Off but it bled a lot so I covered it with cotton. (Focus group with transgender sex workers) These solutions were recognized as only temporary and implicating a risk of infection. One transgendered participant mentioned that she sometimes helped a friend to remove GW with these methods: I had a younger [female] friend… I cut it off with small scissors… [one GW] was stuck in her anus. (Focus group with transgender sex workers) Two interviewees affected by GW looked for medical support soon after noting they had GW. Others looked for medical help after having attempted self-management/medication, and, later, after their GW grew, spread or became a serious problem: Some little warts appeared on my backside and I was a little bit embarrassed to have them checked out, and they grew a lot, and then when they bothered me, I told a friend and [he or she] said to go to a hospital. (Gay man) In all cases, access to medical Procyanidin B1 web treatment was mediated by friends and health promoters: I only used a cream from the pharmacy initially, and then nothing happened. Then from there one day I talked to a friend who worked as a health promoter. She was the one who took me to [the health center]. (Transgender sex worker) One participant mentioned that he found help only after three unsuccessful attempts at health care establishments where the medical personnel didn’t know how to manage GW or didn’t have the instruments for cauterization: There is no medical specialist for that… two physicians told me `men do not get papilloma’ [In another health center the doctor] gave me a prescription for treatment, a cream, but I couldn’t find it and was very expensive… it did not exist in the pharmacies. [Afterwards,] I talked to a friend that is also a doctor, and he said `those are genital warts’ and he wanted to cauterize them but did not have the equipment. (Gay sex worker) Some focus group participants, mainly transgenders, discussed cases of friends who had GW but didn’t seek treatment, which they attributed to “shame”: I asked [my friend] `Hey, what do you have there?’ And she didn’t even know because [she is] young, 19 years old. I toldPLOS ONE | www.plosone.orgHPV and Genital Warts in Peruvian MSM: Experiencesto her that she had to be checked out, but I don’t know, even now she doesn’t pay attention to me, she hasn’t gone to get checked out… I think is because of embarrassment. (Transgender sex worker)Avermectin B1a biological activity DiscussionThis study is the first in-depth, qualitative assessment on HPVrelated GW in South American MSM and transgendered women. We found that while participants were unfamiliar with HPV, experiences with GW were relatively common. Most participants did not differentiate between GW and other health problems affecting the anogenital zone, and two participants recognized that lesions associated with GW could represent an increased HIV risk. GW profoundly affected the emotional, social and sexual lives of those who had them, including the ability to find competent medical care. Our data show how misinformation and GW-related stigma synergize to produce social rejection toward those who have GW, and limit their search for treatment. A particular concern arises among self-treatment of GW which could result in anogential wounds or infection, which in turn could exacerbate the risk for HIV infection. Our study results support findings from previous work showing the limited HPV knowledge among men and women from several countries [25?7], including MSM from the U.Off but it bled a lot so I covered it with cotton. (Focus group with transgender sex workers) These solutions were recognized as only temporary and implicating a risk of infection. One transgendered participant mentioned that she sometimes helped a friend to remove GW with these methods: I had a younger [female] friend… I cut it off with small scissors… [one GW] was stuck in her anus. (Focus group with transgender sex workers) Two interviewees affected by GW looked for medical support soon after noting they had GW. Others looked for medical help after having attempted self-management/medication, and, later, after their GW grew, spread or became a serious problem: Some little warts appeared on my backside and I was a little bit embarrassed to have them checked out, and they grew a lot, and then when they bothered me, I told a friend and [he or she] said to go to a hospital. (Gay man) In all cases, access to medical treatment was mediated by friends and health promoters: I only used a cream from the pharmacy initially, and then nothing happened. Then from there one day I talked to a friend who worked as a health promoter. She was the one who took me to [the health center]. (Transgender sex worker) One participant mentioned that he found help only after three unsuccessful attempts at health care establishments where the medical personnel didn’t know how to manage GW or didn’t have the instruments for cauterization: There is no medical specialist for that… two physicians told me `men do not get papilloma’ [In another health center the doctor] gave me a prescription for treatment, a cream, but I couldn’t find it and was very expensive… it did not exist in the pharmacies. [Afterwards,] I talked to a friend that is also a doctor, and he said `those are genital warts’ and he wanted to cauterize them but did not have the equipment. (Gay sex worker) Some focus group participants, mainly transgenders, discussed cases of friends who had GW but didn’t seek treatment, which they attributed to “shame”: I asked [my friend] `Hey, what do you have there?’ And she didn’t even know because [she is] young, 19 years old. I toldPLOS ONE | www.plosone.orgHPV and Genital Warts in Peruvian MSM: Experiencesto her that she had to be checked out, but I don’t know, even now she doesn’t pay attention to me, she hasn’t gone to get checked out… I think is because of embarrassment. (Transgender sex worker)DiscussionThis study is the first in-depth, qualitative assessment on HPVrelated GW in South American MSM and transgendered women. We found that while participants were unfamiliar with HPV, experiences with GW were relatively common. Most participants did not differentiate between GW and other health problems affecting the anogenital zone, and two participants recognized that lesions associated with GW could represent an increased HIV risk. GW profoundly affected the emotional, social and sexual lives of those who had them, including the ability to find competent medical care. Our data show how misinformation and GW-related stigma synergize to produce social rejection toward those who have GW, and limit their search for treatment. A particular concern arises among self-treatment of GW which could result in anogential wounds or infection, which in turn could exacerbate the risk for HIV infection. Our study results support findings from previous work showing the limited HPV knowledge among men and women from several countries [25?7], including MSM from the U.
