HIV This Week

Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review. PLoS Med. 2007 Dec;4(12):e339.

Photo credit: UNAIDS/J.Spaull

Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, Baral and colleagues conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data. A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, UNAIDS-classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in a given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3-60.6); low-prevalence countries, 14.4 (95% CI 13.8-14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0-10.2). Significant differences in ORs for HIV infection among men who have sex with men were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2-8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8-24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3-13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7-25.2) where it was not. By region, the odds ratio for men who have sex with men in the Americas was 33.3 (95% CI 32.3-34.2); 18.7 (95% CI 17.7-19.7) for Asia; 3.8 (95% CI 3.3-4.3) for Africa; and 1.3 (95% CI 1.1-1.6) for the low- and middle-income countries of Europe. Men who have sex with men have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. Odds ratios for HIV infection in men who have sex with men are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium-high prevalence settings. Men who have sex with men from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.

Editors’ note: These results reveal that high HIV prevalence rates among men who have sex with men are not limited to any one epidemic level, prevalence category, region, or income level. Action is required to improve surveillance; conduct social science, epidemiological, and behavioural research; and effectively promote and protect the human rights of men who have sex with men while advocating against the stigma and discrimination which are undermining HIV prevention efforts.

Since the first report of AIDS in 5 men who have sex with men (MSM) from Los Angeles, MSM have accounted for a higher proportion of AIDS cases than any other group in countries such as the United States (44%), Canada (65%), and Australia (64%). Although MSM first brought HIV to the world's attention and, even in the absence of external funding, were the first to promote risk reduction strategies, prevention efforts for MSM appear to have faltered. In this article, Jaffe and colleagues examine current HIV epidemiology in MSM, discuss why the epidemic may be re-emerging, and describe what can be done to address it, particularly in the United States. Despite advances in HIV care, almost 6000 MSM with AIDS in the United States died in 2005, and living with HIV is challenging. However, despite strong evidence for a re-emerging HIV epidemic in MSM, silence on this subject is nearly pervasive. Community mobilization of MSM was an important feature of the early response to HIV when the aphorism “silence equals death” captured the need for action. Many community-based organizations were founded to address this challenge, and the need for their advocacy and health promotion activities remains critically important today. Because most HIV transmission between adults is the result of voluntary behaviour, individuals can substantially influence the likelihood that they will either acquire or transmit HIV. A good example of an approach to personal responsibility is the “HIV Stops With Me” social marketing campaign, which emphasizes the role that HIV-positive individuals can take in ending the epidemic. Advances can occur through open discussion, increased HIV testing, funding to develop and implement evidence-based public health interventions, leadership from the gay community and public health officials, and recognition of the role of personal action.  Failure to address difficult issues implies that the HIV epidemic in men who have sex with men must be accepted as inevitable; this cannot be allowed to happen. The tragedy of the epidemic for an earlier generation of MSM must not be repeated.

Editors’ note: Effective HIV prevention strategies recognize that the job is never done. Re-invigorated, adequately resourced, and sustained community mobilisation for safer sex social norms is needed in many high-income countries where the number of men who have sex with men who are living with HIV is increasing.