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Using structural equation modelling to characterise multilevel socioecological predictors and mediators of condom use among transgender women and cisgender men who have sex with men in the Philippines
  1. Arjee Restar1,2,
  2. Adedotun Ogunbajo1,
  3. Alexander Adia1,2,
  4. Jennifer Nazareno1,2,
  5. Laufred Hernandez3,
  6. Theo Sandfort4,
  7. Mark Lurie5,
  8. Susan Cu-Uvin1,2,
  9. Don Operario1,2
  1. 1Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA
  2. 2The Philippine Health Initiative for Research, Service, and Training, Brown University School of Public Health, Providence, Rhode Island, USA
  3. 3Department of Behavioral Sciences, University of the Philippines Manila, Manila, Metro Manila, Philippines
  4. 4HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, New York, New York, USA
  5. 5Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
  1. Correspondence to Dr Arjee Restar; arjee_restar{at}


Background Risks for condomless sex among transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM, respectively) in the Philippines, where HIV recently became a national public health crisis, are shaped and exacerbated by various risk factors across multiple levels.

Methods Between June 2018 and August 2019, we conducted a cross-sectional online study with 318 trans-WSM and cis-MSM respondents from Manila and Cebu cities. Structural equational modelling procedures were performed to determine direct, indirect and overall effects between condom use and latent variables across multiple socioecological levels: personal (ie, condom self-efficacy), social (ie, social capital), environmental (ie, barriers to condom and HIV services) and structural (ie, structural violence, antidiscrimination policies).

Results Adjusted for gender, age, location and income, our model showed that: (1) all latent variables at the structural and environmental levels were significantly positively associated with each other (all ps<0.05); (2) barriers to condom and HIV services were significantly negatively associated with social capital (p<0.001) as well as condom self-efficacy (p<0.001); and (3) there were significantly positive associations between social capital and condom self-efficacy (p<0.001), and between condom self-efficacy and condom use (p<0.001). Moreover, social capital and condom self-efficacy fully mediated and buffered the negative effects between environmental and structural barriers and condom use.

Conclusion This is the first known study pointing to multiple relationships and pathways across multiple socioecological levels that can potentially be leveraged for future interventions aimed at improving condom use among Filipinx trans-WSM and cis-MSM. Such interventions should be multicomponent and build and/or strengthen social capital and condom self-efficacy, as well as intentionally target prominent structural and environmental barriers to condom use.

  • HIV
  • cross-sectional survey
  • epidemiology
  • prevention strategies
  • public health

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  • Handling editor Seye Abimbola

  • Contributors All authors were involved in the conceptualisation of this paper. AR, TS, ML, SC-U and DO designed the analysis for this paper and analysed the data. AR conducted the data analysis and wrote the paper. All authors reviewed the paper.

  • Funding This work was supported by the National Institute of Health-Fogarty International Centre under Grant D43TW010565; Providence/Boston Centre for AIDS Research under Grant P30AI042853; the National Institute on Drug Abuse under Grant R36DA048682. AR is a recipient of the Robert Wood Johnson Foundation Health Policy Research Scholars and a Public Policy Fellow at amFAR, the Foundation for AIDS Research. AO’s contribution is supported by the National Institute on Drug Abuse under Grant R36DA047216. TS’s contribution is supported by NIMH Centre under Grant P30MH43520.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Brown University Human Research Protection Programme Institutional Review Committee in Providence, Rhode Island) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Data cannot be shared publicly per IRB agreement on data sharing and to minimise participant risk and maximise privacy and confidentiality as much as possible. Data are available from the Brown University Institutional Data Access/Ethics Committee (contact via for researchers who meet the criteria for access to confidential data.

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