Lancet Special Issue n HIV in Men wh have Sex with Men (MSM) July 2012 Summary Pints fr Plicy Makers Executive Summary The Lancet MSM and HIV series shw us that HIV epidemics amng MSM are fundamentally different frm ther grups at risk. These differences help explain why HIV epidemics amng MSM expanding in lw, middle, and high incme cuntries, including the U.S., and why current HIV preventin and treatment prgrams fr MSM are nt wrking as well as they shuld. Bilgical, netwrk, and scial/structural factrs cmbine fr MSM and lead t mre rapid and efficient HIV spread in MSM cmmunities individual risk behavirs fr HIV infectin cntribute nly mdestly t these dynamics. New and mre effective HIV preventin prgrams fr MSM must reduce infectiusness thrugh markedly expanding testing and treatment f psitive men, and reduce risk f acquisitin amng negative men, thrugh the use f PrEP, the develpment f a rectal micrbicide, and increased access t and cverage fr cndms and cndm-cmpatible lubricant. Current preventin tls culd reduce new HIV infectins in MSM substantially, but mre and better tls will be needed t achieve an AIDS free generatin fr yung MSM. Stigma, discriminatin, and scial and health care level hmphbia cntinue t limit access and uptake t essential services frm testing t treatment, and frm cndms t PrEP. Plicy refrm and structural changes will be key t expanding cverage and reaching men with culturally cmpetent care. These realities are mst clearly demnstrated amng minrity MSM in the U.S., where black MSM have much higher rates f HIV infectin then ther MSM, despite having lwer individual risks fr HIV. But black MSM als have lwer rates f testing, health care access, health insurance, and successful HIV treatment impacts seen at each step f the treatment cascade. Urgent refrm is needed, in appraches, prgrams and plicies, if we are t make real gains against HIV amng MSM. Future effrts must be mre bilgically based, fcus n delivery f effective interventins, address each gap in the testing t treatment cascade, and ensure safe and affirming spaces fr preventin, treatment, and care. Glbal epidemilgy f HIV infectin in men wh have sex with men Chris Beyrer et al. In 2012, HIV epidemics in MSM are expanding in cuntries f all incmes. Available incidence data frm Thai, Chinese and Kenyan samples f MSM suggest thse epidemics are in rapid expansin phases. HIV infectin rates amng MSM are substantially higher than thse f general ppulatin adult males in every epidemic assessed. A cmprehensive review f the burden f HIV disease in MSM wrldwide fund that pled HIV prevalence ranged frm a lw f 3% in the Middle East and Nrth Africa t a high f 25.4% f MSM in the Caribbean. Bilgical and behaviral factrs make the dynamics f the MSM epidemic different than fr general ppulatins. 1
The disprprtinate HIV disease burden in MSM is explained largely by the high peract and per-partner transmissin prbability f HIV transmissin in receptive anal sex. Mdeling suggests that If the transmissin prbably f receptive anal sex was similar t that assciated with unprtected vaginal sex, five year cumulative HIV incidence in MSM wuld be reduced by 80-90%. Many MSM practice bth insertive and receptive rles in sexual intercurse, which helps HIV spread in this ppulatin. Were MSM limited t ne rle, HIV incidence in this ppulatin ver five years wuld be reduced 19-55% in high-prevalence epidemics. Taking bth factrs (per act transmissin prbability and rle versatility) int accunt explains 98% f the difference between HIV epidemics amng MSM and hetersexual ppulatins behaviral differences accunt fr 2% f the difference. Cmprehensive clinical care fr men wh have sex with men: an integrated apprach Ken Mayer et al. Studies f the life experiences f MSM and ther sexual and gender minrities suggest that psychlgical distress and risk-taking behavir may result in part frm early childhd experiences such as physical and emtinal abuse by family, peers, and/r key cmmunity leaders (e.g. clergy). Several studies frm arund the wrld have shwn that MSM are mre likely t reprt substance use, depressin, vilent victimizatin, and childhd sexual abuse than their hetersexual peers. 2
The frequent c-ccurrence f these cnditins is assciated with increased rates f unprtected sex and enhanced vulnerability t HIV and ther STDs. Despite these develpmental challenges, mst MSM lead healthy and prductive lives. Research is needed t better understand hw many MSM in different cultures are resilient in the face f multiple stressrs, in rder t develp prgrams that can prmte adaptive respnses in sexual and gender minrity yuth. Health care prviders have a key rle t play in imprving the health f their MSM patients thrugh the prvisin f apprpriate screening and cunseling. They shuld ask sexual and gender minrity adlescents abut their md and behavir, screening fr depressin and substance abuse, and shuld make apprpriate referrals fr cunseling and ther supprt. Prviders need t assess sexual histries regularly in rder t determine when MSM clients shuld be screened fr sexually transmitted infectins. Prgrams t train health care prfessinals t prvide culturally cmpetent care t adlescent and adult MSM are urgently needed. Successes and challenges f preventin f HIV preventin in men wh have sex with men Patrick Sullivan et al. HIV preventin appraches t date have been insufficient t curb the HIV epidemics in MSM. Because f the high bilgical risks f HIV transmissin assciated with anal intercurse, the bar fr HIV preventin may be higher fr MSM. T date, n single HIV preventin apprach is sufficient t cntrl the expansin f HIV epidemics amng MSM. In mst parts f the wrld, restricted resurces and legal barriers cmplicate delivery f HIV preventin t MSM. Plicy changes t align resurces with the magnitude f HIV epidemics amng MSM, and t allw MSM t safely access medical care and preventin services, are urgently needed t create an enabling envirnment fr preventin, and an adequately resurced preventin respnse. Several behaviral interventins are smewhat efficacius in reductin f risk behavir amng MSM, but d nt effectively decrease the incidence f new HIV infectins. Behaviral interventins alne are necessary, but insufficient, t address HIV in MSM. Crdinated behaviral, bimedical and structural interventins that incrprate efficacius strategies culd substantially reduce the incidence f HIV in MSM if delivered at scale. Mdeling suggests that, with sufficient cverage, apprpriate packages f alreadyavailable interventins are sufficient t avert at least a quarter f new HIV infectins in MSM in diverse cuntries in the next decade. Despite the ptential f current preventin tls, we must cntinue t develp new preventin mdalities. Fr example, we need cntinued research int a rectal micrbicide, int the ptimizatin f ral PrEP, int an HIV vaccine, and int the efficacy f treatment as preventin fr HIV psitive MSM. 3
Making an impact in HIV epidemics amng MSM will require achieving adequate cverage f packages f preventin interventins. Accrding t ur data, it may be necessary t reach mre than half f at-risk MSM t have substantial impact. T achieve such cverage, plicy refrms, including decriminalizatin f male-male sex, are needed t create enabling envirnments in which men can safely access care and preventin services. Frm persnal survival t public health: cmmunity leadership by men wh have sex with men in the respnse t HIV Gift Trapence et al. HIV has disprprtinately affected gay men and ther MSM since the beginning f the pandemic, and in respnse they have made majr cntributins t the fight against AIDS thrugh advcacy, educatin, research, and design and delivery f preventin, treatment, and care prgrams. The recgnitin by gay men and ther MSM that prtecting persnal health requires cmmunitylevel actin has been catalytic in the respnse t AIDS wrldwide, and will cntinue t be essential. 4
T take maximum advantage f new HIV technlgies and grwing recgnitin f the MSM epidemic, cmmunities will require increased resurces, supprt t develp capacity, and expanded pprtunities t serve and lead. Men wh have sex with men: stigma and discriminatin Dennis Altman et al. Hmphbia is the prduct f deeply ingrained views n gender rles, religin and natinal identity, and must be addressed at a systemic and structural level. Legal equality is imprtant, but nt sufficient; it needs t be supprted by real effrts t build acceptance f human diversity. Arguments fr recgnitin f sexual and gender diversity are imprtant, but need t avid language that can be prtrayed as impsitin f Western mdels f individualism n ther cuntries. Smetimes public statements and aid cnditinality can be cunter-prductive. Exciting new pssibilities fr preventin are likely t be unavailable t many MSM, wh in many parts f the wrld are stigmatized, persecuted and ignred. Cmparisns f disparities and risks f HIV infectin in black and ther men wh have sex with men in Canada, UK, and USA: a meta-analysis Gregri Millett et al. A meta-analysis f 600,000 MSM t assess factrs assciated with disparities in HIV infectin in black MSM in Canada, the UK, and the USA fund that in every cuntry, black MSM were n mre likely than ther MSM t engage in ser-discrdant unprtected sex. Black MSM in Canada and the USA were less likely than ther MSM t have a histry f substance use. Despite being less risky, Black MSM in the UK and the USA were mre likely t be HIV psitive than were ther MSM. This paradx is partly explained by the finding that HIV-psitive black MSM in each cuntry were less likely t start HIV treatment than men f ther races and ethnicities. U.S. HIV-psitive black MSM were als less likely t have health insurance, have a high CD4 cunt, adhere t anti-retrviral treatment, r be virally suppressed than were ther US HIV-psitive MSM. These lw rates f successful treatment fr black MSM are driving new HIV infectins in black MSM netwrks and cmmunities. The meta-analysis fund that yung black MSM in the U.S. were five times mre likely t be HIV psitive cmpared with ther MSM despite engaging in similar risk behavirs. The data shwed that high rates f HIV infectin amng U.S. yung black MSM is due t an earlier sexual debut, a histry f childhd sexual abuse, lder age sex partners, and a lw incme. These results prvide evidence that the greatest HIV-related disparities in US black MSM relative t ther MSM are disparities in HIV clinical care access and use, structural issues (including lw incme, unemplyment, incarceratin, lw educatin), and sex partner characteristics, and the smallest disparities were in sexual and substance-use risk behavirs. 5
Interventins that supprt early initiatin f antiretrviral therapy, adherence, and clinical visits fr HIV psitive black MSM might have a greater effect in the reductin f HIV infectin rates than d thse that fcus n individual sexual r drug use risks. Physicians have a rle in addressing racial disparities in HIV infectin by prviding regular HIV testing t and ART access fr black MSM. Prviders must diagnse and suppress the viral lad f as many lder MSM as pssible t stem increasing rates f new infectins in yung black MSM. Repeat STI testing and treatment f STIs in black MSM shuld be a pririty fr prviders in the USA and the UK. Cmmn rts: a cntextual review f HIV epidemics in black men wh have sex with men acrss the African diaspra Gregri Millett et al. Black MSM are at greater risk fr HIV infectin than are general ppulatins acrss much f the African diaspra. Black MSM wrldwide are 15 times mre likely t be HIV psitive cmpared with the general ppulatins and 8.5 times mre likely cmpared with black ppulatins. Plicies that criminalize hmsexuality, ntably in the Caribbean, are assciated with increased prevalence f HIV infectin in black MSM. Plicy pririties include: Ensuring resurces are allcated t addressing HIV amng black are prprtinate t their rle in HIV epidemics. Remving plicies wrldwide that exacerbate HIV transmissin, stigma, r discriminatin in black MSM. Training law enfrcement fficials t recgnize, interrupt, reprt, and prsecute attacks against MSM in Caribbean and African cuntries. Encuraging Eurpean, Central American, and Suth American cuntries t stratify HIV surveillance data in MSM by race and hld glbal and reginal meetings t share prmising research and prgrams. Prviding basic access t cndms and water-based lubricatin and increase the number f health-care prviders and health centers that can prvide culturally cmpetent care fr black MSM. Designing research studies that emphasize prtective factrs against HIV infectin and interventins that mitigate r neutralize structural (e.g., anti-gay vilence, lw incme, discriminatin) factrs assciated with HIV transmissin risk. 6
A call t actin fr cmprehensive HIV services fr men wh have sex with men Chris Beyrer et al. As f 2011 nly 87 cuntries have reprted prevalence f HIV in MSM. Data are mst sparse fr the Middle East and Africa, regins where criminal sanctins against same-sex behavir can make epidemilgical assessments challenging. All cuntries shuld include MSM in epidemilgic tracking f HIV. Research is central t frging a better respnse t HIV amng gay men. This paper lays ut a detailed research agenda. (See Appendix 1 fr the research agenda.) Research questins include: In Epidemilgy: hw prevalent is HIV in MSM? In Ecnmics: the cst effectiveness f prgramming. In Basic sciences: what frmulatins f rectal micrbicides have mst anti-viral activity? In Prmting ptimal care: hw can we best engage MSM int care? In Cmbinatin appraches: what cmbinatins will have greatest effect n HIV incidence in MSM? In Testing prmising appraches: hw can new technlgies like mbile phne reminders supprt HIV preventin? In Structural appraches: hw des stigma and hmphbia prmte HIV risks and what can we d abut it? Human rights abuses are imprtant scial determinants f vulnerability t HIV. Rights prtectins can enhance uptake, use, and impact f HIV interventins. The best bimedical and behavir change interventins cannt succeed withut spaces in which men can safely seek care and services, cmmunicate penly abut their sexual lives, and be supprted t adpt available preventive ptins. We need t scale a cmprehensive package f HIV and health services fr MSM, including: HIV testing, HIV treatment, cndms and lubricant, mental health and substance abuse services. MSM shuld be treated as whle peple, nt just vectrs f disease. Cmprehensive care fr MSM requires: 1. Well-trained clinicians wh understand the cnditins that are mre cmmn in MSM. 2. Prvider awareness that MSM are whle peple with a range f nn-hiv/std health care needs. 3. Understanding that prvider engagement can enable yuth and lder MSM t develp healthier lifestyles when they cme ut. We did a csting exercise t estimate the affrdability f an effective respnse, measured as the apprximate annual glbal price tag fr a set f interventins likely t reduce cumulative HIV incidence in MSM wrldwide by 25% ver 10 years. The high transmissin efficiency fr HIV in MSM suggests that preventin appraches that can reduce prbabilities f per-act transmissin will prbably be needed t prduce substantial reductins in new infectins. These interventins include antiretrviral based appraches such as HIV treatment and pre-expsure prphylaxis. 7
We estimated that a 25% reductin in HIV incidence in MSM wrldwide wuld crrespnd t 0.5-1.0 millin HIV infectins averted in MSM in the next 10 years. T deliver ral pre-expsure prphylaxis n a glbal scale capable f achieving this reductin, the estimated glbal price tag in the cming year wuld be $26 billin. Future csts are dependent n universal drug prices and thus might be substantially lwer as thse prices fall. One majr cnclusin f the exercise is that greater preventin investments in lwer incme settings can have a substantial impact, given that unmet need is highest and resurces are currently mst limited in these areas. The analysis als pints t the imperative t lwer drug prices in richer cuntries t enable wider use f strategies like pre-expsure prphylaxis. Distributin f cndms and lubricant is an immediately affrdable strategy. A glbal investment f US $134 millin in the cming year culd prvide enugh cndms and lubricant t set a curse tward averting 25% f glbal HIV infectins in the next 10 years. i We lay ut a strategy t greatly imprve the respnse t HIV amng MSM glbally. Fr this strategy we lked at inputs like epidemilgy, scial settings, and clinical factrs. Then we suggest a fur part apprach: 1. Overcme barriers t preventin, treatment and care thrugh decriminalizatin, and targeted prgrams t reduce hmphbia 2. Expand access t evidence based services, bringing t scale preventin and treatment prgrams with evidence f efficacy 3. Develp and implement a crdinated dnr and recipient plan t expand services strategically t maximize the impact f funding. 4. Set targets, measure prgress and hld stakehlders accuntable fr prgress. See Appendix 2 fr specific recmmended actin steps fr gvernments, ministries f health, dnrs, prviders, researchers, and cmmunity members. 8
i This cst estimate includes bth the cst f the cndms and cmpatible lubricant, and a cnservative estimate f csts fr cndm distributin. The cst estimate assumes that the prgram wuld build n existing distributin channels fr cndms and lubricants, including existing distributin prgrams thrugh cmmunity-based rganizatins. 9
Appendix 1 10
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Appendix 2 12
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