MSM and the HIV epidemic in low- and middle-income countries

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Chris Beyrer, MD, MPH, from Johns Hopkins University offered an elegant overview of the epidemiology of the HIV epidemic among men who have sex with men (MSM) in low- and middle-income countries during a symposium at the 18th Conference on Retroviruses and Opportunistic Infections on Monday entitled “Responding to Risk”. 

This meta-analysis looked at four scenarios. Scenario one involved countries with low rates of HIV infection overall where transmission between men who have sex with men was predominant.  The countries included in this scenario were primarily in South and Central America, with the inclusion of Ghana.  Scenario two were countries with epidemics dominated by MSM and injection drug users (IDUs) – Russia, countries in Eastern Europe and Central Asia.  Scenario 3 includes high prevalence countries with dominant generalized heterosexual epidemics and significant MSM epidemics.  Countries in this scenario included Namibia, Botswana, South Africa, Kenya, Tanzania, Malawi, Nigeria and Uganda.  In the context of this scenario, Beyrer noted that only in South Africa and Botswana do women have higher rates of HIV infection than their MSM counterparts.

Scenario four consisted of countries with a mix of transmission groups – MSM, IDU, heterosexuals – and included much of South Asia, Egypt and Senegal.  Ninety-four countries continue to have no data point for MSM.

Beyrer and colleagues surveyed MSM and transgender persons in a selection of countries across all four scenarios.  High-prevalence African countries included in the study included Malawi, Botswana and Namibia. Structural and social barriers to disclosure of sexual identity and to services were very significant.  Large numbers of MSM and transgender persons reported fear of disclosure and fear of seeking health care services.  Reports of being denied health care services and of being blackmailed by health care providers were relatively common. Men who received a recommendation from a health care provider to have an HIV test were significantly more likely to be blackmailed than men who did not.

Beyrer also reported about modeling studies evaluating the impact of providing three key interventions to MSM and transgender persons on the overall epidemic in selected countries.  The interventions highlighted were provision of condoms and lubricant, community-based prevention behavioral interventions, and increased access to antiretroviral therapy. The model projected out five years.  For example, in Kenya, the model projected 94,047 new HIV cases over the five-year period with 11,530 cases—12.3 percent—attributable to MSM.  Provision of these interventions to MSM in Kenya and elsewhere could have a significant positive impact on the overall epidemic.

Beyrer concluded his review by noting that exciting new efficacious prevention interventions for MSM are promising only “if we improve access and human rights.”

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