that the survey was targeting MSM. Another survey targeting transgender people within ImPrEP is still ongoing. No incentives were provided for answering the survey.
Sociodemographics
Age was categorized in the following 3 brackets: 18 to 24, 25 to 34, and ≥35 years. Race was dichotomized as white versus nonwhite (black, mixed-race, Asian, or indigenous) for Brazil and Peru; in Mexico, this question was dichotomized as indigenous versus nonindigenous. Definition of monthly income varied in each country (see Table 1 footnote). Schooling was dichotomized by those who had less than or complete secondary education versus any postsecondary education.
HIV Testing and HIV Risk Perception in the Next Year
Individuals were asked when they were last tested for HIV. The options were as follows: last 3 months, last 6 months, last year, more than 1 year, and never tested. We dichotomized this question in never versus at least once in a lifetime for the multivariate analyses. HIV risk perception was assessed with the question What is your chance of getting HIV in the next year? with possible options grouped into 3 categories for analysis: low (none/low risk), middle (some risk), and high (high risk/certainty of infection) [22].
Sexual Behavior and Preliminary Eligibility for Pre-Exposure Prophylaxis (Adapted From the World Health Organization Risk Criteria for Pre-Exposure Prophylaxis)
Sexual behavior was assessed in the last 6 months with the following: number of male sexual partners (0, 1-5, 6-10, and ≥10); condomless receptive anal sex, condomless insertive anal sex, sex with HIV-positive male partner, sex with a male partner of unknown HIV status, sex under the influence of alcohol, and chemsex or sex under the influence of excitatory drugs (all dichotomized yes/no).
We evaluated preliminary eligibility for PrEP considering the ImPrEP demonstration study's risk-related inclusion criteria, which were adapted from the WHO recommendations for PrEP use (all in the past 6 months): reporting unprotected sex, having an HIV-positive male partner, exchanging sex for money, or having an STI [24]. Individuals were then dichotomized (yes/no) as preliminarily eligible for PrEP based on risk if they fulfilled any of the listed criteria.
Binge drinking [25] was evaluated as follows: In the last six months, did you drink five or more drinks in a couple of hours? A dose was defined as 1 can of beer (300 mL) or 1 glass of wine (120 mL) or 1 shot of distilled alcohol (30 mL of ex. cachaça, vodka, whisky, tequila, mezcal, or pisco). Substance use in the past 6 months included the following: tobacco, marijuana, hash, stimulants (cocaine, crack, amphetamines, and 4-hydroxybutanoic acid), hallucinogens (lysergic acid diethylamide, ketamine), poppers (alkyl nitrites), and erectile dysfunction drugs.
Awareness, Willingness to Use, Barriers, and Facilitators of Daily Oral Pre-Exposure Prophylaxis
Awareness was assessed as follows: Have you ever heard of PrEP? and dichotomized yes/no. A brief explanation of PrEP was provided after respondents had answered the PrEP awareness question. PrEP use was categorized as follows: never, current, and past. We asked respondents to rank 3 PrEP regimens from 1-most preferred to 3-least preferred: daily oral (1 FTC/TDF pill/day), event-driven (2 pills before intercourse and 1 pill 24 hours and 48 hours after), and injectable (injection every 2 months).
Willingness is understood as an intentional behavior based on 2 principles: (1) recognition of the behavioral objective (ie, taking PrEP) and (2) strategies implemented to achieve this objective. The second principle can be experiential processes, which refer to cognitive strategies (eg, believing that PrEP will protect against HIV) or behavioral processes, which are strategies to produce and maintain the behavior (eg, setting an alarm as a reminder to take PrEP) [26]. We used a 5-point Likert scale to assess willingness to use PrEP, anticipated risk compensation, and if participants would use PrEP provided by the MoH at no cost. Willingness to use PrEP was defined as responding highly likely to the statement I would use one daily pill for PrEP. Anticipated risk compensation was defined as responding highly likely or likely to the following statement: I would not use a condom if I used PrEP. PrEP if provided by the MoH was defined as responding highly likely to the statement I would use PrEP if part of a MoH program. The inclusion of the likely category only for anticipated risk compensation was to be more conservative with this as a potentially negative outcome of PrEP use.
Barriers and facilitators to daily oral PrEP were accessed using a 5-point Likert scale (very important to not important) [27]. For descriptive statistics, barriers were defined as responding very important or important, and facilitators were defined as responding very important. The inclusion of important category only for barriers was to more broadly identify relevant obstacles of willingness to use PrEP. Barriers were grouped into the following: informational (eg, concerned by short-term or long-term side effects, that antiretroviral therapy would not work if they became HIV infected while on PrEP, and by lack of 100% protection against HIV), behavioral (eg, concerned by daily pill regimen, talking to a doctor about sex, and having quarterly HIV/STI testing), and beliefs (eg, concerned that taking PrEP implies being at risk of HIV acquisition, sexual partners may expect condomless anal sex, people may assume they are HIV-positive, and people may ask why they are taking pills). For facilitators, we assessed the following: free PrEP, access to free HIV testing, access to other free exams (eg, HIV/STI testing), access to personal PrEP counseling, adherence support from apps, support, and counseling about sex life. Using these groupings, we performed confirmatory factor analysis and calculated the Cronbach alpha to verify if these items could be grouped (each Cronbach alpha was >.70).
Percentage of willingness to use daily oral prep is also given per region. For Brazil, region was categorized according to geopolitical regions: North (7 states), Northeast (9 states), Central-West (3 states and Federal District), South (3 states), and Southeast (2 states). São Paulo and Rio de Janeiro are part of Southeast Brazil, but they were maintained separated in the analysis because of the high number of responders from these 2 states. For Peru, regions are grouped according to their geographical characteristics and political division: Lima (Lima city and Callao), Coast (Lima region and other coastal cities), Sierra (cities of the northern, central, and southern highlands), and Jungle. For Mexico, the regions were Northwest (Baja California, Baja California Sur, Chihuahua, Durango, Sinaloa, and Sonora), Northeast (Coahuila, Nuevo León, and Tamaulipas), West (Nayarit, Jalisco, Colima, and Michoacán), East (Puebla, Veracruz, Tlaxcala, and Hidalgo), North Center (Aguascalientes, Guanajuato, San Luis Potosi, Zacatecas, and Querétaro), South Central (Morelos, State of Mexico, and Mexico City), and South (Guerrero, Oaxaca, Chiapas, Tabasco, Campeche, Quintana Roo, and Yucatán). The last 2 regions (Southwest and Southeast), given their sociodemographic similarities, were included as a single region.
An ethical review board in each country approved the study: in Brazil, INI Evandro Chagas-FIOCRUZ institutional review board (#CAAE 82021918.0.0000.5262); in Mexico, the research ethics committee of the National Institute of Psychiatry Ramón de la Fuente Muñiz (#CEI/C/038/2018); and in Peru, Universidad Peruana Cayetano Heredia Ethical Committee for Research with Human Subjects (#101460). All study participants provided their informed consent electronically before initiating the Web-based survey. No identification of participants was collected.
Participant characteristics, awareness, willingness to use, barriers, and facilitators of PrEP were described by their frequencies, and chi-square tests were used to compare the variables per country (Brazil, Mexico, and Peru). Some survey questions included options such as I do not want to answer or I do not know to aid participant comfort. These answers were considered missing for data analysis. We compared the main outcome (willingness to use PrEP) by participant characteristics using chi-square tests for each country. Multivariable logistic regression was performed calculating adjusted odds ratios to explore factors associated with willingness to use PrEP for each country. Age, income, and schooling (and race in Brazil) were defined a priori as confounders and were kept in the final model for each country, irrespective of statistical significance. Models were created using a backwards stepwise modeling approach; variables with a bivariate P value of less than .01 were included in the initial model and subsequently excluded if their P value was greater than .05. Exclusions were done variable by variable, starting by excluding the variable with the highest P value and then rerunning the model to repeat the process. The final multivariable models included variables that remained significant (threshold of P<.05) after the backwards stepwise process and the a priori defined confounders. All analyses were performed using STATA version 14 (College Station, TX).
During the study, a total of 43,687 individuals provided their informed consent; 20.12% (8790/43,687) were ineligible (Figure 1). Of the 34,897/43,687 (79.88%) eligible individuals, 19,457/43,687 (44.54%) completed the questionnaire and were included in this analysis. Among them, 11,367/19,457 (58.42%) were from Brazil, 5934/19,457 (30.50%) were from Mexico, and 2156/19,457 (11.08%) were from Peru. Almost half of respondents (8981/19,457, 46.17%) lived in the largest urban centers of these countries: São Paulo, Brazil (3198/19,457, 16.44%), Mexico City, Mexico (2618/19,457, 13.46%), Rio de Janeiro, Brazil (1589/19,457, 8.17%), and Lima, Peru (1576/19,457, 8.10%).
Table 1 shows the characteristics of the participants who completed the questionnaire in each country. Their median age was 28 years (interquartile range: 24-34). The proportion of young individuals (18-24 years) was high in Peru (41.23%, 889/2156) and similar in Brazil (28.35%; 3222/11,367) and Mexico (29.76%; 1766/5934). Almost half of respondents from Brazil were white (52.82%, 6004/11,366), whereas the majority from Peru were nonwhite (80.42%, 1672/2079). In Brazil and Peru, fewer individuals were in the high-income category (13.47%, 1531/11,367 and 14.09%; 272/1930, respectively), whereas in Mexico more than a quarter (26.46%, 1419/5363) were in this category. Most participants had at least some postsecondary education in all 3 countries, but this proportion was lower in Brazil (61.14%, 6888/11,266).
Most participants were sexually attracted only to men (89.20%, 17,306/19,401), and the proportion of those attracted to both men and women was highest in Peru (17.13%, 367/2142), followed by Mexico (10.94%, 647/5914) and then Brazil (7.12%, 808/11,348). Among those who were only sexually attracted to women, almost half (45.79%, 125/273) had sex with men in the previous 6 months. Most participants did not have a steady partner (73.57%, 14,195/19,294). Most respondents were recruited on Grindr (68.61%, 13,349/19,457), and this was true for Brazil (67.06%, 7623/11,367) and Mexico (80.91%, 4801/5934), whereas in Peru, the plurality was recruited via Facebook (48.10%, 1037/19,457). Peru has the highest proportion of individuals who never used apps for sexual encounters (19.20%, 414/2156), whereas most Brazilians used them daily (54.05%, 6142/11,363).
Figure 1. Study flowchart. Brazil, Mexico and Peru, 2018.
Overall, 67.51% (13,110/19,419) of respondents would be eligible for PrEP, whereas only 9.80% (1858/18,959) of participants had high HIV risk perception, which was lowest in Brazil (8.94%, 986/11,029). Almost 20% (3862/19,352) had never tested for HIV, and this was highest in Peru (24.47%, 524/2141). A total of 45.66% (8836/19,352) MSM had tested for HIV in the previous 3 or 6 months, and this was highest in Brazil (48.73%, 5505/11,297). Condomless receptive anal sex was reported by 40.13% (7755/19,326) overall, being higher in Peru (44.48%, 954/2145) than in Mexico (40.04%, 2368/5914) and Brazil (39.34%, 4433/11,268). Even with the relatively high proportion of postexposure prophylaxis (PEP) awareness in Brazil (66.07%, 7510/11,367) and Mexico (55.09%, 3269/5934), ever use of PEP was very low in these countries, with only slightly more than 10% (1452/11,326) in Brazil.
Most MSM had heard about PrEP (64.92%, 12,592/19,396; Table 2); however, this proportion was much lower in Peru 46.60% (1002/2150), compared with over 60% in Brazil (68.82, 7794/11,325) and Mexico (64.11; 3796/5921). The majority had never used PrEP (96.19%, 18,685/19,425). Overall, willingness to use PrEP was reported by 64.23% (12498/19,457); this was highest in Mexico (70.07%, 4158/5934), followed by Brazil (62.45%, 7099/11,367) and Peru (57.56%, 1241/2156). Anticipated risk compensation if taking PrEP was reported by 21.83% (4248/19,457) overall. Injectable PrEP was the preferred PrEP regimen among a plurality of the Brazilians (44.61%, 5071/11,368) and Peruvians (41.00%, 884/2156), whereas daily oral PrEP was preferred among the Mexicans (37.92%, 2260/5960).
All information barriers to PrEP were considered important or very important by a majority of respondents in each country. There was less importance assigned to the behavioral and belief barriers to PrEP, the barrier taking pills everyday was considered important or very important by 47.90% (9320/19,457) overall, though this was less of a concern in Mexico 42.08% (2497/5934). The majority of respondents in Mexico and Peru were concerned that taking PrEP indicates being at risk of HIV infection and that their partners might expect condomless anal sex. Among the assessed facilitators to PrEP, only 2 were not considered very important by the majority of the participants: support for taking daily PrEP from apps or messages and counseling about sex.
Table 1. Characteristics of the individuals who completed the questionnaire in Brazil, Mexico, and Peru (2018).
Characteristics Brazil
(N=11,367;
58.42%) Mexico
(N=5,934;
30.50%) Peru
N=2,156;
11.08%) Total
(N=19,457) P valuea
Age (years; n=19,456), median (interquartile range) 29 (24-35) 28 (24-34) 26 (22-31) 28 (24-34) N/Ab
18-24 3222 (28.35) 1766 (29.76) 889 (41.23) 5877 (30.21) <.001
25-35 5364 (47.19) 2991 (50.40) 970 (44.99) 9325 (47.93) N/A
≥36 2780 (24.46) 1177 (19.83) 297 (13.78) 4254 (21.86) N/A
Race (nonwhitec; n=13,446), n (%) 5363 (47.18) N/A 1672 (80.42) 7035 (52.32) <.001
Monthly incomed(n=18,660), n (%) N/A N/A N/A N/A <.001
Low 5136 (45.18) 1544 (28.79) 710 (36.79) 7390 (39.60) —
Middle 4700 (41.35) 2400 (44.75) 948 (49.12) 7087 (37.98) N/A
High 1531 (13.47) 1419 (26.46) 272 (14.09) 4183 (22.42) N/A
Schooling (≤ secondary education; n=19,300), n (%) 4378 (38.86) 1395 (23.60) 461 (21.69) 6234 (32.30) <.001
Sexual attraction (n=19,401), n (%) N/A N/A N/A N/A <.001
Men 10,386 (91.54) 5212 (88.14) 1708 (79.74) 17,306 (89.20) N/A
Women 152 (1.34) 54 (0.91) 67 (3.13) 273 (1.41) N/A
Men/women 808 (7.12) 647 (10.94) 367 (17.13) 1822 (9.39) N/A
Steady partner (yes; n=19,294), n (%) 2916 (25.83) 1576 (26.77) 607 (28.67) 5099 (26.43) .02
Recruitment (n=19,457), n (%) N/A N/A N/A N/A <.001
Grindr 7623 (67.06) 4801 (80.91) 925 (42.90) 13,349 (68.61) N/A
Hornet 2489 (21.90) 569 (9.59) 20 (0.93) 3078 (15.82) N/A
Facebook 780 (6.86) 230 (3.88) 1037 (48.10) 2047 (10.52) N/A
Other 475 (4.18) 334 (5.63) 174 (8.07) 983 (5.05) N/A
Use of apps for sexual encounters (n=19,454), n (%) N/A N/A N/A N/A <.001
Never 835 (7.35) 432 (7.28) 414 (19.20) 1681 (8.64) N/A
Sometimes 4387 (38.60) 3336 (56.22) 1033 (47.91) 8756 (45.01) N/A
Daily 6142 (54.05) 2166 (36.50) 709 (32.88) 9017 (46.35) N/A
Last HIV testing (n=19,352), n (%) N/A N/A N/A N/A <.001
Previous 3 months 3516 (31.12) 1428 (21.15) 551 (25.74) 5495 (28.39) N/A
Previous 12 months 1835 (16.24) 843 (14.26) 277 (12.94) 2955 (15.27) N/A
More than 12 months 1972 (17.45) 1259 (21.29) 468 (21.86) 3699 (19.11) N/A
Never 1986 (17.58) 1352 (22.86) 524 (24.47) 3862 (19.96) N/A
HIV risk perceptione(n=18,959), n (%) N/A N/A N/A N/A <.001
Low 7746 (70.22) 3341 (57.41) 1218 (57.78) 12,305 (64.90) N/A
High 986 (8.94) 634 (10.89) 238 (11.29) 1858 (9.80) N/A
Preliminary eligibility for PrEPf (n=19,419), n (%) 7938 (70.03) 3668 (61.85) 1504 (69.82) 13,110 (67.51) <.001
Number of male sexual partnersg(n=19,376), n (%) N/A N/A N/A N/A <.001
None 873 (7.68) 1401 (23.82) 345 (16.2) 2619 (13.52) N/A
1-5 6036 (53.11) 2872 (48.84) 1145 (53.78) 10,053 (51.88) N/A
6-10 1958 (17.23) 821 (13.96) 290 (13.62) 3069 (15.84) N/A
>10 2499 (21.99) 787 (13.38) 349 (16.39) 3635 (18.76) N/A
Condomless receptive anal sexg (yes; n=19,326), n (%) 4433 (39.34) 2368 (40.04) 954 (44.48) 7755 (40.13) <.001
Condomless insertive anal sexg (yes; n=19,322), n (%) 5106 (45.31) 2511 (42.45) 960 (44.90) 8577 (44.39) <.001
Sex with HIV+ male partnerg (yes; n=19,270), n (%) 1217 (10.82) 712 (12.08) 269 (12.64) 2198 (11.41) .002
Sex with unknown HIV status male partnerg (yes; n=19,133), n (%) 3911 (35.27) 2956 (49.98) 1108 (52.02) 7975 (41.68) <.001
Sex under alcohol useg (yes; n=19,414), n (%) 4190 (36.97) 2089 (35.23) 778 (36.15) 7057 (36.35) .08
Chemsexg (yes; n=19,401), n (%) 1993 (17.60) 948 (16.00) 243 (11.29) 3184 (16.41) <.001
Transactional sexg (yes; n=19,456), n (%) 616 (5.42) 271 (4.57) 155 (7.19) 1042 (5.36) <.001
STI diagnosesfg,h (yes; n=18,875), n (%) 1476 (13.25) 372 (6.52) 197 (9.70) 2045 (10.83) <.001
PEPi awareness (yes; n=19,457), n (%) 7510 (66.07) 3269 (55.09) 778 (36.09) 11,557 (59.40) <.001
PEP use (yes; n=19,393), n (%) 1452 (12.82) 310 (5.24) 81 (3.76) 1843 (9.50) <.001
Binge drinkingg (yes; n=19,390), n (%) 7774 (68.39) 4094 (69.43) 1518 (71.40) 13,386 (69.04) <.001
Substance useg(n=18,906), n (%) N/A N/A N/A N/A N/A
Tobacco 2905 (25.56) 1981 (35.87) 539 (26.72) 5425 (28.69) <.001
Marijuana or hash 2907 (25.57) 1369 (24.79) 471 (23.35) 4747 (25.11) .09
Stimulantsj 1622 (14.27) 545 (9.87) 130 (6.45) 2297 (12.15) <.001
Hallucinogensk 994 (8.74) 248 (4.49) 28 (1.39) 1270 (6.72) <.001
Poppers 735 (6.47) 1233 (22.33) 195 (9.67) 2163 (11.44) <.001
Erectile dysfunction drugg 1054 (9.27) 605 (10.96) 90 (4.46) 1749 (9.25) <.001
aChi-square test.
bN/A: not applicable.
cBlack, Asian, Native American, and Mix race; this question was not available for Mexican respondents.
dFor Brazil, we considered the number of minimum wages in the family monthly income: low ≤3, middle 4-10, high >10 (monthly minimum wage in 2018 was 954 BRL=US $250, currency from June 2018). For Peru, we considered individual monthly income, categorized by number of minimum salaries: low ≤3, middle 4-10, high >10 (monthly minimum wage in 2018 was 850 PEN=US $265). For Mexico, we considered individual monthly income, categorized by number of minimum salaries: low: from no income to <3, middle 3-4, high ≥ 5 (monthly minimum wage in 2018 was 2686 MXN=US $141).
eIn the next year.
fAdapted from the WHO criteria for pre-exposure prophylaxis, which included the following: unprotected anal sex with a male or trans partner, sex with an HIV-positive partner, sex work, or STI diagnosis; all in the past 6 months.
gDuring the previous 6 months.
hSyphilis, gonorrhea, or rectal chlamydia.
iPEP: postexposure prophylaxis.
jCocaine, crack, ecstasy, and GHB (4-hydroxybutanoic acid).
kSolvents, lysergic acid diethylamide, and ketamine.
Table 2. Awareness, willingness to use, barriers, and facilitators to daily oral pre-exposure prophylaxis in Brazil, Mexico, and Peru (2018).
Variables Brazil
58.42%),
n (%) Mexico
(N=5934;
n (%) Peru
n (%) Total
(N=19,457),
n (%) P valuea
PrEPb awareness (yes; n=19,396c) 7794 (68.82) 3796 (64.11) 1002 (46.60) 12,592 (64.92) <.001
Willingness to use PrEP (yes) 7099 (62.45) 4158 (70.07) 1241 (57.56) 12,498 (64.23) <.001
PrEP use (n=19,425) <.001
Never 10,875 (95.67) 5735 (96.97) 2075 (96.78) 18,685 (96.19) N/Ad
Current 266 (2.34) 87 (1.47) 42 (1.96) 395 (2.03) N/A
Past 226 (1.99) 92 (1.56) 27 (1.26) 345 (1.78) N/A
Anticipated risk compensation (yes) 2325 (20.45) 1380 (23.26) 543 (25.19) 4248 (21.83) <.001
PrEP if part of Ministry of Health program (yes) 5814 (51.15) 4113 (69.31) 1165 (54.04) 11,092 (57.01) <.001
Preferred PrEP regimen <.001
Daily oral 3802 (33.45) 2260 (37.92) 719 (33.35) 6771 (34.80) N/A
Event-driven 2494 (21.94) 1491 (25.13) 553 (25.65) 4538 (23.32) N/A
Injectable 5071 (44.61) 2193 (36.96) 884 (41.00) 8148 (41.88) N/A
Barriers to daily oral PrEPe N/A
Afraid of short-term side effects 6805 (59.87) 4126 (69.53) 1614 (74.86) 12,545 (64.48) <.001
Afraid of long-term side effects 7601 (66.87) 4601 (77.54) 1721 (79.82) 13,923 (71.56) <.001
Afraid that antiretroviral therapy would not work if infected 6522 (57.38) 5031 (84.78) 1810 (83.95) 13,363 (68.68) <.001
Afraid of not being 100% protected against HIV 7831 (68.89) 4900 (82.57) 1794 (83.21) 14,525 (74.65) <.001
Taking pills everyday 5774 (50.80) 2497 (42.08) 1049 (48.65) 9320 (47.90) <.001
Talking to a doctor about sex life 2670 (23.49) 1897 (31.97) 886 (41.09) 5453 (28.03) <.001
Having HIV/ sexually transmitted infection testing every 3 months 5025 (44.21) 2615 (44.07) 1120 (51.95) 8760 (45.02) <.001
Taking PrEP means that I am at risk of HIV infection 4540 (39.94) 3339 (56.27) 1203 (55.80) 9082 (46.68) <.001
My partners may expect condomless anal sex 4310 (37.92) 3584 (60.40) 1190 (55.19) 9084 (46.69) <.001
Afraid that people may think I am HIV+ 4303 (37.86) 1966 (33.13) 950 (44.06) 7219 (37.10) <.001
Afraid that people ask me why I am using PrEP when they see me taking the pills 3709 (32.63) 1663 (28.02) 880 (40.82) 6252 (32.13) <.001
Facilitators to daily oral PrEPf N/A
Free PrEP 8797 (77.39) 4317 (72.75) 1474 (68.37) 14,588 (74.98) <.001
Access to free HIV test 8573 (75.42) 4554 (76.74) 1567 (72.68) 14,694 (75.52) .001
Access to other free exams 8052 (70.84) 4285 (72.21) 1499 (69.53) 13,836 (71.11) .04
Access to personal PrEP counseling 7103 (62.49) 4129 (69.58) 1444 (66.98) 12,676 (65.15) <.001
Support from apps or messages 5464 (48.07) 2880 (48.53) 1160 (53.80) 9504 (48.85) <.001
Support and counseling about my sex life 4272 (37.58) 3138 (52.88) 1175 (54.50) 8585 (44.12) <.001
bPrEP: pre-exposure prophylaxis.
cThe full sample, N=19,457, is included unless otherwise specified.
dN/A: not applicable.
eBarriers were grouped into PrEP information, beliefs, and behaviors. The percent shown is of participants responding that the barrier was important or very important.
fThe percent shown is of participants responding that the facilitator was very important.
Figure 2. Willingness to use daily oral pre-exposure prophylaxis per region. Brazil, Mexico and Peru, 2018. Percentage of willingness to use daily oral prep is given per region; n is total number of participants per region or country.
The proportion of individuals willing to use PrEP by characteristics and country are provided in the Multimedia Appendix 1. There were geographic differences in willingness to use PrEP (see Figure 2). In Brazil, willingness to use PrEP varied across the country, being higher in Rio de Janeiro (66.77%, 1061/1589) and São Paulo (63.20%, 2021/3198; P<.001). In Mexico, it was higher in the West (73.39%, 480/654) and Central-South (71.50%, 1872/2618), but lower in Central-North (64.58%, 310/480; P=.002). There was no statistically significant difference by region in Peru (P=.09).
In each country's final multivariable model, PrEP awareness and PrEP facilitators were positively associated, whereas behavioral and belief barriers were negatively associated with willingness to use PrEP. HIV risk perception was positively associated with willingness to use PrEP in Brazil and Peru, whereas daily use of apps for sexual encounters was positively associated only in Mexico and Peru. HIV testing at least once in a lifetime was positively associated with willingness to use PrEP only in Brazil. Mexico was the only country where age was significantly associated with willingness to use PrEP, with the older age categories (25+ years) reporting significantly less willingness compared with the youngest category (18-24 years). Informational barriers were negatively associated in Brazil but positively associated with willingness to use PrEP in Peru (Table 3).
Table 3. Factors associated with willingness to use daily oral pre-exposure prophylaxis in Brazil, Mexico, and Peru (2018).
Variable Variable Brazil Mexico Peru
Bivariate models, ORa (95% CI) Multivariate model, AORb (95% CI)c Bivariate models, OR (95% CI) Multivariate model, AOR (95% CI)c Bivariate models, OR (95% CI) Multivariate model, AOR (95% CI)c
18-24 Ref.d Ref. Ref. Ref. Ref. Ref.
25-35 1.11 (1.02-1.21) 0.95 (0.86-1.06) 1.06 (0.93-1.21) 0.84 (0.71-0.98) 1.32 (1.10-1.59) 1.06 (0.85-1.34)
≥36 1.13 (1.01-1.25) 0.97 (0.86-1.10) 0.95 (0.81-1.11) 0.81 (0.66-0.99) 1.47 (1.13-1.93) 1.36 (0.97-1.90)
Color (nonwhitee vs white) 0.95 (0.88-1.02) 1.01 (0.93-1.10) N/Af N/A 0.88 (0.70-1.09) —g
Monthly incomeh
Low Ref. Ref. Ref. Ref. Ref. Ref.
Middle 1.20 (1.11-1.31) 1.08 (0.99-1.19) 1.05 (0.90-1.23) 0.99 (0.84-1.18) 1.37 (1.12-1.66) 1.28 (1.02-1.63)
High 1.31 (1.16-1.47) 1.27 (1.10-1.46) 1.11 (0.96-1.28) 0.92 (0.78-1.11) 1.51 (1.14-2.01) 1.20 (0.84-1.71)
Schooling (any postsecondary education vs ≤ secondary education) 1.15 (1.07-1.25) 0.99 (0.90-1.08) 1.24 (1.09-1.41) 1.07 (0.92-1.26) 1.19 (0.96-1.46) 0.86 (0.66-1.12)
Steady partner (yes vs no) 1.06 (0.97-1.16) — 1.14 (1.01-1.30) — 1.05 (0.87-1.27) —
HIV testing (at least once lifetime vs never) 1.48 (1.34-1.63) 1.12 (1.00-1.25) 1.42 (1.25-1.61) — 1.36 (1.12-1.66) —
Use of apps for sexual encounters
Never Ref. — Ref. Ref. Ref. Ref.
Sometimes 1.06 (0.91-1.23) — 1.38 (1.13-1.70) 1.15 (0.90-1.47) 1.32 (1.05-1.66) 1.18 (0.91-1.53)
Daily 1.39 (1.20-1.62) — 1.84 (1.48-2.28) 1.34 (1.04-1.73) 1.65 (1.29-2.11) 1.34 (1.01-1.78)
HIV risk perceptioni
Low Ref. Ref. Ref. — Ref. Ref.
Middle 1.38 (1.26-1.53) 1.18 (1.06-1.31) 1.34 (1.18-1.51) — 1.34 (1.11-1.63) 1.32 (1.06-1.63)
High 1.99 (1.71-2.31) 1.53 (1.30-1.80) 1.75 (1.43-2.14) — 1.83 (1.36-2.46) 1.58 (1.14-2.19)
Preliminary eligibility for PrEPj (yes vs no) 1.62 (1.50-1.76) 1.33 (1.22-1.46) 1.47 (1.32-1.65) 1.29 (1.13-1.47) 1.20 (1.00-1.44) —
Number of male sexual partnersk (>5 vs ≤5) 1.55 (1.44-1.68) 1.19 (1.09-1.30) 1.60 (1.40-1.83) 1.18 (1.01-1.38) 1.42 (1.17-1.71) —
Sex under alcohol usek (yes vs no) 1.16 (1.07-1.26) — 1.17 (1.03-1.33) — 1.08 (0.89-1.30) —
Chemsexk (yes vs no) 1.24 (1.12-1.38) — 1.48 (1.25-1.76) — 1.44 (1.09-1.92) —
PrEP awareness (yes vs no) 1.98 (1.82-2.14) 1.66 (1.52-1.81) 2.37 (2.11-2.66) 2.05 (1.79-2.34) 2.03 (1.70-2.42) 1.84 (1.51-2.26)
Anticipated risk compensation (yes vs no) 1.48 (1.34-1.63) 1.32 (1.18-1.47) 1.37 (1.19-1.57) 1.37 (1.17-1.59) 1.24 (1.02-1.52) —
Barriers: Information, mean (SD) 0.94 (0.93-0.95) 0.95 (0.94-0.97) 0.97 (0.96-0.99) — 1.03 (1.01-1.06) 1.05 (1.01-1.08)
Barriers: Behaviors, mean (SD) 0.93 (0.92-0.94) 0.95 (0.94-0.96) 0.92 (0.90-0.93) 0.94 (0.92-0.95) 0.95 (0.93-0.97) 0.95 (0.92-0.98)
Barriers: Believes, mean (SD) 0.95 (0.94-0.95) 0.97 (0.96-0.98) 0.93 (0.91-0.94) 0.95 (0.93-0.97) 0.95 (0.93-0.97) 0.95 (0.92-0.97)
Facilitators, mean (SD) 1.07 (1.06-1.08) 1.09 (1.08-1.10) 1.07 (1.05-1.08) 1.11 (1.09-1.12) 1.07 (1.05-1.09) 1.11 (1.08-1.14)
aOR: odds ratio.
bAOR: adjusted odds ratio.
cVariables with P<.01 in bivariate models were included in the initial multivariable model. Variables with P<.05 were kept in the final multivariable models, excepted for age, monthly income, and schooling defined a priori for all countries, and race only for Brazil; statistically significant associations at P<.05 in italics. Region did not remain in the final multivariate models and bivariate analysis is not shown.
dRef.: reference.
eBlack, Asian, Native American, or Mix race.
fN/A: not applicable.
gNot statistically significant.
hFor Brazil, we considered the number of minimum wages in the family monthly income: low ≤3, middle 4-10, high >10 (monthly minimum wage in 2018 was 954 BRL=US $250, currency from June 2018). For Peru, we considered individual monthly income, categorized by number of minimum salaries: low ≤3, middle 4-10, high >10 (monthly minimum wage in 2018 was 850 PEN=US $265). For Mexico, we considered individual monthly income, categorized by number of minimum salaries: low, from no income to <3, middle 3-4, high ≥ 5 (monthly minimum wage in 2018 was 2686 MXN=US $141).
iIn the next 12 months.
jAdapted from the WHO criteria for pre-exposure prophylaxis, which included the following: unprotected anal sex with a male or trans partner, sex with an HIV-positive partner, sex work, or STI diagnosis; all in the past 6 months.
kDuring the previous 6 months.
This study shows that MSM from Brazil, Mexico, and Peru are willing to use daily oral PrEP. Willingness to use PrEP was higher in Mexico, followed by Brazil and then Peru. There were similarities in the factors associated with willingness to use PrEP across the 3 countries, and the most important factor was PrEP awareness. It is likely that as PrEP awareness increases in these settings, willingness to use PrEP will also increase. This trend was observed in Brazil [20,21] and in a recent meta-analysis evaluating the factors associated with willingness to use PrEP in low- and middle-income settings [17].
In our models, younger age was significantly associated with willingness to use PrEP in Mexico but not in Brazil and Peru. This is a concern as younger MSM are at high risk of HIV acquisition in Latin America [28] and are experiencing an increase in HIV cases in Brazil [7], Mexico [29], and Peru [30]. The association of income with willingness was different by country; higher income was associated with willingness in Peru and Brazil, whereas there was no association in Mexico. To improve equity in PrEP access, interventions to increase knowledge of PrEP among lower-income and young MSM are essential, and this could be achieved with community-based educators and Web-based advertisements, as internet access is becoming more available in Latin America [31]. Nevertheless, this finding should be interpreted with caution as respondents with lower income may associate their willingness to use PrEP with accessibility to PrEP free of charge within the public health system. Of note, more Mexican MSM reported interest in PrEP as part of a MoH program (free of charge) than Brazilians or Peruvians. In addition, almost 75% of the entire sample thought that PrEP at no cost is very important or important.
Our regression models captured that informational barriers were significantly associated with willingness to use PrEP in Peru. This unexpected result is likely owing to the limited available information, reflected by the low observed PrEP awareness. In all 3 countries, higher HIV risk perception and higher risky sexual behavior were associated with willingness to use PrEP, reflecting that the individuals to whom PrEP is targeted are those willing to use it. This is corroborated by other studies accessing willingness to use PrEP [21,22,32]. Anticipated risk compensation (the possibility of not using condoms while on PrEP) was associated with willingness in Brazil and Mexico but not in Peru. Risk compensation is a recurrent concern related to PrEP, and evidence of this was recently observed in other studies [33,34]; conversely, there was no statistically significant increase in condomless receptive anal sex during the PrEP Brazil study [35] or in a study conducted in Thailand [36]. Risk compensation continues to require monitoring and adequate PrEP education.
Notably in Brazil and Peru, the majority of participants would prefer injectable PrEP, and for Mexico, it was the second preferred regimen, just slightly below daily oral PrEP. Event-driven PrEP was third in all 3 countries. Injectable PrEP regimens, currently under study, may be useful and acceptable for MSM who have shown low adherence for oral PrEP regimens. As new PrEP technologies become available, it will be important to continue providing education and collecting information on preferences.
The samples included from each country were distinct; most likely, this was related to the recruitment methods. The fact that a higher proportion of lower-income MSM was included in Brazil could be explained by the increase of internet access in this country, where it is estimated 1 smartphone per person [31]. As expected, most of respondents are from each country's urban large regions where more MSM are concentrated, as well as where access to internet is easier. Brazilian MSM reported more male sexual partners than Mexican and Peruvians but lower rates of steady partner and condomless receptive anal sex. In a recent, large sample of MSM in Brazil, having more sex partners was associated with condomless receptive anal sex among MSM aged ≥25 years but not among those aged 18 to 24 years [37]. The higher proportions of STI diagnoses and PEP use in Brazil could be explained by the higher availability and access to exams and PEP free of charge in this country, especially in the Southeast region where most respondents live. Peruvian MSM reported more condomless receptive anal sex, transactional sex, binge drinking, and more had never tested for HIV than in the other countries.
Some study limitations should be considered. First, Web-based studies are not probabilistic sampling strategies, precluding the generalization of the findings. Given the cross-sectional nature of the data, causality and the direction of association may not be inferred. All collected data were self-reported by participants and may be subject to bias. Our data are subject to recall bias owing to 6-month or 12-month recall periods. There is also a concern about participants taking the survey multiple times. To mitigate this bias, the first question of the survey was as follows: Are you answering this survey for the first time? (3.3% of participants answered no and were excluded from the study). Finally, we have no ability to assess the veracity of respondents truly being MSM; the analysis included self-identified MSM independent of their sexually activity in the previous 6 months or their self-identified sexual attraction. There were respondents who reported being sexually attracted only to women–though importantly, among this group, 45.8% (125/273) reported having sex with a man in the past 6 months. We believe the population of interest were reached by and responded to this survey.
In this first cross-country, Web-based survey in Latin America willingness to use PrEP was found to be high and directly related to levels of awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand among MSM at high risk who can benefit from this prevention technology. Social media campaigns and campaigns in STI clinics may be valuable to achieve this goal. This study presents important information to support the implementation of PrEP for MSM in Brazil, Mexico, and Peru.
This project was made possible, thanks to Unitaid's funding and support. Unitaid accelerates access to innovative health products and lays the foundations for their scale-up by countries and partners. Unitaid is a hosted partnership of the WHO. We would like to thank the MoH of Brazil, Mexico, and Peru.
TST, KAK, and EHVR did the literature search and developed the survey. TST, KAK, EHVR, and OAE analyzed the data and generated the tables and figures. TST, KAK, and EHVR interpreted the data. TST, KAK, EHVR, and DDS drafted the manuscript. BH, SD, CP, MB, HLG, RRG, BG, CC, and VGV revised the manuscript and contributed intellectually.
Proportion of individuals willing to use pre-exposure prophylaxis by characteristics and country.
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FTC/TDF: emtricitabine/tenofovir
ImPrEP: implementation PrEP
MoH: Ministry of Health
MSM: men who have sex with men
PEP: postexposure prophylaxis
PrEP: pre-exposure prophylaxis
STI: sexually transmitted infection
Edited by G Eysenbach; submitted 21.02.19; peer-reviewed by G Ravasi, A Nunn, S Yi, B Castonguay; comments to author 20.03.19; revised version received 15.05.19; accepted 16.05.19; published 17.06.19
©Thiago Silva Torres, Kelika A Konda, E Hamid Vega-Ramirez, Oliver A Elorreaga, Dulce Diaz-Sosa, Brenda Hoagland, Steven Diaz, Cristina Pimenta, Marcos Benedetti, Hugo Lopez-Gatell, Rebeca Robles-Garcia, Beatriz Grinsztejn, Carlos Caceres, Valdilea G Veloso, ImPrEP Study Group. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 17.06.2019.
Torres TS, Konda KA, Vega-Ramirez EH, Elorreaga OA, Diaz-Sosa D, Hoagland B, Diaz S, Pimenta C, Benedetti M, Lopez-Gatell H, Robles-Garcia R, Grinsztejn B, Caceres C, Veloso VG, ImPrEP Study Group