Definition of the Prevention Area
Globally, men who have sex with men (MSM) are disproportionately affected by HIV and urgently need increased coverage by quality prevention interventions. Evidence has shown that sustained combination approaches to HIV prevention that simultaneously address biomedical, behavioral and structural risks are most effective at reducing HIV transmission in generalized, concentrated, and mixed epidemic scenarios. Despite this evidence and the disproportionate epidemic burden that MSM shoulder, HIV prevention services remain sub-optimal in many countries.
Not all MSM have an identity associated with their sexual preferences and behavior; and those who do not self-identify as MSM pose a formidable challenge to programs that seek to reach them. For example, the term "MSM" can include gay- or bisexual-identified men, transgender men who have sex with men, men who identify as completely heterosexual, men who identify through indigenous identities outside the largely Western concepts of hetero- or homosexuality, or men with no particular sexual identity at all. In many cultures, heterosexism (the assumption that everyone is heterosexual) is pervasive, and any behavior or identity that deviates from a heterosexual cultural norm is stigmatized and discriminated against, and in some cases is criminalized.
Individual-level risks for HIV acquisition in MSM include unprotected receptive anal intercourse, a high frequency of male partners, a high number of lifetime male partners, injecting and non-injecting drug use, a high viral load in the index partner, and mental health issues. At the structural level, risks include criminalization of same-sex behavior, avoidance of health services out of fear of discrimination, and breaches of privacy and confidentiality. To succeed, HIV prevention interventions must take into account the complexities of MSM identity their multiple levels of risk. Combination approaches that simultaneously address behavioral, biomedical, and structural risks are an effective way to do this. At all levels, MSM individuals and communities must be involved in conceptualizing, planning, implementing, and evaluating research and programming.
Epidemiological Justification for the Prevention Area
Three decades into the epidemic, HIV continues to disproportionately affect MSM everywhere. Globally, MSM are 19 times more likely to be infected by HIV than the general population of reproductive age and have an overall HIV prevalence of 12 percent (http://www.amfar.org/uploadedFiles/_amfarorg/Articles/On_The_Hill/2013/K...(2).pdf). Many MSM also have female sexual partners and can function as a bridge, bringing HIV to other populations. Nevertheless, research and interventions focused at MSM are still under-prioritized by governments, donors, and civil society. Surveillance data, when available, is limited and likely underestimates both the size of the population of MSM and their HIV prevalence rates. Some estimates suggest that as few as 5 percent of MSM worldwide have access to basic HIV prevention services.
There is evidence to show that prevention interventions aimed to engage MSM can reduce risk for HIV infection among MSM. Group- and community-level behavioral interventions among MSM have been shown to lead to up to a 43 percent decrease in unprotected anal sex; and group-level interventions have been shown to increase the odds of condom use by as much as 81 percent. A recent study suggested that behavioral interventions that reach 25 percent or more of non-self-identified MSM are more effective than those targeting self-identified MSM alone. Another study suggested that countries that combine MSM-specific community-based behavioral prevention interventions with condom and condom-compatible lubricant distribution can reduce new HIV infections among both MSM and the general population. Evidence also shows that episodic and/or single-track interventions tend to be less effective in the long term, which highlights a need for sustained combination prevention approaches.
Core Programmatic Components
The World Health Organization (WHO), with other global agencies, has identified a set of evidence-informed, mutually reinforcing biomedical, behavioral, and structural HIV prevention intervention components which, when combined, effectively reduce HIV infection among MSM. The following are some examples of strongly-recommended program components:
- Biomedical approaches aim to reduce HIV transmission and acquisition risk. Current approaches that WHO strongly recommends include condom distribution with silicone- and water-based lubricants, combined with counseling and education, HIV testing services (HTS), sensitization of HTS sites to MSM needs, screening and treatment for sexually transmitted infection (STI) (for genital, oropharyngeal, and anorectal STIs), and antiretroviral therapy, including post-exposure prophylaxis. Though these are the current approaches, the combination prevention toolkit is growing as more research is done around pre-exposure oral prophylaxis (PrEP) and rectal microbicides.
- Structural prevention activities aim to bring about social change in the general population by reducing stigma and discrimination and other barriers to effective prevention and treatment of HIV. Decriminalization of same-sex behaviors, policies that safeguard MSM and transgender rights, engagement with the media, and community and health systems strengthening are all examples of viable program components. However, none of these can be effective unless communities are successfully mobilized, engaged, and empowered. Community members must be involved in a collaborative, iterative process. Moreover, evidence-informed advocacy is an important step towards achieving positive structural change.
- Behavioral approaches aim to promote safer behaviors to prevent HIV. Specifically, such approaches include sustained efforts to increase the use of condoms paired with water- and silicone-based lubricants; reduce the frequency of unprotected anal sex; and increase health-seeking behavior. Behavior change communication (BCC) can be delivered effectively at individual, group and community levels. BCC can include mobile phone messages, Internet-based strategies and social marketing campaigns, and other message delivery from diverse communication platforms, including sex venue "hot spots," health care facilities, and the general community.
Accurate estimates of the size of the MSM population are essential to the design of prevention interventions. This poses a significant challenge, since many MSM do not self-identify or choose not to disclose their sexuality. A number of methods, including the relatively new network scale-up method, have shown effectiveness for use with MSM. UNAIDS recommends making estimates by triangulating results from more than one method, and cautions researchers and programmers to interpret data with care, and to clearly acknowledge sampling method biases.
Current Status of Implementation Experience
Regardless of which combination of prevention approaches is used, a number of overarching best practices are recommended to improve the reach and quality of all MSM-focused HIV programs:
- Involve MSM and MSM living with HIV in program design, implementation, and evaluation. The most deep-reaching and successful approaches to prevention interventions leverage the community ties and experiences of MSM, their networks, an understanding of factors affecting HIV risk and their ability to connect meaningfully with other MSM.
- Ensure confidentiality. Given the high levels of stigma and discrimination that MSM face, confidentiality is a key requirement.
- Provide training for both general health care staff and staff who work in HIV prevention, care, and treatment programs, to help them provide high-quality, stigma-free services.
- Reach beyond MSM groups. Interventions that target general audiences in addition to MSM audiences have been shown to also reach diverse subgroups of MSM, including non-self-identified MSM.
- Collect and use strategic information such as ongoing surveillance, research studies, and monitoring and evaluation data, and incorporate new knowledge and technological advances as they emerge.
- Link, integrate and co-locate services, especially to HIV care and treatment for HIV-positive MSM. This is particularly important, as anti-retroviral therapy has been identified as a key component of successful HIV prevention.
Although many studies demonstrate the reproducibility of research and the effectiveness of behavioral interventions with MSM in the United States, far less information is available for program outcomes in other geographic areas, such as Africa and Asia, and among hard-to-reach subgroups of MSM. To inform future interventions, more investment must be made in conducting research in these other contexts and publishing findings widely.